Chapter 5: Psychological Disorders and Psychotherapy
For most of human history, people whose minds worked differently were feared rather than helped. Those who saw things that were not there, spoke to people no one else could see, or could not stop weeping were often called “possessed”, and were chained, beaten or starved in the belief that this would drive out evil spirits.
In the 1790s, a French physician named Philippe Pinel walked into the asylums of Paris and noticed something others had missed. These were not monsters or criminals, but unwell people in need of care. Working with the asylum superintendent Jean-Baptiste Pussin, Pinel took a step that shocked his colleagues: he ordered the chains removed from patients who had been shackled for years.
Everyone expected chaos. Instead, many patients grew calmer once they were treated with kindness, allowed to move freely, and spoken to as human beings. Pinel argued that disturbed behaviour is a condition of the mind that can be observed, studied and treated, not a curse to be punished.
That single decision helped shape the modern approach to mental illness: observe carefully, classify honestly, and treat humanely. This chapter walks the same path — from asking what “abnormal” really means, to naming the major disorders, to understanding the therapies used to help.
Diagram
Fig. 5.0-1 – illustration of the late-18th-century asylum reform: a calm physician directing attendants to unlock the chains of a seated patient, other patients standing freely nearby, symbolising the shift from punishment to humane care
Hold on to the five questions below. You may not be able to answer them yet — but you will be able to answer every one of them by the end of this chapter.
5.1 Understanding Abnormal Behaviour
In everyday conversation we call all kinds of things “abnormal” — an odd haircut, a strange hobby, a bad mood on a Monday morning. In psychology the word carries a much narrower and more careful meaning. A psychological disorder, also called a mental disorder, is a pattern of thoughts, feelings and behaviours that is unusual, distressing and disabling enough to interfere with a person’s ordinary life.
The first thing to notice is that there is no sharp line separating “normal” from “abnormal”. Almost every one of us has some quirk, fear or habit that others might find strange. The useful question, then, is not simply whether a behaviour is unusual, but whether it prevents a person from adjusting to and coping with the demands of everyday living.
5.1.1 What Do We Mean by “Abnormal”?
The word abnormal literally means “away from normal” — the prefix ab- means “away from”. But this only pushes the question back a step: what exactly is “normal”?
The Statistical View
One simple answer, the statistical view, says that whatever is rare or uncommon in a population is abnormal. On this view, most people cluster around the middle of any measurement, and those far from the average are “abnormal”.
This cannot be the whole story. A chess grandmaster, a mathematical prodigy or a brilliant classical singer is statistically very rare, yet we would never call them disordered. Rareness by itself simply is not enough to mark a behaviour as a disorder.
The Four Ds
Because rareness alone fails, psychologists look instead for a cluster of features. These are often summarised as the four Ds of abnormality: deviance, distress, dysfunction and danger. As shown in Fig. 5.1-1, the more of these features that are present, and the stronger they are, the more confidently a behaviour is judged to be abnormal.
Deviance refers to behaviour that departs sharply from a society’s norms, rules and shared expectations of what is acceptable.
Distress means that the behaviour causes real suffering, worry or unhappiness — either to the person themselves or to those close to them.
Dysfunction means the behaviour interferes with the person’s ability to carry out ordinary daily activities such as studying, working, or keeping up relationships.
Danger means the behaviour creates a risk of harm to the person themselves or to other people.
Diagram
Fig. 5.1-1 – the four Ds of abnormality shown as four labelled boxes (Deviance, Distress, Dysfunction, Danger), each with an arrow pointing towards a central label “Abnormal behaviour”
No single D is enough on its own. A behaviour that is merely unusual (deviance) but causes no suffering and disrupts nothing is not a disorder. It is the coming together of these features that matters. Behaviour of this kind is described as maladaptive — meaning it works against the person’s own wellbeing and adjustment rather than helping them cope.
5.1.2 Perspectives on Abnormal Behaviour
Knowing that a behaviour is abnormal still does not tell us why it appears. Here the different schools of psychology part ways, each offering its own explanation. These explanations are called perspectives or models.
Broadly, they fall into three families: the biological, the psychological (which itself contains four approaches), and the socio-cultural. Fig. 5.1-2 shows how each points to a different set of causes for the same disturbed behaviour.
Diagram
Fig. 5.1-2 – central label “Abnormal behaviour” with arrows radiating to three perspectives: Biological; Psychological (branching into Psychoanalytic, Behavioural, Humanistic, Cognitive); and Socio-cultural
5.1.2.1 The Biological Perspective
The biological perspective, sometimes called the medical perspective, explains abnormal behaviour in terms of physical problems in the body — especially the brain and nervous system.
It points to causes such as faulty genes and inherited genetic predisposition, imbalances of neurotransmitters (the chemical messengers that carry signals from one nerve cell to the next), hormonal disturbances, infections, and damage to particular brain structures. For example, low activity of the neurotransmitter GABA has been linked to anxiety, while dysfunctions in certain brain regions have been linked to schizophrenia.
The strength of this perspective is that it rests on measurable biology and has produced genuinely effective medicines. Its honest limitation is that it can overlook the role of thinking, learning and social conditions — the same brain chemistry cannot by itself explain why one person copes with a difficulty while another is overwhelmed.
5.1.2.2 The Psychological Perspective
The psychological perspective looks inward — at learning, thinking, emotions and hidden conflict — rather than at the body. It is a family of four related approaches.
Psychoanalytic Approach
Founded by Sigmund Freud, this approach traces abnormal behaviour to unresolved conflicts buried in the unconscious — the part of the mind holding thoughts, memories and desires we are not aware of. These conflicts usually take root in childhood, pitting primitive urges against the demands of conscience and reality.
When such repressed conflicts threaten to surface, they produce anxiety, and the mind’s usual defence mechanisms — the strategies it uses to keep threatening material out of awareness — may fail to hold. The symptoms of a disorder are, on this view, the disguised outbursts of what has been pushed out of sight.
Behavioural Approach
The behavioural approach draws on learning theory: abnormal behaviour is learned, in exactly the same way as normal behaviour. Three kinds of learning are involved.
Through classical conditioning (learning by association, in which a neutral event comes to trigger a response because it has repeatedly occurred alongside another event), a child bitten by a dog may come to fear all dogs. Through operant conditioning (learning shaped by consequences — behaviour followed by reward is repeated, behaviour followed by punishment is dropped), a person who finds that alcohol eases tension may drink more and more. Through observational learning (learning by watching and imitating others), a child may pick up a parent’s fearful reaction to a harmless object.
Because such behaviours are learned, they can in principle be unlearned — a hopeful idea that underlies behaviour therapy later in this chapter.
Humanistic Approach
The humanistic approach centres on the self and the drive to grow. It locates abnormality in incongruence — a gap between the ideal self (the person one wishes to be) and the real self (the person one actually is).
This gap is often widened by conditions of worth — the felt sense that one is acceptable only if one meets other people’s expectations. Blocked from being their true self, and forever falling short of an impossible ideal, the person becomes anxious and unfulfilled.
Cognitive Approach
The cognitive approach locates the cause in faulty thinking. Distorted perceptions, irrational beliefs and negative interpretations of ordinary events leave a person anxious or low. A child whose parents grow busy with a new baby may conclude “they no longer love me” and act out for attention. Repeated over time, such faulty interpretations harden into lasting disturbance.
5.1.2.3 The Socio-cultural Perspective
The socio-cultural perspective looks outward, at society. It argues that abnormal behaviour reflects the pressures and conditions of a person’s social world — poverty, unemployment, discrimination, family conflict, and a lack of education, care or support.
It also reminds us that what counts as abnormal is not fixed but varies from one culture to another.
Bringing the Perspectives Together
No single perspective holds the whole truth. Most psychologists today accept that disorders usually arise from several causes acting together, with biology, learning, thinking and social conditions each playing a part.
