Psychological Disorders

2.1 Core concepts

NCERT opens with Carl Jung's observation — "How can I be substantial without casting a shadow? I must have a dark side, too, if I am to be whole" — to remind the student that psychological distress is part of the human condition, and that adaptation (the ability to modify one's behaviour in response to changing environmental requirements) is the central yardstick by which normality is judged (NCERT §Introduction, p. 70). When behaviour cannot be modified to meet the situation, it is maladaptive, and the study of such behaviour, its causes, consequences and treatment is called Abnormal Psychology.

Most definitions of abnormality share the "four Ds" — Deviance (behaviour is different, extreme, unusual, even bizarre), Distress (unpleasant and upsetting to the person and to others), Dysfunction (interferes with the person's ability to carry out daily activities in a constructive way) and Danger (to the person or to others) (NCERT §Concepts of Abnormality and Psychological Disorders, p. 70). Two basic and conflicting views emerge from this. The first views abnormality as deviation from social norms — behaviour that breaks a society's culturally-grounded norms is labelled abnormal; a society valuing competition will accept aggression, while one valuing cooperation (like India) may treat it as abnormal (NCERT p. 71). NCERT criticises this view because it assumes that socially accepted behaviour is normal, equating normality with conformity. The second view defines abnormality as maladaptive — behaviour is abnormal if it interferes with the well-being of the individual and the group, where well-being is not mere maintenance but includes growth and fulfilment, i.e., self-actualisation in Maslow's need-hierarchy theory (NCERT p. 71). NCERT also flags stigma — the "mark of shame" attached to mental illness that prevents people from seeking help.

There are three recurring historical perspectives (NCERT §Historical Background, pp. 71–72). The supernatural approach attributes abnormality to magical or evil forces — bhoot-pret, shaitan (the devil) — and prescribes exorcism by countermagic and prayer, with the shaman or ojha serving as the human medium for spirits. The biological/organic approach was developed by the philosopher-physicians of ancient Greece — Hippocrates, Socrates and especially Plato, who developed the organismic approach viewing disturbed behaviour as arising out of conflict between emotion and reason. Galen elaborated Hippocrates's doctrine of the four humours — blood, black bile, yellow bile and phlegm — derived from the four elements earth, air, fire and water; imbalance among these humours was believed to cause disorders. NCERT explicitly parallels this with the Indian Ayurvedic notion of three doshas — vata, pitta and kapha — mentioned in the Atharva Veda (NCERT p. 72). The third recurring perspective is the psychological approach, attributing disorders to inadequacies in the way an individual thinks, feels or perceives the world.

The Middle Ages revived demonology with witch-hunts, though early Middle Ages also saw St. Augustine writing extensively about feelings, mental anguish and conflict — laying the groundwork for modern psychodynamic theories. The Renaissance brought humanism: Johann Weyer emphasised psychological conflict and disturbed interpersonal relationships as causes, and insisted 'witches' were mentally disturbed and required medical, not theological, treatment (NCERT p. 72). The seventeenth-eighteenth centuries — the Age of Reason and Enlightenment — saw scientific method replace faith and dogma, leading to the Reform Movement, asylum reforms across Europe and America, and ultimately deinstitutionalisation, the inclination to provide community care for recovered mental patients (NCERT pp. 72–73). The modern convergence is the interactional or bio-psycho-social approach in which biological, psychological and social factors jointly play roles in the expression and outcome of disorders.

Classification systems are essential because they enable communication among psychologists, psychiatrists and social workers and help in identifying causes and processes of disorders (NCERT §Classification, p. 73). The American Psychiatric Association has published the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), which presents discrete clinical criteria for the presence or absence of disorders. The classification scheme officially used in India and elsewhere is the tenth revision of the International Classification of Diseases (ICD-10) known as the ICD-10 Classification of Behavioural and Mental Disorders, prepared by the World Health Organisation (WHO).

