These are the techniques used by the psyche to protect itself from overwhelming anxiety or stress. These are not entities in themselves, but explanations derived originally from psychoanalysis to explain symptoms and behaviour. The list below is not exhaustive but describes those most commonly seen in practice.
Altruism Describes the mechanism of satisfying one's own needs through the lives of others. For example, the man who wished he had become a doctor may ‘push’ his family into this career and blame himself if they do not fulfil his expectations.
Denial Defined as the expressed refusal to acknowledge a threatening reality (for example, ‘it can't happen here’). It is of relevance especially to those with serious physical illnesses, where the patient denies being told of the presence of any illness in themselves or their loved ones. It may persist despite constant reiteration of the facts. The term denial is often used, inappropriately, for the knowing or conscious avoidance of painful topics or thoughts.
Displacement The process by which interest and/or emotion is shifted from one object onto another less-threatening one, so that the latter replaces the former. Thus the person who loses a child in a road accident and thereafter devotes themselves tirelessly to campaigning against dangerous driving is exhibiting this defence. From a psychological perspective, the affect that attached to the child is replaced by the affect attached to the ideals of the campaign. More prosaically, the person who is having problems at work may displace the anger felt for their boss onto their family by displaying irritability and moodiness at home, or a spinster may accumulate numerous cats rather than children.
Idealisation The ascribing of omnipotence to another person or organisation (for example, ‘you will save me’).
Identification with the aggressor Observed where the victim begins to assume the qualities or faults of the opponent. This may show itself as the battered wife believing she deserves to be beaten and justifying her husband's aggression to her. The ‘Stockholm syndrome’ is another example (Favaro et al, 2000).
Projection The defence against unpalatable anxieties, impulses or attributes in one's own psyche, which are attributed to an external origin. For example, the person who attributes indecision to others may be unconsciously projecting their own indecisiveness. Thus internal threats become externalised and then are easier to handle.
Recent decades have seen a considerable renaissance of scientific interest in the study of human consciousness in general (Edelman, 1989; Dennett, 1991; Damasio, 2000). For the purposes of descriptive clinical psychopathology, consciousness can be simply defined as a state of awareness of the self and the environment. In the fully awake subject the intensity of consciousness varies considerably. If someone is carrying out a difficult experiment their level of consciousness will be at its height, but when they are sitting in an armchair glancing though the newspaper the intensity of their consciousness will be much less. In fact, when subjects are monitoring a monotonously repetitive set of signals, short periods of sleep may occur between signals and are not recognised by the subject, but are shown clearly by changes in the electroencephalogram (EEG).
Before we can discuss the disorders of consciousness we must deal with the possibly confounding issue of attention. Attention can be active when the subject focuses their attention on some internal or external event, or passive when the same events attract the subject's attention without any conscious effort on their part. Active and passive attention are reciprocally related to each other, since the more the subject focuses their attention the greater must be the stimulus that will distract them (i.e. bring passive attention into action).
Disturbance of active attention shows itself as distractibility, so that the patient is diverted by almost all new stimuli and habituation to new stimuli takes longer than usual. It can occur in fatigue, anxiety, severe depression, mania, schizophrenia and organic states. In abnormal and morbid anxiety, active attention may be made difficult by anxious preoccupations, while in some organic states and paranoid schizophrenia, distractibility may be the result of a paranoid frame of mind. In other individuals with acute schizophrenia, distraction may be regarded as the result of formal thought disorder because the patient is unable to keep the marginal thoughts (which are connected with external objects by displacement, condensation and symbolism) out of their thinking, so that irrelevant external objects are incorporated into their thinking.
Attention is affected by an individual's mind-set, which, in the absence of mental illness, is generally non-rigid and is altered in response to incoming information.
Blocq's disease Also known as astasia-abasia. This is the inability to walk or stand in a normal manner. The gait is bizarre and is not suggestive of any organic lesion. It is often characterised by swaying and almost falling, with recovery at the last moment. It is a conversion symptom (dissociative motor disorder in ICD–10 and conversion disorder in DSM–IV).
Briquet's syndrome Now called somatisation disorder, Briquet's syndrome is a condition in which there are multiple physical complaints, in several systems, for which no physical cause is found. It begins usually before the age of 30 years, runs a chronic course and is associated with frequent medical contact. The term was used synonymously with St Louis hysteria, although conversion or dissociative features are rare.
