INDIAN JOURNAL OF CLINICAL PSYCHOLOGY

Editorial Board, Journal Committee, Executive Council & i-ii Secretariat Volume 43, Number - 1 March, 2016 Instructions to Authors iii-v ISSN 0303-2582 Editorial GYNAE – C – PSYCH – OLOGY : NEED OF TODAY 1-4 K.S. Sengar Research Articles 5-11 Effect of Neuro-Feedback Training on Cognitive (Executive) Function in Obsessive Compulsive Disorder (OCD) Priyanka Lenka, Masroor Jahan and V. K. Sinha Application of Self- Regulatory Executive Function (S-REF) 12-19 Model in Psychopathology Formulation of Patients with Anxiety Disorders Soheli Datta and Sanjukta Das (I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ 20-25 Adults with Stuttering : A Preliminary Study Sanjeev Kumar Gupta Crisis and Trauma in Academic Settings: Implications for 26-32 Campus Mental Health L. N. Suman Memory Functioning in Patients with Schizophrenia and 33-36 (GLWRU Obsessive Compulsive Disorder in Remission : A Comparative Study K. S. Sengar Jashobanta Mahapatra, Sushree Sangita Behura, Narendranath Samantaray, Pratit Pattnaik and Saumyashree Mohapatra Role of Memory Rehabilitation on Persons with Alcohol 37-45 Dependence Sheril Elizabeth Jose, K. S. Sengar and Archana Singh A Comparative Study of Receptive Speech among Male and 46-50 Female Cases with Schizophrenic Illness Riju Raj Roy, Anand Manjhi and J. Mahto Therapeutic Effects of Yoga on Generalized Anxiety Disorder 51-57 Laiju S. and Sananda Raj Psychometric Properties of Hindi Version of Peace of Mind, 58-64 Harmony in Life and Sat-Chit-Ananda Scales Kamlesh Singh, Shambhovi Mitra and Pulkit Khanna

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76 INDIAN JOURNAL OF CLINICAL PSYCHOLOGY

Volume 43 March 2016 No. 1

Editor : K. S. Sengar

Editorial Board Editorial Advisory Board Anisha Shah (Bengaluru) A. K. Srivastava (Kanpur) Ashima N. Wadhawan (Delhi) Amool R Singh (Ranchi) D. P. Sen Mazumdar (Delhi) D. K. Sharma (Delhi) M. K. Mondal (Delhi) Devvrata Kumar (Bengaluru) M. S. Thimappa (Bengaluru) K. B. Kumar (NOIDA) R . G. Sharma (Varanasi) K. Pramodu (Kozikode) S. C. Gupta (Lucknow) L. S. S. Manickam (Mysuru) T. B. Singh (Patna) Maitreyee Dutta (Tezpur) Distinguished Former Editors Manjari Srivastava (Mumbai) S. K. Verma (1974 – 1983) N. G. Desai (Delhi) S. K. Maudgil (1984 – 1986) Rajeev Dogra (Rohtak) S. C. Gupta (1987 – 1889) S. L. Vaya (Ahmedabad) D. K. Menon (1990 – 1991) U. K. Sinha (Delhi) R. Kishore (1992) Sanjukta Das (Kolkata) K. Dutt (1993) Shweta Singh (Lucknow) K. Rangaswami (1994 – 1995) S S Nathawat (1996 – 2002) Russy Tamanna (Delhi) Amool R Singh (2003 – 2006) Nawab Akhtar Khan (Mysuru) Ashima N Wadhawan (2007) Shweta (Singapur) S P K Jena (2008- 2011) Renuka Jena (UK)

Statistical Consultant Ram C Bajpai (Singapur)

i JOURNAL COMMITTEE K.S. Sengar (Chairman) Rakesh Kumar (Agra) S. Balakrishnan, (Chennai) Jashobanta Mohapatra, (Cuttak) P T Sasi, (Thrissur) Kalpana Srivatava, (Pune) ([2I¿FLR0HPEHU EXECUTIVE COUNCIL

President President Elect Amool R Singh K Girish ( Thiruananthpuram) RINPAS, Kanke, Ranchi (Jharkhand) [email protected] [email protected], [email protected]

Immediate Past President Hon. General Secretary V. C. George Kalpana Srivastava Miraj Dept of Psychiatry, AFMC, Pune (Mah) [email protected] [email protected]

Immediate Past Hon. Gen. Secretary Treasurer Masroor Jahan B N Roopesh RINPAS, Kanke, Ranchi (Jharkhand) NIMHANS, Bangalore [email protected] [email protected]

COUNCIL MEMBERS All India East Zone Sanjukta Das Sameeta Nag [email protected] [email protected]

Manoj K. Bajaj Bidita Bhattacharya [email protected] [email protected]

West Zone North Zone Smita Pandey Vikas Sharma [email protected] [email protected]

Sudipta Roy Atul Kumar [email protected] [email protected]

South Zone President Nominee Sreehari R. S.L. Vaya [email protected] [email protected]

Jini K. Gopinath Minkesh Chaudhry [email protected] [email protected]

SECRETARIAT Department of Psychiatry, Armed Forces Medical College (AFMC), Pune (Maharashtra) India.

ii INSTRUCTIONS TO AUTHORS

IJCP welcomes the submission of manuscript Guidelines for Manuscript Preparation in all areas of treatment, prevention and promotion /HQJWKDQGVW\OHRI0DQXVFULSW of mental health especially on issues that appeal Full length manuscript length should not to clinicians, researchers, academicians and exceed more than 5000 words tentatively 15 typed SUDFWLWLRQHUV LQ WKH ¿HOG RI PHQWDO KHDOWK 7KLV pages total (including cover page, abstract, text, journal publishes Research / Original Articles, UHIHUHQFHV WDEOHV DQG ¿JXUHV  ZLWK DSSURSULDWH Review Articles, Brief Communications, Case margins (at least 1 inch) on all sides and a standard Reports, Letter to Editor, Book Reviews and News font (e.g. Times New Roman) of 12 points ( no about conferences etc. Manuscript must be prepared smaller). The entire manuscript (text, references, in IJCP format outlined below. Before submission of tables etc) must be double spaced, one side on a paper a manuscript to IJCP it is mandatory that all authors of good quality. The manuscript should conform have read the manuscript and owe the responsibility. the Vancouver style. The text of observational and The research that is reported in IJCP must be experimental study should be divided into following conducted after the approval of ethical committee sections: Title of the Paper, Name of the Author (s), and information regarding the same should be Abstract, Introduction, Method, Results, Discussion furnished in the method section. In general, at least and References. Manuscript should be prepared in ¿IW\ SHUFHQW RI WKH DXWKRU VKRXOG EH PHPEHU RI following format: ,$&3 DQ\FDWHJRU\ D &RYHU 3DJH  7LWOH 3DJH (Page 1) should Publication Policy consist Title of the Article, name of the author The IJCP policy advice the author of (s)/ corresponding author (s), institutional manuscript not to submit the same manuscript in two DI¿OLDWLRQ WHOHSKRQH PRELOH QXPEHU H PDLO or more journals for concurrent consideration and the addresses, if any. It should also consist the same must be stated in cover letter. IJCP requires the source of support, if any, received in any form DXWKRUWRUHYHDODQ\SRVVLEOHFRQÀLFWRILQWHUHVWLQ (grant, equipment, drugs etc.) and word count, the conduct and reporting of the study. They should QXPEHURIWDEOHV¿JXUHVXVHGLQWKHDUWLFOH also describe their role and participation in designing the study; data collection; analysis; interpretation of &RQÀLFWRI,QWHUHVW data; writing of report and / or in decision to submit Authors are required to complete a declaration the report for publication. Acknowledgement must of competing interest on their cover letter or on be furnished in condition of participation in the separate page. They should also describe their study in any form or if the material (picture, tables role and participation in designing the study; or any other data, with permission) has been taken data collection; analysis; interpretation of data; from any other place/source and is part of the study/ writing of report and / or in decision to submit manuscript. Ethical standards must be followed in the report for publication. the treatment of their sample, human or animals, or Acknowledgements: to describe details of treatment and research must Acknowledge to them who have been involved be approved from ethical committee. Approval / contributed substantially in conception, letter should be submitted to editor, IJCP (for ethical design, data collection, interpretation of data principles one can visit www.apa.org/ethics). RUDQ\RWKHUVLJQL¿FDQWFRQWULEXWLRQLQVWXG\ IJCP requires from Author/ Authors to transfer E 3DJH  should consist only title of the study copyright to IJCP for accepted manuscript before abstract and key words (up to 6 key words) publication.

For further details of manuscript preparation “Publication Manual of American Psychological Association (6 th ed.)” can be consulted (also visit www.apastyle.org).

iii Abstract WKH¿QGLQJVLQWKHOLJKWRIFXUUHQWO\DYDLODEOHOLWHUDWXUH Abstract up to 250 words should be given on whether supporting the results or contradictory. page 2 of the manuscript and must include: Aims/ Findings to be concluded and limitation, implication Objectives: A brief about the purpose of the study RIWKH¿QGLQJVRQFXUUHQWFOLQLFDORUDFDGHPLFVHWXS Method: description of the data (e.g. N, age, sex, and future direction should also be delineated clearly. 6(6 HWF  EULHÀ\ SURFHGXUH WRROV XVHG VWDWLVWLFDO SURFHGXUH HWF 5HVXOWV GHWDLO ¿QGLQJV DQG REFERENCES Conclusi on . Abstract must communicate the glimpse References should be listed in alphabetical of the study. order as per guideline delineated in APA Manual. Each reference presented in reference list must Key Words appear in the text and references cited in text must After the abstract, authors should provide key be present in reference section. Some examples for word (5 – 6 in numbers) which mainly deals with citation of references are as under. the study. a. Article from Journal c. Page 3 should contain the actual article Singh., R. S., & Oberhummer, I. (1980). beginning with title, introduction and ending Behaviour therapy within a setting of karma with references. yoga. Journal of Behaviour Therapy and INTRODUCTION Experimental Psychiatry ,11, 135-141 Provide a context for the study. Focus on the b. Journal Article in Press theoretical origin of the problem and its nature and Kharitonov, S. A., & Barnes, P. J. (in Press), VLJQL¿FDQFH LQ SUHVHQW VFHQDULR $OVR GHDOV ZLWK Behavioural and social adjustment. Journal of existing knowledge of present day. Personality and Social Psychology. METHOD c. Conference Proceedings Published Includes Aims/Objectives, Hypothesis, source Jones, X. (1996). Prevalence of Mental & of population and selection criteria, participants, Behavioural disorder. In Proceedings of the tools and techniques used. This section of each First National Conference of World Psychiatry empirical report must contain the description of Association, 27-30 June; Baltimore. Edited by participants, detail description of measure used for Smith Y. Sumeham: Butter \vorth-Heinemann; study and statistical procedure applied. Statistical pp. 16-27. procedure should be described with enough detail d. Book Chapter, or Article in Edited Book by emphasizing the procedure used for processing Singh, A K., Mishra, R S., & Banerjee, S the data including software package and its version. (2012). Pattern of perception of mental illness 6WDWLVWLFDOUHSRUWLQJPXVWFRQYH\FOLQLFDOVLJQL¿FDQFH in North America and Central India : A cross Author should report descriptive statistics for all cultural study. In Hutton, J., Devika, N., Mohd, continuous study variable and effect sizes for the S H., & Robert, L S Perception of Mental SULPDU\ VWXG\ ¿QGLQJV$XWKRUV VXEPLWWLQJ UHYLHZ Illness across teh Globe. (Pp 456-479), Print articles should describe the method used for locating, Vision Press, India. selecting, extracting and synthesizing data. f. Entire Issue or Special Section of Journal RESULTS Ponder, B. Johnston, S., Chodosh, L. (Eds.) After processing the data, obtained values to be (2006). Innovative oncology. In Breast Cancer presented in table/graphic form or in illustrations. Research, 10, 1-72. This should include the demographic correlates and study variables. g. Whole Conference Proceedings Smith, Y. (Ed) (1996). Proceedings of the DISCUSSION First National Conference of World Psychiatry This section should focus on the discussion of Association, 27-30 June : Baltimore. Edited by

iv Stoneham : Butterworth-Heinemann. Pp 16- For further details for preparation of 27. PDQXVFULSW WDEOHV ¿JXUHV UHIHUHQFHV PHWULFV h. Complete Book authors are advised to consult Publication Manual of Margulis, L. (2005) Cognitive Sciences . New the American Psychological Association (6th ed.) or Haven: Yale University Press. can also visit to www.apastyle.org. i. Monograph or Book in a Series MANUSCRIPT SUBMISSION: Gupta, S.C., & Sethi B.B. (1987). Psychiatric Two sets of Manuscript, neatly typed in Morbidity in Uttar Pradesh. Monograph of double space, printed on one side on the paper of Culture & Society, 10 (1, Serial No. - 25). good quality along with soft copy (CD) should be j. Technical & Research Reports submitted to the Editor, IJCP on address given below. Shankar, M., Dutta, K., & Tiwari, A. K. (1995). Cover Letter, Declaration, Ethical Committee Mental Health in Schools (DGHS Publication $SSURYDODQG/HWWHURI&RQÀLFWPXVWEHHQFORVHG No. 10, 2), Delhi. Govt. Printing Press. NB: After the receipt of the manuscript by HGLWRULDO RI¿FH LW LV PDQGDWRU\ WR EH UHYLHZHG E\ k. Ph. D. Thesis board of reviewers which may take time. Authors Kohavi, R. (1995). Psychosocial function in are requested to give some grace period to editorial diabetics, Ph.D. thesis. All India Institute of RI¿FH $V VRRQ DV WKH RSLQLRQ  FRPPHQWV RI WKH Medical Sciences. New Delhi. UHYLHZHU ZLOO EH UHFHLYHG E\ WKH HGLWRULDO RI¿FH I. Link/URL same will be forwarded to corresponding author. In Morse, S.S. (1995). Factors in the emergence case, manuscript is not found suitable for publication of infectious diseases. F merg Infect Dis [serial in IJCP, will not be returned to the Author. However, on the Internet] Jan-Mar [cited 1996 Jun 5); if some author is interested to take their manuscript 1(1). Available from: URL: http://www.cdc. back, need to send the S elf Addressed and Stamped gov/ncidod/EID/eid.htm. envelope WRWKHHGLWRULDORI¿FHZLWKUHTXHVWOHWWHUIRU taking manuscript back. TABLES AND ILLUSTRATIONS: Table should be clearly prepared and double space typed with proper margin, presented on All Manuscript must be Submitted to: separate sheet. All table should be numbered and the Dr. K. S. Sengar same must appear in text (e. g. table number .... to Editor, IJCP be inserted here). Each Table must carry brief title. Avoid long and multiple box table. Sample is as Additional Professor, under : Department of Clinical Psychology

Conditions Schizo (n=30 Normal (n=30) t RINPAS, Kanke, Ranchi – 834006

Mean SD Mean SD Jharkhand (India) Mobile. : 91 94317 69001, 91 95700 93721 Visual 1.7 0.94 0.7 0.01 0.45**

Auditors 3.0 0.02 2.6 0.96 0.11* Submission of manuscript can also be done p< 01*, p<001** through mail: [email protected] *UDSKLF ¿OHV ¿JXUH  RI JRRG TXDOLW\ GLJLWDO print is required to be submitted in JPG or TIF format by hiding identity in case of person or place of importance.

v INDIAN JOURNAL OF CLINICAL PSYCHOLOGY

7KH ,QGLDQ MRXUQDO RI &OLQLFDO 3V\FKRORJ\ LV DQ RI¿FLDO SXEOLFDWLRQ RI Indian Association of Clinical Psychologists. It is peer reviewed journal published biannual in the month of March and September. It was started in 1974 and is being published regularly. The journal has long circulation amongst the various professionals like Clinical Psychologists, Psychiatrists, Psychiatric Social Workers and others who have interest in the area of mental health. Journal publishes Research Articles, Review Articles, Case Reports, Book Reviews, Brief Communication and Letters to Editor. The journal encourages the articles related to theory based interventions, studies that investigate mechanism of change, effectiveness of treatment in real world setting. Journal also accepts the articles in the area of Women, Child & Adolescents and Community Mental Health. Articles related to epidemiology, critical analysis and meta analysis of treatment approaches, health care economics etc. are also accepted. Journal is registered with Registrar of News Papers of India (RNI 26039/74) Subscription Institutional Individual India Rs. 2000 per year Rs. 1000 per year Overseas U.S. $ 200 per year U.S. $ 100 per year Terms & Conditions/Mode of Payment: Payment should be made by multi city Cheque or Demand Draft, drawn in favour of the Editor, IJCP, payable at Ranchi and to be sent to : Dr. K.S. Sengar, Editor, IJCP, RINPAS, Kanke, Ranchi - 834 006 (Jharkhand) INDIA. email : [email protected] Form IV INDIAN JOURNAL OF CLINICAL PSYCHOLOGY, 2016, Vol. 43, No.1 Statement about the ownership and other particulars about Indian Journal of Clinical Psychology : 1. Place of Publication : Ranchi 2. Periodicity of Publication : Half-Yearly 3. Printer's Name : Annapurna Press & Process, 5, Main Road, Ranchi (Jharkhand) 4. Editor's and Publisher's Name : Dr. K. S. Sengar 5. Nationality : Indian 6. Address : Department of Clinical Psychology, Ranchi Institute of Neuro Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi -834 006 (Jharkhand), INDIA Phone : 91 94317 69001, 91 95700 93721 7. Name and address of individuals & Who own the Journal & partners or share holders holding more than one percent of the total capital : Indian Association of Clinical Psychologists I, Dr. K. S. Sengar, hereby declare that the particulars given above are true to the best of my knowledge and belief.