A useful way to picture this is the diathesis-stress model. It proposes that a person may carry an inborn or acquired vulnerability — the diathesis, meaning a predisposition — which develops into an actual disorder only when it meets enough environmental stress. Neither the vulnerability nor the stress alone is usually sufficient; it is their combination that tips a person into disorder.
5.2 Classification of Mental Disorders
There are hundreds of ways a mind can be troubled, and many disorders share overlapping features. Without an agreed system for sorting them, no two professionals could be sure they were talking about the same thing. The study and treatment of mental disorders therefore depends on careful classification — the grouping of disorders into named categories with clear, agreed descriptions.
Before a disorder can be classified, though, the professional must first understand the person in front of them. That understanding comes through two steps that this section begins with.
5.2.1 Why Classify Mental Disorders?
When a psychologist or psychiatrist meets a person seeking help, they begin by gathering information — about the difficulties the person is facing, their present life, their past, their relationships and their history. This information-gathering step is called assessment.
The purpose of assessment is diagnosis — identifying which disorder, if any, best fits the person’s pattern of symptoms. To reach a diagnosis, the professional matches the observed cluster of symptoms against the recognised categories in a classification system. This is where classification proves its worth. It matters for several reasons.
First, it provides a common language. When one clinician records a diagnosis, another clinician anywhere can understand exactly what is meant, because both are using the same agreed names and descriptions. Without this, communication between researchers, clinicians and patients would collapse into confusion.
Second, it guides diagnosis and treatment. A precise category tells the professional what other symptoms to look for, how the condition usually develops, and which treatments have worked for similar cases.
Third, it makes research possible. To study a disorder, researchers must be able to gather groups of people who genuinely have the same condition. Shared categories let them assemble such comparable groups and compare findings across studies and countries.
5.2.2 The DSM-IV and Its Five Axes
Two major classification systems are used worldwide. The ICD-10 — the tenth revision of the International Classification of Diseases — is produced by the World Health Organization (WHO) and covers all diseases, not only mental ones. The DSM-IV — the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1994 by the American Psychiatric Association (APA) — deals specifically with mental disorders and is especially widely used by clinicians.
The most distinctive feature of the DSM-IV is its multiaxial system: instead of reducing a person to a single label, it asks the clinician to describe them along five separate axes, each capturing a different side of the picture. Fig. 5.2-1 sets out the five axes together.
Diagram
Fig. 5.2-1 – the DSM-IV multiaxial system shown as five stacked labelled bars, Axis I to Axis V, each with a one-line note on what it records
Axis I — Clinical disorders. This axis records all the major mental disorders except personality disorders and intellectual disability. It covers conditions such as anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, and eating disorders.
Axis II — Personality disorders and intellectual disability. This axis records long-standing personality disorders and intellectual disability (which the DSM-IV labels “mental retardation”). These are placed on a separate axis so that they are not overlooked when attention is drawn to a more obvious Axis I condition.
Axis III — General medical conditions. This axis notes any physical illness the person has, because bodily conditions can cause, worsen or complicate a mental disorder and must be considered in treatment.
Axis IV — Psychosocial and environmental problems. This axis records the social and life stresses affecting the person — such as the loss of a loved one, unemployment, family conflict, poverty, or difficulties with education or housing — that may influence the disorder and its treatment.
Axis V — Global Assessment of Functioning. This axis gives the clinician’s overall rating of how well the person is coping in daily life, recorded on the Global Assessment of Functioning (GAF) scale. It places the person on a continuum from good mental health to severe impairment, which helps in planning treatment and predicting its likely outcome.
Taken together, the five axes make the DSM-IV a convenient framework for organising everything a clinician needs to know, giving a comprehensive picture of a person’s current state rather than a single narrow label.
The system is not perfect. Because classification lists symptoms without always explaining their causes, and because a diagnostic label can encourage stigma and stereotyping, professionals are trained to use these categories as tools to help the person — never as a way of reducing them to a name.
5.3 Anxiety Disorders
Everyone feels anxiety — a general feeling of fear, unease and apprehension about a possible threat. In mild doses it is useful. A little anxiety before an examination sharpens attention and pushes you to prepare. The trouble begins when anxiety becomes excessive, constant and out of all proportion to any real danger, so that it disrupts rather than helps everyday life.
When anxiety reaches that maladaptive level, it may take the form of one of the anxiety disorders. As shown in Fig. 5.3-1, the main forms studied here are generalised anxiety disorder, the phobic disorders, and obsessive-compulsive disorder.
Diagram
Fig. 5.3-1 – a central label “Anxiety disorders” branching into Generalised Anxiety Disorder, Phobic Disorders (specific phobia, social phobia, agoraphobia) and Obsessive-Compulsive Disorder
A word of caution before we begin. The symptoms listed in this section are here to help you understand each disorder, not to diagnose yourself or anyone else. Recognising a symptom in yourself is normal and does not mean you have a disorder. A real diagnosis can be made only by a trained mental health professional after careful assessment — never from a textbook, a checklist or an online quiz.
5.3.1 Generalised Anxiety Disorder (GAD)
Generalised anxiety disorder (GAD) is diagnosed when a person’s worry becomes excessive, chronic and unreasonable, spreading across many areas of life rather than fastening on any one thing. The worry is free-floating: as soon as one concern is settled, another takes its place.
Symptoms
A person with GAD typically shows uncontrollable, excessive worry about a range of everyday events, persisting on most days for more than six months. They find the worry very hard to control and stay constantly on the lookout for signs of threat. Alongside this run restlessness, irritability, being easily fatigued, muscle tension and headaches, difficulty concentrating, and disturbed sleep.
Causes
No single cause explains GAD; several of the perspectives met earlier combine. A family history and the personality trait of neuroticism — a tendency to experience negative emotions readily — raise a person’s vulnerability. Biologically, low activity of the neurotransmitters GABA and serotonin has been linked to persistent anxiety.
On the psychological side, the cognitive view holds that anxious people habitually direct their attention towards threat and interpret even neutral events as dangerous. The psychoanalytic view sees GAD as the overflow of unconscious conflict when defence mechanisms cannot contain it. Finally, a life filled with uncontrollable and unpredictable stress — an unstable job, an unpredictable relationship — makes the disorder more likely.
5.3.2 Phobic Disorders
A phobia is an extreme and irrational fear of a particular object or situation that poses little or no real danger. The fear is out of all proportion to the actual threat, feels uncontrollable, and drives the person to avoid whatever triggers it. Often the person knows the fear is unreasonable, yet cannot overcome it. The DSM-IV groups phobias into three types.
5.3.2.1 Specific Phobia
A specific phobia is an intense, persistent fear of a particular object or situation — such as snakes, dogs, insects, heights, blood, injections, or enclosed spaces. Exposure to the feared thing, or even the mere anticipation of it, sets off an immediate rush of fear and anxiety. The person recognises the fear as excessive but avoids the object at all costs, or endures its presence with great distress.
5.3.2.3 Agoraphobia
Agoraphobia is an extreme fear of places or situations from which escape might be difficult, or in which help might not be available should something go wrong — crowded markets, public transport, open spaces, or being far from home. The person feels trapped or helpless in such places and begins to avoid them. In severe cases they may become unwilling to leave the house at all. Much of the fear centres on experiencing frightening bodily sensations, such as those of a panic attack, in a situation from which they cannot easily withdraw.
Causes of Phobias
The learning view offers the clearest account: phobias are often learned through classical conditioning, when a neutral object comes to be paired with a frightening experience. They can also be acquired indirectly through observational learning, simply by watching someone else react with fear.
Biology and temperament matter too. Children who are shy, timid and easily distressed — described as behaviourally inhibited — are more prone to develop phobias later. The evolutionary view adds the idea of preparedness: we seem biologically primed to fear things that threatened our ancestors, such as snakes and heights, which is why such phobias are so common. For social phobia, the cognitive view stresses the person’s habit of misreading ordinary social events as signs of rejection.
