CRITERION OF ABNORMALITY

begin by writing about how the task of defining mental disorders in itself is not
straightforward- no single answer.
-issues about cultural relativity, historical changes in the meaning of madness- Evolves over
time, constructed by prevailing socio economic political stuff
psychological normality in itself is not a very well-defined standard and hence, the deviance
from it also is not very well established- Idea of normalcy quite vague when it comes to psych
functioning
-how complicated it is. However efforts and definitions have been derived for this
phenomena. And these are the various ways in which abnormality is spelled out or defined

5 Ds of abnormality:

1. Deviance

2. Dysfunctional living/maladaptive

3. Distress

4. Dangerousness

5. Duration

DEVIANCE

Abnormality is defined as being ‘different’ or deviant from the norm or normal behavior.
They are ‘away from the norm’. This norm can be statistical (infrequently occurring
behavior lying in the extremes of the normal probability curve which is not possessed by
the majority of the population). The norm can also be cultural in nature (any behavior which
is not culturally acceptable is abnormal).

Statistical Deviance

It involves something which is not seen very commonly as its prevalence would be too low. The
deviance can be related to thoughts (e.g. people with social phobia), feelings (e.g. being highly
anxious or very low in anxiety) and behaviour (e.g. hyperactivity in ADHD or very low
levels of activity in catatonic patients). These individuals with abnormalities are very few in
number.+

Statistical deviance is based on psychometric tests in which norms reflect the normality of
behaviour. If the scores are too low or too high as compared to the norms, they are
considered abnormal.

Evaluations of statistical deviance:

Advantages:
 ● An objective and easily quantifiable measure of abnormality/normality. They
are standardized

● It has a dimensional view because high, low and average scores fall on the
same continuum. It moves away from the problematic ‘categorical view’ of
abnormality.

Disadvantage

● It does not suggest what characteristic trait should be measured to determine normality.
● It also does not provide an objective basis for deciding whether abnormality is
unidirectional or bidirectional. The clinician decides whether either high or low is
indicative of psychopathology or only low or high indicates psychopathology. For
example intellectual deficiency is indicated by an IQ of 70 and below. It does not tell
why the threshold is taken at 70. It can only be analyzed by the clinicians involved. In
such a case, too high IQ should also be considered pathological?
● It also poses a question on how to decide a cut off point for deciding abnormality.
These cut-offs may vary as per context.
● This further questions the objectivity of the statistical measures because value judgment
comes into role.

● When normality is held by most people, being abnormal should be an indicator of

uniqueness or originality. It questions the problems associated with herd mentality.

Cultural Deviance

Anything which is not appropriate or not sanctioned by the cultural norm will be referred to
as abnormality. For example, Sudhir Kakkar gives an illustration of a client (a 25 year old man)
whose parents claim that their boy is stubborn and does things his own way. This stubbornness is
constructed as psychopathological because it is considered unacceptable in a largely
collectivistic society. Some other examples may include having sexual relations/ fantasies of
children, man wanting to take up the responsibility of women (gender dysphoria).

Thus, defining abnormality is not objective but is a culmination of various values.

Evaluations of Cultural deviance

Advantages

● It accepts that cultural norms may vary and the notion of abnormality may also vary.
It is considerate of cultural context to define abnormality rather than having a
Universalist view.

Disadvantages
 ● It does not question the sanity of cultural norms. If a cultural norm is unacceptable, it
may be termed as psychopathological but not always cultural norms are appropriate.
There are many examples of norms that are undesirable and unjust. For example, if
someone questions the power relation between man and women in patriarchal society,
their behaviour may be termed as deviant.
● It does not question the authority who make these cultural norms. Generally, the
culture promoted is one endorsed by the elites and powerful groups and individuals who
have greater control.

● It confounds normality with conformity. It is possible that conforming to a norms may

be pathological such as in the cases of mob lynching or anti-Jews sentiment.

DYSFUNCTIONAL LIVING/ MALADAPTIVE

Dysfunctional living is one of the most important criteria to define psychological disorders. It
assumes that abnormality impairs an individual’s ability to function effectively, have good
relations and manage work & education.

Dysfunctional living is determined through two ways.

1. First, comparison with role requirements.

2. Second, an individual's comparison with age-related standards of behaviour. For
example, a child with mental retardation is unable to keep up with the age appropriate
development milestones like walking, talking, playing etc.

Evaluations

Advantages

1. It defines normality with an individual’s ability to function within an environment.

2. It is more practical in nature.

Disadvantage

1. It does not consider if the roles assigned to the individual are oppressive or not. For
example, there are oppressive standards to which women in patriarchal society have to
live up to. They are expected to balance both professional and personal life together
without any assistance. It is important to question this duality.
2. It is biased towards the idea of ‘fitting in’ within a given appropriate standard of an
individual. This can be very problematic.

DISTRESS

Distress is a lay man criteria to define psychopathology. It can be personal or social.

Distress views abnormality as which creates suffering and agony for the person and others
around them.

Personal Distress

A psychological disorder creates distress or agony for the individual. This criteria has also
been acknowledged by DSM-5.

Evaluations

Advantages

1. It allows the individual to make judgments about their own feelings and emotions.
The individual has greater control.

Disadvantage

1. Distress is a vague term. A person can be distressed due to various reasons, both
pathological and non-pathological. For instance, a distress caused due to loss of a job or
loss of loved one is non pathological and is influenced by larger social factor. In another
case, distress can be caused by a biologically occurring pathology. So, it poses a question
of how one can differentiate between the two boundaries of social suffering and
psychopathology.
2. In a few disorders, individuals do not experience distress. For example, anti-social
personality disorder, sexual perversion etc.

Social Distress

A psychological disorder causes agony and distress for people around. For example, antisocial
personality disorder, narcissistic personality disorder etc.

Evaluations

Advantage

1. It is commonsensical and practical in nature.

Disadvantages

1. It can be misused to witch-hunt for people who don't conform to a set criteria.
2. Anyone who does not fit into the role requirement prescribed by the society can also
cause distress to others. For example, gender normative people have distress from gender
fluid people.

DANGEROUSNESS

A behaviour which is injurious to safety and body integrity is psychopathological. Suicide is

psychopathological because it endangered the victim’s body. Some other examples may
include disorders like homicidal tendency, antisocial personality etc. as they pose danger to the
body integrity of the people around and their safety.

Evaluations

Advantage

1. It is a commonsensical and practical criteria.

Disadvantages

1. Dangerousness is determined by the clinician and sometimes it is difficult for

clinician to predict dangerousness.
2. Determining depends on the value judgment of the clinician which may be
problematic.
3. Mental health promoters play a role in ensuring public safety but it is majorly
under jurisdiction of the state agency. So, there is an overlap of responsibilities.

4. People may also be involuntarily detained in the name of dangerousness. In

such a case, treatment is done without the patient's consent. This can be
invasive, yield untrustworthy results and lead to violation of human rights.

DURATION

A disorder will be qualified as one only if it lasts for a duration of time and is consistent.
Symptoms must last for a specified period of time in the patient.

ADDITIONAL CRITERIA OF ABNORMALITY

Unpredictable: A psychological disorder is highly unpredictable which can then have adverse
consequences.

Irrationality: They are illogical and are not based on reality. For example, phobia and
hallucinations.

Note: It is important to note that no single criteria in itself can define what behaviour is
abnormal. Usually a combination of criteria are adopted.

DEFINITION OF DISORDER ACC TO DSM- 5

In the definition of mental disorder as per DSM-5 which is the Diagnostic and Statistical
Manual of Mental Disorder, released in 2013 there is a combination of criterias being adopted
for defining abnormality.

According to this definition:

A mental disorder is a syndrome characterized by clinically significant disturbance in an
individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the
psychological, biological, or development processes underlying mental functioning. Mental
disorders are usually associated with significant distress or disability in social, occupational, or
other important activities. An expectable or culturally approved response to a common stressor
or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior
(e.g. political, religious, or sexual) and conflicts that are primarily between the individual and
society are not mental disorders unless the deviance or conflict results from a dysfunction in the
individual, as described above.

Certain suggestions towards the definition

First, while harm can be used to define mental disorders, certain postulated entities may
need careful evaluation of individual vs. societal harm, as well as societal
accommodation.

Second, while dysfunction may be used to characterise mental disorders, the field
would benefit from more precisely defined indicators of dysfunction.

Third, evidence of diagnostic validity and clinical utility should be incorporated into
the definition of mental disorder, as well as the type and extent of data required to
support such judgements.