7KHLQIRUPDWLRQSXEOLVKHGLQWKHMRXUQDOUHÀHFWVWKHYLHZVRIWKHDXWKRUDQGQRWRIWKHMRXUQDORULWVHGLWRULDO board or Association. Author will be solely responsible for the information presented herein and its accuracy or completeness. Journal represent that the information is presented herein is complete and accurate and not responsible for any errors or omission. The copies of the journal to members of the association/subscribers are sent by ordinary post and editor or editorial board will not be responsible for non delivery of the journal. However, for ensured delivery of the journal LWLVPDQGDWRU\WRUHTXHVWWKHHGLWRULDORI¿FHWRVHQGWKHMRXUQDOE\UHJLVWHUHGSRVWRUVSHHGSRVW)RUWKLVWKHSRVWDO charges for speed post or registered post will essentially borne by member / subscriber. Claims for missing issues will be serviced without any additional cost. However, the claims must be made within stipulated period (2 months after the publication of journal).

vi Indian Journal of Clinical Psychology Copyright, 2016 Indian Association of 2016, Vol. 43, No. 1, 1-4 Clinical Psychologists (ISSN 0303-2582) Editorial GYNAE – C – PSYCH – OLOGY : NEED OF TODAY K. S. Sengar

Since the inception of the concept of gender. The psychosocial and cultural factors play Community living every society had talked about the DVLJQL¿FDQWUROHLQGHDOLQJWKHSDWLHQWVRIDQG complex understanding of psychology of women. by any gender. The medicine is practiced in many The Women Health and specially Women Mental different ways by men and women with different Health has always remained a matter of negligence. personalities, attitude and beliefs and the several The reason may be their complicated emotionality kind of projection, fantasies, beliefs and resistances DQGFRQ¿QHPHQWSRRUH[SRVXUHRIVRFLDOLVVXHVLQ appear on both side (client and clinician as well) frontline as core stakeholder, less participation or affect the gynaecologist's patient relationships. opportunities in decision making process etc. But Women frequently project on male gynaecologist with the untiring effort of some social reformer as their problems concerning men and the way they Raja Ram Mohan Rai, Dayanand Saraswati and view male sex similarly male gynaecologists can others who put their whole life for the upliftment also project on the patients their problem regarding of the conditions of women through improving women as well as the peculiar way they view the their social, economical and educational conditions female sex and by that gynaecologist–patient's especially in Indian society. Apart for this since therapeutic relationship often acquires very recent past with advent of newer communication “neurotic pattern”. The fact is that in Women’s means and technological developments, the females Medicine the fundamental for patient's to be “in have also been empowered /well equipped and had tune” for strong therapeutic relationship. The GHYHORSHG FRQ¿GHQFH WR VWHS WRJHWKHU ZLWK WKH psychological dynamics of therapeutic relationship GHYHORSLQJVRFLHW\LQHYHU\¿HOGIURPZDUIDUHDQG often remains at subconscious or unconscious technology to agriculture. They have now become a level not only on the part of patient but also the biggest workforce in the all sectors and contributing part of male or female doctors. The clinical VLJQL¿FDQWO\LQEXLOGLQJRIHFRQRP\RIDQ\FRXQWU\ SV\FKRORJLVWFDQSOD\DVLJQL¿FDQWUROHLQRULHQWLQJ Even after the remarkable advancement in and evaluating the emotionality, projections of information technology when all the information is G\QDPLFVDQGUHÀHFWLRQRIWKHLUEHKDYLRXUWRZDUGV easily accessible to every/any one at any/every time each other by gynaecologist and patient as well and and the health advice is accessible for all through building strong therapeutic relationship needed for satellite clinics and telemedicine, but certain issues better recovery. are still remaining unresolved. As it is always For the issues related to Gynaecology women considered that Ob/ gyn. is extremely complex still remain hesitant to disclose and good amount of and problematic speciality. The reasons may be VLJQL¿FDQWLQIRUPDWLRQUHPDLQVXQGLVFORVHGZKLFK the Women’s Medicine is never discussed neither is essential to deal the problem faced by individual. within Gynaecology nor out of it. The reasons may In the area of health especially Mental Health be - 1) incapability to perceive the determined in Indian scenario the women are less priority IDFWRUVUHÀHFWDERXWWKHP QRWZDQWLQJWRDGPLWWKH EHQH¿FLDU\VWDNHKROGHU DV HYLGHQFHG E\ YDULRXV existence of these facts 3) the interest, convenience national and international reports. Unfortunately, and beliefs that dominate Women’s medicine. the majority of women with mental health issues The Women Medicine deals with gynaecology, including those who are pregnant and postpartum obstetrics and obstetric surgery. These all three failing to receive adequate treatment for their are technically very different medical speciality. mental health sufferings (Poleshuk, 2013). When Clinical Psychology is relevant in all three branches issue relate to sexuality, reproduction, prepartum, as the psychology of gynaecology deals the issues postpartum, menstruation, menopause, prenatal, related to consciously or unconsciously projected perinatal and infertility it becomes more complex. dynamics of patients and gynaecologist as well The scenario in world is almost same. No females in building therapeutic relationships of either are preferring to be examined their genitalia by

1 K.S. Sengar / GYNAE – C – PSYCH – OLOGY : NEED OF TODAY male gynaecologist except their husband who has and poverty can leave ob/gyn providers feeling been bestowed this right by virtue of entering in uncertain and overwhelmed as to how to respond the holy institution “marriage”. They believe that to complexity of their patient's needs. Today the any male inspecting a female’s genitalia would be service providing system in any area is overwhelmed violating the SACRED husband and wife intimacy- with newer technological developments and in the which they both believe GOD recognized. The area of Women's Medicine the "patient centered, condition in India is little more critical. The Asian comprehensive, coordinated, and accessible females still not very clear where to seek the help health care delivery model" is the requirement when matter related to psychological issues of of present era. The clinical Psychologist can Gynaecological area comes. May be because of provide their services in screening, consultation, value laden thinking and culturally loaded thought psychotherapeutic engagement, provision of and behaviour impede them not to visit any other psychotherapy, collabouration, facilitation of professional except Gynaecologist preferably of the patient- service provider relationships, education same gender. Moreover, many Ob/gyn (Obstetrics/ and research. gynaecology) feel ill equipped to talk with their In practice many cases have been reported that patients regarding emotional and safety issues due to fear of breaking celibacy or fear of painful related to intimate relationship and sexual activity. YDJLQDOLQVHUWLRQRUDVWURQJ¿[DWHGWKLQNLQJWKDW Hence, the services of clinical psychologist/ God/Goddess will become angry if one will break women's health psychologist may be useful in virginity and mishappening will take place in life of providing the support and intervention, gathering self and/or family or fear of delivering child or…... the information, relationship, physically and emotionally safe contact, pregnancies prevention, Because of such irrational fear/thought the sexual functioning and communication. The female partner is often avoiding the sexual encounter clinical psychologist Women Health Psychologist with her counterpart. Some cases have also been FDQ¿OOWKHJDSE\SURYLGLQJFRQVXOWDWLRQWRVHUYLFH reported with the complaint of uncooperativeness providers(Ob/gyn) about the guidelines of how or complete denial of sexual encounter compelled to assess and address the sexual dysfunctions by the irrational thought, fear of producing child (Armstrong, 2011). which is very painful act / exercise which may not tolerated by them. Apart from the traditional mental The Women's Medicine (Ob/Gyn) providers and sexual disorders with the revolutionary changes increasingly have been called upon to address in information technology and growing awareness LGHQWL¿FDWLRQDVVHVVPHQWSUHYHQWLRQDQGWUHDWPHQW about the issues related to mental health, sexuality of behavioural health concerns as part of their and reproductive science has explored newer mission to deliver reproductive health care. But researches consistently show that Ob/gyn practices dimension and today it is established fact that role fail to address, treat women's behavioural health of mental health professionals especially clinical needs adequately, including anxiety, depression, SV\FKRORJLVWV KDV EHFRPH VLJQL¿FDQW LQ WKH DUHDV eating disorder and substance abuse etc. Ob/gyn which were considered to be reserved for one or service providers generally focus on the women RWKHUVSHFL¿FVSHFLDOLW\RIPHGLFDOVWUHDPHJ2EV health care needs and they often have a primary & Gynaecology (even other medical professionals focus on developmental issues such as menstruation, are not considered competent to help the client), initiation of contraception, pregnancy, child birth Oncology etc. and menopause. The challenges often seen in Menstruation is another complicated and combination with these transitional period - such as GLI¿FXOW WUDQVLWLRQDO SKDVH LQ OLIH RI ZRPHQ unintended pregnancies, infertility, pregnancy loss, Though, onset of menstruation does not always FKURQLF LOOQHVV DQG SDLQ PRRG VOHHS GLI¿FXOWLHV FDXVHVLJQL¿FDQWGLI¿FXOW\WRHYHU\RQHEXWIRUVRPH caregiving challenges, interpersonal trauma menstruation is complicated period with multiple

2 K.S. Sengar / GYNAE – C – PSYCH – OLOGY : NEED OF TODAY physical and emotional problems. Premenstrual cases reported in the clinics disclose the fact that Dysphoric Disorder (PMDD), chronic pelvic pain, developed the idea not to produce the child at least VWLIIQHVVDQGSDLQIXOVHQVDWLRQRQEUHDVWKRWÀDVKHV female child because of the fear that same incidence tenderness and many more symptoms may appear may happen to her also. in females during menstruation period. Though, In such circumstances clinical psychologists the antidepressant is the choice of medicine to treat FDQ RIIHU VLJQL¿FDQW UHPHGLDO PHDVXUH E\ WKH30''EXWHI¿FDF\RIWKDWLVVWLOOTXHVWLRQDEOH participating in meeting with family and service &RJQLWLYHEHKDYLRXUWKHUDS\KDVSURYHQLWVHI¿FDF\ providers to discuss their concern and goal. The in treatment of PMDD and also to help them to clinical psychologist is well equipped and well identify triggers of their irritability, reduce their suited to emphasize the concept of interdependence dysphoria, improve their mood and effectively and its effect on the physical and emotional well communicate with others about their needs. being and to offer various psychological measures Approximately 14% of pregnant women and to improve the functioning and reduce the stress 13-34% of postpartum women expressing clinically and pain interference. CBT and interpersonal VLJQL¿FDQWGHSUHVVLRQDQGDQ[LHW\DQGVRPHWLPH psychotherapy has proven its use / worth in psychosis too (Lan Carter et al., 2010). In such managing chronic pain/ pelvic pain (Poleshuk, FLUFXPVWDQFHV VHUYLFH SURYLGHU 2EJ\Q  ¿QG 2010; Paras et al., 2009). themselves ill equipped to handle these problems The pregnancy loss is devastating and painful and even identifying these problems. The clinical experience in life of women and causes stressful psychologist/ Women's health psychologist can reactions, psychological trauma and sometime provide psychotherapy/counselling to women and long lasting symptom of anxiety, stress and grief. WKHLU IDPLOLHV ZKR ¿QG WKHPVHOYHV WKDW WKH\ DUH It is also painful for Ob/ gyn as they have to depressed or suffering with their feelings beyond what obstetrician /gynaecologist (Ob/gyn) can communicate for such devastating information to offer. Support and psychotherapy can ease the parents. Supplying such bad news may cause some transition and help to work toward betterment. unwanted reactions to parents. The obstetricians The clinical psychologist can also help women may also experience grief, sadness and guilt because and couple to explore their feelings, reframe their some time the develop the idea that even after all expectation, explore their resources and support efforts they are unable to help the couple. In such as needed and prepare for anticipating change. circumstances too clinical psychologist/women Clinical Psychologist can also play a crucial health psychologist can provide intervention and role in working with women, their partners and support and help them to overcome from loss and professionals(Ob/gyn) to provide treatment and sufferings, grief reactions and re-establish the reduce the risk of pain, depression, anxiety and interpersonal relationship to both parents (couple) other emotional sufferings during pregnancy or and service provider as well. postpartum period. Psychotherapy (CBT/ IPT and The menopause specially late perimenopause Mindfulness therapy) may be targeted to reduce the LVDVLJQL¿FDQWWUDQVLWLRQLQOLIHRIZRPHQZKLFK negative feelings about self and world, becoming increases the vulnerability of various mental mother, coping with new role with a partner or other health issues/problems. Women may face various family member, maintaining proper body image, YDVRPRWRUV\PSWRPVVXFKDVKRWÀDVKHVRUQLJKW enhancement of self esteem, attending self care and VZHDWV DQG  RU GHSUHVVLRQ 7KH\ DOVR ¿QG SRRU nurturing partner's relationship. social support as children leaving home, ailing History of physical, emotional and social parents, aging and other life transition may be DEXVH LV VLJQL¿FDQWO\ FRUUHODWHG ZLWK SHOYLF SDLQ associated with menopause. Psychotherapy will and post traumatic stress disorder and some time in EHYHU\DSSURSULDWHWUHDWPHQWLIWKHUHLVVLJQL¿FDQW some cases also causes reproductory problems. The life changes /losses (Bormberger & Kravitz, 2011).

3 K.S. Sengar / GYNAE – C – PSYCH – OLOGY : NEED OF TODAY

Psychotherapy can help to develop coping in women compliance cannot be undermind. Women in Ob/gyn and strategies to manage vasomotor symptoms and (obstetrics & gynaecology) setting experience high sleep disruptions. Psychotherapy can also help to level stress as they juggle multiple roles including develop hopes, dreams for future reducing the fear working and care for children, elderly parents and and developing, negotiation/strengthening more other family members. They also may experience satisfying relationship with their partners. LQWHUSHUVRQDOGLI¿FXOWLHVVXFKDVLQWLPDWHSDUWQHUV Prior consultation with clinical psychologist / violence, intimate communication and issues related cognitive therapist, women heath psychologist may to sexuality. A clinical psychologist can provide an help to manage the post-partum issues and make important perspective and understanding of the labour room entry less painful and better marital numerous factors and reproductive health issues relationship. Change in cognition will develop the including post traumatic stress disorder, depression, acceptance of consequences of labour room and help prepartum anxiety, stress and other mental health to develop understanding that becoming mother issues. is more pleasurable and happy movements for a REFERENCES women when compared to the pain and suffering Armstrong, C. (2011). ACOG guideline on sexual of labour room. The hypnotherapy before going dysfunction in women. American Family WRODERXUURRPKDVEHHQVLJQL¿FDQWO\HIIHFWLYHLQ Physician, 84, 705–709. reducing pain, suffering, fear and preparing them to Bromberger, J. T., & Kravitz, H. M. (2011). Mood and accept new role and cope with new responsibilities menopause: Findings from the Study of Women’s in women before/during delivery of the child. Health Across the Nation (SWAN) over 10 years. Obstetrics and Gynecology Clinics of North Many women present to ob/gyn practitioners America, 38, 609–625. in need of behavioural health treatment, yet their Lancaster, C. A., Gold, K. J., Flynn, H. A., Yoo, H., needs are often missed. Common health issues Marcus, S. M., & Davis, M. M. (2010). Risk factors seen in ob/gyn practices such as problem with for depressive symptoms during pregnancy: A menstruation, pregnancy, and menopause - are systematic review. American Journal of Obstetrics closely linked with behavioural health especially and Gynecology, 202, 5–14. women struggling with the physical and mental Paras, M. L., Murad, M. H., Chen, L. P., Goranson, E. health and implication of interpersonal trauma. N., Sattler, A. L., Colbenson, K. M., & Zirakzadeh, A. (2009). Sexual abuse and lifetime diagnosis +HQFH 2EJ\Q SUDFWLFHV EHQH¿W IURP KDYLQJ D of somatic disorders: A systematic review and Clinical Psychologist/ Women Health Psychologist meta-analysis. JAMA: Journal of the American in their health care team to offer screening, Medical Association, 302, 550–561. doi:10.1001/ engagement, assessment, consultation, treatment jama.2009.1091 and health promotion to women's health patients and Poleshuck, E. L., Talbot, N. E., Zlotnick, C., Gamble, consultation and support to Ob/gyn practitioners to S. A., Liu, X., Tu, X., & Giles, D. E. (2010). improve research and training as well. Interpersonal psychotherapy for women with comorbid depression and chronic pain. Journal The integration of behavioural health into of Nervous and Mental Disease, 198, 597–600. primary care and Ob/gyn is innovation with many doi:10.1097/NMD.0b013e3181ea4d3d positive effects. The role of clinical psychologist Poleshuck, E. L., Cerrito, B., Leshoure, N., Finocan- LQ WKH DUHD RI :RPHQ V 0HGLFLQH VSHFL¿FDOO\ Kaag, G., & Kearney, M. H. (2013). Underserved regarding the implementation of psychological, women in a women’s health clinic describe their psychosocial interventions as psycho-social care experiences of depressive symptoms and why they have low uptake of psychotherapy. Community and to understand and manage various stressor and Mental Health Journal, 49, 50– 60. other psychological symptoms that of women's reproductive health problems; to provide optimal individualized care and to enhance treatment

4 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 5-11 Clinical Psychologists (ISSN 0303-2582) Research Article Effect of Neuro-Feedback Training on Cognitive (Executive) Function in Obsessive Compulsive Disorder (OCD)

Priyanka Lenka 1, Masroor Jahan 2*, and V. K. Sinha 3 Abstract e present pre- post design study aimed to assess the e€cacy of Neuro-feedback training in improving cognitive (Executive) function of patients having Obsessive Compulsive Disorder (OCD). Based on inclusion and exclusion criteria, a total of 50 obsessive compulsive patients were selected. Twenty ve of them were randomly assigned to experimental group and 25 were assigned to control group. e 25 patients in experimental group received neuro-feedback (EEG-biofeedback) intervention plus treatment as usual (TAU) and 25 of them in the control group received treatment as usual (TAU) only. A‚er establishing rapport and the explaining the purpose of the study details of the socio-demographic data were gathered. Y-BOCS Checklist, Y-BOCS or Yale-Brown Obsessive Compulsive Scale, Wisconsin Card Sorting Task, (WCST) were administered for baseline assessment. Experimental group received 20 sessions of alpha theta protocol (40 minutes per session on average 5 sessions per week along with TAU. A‚er the completion of 4 weeks (approximately) both groups were assessed again by Y-BOCS, WCST. Again a‚er two weeks the experimental group was assessed using above mentioned tests and rating scales. e ndings showed improvement in cognitive (executive) function in patients in experimental group receiving EEG-Biofeedback in comparison to control group. Key Words: Cognitive rehabilitation, Biofeedback, EEG Neuro-feedback Training, alpha EEG Training, theta EEG Training Neurofeedback, also called and executive functioning. EEG studies have reported electroencephalogram (EEG) biofeedback or medial frontal hyperactivity in OCD (Koprivova et neurotherapy. Neurofeedback training is brainwave al., 2011). Authors recommended that these consistent biofeedback. Research has shown that many kinds results based on EEG source localization are of RI SV\FKRORJLFDO GLI¿FXOWLHV DUH DVVRFLDWHG ZLWK practical interest for therapeutic intervention. problems in activation (over-activation, under- Based on review of literature we hypothesised activation or disturbed coordination) in various areas that EEG Neurofeedback should be effective in the of the brain. Obsessive-compulsive disorder is an management of OCD. EEG Neurofeedback has been DQ[LHW\ GLVRUGHU ZKHUH REVHVVLRQV DUH GH¿QHG DV IRXQGHIIHFWLYHLQPDQDJHPHQWRIFRJQLWLYHGH¿FLWVLQ ideas, thoughts, images and impulses that enter the other conditions, e.g., alcohol dependence (Ghosh et al., participant’s mind repeatedly and compulsions are  5HLQHUHWDO  KDYHDOVRIRXQGVLJQL¿FDQW repetitive stereotyped behaviour that are performed improvement in cognitive functioning in theta EEG in response to an obsession in order to ignore or training group indicating a clear relationship between suppress such thoughts (Andrews, 2003). memory consolidation and theta Neurofeedback. Findings suggest cognitive impairment on 3XEOLVKHG UHVHDUFK DVVHVVLQJ WKH HI¿FDF\ RI tasks of spatial working memory, spatial recognition Neurofeedback training in Obsessive–Compulsive and motor slowing suggestive of a syndrome of Disorder is limited. Zoefel et al. (2011) in their frontal–subcortical dysfunction with prominent study took 12 participants (23.7±2.3 years) in the executive function impairment in OCD patients Neurofeedback training (NFT) and 10 in the control 3XUFHOO HW DO  2&' SDWLHQWV VKRZ GH¿FLW JURXS “ \HDUV  LQ WKHLU ¿QDO VDPSOH 7KH in the area of attention, problem solving, working SDUWLFLSDQWVLQWKH1)7UHFHLYHG¿YHVHVVLRQVZLWKLQ memory, set shifting and response inhibition (Rao et 1 week by means of EEG (electroencephalogram) al., 008). Dittrich and Johansen (2013) have reported Neurofeedback dependent on the current upper alpha VLJQL¿FDQWO\LPSDLUHGSHUIRUPDQFHRI2&'JURXSLQ DPSOLWXGH 7KH\ WHVWHG FRJQLWLYH DELOLW\ RQ WKH ¿UVW comparison to healthy participants in decision making DQG¿IWKVHVVLRQE\DPHQWDOURWDWLRQWHVW,QWKHVWXG\

