 as well as different types of personality disorders, the way they have been classified, the way they have been talked about with reference to their diagnostic criteria in the DSM manual. Till now, what we were doing in this module was that we were broadly looking at different type of problems, especially we looked only at the neurotic disorders. But our attempt was primarily initially to establish distinction between neurotic and psychotic disorders with respect to certain parameters, that was one. And second, we tried our best to globally look at different type of neurotic disorders. Today, we are going to talk specifically about two set of disorders, the adjustment disorders and the personality disorders, the way they have been referred to in the DSM manual. And therefore, the words that you see here, it is basically taken from the DSM manual. First, we look at the diagnostic criteria for adjustment disorders. Now, the most interesting thing that you would find here is that it would talk about the onset period, it would also talk about the duration, that you should have lived with the symptom for certain period of time. What should have triggered it? These two things would be common. Three, it would talk about the type of symptoms that reflects a particular disorder. And four and most importantly, it would also talk about the rejection criteria. Hence, if one shows this type of symptom, but is also diagnosed with some x, y, z type of a problem, then it is not supposed to be considered as this particular disorder. So, this is a broad way, the way DSM manual talks about different types of diagnostic criteria. With reference to adjustment disorder, it says that the development of emotional or behavioral symptoms in a response to an identifiable stressor occurring within three months of the onset of the stress. So, number one, the stressor that has led to certain type of problem should be identifiable. You cannot report that I do not know why, but I feel this. So, I do not know why is something that you have to get rid of when you are making a diagnosis about adjustment disorder. Two, from the onset, you should realize that the symptoms have started occurring within the first three months. The second criteria is that these symptoms or behaviors are clinically significant as evidenced by either of the following. First, marked distress that is in access to what would be expected from exposure to the stressor. So, you find that there is a intense amount of distress that has been associated with this stressor and the reflection of in the behavior is exorbitantly high in nature compared to usually what people show. Say for example, if somebody by and large a large number of people show a problem up to a certain extent, it would be considered to be that find by and large in this type of a situation with this type of a stressor. By and large people show this extent of behavior, but if you go much beyond that, that is the marked distress that you show. And second, significant impairment in social and occupational functioning. Occupational also includes academic if you are still into studies. Now, there is a significant impairment in your social functioning, the way you used to interact with others, the way you used to perform your social activities, there is a sharp decline in that. One, two, there is also impairment in terms of your occupational engagement or your academic engagement. The third criteria is that the stress related disturbances does not meet the criteria for another. The stress related disturbances, they do not meet the criteria for another specific axis 1 disorder, axis 1 axis these axis we have not discussed, we are not going to do that. And now comes the rejection criteria, the rejection criteria are where you say that the symptom do not represent bereavement. If you have suffered a loss of somebody very near to you and you are in the state of bereavement, then you cannot know diagnose the same person that you are under this influence of a particular stressor and hence you qualify for adjustment disorder. So, the symptom should not be you know representation of bereavement and also once the stressor or its consequence has terminated the symptom do not persist for additional 6 months. So, you have a stressor that has led to a particular problem. You show disproportionately high emotional and behavioral symptoms, especially with respect to impairment in your occupational engagement, academic engagement also in terms of the marked distress that you show compared to the others. That should be there, but once the stressor is over this symptom should maximally stay with you till next 6 months not beyond that. So, if a problem meets these diagnostic criteria, here you have both the inclusive and the exclusion criteria. If you have these things then you are included in this disorder, the last ones are exclusion criteria, that if you have these things then you are excluded from this disorder. So, if it is beyond 6 months you are excluded, if you are bereaving then you are excluded. So, these are the 2 exclusion criteria, the upper ones are the inclusion criteria. Now, this is how adjustment disorder clinically is diagnosed. Now, these adjustment disorders are classified as acute or chronic which is basically time dependent. So, if the symptoms less than 6 months then it is considered that the adjustment disorder is of acute nature. And if the symptoms they exceed beyond 6 months limit then it is considered to be chronic adjustment disorder. So, whether it is acute or chronic it is time dependent. As we saw in the previous slide the standard template says that once the stressor is available the behavioral and the emotional changes should come in the 3 months after the exposure to the stressor. And it can maximally you know go up to the symptoms can persist for another 6 months fine. Now, the type of you know problems that are reported in the clinic based on that the adjustment disorder has been classified into 6 different subgroups. So, we have 6 subtypes based on the prominence of