Classification
History and Development of DSM and ICD

Historically, there are evidences of description of some mental disorders as early as 3000 BC.
The syndromes of melancholia and hysteria find mention in Egyptian and Sumerian literature of
2600 BC. Ayurveda, the Indian system of medicine had included a classification of psychiatric
disorders under medical illnesses in 1400 BC. In the modern system of medicine, Hippocrates
(460-370 BC) is generally credited for bringing the concept of psychiatric illnesses to medicine.
He classified mental illness into delirium, mania, paranoia, hysteria, melancholia resulting from
four basic temperaments.

In the modern psychiatry, the first major attempt of classifying mental disorders was made by
Emil Kraepelin (1856-1926), who used three approaches towards classification of mental
disorders: clinical-descriptive, the somatic, and the course. His primary classifications were
manic depressive psychosis and dementia praecox Later Eugen Bleuler renamed dementia
praecox as schizophrenia, a diagnostic term which is in use even after 100 years of its
introduction. Kraepelin also differentiated paranoia from dementia praecox, delirium from
dementia, and, also introduced the concepts of psychogenic neuroses and psychopathic
personalities. Sigmund Freud (1856-1939) made important contributions towards the
classification of neuroses and personality disorders.
 In the current scientific world, there are two official classification systems: World Health
Organisation’s International Classification of Diseases (ICD) and the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).
Features of Classification
1. Atheoretical with regard to causation:

This means that even though in the DSM, there is greater attention being given to looking at
disorders, in terms of, their biological causal factors the commonalities in the biological causal
factors across disorders, but still on the paper however on paper, both DSM and ICD do not
make any claim. It does not take any position on the fact that the classification system is based
on the differences in the etiological processes

So that is the first thing that the classification is not based on differences, in causation or it is not
premised on the foundation of causation. Secondly, The classification is also not saying that
these disorders are only biologically caused. There is a bias towards biological causation,
obviously, because psychiatry is a medical specialty, but it does not state it.

There is still a space, even if it's not inviting space, but it has a big begrudging space. Psychiatry
has to keep a space open for psychological and social factors because the psychological disorders
cannot just be reduced to a biological abnormality.
2. Polythetic Approach to classification, ie., diagnosis is made according to how close a
candidate meets a prototype.
3. Largely categorical form of classification but increasingly becoming more hybrid by
including features of dimensional classification
4. Describes signs, symptoms and associated features of the disorders (eg, course of the
disorder, premorbid personality and adjustment, epidemiology. prognosis,
differential diagnosis, lab findings of neurological and psychophysiological
correlates, psychological test scores etc.)
Need and Purpose of Classification
1. Communication: Most sciences rely on classification (e.g., the periodic table in chemistry
and the classification of living organisms). Classification systems provide us with a
nomenclature (a naming system). This gives clinicians and researchers both a common
language for complex clinical conditions. Without having a common set of terms to
describe specific clinical conditions, clinicians would have to talk at length about each
patient individually to provide an overview of the patient’s problems. But if there is a
shared understanding of what the term “schizophrenia” means, for example,
communication across professional boundaries is simplified and facilitated.
2. Structure information: Classification systems enable us to structure information in a more
helpful manner. They shape the way information is organized. For example, most
classification systems typically place diagnoses that are thought to be related in some
way close together. In DSM-5, the section on anxiety disorders includes disorders (such
as panic disorder, specific phobia, and agoraphobia) that share the common features of
fear and anxiety.
3. Facilitates research: Organizing information within a classification system also allows us
to study and learn new things. In other words, classification facilitates research, which
gives us more information and facilitates greater understanding, not only about what
causes various disorders but also how they might best be treated.
4. Social and political implications: The classification of mental disorders has social and
political implications. 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 it furthermore delineates which types of psychological
difficulties warrant insurance reimbursement and the extent of such reimbursement.

Classification and Diagnosis

Organizing principles of contemporary classifications (types of classification):

1. Categorical Classification: Psychiatric disorders have traditionally been classified by
dividing them into categories that are supposed to represent discrete clinical entities. This
approach considers illness as being either present or absent. Using the prototype
approach, the disorder is labeled to be either present or absent. For a particular case, the
set of symptoms either constitutes a disorder or not, and there are no "In between"
diagnoses. According to this approach, there may be a large number of disorders
depending on the prototypes. If symptoms of two disorders are present, then the two
disorders are said to be present as comorbid disorders (e.g., generalized anxiety disorder
and depressive disorder existing as comorbid disorders). According to the categorical
approach, disorder is distinct from normalcy i.e., either one is ill or not ill).

2. Dimensional Approach: According to this approach, symptoms of disorder exist on a

dimension which is a continuum from normal to severely ill. Dimensionality can be
 envisaged in terms of number (count) of symptoms (e.g., five out of eight symptoms to
diagnose major depressive disorder) and severity of each symptom group (e.g. positive,
negative, disorganized, cognitive, affective dimensions of schizophrenia). A disorder
with three or more ordinal categorles (e.g., mild, moderate, and severe) can be said to
have a dimensional approach. Scales such as Hamilton Depression Rating Scale (HDRS)
represent a dimensional evaluation. The dimensional approach suggests that symptoms
may be present in normal as well as in II. A cutoff is used to ascertain the threshold of
diagnosis (which transforms the disorder into categorical). The diagnostic threshold is
determined by the expert's opinion

3. The multiaxial approach: Multiaxial assessment is a system or method of evaluation,

grounded in the biopsychosocial model of assessment that considers multiple factors in
mental health diagnoses, for example, multiaxial diagnosis is characterized by five axes
in the version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV
TR; American Psychiatric Association, 2000).

A multiaxial approach enhances organization and communication of complex

information in a concise and comprehensive manner, while recognizing the heterogeneity
of individuals with the same diagnosis (Oken, 2000).

Clinical neuropsychologists typically employ a multiaxial approach when performing a

comprehensive assessment of a client’s medical, psychological, developmental, and
environmental/social status. Essen- Møller was probably the first to propose such a
system for use in psychiatry. However, multiaxial schemes are too complicated and time-
consuming to be suitable for everyday use, especially if the clinical utility of each axis
has not been demonstrated. Indeed, for these reasons, DSM- 5 removed the multiaxial
diagnostic classification system used in DSM- IV, replacing it with a simpler approach.

From DSM III TO DSM IV TO DSM V

● Classification systems like DSM help us in understanding the various disorders,
differences among them, their causes and to plan treatment.
● According to Barlow and Durand (2005), DSM-III in 1980 was a landmark in the history
of nosology (classification) as it departed radically from its predecessors, and three
changes stood out:
1. Atheoretical approach to diagnosis was attempted that used the precise description
of the disorder rather than theories of causal factors.
2. Specific, and detailed criteria for disorders helped to study their reliability and
validity.
 3. It introduced a “multiaxial system” that allowed clinicians to have a detailed
information about their patients through rating them on five different dimensions,
or axes. The details of multiaxial system are given below.

Axis I : The disorder itself, such as, schizophrenia or mood disorder

Axis II : More enduring (chronic) disorders of personality
Axis III : Physical disorders and conditions
Axis IV : Amount of psychosocial stress reported by the patient and
rated by the clinician in a dimensional fashion
Axis V : Current level of adaptive functioning

● A revision of DSM-III called DSM-III-R was published in 1987, with further

improvement in reliability and validity.
● Problems with DSM-III and III-R:
1. Some of the diagnostic categories had low reliability.
2. Some criteria were whimsically rather than empirically established, e.g., one of
the criteria for panic was four panic attacks in a four-week period. A figure
reached through an approximation rather than research.
● Despite shortcomings, DSM-III and III-R had a substantial impact. It was more popular
and more clinicians used it than the ICD system.
● ICD-10 was published in 1993 and to increase compatibility between DSM and ICD-10,
work on DSM-IV and ICD-10 was started simultaneously.
● DSM-IV (1994) and DSM-IV-TR (2000)

According to Barlow and Durand (2005):

○ Scientific data was used to make changes in the diagnostic system;
○ Reanalysis of large set of data was done to increase its utility for DSM-IV;
○ Independent field trials examined the reliability and validity of alternative sets of
definitions or criteria, and, in some cases, the possibility of creating a new
diagnosis (Widiger et al., 1998);
○ The distinction between organically and psychologically based disorders was
eliminated;
○ The “multiaxial system” remains with some changes in the five axes. These
changes were as follows:

Axis I : Pervasive Developmental Disorders (PDD), Learning Disorders

(LD), motor skills disorders, and communication disorders, previously
coded on Axis II are now coded on Axis I.
Axis II : Personality disorders and mental retardation
Axis III : General medical conditions
Axis IV : Psychosocial and environmental problems (instead of
psychosocial stress in DSM-III & III-R)
 Axis V : Current level of functioning using the GAF; Global Assessment
of Functioning (rating scale of 0-100) in life areas (social and
occupational relationships and use of leisure time).