5.3.3 Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder (OCD) is an anxiety disorder built around two linked features. Obsessions are recurring, unwanted and intrusive thoughts, urges or images that force their way into the mind and cause intense anxiety. Compulsions are repetitive behaviours or mental acts — such as washing, checking, ordering, counting or silently repeating words — that the person feels driven to perform in order to reduce that anxiety.
The person usually recognises that the obsessions are their own and that they are excessive, yet cannot stop them. Common examples include an intrusive fear of contamination that drives repeated hand-washing, or a nagging doubt that the door is unlocked that drives repeated checking. The obsessions and compulsions become so time-consuming that they disrupt daily life.
The OCD Cycle
Why do compulsions take such a grip? The answer lies in a self-feeding loop, shown in Fig. 5.3-2. An intrusive obsession triggers anxiety; the compulsion brings a moment of relief; and that relief acts as a reward that makes the person far more likely to repeat the compulsion the next time the thought returns. In the language of learning, the compulsion is reinforced through operant conditioning, so the cycle tightens each time it turns.
Diagram
Fig. 5.3-2 – flow: obsessive thought → rising anxiety → compulsive behaviour → temporary relief → relief reinforces the behaviour → obsessive thought returns (a repeating cycle)
Several causes feed into OCD. Biologically, overactivity in a brain circuit linking the caudate nucleus and the orbitofrontal cortex, together with disturbed serotonin activity, has been implicated, and the disorder tends to run in families. The cognitive view points to thought-action fusion — the mistaken belief that merely having a thought (such as harming someone) is as bad, or as likely, as actually doing it. This belief fuels the anxiety that the compulsions try to quiet.
5.4 Mood Disorders
Our mood is the general emotional tone that colours our experience over hours or days. Everyone’s mood rises and falls — we feel cheerful on a good day and flat on a bad one. These ordinary swings are part of normal life.
Mood disorders are something quite different. Here the disturbance of mood is severe and lasting — a mood pushed to an extreme low, or an extreme high — and it is intense enough to damage the person’s relationships, studies or work. Mood disorders fall into two broad groups: major depressive disorder, in which mood moves in one direction only, and bipolar disorder, in which it swings between two poles.
5.4.1 Major Depressive Disorder
Major depressive disorder, also called severe depression or unipolar depression, is built around at least one major depressive episode — a period of at least two weeks during which the person feels persistently low and loses interest or pleasure in almost everything they do.
Symptoms of Major Depression
The central features are a depressed mood — a feeling of sadness, emptiness and tearfulness — and anhedonia, the loss of the ability to feel pleasure or interest in activities once enjoyed. In children and adolescents, this low mood may show itself as irritability rather than obvious sadness.
Alongside these come feelings of worthlessness, low self-confidence and inappropriate guilt; a marked change in appetite and weight; sleep disturbance, whether difficulty sleeping or sleeping too much; fatigue and loss of energy; and a reduced ability to think or concentrate. In severe cases, recurrent thoughts of death may occur.
Causes of Major Depression
Biologically, depression has been linked to low levels of thyroid hormone and of serotonin, which in turn affects other mood-regulating chemicals such as dopamine and norepinephrine. It also has a strong genetic component: depression is several times more common among the children of parents who have experienced it.
The cognitive view offers two influential accounts. The first is learned helplessness, the giving-up that follows when a person repeatedly meets situations they cannot control and comes to believe that nothing they do will make a difference.
The second cognitive account comes from Aaron Beck, who observed that depressed people are trapped in a negative cognitive triad — a three-part pattern of automatic negative thinking, shown in Fig. 5.4-1. They see themselves as worthless, the world around them as harsh and unloving, and their future as hopeless.
Diagram
Fig. 5.4-1 – Beck’s negative cognitive triad as a triangle with three linked nodes: negative view of the self, negative view of the world, negative view of the future, all feeding into “depression”
Other perspectives add further pieces. The humanistic view sees depression arising when a person, painfully aware of the gap between their ideal and real self, responds with self-criticism instead of adjusting their goals. The behavioural view holds that depression sets in when a person’s behaviour is punished or is no longer positively reinforced. The psychodynamic view traces it to loss and grief, with anger turned inward against the self. Finally, stressful life events — bereavement, divorce, serious illness or financial trouble — often trigger an episode.
5.4.2 Bipolar Disorder
Bipolar disorder, once called manic-depression, is expressed through dramatic shifts of mood between two opposite poles. At one pole is mania — a state of abnormally elevated mood, euphoria and energy. At the other is depression. Episodes of each tend to follow one another in a cyclic pattern, and may last for days, weeks or months.
Fig. 5.4-2 pictures this swing over time, rising above and falling below the person’s ordinary mood.
Diagram
Fig. 5.4-2 – a wavy line of mood plotted against time, rising into a labelled “manic episode” peak and dropping into a labelled “depressive episode” trough, crossing a dashed “normal mood” baseline in between
Symptoms of a Manic Episode
Because the depressive episodes of bipolar disorder resemble those already described, the distinctive features to learn are those of a manic episode.
During mania the mood is persistently elevated or irritable for at least a week. The person is irrationally optimistic and unusually talkative, holds an inflated view of their own powers and importance, needs far less sleep than usual, and is extremely active and energetic. Their thoughts race and jump from one idea to the next, and they are easily distracted. Impaired judgement leads to impulsive involvement in risky but pleasurable activities, such as reckless spending or unwise ventures.
Causes of Bipolar Disorder
The genetic influence in bipolar disorder is even stronger than in unipolar depression; the children of a parent with bipolar disorder are at greater risk of developing it.
Neurochemically, norepinephrine and dopamine activity is raised during manic episodes and lowered during depressive ones, while serotonin activity tends to be low overall. The psychodynamic view interprets mania as a defence of denial — the mind papering over underlying feelings of worthlessness with a burst of forced optimism — which is why the elation eventually collapses back into depression.
5.5 Personality Disorders
Personality is the set of stable, characteristic patterns of thinking, feeling and behaving that make each of us distinctive. These patterns are usually flexible enough to let us adapt to different situations.
A personality disorder appears when this pattern becomes inflexible, extreme and lasting — so rigid that it consistently clashes with the expectations of the person’s social world and disrupts their life. Because the pattern is part of the person’s very character, personality disorders differ from anxiety or mood disorders, which come and go.
The syllabus focuses on three of these disorders, shown together in Fig. 5.5-1.
Diagram
Fig. 5.5-1 – “Personality disorders” branching to three labelled nodes, each with its core feature: Anti-social (disregard for others’ rights); Avoidant (fear of rejection and inadequacy); Dependent (excessive need to be cared for)
5.5.2 Avoidant Personality Disorder
Avoidant personality disorder, sometimes called anxious personality disorder, is marked by a pervasive pattern of social inhibition, deep feelings of inadequacy, and hypersensitivity to being judged. What makes it poignant is that the person often wants closeness but avoids it, held back by the fear of rejection.
Symptoms of Avoidant Personality Disorder
The person imposes social isolation on themselves and is preoccupied with the possibility of being criticised or rejected. They show extreme shyness and anxiety in social situations, driven by a fear of being shamed or ridiculed, and hold a low opinion of themselves. As a result they are reluctant to enter social interactions and keep their relationships few and limited.
Causes of Avoidant Personality Disorder
Genetically, inheritable traits of neuroticism and introversion make a person more prone to the shyness and fearfulness at the core of the disorder. The psychodynamic and environmental view adds that early, repeated experiences of criticism or rejection — from parents or peers — lead the person to adopt avoidance as a defence, keeping others at a distance to protect themselves from further hurt.
5.5.3 Dependent Personality Disorder
Dependent personality disorder, also called asthenic personality disorder, involves a pervasive and excessive need to be taken care of. This leads to clinging, submissive behaviour and a strong fear of separation.