the symptoms. The first subtype is with depressed mood and the characteristic for that is that you should have a malfunctioning of depressed mode tear fulness or feeling of hopelessness which basically you know dominates the set of symptoms that you are representing. So, either you are in a complete sinking state very very depressed mood state or your depression goes to the extent that you become completely hopeless. Then you recollect certain things and then suddenly you have tears rolling down your eyes. If these symptoms dominate then it is considered as with depressed mood subtype. Second subtype of adjustment disorder which is with anxiety which is manifested in terms of nervousness worry or jittery behavior. Fear of separation from the major attachment figure might be manifested in the case of children. So, for adults it is basically nervousness worry and the jittery feeling. In children there could be a great fear of being separated from the main adult figure whom the child basically attaches himself or herself to. Usually it would be the mother the father in the absence of one of the parents it could be the caregiver. So, you live with this anxiety and the worry the jitteriness this now dominates overall your symptoms that you reflect. The third subtype which is basically mixed anxiety and depressed mood here the manifestation is basically the combination of both. So, you find yourself in the state of depression you find yourself in the state of hopelessness. You also experience tearfulness and at the same time what you also realize is great degree of worry nervousness and many a times you feel very jittery. So, if these two things combine then it is considered to be the third subtype which basically combines both the depressive mood state as well as the anxiety state. Then the fourth subtype of adjustment disorder which is basically with disturbance of conduct which is manifestation of disturbance in conduct that violates age appropriate social norms and rules. There are well defined age specific norms. Society has evolved it and large number of people mostly people follow those norms and if there are violations there are no minor transgression from the standard template that has been accepted by the society. But here what you see is that one keeps on violating the age appropriate norm. This means that you show great degree of inability in terms of complying to the standard code of conduct that the society has prescribed for somebody of your age. If that happens if you show great degree of inability in terms of complying to the norm of the society and therefore, your conduct is far different far deviant compared to the rest of the people of your own age in your society then that is adjustment disorder which has basically the disturbance of conduct. Unfortunately, we do not have survey on our Indian population as to what percentage of people in which age bracket show these types of things. But I am sure you would find a percentage significant percentage of people who would fall in this category who have great degree of inability in terms of complying to certain norms. I am not suggesting that all those who do what I am going to say now fall in this category, but you would find people who have very different type of reflection in their behavior. One explanation of such behavior could be where you have learnt in a faulty way. So, the outcome that one sees is basically an output of a faulty learning. The second possibility could be where you actually have a problem where you have great degree of inability in terms of complying to the norm. You must have seen in our country many places work places especially where it is boldly written here. Do not spit in most of the buildings we will find it written on the walls especially the corners staircases turning point on the staircases. I am sure you must have seen it, but what is the sad part is that you will find people who would ensure that they spit exactly where it is written do not spit. Same is you know urinating at public places. Many walls many walls you will find nowhere on very bold bold font is written there know that one should not urinate here. And still you would find the whole place stinks nobody bothers about it. Now, one way of looking at these problems could be that find you have not made sufficient option for people to spit or you have not made public toilets at certain distances. And therefore, one has difficulty restraining oneself when one feels the urge for doing it. But what about situations where things are provided facilities are provided, but you still do not have you know that whole generic sense that find a common sensical behavior know that this is not to be done. And especially problem comes when it is the instructions are clearly written there and you deliberately violate there. So, when you spit where it is written do not spit when you exactly urinate where it is written that you should not urinate at this place. This shows that you have know if you have that type of an urge that is a need to relook at people who do this thing. I am not saying this is a problem, but I am just giving very different type of an example. Now, we are left with just know couple of more lectures and right from the beginning the whole process that the door has to be shut. You would realize that small subset which will make an entry into the room and still would not bother that the door needs to be shut. Today also you witnessed it now. Now, if you make a small child learn the norm that this is what has to be done interact with teachers of play groups nursery. They will tell you know that children they just see it you do not have to even instruct them they will start following it. This is how the psychology of learning explains the whole process of imitation. When a verbal instruction is given that once the bell goes we formally begin the lecture the door needs to be shut. And still you find that five seven people who do not bother complying to the instruction. And it is not not complying on a single day it is a non compliance