Capgras syndrome An uncommon syndrome in which the patient believes that a person to whom they are close, usually a family member, has been replaced by an exact double. The underlying psychopathology is delusional misidentification rather than a hallucinatory experience. Other related delusional misidentification syndromes also exist. These include Fregoli syndrome (see below), the syndrome of intermetamorphosis and the syndrome of subjective doubles. The syndrome of intermetamorphosis is characterised by delusions that people have swapped identities while maintaining the same appearance, so it is not just a disguise but a total transformation that is psychological as well as physical. The syndrome of subjective doubles is characterised by the delusional belief that the patient has a double or doppelganger. In reduplicative paramnesia there is a delusional belief that identical places and events exist.
Charles-Bonnet syndrome This is a syndrome of visual hallucinations without any other psychotic features or any evidence of psychiatric disorder. It is associated with visual impairment. The content of the hallucinations varies from straight lines to complex pictures of people and buildings. They may be enjoyable or distressing. Its importance for psychiatrists lies in not making an erroneous diagnosis of a psychiatric disorder.
Cotard syndrome A delusion in which the person believes that they are dead. It may be accompanied by delusions that they are rotting, smell malodorous or that parts of the body do not exist (nihilistic delusions). The individual may also be deluded that they have no head, that they have a shadow and cannot see themselves in the mirror.
Memory is of three types: sensory, short-term and long-term. It can be compared to a sieve with holes of varying size to assist in identifying material that is relevant from that which is irrelevant. The first, known as sensory memory, is registered for each of the senses and its purpose is to facilitate the rapid processing of incoming stimuli so that comparisons can be made with material already stored in short- and long-term memory. Since there are numerous stimuli bombarding the individual, selective attention allows for the sifting of relevant material from sensory memory for further processing and storage in short-term memory. As a consequence, most sensory memory fades within a few seconds. Short-term memory, also called working memory, allows for the storage of memories for much longer than the few seconds available to sensory memory. Short-term memory aids the constant updating of one's surroundings. For example, if you saw a person walking a dog and a few seconds later heard a dog bark you would not be surprised since you would identify the likely source of the sound from sensory (visual) memory that had been processed and encoded in shortterm (working) memory.
When memories have been rehearsed in short-term memory they are encoded into long-term memory. Encoding is the process of placing information into what is believed to be a limitless memory reservoir, which can occur for specific stimuli as well as for the general memory. For example, passing a large two-storey house painted yellow with a tennis court and two sports cars in front might be recalled exactly (visual encoding) or recalled in more general terms as the large home of a wealthy owner (semantic encoding).
The storage of material in long-term memory allows for recall of events from the past and for the utilisation of information learned through the education system. It is resilient to attack, unlike short-term memory, which is sensitive to disorders of brain tissue such as Alzheimer's disease.
Autobiographical memory refers to the memories for events and issues that relate to oneself. These may be for specific facts, for example whether you are you married, and specific experiences, for example your wedding day.
Psychiatric illness may be associated with objective or subjective motor disorders. This chapter is chiefly devoted to objective motor disorders. However, it is important to note at the outset that subjective motor disorders may also occur.
Subjective motor disorders: the alienation of motor acts
Normally humans experience their actions as being their own and as being under their own control, although this sense of personal control is never in the forefront of consciousness, except when a particular effort is made to overcome the effects of fatigue or toxic substances that are clouding our consciousness and making it difficult for us to control our bodies. In obsessions and compulsions the sense of possession of the thought or act is not impaired, but the patient experiences the obsession as appearing against their will, so that although they have lost control over a voluntary act they still retain personal possession of the act.
In schizophrenia the patient may not only lose the control over their thoughts, actions or feelings, but may also experience them as being foreign or manufactured against their will by some foreign influence. These symptoms are known as ideas or delusions of passivity. The patient may also develop secondary delusions that explain this foreign control as the result of radio waves, X-rays, television, witchcraft, hypnosis, the internet, and so on. This can be described as a delusion of passivity. There is some evidence that delusions of passivity are related to anomalies of the parietal lobe (Maruff et al, 2005), but this association requires further study to clarify the precise anomalies that may underlie these phenomena.