Symptoms of Dependent Personality Disorder
The person finds it very hard to make everyday decisions without a great deal of advice and reassurance, and needs others to take responsibility for the major areas of their life. They struggle to disagree with people for fear of losing support, and find it difficult to start projects on their own.
They will go to considerable lengths to gain care and support, feel helpless or uncomfortable when alone, and — when one close relationship ends — urgently seek another to replace it. Underlying all of this is a preoccupying fear of being left alone and unable to cope.
Causes of Dependent Personality Disorder
Genetically, inheritable traits of neuroticism and agreeableness incline a person towards anxiety and clinging, trusting behaviour. The behavioural and cognitive view points to authoritarian or over-protective parenting that rewards dependence and discourages the child from developing autonomy. Groomed in this way, the child comes to believe they are incapable of managing on their own, and this belief carries into adult life.
Comparing the Three Disorders
5.6 Neurodevelopmental and Childhood Disorders
Some disorders first appear not in adulthood but in early childhood. A neurodevelopmental disorder is a condition that arises while the brain and nervous system are still developing, and it usually affects learning, behaviour, communication or self-control from a young age.
Almost every child is sometimes inattentive, restless or clingy. What turns ordinary childhood behaviour into a disorder is severity and persistence — the behaviour is far greater than is typical for the child’s age, lasts for months, appears in more than one setting, and clearly interferes with the child’s life.
The syllabus covers two neurodevelopmental disorders — ADHD and autism spectrum disorder — and one childhood anxiety disorder, separation anxiety disorder.
5.6.1 Attention Deficit Hyperactivity Disorder (ADHD)
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which a child shows a persistent, age-inappropriate pattern of inattention and, or, hyperactivity and impulsiveness. The signs are usually noticeable before the age of six and appear in more than one situation, such as both at home and at school.
The symptoms fall into two clusters, shown in Fig. 5.6-1.
Diagram
Fig. 5.6-1 – ADHD shown as two symptom clusters side by side: “Inattention” (short attention span, careless mistakes, forgetful, cannot follow instructions) and “Hyperactivity–Impulsiveness” (restless, fidgets, talks excessively, acts without thinking, cannot wait a turn)
Inattention
The child has a short attention span and is easily distracted. They make careless mistakes in schoolwork, seem forgetful and often lose things, cannot stick to tedious or time-consuming tasks, and find it hard to listen to and follow instructions.
Hyperactivity and Impulsiveness
The child cannot keep still or sit quietly, fidgets constantly, and shows excessive physical movement. They talk a great deal, struggle to wait their turn, act without thinking things through, interrupt conversations, and often have a poor sense of danger.
5.6.2 Autism Spectrum Disorder
Autism spectrum disorder is a neurodevelopmental disorder marked by persistent difficulties in social interaction and communication, together with restricted and repetitive patterns of behaviour and interests. It is called a spectrum because it varies enormously in how it affects each child.
Children with autism often find it hard to relate to others and to understand other people’s feelings. They may struggle to start or hold a social interaction, and to express their own emotions or talk about their experiences. Many are delayed in developing speech, or do not develop it, and some repeat the same words or phrases over and over.
Their interests tend to be narrow, and they show repetitive behaviours such as rocking or lining objects up in a row, which may sometimes include self-injurious movements. They are usually insistent on the same routine and environment, become distressed by change, and often dislike loud noises or show unusual responses to everyday sensations.
5.6.3 Separation Anxiety Disorder
Separation anxiety disorder is a childhood anxiety disorder in which a child feels excessive and developmentally inappropriate fear or distress about being separated from home or from the people they are attached to. A little separation anxiety is normal in very young children; it becomes a disorder only when it is far more intense and long-lasting than is usual for the child’s age.
The child experiences extreme distress at the thought of, or during, separation from home or from a caregiver. They worry constantly that something bad will happen — that a parent will come to harm, or that they themselves will be lost or taken away. They may refuse to go to school, resist being alone or sleeping away from a caregiver, have repeated nightmares about separation, and complain of physical symptoms such as headaches or stomach-aches when a separation is coming.
5.7 Schizophrenia
Schizophrenia is one of the most serious, and most misunderstood, of all psychological disorders. It is a condition in which a person gradually loses contact with reality, so that their thoughts, perceptions, emotions and behaviour no longer fit the world around them.
5.7.1 The Nature of Schizophrenia
At the heart of schizophrenia lies a loss of contact with reality. A person may perceive things that are not there, or hold beliefs that no evidence can shake, and their thinking and communication grow increasingly confused. Alongside this comes a steady decline in the ability to work, study and relate to others.
Schizophrenia usually develops slowly, and is often diagnosed only after a long period, because its outward signs emerge gradually. Not every symptom appears in every person; instead, the symptoms turn up in different combinations. To make sense of this variety, the DSM-IV groups the symptoms into two families — positive and negative.
5.7.2 Positive and Negative Symptoms
The distinction between positive and negative symptoms is not about “good” and “bad”. Positive symptoms are experiences or behaviours that are added — present in the person although normally absent in everyone else. Negative symptoms are normal abilities that are lost or reduced. Fig. 5.7-1 sets the two families side by side.
Diagram
Fig. 5.7-1 – schizophrenia symptoms in two columns: “Positive symptoms” (delusions, hallucinations, disorganised thinking and speech, bizarre motor behaviour) and “Negative symptoms” (social withdrawal, avolition, affective flattening, anhedonia, alogia)
Positive Symptoms
Delusions are firmly held, rigid false beliefs that have no basis in reality — for example, a person may be convinced that someone is spying on them. Hallucinations are vivid sensory experiences of something that is not actually present; the most common are auditory, such as hearing imaginary voices that comment on the person’s actions or give them commands.
Disorganised thinking and speech show up as a jumping from one unconnected idea to another — a loosening of associations, or derailment — so that in severe cases the speech becomes incoherent. The person may invent new words with no shared meaning (neologisms), or, at the extreme, produce a jumble of unconnected words known as word salad.
Bizarre motor behaviour is grouped under the umbrella term catatonia, and ranges from far too little movement to far too much — odd repetitive actions, strange fixed postures, or the senseless imitation of other people.
Negative Symptoms
Social withdrawal is a loss of concern for the social world; the person may neglect hygiene and remain silent and cut off from others. Avolition is a loss of motivation or drive, so that even simple tasks are never begun or finished.
Affective flattening is a marked reduction in emotional expression, leaving the face and voice apathetic and unresponsive. Anhedonia, the loss of the ability to feel pleasure, is common too, and alogia shows as a poverty of speech — brief, empty, one-word replies.
5.7.3 Types of Schizophrenia
The DSM-IV describes several forms of schizophrenia. The syllabus focuses on three main types, each dominated by a different cluster of symptoms.
5.7.3.1 Paranoid Schizophrenia
Paranoid schizophrenia is the most common form, marked by a high level of suspicion and mistrust of others. It is dominated by well-organised delusions and hallucinations, while the person’s thinking, emotions and attention remain comparatively intact.
The delusions are often of two kinds. A delusion of persecution is the belief that one is being plotted against, followed or poisoned. A delusion of grandeur is the belief that one is a specially powerful, wealthy or famous person. Because their other mental abilities are relatively preserved, the person can build these delusions into elaborate, though illogical, systems of belief.
5.7.3.2 Disorganized Schizophrenia
Disorganized schizophrenia, also called hebephrenia, centres on disorganised thought and speech, disorganised or inappropriate behaviour, flattened or inappropriate emotion, and a gradual social withdrawal.
The person’s speech may show loosening of associations, echolalia (mechanically repeating words that others have just said), or even baby talk. Their behaviour becomes grossly disorganised, so that ordinary self-care such as bathing and dressing breaks down. Their emotional responses are frequently inappropriate — giggling for no reason, or reacting to sad news with laughter.
5.7.3.3 Catatonic Schizophrenia
Catatonic schizophrenia is marked by unusual disturbances of movement. In catatonic stupor the person becomes immobile and mute, and may hold a fixed, odd posture for hours (catalepsy), resisting any attempt to move them. In waxy flexibility, their limbs can be moved by another person into a position, which they then hold in place.