for the full set of thirty nine thirty eight days. We are probably on forty thirty eight or thirty nine day. Then it is it becomes a cause of concern that what is it that does not make you rethink. Consider yourself against those who will ensure that know they do it meticulously. There must be some difference know between the two set of people. So, right from small things like this which might occur very small but I would say know that there is a need to revisit if I am habitual of doing things the same way. Then it becomes a cause of concern if I have done it today fine it is not a cause of concern. But if I am habitual of doing it then it is a cause of concern. C C will tell you know that many people who will switch on the system but will not switch it off. So, the system you have to depute somebody to shut down all the PCs know after the work hour is over. You shift mouse from one PC to the other but do not ensure that it has to be replaced from where you had taken it back. These are know very small type of things that might look very small in nature but these are really something that if you repeat in your life then you should certainly we know reflecting upon your own behavior. Why is it that I have certain type of inability in doing that what others can very conveniently perform. I am not scaring you know but telling you that it is always good to be reflective in nature. Then the fifth subtype which is basically with mixed disturbance of emotion and conduct. Till now we were only thinking that you have difficulty in terms of complying to age appropriate social norms. Now comes a situation where one manifest emotional symptoms such as anxiety as well as inability to know follow the age appropriate norms of the society. Now it is far more complicated know when it is not only your inability to comply to the age appropriate norms of the society but at the same time you also start showing certain height and degree of emotions. Then it really know becomes a cause of concern. You will find many people know I would tell you that say you have to board a train sometime in the afternoon but since last night you have know great degree of anxiety. You have packed something and you check it in the dream you see as if know you have missed the train you started chasing it but somehow you could not board it. All types of anxiety gets reflected. That could also be your possibility and then you realize that on the platform I am sure you must have seen it on Kanpur Central also it is very common. A train comes stops people who are inside the train and still has to continue their journey would prefer to get down on the platform for whatsoever reason. If you have got down to buy something if you have got down for water I can understand that know and you wait till the signal is green and till the know driver blows the horn. And once the train starts moving slowly then you walk with the train and finally when the train catches up some speed you run and then board it and there is a great degree of thrill in it I have done it. I am sure you must have seen know people who take great degree of know derive great degree of pleasure in doing that. If you think it rationally how prudent is it for an adult human being to repeats this type of or even do it once in their life. Those who would give the physiological explanation will tell you that you have know such type of exciting activities triggers the neurotransmitters in the reward center of the brain. So, because the reward center of the brain gets reactivated out of such type of activities therefore, you feel and urge to do so. So, Kanpur Central and again the next stop again you repeat the exercise again you repeat the exercise. You have a reserved seat but then you take pride in standing near the gate with half the body outside the body of the train and great degree of pleasure that you derive out of it. Compare them to somebody who had a very disturbed sleep last night because the next afternoon he has to board a train. Somebody who would know look at the crowd which is making an attempt to board a particular bogey through a gate and you feel great degree of inability. There would be very few but I have seen cases know where somebody would return back home and saying that over there were too many passengers. I could very easily understand that I would not be able to get into the train and therefore, I came back. There is no point travelling when I cannot get into it and then comes the last subtype what is called as the unspecified category. Here what you see is the manifestation of maladaptive reactions to stressors that are not classified in the five subtypes that we have discussed. Such reactions include physical complaint, social withdrawal or academic inhibitions. So, these are the prominent things that you see. Five subcategories very clearly defined. Sixth, you find that this person has some adjustment disorder but cannot be classified into the first five subtypes but by and large shows certain types of physical symptoms, certain type of social withdrawal, certain type of academic inhibitions then you consider that he belongs again to the adjustment disorder category but of the sixth subtype. So, this was all about the adjustment disorders. Now, we come to personality disorders. I must tell you one thing. I deliberately made an attempt not to touch on any of the disorders which are of grave order. Otherwise, if you read the DSM manual or the ICD classification, you have a thick volume which describes all types of things. But those are the guiding principles for the practitioners. I have deliberately chosen to remain on the brink and throughout this course what we have been doing is that you would always start from normal and come very close to abnormal pattern of behavior but we do not touch abnormality again turn back. Repeatedly, we have swings between normal to extreme of behavior which could be considered very close to abnormality. But somehow personality disorder, many of it you would realize that crosses that brink and therefore you would