Some individuals with severe anxiety may feel they cannot think clearly or are unable to carry out ordinary volitional activity. They may therefore feel ‘as if’ they are being controlled by foreign influences. As they have difficulty in thinking and putting their thoughts into words they may give the impression that they know that their thoughts are under foreign control, so it may be difficult to distinguish these ‘as if’ experiences from true passivity phenomenon, as seen in schizophrenia. This distinction is, however, crucial if misdiagnosis is to be avoided.
Classification of motor disorders
It is difficult to classify motor disorders, because although clear-cut individual motor signs, such as stereotypies, can be treated as if they were neurological symptoms, it is much more difficult to classify more complicated patterns of behaviour.
South–South cooperation has tended to focus on production and distribution issues rather than macroeconomic questions such as identifying the key concerns of the developing world. It has prioritised and indeed – intensified industrialisation as a way of reducing inequality, overcoming under- and unemployment, and promoting skill development. This view rests on the Prebisch's proposition that sluggish growth in demand for peripherally-produced commodities and a burgeoning peripheral demand for industrial products manufactured at the centre, results in declining terms of trade for developing countries. This, in turn, makes it difficult for developing countries to generate sufficient export earnings to finance the imports they need for their development, hence causing them always to operate under threat of a current account deficit.
This view also ties in with India's own experience of skill development. Nehru's original initiative in inviting China and Indonesia to send students to India for technical training programmes expanded sufficiently to warrant a new, enlarged programme that consolidated India's fellowship and training programmes under the ITEC banner. By 2014, ITEC was offering 10,000 training slots to 167 partner countries; the slots were spread over nearly 270 courses in 47 different institutions regarded as centres of excellence in their areas of work.
Experience of this kind was useful in informing India's commitment to the Initiative for ASEAN Integration (IAI), a programme of the ASEAN Secretariat that aims to reduce the gap between advanced and new members from the Cambodia, Laos, Myanmar and Vietnam region (CLMV). India's involvement came in response to a call from the ASEAN Secretariat for its partner countries, including India, to take special measures to help narrow the development divide and promote national competitiveness through intra-regional cooperation.
Indian interest in the CLMV region is very clear; Delhi has already been engaged with CLMV countries at the bilateral level and was keen to respond to the call from ASEAN heads of state and governments at their 2003 summit conference that led to the launch of the IAI. The specific mandate for a programme resembling the one that India had already begun came about in 2003 with the declaration of the ASEAN Concord (known as Bali Concord-II). This declaration stressed deepening and broadening ASEAN cooperation through a technical and development cooperative effort that could address the development divide.
Since India's Independence, almost all government ministries have operated in line with requests from partner countries. It is not only the MEA that initiates and manages development cooperation-related programmes. Line ministries, particularly those of Agriculture, Science and Technology, Health and Family Welfare, Environment and Forest, Human Resource Development and related agencies also play an important part (see Figure 3.1).
Chapter 2 included a discussion of the role of Exim Bank, an instrument of the MoF, in the new arrangements for managing credit lines. Line ministries become involved when a related demand is raised by partner countries. Socio-economic indicators show that most partner countries are at a stage where innumerable sectoral challenges dominate their policy concerns, a situation duly reflected in the nature of the demands that India faces. The line ministries’ response, however, varies depending on how they balance domestic pressures against external demands. For some, domestic demand is such that their thrust is largely towards developed countries. The Department of Biotechnology (DBT), for example, had major programmes with the South since its establishment, but this demand began to taper off from 2006 in response to a growing thrust toward linkages with developed countries. The DBT Annual Report for 2012–13, as in previous years, has nothing to report on India's engagement with developing countries. It is clear that even if MEA pushes for closer ties with a specific set of countries its intentions would remain in the realm of rhetoric if line ministries do not respond with the requisite commitment. At times, individual preferences and priorities seem to prevail for the selection of particular countries and programmes. It goes without saying that in some instances, the traction for cooperation with Northern partners and visits to those countries is extremely strong.
Reaction from line ministries also depends on the nature of any international links they may have. In that respect the policies of international institutions have important implications for the nature of the programmes line ministries develop; for instance the World Health Organization (WHO) might facilitate programmes from the Ministry of Health (MoH) to other developing countries. Similarly, FAO or International Fund for Agricultural Development (IFAD) would influence the involvement of the Ministry of Agriculture (MoA). Such influence may be direct, or through personal exposure and other indirect contacts such as seminars, workshops, or fellowship programmes.