At the opposite extreme, catatonic excitement is a burst of excessive, aimless activity. The person may also show negativism, stubbornly resisting or refusing instructions, and may senselessly repeat other people’s words (echolalia) or imitate their movements (echopraxia).
Comparing the Three Types
5.8 Psychotherapy
Recognising a disorder is only half the story. The other half is helping the person recover — and this is where psychotherapy comes in. It is the treatment that the chapter opener’s reformer, Pinel, was reaching towards when he chose care over chains.
5.8.1 What Is Psychotherapy?
Psychotherapy is the treatment of psychological disorders by psychological means rather than by medicine or surgery. It works through a structured, confidential relationship between a trained professional and the person seeking help, and is often described simply as a “talking treatment”.
Whatever its form, psychotherapy sets out to offer the person a safe and supportive space to voice their problems, to understand how past experiences shape present difficulties, to restore their ability to make decisions, to heal emotional wounds, and to build skills for coping with life’s stresses.
Because psychologists disagree about what causes disorders, they have developed different families of therapy, each aimed at a different assumed cause. We shall look at four: psychodynamic, client-centred, behavioural and cognitive behaviour therapy.
5.8.2 Psychodynamic Therapy
Psychodynamic therapy, also called psychoanalysis, grows out of Freud’s theory that disorders spring from unresolved conflicts buried in the unconscious. Its central goal is to make the unconscious conscious — to bring hidden conflicts into the open, where the person can finally understand and release them.
Freud pictured personality as having three parts: the id, which seeks immediate satisfaction; the ego, which balances these urges against reality; and the superego, the moral conscience. When the ego pushes unacceptable urges out of sight into the unconscious, the unresolved conflict remains and later resurfaces as symptoms. Therapy aims to uncover this buried material.
The Techniques of Psychoanalysis
In free association, the client relaxes, often on a couch, and says whatever comes into their mind — however trivial, illogical or embarrassing — without holding anything back. By tracing the connections between these free-flowing ideas, the therapist gathers clues to the unconscious.
In dream analysis, dreams are treated as symbolic expressions of unconscious wishes. The therapist looks beneath the manifest content (the actual story of the dream as remembered) to reach the latent content (its hidden, underlying meaning).
Resistance is the client’s unconscious unwillingness to face threatening material. They may suddenly fall silent, change the subject, or miss an appointment — a sign, paradoxically, that the therapy is nearing something important.
Transference occurs when the client unconsciously redirects feelings once held towards a significant person, such as a parent, onto the therapist, who becomes a stand-in for that figure. In counter-transference, the reverse happens: the therapist projects their own feelings onto the client.
Diagram
Fig. 5.8-1 – two facing figures labelled “Client” and “Therapist”: an arrow from client to therapist labelled “Transference” (feelings for a significant person redirected onto the therapist) and an arrow from therapist to client labelled “Counter-transference” (the therapist’s own feelings projected onto the client)
Strengths and Limitations
Psychoanalysis was the first great system of psychotherapy and remains influential. But it is often criticised as lengthy, expensive and subjective, with little hard evidence for its claims, and for dwelling on the distant past rather than the person’s present difficulties.
5.8.3 Client-centred Therapy
Client-centred therapy, also called person-centred therapy, was developed by the humanist Carl Rogers. Rogers believed that everyone has an inborn self-actualising tendency — a drive to grow and fulfil their potential — and that disorders arise when conditions of worth create incongruence between the ideal and real self.
Notice Rogers’s choice of the word “client” rather than “patient”. A patient is sick and waits to be cured; a client is an active partner seeking help to solve their own difficulties. In this therapy the therapist is not an expert who directs, but a facilitator who guides — an approach called non-directive counselling. The aim is to reduce incongruence, raise the client’s sense of self-worth, and help them become a fully functioning person who lives openly and true to themselves.
The Core Conditions
Rogers held that three attitudes in the therapist make growth possible.
The first is unconditional positive regard — accepting and valuing the client completely, without judgement and without conditions, so that they feel safe enough to be honest.
The second is empathy, or empathetic understanding — sensing the client’s feelings accurately, seeing the world as they see it, and communicating that understanding back to them. In practice this involves active listening (giving the client full, attentive focus) and paraphrasing (reflecting back what they have said, to show it has been understood).
The third is genuineness — the therapist being real and honest rather than hiding behind a professional mask, which lets the client relate to them as one living person to another.
Together these conditions create a warm, accepting relationship in which the client feels free to explore their feelings and, exercising their own free will, to change in the directions they choose.
5.8.4 Behavioural Therapy
Behavioural therapy rests on a simple, hopeful premise: because maladaptive behaviour is learned, it can also be unlearned. Rather than digging into the past, it concentrates on changing present behaviour, drawing on classical conditioning, operant conditioning and observational learning.
5.8.4.1 Techniques Based on Classical Conditioning
These techniques work by breaking the learned association between a stimulus and an unwanted response such as fear.
In flooding, also called implosion therapy, the person is exposed directly and at full intensity to the feared object or situation, within a safe and controlled setting, and kept there until the anxiety subsides on its own. This works because fear responses are time-limited — they cannot stay at their peak forever. A new association forms: the feared object now leads to no harm and no anxiety. Because it is so intense, flooding is used with caution and is unsuitable for people with certain conditions such as heart disease.
In systematic desensitization, the same exposure happens, but slowly and gently. First the person learns deep muscle relaxation. Next they build a fear hierarchy — a ladder of feared situations from the mildest to the most frightening, as shown in Fig. 5.8-2. Then, staying relaxed, they work up the ladder one step at a time, because relaxation and anxiety cannot coexist. Each step is repeated until it no longer stirs any fear.
Diagram
Fig. 5.8-2 – a “fear hierarchy” shown as a ladder for a spider phobia, rising from the least feared step (thinking about a spider) through intermediate steps (looking at a photo, seeing a real spider in a box) to the most feared step at the top (letting a spider crawl on the hand), each rung paired with relaxation
5.8.4.2 Techniques Based on Operant Conditioning
These techniques change behaviour by managing its consequences.
In shaping, a new and desired behaviour is built up gradually by rewarding successive approximations — each small step that comes closer to the target behaviour is reinforced until the whole behaviour is learned. It is especially useful for teaching new skills.
In a token economy, desired behaviours earn tokens, which can later be exchanged for agreed privileges or rewards such as extra outings or treats. The exact value of each behaviour is stated clearly in advance. Fig. 5.8-3 shows the cycle. Token economies are widely used by parents and teachers, and in rehabilitation settings, to build and maintain healthy behaviour.
Diagram
Fig. 5.8-3 – the token economy cycle as four linked stages: the person shows the desired behaviour → earns a token → collects tokens → exchanges tokens for a chosen privilege or reward, which reinforces the behaviour
5.8.4.3 Modelling
Modelling is based on Bandura’s social learning theory, which holds that we learn by observing and imitating others. In this technique the client learns new skills, or unlearns fears, by watching a model perform the desired behaviour — for instance, watching someone handle a feared object calmly, and then copying it. Modelling is often used to teach everyday skills and to reduce specific fears.
5.8.5 Cognitive Behaviour Therapy (CBT)
Cognitive behaviour therapy (CBT), popularised by Albert Ellis and Aaron Beck, is one of the most widely used therapies today, prized for working well in a short time. It begins from the idea that distress flows not from events themselves but from the irrational thoughts and beliefs through which we interpret them. CBT combines the reshaping of these thoughts with practical behavioural techniques.
Albert Ellis captured this in his Rational Emotive Therapy (RET) and its A-B-C-D-E model, shown in Fig. 5.8-4.