find behaviors which are little more grave in their nature. Now, personality disorder has been defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. Remember one thing, cultural norms are still given priority even in clinical diagnosis. So, when you draw the line that this is what is expected out of you, that line might vary from culture to culture that might be very much true and therefore it is always recommended that when you are consulting an expert because you are having some type of a symptom it is always good to consult somebody who belongs to your culture or if you do not have the access to somebody who belongs to your culture then meet somebody who is much more aware about your cultural norms otherwise there could be certain type of mis judgments. So, you realize that there is an inner pattern in the inner experience as well as in behavior which primarily deviates from the cultural expectation the cultural norms with an onset in adolescence or early adulthood. So, the onset of such problems would be either adolescent years or adulthood. Remember that the problem in children are classified separately and by and large it has been observed worldwide in the clinics that most of the reported cases in the clinics they fall between 16 to 40, 45 years of age. The people who come forward with the symptoms they fall in this bracket. So, the onset has to be in the adolescent years or in the adulthood early adulthood and the manifested behavior is pervasive and inflexible leading to distress or impairment. So, great degree of inflexibility as well as pervasive pattern repetition is there in the behavior. This pattern is manifested in two or more of the following areas. So, you have four major areas cognitive functions, effective functions, interpersonal functioning and impulse control and out of these four minimum of two or more area should be affected. So, minimum two has to be influenced only then you consider that perhaps this problem needs to be revisited and it could be one of the personality disorders. So, once again you see just like a dissonant disorder here also you have certain inclusion criteria you have certain exclusion criteria. This is very common in all type of psychological disorders psychiatric disorders there has to be a well defined inclusion as well as exclusion criteria. You have not been exposed to experimentation in psychology, but if you look at the scientific literature in psychology and the way psychological experiments are performed. You would find that for all type of sample selection the experimenter has to define the inclusion as well as the exclusion criteria that if you meet these criteria only then you will be qualified to be considered as a participant in the study. At the same time you also define that if you have these set of things then you will not be accepted as a participant in my study. In all you know journal articles will find very clearly in the studies the inclusion and exclusion criteria being defined. So, is the case with clinical diagnosis too. Now, we are coming with the diagnostic criteria of the APA for cluster A personality disorder. Again we have cluster A cluster B we are not going into the details of what is why it is cluster A why it is cluster B we are not going into those details. Remember one thing you know there is no point you know noting down all the diagnostic criteria you should not even try to memorize it you are not going to practice it in the clinic now. So, there is no point you know writing it down or memorizing it what I will ask you is only to pay attention to what actually is the nature of the problem. So, that if one is reflecting on one's own behavior or looking at the behavior of people in and around oneself. One could feel know that is it normal behavior or is it that such type of behavior requires know an intervention that is the only reason why we are discussing these things. Now, the diagnostic criteria for paranoid personality disorder paranoid traits you understand yes no anybody who says no. So, it is basically the degree of suspicion that is attached to it know that you are suspicious about an individual about an act about the whole phenomena that is the defining know criteria for paranoid reactions. So, in paranoid personality disorder there is a pervasive distrust or suspiciousness of others. So, I distrust people by and large I am suspicious about them such that their motives are interpreted as malevolent beginning by early adulthood and present in varieties of context as indicated by four or more of the following. Now, you have seven different know distinctions made here and out of these seven minimum of four should be achieved to be classified as paranoid personality disorder what are them suspects without sufficient basis that others are exploiting harming or deceiving you. So, great degree of suspicion which is basically the defining criteria of paranoid reaction and you do not have sufficient basis for it, but then still you feel that others are using you you are being exploited there is a looming danger of harm any time the harm might inflict you or you are being cheated you are deceived to preoccupied with unjustified doubts about the loyalty or trust worthiness of people usually friends and close associates. So, all you do is that you have a doubt on their loyalty although you know tend to be very friendly to me, but I do not know if you are really my friend and you keep doubting this you stay with this doubts three is reluctant to confide in others because of unwarranted fear that the information will be used in a malicious way against that individual. So, you hear from others, but you are extremely reluctant you do not confide in people you do not share things with others in close friendships in close associations people confide please do not tell it to others, but you know this has happened to me once I did it people confide in you, but those who confide basically the relationship is based on a trust a confidence that I have shared it with you and because I have told you that do not