The process of decolonisation began soon after the end of World War II and India was one of the first countries to gain independence. Many other developing countries that gained independence in the 1950s and 1960s faced a common problem: to eradicate poverty and bring the fruits of economic and social development to their people. It was this shared challenge that inspired early initiatives to promote SSC. India was one of the leaders of this movement, which essentially was based on Third World solidarity. Countries of the developing world not only cooperated in sharing their modest capabilities and resources with each other on the basis of mutual benefit, but also created forums through which they could work to create a more level playing field from which to promote their interests in the international economic order. The NAM became an influential vehicle for that purpose while the G-77 emerged as a key grouping of developing countries that worked on promoting the economic and trade interests of developing countries at the UN and in negotiations with the economically developed countries of the West. The G-15 was formed by NAM as a means of engaging the G-7 developed countries in a dialogue over reform of the international economic order. Nevertheless, while initiatives of this kind were successful in achieving some benefits for the developing world the essential structure of the global economy stayed mostly unchanged and the demands of NAM and the G-77 remained in the realm of rhetoric. There was certainly some progress in promoting economic cooperation among developing countries but it was limited in both scope and scale. The SSC could serve only as a modest supplement to the much more important role played by the ODA bilaterally as well as multilaterally, from developed to developing nations.
With the end of the Cold War around 1990, NAM itself lost much of its traction. The sense of solidarity that marked its early years became less evident as conflicts between the developing countries themselves became more numerous and frequent. There was also a growing divergence in the rates of development achieved by different countries. The oil crisis of the early 1970s paved the way for the emergence of a group of affluent oil-exporting countries that had little in common with the majority of poorer nations.
During the past decade or so, several new trends have emerged on the global geopolitical and economic scene. Some of them have taken shape over the years, establishing new frontiers for the Indian development cooperation programme. As noted in earlier chapters, apart from an increase in funding volumes, new features and novel modalities have come to define Indian's development cooperation programmes. The new trends are discernible both on the ground, where projects and programmes are delivered, and at headquarters, where governance mechanisms and – more importantly – an institutional framework have evolved. This chapter explores some of the major shifts that have advanced the frontiers of engagement and opened up new avenues for development partnerships. It also looks at possible challenges to be addressed if resources are to be best utilised in the process.
Several new directions have influenced the profile of India's development cooperation programmes. In this regard, the effort to reach out to partner countries’ communities and CSOs, along with local governments, in the implementation of development programmes has been extremely well-received. Secondly, the establishment of the DPA is expected to ensure optimum resource utilisation for greater returns, with a due role reserved for territorial divisions in the MEA. Its efforts in consolidating country- and region-specific information and analysis will make this possible. The third major move is a greater push for S&T and the fourth, and most important, addition is the rise in total allocations and expenditure by the government (although MoF has yet to insulate these allocations).
There are areas of concern as well, which in due course may pose major challenges to the development partnership programme. At the practical level, they need to be addressed adequately and wholeheartedly so that the programmes become more enduring and resilient. First and foremost in this list is the health of Exim Bank, which is of key importance to the LoC programme. Even though the Cabinet has amended the 2005 policy to allow other public sector banks to extend LoCs, it is still the Exim Bank that dominates the field and any major default on a LoC would have crucial implications for it. It is therefore extremely important that all possible sources of potential trouble be addressed before it is too late.
Although personality disorder has no specific psychopathology, the problems associated with its distinction from Axis I disorders justifies its inclusion. True to the Germanic tradition of Schneider, who believed there was overlap between personality disorder and the neuroses, the ICD−10 Classification of Mental and Behavioural Disorders (ICD−10; World Health Organization, 1992) does not distinguish them either and classifies them on a single axis, whereas the Diagnostic and Statistical Manual of Mental Disorders (DSM−IV; American Psychiatric Association, 1994) classifies personality disorder on a separate axis from mental state disorders.