1. Research Scholar 2. Additional Professor, Dept. of Clinical Psychology, RINPAS, Ranchi 3. Director Professor of Psychiatry, Central Institute of Psychiatry, Kanke Ranchi - 834006 *Corresponding Author: Dr Masrror Jahan. Email:

5 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ...... individually determined upper alpha was increased Y BOCS or Yale-Brown Obsessive Compulsive independently of other frequency bands. They found Scale (Wayne Goodman, 1989): that enhancement of cognitive performance was Y BOCS scale consists of 10 items rating scale VLJQL¿FDQWO\ODUJHUIRUWKH1HXURIHHGEDFNJURXSWKDQ to evaluate the severity of illness in individuals with for a control group who did not receive feedback. Thus, obsessive-compulsive disorder (OCD). Items are rated WKH ¿QGLQJV VKRZHG LQGLYLGXDOO\ GHWHUPLQHG XSSHU on a 0 to 4 scale (o=one and 4=extreme). alpha frequency band in EEG (electroencephalogram) Neurofeedback parameter resulted in enhancement in Wisconsin Card Sorting Task, (WCST) Heaton, (1981): cognitive performance. The WCST was developed by Berg et.al, (1948). The WCST provides objective scores of overall success ,QYLHZRIGHDUWKRIVWXGLHVRQHI¿FDF\RI1HXUR DQGDOVRIRUVSHFL¿FVRXUFHVRIGLI¿FXOW\RQWKHWDVN feedback Training on Cognitive Function (Executive HJLQHI¿FLHQWLQLWLDOFRQFHSWXDOL]DWLRQSHUVHYHUDWLRQ Function) in Obsessive Compulsive Disorder, the IDLOXUH WR PDLQWDLQ D FRJQLWLYH VHW DQG LQHI¿FLHQW current study is being undertaken to explore the effect learning across stages of the test). A WCST deck is of Neuro-feedback on Cognitive function (Executive) made up of 128 response cards, and 4 stimulus cards. in Obsessive Compulsive Disorder. Each stimulus card has a different number, color, and METHOD shape of symbol. Sample: Multi Channel Biofeedback Device: A sample of 50 patients was selected from the Multi channel Biofeedback Device developed in-patient and out-patient departments of Central by thought technology Ltd. consists basically of Institute of Psychiatry (CIP) for the current study. ELRJUDSK LQ¿QLWL PXOWLPHGLD VRIWZDUH  SURFRPS Among the total number of patients 25 were randomly LQ¿QLWL(QFRGHU+DUGZDUHDVHQFRGLQJ SURFHVVLQJ assigned for neuro-feedback (EEG-biofeedback) devises will be used for the study. It can give real time intervention plus treatment as usual (TAU) and 25 computerized biofeedback & data acquisition. The of them were assigned for (TAU) only. The patients encoder is able to render a wide & comprehensive having diagnosis of Obsessive-Compulsive Disorder range of signs used in clinical observation & as per ICD-10 DCR (WHO 1992), both sexes (male biofeedback thought technology's advanced design & female), age range between 18 to 50 years, giving and active electronic sensors meet rigorous standards informed consent for being part of the study, OCD for instrument accuracy, sensitivity, durability and with only co-morbidity of depression, minimum level case of use. All sensors are completely non invasive of 8 years of education were included. Patients having & require little or no preparation for use. Present study history of any chronic physical illnesses, organic was done using EEG -Z. brain syndromes, and substance abuse/dependence, OCD with poor insight, psychotic symptoms or other Procedure: psychiatric illness except depression were excluded. This is a hospital based on pre-post design prospective study. The study was approved by the Measures: ethics committee of Central Institute Psychiatry The following tools have been administered in (CIP). For the purpose of intervention, 50 patients the study. with diagnosis of Obsessive Compulsive Disorder (OCD) as per lCD 10/DCR (WHO, 1992) criteria Socio-demographic & Clinical Data Sheet: were randomly selected from CIP, Ranchi, Jharkhand, A socio-demographic & clinical data sheet will India on the basis of inclusion and exclusion criteria be used to get some primary information regarding for both groups. Informed consent was obtained from socio demographic variable. all participants of this study. Afterward they were Y-BOCS Checklist (Wayne Goodman, 1989): randomly assigned to the EEG –biofeedback plus The Checklist asks the patient to indicate Treatment as Usual of CIP group (experimental group; ZKHWKHURUQRWVKHKDVVSHFL¿FW\SHVRIREVHVVLRQV 25 participants) and Treatment as Usual -only group or compulsions. The checklist groups obsessions and (control group; 25 participants). After establishing compulsions into broad categories of symptoms. rapport and the explaining the purpose of the study the

6 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ...... details of the socio-demographic data were gathered. religion, marital status, occupation, socio-economic Y-BOCS Checklist, Y-BOCS or Yale-Brown Obsessive status and habitat between both groups. It was found Compulsive Scale, Wisconsin Card Sorting Task, that 36% (9) participants were males and 64% (16) (WCST) were administered for baseline assessment. participant were females in experimental group and The participants received 20 sessions of alpha theta 48% (12) participant were males and 52% participant protocol (40 minutes per session on average 5 sessions were females in control group. The table also shows per week) in the treatment of patients with Obsessive 92% participants were Hindus while in control group Compulsive Disorder. Participants in the Experimental 76% were Hindus and 24% belonged to others. There group received EEG Biofeedback sessions along with were 68% married participants and 32% unmarried TAU. EEG-Biofeedback was performed on EEG participants in experimental group and in control group biofeedback system (Procomp+/Biograph programme- 60% participants were married and 40% were unmarried. Thought Technology Ltd (2006) version- 3.0 (SA7500) The table also shows 20% participants were employed whereas 80% were unemployed in experimental group keeping one electrode active. Participants in control and 24% participants were employed while 76% group received only treatment as usual (TAU). After participants were unemployed in control group. The the completion of 4 weeks (approximately) both groups table reveals 92% participants belonged to middle were assessed again by Y-BOCS, WCST. Again after class and 84% participants belonged to middle class in two weeks the experimental group was assessed by the control group. The table also reveals 84% participants above mentioned test and rating scale. belonged to urban background in experimental group STATISTICAL ANALYSIS while in control group 32% participants belonged to rural background whereas 68% participants belonged Student's t test and Chi Square were used to to urban background. complete the demographic and clinical characteristics of the two groups. The Cognitive (Executive function) was Table 2: Comparison of Socio demographic compared and analyzed using repeated measure ANOVA. Variables (Categorical) between the Two Groups RESULTS Group- 1 Group-2 Table 1 shows comparison of age and education Variables Eperimental Control x2 df p between experimental and control group. Mean age N=25) (%) N=25) %) of experimental group was 32.68 (±7.94) years and mean age of control group was 28.24 (±7.18) years. Male 9 36% 12 48% Sex 1 0.158 Mean education of experimental group was 13.04 Female 16 64% 13 52% 0.39 years (±2.68) and mean education of control group ZDV  \HDUV “  7KHUH ZDV VLJQL¿FDQW Hindu 23 92% 19 76% Religion 2.38 1 0.099 difference noted in age of experimental and control Other 2 08% 6 24% JURXS$JH ZDV IRXQG WR EH VLJQL¿FDQWO\ KLJKHU LQ Married 17 68% 15 60% experimental group compared to control group. Marital 0.55 1 0.196 Status Table 1: Comparison of Socio demographic Variables Unmarried 8 32% 10 40% (Continuous) between the Two Groups. Employed 5 20% 6 24% Occupa- 0.11 1 0.252 tion Variables Group 1 Group 2 Unemployed 20 80% 19 76% Experimental Group) (Control Group) t df p Mean ± SD Mean ± SD Socio Lower 2 8% 4 16% 1.69 1 0.163 economic 1.75 Age (in 32.68±7.94 28.24±7.18 2.07 48 .044* Status Middle 23 92% 21 84% 1 0.113 years) Rural 4 16% 8 32% Education 13.04±2.68 12.28±2.31 1.08 48 .285 Habitat 1.75 1 0.113 (in years) Urban 21 84% 17 68%

*p≤0.05 Table 3 shows comparison of mean duration Table 2 shows frequency and percentage of sex, of illness between experimental group and control

7 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ...... group. ere was no signi€cant dierence found 7KH WDEOH UHYHDOV QR VLJQL¿FDQW KLVWRU\ RI between groups with regard to duration of illness. past psychiatric illness in experimental group and Table also shows comparison of mean age of onset FRQWURO JURXS 7KHUH ZHUH DOVR QR VLJQL¿FDQW SDVW of illness between both groups and no signi€cant medical history in experimental group and control dierence was found between two groups with regard group. The table also reveals 44% participants had to age of onset of illness. family history of medical illness in experimental Table 3: Comparison of Clinical Variables group whereas 36% participants had family history of medical illness in control group. (Continuous) between the Two Groups: Variables Group -1 Group - 2 Table 5 shows that score on YBOCS reduced (Experimental (Control VLJQL¿FDQWO\DWWLPH%DQG7LPH&FRPSDUHGWRWLPH Group) Group) t df P Mean ± SD Mean ± SD A. The effect size for this change was 0.827 with observed power of 1. Duration of Ill- 7.62 ±7.42 5.28±3.96 1.38 48 0.171 ness (in yrs.) Table 5: Comparison of Scores of Y-BOCS across Age of Onset (in yrs.) 25.08±8.10 23.32±7.60 0.79 48 0.433 Different Time Points of Assessment in the Experimental Group Receiving Table 4 shows frequency and percentage of past Neurofeedback: psychiatric history, past medical history, family history of medical illness, family history of psychiatric illness and handedness between both groups.

Table 4: Comparison of Socio demographic F p Time Time B Four (after SD ± Mean Weeks) Six (after C Time Weeks) SD ± Mean Partial size Effect Squared Eta Powera Observed hoc Post Variables (Discrete) between the Two Baseline A Time Groups: YBOCS 25.36 15.12 14.20 A>B, Group 1 Group 2 1918.74 .001*** 0.827 1 ±4.36 ±4.13 ±4.0 A>C (Eperimental (Control X2 df p Group Group) Variables WCST total perseverative error reduced Freque Freque (%) % ncy(n) ncy(n) VLJQL¿FDQWO\DWWLPH%DQG7LPH&FRPSDUHGWRWLPH A. The effect size for this change was 0.321; with 0 0% 0 0% 0.31210.50 Past 0ECJEł?=JP observed power of 0.989. The Table also shows Psychiatric Not that score on WCST total nonperseverative error History 25 100% 25 100% OECJEł?=JP GLG QRW UHGXFH VLJQL¿FDQWO\ DW WLPH % DQG 7LPH C compared to time A. The Table also shows that 0ECJEł?=JP 0 0% 0 0% Past scores on WCST conceptual level response reduced medical Not 0.312 1 0.50 History 25 100% 25 100% VLJQL¿FDQWO\ DW WLPH % DQG 7LPH & FRPSDUHG WR OECJEł?=JP time A. The effect size for this change was 0.303 Family 0ECJEł?=JP 11 44% 9 36% with observed power of 0.982. history of Medical Not 0.564 1 0.19 The Table also shows that scores on WCST 14 56% 16 64% Illness OECJEł?=JP FDWHJRULHVFRPSOHWHGUHGXFHGVLJQL¿FDQWO\DWWLPH Family 0ECJEł?=JP 8 32% 8 32% B and Time C compared to time A. The effect size history of 0.23 for this change was 0.288; with observed power of Psychiatric Not 1.00 1 17 68% 17 68% 0.962. The Table also shows that score on WCST Illness OECJEł?=JP IDLOXUHWRPDLQWDLQVHWUHGXFHGVLJQL¿FDQWO\DWWLPH Right 24 96% 25 100% B and Time C compared to time A. The effect size Handedness 0.312 1 0.50 Left 1 4% 0 0% for this change was 0.159 with observed of 0.698

8 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ......

Table 6: Comparison of Scores of Cognitive Functions ZDV QR VLJQL¿FDQW GLIIHUHQFH LQ VFRUHV RI :&67 DW (WCST) Across Different Time Points of baseline. Assessment in the Experimental Group Receiving Neurofeedback: Table 7: Comparison of Scores of WCST at Baseline of Assessment between the Experimental and the Control Groups: a

p Experi- Time A Time Power Weeks)

Baseline Control F Posthoc Observed Observed taSquared Six weeks) Six Mean ± SD ± Mean Mean ± SD ± Mean

E mental t p Time C (after (after C Time ffect Size Partial Partial Size ffect Group E

Time B (after Four (after B Time Group 124.64 119.36 122.20 WCST Total Trials WCST 1.48 .058 0.291 wcst.t.trial.B 124.64 125.96 0.527 0.601 ±7.27 ±16.91 ±13.03 0.239 Wcst.t.correct.B 68.76 64.12 1.323 0.192 Wcst.p.res.B 43.68 46.64 0.454 0.652 68.76 75.64 76.80 B>A 3.71 0.134 0.622 C>A Wcst.p.err.B 36.44 38.96 0.526 0.602 WCST

±12.04 ±13.44 ± 9.11 0.036*

TotalCorrect Wcst.np.err.B 20.48 22.88 0.877 0.385 Wcst.con. resp.B 51.08 46.44 0.934 0.355 Wcst.cat.comp.B 3.20 2.52 1.494 0.142 43.68 27.28 29.12 A>B 11.84 0.330 0.992 A>C Wcst.fail.set B 0.96 1.60 1.644 0.107 ±20.70 ±13.94 ±13.26 0.001*** x wcst.t.trialB: wcst total trials at baseline tive Responses tive Wcst.t.correctB: wcst total correct at baseline

WCST total Percevera- WCST x x Wcst.p.resB: wcst total perceverative responses at baseline Wcst.p.err.B: wcst total perceverative error at baseline 36.44 24.24 25.28 A>B x 11.36 0.321 0.989 A>C Wcst.np.errB: wcst total non perceverative error at baseline ±15.47 ±12.17 ±10.45 x 0.001*** x Wcst.con.respB: wcst conceptual level response at baseline ceverative Error ceverative WCST total Per- WCST x Wcst.cat.compB: wcst categories completed at baseline x Wcst.fail.setB: wcst failure to maintain set at baseline 20.48 18.36 17.44 Table 8 shows comparison of WCST scores 1.94 0.075 0.334

±7.83 ±7.64 ±5.62 0.154 between two groups after treatment. It reveals that WKHUH ZDV VLJQL¿FDQW GLIIHUHQFH LQ ZFVWWFRUHFW WCST TotalNon- WCST Perceverative Error Perceverative (p<.05), wcst.np.err1 (p<.05), wcst.con.resp1 (p<.05), wcst.cat.comp.1 (p<.05) post intervention. 51.08 65.36 65.52 B>A 10.43 0.303 0.982 C>A ±19.01 ±14.90 ± 8.99 Table 8: Comparison of Scores of WCST Post In- .001*** tervention between the Experimental and Level Response Level WCST Conceptual ConceptualWCST the Control Groups : B>A Experimental Control 3.20 4.20 4.48 t P 09.69 0.288 0.962 C>B Group Group ±1.95 ± 1.44 ± 0.15 .001*** wcst.t.trial 1 119.36 123.64 1.016 0.315 WCST Catego- WCST riesCompleted Wcst.t.correct 1 75.64 67.40 2.213 0.032 Wcst.p.res1 27.28 34.60 1.661 0.103 B>A 1.00 2.04 ± 1.7 Wcst.p.err.1 24.24 29.96 1.611 0.104 04.33 0.159 0.698 C>A

1.10 1.51 1.15 .022* Wcst.np.err1 18.36 24.60 2.294 0.026 MaintainSet

WCST Failure to WCST Wcst.con.resp1 65.36 52.12 2.996 0.004 S” S” Wcst.cat.comp.1 4.20 2.88 2.896 0.006 WCST: Wisconsin Card Sorting Task Wcst.fail.set1 1.96 1.54 1.030 0.308 Table 7 shows comparison of WCST scores x wcst.t.trial1: wcst total trials post intervention between two groups at baseline. It reveals that there x Wcst.t.correct 1: wcst total correct post intervention

9 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ......

x Wcst.p.res1: wcst total perceverative responses post intervention Tab le 9 shows eect of EEG-Biofeedback x Wcst.p.err1.: wcst total perceverative error post intervention and change in psychopathology as compared x Wcst.np.err1: wcst total non perceverative error post intervention in experimental and control group. Group x Wcst.con.resp1: wcst conceptual level response post intervention psychopathology interaction reveals that there was signi€cant interaction in WCST.fail.set with x Wcst.cat.comp1: wcst categories completed post intervention experimental group showing better ecacy as Wcst.fail.set1: wcst failure to maintain set post intervent ion x compared to control group. (F=4.08, P=.04). ‚e Tabl e 9 shows effect of EEG-Biofeedback eect size for WCST.fail.set was mild. (partial eta and change in psychopathology as compared square = .080). in experimental and control group. Group wcst.t.trial: wcst total trials psychopathology interaction reveals that there x Wcst.t.correct : wcst total correct ZDV VLJQL¿FDQW LQWHUDFWLRQ LQ :&67IDLOVHW ZLWK x H[SHULPHQWDO JURXS VKRZLQJ EHWWHU HI¿FDF\ DV x Wcst.p.res: wcst total perceverative responses compared to control group. ( F=4.08, P=.04). The x Wcst.p.err.: wcst total perceverative error post effect size for WCST.fail.set was mild. (partia l eta intervention square = .080). x Wcst.np.err: wcst total non perceverative error Wcst.con.resp: wcst conceptual level response Table 9: Comparison of Pre and Post Intervention x Scores of Various WCST Test between x Wcst.cat.comp: wcst categories completed Experimental and Control Groups. x Wcst.fail.set: wcst failure to maintain set Partial eta Observed F p DISCUSSION Squared Power The current study is being undertaken to Time 5.27 .026 .099 .614 explore the effect of neuro-feedback on cognitive WCST. t. Group .845 .363 .017 .147 function (executive) in obsessive compulsive trials Time x Group .800 .376 .016 .142 disorder. In the present study we have found that Time 5.944 .019 .110 .666 WKHVFRUHRQ<%2&6UHGXFHGVLJQL¿FDQWO\DWWLPH% WCST. t. Group 4.74 .034 .090 .569 (after treatment) and Time C (follow up) compared correct Time x Group .746 .392 .015 .135 to time A (baseline). The effect size for this change Time 17.751 .000 .270 .985 was 0.827 with observed power of 1. WCST. p. Group 1.347 .251 .027 .206 7KH¿QGLQJVDOVRVKRZHGWKDWVFRUHRQ:&67 res Time x Group .417 .521 .009 .097 WRWDO FRUUHFW UHGXFHG VLJQL¿FDQWO\ DW WLPH % DQG Time C compared to time A. The effect size for this Time 20.103 .000 .295 .992 change was 0.134 with observed power of 0.622. WCST. p. Group 1.391 .244 .028 .212 The score on WCST total perseverative response err. Time x Group .458 .502 .009 .102 UHGXFHGVLJQL¿FDQWO\DWWLPH%DQG7LPH&FRPSDUHG Time .014 .907 .000 .052 to time A. The effect size for this change was 0.330 WCST. Group .014 .907 .000 .052 np. with observed power of 0.992. The scores on WCST error Time x Group 1.282 .263 .026 .199 WRWDOSHUVHYHUDWLYHHUURUUHGXFHGVLJQL¿FDQWO\DWWLPH Time 13.253 .001 .216 .946 B and Time C compared to time A. The effect size WCST, Group 5.474 .024 .102 .630 for this change was 0.321; with observed power con.resp of 0.989. The scores on WCST conceptual level Time x Group 2.460 .123 .049 .336 UHVSRQVHUHGXFHGVLJQL¿FDQWO\DWWLPH%DQG7LPH& Time 8.824 .005 .155 .829 compared to time A. The effect size for this change WCST. Group 6.452 .014 6.452 .702 was 0.303 with observed power of 0.982. The scores cat.comp. Time x Group 1.954 .169 .039 .278 RQ:&67FDWHJRULHVFRPSOHWHGUHGXFHGVLJQL¿FDQWO\ Time 3.456 .069 .068 .445 at time B and Time C compared to time A. The effect WCST. Group .111 .741 .002 .062 size for this change was 0.288; with observed power fail.set Time x Group 4.083 .049 .080 .508 of 0.962. The score on WCST failure to maintain set