tell it to others will certainly not share it with others that the loyalty would remain there. In this case you do not trust the loyalty of others at the same time you have your own inability to confide in others and therefore, you stay with all types of experiences you do not share it with others this in itself could be great problem know when you keep on keep on storing everything within you for reads hidden demeaning or threatening meaning into benign remarks or events know. So, you somehow know have a tendency to deliberately read between the lines this is what your claim is that all those things are not clearly spelled out, but I can very easily make meaning out of it I can read between the lines and I can understand that there is know although the line is positive, but the intention is wrong. So, overall you consider that this is demeaning to you you consider that this could be threatful for your own ego 5 persistently you bear some amount of grudge against others like you do not forget the insult that was committed to you once the teacher slapped you once and even after 40 years sometime that slap echoes in your ears you are not able to forget that insult some injury that has taken place you are not able to forget it or certain slides that has happened to you. So, basically you know once somebody you hold responsible for some negative experience of your life you do not forget that in you do not forgive that individual you neither forget the episode nor forgive the individual the sixth one there is a perceived attack on his or her character or reputation that are not apparent to others and is quick to react in the state of anger or you counter attack. So, basically once again you perceive certain amount of attack that can take place and therefore, you retaliate you counter attack because you consider that your character your reputation is at stake and the last one has a recurrent suspicion without justification regarding fidelity of spouse or sexual partner out of these 7 minimum of 4 should be present for an individual to be classified as paranoid personality disorder. Now, if you look at this and you say that fine no even in my own wing there are 7 people we are very close to each other we do spend sufficient time together, but I do not trust 4 of them that could be a practical situation no, but the truth also is that when you say that I do not trust 4 of them it also means that you are saying that I trust 3 of them remember that I am deviating now you would find 2 set of people people who are very good in terms of initiating relationships or how are you it is a nice meeting you. In one go they will start you know introducing themselves the interaction will begin and they are very smart in terms of initiating relationship and the opposite end you have people who are not very good at initiating relationship. So, you make them into a room they will come and very quietly occupy the chair look at the blackboard which has not been you know filled with any details, but you keep on keep on doing that and the person sitting next to you ensure that you do not talk to him or her basically I am saying that you are bad at initiating relationship, but there could be possibility that the person who is not good at initiating relationship could be fantastic in terms of maintaining relationship. So, people whom you can classify as people who are very good at initiating relationship people who are very good at maintaining relationship. So, if once I am your friend if I am friendly to you then irrespective of whatever comes on our way throughout the life we maintain that friendship. Any relationship is bound to know have some hiccups some ups and downs are bound to happen, but then you show great degree of know your ability in terms of maintaining it. You can very easily classify people in these two categories people who are good at initiating relationship people who are good at maintaining relationship and people who are usually very good at maintaining relationship will tell you how many friends do I have one, two and usually will realize that they have very difficulty going beyond three or four for last so many years. So many know right from school mates to people in the neighborhood to wing mates to batch mates to what not people who came for tukriti, antaragini and all types of festivals know and still you say that in my life I could find three good friends, but you say that you know we are still in touch with each other we have never met since we graduated, but we are still in touch with each other that is the degree of maintaining relationship. People who are very good at initiating relationships are usually bad in terms of sustaining the level of friendship therefore, in paranoid setup when you are driven with that paranoid personality disorder it is not that you will know have you will have only limited number of friends by and large people who have this tendency the way we are classifying them good at initiating or maintaining relationship we will have know a limited number of friends I am sure know on the Facebook accounts if you see you would find people who will know keep sending ad request to all types of people know and you take pride in saying that I have right now 10,566 friends in my list the number is what matters people who would know suddenly you know poke you I am not feeling sleepy and would find people who would know we very reluctant they will receive know the ad requests and usually they will refrain from adding them to their list we will find both type of people paranoid personality type is basically based on the fact that there is an there is a pervasive inner feeling within you which does not allow you to trust others it could be your friends it could be your colleagues it could be your own partner the seventh one you would somehow have great degree of inability understanding that the person could actually be very true to me so you do not find others to be trustworthy and at the same time because of this intention you do not even feel sharing yourself you do not