Factors underlying abnormal behaviour are presented through several converging models (NCERT §Factors Underlying Abnormal Behaviour, pp. 73–75). Biological factors include faulty genes, endocrine imbalances, malnutrition, injuries and abnormal activity by certain neurotransmitters — anxiety disorders are linked to low GABA activity, schizophrenia to excess dopamine activity, and depression to low serotonin activity. Genetic factors are linked to bipolar disorder, schizophrenia and intellectual disability — though many genes combine rather than any single gene producing a disorder. The psychodynamic model (Freud) holds that behaviour is determined by unconscious psychological forces — id (instinctual needs/drives/impulses), ego (rational thinking) and superego (moral standards) — and abnormal symptoms are a symbolic expression of unconscious mental conflicts traceable to early childhood or infancy. The behavioural model holds that both normal and abnormal behaviours are learned through classical conditioning (temporal association), operant conditioning (behaviour followed by a reward) and social learning (imitation). The cognitive model holds that abnormal functioning results from cognitive problems — irrational assumptions, illogical thinking and overgeneralisation (broad negative conclusions on the basis of a single insignificant event). The humanistic-existential model holds that human beings are born with a natural tendency to be friendly and constructive and a drive to self-actualise; existentialists add that we have the freedom to give meaning to our existence and those who shirk this responsibility live empty, inauthentic, dysfunctional lives.

The socio-cultural model highlights family systems (the enmeshed family in which members are overinvolved in each other's activities, thoughts and feelings), social networks (isolation and lack of social support increase and prolong depression), and societal labels and roles — labels of 'deviant' or 'mentally ill' tend to stick, and the person learns to accept and play the sick role (NCERT p. 75). One of the most widely accepted explanations is the diathesis-stress model: psychopathology develops when a biological diathesis (inherited predisposition/aberration) carrying a vulnerability to disorder is set off by pathogenic stressors; the model has been applied to anxiety, depression and schizophrenia (NCERT p. 75).

The major psychological disorders follow DSM-5. Anxiety Disorders are the most common category (NCERT pp. 76–77; Table 4.1). Generalised Anxiety Disorder features prolonged, vague, unexplained intense fears not attached to any particular object, accompanied by hypervigilance (constantly scanning the environment for dangers) and motor tension (restless, shaky). Panic Disorder consists of recurrent unpredictable anxiety attacks — abrupt surges of intense terror with shortness of breath, dizziness, trembling, palpitations, choking, nausea, chest pain and fear of going crazy, losing control or dying. Phobias are irrational fears attached to specific objects, people or situations: specific phobias (animals, enclosed spaces), social anxiety disorder (social phobia) (intense fear in interactions with others) and agoraphobia (fear of entering unfamiliar situations, often making the person unable to leave home). Separation Anxiety Disorder (SAD) features developmentally inappropriate fear and anxiety about separation from attachment figures.

Obsessive-Compulsive and Related Disorders (NCERT pp. 77–78). Obsessive behaviour is the inability to stop thinking about a particular idea or topic — the person finds these thoughts unpleasant and shameful. Compulsive behaviour is the need to perform certain behaviours over and over again — counting, ordering, checking, touching, washing. The category also includes hoarding, trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder).

Trauma- and Stressor-Related Disorders include post-traumatic stress disorder (PTSD) — recurrent dreams, flashbacks, impaired concentration, emotional numbing after natural disasters, terrorist bomb blasts, accidents or war — plus Adjustment Disorders and Acute Stress Disorder (NCERT p. 78).

Somatic Symptom and Related Disorders are conditions with physical symptoms in the absence of physical disease (NCERT p. 78). Somatic Symptom Disorder involves persistent body-related symptoms with overpreoccupation and frequent doctor visits. Illness Anxiety Disorder involves persistent preoccupation about developing a serious illness — concern is the anxiety itself rather than actual symptoms. Conversion Disorder features sudden loss of motor or sensory function — paralysis, blindness, deafness, difficulty walking — with no physical cause, often following a stressful experience.

Dissociative Disorders involve severance of connections between ideas and emotions (NCERT pp. 78–79; Box 4.1). Dissociative Amnesia is extensive but selective memory loss without organic cause; its subtype dissociative fugue features unexpected travel away from home, assumption of a new identity and inability to recall the previous one. Dissociative Identity Disorder (multiple personality disorder) — the most dramatic — involves two or more separate and contrasting personalities, often associated with a history of childhood abuse. Depersonalisation/Derealisation Disorder is a dreamlike state of being separated from self and reality.