10 Priyanka Lenka et al. / Effect of Neuro-Feedback Training on Cognitive (Executive) Function in ......

UHGXFHGVLJQL¿FDQWO\DWWLPH%DQG7LPH&FRPSDUHG REFERENCES to time A. The effect size for this change was 0.159 Andrews, G. (2003). The Treatment of Anxiety Disorders: with observed of 0.698. Clinician Guides and Patient Manuals . Cambridge The comparison of WCST scores between University Press: Cambridge. two groups at baseline revealed that there was no *KRVK7-DKDQ0 6LQJK$5  7KHHI¿FDF\ VLJQL¿FDQWGLIIHUHQFHLQVFRUHVRI:&67DWEDVHOLQH of electroencephalogram neurofeedback training The comparison of WCST scores between two groups in cognition, anxiety and depression in alcohol DIWHU WUHDWPHQW UHYHDOHG WKDW WKHUH ZDV VLJQL¿FDQW dependence syndrome: A case study. Industrial difference in wcst.t.corect1 (p<.05), wcst.np.err1 Psychiatry Journal, 23, 166-170. (p<.05), wcst.con.resp1 (p<.05), wcst.cat.comp.1 S   SRVW LQWHUYHQWLRQ 6LJQL¿FDQW LPSURYHPHQW Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, in the cognitive function (executive function) after C., Fleischmann, R. L., Hill, C. L., & Charney, D. EEG neurofeedback training is in accordance with S. (1989). The Yale-Brown Obsessive Compulsive the previous studies reporting improvement in Scale: I. Development, use, and reliability. Archives patients of other conditions also (Ghosh, et al., 2014; of General Psychiatry, 46 (11), 1006-1011. Reiner et al., 2014). Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., The effect of EEG-Biofeedback and change in & Curtiss, G. (1981). Wisconsin Card Sorting Test psychopathology as compared in experimental and (WCST). Odessa, FL: Psychological Assessment Resources. control group. Group psychopathology interaction UHYHDOV WKDW WKHUH ZDV VLJQL¿FDQW LQWHUDFWLRQ LQ Koprivova, J., Congedo, M., Horacek, J., Prasko, J. Raska, WCST.fail.set with experimental group showing M., Brunovsky, M., Kohutova, B., & Hoschl, EHWWHUHI¿FDF\DVFRPSDUHGWRFRQWUROJURXS )  C. (2011). EEG source analysis in obsessive- P=.04). The effect size for WCST.fail.set was mild. compulsive disorder. Clinical Neurophysiology , 122 SDUW 7KH ¿QGLQJV RI WKH SUHVHQW VWXG\ DUH VLPLODU (9), 1735-1743. to that of Zoefel et al. (2011), who have also found Purcell, R., Maruff, P., Kyrios, M., & Pantelis, C. (1998). that individually determined upper alpha frequency &RJQLWLYHGH¿FLWVLQREVHVVLYH±FRPSXOVLYHGLVRUGHU band in EEG (electroencephalogram) neurofeedback on tests of frontal–striatal function. Biological parameter resulted in enhancement in cognitive Psychiatry, 43 (5), 348-357. performance. Rao, N. P., Reddy, Y.C.J. & Kumar, K. J. (2008). Are CONCLUSION QHXURSV\FKRORJLFDO GH¿FLWV WUDLW PDUNHUV LQ 2&'" Progress in Neuropharmacology and Biological The treatment of any illness is aimed not only Psychiatry , 32, 1574-1579. at providing symptomatic relief but also, returning the patient to his optimum level of his functioning. Reiner, M., Rozengurt, R., & Barnea, A. (2014). Better 7KH ¿QGLQJV RI WKH SUHVHQW VWXG\ VKRZHG than sleep: Theta neurofeedback training accelerates improvement in cognitive (executive) function memory consolidation. Biological Psychology , 95, after EEG-Biofeedback training in Obsessive 45-53. Compulsive patients. The current study revealed Zoefel, B., Huster, R. J., & Herrmann, C. S. (2011). that neurofeedback (electroencephalogram (EEG) Neurofeedback training of the upper alpha frequency biofeedback) can be used as a clinical intervention for band in EEG improves cognitive performance. improving functions and maintaining the durability Neuroimage , 54 (2), 1427-1431. of such gains. Study should be replicated on larger sample with longer follow-up. Improvement in cognitive functions through EEG neurofeedback should be assessed across subgroups of obsessive compulsive disorder.

11 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 12-19 Clinical Psychologists (ISSN 0303-2582) Research Article Application of Self- Regulatory Executive Function (S-REF) Model in Psychopathology Formulation of Patients with Anxiety Disorders

Soheli Datta* 1 and Sanjukta Das 2

ABSTRACT The S-REF model of psychological disorder (Wells & Mathews, 1994) integrates information with the purpose of understanding the meta-system involving voluntary control of cognition, procedural knowledge and interactions among different levels of information processing. In anxiety disorder, the locus of explaining the symptoms is in their psychopathology formation. The present study aims to explore the application of S-REF model in psychopathology formulation among Generalized Anxiety Disorder (GAD), Social Phobia and Mixed Anxiety & Depressive Disorder. The sample consisted of 6 patients, including 2 from each group, on whom, Meta- Cognition Questionnaire (MCQ) (Cartwright-Hatton & Wells, 1997), Presumptive Stressful Life Event Scale (PSLES) (Singh et al., 1984), and Thematic Apperception Test (TAT: Morgan & Murray, 1935), were administered along with clinical interviews. Psychopathology formation for each of the 3 groups was formulated with the S-REF model using the chief complaints of the patients, scores obtained from MCQ and PSLES and meta-cognitive components from TAT narratives. Findings indicate that psychopathology formation takes place through various inputs from the family and environment which form a meta-system in an individual including meta- beliefs about the self and meta-plans about dealing with the incoming stress which monitors the cognitive style and cognitive attentional syndrome leading to cognitive and emotional problems, the output manifestations being the symptoms. Key Words: Metacognition, Anxiety, Psychopathology, Life events

INTRODUCTION strategies to reduce threats and control cognition. Metacognition describes a range of inter- Psychological disorders results from the maintenance related factors comprised of cognition that monitors, of such emotional responses and are maintained controls, and appraises the products and process because of the individual’s thinking style (their of awareness and thereby shapes what we pay meta-beliefs) and strategies (their meta-plans). The attention to and the factors that enter consciousness. unhelpful style, found in such disorder is called the The concept of metacognition describes a range Cognitive Attentional Syndrome (CAS), consisting of interrelated factors that are comprised of any of worry, threat monitoring, unhelpful thought knowledge or cognitive process that is involved in the control strategies, and other forms of behaviour that interpretation, monitoring, or control of cognition. prevent adaptive learning. The CAS is the result This can be explained by the basic model, called the of erroneous metacognitive beliefs that control Self-Regulatory Executive Function Model (S-REF; and interpret thinking and feeling states. Thus, the Wells & Matthews, 1994, 1996; Wells, 2000). It individual who is prone to activate this response offers an account of the cognitive and metacognitive pattern is more likely to show a persistence of anxious factors involved in the maintenance of emotional arousal and to develop repeated panic attacks. Such disorders in the presence of stressful life events. a pattern will support the growth of beliefs about the The model proposed that the emotions of uncontrollable and harmful consequences of anxiety. anxiety and sadness are basic internal signals of According to the S-REF model (Wells & Matthews, a discrepancy in self-regulation and of threats to 1994), worry elabourates memory representations well-being. Such emotions are normally of limited of the stressor and leads to greater accessibility of duration because the person engages in coping threat, which results in the escalation of perceived 1. Assistant Professor, Department of Applied Psychology, University of Calcutta 2. Professor, Department of Psychology, University of Calcutta * Corresponding Author: Dr Sanjukta Das E mail: [email protected]

12 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ...... stress. The S-REF theory (Wells & Matthews, 1994, signs. These signs and symptoms are associated 1996) of emotional disturbances seem to suggest with marked social or occupational dysfunction. It that metacognitive theory could be relevant to has been found that negative beliefs about worry understanding the link between perceived stress and is highest among Generalized Anxiety Disorder negative emotion. which might be due to the fact that worrying can Over the past few decades, researchers have create its own problems that contribute to the witnessed a surge in psychological research on need for further worrying in order to cope, and implicit and underlying cognitive processes, in a contribute to the strengthening of negative beliefs variety of research areas including memory (Squire, about thought processes (Wells, 1994a, 1995). It 1992), learning (Cleermans, in press), and in social is least in Mixed Anxiety and Depressive Disorder cognition (Bargh, 2005). Common to these different and is still lesser among Social Phobia (Datta, Das areas of research is an attempt to assess processes that & Dogra, in press) which might be because Social are not readily captured by conscious introspection, phobia is characterized by persistent fears of negative assessment techniques and tools or cannot easily be evaluation in social interactions and performance FRQWUROOHGEXWWKDWQHYHUWKHOHVVLQÀXHQFHEHKDYLRXU VLWXDWLRQV $3$   DQG LV QRW IUHH ÀRDWLQJ LQ to a great extent. Attempting to assess these implicit other situations. Negative belief about thoughts is processes involved in psychopathology is in itself highest among Generalized Anxiety Disorder than not new, and goes back to Freud’s free association the other groups, namely social phobia and mixed methods and the use of projective tests (Mc Clelland, anxiety depressive disorder, where, Generalized Koestner, & Weinberger, 1989). They illustrated that Anxiety Disorder can be characterized as a high underlying cognition measures may be important QHJDWLYH PHWDFRJQLWLRQ SUREOHP ZLWK QRQVSHFL¿F for increasing understanding of a variety of types combinations of health and social worry (Datta, of psychopathology and thereafter, much of the Das & Dogra, in press). This is, consistent with the clinically relevant work has occurred in the anxiety S-REF (Self Regulatory Executive Function) model DQG PRRG GLVRUGHUV ¿HOG ZKHUH LW ZDV IRXQG WKDW (Wells & Matthews, 1996), beliefs that thoughts the locus of explaining the symptoms is in their were uncontrollable or dangerous, and that thoughts psychopathology formation. need to be controlled, were associated with more In Generalized Anxiety Disorder, anxiety Post-Event Processing. Positive beliefs about worry is generalized and persistent but not restricted to, is mostly in social phobias than in the other anxiety or even strongly predominating in, any particular disorder groups, and might be assumed that positive environmental circumstances. There are complaints beliefs about worry are the starting point for the of continuous feelings of nervousness, trembling, development of excessive worry in social phobia muscular tension, sweating, light-headedness, (Datta, Das & Dogra, in press). Positive beliefs about palpitations, dizziness, and epigastric discomfort. worry was found to be least among Generalized Individuals suffering from Social Phobia often fear Anxiety Disorder as they report less positive being humiliated, embarrassed, or judged negatively reasons for worrying (Borkovec & Roemer, 1995; in social situations and may fear that they will Datta, Das & Dogra, in press), and that proneness behave inappropriately or possibly be scrutinized to pathological worry characteristic of Generalized by others. Clark and Wells (1995) assume that Anxiety Disorder is associated with negative beliefs individuals with social phobia activate a series of about worry (Cartwright-Hatton & Wells, 1997; negative beliefs about themselves as social subjects Wells & Papageorgiou, 1998). when they are faced with social situation. Mixed The present study is aimed at formulating anxiety and depressive disorders is characterized psychopathology formation based on the S-REF by dysphoria combined with other depressive and model of psychological disorders and how it gets anxiety symptoms that are sub-threshold for a LQÀXHQFHGE\VHYHUDOSV\FKRVRFLDOIDFWRUV QDPHO\ diagnosis of a primary affective or anxiety disorder. metacognition and stressful life events) of patients The clinical picture of anxiety disorders suffering from Generalized Anxiety Disorder, Social involves a variety of symptoms and characteristic Phobia and Mixed Anxiety and Depressive Disorder.

13 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ......

Thereby, a focus on the 3 clinical disorders has x Having a treatment history and are under been taken into concern for theoretical purpose on medical consultation the basis of metacognitive components of patient’s x Understands either Bengali or English and narratives, clinical complaints and clinical ratings. comprehends the test materials adequately and Everyday experience suggests that people perceive responds to it were included in the group. their surroundings differently from one another and However, patients who had implying to individual differences in perception.

Differences in perception are related to anxiety x $Q\RWKHUVLJQL¿FDQWSK\VLFDOGLVDELOLW\ features, like, worry, tension and apprehensiveness. x Confusing report and doubt about co-morbidity Given the breadth of these relationships, it seems of any psychological and neurological likely that anxiety would also be related to differences problems in the ways in which people view their surroundings. x Past psychiatric illness and confusing Knowledge of differences in clinical presentation x Non-corroborative and inconsistent data given is important for developing interventions and by patients or informants were excluded from evaluating treatment outcome as well. the group. METHOD Description of the Tools : The present study aims to explore the Patients were asked to give their consent application of S-REF model in psychopathology on collection of data and were informed about no formulation among Generalized Anxiety Disorder foreseeable risk and discomfort in the process of this (GAD), Social Phobia and Mixed Anxiety & study. All the information collected would be kept Depressive Disorder. FRQ¿GHQWLDODQGZLOORQO\EHXVHGIRUUHVHDUFKSXUSRVH without disclosing the identity of the participant. Sample: Thereafter, they were asked to voluntarily participate The clinical groups were obtained from the in the study. A semi structured proforma to assess the Out Patient Departments (OPD) of hospitals of socio-demographic details was administered along West Bengal, and also obtained from the University with the other tools of measurement of Calcutta, Department of Psychology, Clinical The Metacognition Questionnaire (MCQ); Hatton 3V\FKRORJ\ 8QLW WKHLU GLDJQRVLV EHLQJ FRQ¿UPHG & Wells, (1997): by the respectable doctors attending their respective OPD and are under medical consultation. The This questionnaire was devised by Cartwright- patients diagnosed by clinicians with the disorders Hatton and Wells, (1997) to assess individual were approached and consent from them was taken. differences in positive and negative beliefs about Moreover, co-morbid conditions on the basis of worry and intrusive thoughts, meta-cognitive testing were ruled out and thereby, a sample of subjects monitoring and judgement of cognitive energy. MCQ was considered in the present study. Altogether the consists of 5 replicable factors, namely, Positive sample consisted of 6 subjects including 2 patients in Beliefs about Worry, Negative Beliefs about Worry each of the groups having GAD, Social Phobia and Focusing on Uncontrollability and Danger, Negative Mixed Anxiety and Depressive Disorder. %HOLHIVDERXW7KRXJKWV/RZ&RJQLWLYH&RQ¿GHQFH and Cognitive Self-Consciousness assessed by 65 Inclusion-Exclusion Criteria: items in total. Internal Consistency (Cronbach’s Patients who were alpha) for subscales is 0.72-0.89. Stability as x Suffering from Mixed Anxiety and Depressive DVVHVVHGE\WHVWUHWHVWFRHI¿FLHQWVDFURVVDZHHN Disorder, Generalized Anxiety Disorder and time interval range between 0.76 and 0.89 for the Social Phobia since a considerable period and individual subscales. diagnosed by the psychiatric consultants and is Presumptive Stressful Life Event Scale (PSLES); currently under treatment using ICD 10, Singh et al., 1984): x Attending OPD of psychiatry of local medical It consists of 51 life events having a test-retest colleges and hospitals of West Bengal reliability of 0.73

14 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ......

The Thematic Apperception Test (TAT); Morgan For each of the 3 groups, 2 patients were administered & Murray, 1935): with Thematic Apperception Test, the common and It is a technique for the investigation of DJUHHG XSRQ ¿QGLQJV E\ WKH LQWHUSUHWHUV ZHUH WKHQ the dynamics of personality, as it manifests itself included in the study. in interpersonal relations and in the apperception RESULTS AND DISCUSSION or meaningful interpretation of the environment. Inter-rater reliability often exceeds the 0.80 to 0.85 The chart below shows the components of range. A test-retest correlation of 0.30 is found the S-REF model of metacognition based upon the along, though internal consistency is low. Inter-rater SUHVHQWLQJFRPSODLQWVRIWKHSDWLHQWVDQGWKH¿QGLQJV reliability varies with studies from 0.30 to 0.90. on Thematic Apperception Test narratives, and Procedure : Quantitative Analysis of Meta Cognitive Questionnaire For the present study, a sample of 6 individuals and Presumptive Stressful Life Event Scale scores was taken into consideration who has a treatment history of Mixed Anxiety and Depressive Disorder, (Datta, Das & Dogra, in press) for the 3 clinical groups Generalized Anxiety Disorder and Social Phobia, The Compo Generalized Social Phobia Mixed subjects were selected on the basis of the inclusion/ Anxiety Anxiety and exclusion criteria after getting their consent. The nents Disorder Depressive nature of the research was explained to them. They Disorder were asked to volunteer for the study and it was Distant Distant Distant relation DVVXUHGWKDWWKHLUUHVSRQVHVZLOOEHVWULFWO\FRQ¿GHQWLDO relation with relation with with authority authority and authority and and opposite sex and it would not be used in any other way apart from contemporary contemporary contemporary using it in the present study. Administration of the ſIWTGUCNQPI ſIWTGUYCU ſIWTGUYCURGTE tools was done individually by the researcher. The YKVJFGRTKXKPI RGTEGKXGFCNQPI GKXGF5KIPKſECPV sample included 3 groups, one, who are presently dangerous and YKVJFGRTKXKPI stressful life Input experiencing Generalized Anxiety Disorder (n=2) unsupportive environment. events is more in environment. Critical the life time than second who are having Social Phobia (n=2) and Mixed Stressful life comments KPVJGNCUV[GCT Anxiety and Depressive Disorder (n=2). Comparisons events has mainly came contributing to of the obtained scores were made among the sample of been found to from the the long term Mixed Anxiety and Depressive Disorder, Generalized be more in the family and symptoms Self environment is perceived to Anxiety Disorder and Social Phobia (Datta, Das and lifetime than in the last year DGKPCFGSWCVG Dogra, in press). Thereafter, patient’s consent about FGRTGUUGFCPF administration of Thematic Apperception Test was YGCMYKVJDQVJ taken. Psychopathology formation for each of the 3 positive and negative belief groups was formulated with the S-REF model using the about worry chief complaints of the patients, scores obtained from along with MCQ and PSLES (Datta, Das & Dogra, in press) and lower cogniti ve meta-cognitive components from TAT narratives, for EQPſFGPEG an idiosyncratic understanding and conceptualization Negative meta The self is Psychological: of the patients, their clinical problems and formation belief about perceived to engages in YQTT[PGICVKXG DGKPCFGSWCVG thinking of psychopathology. Meta- beliefs about FGRTGUUGF VJQWIJVUCNQPI weak and Behavioural: worries Analysis of Data: belief with self was JGNRNGUU perceived to feels getting CDQWVGXGPVU Qualitative analysis was done using the aggression presenting complaints of the patients, narrations of DGKPCFGSWCVG freeze while FGRTGUUGF VCNMKPIYQWNF directed towards self WKH7KHPDWLF$SSHUFHSWLRQ7HVWDQGDOVRWKH¿QGLQJV weak and not organize CPFQVJGTU from the quantitative analysis (Datta et al., in press). helpless RTQRGTN[ Metacognitive components f URP WKHVH ¿QGLQJV greater negative were then used for the purpose of psychopathology belief about formulation using the S-REF model of Metacognition. worry

15 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ......