The history of personality disorder is one of the oldest in psychiatry dating back to Hippocrates, who believed that the balance between the four humours represented the different elements of personality, being identified as yellow bile from the liver, black bile from the spleen, blood and phlegm. These represented choleric (bad-tempered), melancholic (gloomy), sanguine (optimistic/confident) and phlegmatic (placid/apathetic) traits respectively.
The person who contributed most to our modern understanding of personality is undoubtedly Schneider, although his work Psychopathic Personalities for Modern Classificatory Schemes, first published in 1923, was not translated into English until 1950. He defined those with personality disorder as ‘those who suffer or make society suffer on account of their abnormality’, a view that is found in both of the contemporary classifications. He used the term ‘psychopathic’ in a broad sense to describe the totality of personality disorders, although this term has had a more restricted use in recent decades.
Personality can be defined as the totality of the person's emotional and behavioural traits that characterise their day-to-day living. Personality disorders are deeply ingrained, maladaptive patterns of behaviour, generally recognisable by adolescence and continuing throughout adult life.
Dimensions and categories
The modern understanding of personality is derived from trait psychology and it places traits on a continuum from absent to severe. Only those traits that reach a threshold for severity (impinging on self or others negatively) are regarded as pathological. In order to diagnose a specific personality disorder it is necessary to have a cluster of traits that are at or above this threshold. However, since most of the categories of personality disorder classified in ICD−10 and DSM−IV have not been validated and overlap with each other, there is debate about whether this categorical approach is the best way to conceptualise personality.
Recent decades have seen a revival of interest in the study of the self, selfawareness and various changes in self-awareness, especially in the context of mental illnesses such as schizophrenia (Sass & Parnas, 2003; Harland et al, 2004). Although there is a substantial German literature on Ichbewusstsein or ego consciousness, both of these terms have now been replaced by the term ‘self-experience.’ Jaspers (1997) has pointed out that there are four aspects of self-experience, the awareness of:
• existence and activity of the self
• being a unity at any given point in time
• continuity of identity over a period of time
• being separate from the environment (or, in other words, awareness of ego boundaries).
It is possible to discuss disorders of self-awareness under these four headings, but a number of other symptoms can be regarded as disturbances in two of these aspects of self-experience: awareness of existence and activity of the self and awareness of being separate from the environment.
Disturbance of awareness of self-activity
All events that can be brought into consciousness are associated with a sense of personal possession, although this is not usually in the forefront of consciousness. This ‘I’ quality has been called personalisation (Jaspers, 1997) and may be disturbed in psychological disorders. There are two aspects to the sense of self-activity: the sense of existence and the awareness of the performance of one's actions.
A change in the awareness of one's own activity occurs when the patient feels that they are no longer their normal natural self and this is known as ‘depersonalisation’. Often this is associated with a feeling of unreality so that the environment is experienced as flat, dull and unreal. This aspect of the symptom is known as ‘derealisation’. The feeling of unreality is the core of this symptom, and it is always, to a greater or lesser extent, an unpleasant experience; which distinguishes it from ecstatic states.
When the patient first experiences the symptom they are likely to find it very frightening and often think it is a sign that they are going mad. In the course of time they may become more or less accustomed to it. Many patients who complain of depersonalisation also state that their capacity for feeling is diminished or absent.
Disorders of thought include disorders of intelligence, stream of thought and possession of thought, obsessions and compulsions and disorders of the content and form of thinking.
Disorders of intelligence
Intelligence is the ability to think and act rationally and logically. The measurement of intelligence is both complex and controversial (Ardila, 1999). In practice, intelligence is measured with tests of the ability of the individual to solve problems and to form concepts through the use of words, numbers, symbols, patterns and non-verbal material. The precise age at which intellectual growth appears to slow down depends on the type of test used, but it now appears that intelligence, as measured by intelligence tests, begins its slow decline in middle-age and proceeds significantly less rapidly than previously believed (McPherson, 1996).
The most common way of measuring intelligence is in terms of the distribution of scores in the population. The person who has an intelligence score on the 75 percentile has a score that is such that 75% of the appropriate population score less and 25% score more. Some intelligence tests used for children give a score in terms of the mental age, which is the score achieved by the average child of the corresponding chronological age. For historical reasons, most intelligence tests are designed to give a mean IQ of the population of 100 with a standard deviation of 15. Even if the distribution of scores is not normal, percentiles can be converted into standard units without difficulty and this is probably the best way of measuring intelligence.