Depressive Disorders (NCERT pp. 79–80). Major Depressive Disorder is a period of depressed mood and/or loss of interest or pleasure in most activities, with changes in body weight, sleep problems, tiredness, slowed behaviour, agitation, thoughts of death and suicide, and feelings of worthlessness or excessive guilt. Risk factors include genetic make-up, age (women at higher risk in young adulthood; men in early middle age), gender, negative life events and lack of social support.

Bipolar and Related Disorders include Bipolar I (mania alternating with depression — manic episodes rarely appear alone, hence the older name "manic-depressive disorder"), Bipolar II and Cyclothymic Disorder (NCERT p. 80). NCERT discusses suicide here as a multi-causal phenomenon, the strongest risk factor being a previous suicidal attempt; WHO-recommended measures include limiting access to the means of suicide, responsible media reporting, alcohol-related policies, early identification and training of health workers.

Schizophrenia Spectrum and Other Psychotic Disorders (NCERT pp. 81–82). Symptoms group into three categories — positive, negative and psychomotor. Positive symptoms are pathological excesses or bizarre additions: delusions (firmly held false beliefs without basis in reality), with subtypes — persecution (most common — being plotted against), reference (special meaning attached to others' actions), grandeur (specially empowered) and control (thoughts/actions controlled by others); formal thought disorders — loosening of associations/derailment, neologisms (inventing new words/phrases) and perseveration (persistent inappropriate repetition); hallucinations (perceptions in the absence of external stimuli) — auditory hallucinations are most common (second-person addressed to the patient; third-person referring to the patient), and there are also tactile (tingling, burning), somatic (e.g., snake crawling inside the stomach), visual, gustatory (food tastes strange) and olfactory (smell of poison/smoke) hallucinations; and inappropriate affect (emotions unsuited to the situation). Negative symptoms are pathological deficits: alogia (poverty of speech), blunted affect (less emotion), flat affect (no emotion at all), avolition (apathy/inability to start or complete a course of action), and social withdrawal. Psychomotor symptoms appear as reduced spontaneous movement, odd grimaces and catatonia — catatonic stupor (motionless and silent for long stretches), catatonic rigidity (rigid upright posture for hours) and catatonic posturing (assuming awkward, bizarre positions).

Neurodevelopmental Disorders manifest in the early stage of development (NCERT pp. 82–83). Attention-Deficit/Hyperactivity Disorder (ADHD) has two main features — inattention (difficulty sustaining mental effort, disorganisation, forgetfulness, distractibility) and hyperactivity-impulsivity (constant motion, inability to wait/take turns, acting before thinking). Autism Spectrum Disorder features widespread impairments in social interaction and communication and stereotyped patterns of behaviour and interests; about 70 per cent of children with autism spectrum disorder have intellectual disabilities. Intellectual Disability refers to below average intellectual functioning with IQ of approximately 70 or below and deficits in adaptive behaviour (communication, self-care, home living, social/interpersonal skills, etc.) manifested before the age of 18 years (Table 4.2 details mild/moderate/severe/profound levels by IQ range and area of functioning). Specific Learning Disorder involves difficulty in perceiving or processing information efficiently — problems in reading, writing or mathematics.

Disruptive, Impulse-Control and Conduct Disorders include Oppositional Defiant Disorder (ODD) (age-inappropriate stubbornness, irritability, defiance, hostility) and Conduct Disorder/antisocial behaviour (actions that violate family and social norms — verbal, physical, hostile and proactive aggression) (NCERT p. 84).

Feeding and Eating Disorders include Anorexia Nervosa (distorted body image leading to refusal to eat and starvation), Bulimia Nervosa (excessive eating followed by purging through laxatives or vomiting, feelings of disgust) and Binge Eating (frequent out-of-control eating at higher than normal speed without purging) (NCERT p. 84).

Substance-Related and Addictive Disorders cover problems associated with regular and consistent use of alcohol, heroin, cocaine, tobacco and opioids that alter the way people think, feel and behave (NCERT pp. 84–86). Alcohol abuse leads to social and occupational dysfunction, tolerance, withdrawal and damages family and physical health (Box 4.2). Heroin overdose can paralyse breathing and cause death. Cocaine dependence dominates the person's life and produces depression, fatigue and irritability on withdrawal. Box 4.3 lists DSM-5 commonly abused substances — Alcohol; Stimulants (dextroamphetamines, metaamphetamines, cocaine); Caffeine (coffee, tea, chocolate); Cannabis (marijuana, bhang); Hallucinogens (LSD, mescaline); Inhalants (gasoline, glue, paint thinners); Tobacco (cigarettes, bidi); Opioids (morphine, heroin, cough syrup, painkillers); Sedatives, Hypnotics or Anxiolytics (sleeping pills, anti-anxiety medication).