○ Extensive description of diagnostic categories: For each disorder there is a

description of essential features, associated features (lab findings and physical
examinations), research literature about age of onset, course, prevalence and sex
ratio, familial pattern, and differential diagnosis.
○ Social and Cultural Considerations: “Cultural formulation guidelines” is a plan for
integrating important social and cultural influences on diagnosis (Mezzich et al.,
1999), e.g., what is the primary social and cultural group of a patient (e.g.,
Chinese, Hispanic, etc.).‘Have the immigrants mastered the language of their new
country?Does the patient use term and descriptions from his or her “old” country
to describe the disorder?’These cultural considerations must not be overlooked in
making diagnosis and planning treatment, but yet, there is no research supporting
the utility of these cultural formulation guidelines (Alarcon et al., 2002).
○ Overall, the reliability of DSM has improved due to increased explicitness of the
DSM criteria; use of standardized, reliably scored interviews for collecting the
information needed for a diagnosis.

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

DSM-IV and DSM-IV-TR:
1. The diagnostic criteria continued to result in rather frequent diagnosis of
comorbidity.
2. Heterogeneity within the diagnostic groups was unacceptable to the
researchers and it contaminated treatment outcome.
3. The erratic thresholds for inclusion and exclusion could not differentiate
the normal from abnormal or syndromal from subsyndromal disorders.
Clinicians would then resort to the not otherwise specified (NOS)
diagnoses.
4. The DSM IV did not consider emerging clinical conditions like addiction
to the internet or the so called nocturnal refrigerator raids.
5. Some authors had noticed that the number of psychiatric classification had
"swollen to kaleidoscope of pulative disorders"

○ Continued efforts to improve DSM has led to DSM-5

The DSM-5 was published in 2013 after much debate and controversy. The
key aspects are as follows:
● Grouping of disorders into similar clusters based on shared pathophysiology, genetics,
disease risk, and other findings from neuroscience and clinical experience rather than
symptom expression
 1. Eg: Much of the research from genetics and psychiatry over the past 20 years
points to an overlapping genetic liability between psychotic and mood disorders,
particularly bipolar disorder, that believe DSM-IV's separation of these as
distinctive. In the DSM-5 classification, the chapter on schizophrenia and other
psychotic disorders is sequenced with that of bipolar and related disorders (which
are now separated from unipolar mood disorders)
2. Eg - ASD and ADHD are now grouped together in neurodevelopmental disorders
● The DSM-5 organization also reflects a broader clustering among groups of diagnostic
categories, with those that tend to have similar premorbid personality traits and/or co-
occur being placed proximally to one another.
1. Eg. - Placing neurodevelopmental disorders, schizophrenia and other psychotic
disorders in successive chapters.
● The DSM-5 Includes dimensional aspects of diagnosis along with categories. Although,
ultimately, diagnosis is still largely dependent on a "yes or no" decision, use of specifiers,
subtypes, severity ratings, and cross-cutting symptom assessments help clinicians better
capture gradients of a disorder that might otherwise be hindered by a strict categorical
approach.
1. Eg. - The specifier "with anxious distress" with Depressive Disorder yields
clinically useful information about a variant of Depressive disorder that would
likely be masked under a residual diagnosis of "not otherwise specified" in the
DSM-IV, and may bring greater awareness to clinicians and researchers about the
importance of assessing anxiety in the presence of mood symptoms.
● Some DSM-IV disorders were combined to form spectra disorders in the DSM-5.
1. Eg. - ASD includes symptoms that characterize previous DSM-IV autism
disorder, Asperger's disorder, child disintegrative disorder, and pervasive
developmental disorder NOS. This proposed revision was developed because of
the presence of very poor reliability data, that failed to validate their continued
separation. A child previously diagnosed with Asperger's disorder under the
DSM-IV could therefore be diagnosed under the DSM-5 with ASD, with the
specifiers "without Intellectual impairment" and "without structural language
impairment
● Combining Disorders
1. Eg. - ASD, Somatic symptom Disorders, Substance Use Disorders -
● Splitting Disorders
1. Eg. -Obstructive sleep apnea, Hypopnea syndrome, Central sleep apnea, and
Sleep related hypoventilation divided into separate disorders.
● New Disorders
1. Eg. - Hoarding Disorder, Disruptive Mood dysregulation disorder, Binge eating
disorder, Restless legs syndrome
● Removal of aspects of DSM IV
1. Eg. - Removal of the bereavement exclusion for major depressive episodes
● Removal of Multi-Axial System
● Changing names
○ Despite several improvements have been made in DSM-5, however, it continues
to suffer from the problem of labeling.
DSM IV-TR

The DSM-IV (TR) recommends clinicians to assess an individual’s mental state across five
factors or axes. Together the five axes provide a broad range of information about the
individual’s functioning, not just a diagnosis. The system contains the following axes:

1. Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical
Attention
This axis incorporates a wide range of clinical syndromes, including anxiety disorders,
mood disorders, schizophrenia and other psychotic disorders, adjustment disorders, and
disorders usually first diagnosed during infancy, childhood, or adolescence (except for
mental retardation, which is coded on Axis II). Axis I also includes relationship problems,
academic or occupational problems, and bereavement, conditions that may be the focus of
diagnosis and treatment but that do not in themselves constitute definable psychological
disorders. Also coded on Axis I are psychological factors that affect medical conditions,
such as anxiety that exacerbates an asthmatic condition or depressive symptoms that delay
recovery from surgery.

2. Axis II: Personality Disorders and Mental Retardation

Personality disorders are enduring and rigid patterns of maladaptive behaviour that
typically impair relationships with others and social functioning. These include antisocial,
paranoid, narcissistic, and borderline personality disorders. Mental retardation, which is
also coded on Axis II, involves pervasive intellectual impairment. People may be given
either Axis I or Axis II diagnoses or a combination of the two when both apply. For
example, a person may receive a diagnosis of an anxiety disorder (Axis I) and a second
diagnosis of a personality disorder (Axis II).

3. Axis III: General Medical Conditions

All medical conditions and diseases that may be important to the understanding or
treatment of an individual’s mental disorders are coded on Axis III. For example, if
hypothyroidism were a direct cause of an individual’s mood disorder (such as major
depression), it would be coded under Axis III. Medical conditions that affect the
understanding or treatment of a mental disorder (but that are not direct
causes or the disorder) are also listed on Axis III. For instance, the presence of a heart
condition may determine whether a particular course of drug therapy should be used with a
depressed person.
 4. Axis IV: Psychosocial and Environmental Problems

The psychosocial and environmental problems that affect the diagnosis, treatment, or
outcome of a mental disorder are placed on Axis IV. These include job loss, marital
separation or divorce, homelessness or inadequate housing, lack of social support, the death
or loss of a friend, or exposure to war or other disasters. Some positive life events, such as
a job promotion, may also be listed on Axis IV, but only when they create problems for the
individual, such as difficulties adapting to a new job.

5. Axis V: Global Assessment of Relational Functioning (GARF)

The clinician rates the client’s current level of psychological, social, and occupational
functioning using a 0-100 scale. The clinician may also indicate the highest level of
functioning achieved for at least a few months during the preceding year. The level of
current functioning indicates the current need for treatment or intensity of care. The level of
highest functioning is suggestive of the level of functioning that might be restored. The
GARF Scale can be used to indicate an overall judgment of the functioning of a family or
other ongoing relationship on a hypothetical continuum ranging from competent, optimal
relational functioning to a disrupted, dysfunctional relationship (APA. 2000).