Psychological: Behavioural: Psychological: META SYSTEM

worry about worry about anxiety related BELIEF : negative belief about worry, negative beliefs about HWVWTGTGOCKPU VJGYQTT[ to self and how thoughts, self is inadequate, depressed, weak and helpless Meta- tensed most of aggression to deal with PLANS : Psychological : worry about future, remains tensed VJGFC[HCPVCU[ when the worry environ- mental most of the day, fantasy thinking, Behavioural : worry about the worry, aggression plans thinking does not resolve deprivation when the worry does not resolve Behavioural: Behavioural: Psychological: worries aggression engages in MONITORING CONTROL CDQWVGXGPVU when the worry thinking aggression does not resolve COGNITIVE STYLE directed or avoidance APPRAISAL towards self behaviour Lack of love/ deprivation, future is perceived to be CPFQVJGTU hopeless and helpless, low cognitive confidence and consciousness

Lack of love/ Lack of love Lack or loss of CAS deprivation and fear of love was found was found out separation Increase in emotional activation and worry for and the future QWVCNQPIYKVJ future, focus on danger and future misfortunes YCUHQWPFQWV worries and is perceived Low Cognitive to be hopeless has feelings of LOW LEVEL Cognitive %QPſFGPEG INTRUSION PROCESSING BIASING CPFJGNRNGUU sadness. Appraisal along with and self low cognitive consciousness INPUT OUTPUT EQPſFGPEG along with Distant relation with authority and Emotional : worrying, tension and self fear of social contemporary figures consciousness Behavioural : unstable relationship situations Depriving, dangerous and unsupportive and impulsivity environment Increase in Increase in Increase in Thought Control : does not think emotional Stressful life events in more in the lifetime about it, although he fails to control emotional emotional than in the last year, contributing to the his thoughts activation activation and CEVKXCVKQPRNCP illness and worry for avoidance of the for future and present and plan Flow Diagram Showing Psychopathology HWVWTGHQEWU also relieves in for future along Formulation of Mixed Anxiety and Depressive CAS on danger with un - the past and future controllability Disorder Based on Presenting Complaints, misfortunes of thoughts Qualitative Analysis and Quantitative Analysis:

Emotional: Behavioural: Emotional: META SYSTEM YQTT[KPI unstable tension and Output BELIEF : self is inadequate, depressed, and weak, tension relationship and social anxiety with both posit ive and negative belief about impulsivity worry, lower cognitive confidence PLANS : Psychological : engages in thinking Thought Control: Behavioural: Thought Emotional: Behavioural : worries about events, does not think avoidance Control: tries YQTT[KPI aggression directed towards self and CDQWVKVCNVJQWIJ behaviour not to think VGPUKQP others, he fails to control about the social UCFPGUU his thought s situation but is helplessness MONITORING CONTROL never able to COGNITIVE STYLE control it APPRAISAL Behavi - oural: Thought Lack or loss of l ove, worries and has feelings of #IITGUUKQP Control: does sadness CAS Lack of interest not think about the emotion Increase in emotional activation, plan for future and in activities also relieves in the past provoking event INTRUSION BIASING

Using The S-REF (Self Regulatory Executive LOW LEVEL Function) model of psychological disorder with meta- PROCESSING cognitions revealed, after Wells and Mathews (1994). A detailed qualitative analysis has been given as follows. INPUT OUTPUT Distant relation with authority Emotional : worrying, Flow Diagram Showing Psychopathology and opposite sex contemporary tension, sadness, helplessness figures Behavio ural : aggression, Formulation of Generalized Anxiety Disorder Significant stressful life events lack of interest in activities more in the life time than in the Thought Control : does not Based on Presenting Complaints, Qualitative last year, contributing to the think a bout it Analysis and Quantitative Analysis: long term symptoms

16 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ......

Flow Diagram Showing Psychopathology self is perceived to be inadequate, depressed, Formulation of Social Phobia based on weak and helpless, thereby arriving at a meta- Presenting Complaints, Qualitative Analysis and plan. His psychological frame of mind rests upon Quantitative Analysis: worrying about future, remaining tensed most of META SYSTEM the day and engaging in fantasy thinking and his

BELIEF : self is inadequate, depressed, weak and helpless, behaviour involves worry about the worry, and I would get freeze while talking or would not be able to getting aggressive when the worry does not resolve. organize properly, greater negative belief about worry This is thereafter, monitored and controlled by the PLANS : Psychological : anxiety related to self and how to cognitive style of the individual. The appraisal of deal with environmental deprivation which involves lack of love/ deprivation, future Behavioural : aggression when the worry does not perceived to be hopeless and helpless, low cognitive resolve or avoidance behaviour FRQ¿GHQFH DQG VHOI FRQVFLRXVQHVV OHDGLQJ WR WKH cognitive attentional syndrome involving increase in emotional activation and worry for future, focus on MONITORING CONTROL GDQJHUDQGIXWXUHPLVIRUWXQHVZKLFKDJDLQPRGL¿HV

COGNITIVE STYLE the appraisal system. These are further monitored and controlled by intrusive thoughts and biasing APPRAISAL leading to a low level of cognitive and emotional Lack of love and fear of separation, Low Cognitive functioning. The output of which being worrying Confidence and self consciousness, fear of and tension (emotional), unstable relationship and social situations impulsivity (behavioural) but the individual tries CAS not think about it, although he fails to control his Increase in emot ional activation and avoidance of the thoughts (thought control). However, this is again present and plan for future, uncontrollability of thoughts maintained by the inputs from the family and social INTRUSION BIASING environment. LOW LEVEL Integrated Summary of the Psychopathology PROCESSING Formulation in Social Phobia: In Social Phobia, as obtained from the following INPUT OUTPUT study, various inputs like distant relation with Distant relation with authority Emotional : tension and social and contemporary figures anxiety DXWKRULW\DQGFRQWHPSRUDU\¿JXUHVGHSULYLQJVRFLDO environment, and critical comments from family and Depriving environment Behavioural : avoidance environment, contributes to the illness. The meta Critical comments from family Thought Control : tries not to system is therefore composed of meta beliefs and and environment think about the social situation but meta plans. The meta belief that has been found from is never able to control it the complaints, qualitative and quantitative analysis reveals the self to be inadequate, depressed, weak Integrated summary of the Psychopathology and helpless, he feels that he would get freeze while Formulation in Generalized Anxiety Disorder: talking or would not be able to organize properly, In Generalized Anxiety Disorder, as obtained greater negative belief about worry and thereby from the following study, various inputs like distant arriving at a meta plan. His psychological frame UHODWLRQ ZLWK DXWKRULW\ DQG FRQWHPSRUDU\ ¿JXUHV of mind rests upon anxiety related to the self and depriving, dangerous and unsupportive environment how to deal with environmental deprivation and and stressful life events in the lifetime, contributes to his behaviour involves getting aggressive when the the illness. The meta-system is therefore composed worry does not resolve and avoidance behaviour. of meta-beliefs and meta-plans. The meta-belief This is thereafter, monitored and controlled by the that has been found from the complaints, qualitative cognitive style of the individual. The appraisal of and quantitative analysis reveals negative belief which involves lack of love and fear of separation, about worry, negative beliefs about thoughts the ORZ FRJQLWLYH FRQ¿GHQFH DQG VHOI FRQVFLRXVQHVV

17 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ...... and fear of social situations leading to the cognitive is again maintained by the inputs from the family and attentional syndrome involving increase in emotional social environment. activation and avoidance of the present and plan The analysis of psychopathology formulation for future, along with uncontrollability of thoughts suggests differences among the groups. In ZKLFK DJDLQ PRGL¿HV WKH DSSUDLVDO V\VWHP 7KHVH Generalized Anxiety Disorder, the meta-system is are further monitored and controlled by intrusive LQÀXHQFHG E\ QHJDWLYH EHOLHIV DERXW WKRXJKWV DQG thoughts and biasing leading to a low level of worries leading to a cognitive style that is focussed cognitive and emotional functioning. The output of around future danger and misfortune, the output which being tension and social anxiety (emotional), being worry, whereas is Social Phobia, the meta- avoidance (behavioural) but the individual tries not V\VWHP LV LQÀXHQFHG E\ QHJDWLYH EHOLHIV DERXW WKH to think about the social situation but is never able self leading to a cognitive style that is focussed to control it (thought control). However, this is again around avoidance of present and plan for future, the maintained by the inputs from the family and social output being avoidance. Lastly, in Mixed Anxiety and environment. 'HSUHVVLYH'LVRUGHUWKHPHWDV\VWHPLVLQÀXHQFHG Integrated Summary of the Psychopathology by both positive and negative beliefs about worries Formulation in Mixed Anxiety and Depressive leading to a cognitive style that is focussed around Disorder: relieving in the past and plan for future, the output In Mixed Anxiety and Depressive Disorder, being worry, sadness and lack of interest in activities as obtained from the following study, various inputs However, the present study is found to have like distant relation with authority and opposite sex certain limitations. These factors if considered FRQWHPSRUDU\¿JXUHVVLJQL¿FDQWVWUHVVIXOOLIHHYHQWV to a greater extent may make this present study more in the life time, contributes to the long term meet higher degrees of sophistication and thereby symptoms of the illness. The meta system is therefore this may increase its generalizability. There was composed of meta beliefs and meta plans. The meta a limited sample size because of time constraints, belief that has been found from the complaints, loss of subjects due to inconsistency of information qualitative and quantitative analysis reveals the self is provided, the age range taken for the group for the inadequate, depressed, and weak, with both positive purpose of psychopathology formation was not too and negative belief about worry, lower cognitive broad, and other socio-economic classes other than FRQ¿GHQFHDQGWKHUHE\DUULYLQJDWDPHWDSODQ+LV low and middle class should have also been included. psychological frame of mind rests upon engaging CONCLUSION: in thinking and his behaviour involves having The psychopathology formulation thus reveals worries about events, and aggression is mainly that various inputs from the family and environment directed towards self and others. This is thereafter, forms a meta-system in an individual where there monitored and controlled by the cognitive style of are meta-beliefs about the self and meta-plans about the individual. The appraisal of which involves lack dealing with the incoming stress which monitors and or loss of love, worries and has feelings of sadness controls the cognitive style and cognitive attentional leading to the cognitive attentional syndrome syndrome leading to cognitive and emotional involving increase in emotional activation, plans problems, the output of which being the symptoms for future and also he sometimes relieves in the of the illness. It was found that patients across SDVWDQGZKLFKDJDLQPRGL¿HVWKHDSSUDLVDOV\VWHP cultures show diversities and differences in meta- These are further monitored and controlled by FRJQLWLYH SUR¿OH ZKLFK LQÀXHQFHV WKHLU PRQLWRULQJ intrusive thoughts and biasing leading to a low level and adjustment of their thoughts, interactions and of cognitive and emotional functioning. The output relationships with others. The study highlights the of which being worrying, tension, sadness and HI¿FDF\RI65()PRGHOLQWKHSUHVHQWVRFLRFXOWXUDO helplessness (emotional), aggression, lack of interest context and how deviations from pre-determined in activities (behavioural) but the individual tries therapy structure, based on western culture, was not think about the emotion provoking events and is involved in. Findings suggest meta-cognitive successful at times (thought control). However, this appraisals of thoughts do make a contribution to the

18 Soheli Datta et al. / Application of Self-Regulatory Executive Function (S-REF) ...... disorders under study also revealed an understanding Datta, S., Das, S. & Dogra, A. K., (2015). Generalized RIVSHFL¿FLQWHUFXOWXUDOPHWDFRJQLWLRQVDQGZLWKWKH Anxiety Disorder, Social Phobia and Mixed Anxiety obtained information, some inter-cultural preventive & Depressive Disorder: A Comparative Study of measures, and intervention strategies could be Metacognition and Stressful Life Events. Indian planned using meta-cognitive therapy and executed Journal of Psychological Issues ( in press ). in the different anxiety disorder groups in the present McClelland, D. C., Koestner, R., & Weinberger, J. (1989). population which may enhance the quality of life +RZGRVHOIDWWULEXWHGDQGLPSOLFLWPRWLYHVGLIIHU" of these patients. However, the study picturized Psychological Review , 96, 690–702. differences in psychopathology formation across the Morgan, Ch.D. & Murray, H.A. (1935) A method for disorders hence for further validation the study might investigating fantasies: The Thematic Apperception be conducted with larger sample siz e. Test. Archives of Neurology and Psychiatry , 34, pp. 289-306. REFERENCES: Singh, G., Kaur, D. & Kaur, S.(1984) Presumptive Stressful American Psychiatric Association (APA) (2000). Life Events Scale (PSLES) — A New Stressful Life Diagnostic and Statistical Manual of Mental Events Scale For Use In India Disorders (4th ed. TR). Washington, DC: Author. Squire, L. R. (1992). Memory and the hippocampus: A Bargh, J. A. (2005). Bypassing the Will: Toward V\QWKHVLV IURP ¿QGLQJV ZLWK UDWV PRQNH\V DQG Demystifying the Nonconscious Control of Social humans . Psychological Review , 2, 195–231. Behavior. In R. R. Hassin, J. S. Uleman, & J. A. Well, A (2000). Emotional Disorder and Metaccognition . Bargh (Eds.), The New Unconscious (pp. 37–58). Chi Chester, Uk:Willy. New York: Oxford University Press. Wells, A. (1994a). Attention and the control of worry. Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety In G. C. L. Davey & F. Tallis (Eds.), Worrying: disorder subjects: Distraction from more Perspectives on Theory, Assessment, and Treatment (pp. 91-114). Chichester, UK: Wiley. HPRWLRQDOO\ XSVHWWLQJ WRSLFV" Behavior Therapy and Experimental Psychiatry , 26, 25-30. Wells, A. (1995). Metacognition and worry: A cognitive Cartwright-Hatton, S., & Wells, A. (1997). Beliefs model of generalized anxiety disorder. Behavioral about worry and intrusions: The Metacognitions and Cognitive Psychotherapy, 23,301-320. Questionnaire and its correlates. Journal of Anxiety Wells, A., & Matthews, G. (1994). Attention and Disorders, 11,279-296. Emotion: A Clinical Perspective. Hove, UK: Clark, D. M., & Wells, A. (1995). A cognitive model of Lawrence Erlbaum social phobia. In: R. Heimberg, M. Liebowitz, D. Wells, A., & Matthews, G. (1996). Modelling cognition in A. Hope, & F. R. Schneier (Eds.), Social Phobia: emotional disorder: the S-REF model. Behaviour Diagnosis, Assessment and Treatmen t(pp. 69–93). Research and Therapy, 34, 881–888. New York: Guilford Press. Wells, A., & Papageorgiou, C. (1998). Relationships Cleermans, A. (2015). Conscious and unconscious between worry, obsessive–compulsive symptoms cognition: A graded, dynamic, perspective. and meta-cognitive beliefs. Behaviour Research and International Journal of Psychology ( in press) . Therap y, 36, 899–913.

19 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 20-25 Clinical Psychologists (ISSN 0303-2582) Research Article (I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWVZLWK Stuttering: A Preliminary Study

Sanjeev Kumar Gupta* 1

ABSTRACT 7KHDLPRIWKLVSUHOLPLQDU\VWXG\ZDVWRH[DPLQHWKHHI¿FDF\RIPLQGIXOQHVVEDVHGFRJQLWLYH behavior therapy (CBT) for enhancing communication attitude, quality of life, self-esteem and VSHHFKÀXHQF\LQDGXOWVZKRVWXWWHU$SUHSRVWLQWHUYHQWLRQDOGHVLJQZDVHPSOR\HG7KHVDPSOH consisted of 5 adults with the diagnosis of stuttering. The therapeutic program included 15-20 sessions of one hour each. The pre and post intervention assessments were done using Toronto 0LQGIXOQHVV 6FDOH 0RGL¿HG (ULFNVRQ 6FDOH RI &RPPXQLFDWLRQ$WWLWXGHV:+2 4XDOLW\ RI Life-BREF Scale, Beck Anxiety Inventory, Rosenberg's Self-Esteem Scale, Perceptions of 6WXWWHULQJ,QYHQWRU\DQG6WXWWHULQJ6HYHULW\,QVWUXPHQW7KH¿QGLQJRIWKHVWXG\VKRZVWKDW mindfulness-based CBT is effective in treatment of adults who stutter. Key Words: Cognitive behavior therapy, Communication attitude, Mindfulness, Quality of life, Stuttering

INTRODUCTION VWXWWHU PD\ KDYH VLJQL¿FDQWO\ KLJK OHYHOV RI VRFLDO Stuttering is a developmental speech disorder anxiety (Kraaimaat, Vanryckeghem, & Van Dam- ZLWKPXOWLSOHHWLRORJLFDOIDFWRUV6WXWWHULQJLVGH¿QHG Baggen, 2002; Menzies et. al., 2008). The primary as speech that is characterized by frequent repetition goal of CBT in adults who stutter is to reduce social or prolongation of sounds or syllables or words, or by avoidance behaviour as well as anxiety (Craig, 2006; frequent hesitation or pauses that disrupt the rhythmic Menzies, Onslow, Packman, & O’Brian, 2009). ÀRZRIVSHHFK ,&':+2 7KXVWKHFRUH The term ‘mindfulness’ is an English behaviours of stuttering are repetitions, prolongations translation of the Pali word sati. Pali was the and blocks (Guitar, 2006). It occurs in approximately language of Buddhist psychology 2,500 years ago, 1% of the general population (Bloodstein, 1995) and and mindfulness is the core teaching of this tradition. in 5% of primary school children (Onyeizugbo, 2011). Sati connotes awareness, attention, and remembering It is more common in men than in women by a ratio of *HUPHU   0LQGIXOQHVV KDV EHHQ GH¿QHG 4:1 (Onyeizugbo, 2011). as “the awareness that emerges through paying Cognitive Behavior Therapy (CBT) is one attention on purpose, in the present moment, and of the major orientations of psychotherapy (Roth nonjudgementally to the unfolding of experience & Fonagy, 2005). It is mainly concerned with moment by moment” (Kabat-Zinn, 2003). understanding the role of cognitions or the personal Mindfulness in psychotherapy is an awareness of meaning that the individuals assign to events and present experience with acceptance (Germer, 2005). on working within this domain in order to achieve Mindfulness-based Cognitive Therapy (MBCT) cognitive as well as behavioural change (Beck, is a manualized group intervention program that  ,WLVVWUXFWXUHGIRFXVHGRQVSHFL¿FSUREOHPV integrates mindfulness techniques and elements of time-limited and educative, encouraging individuals cognitive-behavioral therapy (Segal, Williams, & WRXQGHUVWDQGWKHLUGLI¿FXOWLHVEHWWHU %HFN  Teasdale, 2002). CBT is used with adults experiencing high levels of Mindfulness-based therapies have shown social anxiety related to stuttering and speaking. It has effectiveness in the reduction of depression and been reported that approximately 50% of adults who anxiety symptoms in clinical and unpleasant affect