open yourself and this is a double blind that you are basically adopting in life know so neither you allow yourself to open up before others and those who do so you do not trust them so first barrier for your own self second barrier in terms of not positively evaluating them this is what defines the paranoid personality disorder then we come to the cesoid personality disorder cesoid basically know is closer to the cesophonic tendency know a pervasive pattern of detachment from social relationships prominences of detachment in social relationships and a restricted range of expression of emotions in interpersonal settings so you have only limited number of emotional expressions that you show in public beginning once again by early adulthood and present in a variety of context and remember once again out of seven minimum four should be achieved for it neither desires nor enjoys close relationships including being part of a family you can understand how weird it could be that you do not have the desire to be part of something including family so no close relationships with anybody to almost always chooses solitary activities people who are bad in terms of group activities I must be share with you know that in certain type of recruitment processes you have certain type of task group tasks especially in the say uniformed services I do not know about the police intake process I think there they do not do it to the best of my knowledge but armed forces the elite commando trainings there you have no certain type of group activities and the person who moderates the whole show ensures that you should participate as a group not individually so usually what happens as individuals we have our own capabilities everybody has certain capability no at the same time every individual has his or her own limitations so if you are able to chip in with your own abilities then as a group you become very very strong and therefore if you are able to work in a group if you are able to become a good leader or even a good follower you will find literature in psychology which would suggest you that only good leaders can be good followers so even if you show your ability as a very good follower in a certain setup which means that given an opportunity you can be an exemplary leader so if you do not succeed in performing things in a group then in certain intake processes the whole group is wiped out this group this set of people they cannot work in group so not recommended for a given type of a task you cannot join the profession in scissor personality type these people have their great inability in terms of working with others now working with others is again a usual problem that you will find in people who have very heightened ego you remember we had discussed once know the pilots and the co-pilots and the flight engineers their interaction in the flights no there are interesting psychological studies on air crashes suggesting that the personality type of the pilot influences the accident to certain extent so if you have your inability to work in group and you show your preference to work in isolation that is the second criteria third has little if any interest in having sexual experience with other person so even that lust the biological urge that you find which is naturally available to all human beings all animal species you find that here is the person who does not have a lust for that for takes pleasure in selected activities very few if any lacks close friends or confidence other than first degree relatives you have your first degree relative would be your parents beyond that you do not intimately interact with people appears indifferent to praise or criticism of others so either you pray or great work great great great you clap and this man is very neutral and you criticize what have you done again very neutral I must tell you that you should accept this very criteria with a pinch of salt because in religious text you would find that they prescribe rather that you should attain a state of indifference where neither praise deviates you from your track nor does criticism so you have chosen a path you have your defined goal and you are trying to achieve it you should not be made to swing from the desired track that you have thought for yourself based on praise or criticism this is you will find uniformly in all religious texts but here basically what it means is that the indifference which is not guided by the way it is described in the religious context but it is basically because you have difficulty in processing effect of others and last one shows emotional coldness detachment or flattened emotional reactions so you are emotionally numb very cold noise to see I am sure you must have seen one or two people like that now people who will shake their hand but will know ensure that you catch hold only of small part of their palm and you go with a broad smile nice meeting that coldness in the reaction detachment something has happened and you say you have fallen on fractures may be doctors will heal it usually the normal reaction is that once something happens you feel attracted towards it and if you find that there is actually you know if a fracture is taken plus you there is a natural sense of a concern that comes for the sufferer and there is a flattened effect flattened effect is no emotional swings no so the context might change and accordingly the desired emotional reaction will change but then nothing changes in you that is the scissoride personality type but again what I would like to do is that just two more sub types are there once we discuss that we will once again revisit that whole know extremes of behavior that we had discussed with respect to dimensions of subjective adjustment and then we will try to correlate no let us see there also we were talking about the streams here also we are talking about extremes so in terms of extreme of normal behavior also where to draw the line that if the moment I cross it I am no more normal clinically speaking so we will perform that exercise in the coming week.