DSM V
DSM 5: Limitations of DSM IV:
● The diagnostic criteria continued to result in rather frequent diagnosis of comorbidity.
● Heterogeneity within the diagnostic groups was unacceptable to the researchers and it
contaminated treatment outcome.
● The erratic thresholds for inclusion and exclusion could not differentiate the normal from
abnormal or syndromal from subsyndromal disorders. Clinicians would then resort to the
not otherwise specified (NOS) diagnoses.
● The DSM IV did not consider emerging clinical conditions like addiction to the internet
or the so called nocturnal refrigerator raids.
● Some authors had noticed that the number of psychiatric classification had "swollen to
kaleidoscope of pulative disorders"

DSM 5: Development:
● The first DSM 5 Research Planning Conference held in 1999
● Attended by experts in family and twin studies, molecular genetics, basic and clinical
neurosciences, cognitive and behavioral sciences, and covered issues in development
throughout the lifespan and disability.
 ● Focused on issues like lacunae in the DSM IV system of classification, disability and
impairment, newer insights from the research in neuroscience, need for improved
nomenclature, and the impact of cross cultural issues.
● Since 2008, 397 participants worked in 13 work groups, six study groups, and a task
force of advocates, clinicians, and researchers. Each committee had co-chairs from both
the US and another country
● Much of the decision-making was also driven a desire to ensure better alignment with the
International Classification of Diseases and its 11th edition (ICD-11).

Features of DSM 5
● Grouping of disorders into similar clusters based on shared psychopathology, genetics,
risk factors and other findings from neuroscience and clinical experience rather than
symptom expression.

Eg: Much of the research from genetics and psychiatry over the past 20 years points to an
overlapping genetic liability between psychotic and mood disorders, particularly bipolar
disorder, that believe DSM-IV's separation of these as distinctive, In the DSM-5
classification, the chapter on schizophrenia and other psychotic disorders is sequenced
with that of bipolar and related disorders (which are now separated from unipolar mood
disorders)

● It reflects a broader clustering among groups of diagnostic categories with those that
tend to have similar premorbid personality traits and/or co-occur being placed proximally
to one another.

Eg: Placing neurodevelopmental disorders, schizophrenia and other psychotic disorder in

successive chapters.

● Dimensional aspects of diagnosis along with categories are included in DSM 5.

Although ultimately the diagnosis is still largely dependent on a ‘yes or no’ decision, use
of specifiers, subtypes, severity rating and cross cutting symptom assessment help
clinicians better capture gradients of a disorder that might otherwise be hindered by a
strict categorical approach.

Eg: The specifier "with anxious distress" with Depressive Disorder yields clinically
useful information about a variant of Depressive disorder that would likely be masked
under a residual diagnosis of "not otherwise specified"

● Some DSM-IV disorders were combined to form spectra disorders in the DSM-5.
 Eg: ASD includes symptoms that characterize previous DSM IV autism disorder,
Asperger's disorder, child disintegrative disorder, and pervasive developmental disorder
NOS. This proposed revision was developed because of the presence of very poor
reliability data that failed to validate their continued separation.

● Gender differences have been accounted for by diagnosis by providing the differences in
prevalence rates and symptoms between male and female patients. For example, antisocial
disorder (prevalence is higher in males) and anorexia (higher prevalence in females) and
symptoms of conduct disorder are different in males and females (Butcher et al., 2016).

● The DSM-5 contains a structured interview which has a sixteen item Cultural
Formulation Interview (CFI). The interview enquires about the patient’s perspectives on
their present problems, how they perceive the influence of others in influencing them
problems, ways in which their cultural background can influence their adjustment and
their experiences in seeking treatment for their problems.

● Some disorders like Somatic symptom disorder, ASD, Substance Abuse Disorders have
been combined in DSM 5.

● Some disorders like Obstructive sleep apnea, central sleep apnea, Hypopnea syndrome
and sleep related hypoventilation have been divided into separate disorders.

● New disorders like Hoarding Disorder, Binge eating disorder, Disruptive Mood
Dysregulation Disorder, Restless Legs Syndrome have been introduced.

● Some names have been changed to incorporate more sensitive terminologies. Eg:
Mental Retardation is now referred to as Intellectual Disability. Substance Related and
Addictive Disorders are now known as substance use disorder. “Not Otherwise Specified
Categories” have been changed to “Other Specified” and “Unspecified” Categories.

● The redundant aspects of DSM IV have been removed from the new edition. This
includes the removal of the multiaxial system

● ICD 11:

Features of ICD 11

· Ordering the diagnostic groupings following a developmental perspective (hence,

neurodevelopmental disorders appear first and neurocognitive disorders last in the
classification)

· Grouping disorders together based on putative shared etiological and pathophysiological

factors (c.g., disorders specifically associated with stress) as well as shared phenomenology
(e.g., dissociative disorders)
· Incorporation of dimensional approaches within the context of an explicitly categorical
system

· Culture-related information was systematically incorporated based on a review of the

literature on cultural influences on psychopathology and its expression for each ICD-11
diagnostic grouping

· Anxiety or fear-related disorders

· Catatonia Disorders of bodily distress or bodily experience

· Disorders due to substance use or addictive behaviors

· Disorders specifically associated with stress

· Disruptive behavior or dissocial disorders

· Dissociative disorders

· Elimination disorders

· Factitious disorders

· Feeding or eating disorders

· Impulse control disorders

· Mental or behavioural disorders associated with pregnancy, childbirth and the puerperium

· Mood disorders

· Neurocognitive disorders Neurodevelopmental disorders

· Obsessive-compulsive or related disorders Paraphilic disorders

· Personality disorders and related traits

· Schizophrenia or other primary psychotic disorders

Limitations of Psychiatric Classification Systems:
● It takes away the attention from the broad question "What is
psychopathology/abnormality?"

Classification of both, disorders or even general things like trees, animals etc, the focus
remain on typology, how is one different from another. It focuses on distinguishing thing
however this takes away from the question “what is abnormality etc instead it focuses of
how many times of psychopathologies are there? (PHILOSOPHICAL PROBLEMS)

● Atheoretical wrt causation

classification is based upon on symptom expression rather than underlying causal

mechanism. It offers very non -specific causation. Largely it places more emphasis on
 symptom expression yet DSM 5 is trying to bring in more emphasis on looking at
biological causal mechanisms and using that to classify disorders.

● Symptom based language informs us very less regarding the lived experience of the
person

It gives limited information about what the person is feelings.

It talks about how the disorder is manifested in terms of behaviours, in terms of sleep
patterns, social behaviours etc, however their living experience is not talked about.

● Medicalization of psychological suffering

The social suffering of an individual is reduced to a symptoms and of given treatment.

Language is very medicalized.
While these are alright for other kinds of bodily diseases as they are truly governed by
various branches of medical science however psychological disorders have gray areas
which is the ambiguous space between biology, psychology and social order.
A faulty way of looking at the body is looking it as a biological entity on which the social
and psychological factors have a later effect on.

● Pathologization of everyday life

e.g., Indian women - word tension being used as a sign of cultural syndrome.
Whatever happens in everyday life, the diversity of experiences that goes in the common
everyday life parts of it are being pathologized and being boxed into disorders us a
dangerous tendency, although this debate is difficult to settle as recognizing a disorder
has its own advantages.

● Circularity incipient in classification

Both signs and symptoms are being looked as both the explanations as well as descriptors
of a disorder. E.g., Schizophrenia
How do we know that a patient has schizophrenia?
We look at certain markers, like whether she experiences auditory hallucinations,
has lack of insight, strange beliefs etc, so these are the signs and symptoms of
schizophrenia( hallucinations, lack of
insight etc)

Why does she have strange beliefs and experience hallucination?

The answer to this question sadly becomes because she suffers from
schizophrenia.
 The diagnostic label is standing both for certain signs and symptoms and is also standing
for the reason why these signs and symptoms are present.
Diagnostic labels are criticized as they are overvalued as they seem to provide more
information then what they carry.

● Reliability issues: Lack of long term stability of diagnosis, poor inter-diagnostician

consensus

Stability of diagnosis is not very high. A person may be diagnosed with different
disorder, issues also arise with comorbidity.
Over time, the changing phenomenology of the disorder get attracted different kinds of
diagnosis, clinicians come up with different diagnosis , there is lack of interdiagnositician
agreement with regard to the diagnosis

● Validity issues of Categorical form of classification:

○ Boundary confusions: We don't know where one disorder ends and other begins
e.g., Autism ends and Asperger's begins or schizophrenia ends and schizoaffective
begins etc., this happens due to the categorical classification of disorders as they
become very discreet, due to this reason, dimensional approach is being more
accepted and spectra disorders are being accepted.