1. Clinical Psychologist, Department of Clinical Psychology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India *Corresponding Author - Dr Snjeev Kumar Gupta, E mail: [email protected]

20 6DQMHHY.XPDU*XSWD(I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWVZLWK6WXWWHULQJ and psychological stress in non-clinical population Toronto Mindfulness Scale (TMS; Lau et al., 2006 ): (Grossman, Niemann, Schmidt, & Walach, 2004; It is a 13-item state-mindfulness measure Bohlmeijer, Prenger, Taal, & Cuijpers, 2010). MBCT that uses a 5 point Likert-type scale from not at all has been shown to be effective in the reduction (0) to very much (4). The scale has two sub-scales: of attention problems, anxiety symptoms and Curiosity, 6 items, subscale score ranging from 0-24, behavioural problems in individuals (Semple, Lee, and Decentering, 7 items, with a subscale score Rosa, & Miller, 2010). Research evidence suggests ranging from 0-28. Cronbach’s alphas are reported to that MBCT is effective in the improvement of range from 0.86 to 0.91 for Curiosity and 0.85 to 0.87 anxiety, stuttering, communication attitude, and self- for Decentering (Park et al., 2013). esteem in adolescents (Gupta, 2015). Research studies show that speech therapy 0RGL¿HG (ULFNVRQ 6FDOH RI &RPPXQLFDWLRQ treatment for stuttering is available in early Attitudes (MESCA; Andrews, & Cutler, 1974): childhood (Jones et al., 2005) but stuttering in adults MESCA measures communication attitude. is much less responsive to speech therapy (Craig & This 24- item scale distinguishes the extent to which Hancock, 1995). Thus, the aim of present study was a stuttering person's communication attitude deviates WRH[DPLQHWKHHI¿FDF\RIPLQGIXOQ ess-based CBT from normed attitudes. Statements require a true or for enhancing mindfulness, communication attitude, false answer. The higher the score, the poorer is the TXDOLW\ RI OLIH VHOIHVWHHP DQG VSHHFK ÀXHQF\ DQG communication attitude. reducing level of anxiety, frequency and severity of stuttering in AWS. WHO Quality of Life-BREF Scale (WHOQOL- BREF; WHOQOL Group, 1998): METHOD AND MATERIALS ,WFRQVLVWVRILWHPVDQGSURYLGHVDSUR¿OH A pre–post intervention design was adopted. of scores on four dimensions of quality of life: 7KHVDPSOHFRQVLVWHGRI¿YHDGXOWVZLWKWKHGLDJQRVLV physical health, psychological, social relationships, of stuttering (ICD-10, DCR), and was recruited and the environment. The WHOQOL-BREF from Out Patient Clinic of Department of Clinical questionnaire was scored after its administration on Psychology based on inclusion and exclusion the study subjects; the raw scores were converted criteria. Participants with the diagnosis of stuttering, WR WUDQVIRUPHG VFRUHV 7KH ¿UVW WUDQVIRUPDWLRQ aged between 18 to 34 years, educated at least converts scores to a range of 4-20 and the second upto class X and having obtained a minimum total transformation converts domain scores to a 0-100 score of 20 on Stuttering Severity Instrument (SSI; Riley, 1994) were included in the study. Participants VFDOH+LJKHUVFRUHVUHÀHFWDEHWWHUTXDOLW\RIOLIH ZLWK VLJQL¿FDQW PHGLFDO SV\FKLDWULF QHXURORJLFDO Beck Anxiety Inventory (BAI; Beck & Steer, 1990): disorders as associated conditions, obtaining less It is a 21-item scale developed to assess the than 20 total scores on SSI and having previous severity of anxiety symptoms. Respondents are exposure to the cognitive behavioural intervention asked to rate each item on a 4-point scale ranging were excluded. The purpose and procedure of from 0 (not at all) to 3 (severely, can barely stand study were explained to the participants, informed it). Ratings are for the past week. Items are summed FRQVHQW ZDV WDNHQ DQG FRQ¿GHQWLDOLW\ ZDV DVVXUHG to obtain total scores ranging from 0 to 63 (Beck, & as enshrined in the mandate on ethical guidelines Steer, 1993). followed at the institute (Venkatesan, 2009). Rosenberg's Self-Esteem Scale (RSES; Rosenberg, Measures: 1965): Socio-Demographic and Clinical Data Sheet: A 10-item scale that measures global self- A Socio-demographic and Clinical Data Sheet worth by measuring both positive and negative was used to obtain the relevant information on the feelings about the self. The scale is believed to be demographic and clinical history. unidimensional. All items are answered using a

21 6DQMHHY.XPDU*XSWD(I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWV:KR6WXWWHU$3UHOLPLQDU\6WXG\

4-point Likert scale format ranging from strongly our emotions, physiology, and behavior (Beck, agree to strongly disagree. Items 2, 5, 6, 8, 9 are  1HJDWLYHDXWRPDWLFWKRXJKWVZHUHLGHQWL¿HG reverse scored. Give “Strongly Disagree” 1 point, and challenged by checking the evidence. They were “Disagree” 2 points, “Agree” 3 points, and “Strongly taught deep breathing and relaxation techniques to Agree” 4 points. Sum scores for all ten items. Keep control speech-related anxiety. Cognitive/speech scores on a continuous scale. Higher scores indicate restructuring was incorporated to modify speech- higher self-esteem. related dysfunctional beliefs. Problem solving technique was introduced to increase their sense of Perceptions of Stuttering Inventory (PSI; Woolf, EHLQJDEOHWRFRSHXSZLWKVSHHFKUHODWHGGLI¿FXOWLHV 1967): when they arise. They were asked to self-monitor The PSI is a 60-item inventory equally divided the speech-related anxiety symptoms during into three dimensions: (a) Struggle, (b) Avoidance, communication with stranger and authority persons and (c) Expectancy. For each item, participants and also asked to self-monitor the speech-related indicated how well the described behavior was G\VIXQFWLRQDOEHOLHIVDQGVSHHFKUHODWHGGLI¿FXOWLHV characteristic of their stuttering. Ginsberg (2000) if any, and maintain the diary for the same. found that participants’ self-ratings of stuttering Procedure: severity were closely associated with their scores on Patients with stuttering were screened based the PSI (correlations ranged from .89 for expectancy on inclusion and exclusion criteria. After that they to .92 for total perceptions of stuttering). Severity underwent pre assessment on various scales, namely, levels for each of the three dimensions according to 7RURQWR0LQGIXOQHVV6FDOH0RGL¿HG(ULFNVRQ6FDOH scores on the PSI are mild (0–7), moderate (8–11), of Communication Attitudes, WHO Quality of Life- moderate to severe (12–15), and severe (16–20). BREF Scale, Beck Anxiety Inventory, Rosenberg's Self-Esteem Scale, Perceptions of Stuttering Stuttering Severity Instrument-3 (SSI-3; Riley, 1994): Inventory, and Stuttering Severity Instrument. After It is a measure of stuttering severity and was pre assessment all the participants were subjected to based on a 20-min interview session. The interview treatment program. The Treatment program consisted was then used to assess the frequency and duration of of 15-20 sessions of mindfulness-based CBT that stuttering and any associated physical concomitants, were held over a period of eight weeks. Two to three and these were converted to SSI-3 scores using the sessions were held every week and each session VSHFL¿HGJXLGHOLQHV7KHDGXOWZKRVWXWWHUVFRUHG lasted for 60 minutes. After Intervention, they were or higher, this score placed between the 12 and 23rd again rated on same measures. Participants were SHUFHQWLOH DQG UDWHG DV PLOG +LJKHU VFRUH UHÀHFWV assigned homework consisting of regular practice at higher severity level of stuttering. home and maintenance of a diary for the same. They were also asked to evolve strategies they could use to Therapeutic Program: GHDOZLWKGLI¿FXOWVSHHFKVLWXDWLRQV Mindfulness-based CBT program included orientation regarding the nature, causes, treatment Statistical Analysis: of stuttering, Mindfulness techniques and CBT. Statistical analysis was carried out using the Mindfulness techniques incorporated sitting following formula: Percentage of change/therapeutic mindfulness meditation; awareness about their change = [(Pre treatment Score – Post treatment thoughts, feelings and body; awareness of the present Score)/ Pre treatment Score] × 100. Clinically moment and past; present and future thinking and VLJQL¿FDQW FKDQJHV  DQG DERYH  EDVHG RQ SUH acceptance into daily life (Semple, etal., 2006). and post treatment scores were used to assess the The ‘cognitive-behavioural model’ of effect of the therapeutic program (Blanchard & stuttering was drawn and discussed with the Schwarz, 1988). SDUWLFLSDQWVDVSHUWKHLUVSHFL¿FVLJQVDQGV\PSWRPV The cognitive-behavioural model is based upon the RESULTS DVVXPSWLRQ WKDW RXU WKRXJKWV DQG EHOLHIV LQÀXHQFH Table-1: Pre and Post Intervention Assessment

22 6DQMHHY.XPDU*XSWD(I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWV:KR6WXWWHU$3UHOLPLQDU\6WXG\ Scores with Improvement Percentage Measures Case 1 Case 2 Case 3 Case 4 Case 5 Pre Post Imp % Pre Post Imp % Pre Post Imp % Pre Post Imp % Pre Post Imp % TMS 22 35 59* 15 26 73* 23 37 60* 18 29 61* 20 33 55* MESCA 19 09 52* 21 07 66* 21 10 52* 17 06 64* 23 10 56* WHOQOL-BREF 65 99 52* 56 89 58* 63 96 52* 59 95 61* 61 96 57*

RSES 14 24 71* 12 21 75* 17 28 64* 18 31 72* 21 33 57* BAI 35 11 68* 41 16 60* 36 16 55* 46 19 58* 37 14 62*

PSI 56 27 51* 44 20 54* 41 19 53* 29 14 51* 43 18 58* SSI 35 17 51* 25 12 52* 26 11 57* 32 15 53* 26 13 50* &OLQLFDOO\ 6LJQL¿FDQW &KDQJHV  DQG DERYH  EDVHG RQ SUH DQG SRVW WUHDWPHQW VFRUHV 706 7RURQWR 0LQGIXOQHVV 6FDOH 0(6&$ 0RGL¿HG (ULFNVRQ 6FDOH RI &RPPXQLFDWLRQ$WWLWXGHV :+242/%5() :+2 Quality of Life-BREF; RSES: Rosenberg Self-Esteem Scale; BAI: Beck Anxiety Inventory; PSI: Perceptions of Stuttering Inventory; SSI: Stuttering Severity Instrument. Case 1: Mr. S.K. is a 25 years old businessman, I of stuttering (54%), and severity of stuttering (52%) PUC pass, belonging to middle socioeconomic (table-1). status, and has a normal birth and developmental history. He came with the chief complaints of Case 3: G\VÀXHQWVSHHFKZKLFKKDVLQFUHDVHGLQWKHODVW¿YH Ms. F.R.P. is an 18 years old, IInd PUC pass, \HDUV '\VÀXHQW VSHHFK VLJQL¿FDQWO\ LPSDFWHG KLV belonging to middle socioeconomic status and is personal and business life. He has reported severe the younger of two siblings. She has normal birth level of stuttering on SSI (35). After attending the and developmental history. She came with the chief intervention, improvement was observed in the level FRPSODLQWVRIG\VÀXHQWVSHHFKIRUODVWHLJKW\HDUV of mindfulness (59%), communication attitudes She has reported moderate level of stuttering on SSI (52%), quality of life (52%), self-esteem (71%) (26). After attending the intervention, improvement and whereas reduction was found in the anxiety was observed in the level of mindfulness (60%), symptoms (68%), perceptions of stuttering (51%), communication attitudes (52%), quality of life and severity of stuttering (51% ; table-1). (52%), self-esteem (64%) and whereas reduction was found in the anxiety symptoms (55%), perceptions Case 2: of stuttering (53%), and severity of stuttering (57%; Mr. M.T.S. is a 19 years old, B.Sc. IInd year table-1). student, belonging to middle socioeconomic status and is the eldest of two siblings. He has normal birth Case 4: and developmental history. He came with the chief Mr. C.L. is a 34 years old businessman, B.Com. FRPSODLQWVRIG\VÀXHQWVSHHFKZKLFKKDVLQFUHDVHG pass, belongs to middle socioeconomic status and LQ WKH ODVW RQH DQG KDOI \HDUV '\VÀXHQW VSHHFK has normal birth and developmental history. He VLJQL¿FDQWO\LPSDFWHGKLVSHUVRQDODQGFROOHJHOLIH FDPHZLWKWKHFKLHIFRPSODLQWVRIG\VÀXHQWVSHHFK He has reported moderate level of stuttering on SSI VLQFH FKLOGKRRG '\VÀXHQW VSHHFK VLJQL¿FDQWO\ (25). After attending the intervention, improvement impacted his business life. He has reported severe was observed in the level of mindfulness (73%), level of stuttering on SSI (32). After attending the communication attitudes (66%), quality of life intervention, improvement was observed in the level (58%), self-esteem (75%) and whereas reduction was of mindfulness (61%), communication attitudes found in the anxiety symptoms (60%), perceptions (64%), quality of life (61%), self-esteem (72%)

23 6DQMHHY.XPDU*XSWD(I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWV:KR6WXWWHU$3UHOLPLQDU\6WXG\ and whereas reduction was found in the anxiety improvements in psychological functioning but did symptoms (58%), perceptions of stuttering (51%), QRWLPSURYHÀXHQF\ and severity of stuttering (53%)(table-1). In conclusion, mindfulness-based CBT Case 5: program is effective to bring positive changes Mr. R.K. is a 20 years old, B.Tech. IInd year LQ WKH PHDVXUHV RI DQ[LHW\ VSHHFK G\VÀXHQF\ communication attitude, mindfulness, self-esteem, student, belonging to middle socioeconomic status and having normal birth and developmental history DQGTXDOLW\RIOLIHLQ$:6$:6PD\LQGHHGEHQH¿W from the mindfulness-based CBT program, because FDPHZLWKWKHFKLHIFRPSODLQWVRIG\VÀXHQWVSHHFK ZKLFKKDVLQFUHDVHGLQWKHODVWWKUHH\HDUV'\VÀXHQW WKH OHVV DQ[LHW\ WKH\ H[SHULHQFH WKH PRUH ÀXHQWO\ they speak and would have high self-esteem and VSHHFK VLJQL¿FDQWO\ LPSDFWHG KLV FROOHJH OLIH +H has reported moderate level of stuttering on SSI FRQ¿GHQFH LQ WKHLU DELOLW\ WR FRPPXQLFDWH PRUH (26). After attending the intervention, improvement positive communication attitude; more awareness was observed in the level of mindfulness (55%), towards speech situations and less chances to relapse. communication attitudes (56%), quality of life Therefore, mindfulness-based CBT program can be (57%), self-esteem (57%) and whereas reduction was used for the long-term management of AWS. found in the anxiety symptoms (62%), perceptions A large sample is needed to generalize the of stuttering (58%), and severity of stuttering (50%) results. Further empirical researches are also needed (table-1). with larger sample size using double blind procedure, FRQWUROJURXSDQGIROORZXSWRWHVWWKHHI¿FDF\RI DISCUSSION mindfulness-based CBT for the management of The aim of the present study was to examine AWS. WKH HI¿FDF\ RI PLQGIXOQHVVEDVHG &%7 LQ WKH management of AWS. The therapeutic change in REFERENCES the score of the various scales shows clinically Andrews, G., & Cutler, J. (1974). Stuttering therapy: The VLJQL¿FDQW UHVXOWV IURP SUH WR SRVW LQWHUYHQWLRQ relation between changes in symptom level and (table-1). The overall reduction of anxiety symptoms attitudes. Journal of Speech and Hearing Disorders , ZDV IRXQG LQ DOO ¿YH FDVHV IURP  WR  39 (3), 312-319. reduction of severity of stuttering from 51% to Beck, A. T., & Steer, R. A. (1993). Beck Anxiety 57%, and reduction of perception of stuttering Inventory Manual. San Antonio, TX: Psychological from 51% to 58% whereas the improvement was Corporation. found in the level of mindfulness from 55% to 73%, Beck, A. T., & Steer, R.A. (1990). Manual for the Beck communication attitude from 52% to 66%, quality Anxiety Inventory. San Antonio, TX: Psychological of life from 52% to 61%, and self-esteem from 57% Corporation. to 75%. The study demonstrates that mindfulness- Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond . EDVHG &%7 VKRZV VLJQL¿FDQW LPSURYHPHQW RQ WKH London: Guilford Press. PHDVXUHV RI DQ[LHW\ V\PSWRPV G\VÀXHQW VSHHFK self-esteem, mindfulness, communication attitude Blanchard, E. B., & Schwarz, S. P. (1988). Clinically and quality of life after completion of therapy at post VLJQL¿FDQW FKDQJHV LQ EHKDYLRUDO PHGLFLQH assessment. Behavioral Assessment, 10 (2), 171–188. 7KH¿QGLQJRIWKHSUHVHQWVWXG\LVLQOLQHZLWK Bloodstein, O. (1995). A Handbook on Stuttering (5th ed.). WKHVWXG\RI*XSWD  ZKRVWXGLHGWKHHI¿FDF\ San Diego, CA: Singular Publishing Group. of MBCT program in adolescent who stutter and Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). found MBCT program plays a vital role in managing The effects of Mindfulness-Based Stress Reduction stuttering, improving communication attitude, and therapy on mental health of adults with a chronic ERRVWLQJ VHOIFRQ¿GHQFH DQG VHOIHVWHHP WR IDFH medical disease: A meta-analysis. Journal of the social situation. On the other hand, Menzies, Psychosomatic Research , 68 (6), 539–544. et al., (2008) study found that CBT treatment Craig, A. R., & Hancock, K. (1995). Self-reported factors ZDV DVVRFLDWHG ZLWK VLJQL¿FDQW DQG VXVWDLQHG related to relapse following treatment for stuttering.