The A, activating event, is the situation or trigger. The B, belief, is what the person believes about that event — a belief that may be rational or irrational. The C, consequence, is the emotional and behavioural result; irrational beliefs lead to unhealthy consequences such as anxiety, depression or anger. The D, disputing, is the therapist’s active challenging of the irrational belief, questioning how valid it really is and looking for evidence against it. The E, expected new behaviour, is what follows if disputing succeeds: the irrational belief is replaced by a rational one, and a healthier emotion and response take its place.
Diagram
Fig. 5.8-4 – flow of Ellis’s A-B-C-D-E model: Activating event → Belief (rational or irrational) → Consequence (emotion and behaviour) → Disputing the irrational belief → Expected new behaviour (a healthier emotion and response)
Aaron Beck’s cognitive therapy makes a similar point. Beck argued that unpleasant childhood experiences can leave a person with a negative core schema — a deep, distorted way of seeing themselves and the world that colours everything negatively. Through gentle, non-threatening questioning, the therapist helps the client identify and reshape these thoughts, a process called cognitive restructuring, which lifts depression and anxiety.
5.10 Summary
There is no sharp line between normal and abnormal behaviour. Behaviour is judged abnormal not because it is rare, but when it clusters the four Ds — deviance, distress, dysfunction and danger — and so becomes maladaptive.
Abnormal behaviour is explained through several perspectives: the biological (genes, neurotransmitters, brain problems), the psychological — with its psychoanalytic, behavioural, humanistic and cognitive approaches — and the socio-cultural. The diathesis-stress model ties them together: a vulnerability develops into a disorder only when it meets enough stress.
Assessment gathers information about a person, and diagnosis matches their symptoms against a classification system. Classification gives a shared language, guides treatment and supports research.
Two systems dominate: the ICD-10 (WHO) and the DSM-IV (APA), which the ISC course follows. The DSM-IV is multiaxial, assessing a person on five axes — clinical disorders; personality disorders and intellectual disability; general medical conditions; psychosocial and environmental problems; and overall functioning (GAF).
Anxiety is adaptive in small amounts but becomes a disorder when it is excessive, chronic and unreasonable. Generalised anxiety disorder is uncontrollable, wide-ranging worry lasting over six months.
A phobia is an intense, irrational fear leading to avoidance; the DSM-IV recognises specific phobia, social phobia and agoraphobia. Obsessive-compulsive disorder pairs intrusive obsessive thoughts with repetitive compulsions in a self-feeding cycle of anxiety and relief.
Mood disorders involve severe, lasting disturbances of mood. Major depressive disorder centres on a two-week episode of low mood and loss of pleasure (anhedonia); its causes include low serotonin, learned helplessness (Seligman) and the negative cognitive triad (Beck).
Bipolar disorder is marked by cyclic swings between manic episodes — elevated mood, high energy, racing thoughts, risky behaviour — and depressive episodes.
Personality disorders are enduring, inflexible and extreme patterns of character. The three studied are anti-social (disregard for others’ rights), avoidant (social inhibition and fear of rejection) and dependent (an excessive need to be cared for).
Some disorders appear in childhood. ADHD combines inattention with hyperactivity and impulsiveness; autism spectrum disorder involves difficulties in social interaction and communication with restricted, repetitive behaviour; separation anxiety disorder is excessive, developmentally inappropriate distress at separation.
Schizophrenia is a severe loss of contact with reality — not a “split personality”. Its positive symptoms are added experiences (delusions, hallucinations, disorganised thought and speech, bizarre movement); its negative symptoms are lost abilities (social withdrawal, avolition, affective flattening, anhedonia, alogia).
The three main types of schizophrenia are paranoid (organised delusions of persecution or grandeur), disorganized or hebephrenic (disorganised thought, speech and behaviour, inappropriate affect) and catatonic (disturbances of movement such as stupor, waxy flexibility and excitement).
Psychotherapy treats disorders by psychological means through a confidential relationship. Psychodynamic therapy makes the unconscious conscious using free association, dream analysis, and the handling of resistance, transference and counter-transference.
Client-centred therapy (Rogers) is non-directive and rests on three therapist conditions — unconditional positive regard, empathy and genuineness — to reduce incongruence and help the person become fully functioning.
Behavioural therapy assumes maladaptive behaviour is learned and can be unlearned. Classical-conditioning techniques include flooding and systematic desensitization; operant techniques include shaping and token economy; and modelling teaches behaviour through observation.
Cognitive behaviour therapy holds that distress comes from irrational beliefs, not events. Ellis’s Rational Emotive Therapy follows the A-B-C-D-E model — activating event, belief, consequence, disputing and expected new behaviour — while Beck’s cognitive therapy reshapes negative core schemas through cognitive restructuring.
Psychosocial rehabilitation is a multidisciplinary approach that rebuilds the skills and social life eroded by long-term illness. Its components include deinstitutionalisation, social inclusion, occupational therapy, social skills training, vocational rehabilitation, and cognitive retraining, all aimed at independent living in the community.
5.11 Key Terms
- A-B-C-D-E model — Ellis’s five-step framework in RET: activating event, belief, consequence, disputing the irrational belief, and expected new behaviour.
- Active listening — giving a client full, attentive focus so they feel genuinely heard.
- Affective flattening — a negative symptom of schizophrenia; a marked reduction in emotional expression.
- Agoraphobia — an intense fear of places or situations from which escape or help would be difficult, leading to avoidance.
- Alogia — a negative symptom of schizophrenia; poverty of speech, giving only brief, empty replies.
- Anhedonia — the loss of the ability to feel pleasure or interest in activities once enjoyed.
- Anti-social personality disorder — a lasting pattern of disregard for, and violation of, the rights of others, with little remorse.
- Anxiety — a state of fear, worry and apprehension about a possible future threat.
- Assessment — the gathering of information about a person’s difficulties, history and functioning.
- Attention deficit hyperactivity disorder (ADHD) — a neurodevelopmental disorder marked by age-inappropriate inattention and, or, hyperactivity and impulsiveness.
- Autism spectrum disorder — a neurodevelopmental disorder marked by difficulties in social interaction and communication, with restricted, repetitive behaviour.
- Avoidant personality disorder — a lasting pattern of social inhibition, feelings of inadequacy and hypersensitivity to rejection.
- Avolition — a negative symptom of schizophrenia; a loss of motivation to begin or finish tasks.
- Biological perspective — the view that abnormal behaviour arises from physical causes such as genes, neurotransmitters and brain problems.
- Bipolar disorder — a mood disorder with cyclic swings between manic and depressive episodes.
- Catalepsy — holding a fixed, odd bodily posture for a long time, seen in catatonic schizophrenia.
- Catatonia — an umbrella term for the disturbed motor behaviour seen in schizophrenia, from stupor to excited movement.
- Catatonic excitement — a burst of excessive, aimless movement in catatonic schizophrenia.
- Catatonic schizophrenia — a type of schizophrenia dominated by disturbances of movement.
- Catatonic stupor — a state of immobility and muteness in catatonic schizophrenia.
- Classical conditioning — learning by association, in which a neutral event comes to trigger a response through repeated pairing.
- Classification — the grouping of disorders into named categories with agreed descriptions.
- Client-centred therapy — Rogers’s non-directive therapy that uses acceptance, empathy and genuineness to help a person grow.
- Cognitive behaviour therapy (CBT) — a therapy that eases distress by reshaping irrational beliefs alongside behavioural techniques.
- Cognitive restructuring — the process, in Beck’s therapy, of identifying and reshaping negative patterns of thought.
- Cognitive retraining — rehabilitation that rebuilds mental abilities such as attention, memory and problem-solving.
- Compulsions — repetitive behaviours or mental acts performed to reduce the anxiety caused by obsessions.
- Conditions of worth — the felt sense that one is acceptable only if one meets other people’s expectations.
- Core schema — a deep, distorted way of seeing oneself and the world, formed from early experience (Beck).
- Counter-transference — the therapist’s projection of their own feelings onto the client.
- Danger — one of the four Ds; behaviour that risks harm to the self or others.