○ Comorbidity: It is a problem when we diagnose two or more disorders in one

person. e.g., GAD and Depressive disorder or Eating and Depressive disorders -
more stigmatizing, more medical treatment, poor prognosis. The problem is that if
two or more disorders are presented together in a clinical sample then there is a
possibility that there is an underlying etiological mechanism, which is running
across these disorders causing them to hang together then it would be better to
refer to these disorders by a singular name.

○ Overuse of residual categories: Many disorders do not fit any diagnostic

classification. This problem occurs due to very rigid criteria areas, of the criteria
are met then, it is accepted as a disorder if not then it is included in these
categories of NOS, which is like a waste paper basket that has no identifying
symptoms and is defined by the fact they have symptoms but not to the extent that
it be classifies as a disorder. - write from notes

○ Low Predictive Validity: Once a person is diagnosed ideally, it should give ideas
about how the disorder would proceed, ( the course, the prognosis, the treatment
of the illness.) However, often that is also something which is not available in
 various kinds of diagnostic categories. The disorders show quite a lot of variation
in their courses.

Psychiatric Diagnosis
Diagnosis cannot be made without a classification because diagnosis involves matching the
signs and symptoms with the definitions given and the criteria in the classification system.

It is the clinical practice of determining which condition or disease explains the patient's
symptoms and signs by matching them with the classification system so that treatment can be
prescribed.
● Need of Diagnosis:
○ Communication amongst clinicians and researchers
○ Treatment Planning
● Critique:

1. Biased diagnosis based on social characteristics of patients: The clinicians often

make diagnostic judgements not on the basis of signs and symptoms rather on the
clinical picture whose bases will be made on basis of male or female, rural or urban,
black or white or cisgender or gender fluid person or a person with non-heterosexual
preferences etc.

2. Fads in diagnosis- Psychiatry goes through trends, there have been times wherein
certain disorders were more identifies e.g., Bipolar in US shifted from an extremely
unusual diagnosis to a more common one, this may be due to development of new
technology, tests etc or even the aggressive marketing efforts of drug companies,
the power pharmaceutical companies come up with their own drugs for particular
kins of clinical problem so there is a big nexus that has been developed.

3. Obscuring of personal, social and cultural contexts: Diagnosis is often biased when it
takes into consideration the social factors, thus this is a biased diagnosis , they
become like heuristics for making diagnosis and does not relate to the signs and
symptoms . Diagnosis reduces a person into a label while in comparison the case
formulation tries to understand the characteristics of the person, familial background,
growing up experiences, educational life, immediate stressors etc

4. The Individualizing of problems rather than looking at the person at someone with a
connection with the environment.

5. Stigma and disempowerment- it is a fallout of diagnosis as mental health diagnosis

are very stigmatizing, it depowers the person and also removes them from
responsibility as they are believed to be not in senses, a mad person who can't make
rational decisions etc.
 6. Removal of responsibility
7. Omission of client's viewpoint
8. Loss of personal meaning

CLINICAL ASSESSMENT
Clinical assessment is the systematic evaluation and measurement of psychological,
biological, and social factors in an individual presenting with a possible psychological
disorder. Clinical psychologists collect the data and evaluate the information from the
individual with regard to psychological disorder, to make diagnosis, plan the treatment, and
prognosis (predict the outcome).
Clinical diagnosis- process through which a clinician arrives at a general “summary
classification” of the patient’s symptoms by following a clearly defined system such as DSM-
5 or ICD-10
Assessment is an ongoing process and may be important at various points during treatment,
not just at the beginning—for example, to examine the client’s progress in treatment or to
evaluate the outcome.

The basic elements of an effective assessment include:

● Identifying the presenting problem or major symptoms and behavior the client is
experiencing.
● Clear understanding of the nature of difficulty and including a diagnostic classification
to help in planning and managing the appropriate treatment.
● Clear understanding of the individuals behavioral history, intellectual functioning,
personality characteristics and environmental pressures. This information should be
integrated into a meaningful picture called "dynamic formulation" (hypotheses about
what is driving the person to behave in maladaptive ways and hypotheses about the
client’s future behavior as well).
● Ensuring that the assessment procedure are culturally sensitive, i.e., ensuring that the
characteristics of the test being employed are appropriate across cultures and that the
assessment process is free of biases.
● In order to be effective, psychological test or clinical assessment must be reliable, valid
and standardized:
○ Reliability: In the context of assessment or classification, reliability is an index of
the extent to which a measurement instrument can agree that a person’s behavior
fits a given diagnostic class.
○ Validity: In the context of testing or classification, validity is the degree to which
a measure accurately conveys to us something clinically important about the
person whose behavior fits the category, such as helping to predict the future
course of the disorder.

(The validity of a mental health measure or classification presupposes reliability.

If we can’t confidently pin down what the diagnosis is, whatever useful
information a given diagnosis might convey about the person being evaluated is
 lost. However, good reliability does not in itself guarantee validity. Reliable
assignment of a person’s behavior to a given class of mental disorder will prove
useful only to the extent that the validity of that class has been established
through research.)

o Standardization: Standardization is a process by which a psychological test is

administered, scored, and interpreted in a consistent or “standard” manner.
Many psychological tests are standardized to allow the test user to compare a
particular individual’s score on the test with a reference population, often
referred to as a normative sample.

● In order for psychological assessment to proceed effectively, the client being evaluated
must feel comfortable with the clinician, i.e., there should be mutual trust and
rapport between the clinician and the client.

The following are the main types of assessment for psychological disorders:

Biological assessment:
With certain psychological problems, a medical evaluation is necessary to rule out the
possibility of physical abnormalities causing that problem. Medical evaluation may include:
1. General physical examination:
Cases in which physical symptoms are part of the presenting clinical picture, a physical
examination is recommended. A physical evaluation is the same as getting a "medical
check up", a medical history is obtained and the major systems of the body are
checked. This is an important procedure for disorders that entail physical problems, such
as addictive disorders, and organic brain syndromes etc.

2. Neurological examination:
Because brain pathology is sometimes involved in some mental disorders, a specialized
neurological examination can be administered. These examinations include brain
imagery, seeing the brain and how its structure, functioning and chemical make-up
may be related to abnormal behavior.
○ Electroencephalogram (EEG/ECG): An EEG is a graphical record used to
assess brain wave patterns in awake and sleeping states. It gives us
information of the brain’s electrical activity. An EEG may reveal a
dysrhythmia, or irregular pattern, in the brain’s electrical activity, which might
be caused by a brain tumor or other lesion.
○ Computerized Axial Tomography (CAT) scan: Through the use of cross-
sectional X-rays, a CAT scan reveals information about the localization and
extent of anomalies in the brain’s structural characteristics. The moving X-ray
beams produce images of the brain, measure the amount of radioactivity and
detects subtle differences in tissue density.
 ○ Positron Emission Tomography (PET) Scan: measures both brain structure
and function. It reveals the metabolic or biochemical functions of the tissues
and organs. The PET scan uses a radioactive drug (tracer), which when
injected in the blood stream emits a particle called a positron. This particle
collides with an electron and a high-energy light particle shoots out from the skull
in opposite directions. This is detected by the scanner and converted into images
of a functioning brain. The images show what parts of the brain are working
and what parts are not.
○ Magnetic Resonance Imaging (MRI): MRI involves the precise measurement
of variations in magnetic fields caused by the varying amounts of water
content of various organs. The person is placed inside a large, circular magnet,
which causes the hydrogen atoms in the body to move. The magnetic force is
turned off, the atoms return to their original position and produce an
electromagnetic signal which is translated into pictures of brain tissue.
○ Functional MRI (fMRI): It allows to take pictures of brain at work. most often
measures changes in local oxygenation (i.e., blood flow) of specific areas of
brain tissue that in turn depend on neuronal activity in those specific regions.