24 6DQMHHY.XPDU*XSWD(I¿FDF\RI0LQGIXOQHVV%DVHG&RJQLWLYH%HKDYLRU7KHUDS\LQ$GXOWV:KR6WXWWHU$3UHOLPLQDU\6WXG\

Australian Journal of Human Communication stutter: A tutorial for speech-language pathologists. Disorders , 23 (1), 48-60. Journal of Fluency Disorders , 34 (3), 187-200. Craig, A., & Tran, Y. (2006). Fear of speaking: chronic 2Q\HL]XJER(8  6LPSOL¿HG5HJXODWHG%UHDWKLQJ anxiety and stammering. Advances in Psychiatric Treatment for an Adult with Stuttering: A Case Treatment, 12(1), 63-68. Study. Indian Journal of Clinical Psychology , 38 (1), 89-94. *HUPHU&.  0LQGIXOQHVVZKDWLVLW":KDWGRHVLW PDWWHU",Q*HUPHU&.6LHJHO5' )XOWRQ3 Park, T., Reilly-Spong, M., & Gross, C. R. (2013). R. (Eds.), Mindfulness and Psychotherapy (pp. 5-7). Mindfulness: A systematic review of instruments New York: Guilford Press. to measure an emergent patient-reported outcome (PRO). Quality of Life Research, 22(10), 2639-2659. Ginsberg, A. P. (2000). Shame, self-consciousness, and locus of control in people who stutter. The Journal Riley, G. D. (1994). Stuttering Severity Instrument for of Genetic Psychology , 161 (4), 389–399. Children and Adults (3rd ed.). Austin, TX: Pro-Ed. Grossman, P., Niemann, L., Schmidt, S., & Walach, Rosenberg, M. (1965). Society and the adolescent self- H. (2004). Mindfulness-Based Stress Reduction image. Princeton, NJ: Princeton University Press. DQG KHDOWK EHQH¿WV $ PHWDDQDO\VLV Journal of Roth, A., & Fonagy, P. (2005). What Works for Whom: A Psychosomatic Research, 57 (1), 35-43. Critical Review of Psychotherapy Research (2nd Guitar, B. (2006). Stuttering: An Integrated Approach ed.). London: Guildford Press. to its Nature and Treatment (3rd ed.). Baltimore: Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. Lippincott Williams & Wilkins. (2002). Mindfulness-based Cognitive Therapy for Gupta, S. K. (2015). Mindfulness-based Cognitive Therapy Depression: A New Approach to Preventing Relapse. in Early Adolescents who Stutter. Delhi Psychiatry New York: Guilford Press. Journal, 18 (2), 452-455. Semple, R. J, Lee, J., & Miller, L. F. (2006). Mindfulness- Jones, M., Onslow, M., Packman, A., Williams, S., Ormond, Based Cognitive Therapy for Children. In Baer, R., T., Schwarz, I., & Gebski, V. (2005). Randomised (ed.). Mindfulness-based Treatment Approaches: controlled trial of the Lidcombe programme of Clinician’s Guide to Evidence Base and Applications early stuttering intervention. British Medical (pp. 143-166). San Diego, CA: Elsevier. Journal, 331 (7518), 659-661. doi.org/10.1136/ Semple, R. J., Lee, J., Rosa, D., & Miller, L. F. (2010). bmj.38520.451840.E0 A randomized trial of mindfulness-based cognitive Kabat-Zinn, J. (2003). Mindfulness-based interventions therapy for children: Promoting mindful attention in context: Past, Present, and future. Clinical to enhance social-emotional resiliency in children. Psychology: Science and Practice , 10 (2), 144-156. Journal of Child and Family Studies, 19 (2), 218- 229. Kraaimaat, F. W., Vanryckeghem, M., & Van Dam-Baggen, R. (2002). Stuttering and social anxiety. Journal of Venkatesan, S. (2009). Ethical Guidelines for Bio Fluency Ddisorders, 27 (4), 319-331. Behavioural Research. Mysore: All India Institute of Speech and Hearing. Lau, M. A., Bishop, S. R., Segal, Z. V., Buis, T., Anderson, N. D., Carlson, L., & Devins, G. (2006). The Toronto WHOQOL Group. (1998). Development of the World Mindfulness Scale: Development and validation. Health Organization WHOQOL-BREF quality of Journal of Clinical Psychology, 62 (12), 1445-1467. life assessment. Psychological Medicine , 28 (3), 551-558. Menzies, R. G., O’Brian, S., Onslow, M., Packman, A., St Clare, T., & Block, S. (2008). An experimental Woolf, G. (1967). The assessment of stuttering as struggle, clinical trial of a cognitive-behaviour therapy avoidance, and expectancy. International Journal of package for chronic stuttering. Journal of Speech, Language & Communication Disorders , 2 (2), 158- Language, and Hearing Research, 51 (6), 1451- 171. 1464. World Health Organization (1993). International Menzies, R. G., Onslow, M., Packman, A., & O’Brian, S. &ODVVL¿FDWLRQRI0HQWDODQG%HKDYLRXUDO'LVRUGHUV (2009). Cognitive behavior therapy for adults who Diagnostic Criteria for Research (ICD-10). Geneva: WHO.

25 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 26-32 Clinical Psychologists (ISSN 0303-2582) Research Article Crisis and Trauma in Academic Settings: Implications for Campus Mental Health L. N. Suman* Abstract The aim of the study was to examine perceived crisis situations in academic settings, their consequences, management and prevention among teaching staff of colleges and schools. The sample consisted of 30 teaching staff (Mean age: 34.24 years) from Kerala who attended a one-day workshop on crisis management in academic settings. Data were obtained using a sociodemographic data sheet and an academic crisis information data sheet. The data obtained were analyzed using descriptive statistics. Results revealed that 25 participants (83.33%) had no previous exposure to crisis management programs and a mean rating of 4.84 on a scale of 1 to 10, indicated moderate OHYHO RI FRQ¿GHQFH LQ KDQGOLQJ FULVLV VLWXDWLRQV7\SHV RI FULVLV LGHQWL¿HG DPRQJ VWXGHQWV ZHUH academic stress, behavior problems and misuse of technology with consequences ranging from DFDGHPLF GHFOLQH HPRWLRQDO SUREOHPV DQG LQWHUSHUVRQDO FRQÀLFWV 6XJJHVWLRQV IRU LQWHUYHQWLRQ included employment of a trained counsellor, improving teacher-student relationships and crisis management training for teachers while prevention methods suggested included counselling and OLIHVNLOOVWUDLQLQJIRUVWXGHQWV7KH¿QGLQJVKDYHLPSOLFDWLRQVIRUDGGUHVVLQJFULVLVDQGWUDXPDLQ academic settings and for improving campus mental health. Key Words: Crisis, Trauma, Academic Setting, Campus Mental Health, Teachers, Students INTRODUCTION $FULVLVLVGH¿QHGDVDSHULRGRISV\FKRORJLFDO and require the attention of mental health service disequilibrium, experienced as a result of a hazardous providers (Zivin, et al, 2009). Failure to act quickly HYHQW RU VLWXDWLRQ WKDW FRQVWLWXWHV D VLJQL¿FDQW ZRXOGOLNHO\OHDGWRPRUHVHULRXVSUREOHPVFRQÀLFWV problem that cannot be remedied by using familiar and crisis situations. Chafouleas, et al (2016) in a coping strategies. Events that can precipitate a crisis review of literature related to trauma informed care include natural disasters, terrorist attacks, violent in academic settings, reported that till recently, the crimes, accidents, interpersonal violence, sudden focus was on academic domains in terms of assessing death of a loved one, diagnosis of a severe illness the functioning of students. The focus in now shifting and becoming disabled. Crisis reactions occur in to the examination of connections among social, the acute stage, soon after the crisis event, and are emotional, behavioural, and mental health outcomes characterized by shock, confusion, disbelief, anxiety as facilitators or impediments to overall success and anger. A crisis disrupts routine functioning and in academic settings. They opined that the 4 R’s WKH LQGLYLGXDO PD\ KDYH GLI¿FXOW\ LQ SXUVXLQJ OLIH recommended by SAMHSA (2014) can be used to goals (Roberts, 2005). plan trauma informed services for students. The 4 Crisis situations and traumatic events occur in R’s are: (a) realization about trauma and its effects academic settings also and to respond effectively, (b) recognition of the signs of trauma (c) response educational institutions need to be aware of the that appropriately embraces trauma understanding potential impact of traumatic events and have across tiers of service delivery (d) resist practices that knowledge about how to identify traumatic stress could inadvertently re-traumatize. This would require symptoms. Poor academic performance has been training of teachers to increase their capacity to use evident in youth exposed to trauma or those with trauma-informed skills and strategies. traumatic stress symptoms when compared to peers Woodbridge, et al. (2016) reported that who have not experienced trauma(Perfect, et al, WUDXPDWL]HG VWXGHQWV DUH UDUHO\ LGHQWL¿HG ZLWK 2016). Mental health problems such as anxiety, accurate and systematic screening methods. They depression, self-harm behaviours and suicidal also do not commonly receive mental health or ideation are fairly common among college students special education services. They highlighted the

Professor, Department of Clinical Psychology, NIMHANS, Bangalore and Consultant, Trauma Recovery Clinic, NIMHANS Centre for Well-Being * Corresponding Author; Dr L N Suman, E mail: [email protected]

26 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health importance of assessing different types of trauma succeed. In this context, Nadeem and Ringle (2016) experienced by students such as interpersonal and reported that school-based trauma-focused services non-interpersonal trauma as well as direct and requires actively identifying students who might indirect trauma. Exposure to traumatic events can not otherwise receive attention and they may be lead to adverse consequences particularly among more likely to be perceived as being non-central those who lack parental nurturance and support. A to schools’ educational mission compared to other study in the Indian setting indicated that childhood types of supportive student services that involves $'+' ZDV DVVRFLDWHG ZLWK DFDGHPLF GLI¿FXOWLHV academic achievement and other goals. This can lead problems with family and peers, poor social skills to de-adoption of an evidence-based intervention and aggressive behavior. Alcohol problems in a program that would have been helpful for students. parent were associated with adolescent substance Although psychological problems, substance use and disturbed family relations (Ingavale & abuse and self-harm behaviours among college Suman, 2012). It has also been found that boys score students have been studied in the Indian setting, higher on psychological distress and have more there is a dearth of studies that have examined crisis favourable attitudes towards alcohol use (Kirmani & situations, traumatic events and trauma reactions Suman, 2010). The potential for emotional problems VSHFL¿FDOO\ 7KH SUHVHQW VWXG\ ZDV FDUULHG RXW WR interacting with substance abuse and triggering a address this lacuna. The aim of the study was to crisis in academic settings needs to be recognized examine perceived crisis situations in academic and administrators of academic institutions have to settings, their consequences, management and be adequately prepared for eventualities. prevention among the teaching staff. Behaviourally, trauma exposure has been METHOD shown to contribute to higher levels of aggression, Sample: The sample consisted of 30 participants assaultive behavior, disruptive behavior, who attended a one-day workshop titled ‘TEACH: hyperactivity, impulsivity, sexual promiscuity, sleep Trauma, Emergencies and Crises Help’- a workshop dysfunction, and substance abuse and dependence on crisis management in academic settings. The among students (Perfect, et al, 2016). In a review of workshop was conducted on 22nd September 2015 literature on determinants of psychological stress and in the Department of Psychology, Prajyoti Niketan suicidal behavior among Indian adolescents, Kumar College, Pudukad, Thrissur, Kerala. and Talwar (2014) found that high stress levels among students was related to substance abuse and Tools: self-harm behaviours. Risk factors for psychological 1. Sociodemographic Data Sheet: disorders included social exclusion, violence, peer This was prepared by the investigator to obtain rejection, isolation and lack of family support. information about the participants’ age, gender, Protective factors for mental well-being were linked TXDOL¿FDWLRQ QXPEHU RI \HDUV RI H[SHULHQFH DQG to cohesion at the community level, family well- their work setting. being, individual behavior skills and adolescent 2. Academic Crisis Information Data Sheet: friendly social services, including health services. This was prepared by the investigator to Academic settings have to ensure the availability obtain information about previous exposure to crisis of trained counselors in the campus to respond PDQDJHPHQWSURJUDPVDQGFRQ¿GHQFHLQSURYLGLQJ quickly to crisis reactions. However, availability of crisis interventions (Rated on a scale ranging from the service has to be accompanied by an approach that WRZLWKLQGLFDWLQJYHU\ORZFRQ¿GHQFHDQG HOLFLWVFRQ¿GHQFHLQWKHFDUHRIIHUHG)RULQVWDQFH  LQGLFDWLQJ YHU\ KLJK FRQ¿GHQFH  ,W DOVR DVNHG Zivin, et al (2009) found lack of services use even participants to list out issues related to four domains among students who screened positive for mental of crisis management in academic settings: (i) Types health problems. Breaking barriers to help-seeking of crisis (ii) Consequences of crisis (iii) Managing should focus on the reasons for not approaching crisis (iv) Prevention of crisis. the service provider. Further, sustaining trauma Procedure: informed care is very essential for interventions to The participants were given an overview of the

27 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health workshop and written informed consent was obtained More than half the participants reported that from all of them for completing the sociodemographic academic stress often led to crisis situations when data sheet and the academic crisis information data students experienced an emotional breakdown. sheet. The workshop involved didactic sessions, This was considered to be a high risk situation interactive sessions and small group activities. Data requiring immediate attention. Conduct problems, obtained were analyzed using descriptive statistics GHOLEHUDWH VHOIKDUP F\EHU EXOO\LQJ DQG FRQÀLFWV such as mean, standard deviation, range, frequency between teachers and students were considered to be and percentage. challenging issues that led to crisis situations. Other RESULTS crisis situations were attributed to interpersonal All the participants were from Kerala of whom FRQÀLFWV IDPLO\ UHODWHG GLI¿FXOWLHV VXEVWDQFH 26 were women (86.67%) and 4 were men (13.33). PLVXVHDQGJDQJZDUVUHODWHGWRSROLWLFDODI¿OLDWLRQV The mean age of the participants was 34.24 years The various consequences of crisis are given in (SD=5.83)and they had an average of 6.43 years Table 2. (SD=3.29) of teaching/counselling experience. All of them had postgraduate degrees except one who Table 2: Frequency and Percentage of had an undergraduate degree in nursing. In terms of Consequences of Crisis work settings, 22 (73.33%) were faculty members in Nature of Consequences Freq uency Percentage colleges while 5 (16.67%) were school teachers and Academic decline 18 60.00 one (3.33%) was a school counsellor. Two participants Emotional problems 15 50.00 (6.67%) were trained clinical psychologists and were working in medical/hospital settings as counsellors +PVGTRGTUQPCNEQPƀKEVU 10 33.33 and they were also involved in counselling a Oppositional behavior 7 23.33 VLJQL¿FDQW QXPEHU RI FROOHJH VWXGHQWV ZKR VRXJKW Suicide attempts 5 16.67 help in their settings. 25 participants (83.33%) had no previous exposure to crisis management programs Psychoactive substance abuse 5 16.67 while 5 (16.66%) reported previous exposure to crisis Stress 3 10.00 PDQDJHPHQW SURJUDPV 5DWLQJV RI FRQ¿GHQFH LQ Low self-esteem 3 10.00 providing crisis interventions ranged from 1 to 7 with Health problems 3 10.00 a mean of 4.84 (SD=1.37) indicating moderate level RIFRQ¿GHQFHLQKDQGOLQJFULVLVVLWXDWLRQV Avoidance behavior 2 6.67 The most commonly encountered crisis $ VLJQL¿FDQW FRQVHTXHQFH RI FULVLV DQG situations in academic settings are given in Table 1. interpersonal trauma was academic decline that Table 1: Frequency and Percentage of Types of manifested in various ways. Apart from decline in Crisis in Academic Settings grades, students who were emotionally disturbed Type of Crisis Frequency % missed more classes and showed a reduced interest Academic stress leading to breakdown 16 53.33 in academic achievements. Emotional consequences Behavior problems & self-harm 13 43.33 were primarily sad and anxious mood leading to behaviours ZLWKGUDZQ EHKDYLRU ,QWHUSHUVRQDO FRQÀLFWV ZLWK Crisis due to misuse of technology 12 40.00 other students and oppositional behavior occurred KJŃE?PO>APSAAJPA=?DANOOPQ@AJPO 12 40.00 mainly in response to the person perceived as &JPANLANOKJ=H?KJŃE?POAIKPEKJ=H 11 36.67 triggering the crisis event. Maladaptive coping problems due to romantic relationships strategies such as suicide attempts and psychoactive KJŃE?PO>APSAAJOPQ@AJPO 9 30.00 substance use were also regarded as important Crisis due to family problems 7 23.33 consequences of crisis and trauma. Psychoactive substance abuse 6 20.00 Suggested techniques for management of crisis KJŃE?PO=IKJCPA=?DANO 6 20.00 are given in Table 3. Political rivalry 3 10.00

28 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health

Table 3: Frequency and Percentage of Crisis management through training was also emphasized. Management Technique s: The role of managements in providing a supportive and responsive environment was noted while also Crisis Management Techniques Frequency % FRXQVHOOLQJSDUHQWVDERXWWKHLUFKLOGUHQ¶VGLI¿FXOWLHV Employment of a trained counsellor 20 66.67 and need for addressing them. Other approaches Improving teacher-student 13 43.33 suggested were primarily of an academic nature such relationship as value education and personality development Crisis management training for 12 40.00 classes. teachers Suggested strategies for preventing crisis Setting up a supportive campus 11 36.67 situations are given in Table 4. Counselling for parents 10 33.33 More than half the participants were of the opinion that teaching life skills such as interpersonal Moral/Value education for students 6 20.00 skills and emotion regulation skills would prevent Improving teaching methods 3 10.00 serious emotional consequences among students. Personality development classes for 3 10.00 Nearly half the participants indicated that individual students counseling of the student was important to prevent Special classes for students 2 6.67 VLJQL¿FDQW SUREOHPV DQG WR DOVR HQVXUH SULYDF\ IRU Enforcement of discipline 2 6.67 sensitive matters to be discussed. Crisis preparedness of the teachers and administrative staff was also More than two thirds of the participants considered important for effective prevention of were of the opinion that trained counsellors need crisis situations. The involvement of both parents and to be employed to address psychological needs of peers in prevention efforts was considered necessary students. They also recognized the need to improve apart from encouraging relaxation techniques such as teacher-student relationships in order to pre-empt yoga and recreational activities such as sports and art. possible crisis triggers. DISCUSSION Table 4: Frequency and Percentage of Crisis Academic stress, self-harm behaviors, Prevention Strategies: substance abuse, family problems and interpersonal Crisis Prevention Strategies Frequency % FRQÀLFWVGHVFULEHGDVOHDGLQJWRFULVLVVLWXDWLRQVLQ Teaching life skills to students 16 53.33 WKH SUHVHQW VWXG\ DUH VLPLODU WR ¿QGLQJV UHSRUWHG in other countries. For example, Espelage (2015) Counselling for students 14 46.67 applied a social ecological framework to analyze Teacher training programs 10 33.33 studies related to bullying and violence in academic Admin istrative guidelines & settings. She found that early childhood experiences 8 26.67 preparedness at home, in school, and in the community all interact Involvement of parents in early WRLQÀXHQFHODWHUDFDGHPLFDQGVRFLDOHQJDJHPHQW 7 23.33 management of problems She also found that bullying and campus violence Peer support groups to resolve in general and their aftermath continue to be 6 20.00 ?KJŃE?PON=LE@HU VLJQL¿FDQWSUREOHPVIRUVWXGHQWVWHDFKHUVDQGVWDII Encouragement of sports & arts It was found that experiences of being victimized 4 13.33 among students or bullying other students were associated with Giving special attention to decreased academic achievement. She suggested 3 10.00 academically weak students that future studies should focus on risk behaviours Teaching religious/spiritual practices such as drugs and alcohol use, dating violence, gang 2 6.67 to students involvement and exposure to violence. It was also Teaching yoga to students 1 3.33 considered important for future studies to examine protective factors such as extracurricular activities The need for teachers to be prepared for crisis DQGSRVLWLYH\RXWKDFWLYLWLHV7KH¿QGLQJVIURPWKH