- Defence mechanisms — mental strategies the mind uses to keep threatening material out of awareness.
- Deinstitutionalisation — bringing a person out of long-term institutional care and back into community life with support.
- Delusion of grandeur — a false belief that one is specially powerful, wealthy or famous.
- Delusion of persecution — a false belief that one is being plotted against, followed or harmed.
- Delusions — firmly held false beliefs with no basis in reality.
- Dependent personality disorder — a lasting pattern of excessive need to be cared for, with clinging, submissive behaviour.
- Derailment — a slipping from one unconnected idea to another in disorganised speech.
- Deviance — one of the four Ds; behaviour that departs sharply from social norms.
- Diagnosis — identifying the disorder that best fits a person’s cluster of symptoms.
- Diathesis-stress model — the view that a disorder develops when a predisposition (vulnerability) meets enough stress.
- Disorganized schizophrenia — a type of schizophrenia (hebephrenia) marked by disorganised thought, speech and behaviour and inappropriate affect.
- Distress — one of the four Ds; suffering caused by the behaviour to oneself or others.
- Dream analysis — a psychodynamic technique interpreting dreams as symbolic expressions of unconscious wishes.
- DSM-IV — the fourth edition of the American Psychiatric Association’s manual, using a five-axis system to classify mental disorders.
- Dysfunction — one of the four Ds; interference with the ability to carry out everyday activities.
- Echolalia — mechanically repeating words that others have just said.
- Echopraxia — senselessly imitating another person’s movements.
- Ego — the part of personality that balances the id’s urges against reality.
- Empathy — accurately sensing and understanding a client’s feelings, and conveying that understanding.
- Flooding — a behavioural technique of full-intensity exposure to a feared object until the anxiety subsides.
- Four Ds — the four features used to judge abnormality: deviance, distress, dysfunction and danger.
- Free association — a psychodynamic technique in which the client says whatever comes to mind without censoring.
- Fully functioning person — Rogers’s term for someone who lives openly and true to themselves, the goal of client-centred therapy.
- Generalised anxiety disorder (GAD) — excessive, uncontrollable, wide-ranging worry lasting for more than six months.
- Genetic predisposition — an inherited tendency that makes a disorder more likely.
- Genuineness — the therapist being real and honest rather than hiding behind a professional mask.
- Global Assessment of Functioning (GAF) — a scale rating a person’s overall level of everyday functioning.
- Hallucinations — sensory experiences of things that are not actually present, such as hearing voices.
- Hebephrenia — another name for disorganized schizophrenia.
- ICD-10 — the World Health Organization’s classification of all diseases, including mental disorders.
- Id — the part of personality that seeks immediate satisfaction of urges.
- Ideal self — the person one wishes to be.
- Incongruence — a gap between the ideal self and the real self.
- Latent content — the hidden, underlying meaning of a dream.
- Learned helplessness — the giving-up that follows repeated exposure to situations one cannot control (Seligman).
- Loosening of associations — a disorganised jumping between unconnected ideas in thought and speech.
- Major depressive disorder — a mood disorder built around a two-week episode of low mood and loss of pleasure.
- Maladaptive — working against a person’s own wellbeing and adjustment.
- Mania — a state of abnormally elevated mood, euphoria and energy.
- Manifest content — the actual, remembered story of a dream.
- Mental disorder — a pattern of thoughts, feelings and behaviours abnormal and disabling enough to impair everyday life.
- Modelling — a behavioural technique of learning by observing and imitating a model.
- Mood — the general emotional tone that colours experience over time.
- Mood disorders — disorders involving severe, lasting disturbances of mood.
- Multiaxial system — the DSM-IV’s method of describing a person along five separate axes.
- Negative cognitive triad — Beck’s pattern of negative thinking about the self, the world and the future in depression.
- Negative symptoms — symptoms of schizophrenia in which normal abilities are lost or reduced.
- Negativism — stubbornly resisting or refusing instructions, seen in catatonic schizophrenia.
- Neologisms — invented words with no shared meaning, seen in disorganised speech.
- Neurodevelopmental disorder — a condition arising as the brain develops, appearing early in childhood.
- Neuroticism — a personality trait describing a tendency to experience negative emotions such as anxiety.
- Neurotransmitters — chemical messengers that carry signals between nerve cells.
- Non-directive counselling — a style in which the therapist guides rather than directs the client.
- Observational learning — learning by watching and imitating others.
- Obsessions — recurrent, unwanted, intrusive thoughts or images that cause anxiety.
- Obsessive-compulsive disorder (OCD) — an anxiety disorder pairing intrusive obsessions with anxiety-reducing compulsions.
- Occupational therapy — rehabilitation through meaningful, adapted activities such as work, self-care and leisure.
- Operant conditioning — learning shaped by consequences, with rewarded behaviour repeated and punished behaviour dropped.
- Paranoid schizophrenia — the most common type, dominated by delusions and hallucinations with relatively preserved thinking.
- Paraphrasing — reflecting a client’s words back to show they have been understood.
- Personality — the stable, characteristic patterns of thinking, feeling and behaving that make a person distinctive.
- Personality disorder — a lasting, inflexible and extreme pattern of character that deviates from social expectations.
- Phobia — an intense, irrational fear of an object or situation that leads to avoidance.
- Positive symptoms — symptoms of schizophrenia in which experiences are added that are normally absent.
- Preparedness — the idea that we are biologically primed to fear things that once threatened our ancestors.
- Psychological disorder — a disabling pattern of abnormal thoughts, feelings and behaviour; the same as a mental disorder.
- Psychological perspective — the view that abnormal behaviour arises from mental processes such as learning, thinking and unconscious conflict.
- Psychosocial rehabilitation (PSR) — a multidisciplinary approach that rebuilds skills and social life after long-term illness.
- Psychotherapy — the treatment of psychological disorders by psychological means through a professional relationship.
- Rational Emotive Therapy (RET) — Ellis’s cognitive therapy that disputes irrational beliefs using the A-B-C-D-E model.
- Real self — the person one actually is.
- Resistance — a client’s unconscious blocking of threatening material during therapy.
- Schizophrenia — a severe disorder marked by loss of contact with reality.
- Separation anxiety disorder — a childhood disorder of excessive, developmentally inappropriate distress at separation.
- Shaping — building a new behaviour by rewarding successive steps towards it.
- Social inclusion — establishing people with mental illness as accepted, respected members of society.
- Social phobia — an intense fear of social situations in which one might be judged.
- Social skills training — teaching communication and relationship skills for community life.
- Social withdrawal — a negative symptom of schizophrenia; loss of concern for the social world.
- Socio-cultural perspective — the view that abnormal behaviour reflects social pressures and cultural norms.
- Specific phobia — an intense fear of a particular object or situation, such as animals or heights.
- Superego — the moral conscience of personality.
- Systematic desensitization — a behavioural technique of gradual, relaxed exposure up a fear hierarchy.
- Thought-action fusion — the belief that merely having a thought is as bad, or as likely, as acting on it.
- Token economy — an operant technique in which desired behaviours earn tokens exchangeable for rewards.
- Transference — a client’s redirection of feelings for a significant person onto the therapist.
- Unconditional positive regard — accepting and valuing a client completely, without judgement or conditions.
- Unconscious — the part of the mind holding thoughts and desires we are not aware of.
- Vocational rehabilitation — helping a person return to work or learn a skill, with job training and support.
- Waxy flexibility — a catatonic symptom in which limbs stay in whatever position they are placed.
- Word salad — a jumble of unconnected words in severely disorganised speech.
5.12 Points to Ponder
If what counts as “abnormal” shifts from one culture to another, can there ever be a truly universal definition of mental disorder — or is every diagnosis partly a judgement about a society’s expectations?
A diagnosis can bring relief and open the door to help, yet it can also become a label that follows a person for life. When does naming a disorder help someone, and when might it harm them?