3. Neuropsychological examination:
○ Used for identifying any alteration in behavioral or psychological functioning
that has occurred because of the organic brain pathology.
○ involves the use of various testing devices to measure a person’s cognitive,
perceptual, and motor performance as clues to the extent and location of brain
damage
○ Administration of a test battery to a patient, which may be highly individualized
depending on the patient's case history, or be a standard set of tests.
○ Example of standard test: The Halstead-Reitan neuropsychological test battery.
This battery can help in making diagnostic decisions, e.g., it helps to discriminate
between dementia due to depression and dementia due to a degenerative
brain disease.
○ The Halstead-Reitan battery for adults is made up of a group of tests such as the
following:
1. Halstead category test: Measures a subject’s ability to learn and
remember material and can provide clues as to his or her judgment and
impulsivity.
2. Tactual performance test: Measures a subject’s motor speed, and ability
to learn and use tactile and kinesthetic cues.
3. Rhythm test: Measures attention and sustained concentration through
an auditory perception task.
4. Speech sounds perception test: Determines whether an individual can
identify spoken words.
5. Finger oscillation task: Measures the speed at which an individual can
depress a lever with the index finger.
Psychological assessment
In cases where the psychological difficulty is thought to result from non-organic causes,
psychological assessment is used. attempts to provide a realistic picture of an individual in
interaction with his or her social environment. This picture includes relevant information about
the individual’s personality makeup and present level of functioning, as well as information
about the stressors and resources in her or his life situation.
1. Assessment interviews
○ An assessment interview usually involves face-to-face interaction in which a
clinician obtains information about various aspects of a client’s situation,
behavior, and personality.
○ Assessment interviews can be of two type:
■ Unstructured interview: Relatively open in character, with an
interviewer making moment-to-moment decisions about his or her next
question on the basis of responses to previous ones. Content of the
interview questions is influenced by the habits or theoretical views of the
interviewer. Clients may view unstructured interviews as being more
sensitive to their needs or problem. These interviews provide valuable
information that would not emerge in a structured interview.
■ Structured interview: Tightly controlled and structured so as to ensure
that a particular set of questions is covered. It has a predetermined
theme, is less flexible but yields far more reliable results than the
flexible format.They are also referred to as diagnostic interviews.
○ The reliability of an assessment interview may be enhanced by the use of rating
scales that help focus inquiry and quantify the interview data.

2. Clinical observation of behavior:

○ One of the traditional and most useful assessment tools that a clinician has
available is direct observation of a client’s characteristic behavior. In clinical
observation the clinician provides an objective description of the person’s
appearance and behavior—her or his personal hygiene and emotional
responses and any depression, anxiety, aggression, hallucinations, or
delusions she or he may manifest.
■ Clinical observation takes place either in a natural environment or in a
clinic or hospital setting.
■ Some practitioners and researchers use a more controlled behavioral
setting for conducting observations. These settings might involve tasks
such as staged role-playing, event reenactment, family interaction
assignments, or think-aloud procedures.
○ In addition to making their own observations, many clinicians enlist their clients’
help by providing them instruction in self-monitoring: self-observation and
objective reporting of behavior, thoughts, and feelings as they occur in various
natural settings.
■ This is useful in determining the kinds of situations in which
maladaptive behavior is likely to be evoked.
 ■ Here, a client may be asked to fill out a more or less formal self-report or
a checklist concerning problematic reactions experienced in various
situations.
■ These approaches recognize that people are excellent sources of
information about themselves.
○ Rating scales in clinical observation and in self-reports help to organize
information and to encourage reliability and objectivity.
■ The most useful rating scales enable a rater to indicate not only the
presence or absence of a behavior but also its prominence or degree.
■ Example: Brief Psychiatric Rating Scale (BPRS), The Hamilton Rating
Scale for Depression (HRSD)

3. Psychological tests

Psychological assessment is an umbrella term as assessment is the integration of

information from various sources. Testing however is just taking one sample area of
behavior and then measuring it and quantifying it. Thus, there exists a difference
between Assessment and testing.

○ Psychological tests are a more indirect means of assessing psychological

characteristics.
○ Scientifically developed psychological tests are standardized sets of procedures
or tasks for obtaining samples of behavior. The clinician compares an
individual’s responses on a given test with the test norms and makes an
evaluation about him/her based on those comparisons.
○ These tests can measure coping patterns, motive patterns, personality
characteristics, role behaviors, values, levels of depression or anxiety, and
intellectual functioning etc.

Two general categories of psychological tests are used in clinical practice are:

1. Intelligence tests
○ Wechsler Intelligence Scale for Children-Revised (WISC-IV) and the
Stanford-Binet Intelligence Scale are the most widely used to measure children’
intellectual abilities.
○ Wechsler Adult Intelligence Scale-Revised (WAIS-IV) is used to measure adult
intelligence. It consists of 15 subtests and measures both verbal and nonverbal
intelligence.
○ These test are however, culturally biased and are not time and cost effective.
○ Intelligence tests are only used when it is absolutely necessary to measure an
individual’s intellectual abilities, for example, intellectual impairment, organic
brain damage.

2. Personality tests
○ Projective Personality Tests:
 ■ These tests are semi-structured or unstructured and use ambiguous
stimuli ranging from less ambiguous such as pictures, incomplete
sentence stems, to ambiguous stimuli such as inkblots.
■ Through their interpretations of these ambiguous materials, people reveal
a good deal about their personal preoccupations, conflicts, motives,
coping techniques, and other personality characteristics.
■ Some of the semi-structured projective tests are Rosenzweig Picture-
Frustration test, Thematic Apperception Test, Rotter’s Incomplete
Sentence Blank, and unstructured projective tests are inkblot tests, such as
Rorschach Inkblot Test.
○ Objective Personality Tests:
■ These are the structured personality tests, such as questionnaires, self-
report inventories, or rating scales with carefully phrased and precise
items and alternative responses as choices.
■ The structured format allows objective quantification of the sample of
behavior under study. This precision and quantification increases the
reliability of such tests.
■ Some of the widely used objective personality tests are:
1. NEO-PI (Neuroticism-Extroversion-Openness Personality Inventory)
used for normal population
2. Millon Clinical Multiaxial Inventory (MCMI-III) used for clinical
population.
3. Minnesota Multiphasic Personality Inventory Revised (MMPI-2) used
for adults. It is a self-report questionnaire which covers wide range of
topics from physical condition and psychological states to moral and
social attitudes. It is also used to test psychopathology in an individual
and thus is often utilised in clinical settings.

INTERVENTION:

The term “intervention” means “the act or a method of interfering with the outcome or course
especially of a condition (as to prevent harm or improve functioning)” interventions are actions
performed to bring about change in people. Most generally, it means any activities used to modify
behavior, emotional state, or feelings. Psychological interventions have many different applications and
the most common use is for the treatment of mental disorders. The ultimate goal behind these
interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.
Interventions can be diverse and can be tailored specifically to the individual or group receiving
treatment depending on their needs. This versatility adds to their effectiveness in addressing any kind
of situation.
 REHABILITATION

Rehabilitation refers to restoration or recovery of the biological, psychological and social

functioning of an individual which was lost or impaired due to injury or disability. It is founded
on the premise that all individuals have inherent worth and have their right to be experts in
their own health care. The aim of rehabilitation is to regain maximal functioning, and
independence of the client

Similarities between psychotherapy and rehabilitation

1. Collaborative, professional, individualised, growth-promoting relationship

Differences:

Psychotherapy Rehabilitation
Scope Primarily used in the case of a Used for a wider variety of problems-
mental disorder or mental physical and mental conditions both.
problem. Also be used for impairment or injury in
the functioning of the individual
Goal Directed towards symptomatic Seeks to improve health and functioning
alleviation or reduction in of persons with sensory, motor, cognitive,
symptoms or insight. developmental and emotional difficulties.
Facilitates independent living- provide
housing, vocational rehabilitation, social
support and network enhancement
Example Helping person with depression Speech therapy exercises to help a person
understand the causes and patterns regain language skills after a brain injury,
of their depression making a person with depression join a
hobby class

Delivery Professionally trained and Provided by a multidisciplinary team-

Agents qualified therapists/psychologists doctors, physiotherapists,
psychotherapists, speech and language
therapists etc.

GOALS:

Rehabilitation goals are the desired outcomes for each rehabilitation client (Habel, 1993).
Therefore, the goals of rehabilitation are required to be mutually established by the rehabilitation
professionals in consultation with the client and his family members. Realistic goals are set in
consultation with the client and the family members and other caregivers. The ultimate purpose
is to enhance the client’s wellbeing.

1. Impairment-related Outcomes: These can prevent the loss of functioning, slow the
rate of loss of function, improve or restore the function, compensate for lost function
or maintain the current function.
2. Activity & Participation Outcomes: Can improve an individual's performance such
as communication, mobility, self-care eg. Prosthetic aids,
a. return to education
b. skill development
c. Return to employment
d. Improve quality of life (leisure and recreational activities)
3. Changes in resource use: (outcome of above 2) Reducing dependence on others
[reduction in number of hours of assistance required from others]

Measures
1. Training and exercises [neurocognitive rehabilitation- Alzheimer's and
Parkinson's]
Independent functioning can be maximised by encouragement and reinforcement of
physical and mental exercises required for restoration of the impaired functions. It
requires involvement of the family members. Therefore, the approach should be family-
centred. Larger communities like peers in school, neighbours in neighborhood or
colleagues in the workplace may be involved in supporting the recovery process of the
client.