2.2 Definitions to memorise

2.3 Diagrams / processes to remember

• Table 4.1 — Major Anxiety Disorders and their Symptoms (p. 77): GAD (prolonged vague intense fears with hypervigilance and motor tension), Panic Disorder (frequent attacks with breathlessness, palpitations, dizziness, sense of losing control or dying), Specific Phobia (irrational fears of specific objects/situations), Separation Anxiety Disorder (extreme distress on separation from significant figures), plus Selective Mutism, Substance-/Medication-Induced Anxiety Disorder, and Anxiety Disorder Due to Another Medical Condition.
• Box 4.1 — Salient Features of Somatic Symptom and Related Disorders and Dissociative Disorders (p. 79): pairs each disorder with its defining feature side by side.
• Table 4.2 — Characteristics of Individuals with Different Levels of Intellectual Disability (p. 85): Mild (IQ 55–70), Moderate (35–40 to 50–55), Severe (20–25 to 35–40), Profound (below 20–25) — compares self-help, speech/communication, academics, social, vocational and adult-living domains.
• Box 4.2 — Effects of Alcohol: Some Facts (p. 86): ethyl alcohol is absorbed into the blood and carried to the CNS where it depresses functioning of areas controlling judgment and inhibition.
• Box 4.3 — Commonly Abused Substances (DSM-5) (p. 86): Alcohol, Stimulants, Caffeine, Cannabis, Hallucinogens, Inhalants, Tobacco, Opioids, Sedatives/Hypnotics/Anxiolytics.
• Three-symptom schema for schizophrenia (pp. 81–82): Positive (excesses) | Negative (deficits) | Psychomotor — with delusions, hallucinations, formal thought disorders, alogia, blunted/flat affect, avolition, catatonia mapped to each.

2.4 Common confusions / NTA trap points

• DSM-5 vs ICD-10 — DSM-5 is APA (American); ICD-10 is WHO and is the system officially used in India. NTA often swaps the publishing body.
• Obsession vs compulsion — obsession is the unwanted thought; compulsion is the repeated act. Both occur in OCD.
• Somatic Symptom Disorder vs Illness Anxiety Disorder — Somatic Symptom = physical complaints expressed; Illness Anxiety = worry/anxiety about getting ill (no actual symptoms).
• Conversion Disorder — falls under somatic symptom category, not dissociative — it involves loss of motor/sensory function with no physical cause.
• Dissociative fugue — is a subtype of Dissociative Amnesia, not a separate disorder.
• Anorexia vs bulimia vs binge eating — anorexia involves refusal to eat and starvation; bulimia involves binge eating followed by purging; binge eating involves out-of-control eating without purging.
• Positive vs negative symptoms of schizophrenia — positive = excesses/additions (delusions, hallucinations, inappropriate affect); negative = deficits (alogia, flat affect, avolition). Many students reverse them.
• Auditory hallucinations are most common — not visual. Visual hallucinations are vague perceptions of colour or distinct visions.
• Neurotransmitter links — Anxiety ↔ low GABA, Schizophrenia ↔ excess dopamine, Depression ↔ low serotonin (frequent matching question).
• Bipolar I vs MDD — Bipolar I requires mania; depression alone (without mania) is MDD. Manic episodes "rarely appear alone".
• 70% of autism children have intellectual disability — exact figure tested.
• Intellectual disability cutoff age — before age 18, IQ approximately 70 or below.
• Hippocrates vs Plato vs Weyer — Hippocrates (four humours), Plato (organismic approach), Weyer (psychological causation in Renaissance). Distractors swap them.

2.5 Thinkers / Theories cited in this chapter

Note: NCERT does not name individual authors for the behavioural, cognitive or humanistic-existential models, or for many specific symptoms/disorders. Only thinkers explicitly mentioned in this chapter are listed.