The same depression might be explained by low serotonin, by learned helplessness, or by a life full of loss. If several perspectives each explain it in part, does choosing one over another change what counts as the “right” treatment?
Client-centred therapy assumes people can heal themselves given the right conditions, while behavioural therapy assumes behaviour is shaped by conditioning. Which view of human nature do you find more convincing, and why?
A little anxiety helps us prepare and stay safe, yet too much becomes a disorder. Where should the line be drawn between a useful emotion and an illness — and who should get to decide where it falls?
Pinel removed the chains more than two centuries ago, yet the stigma around mental illness still persists. Why might people’s attitudes change so much more slowly than their treatments — and what might finally shift them?
5.13 Objective Questions
- The “four Ds” used to identify abnormal behaviour are deviance, distress, dysfunction and — [1 mark]
- danger
- discipline
- denial
- diagnosis
- The classification system followed in this course, which describes a person along five axes, is the — [1 mark]
- ICD-10
- DSM-IV
- DSM-5
- ICD-11
- On which axis of the DSM-IV are personality disorders and intellectual disability recorded? [1 mark]
- Axis I
- Axis II
- Axis III
- Axis V
- In obsessive-compulsive disorder, the intrusive unwanted thoughts are obsessions, while the repetitive acts done to relieve them are called — [1 mark]
- delusions
- compulsions
- hallucinations
- phobias
- A firmly held false belief that one is being plotted against or followed is a — [1 mark]
- hallucination
- delusion of grandeur
- delusion of persecution
- neologism
- Catatonic stupor and waxy flexibility are symptoms most associated with — [1 mark]
- paranoid schizophrenia
- catatonic schizophrenia
- disorganized schizophrenia
- bipolar disorder
- The psychodynamic technique in which the client relaxes and says whatever comes to mind, without censoring, is — [1 mark]
- systematic desensitization
- free association
- token economy
- modelling
- In Ellis’s A-B-C-D-E model, the letter D stands for — [1 mark]
- diagnosis
- disputing
- danger
- delusion
For questions 9 to 12, choose the correct option: a. Both A and R are true, and R is the correct explanation of A. b. Both A and R are true, but R is not the correct explanation of A. c. A is true, but R is false. d. A is false, but R is true.
Assertion (A): A statistically rare behaviour is not necessarily abnormal. Reason (R): Abnormality is judged by the clustering of the four Ds, not by rarity alone. [1 mark]
Assertion (A): In systematic desensitization the client is first taught deep muscle relaxation. Reason (R): Relaxation and anxiety cannot be experienced at the same time. [1 mark]
Assertion (A): Rogers deliberately used the word “client” rather than “patient”. Reason (R): He saw the person as an active partner in change rather than someone passively waiting to be cured. [1 mark]
Assertion (A): Schizophrenia means that a person has two or more separate personalities. Reason (R): The word schizophrenia comes from Greek roots meaning “split” and “mind”. [1 mark]
Match the psychologist in Column A with their contribution in Column B. [1 mark]
| Column A | Column B |
|---|---|
| a. Carl Rogers | i. Rational Emotive Therapy |
| b. Albert Ellis | ii. Free association |
| c. Aaron Beck | iii. Client-centred therapy |
| d. Sigmund Freud | iv. Negative cognitive triad |
- Match the symptom in Column A with its meaning in Column B. [1 mark]
| Column A | Column B |
|---|---|
| a. Anhedonia | i. poverty of speech |
| b. Avolition | ii. loss of pleasure |
| c. Alogia | iii. a false sensory experience |
| d. Hallucination | iv. loss of motivation |
Fill in the blank: The negative symptom of schizophrenia marked by a loss of motivation to begin or finish tasks is called ______. [1 mark]
Fill in the blank: According to the ______ model, a disorder develops only when an inborn or acquired vulnerability meets enough environmental stress. [1 mark]
True or False: Flooding exposes a person to a feared object gradually, one small step at a time. [1 mark]
True or False: In a token economy, desired behaviours earn tokens that can later be exchanged for agreed privileges or rewards. [1 mark]
5.14 Check Your Concepts
Define abnormal behaviour and name the four Ds used to identify it. [2 marks] (about 30 words)
What is meant by a phobia? Give one example. [2 marks] (about 30 words)
Name the three main types of schizophrenia and state the dominant feature of each. [2 marks] (about 30 words)
State any two purposes served by classifying mental disorders. [2 marks] (about 30 words)
Differentiate between an obsession and a compulsion. [3 marks] (about 60 words)
Differentiate between the positive and negative symptoms of schizophrenia, giving one example of each. [3 marks] (about 60 words)
Explain briefly the three core conditions that Rogers believed a therapist must offer in client-centred therapy. [3 marks] (about 60 words)
Why is a statistically rare behaviour not necessarily abnormal? Give reasons for your answer. [3 marks] (about 60 words)
Explain the two behavioural techniques based on classical conditioning — flooding and systematic desensitization. [4 marks] (about 100 words)
Describe the main clinical features (symptoms) of a major depressive episode. [4 marks] (about 100 words)
Explain, with an example, how obsessive-compulsive disorder is kept going through a cycle of anxiety and relief. [4 marks] (about 100 words)
Describe the five axes of the DSM-IV, and explain why this multiaxial approach gives a fuller picture of a person than a single label. [6 marks] (about 150 words)
Discuss Ellis’s Rational Emotive Therapy, explaining each step of the A-B-C-D-E model with the help of an example. [6 marks] (about 150 words)
Compare and contrast the psychodynamic and client-centred approaches to psychotherapy, referring to their aims, their view of the therapist’s role, and their techniques. [6 marks] (about 150 words)
Describe the main components of psychosocial rehabilitation and discuss how they help a person with long-term mental illness return to life in the community. [6 marks] (about 150 words)
5.15 Case-Based Questions
- Kabir, a Class XII student, is troubled by a repeated thought that he has forgotten to lock his cupboard, even moments after locking it. He checks the lock again and again, sometimes ten or more times, before he can settle. Each check calms him briefly, but the thought soon returns, and the checking now eats into his study time.
- Which disorder do Kabir’s symptoms most closely suggest? [1]
- Identify the obsession and the compulsion in his case. [2]
- Explain the cycle that keeps this behaviour going. [2] [5 marks]
- For the past few weeks, Sara has lost interest in the music and friends she once loved. She feels tired all the time, sleeps poorly, and keeps telling herself, “I am useless and nothing will ever go right for me.” Her schoolwork has slipped and she rarely leaves her room.
- Which disorder do Sara’s symptoms indicate? [1]
- Identify the pattern of negative thinking she shows, and name the concept that describes it. [2]
- Suggest one therapeutic approach that could help Sara, and explain briefly how it would work. [3] [6 marks]
- Over several months, Aman has become convinced that his neighbours are secretly recording everything he does, though there is no evidence for this. He says he can hear a voice describing his actions as he goes about the day. He has stopped meeting friends and no longer looks after his own hygiene.
- Which disorder, and which type of it, do Aman’s symptoms suggest? [2]
- Classify each of his three main symptoms as either a positive or a negative symptom. [3]
- Suggest one reason why stigma might make it harder for Aman’s family to seek help for him. [1] [6 marks]
- Priya feels an intense, uncontrollable fear of lifts. She climbs the stairs even to the tenth floor of her office, which leaves her exhausted, rather than step into a lift. A therapist suggests a step-by-step programme that begins by teaching her deep relaxation.
- Name the disorder Priya is experiencing. [1]
- Identify the therapy technique the therapist is using, and explain how it works. [3]
- How does this technique differ from flooding? [1] [5 marks]
5.3.2.2 Social Phobia
Social phobia, also called social anxiety disorder, is an intense and irrational fear of social situations — meeting new people, attending gatherings, or speaking in public. At its heart lies a dread of being negatively judged, scrutinised or humiliated. The person may avoid social occasions altogether, or sit silently trying to blend into the background, even while knowing the fear is exaggerated.