2. Support and counseling

3. Modifications to the environment (ramps, braille)

4. Provision of resources and assistive technology (wheelchairs, crutches etc)

Augmentative devices are those which enhance the existing capabilities of the people
with disabilities (for instance, spectacles enhancing vision, hearing aids for hearing or
mobility aids for movement); whereas, alternative devices are those which are used in
developing a parallel or alternative forms of executing certain functions of a client that
are lost due to injury or disability (e.g., communication devices such as, speech
synthesizers for those who have lost their speech, the aphasics; braille for reading of the
visually handicapped, and wheel chairs for the ones with severe locomotors disability
involving the lower limbs). Such improvised ADL kits and appliances compensate the
loss of an ability due to disease or disability to a large extent.
Principles of Rehabilitation
1. Promote Functional adaptation to the environment (independent agent, not
dependent on others)
The prime aim of rehabilitation is to help the individual to adapt to the day-to-day
demands of life, which at times require a change in the life style of the client.
People with developmental disabilities often would not be able to return to a normal
level like that of their normal counterparts.
In case of acquired disability, however the focus is primarily on adaptation to the life
altering situation.

2. Emphasizes on ability [focus is on what the person has and making best use of it]
Rehabilitation professionals should train people in developing existing functions that
remain intact after the traumatic incident to the fullest extent and make maximum use of
them to compensate the functions affected by disease or disability. This may give the
client a sense of accomplishment.

3. Treats client as a whole person

The person with disability should be treated as a holistic being. Denial and non-
acceptance of limitations cause anger and depression in the client. Unconditional regard
for the individual with disability plays a crucial role in enhancing psychological well
being of such clients. Attempt should be made to enhance a sense of self-efficacy in
people with disability. It restores confidence and determination in overcoming many
obstacles both physical and psychological.

4. Disability affects the whole family [systemic view as well, works with person and
the structures surrounding the person]
Disability in a member in any family affects the entire family, as the trauma, physical
cost and psychological burden is shared by all members of the family.

Hence, time should be spent with the family members in listening to them and advising
them and helping them to overcome their negative overwhelming emotional feelings and
bolster their abilities to cope with such family stresses effectively.

PSYCHOTHERAPY

Psychotherapy is an interpersonal treatment

• Based on psychological principles
• It involves a trained therapist and a client [adequately qualified and supervised experience]
 • The client is seeking help for a mental disorder(process where client reaches out) [voluntary basis]

• Intended by the therapist for remedial; backed by psychological principles that have evidence backing
their remedial nature

• Adapted for the individual client and their complaint, disorder etc. [change it to suit individual needs
of the patient] (individualize)

Aimed at improving a person's life

Psychotherapy is related to clinical psychology.

counseling and psychotherapy similarities
Healing, safe therapeutic relationship Used with a wide range of adults, children etc.
Both are aimed at understanding a person's behaviour and feelings - Aimed at improving a person's life

Counselling Psychotherapy

Adjustment related problems (more More focussed on chronic and

everyday problems, present recurrent problems [long-term
situations and problems); focussed focus]; past and patterns over a
specific problem period of time [big-picture oriented
intervention

Short term [some months or weeks] Long-term [continuous or intermittent

over many years]

[more supportive, guidance and Focussed on internal thought feelings

education] that lead to personal growth

Neutral role of therapist Active role of therapist

Features of Psychotherapy
- Both client and therapist mutually agree on the goals of the therapy and what they want to
achieve out of it [patient needs to work on themselves as well]
- Collaborative relationship
- Interpersonal relationship
 - Professional relationship [not like friendship or kinship]
- Governed by ethics and boundaries [payment, protection]
- Psychological basis [no religious basis or supernatural basis or physiological basis]
- Remedial in nature rather than preventive

1. Psychoanalysis and Psychodynamic therapy

2. Client-centred therapy- Carl Rogers

3. Existential therapy- Viktor Frankl

4. Gestalt Therapy- Fritz Perls

5. Behavioural therapy

6. CBT

7. Family systems therapy

8. Feminist therapy
9. Narrative therapy
10. Expressive arts therapy [dance movement, art, music therapy]

Based on type of client served

1. Individual therapy

2. Group therapy

3. Family therapy
4. Couples therapy
5. Child therapy

Based on goals of therapy

1. Symptom alleviation/reduction (e.g. behavioural therapy) vs

2. Insight oriented (e.g. Humanistic and psychodynamic therapy)

Based on nature of therapeutic relationship and process of therapy

1. Supportive: responsive [present, hands-on, active]; Defences are usually not challenged and
therapeutic anxiety is not elevated and sought to be minimised; reassurance, advice, praise,
encouragement is used
2. Expressive: neutral [refrain from suggestions, less-active role, listens more] ; defences are
challenged, therapy related anxiety is examined]; not used in this therapy [reassurance, advice,
praise etc]

Psychoanalytic Existential Person-Centred Gestalt Behavioural CBT Family

System
Therapy

Basic Human beings Huma People are Integri We are all a Emphasizes the Human
Assu are n inherently good and ty and product of cognitive beings are
mpt determined by beings have an inherent whole learning, capacity of the always
early have tendency to be ness we are a individual over placed in a
ions experiences, capacit fully-functional. of total of the everything else, system, in
conflicts and y for Mind is the this context,
unconscious self- thinking habits we a family
feeling and have acquired most important,
motives. awareness, faulty thinking system. This
choice, of the mind system
determines

responsibili behaving. through our is responsible how this

ty with interaction for emotional individual
which with and functions in the

comes the behavioural family and with

environment. disturbances.
anxiety, others. Views
guilt and human as
a will for existing within a
meaning. context. Family
provides context
as to how a
person behaves.

Caus Repressed Inauthenti Distortion and denial of Disintegrat Faulty Faulty beliefs Problematic
al and c living self-actualising ion of the learning and schemas. family
Fact unconsciou and an tendency. self [b/c leading to dynamics (too
ors s conflicts inability to self maladaptive rigid or no
developing choose inherently behaviours boundaries,
since life- strives for [wrong role faulty
childhood. affirming wholeness models, communicatio
values and and focussing on n patterns).
guide integration the
one's life ] inability maladaptive
as per to achieve behaviours
those wholeness of the model,
values. and faulty
integration conditioning]
.

Goal Make these Help Help the Integration Eliminatio Teach clients Awareness of
s unconscious identify the client to of the self n of to catch these these
conflicts conscious. barriers to recognise the maladaptiv faulty beliefs dysfunctional
Help these freedom blocks to e [be aware, patterns and
disturbing ideas get and take growth and to behaviours conscious of then create
integrated into the charge of experience and them] and to new ways of
conscious. one's life more learning of contradict the functioning.
choices. fully. adaptive/ faulty beliefs
effective with
behaviours. contradictory
evidence.
 Ther Classical Relationship and Active, Highly
ape Psychoanalysis: qualities of a directive directive
utic Therapist therapist has been therapist. therapist,
Relat typically is given a lot of Acts more like a
ion neutral. Fairly low importance: like a teacher.
ship level of supportive teacher. Therapist
element, much - Authenticity uses
more expressive questioning,
in nature. Socratic
Therapist in the - Respect dialogue.
background,
intended to push - Accurate
the client go empathy
deeper into
oneself. No - Non-judgement
stimulus given by
therapist, has no
- Non-possessive
other option but to warmth
delve into oneself.

Unconditional
The focus is on positive regard and
working with
transference. genuine
relationship.
GENUINENESS is
key, therapist is
seen in their
humanness. The
therapist needs to
express the non-
loving and negative
emotions in an
appropriate way.

Tech Interpretation, Active listening, Reinforceme Socratic Genograms

niq dream analysis, reflection of feelings, nt, shaping, dialogue, [family trees]
ues free association, clarification, being modelling, collaborative showcase
analysis of present with the client, systematic empiricism information
resistance, focus on moment-to- desensitizatio [find evidence about the family
analysis of moment experiencing n, relaxation in reality in tree and the
transference, of the client [expand techniques, support of relations and
counter understanding and flooding, beliefs that a boundaries
transference awareness of the client assertion and patient holds between the
and the therapist of the social skills very dearly] members.
client] [facial training, self- makes the [representation
expressions, energy management patients look of the family
levels, body language, programs, into evidence to dynamics],
tonal differences]- behavioural support their restructuring,
micro processing of rehearsal. beliefs or reframing,
the session; does not Diagnosis is reject/disregard enactments,
include diagnostic made. them [reveal setting
testing or too much irrationality], boundaries,
questioning or homework joining the
probing. assignments family.
Individualised [thought
analysis of the records],
patient's problems learning new
instead of diagnosis. coping skills,
role-playing,
self-
instructional
training, stress
inoculation
training.