Intelligence scores in a group of randomly chosen subjects of the same age tends to have a normal distribution, but this only applies over most of the range of scores. Towards the lower end of the range there is an increase in the incidence of low intelligence that is the result of brain damage caused by inherited disorders, birth trauma, infections and so on. There are, therefore, two groups of subjects with low intelligence or what is now termed ‘learning disability’ or ‘intellectual disability’. The first group comprises individuals whose intelligence is at the lowest end of the normal range and is therefore a quantitative deviation from the normal. The other group of individuals with learning disability comprise individuals with specific learning disabilities.
It is customary to distinguish between feelings and emotions. A feeling can be defined as a positive or negative reaction to some experience or event and is the subjective experience of emotion. By contrast emotion is a stirred-up state caused by physiological changes occurring as a response to some event and which tends to maintain or abolish the causative event. The feelings may be those of depression, anxiety, fear, etc. Mood is a pervasive and sustained emotion that colours the person's perception of the world. Descriptions of mood should include intensity, duration and fluctuations as well as adjectival descriptions of the type. Affect, meaning short-lived emotion, is defined as the patient's present emotional responsiveness. It is what the doctor infers from the patient's body language including facial expression and it may or may not be congruent with mood. It is described as being within normal range, constricted, blunt or flat.
The classification and description of moods and emotion is bedeviled by the fact that the same terminology is used to describe those that are normal and appropriate (indeed their absence might be considered abnormal) and those that are so pathological as to warrant hospitalisation. Terms, such as depression, anxiety, etc., are examples of similar words being used for normal emotional reactions and for disorders requiring treatment. This failure to differentiate has serious implications, since not only does it cause linguistic confusion but it fails to distinguish the normal from the abnormal.
In this chapter, five levels of emotional reaction and expression that have clinical relevance will be described. The term normal emotional reactions will be used to describe emotional states that are the result of events and that lie within cultural and social norms. Abnormal emotional reactions are those that are understandable but excessive, while abnormal expressions of emotion refer to emotional expressions that are very different from the average normal reaction. Morbid disorders of emotional expression differ from abnormal expressions of emotion in that the person is unaware of the abnormality. Finally there will be a brief overview of morbid disorders of emotion.
Normal emotional reactions
Some emotional reactions are normal responses to events or to primary morbid psychological experiences.
Any discussion of the classification of psychiatric disorders should begin with the frank admission that the definitive classification of disease must be based on aetiology. Until we know the cause of the various mental illnesses, we must adopt a pragmatic approach to classification that will best enable us to care for our patients, to communicate with other health professionals and to carry out high-quality research.
In physical medicine, syndromes existed long before the aetiology of these illnesses were known. Some of these syndromes have subsequently been shown to be true disease entities because they have one essential cause. Thus, smallpox and measles were carefully described and differentiated by the Arabian physician Rhazes in the 10th century AD. With each new step in the progress of medicine, such as auscultation, microscopy, immunology, electrophysiology, etc., some syndromes have been found to be true disease entities, while others have been split into more discrete entities and others jettisoned. For example, diabetes mellitus has been shown to be a syndrome that can have several different aetiologies. On that basis the modern approach to classification has been to establish syndromes in order to facilitate research and to assist us in extending our knowledge of them so that ultimately specific diseases can be identified. We must not forget that syndromes may or may not be true disease entities and some will argue that the multifactorial aetiology of psychiatric disorder, related to both constitutional and environmental vulnerability, as well as to precipitants, may make the goal of identifying psychiatric syndromes as discrete diseases an elusive ideal.
Syndromes and diseases
A syndrome is a constellation of symptoms that are unique as a group. It may of course contain some symptoms that occur in other syndromes also, but it is the particular combination of symptoms that makes the syndrome specific. In psychiatry, as in other branches of medicine, many syndromes began as one specific and striking symptom. In the 19th century, stupor, furore and hallucinosis were syndromes based on one prominent symptom. Later, the recognition that certain other signs and symptoms co-occurred simultaneously led to the establishment of true syndromes. Korsakoff's syndrome illustrates the progression from symptom to syndrome to disease. Initially, confabulation and impressibility among alcoholics were recognised by Korsakoff as significant symptoms.
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