Techniques of feminist therapy: Group therapy [group modality], uses consciousness raising
techniques; traditional therapy looks at helping the individual to become adjustive, functional,
productive in the given society- feminist voice is concerned with consciousness raising about
social structures that are limiting, power analysis, gender role analysis, journal writing,
assertiveness training, role-playing, psycho dramatic methods, cognitive restructuring.

BIOLOGICAL THERAPY

Biological treatment for psychopathology can be of three types,

CONVULSIVE THERAPY

The most popular form is ECT. Premised in the idea that agitating the person will change the thing that
has gone wrong in the neurocircuitry of the person

A. Electroconvulsive therapy: Used in rapid, temporary treatment of severe cases or symptom

alleviation where other treatments have not worked at all. Severe depressive illness, catatonia,
prolonged or severe manic episode are the only cases in which it is administered because it
may be life-threatening and no medicine has worked.
Shock therapy, administered in 2 ways; ECT can be administered in one of two ways. In
bilateral ECT, electrodes are placed on either side of the patient’s head, and brief constant-
current electrical pulses of either high or low intensity are passed from one side of the head to
the other for up to about 1.5 seconds. In contrast, unilateral ECT, involves limiting current
flow to one side of the brain, typically the nondominant side (right side, for most people). A
general anesthetic allows the patient to sleep through the procedure, and muscle relaxants are
used to prevent the violent contractions that, in the early days of ECT, could be so severe as to
cause the patient to fracture bones. A bite block is also used to avoid injury to the teeth.
After the ECT session is over, the patient has amnesia for the period immediately preceding
the therapy and is usually somewhat confused for the next hour or so. Normally, a treatment
series consists of fewer than a dozen sessions, although occasionally more are needed.
Treatments are usually administered two or three times per week. Empirical evidence suggests
that bilateral ECT is more effective than unilateral ECT. Unfortunately, bilateral ECT is also
associated with more severe cognitive side effects and memory problems
Every neurotransmitter system is affected by it. Increases the availability of norepinephrine.
However, how ECT works is still not clear. In the face of doubtful effects of its efficacy and
low info about its therapeutic benefits its use has been severely limited in psychiatry and in
very stringent strategies..

B. Transcranial magnetic stimulation (TMS) is a modern form of ECT. This is a treatment

which specifically targets certain parts of the brain. Clinician places a pulsed [charged]
magnet over a carefully selected area of the scalp and it creates an electric field which
increases or decreases the neuronal activity of the specific area. Found to be quite effective in
treating major depression.TMS is less invasive than surgical interventions and has fewer and
less severe side effects than ECT. The most commonly reported side effects from repeated
TMS sessions are mild headache and a small risk of seizure

2. NEUROSURGERY (LOBOTOMIES) (not in syllabus)

PHARMACOLOGICAL TREATMENT

There are several considerations that should be taken by the physicians before they prescribe drugs or
medicines in the treatment of psychological disorders. These should influence the decisions about the
amount, interval between dosages, combination of doses, and others regarding the prescription. Some
of these are as follow,

● There are individual differences in how quickly people’s bodies break down drugs upon their
ingestion.
 ● Knowledge of plasma concentration of drugs after a single dose: The concept of plasma half-life
is useful here. The half-life of a drug in plasma is the time taken for its concentration to fall by a
half, once dosing has ceased.
● It is usually desirable to avoid combinations of psychotropic drugs whenever possible, and in
case a combination is to be used, it is absolutely essential to know the possible interactions of the
drugs and its enhancing or inhibitin effects.

Psychoactive drugs can be classified as,

● Antipsychotics
● Antidepressants
● Mood-stabilizing drugs
● Antianxiety and hypnosedatives
● Anticonvulsants
● Antiparkinsonian drugs
● Misc. drugs such as stimulants, drugs used in the treatment of eating disorders, drugs used in the
treatment of alcohol and drug dependence, anaesthetics, drugs used in the treatment of dementia,
drugs used in child psychiatry, vitamins, calcium, channel blockers, and other drugs

Mechanism of action of pharmacological drugs

Essentially, all psychoactive drugs interfere with or alter how neurons communicate with each other.

The sites which are altered by these drugs include Acetylcholine, dopamine, GABA, glutamate,
histamine, ion channel, lithium-mimetic, melatonin, norepinephrine, opioid, and serotonin.

A drug may act as (10 modes of action):

Receptor agonist,
Receptor partial agonist
Receptor antagonist
Reuptake inhibitor
Reuptake inhibitor and releaser
Reuptake inhibitor and receptor antagonist
Enzyme inhibitor
Ion channel blocker
Positive Allosteric Modulator
Enzyme modulator

They act by interacting with the neurotransmitter by either increasing or decreasing them.
Agonists mimic neurotransmitters and bind themselves to the synapse. They are the drugs that
increase the activity. They are chemicals that mimic a neurotransmitter at the receptor site and
thus strengthen its effect.

Antagonists block neurotransmitters by binding itself to the synapse. They block or impede
the normal activity of a neurotransmitter at the receptor (dopamine)

Inhibitors prevent unused neurotransmitters from being transmitted to the neuron

[functional deficiency] and increase the period for which the neurotransmitters remain in the
synaptic cleft by inhibiting the reuptake process.

1. Antipsychotic Drugs - They are used for drug-induced psychosis, some organic mental
disorders which involving psychotic features, schizophrenia and related disorders, major
depression with psychotic disorders, delusional disorders as well as mania with psychotic
features. Side effects of these generally include weight gain, seizures, constipation, dry
mouth, urinary retention, impotence etc. First generation of these drugs had more side
effects especially motor issues and second generation were found to be better at treating
both positive and negative symptoms with fewer side effects. Eg- phenothiazines,
Thioxanthenes, Butyrophenones

2. Anti-depressants - Antidepressants are mainly used for the treatment of depression, panic
attacks, agoraphobia, social phobia, OCD, PTSD, GAD etc. Most of them work by
increasing the availability of serotonin, norepinephrine or both. They can be
differentiated as categories which include,

Cyclic antidepressants
Monoaminoxidase inhibitors (MAOI)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Norepinephrine Serotonin Inhibitors Enhancers (NSIE)
Noradrenergic and Specific Serotonergic Antagonists (NaSSAs)
Norepinephrine Dopamine Reuptake Inhibitors (NDRIs)
Serotonin Antagonists and Reuptake Inhibitors (SARI)

Out of these, SSRI’s and SNRI’s are most commonly used and are deemed effective.
Their most common side effects may include dry mouth, constipation, impotence, sedation,
jitterness, precipitation of mania, weight gain, fast and irregular heartbeat (tachycardia).

3. Mood Stabilizing Drugs

They are widely used for the treatment of mood swings observed in Bipolar disorders.
Widely used mood-stabilizers include lithium, valporate, carbamazepine and lamotrigine, where
lithium has shown to reduce the risk of suicide in bipolar patients substantially.
Common side effects include tremors, muscular weakness, cogwheel rigidity, seizures,
weight gain, nausea and diarrhea.

4. Anti-anxiety/ Anxiolytics

They are mostly used for anxiety disorders such as GAD, panic disorder, agoraphobia as well as
agitated depression, short term insomnia, as a pre-medication in anaesthesia, for anti-convulsant
use and in the treatment of alcohol and other drug withdrawal symptoms. Common side effects
of anti-anxiety drugs include nausea, vomitting, weakness, diarrhea, blurred vision, dry mouth,
irritability, inhibition of behaviour etc. They can be categorized as-
1. Barbiturates, which are seldom used today except for controlling seizures or as
anaesthesics during ECT. They are shown to produce multiple side effects such as
excessive sedation, respiratory and circulatory depression, dependence and withdrawal.

2. Benzodiazepines are the most popular choice of drugs fo’ the treatment of acute anxiety
and agitation today. They are rapidly absorbed from the digestive tract and work very
quickly and effectively. At lower doses, they help quell anxiety and with higher doses,
act as sleep inducing agents.