29 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health present study indicate that these issues are relevant relationships and adverse community environment to the Indian context also. along with substance abuse are related to the risk of Reactions to crisis situations such as emotional aggressive and delinquent behavior. Interventions problems, substance use, self-harm behaviours and have to target these factors to reduce aggressive conduct problems among adolescents found in the behaviours such as bullying, interpersonal violence present study have been noted in earlier studies and gang activities as well as to reduce substance as well. In a study of 500 undergraduate college abuse. Inability to intervene quickly will escalate the students adjudicated for violating university rules, tension and traumatize the entire academic institution O’Hare (2001) found three drinking contexts for (Stewart and MacNeil, 2005). alcohol-convivial drinking, personal-intimate The crisis management and crisis prevention drinking and negative coping. He noted that drinking approaches recommended by the participants in to cope with loneliness, worries, disappointments the present study indicates the view that academic or depression can exacerbate problems and lead to VHWWLQJVKDYHWREHVHOIVXI¿FLHQWWRKDQGOHSRVVLEOH additional substance abuse to cope with negative crisis situations and promote a healthy campus feelings. He recommended screening for alcohol life. This is in tune with Eells, et al (2012) who use problems and coping skills training as well as recommended public health approaches for mental H[SHFWDQF\FKDOOHQJHVWUDWHJLHVIRUFRQWH[WVSHFL¿F health promotion and suicide prevention for the interventions among college students. However, student population. They noted that a public health willingness to seek help is important for the students approach would modify environmental stressors and WR EHQH¿W IURP LQWHUYHQWLRQV DV SRLQWHG RXW E\ reduce risk of mental health problems. In a review of Cellucci, Krogh and Vik (2006). In a study of 160 such approaches, they found that fostering a healthy undergraduate students, they found that problem recognition, current symptoms and perceived stigma educational environment, promoting life skills were important predictors of help-seeking attitudes. and resilience, increasing help seeking behaviour, They opined that educational programs that promote identifying students in need of care, providing positive attitude towards help-seeking and target mental and medical health services and delivering stigma that are barriers to health promotion activities coordinated crisis management were effective in should be provided to problem drinkers. educational settings. Screening for depression, anxiety and substance abuse are important among According to Jobes, Berman and Martin the student population for both prevention and early (2005), self-harm behaviours among adolescents are intervention. The public health approach would often linked to disciplinary issues and interpersonal not only require counsellors in all educational FRQÀLFWV &RQÀLFWV ZLWK SDUHQWV DQG SHHUV RU institutions but also the availability of off-campus with a romantic partner are usually implicated in mental health services. Stallman and Hurst (2016) adolescent self-harm attempts. The risk increases if highlighted the need for preventative interventions to the adolescent has a history of mood problems and enhance students’ appraisal of stress and teach them psychoactive substance abuse. The counsellor should coping mechanisms to cope with stressful situations. be aware of increases in anger or anxiety that may be This would reduce the risk for development of warning signs of loss of control and alienation from psychological disorders among college students. VLJQL¿FDQW RWKHUV ZKR PD\ DFW DV EXIIHUV DJDLQVW untoward consequences. They were of the opinion In most cases, the crisis reactions displayed by that to reduce future risk for self-harm and to plan students are normal reactions to unusual or traumatic early intervention, the counsellor should obtain circumstances. Hence, with the support of family, information about ongoing problems not only from teachers, and friends most of them may recover well the adolescent, but also from his parents, teachers within a few weeks. However, some students will and close friends. The information obtained should be more vulnerable to the crisis event and should be incorporated into an intervention plan that takes be given special attention. Regardless of perceived into account multiple sources of stress and trauma. risk level, if after several weeks, crisis reactions do 7KHDGROHVFHQW¶VFRQÀLFWVZLWKSDUHQWVSRRUIDPLO\ not begin to lessen, then referral to a mental health

30 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health professional would be appropriate. In addition, implementation of prevention and intervention some students may demonstrate more severe programs. Professional development is needed to crisis reactions that would indicate the need for an understand how trauma impacts the classroom and to immediate referral to a mental health professional. mobilize ongoing support to help create and sustain These reactions include persistent re-experiencing change. of the crisis event, avoidance behaviours, depression and psychotic symptoms. This indicates that it is CONCLUSIONS important for teachers and academic staff to be Academic settings in the 21st century are aware of signs and symptoms of trauma reactions complex environments that can be stressful and and take appropriate measures. Baweja, et al (2016) challenging for students. Crisis situations and trauma H[DPLQHGWKHIDFWRUVWKDWLQÀXHQFHWHDFKHUV¶VXSSRUW reactions of a diverse nature occur in academic and involvement in successful implementation of an settings all over the world including India. This early intervention, school based trauma program, LQFOXGHVLQGLVFLSOLQHFRQÀLFWVEHWZHHQVWXGHQWVDQG Cognitive Behavioural Intervention for Trauma WHDFKHUVDQGFRQÀLFWVDPRQJVWXGHQWV&RQVHTXHQFHV in Schools (CBITS). They interviewed 40 school of crisis such as academic decline, emotional staff and found that four key themes emerged: (i) SUREOHPV LQWHUSHUVRQDO FRQÀLFWV VHOIKDUP support for CBITS was related to teachers’ perceived behaviours and substance use among adolescents need for a trauma program on campus (ii) teachers need to be recognized and addressed. This requires struggled with the competing priorities of balancing training of both teaching and non-teaching staff in students’ social-emotional needs with their missing trauma informed practices. This would lead to a class to attend CBITS (iii) teachers desired more healthier and safer campus life and considering the direct communication with clinicians (iv) teachers size of the adolescent population in India, this issue felt they needed more trauma education. UHTXLUHVVLJQL¿FDQWDWWHQWLRQ Newgass and Schonfeld (2005) advised REFERENCES against having ad-hoc crisis teams to deal with crisis situations in academic settings. They recommended Baweja, S., Santiago, C.D., Vona, P., Pears, G., Langley, adequate preparedness by having organizational A & Kataoka, S (2016). Improving implementation systems in place that would address three broad of a school based program for traumatized students: areas: safety and security; obtaining, verifying and Identifying factors that promote teacher support and disseminating accurate information to staff, students collabouration. School Mental Health , 8, 120-131. and parents; and emotional needs of those involved Cellucci, T., Krogh, J., & Vik, P (2006). Help seeking in the traumatic event. This preparedness would allow institutions to remain proactive, anticipate for alcohol problems in a college population. The needs, assess developing hazards and identify Journal of General Psychology , 133, 421-433. resources available to respond to a crisis. They also Chafouleas, S.M., Johnson, A.H., Overstreet, H., & recommended that primary interventions should Santos, N.M (2016). Toward a blueprint for trauma- be available in the campus in order to provide informed service delivery in schools. School Mental LPPHGLDWHUHOLHI7KHVHKDYHWREHÀH[LEOHLQRUGHU Health, 8, 144-162. to be applicable to a wide range of problems and VSHFL¿FHQRXJKWRSURYLGHJXLGDQFHDWWKHWLPHRID Eells, G.T., Marchell, T.C., & Corson-Rikert, J (2012). particular crisis. According to Phifer and Hull (2016), A public health approach to campus mental health adopting a trauma-informed approach involves promotion and suicide prevention. Harvard Health system-level changes across the entire academic Policy Review , 13, 3-6. institution, which requires changing mindsets, policy, and classroom practices. Institutions need Espelage, D (2015). Data needs for emerging research to develop a comprehensive plan to identify the issues in bully and violence prevention: Strengths needs of the system, review strategies to approach and limitations of the National Center for behavior issues, and garner adequate resources for Educational Statistics data sets. AERA Open , 1, 1-7.

31 L.N.Suman / Crisis and Trauma in Academic Settings: Implications for Campus Mental Health

Ingavale, A., & Suman, L.N (2012). Psychological research from 1990 to 2015. School Mental Health , problems among college students: 8, 7-43.

Relationship with ADHD and parental alcoholism. Indian Phifer, L.W & Hull, R (2016).Helping students heal: Journal of Clinical Psychology , 39, 103-109. Observations of trauma-informed practices in the schools. School Mental Health , 8, 201-205. Jobes, D.A; Berman, A.L & Martin, C.E (2005). Adolescent suicidality and crisis intervention. In Roberts, Roberts, A.R (2005). Bridging the past and present to the A.R (2005) (Ed). Crisis Intervention Handbook: future of crisis intervention and crisis management. Assessment, Treatment and Research . 3rd Edition, In Roberts, A.R (2005) (Ed). Crisis Intervention Oxford University Press, New York. Pp 406-408, Handbook: Assessment, Treatment and Research. Kirmani, M.N., & Suman, L.N (2010). Gender differences 3rd Edition, Oxford University Press, New York. in alcohol related attitudes and expectancies among Pp- 13 college students. Journal of the Indian Academy of Stallman, H.M & Hurst, C.P (2016).The University Stress Applied Psychology , 36, 19-24. Scale: Measuring domains and extent of stress in Kumar, V & Talwar, R (2014). Determinants of university students. Australian Psychologist , 51, psychological stress and suicidal behavior in Indian 128-134. adolescents: A literature review. Journal of the Stewart, C & Mac Neil, G (2005). Crisis intervention with Indian Association of Child and Adolescent Mental chronic school violence and volatile situations. Health, 10, 47-68. In Roberts, A.R (2005) (Ed). Crisis Intervention Nadeem, E & Ringle, V.A (2016). De-adoption of an Handbook: Assessment, Treatment and Research . evidence based trauma intervention in schools: A 3rd Edition, Oxford University Press, New York. Pp retrospective report from an urban school district. 523-524. School Mental Health , 8, 132-143. Substance Abuse and Mental Health Services Newgass, S & Schonfeld, D.J (2005). School crisis Administration (SAMHSA) (2014). Concept of intervention, crisis prevention and crisis response. Trauma and Guidance for a Trauma-Informed In Roberts, A.R (2005) (Ed). Crisis Intervention Approach .(Pp 9-10), HHS Publication No. (SMA) Handbook: Assessment, Treatment and Research . 14-4884. Rockville, MD. 3rd Edition, Oxford University Press, New York. Woodbridge, M.W., Sumi, W.C., Thornton, S.P., Fabrikant, (Pp 502-503) N., Rouspil, K.M., Langley, A.K & Kataoka, S.H O’Hare, T (2001). The drinking context scale: A (2016). Screening for trauma in early adolescence: FRQ¿UPDWRU\IDFWRUDQDO\VLV Journal of Substance Findings from a diverse school district. School Abuse Treatment, 20, 129-136. Mental Health, 8, 89-105.

Perfect, M. M., Turley, M.R., Carlson, J.S., Yohanna, J Zivin, K; Eisenberg, D; Gollust, S.E and Golberstein, E & Gilles, M.P.S (2016). School related outcomes (2009). Persistence of mental health problems and of traumatic event exposure and traumatic stress needs in a college student population. Journal of symptoms in students: A systematic review of Affective Disorders , 117, 180-185.

32 Indian Journal of Clinical Psychology Copyright, 2015 Indian Association of 2016, Vol. 43, No. 1, 33-36 Clinical Psychologists (ISSN 0303-2582) Research Article Memory Functioning in Patients with Schizophrenia and Obsessive Compulsive Disorder in Remission : A Comparative Study

Jashobanta Mahapatra 1, Sushree Sangita Behura* 2 Narendranath Samantaray³, Pratit Pattnaik 4 and Saumyashree Mohapatra 5

ABSTRACT The present study has been carried out to assess the memory functioning of patients suffering from schizophrenia and Obsessive-compulsive Disorder (OCD) in their remission phase, attending the OPD of Mental Health Institute (COE), SCBMCH, Cuttack. The design in present study was used in the present study is ex post facto design. SAMPLE: The total sample size is 80 among which 40 patients of each group (Schizophrenia and OCD) were assessed. A purposive sampling technique was followed for the collection sample. Nancy Andreasen criteria for Schizophrenia remission, PANSS, Y-Bocs and PGI Memory Scale subtest of PGTBBD tools were used. Mann :KLWQH\8WHVWZDVXVHGLQRUGHUWRNQRZWKHVWDWLVWLFDOVLJQL¿FDQFHGLIIHUHQFHEHWZHHQWKHVH two groups of patients. Results revealed that schizophrenics have more impairment in various domains of memory as compared to the patients with OCD in remission period. Findings of the study concludes that impairment in various components of memory affects the quality of life of an individual which ultimately causes mental disability of an individual in them. Key Words: Memory Functioning, Schizophrenia, Obsessive-Compulsive Disorder (OCD). INTRODUCTION disorders, OCD may be associated with a distinct The importance of memory in the daily life pattern of cognitive impairment. On the basis of of a person with mental illness is vital. Cognitive various clinical observations, researchers have GH¿FLWVDUHFRPPRQDQGFOLQLFDOO\UHOHYDQWIHDWXUHV recently become interested in the memory functioning of schizophrenia and are important indices of of patients with OCD. Neuropsychological testing functional and treatment outcomes in patients (Keefe has revealed evidence of impairment of visuospatial et al., 2007; Green et al., 2000). There is a growing abilities, non verbal memory (Christensen et al., 1992 consensus regarding the importance of incorporating & Savage et al., 1996) and executive functioning FRJQLWLYHGH¿FLWVLQWRWKHPDMRUGLDJQRVWLFV\VWHPV (Lucey et al., 1997). Some reports suggested including Diagnostic and Statistical Manual of GH¿FLW LQ DWWHQWLRQDO VHW VKLIWLQJ DELOLWLHV UHVSRQVH 0HQWDO 'LVRUGHUV DQG ,QWHUQDWLRQDO &ODVVL¿FDWLRQ inhibition, and trial and error learning. (Head et al., of Diseases. Recently, it has been suggested that 1989 & Veale et al., 1996). the diagnostic criteria for schizophrenia should The present study has been carried out to assess VSHFL¿FDOO\ LQFOXGH D FULWHULRQ SHUWDLQLQJ WR the memory functioning of patients suffering from FRJQLWLYH DELOLW\ &RJQLWLYH GH¿FLWV SHUVLVW GXULQJ schizophrenia and Obsessive-compulsive Disorder the stable phase of schizophrenia (Sharma et al., (OCD) in their remission phase, attending the OPD  0RVWUHVHDUFKHUVKDYHUHSRUWHGGH¿FLWVLQWKH of Mental Health Institute (COE), Cuttack. areas of executive functioning, episodic memory, working memory, learning and attention abilities METHODOLOGY in schizophrenia. It is increasingly recognized that Present study adopted case controlled cognitive impairment, especially memory, is an comparative study approach. Purposive sampling integral part of the disease process. technique for selection of sample of 40 patients There is now promoted awareness that like of each group of Schizophrenia and OCD were schizophrenia, mood disorders and neurological collected from OPD of Mental Health Institute,

1. Assoc. Prof. & Head 3,4 &5 Clinical Psychologist, Dept. of Clinical Psychology, Mental Health Inst., S.C.B. Med.Coll., Cuttack, Odisha, 2. Consultant Clinical Psychologist, Bhubaneswar, *Corresponding Author, Sushree Sangita Behura Email id: [email protected] 33 Jashobanta Mahapatra et al. / Memory Functioning In Patients with Schizophrenia and obsessive Disorder ......

S.C.B. Medical College, Cuttack, Odisha, following of an individual. It consists of 10 sub scales dealig inclusion and exclusion criteria. with different areas of memory. Inclusion Criteria: Procedure: Patients who were diagnosed as Schizophrenia 80 samples were selected on purposive and OCD as per ICD-10 criteria with duration of sampling basis following the inclusion and LOOQHVVRI¿YHWRWHQ\HDUVDQGIXO¿OOHGWKHUHPLVVLRQ exclusion criteria. The patients were taken from criteria [Andreasen criteria for schizophrenia patients OPD of Mental Health Institute, (COE) SCBMCH, in remission and OCD patients who earned a score of Cuttack, Odisha. The patients who already have 14 or less (post treatment) in Y-BOCS (Farris et al., been diagnosed as Schizophrenia and Obsessive 2013)], patients with in the age range of 30- 45 years, Compulsive Disorder by the Consultant Psychiatrist educated up to at least matriculation and had given were selected from October 2014 to January 2015 informed consent to take part in the study. from OPD of Mental Health Institute (COE), S.C.B. Medical College. They were assessed twice by the Exclusion Criteria: respective measurements (i.e., PANSS and Y-BOCS) Patients with other co-morbid psychiatric in between these periods in order to be included in the conditions, organic mental conditions and co-morbid remission category. Patients who had earned a cutoff physical illnesses. score of remission on their respective measurements were selected to be taken for this present research Tools: study. The data were collected from the month of ICD-10 criteria for the diagnosis of February 2015 to July 2015. The information was Schizophrenia and OCD. collected from the patient as well as from the care Andreasen, N. Criteria for Patients with giver. Those who were interested in taking part in Schizophrenia in Remission (Andreasen et al., 2005): this study were included. They were explained all about the procedures of the study. Through semi- This test GH¿QHG UHPLVVLRQ DFFRUGLQJ WR structured interview all information were recorded in PANSS operational criteria set up by the Andreasan a carefully designed structured performa. Thereafter, et al. (2005) for remission in Schizophrenia Working all the patients were subjected to detailed evaluation Group. The symptomatic criterion includes eight core using PGI Memory Scale. PANSS items (delusion, unusual thought content, hallucinatory behavior, conceptual disorganization, Data Analysis: mannerism/posturing, blunted affect, social Data analysis was done by using non parametric ZLWKGUDZDO ODFN RI VSRQWDQHLW\  ZLWK D VFRUH ”  statistics, i.e., Mann Whitney U test in order to assess The duration criterion is symptomatic remission WKH OHYHO RI VLJQL¿FDQW GLIIHUHQFH EHWZHHQ WKH WZR maintenance over 6 consecutive months. groups of patients with Schizophrenia and OCD. Positive and Negative Syndrome Scale (PANSS: Kay et al., 1984): RESULTS This is a 30 item, 7-point rating instrument A total of 80 subjects were included in that evaluates positive (7 items), negative (7 items) this study. Majority patients were 30-35 yrs of and general psychopathology symptoms (16 items) age. Most of the patients were males (57.5%) of an individual. in schizophrenia group, whereas in OCD group Yale-Brown Obsessive Compulsive Scale ( Wayne male-female numbers were same. Majority of Goodman, 1989) : patients were Hindus in case of both the groups. Y - BOCS developed by Goodman et al. Majority of schizophrenic patients (45%) had consisting of 10-items (clinician-rated) for assessing PLQLPXP TXDOL¿FDWLRQ RI PDWULFXODWLRQ DQG the severity of obsessive compulsive symptoms in 30% were graduate. 50% of OCD patients were patients with OCD. graduated. Majority of schizophrenic patients PGI MEMORY SCALE (Pershad &Verma,1977): were married (72.5). Most of the OCD patients This scale is developed by Dwaraka Pershad were belonging from urban area (62.5%). Both the and S K Verma. It assesses the memory functioning group were matched and there was no statistically

34 Jashobanta Mahapatra et al. / Memory Functioning In Patients with Schizophrenia and obsessive Disorder ......

Table-1 Comparison of Socio- demographic Table-2 Comparison of Memory Scores between Characteristics of Patients with Schizophrenia Schizophrenia and Obsessive-Compulsive and Obsessive-Compulsive Disorder: Disorder Group: Schizo- Parameters of Schizophrenia OCD Z p OCD P phrenia X2 df value Memory (n=40) (n=40) Value Value No. %) No. (%) Remote Memory 47.18 33.83 2.753 .006* 30-35 19(47.5%) 21(52.5%) Age Recent Memory 47.88 33.13 3.534 0.001* Groups 36-40 12(30%) 9(22.5%) 0.581 2 0.748 Mental Balance 44.49 36.51 1.784 0.074 (yrs) Attention and 41-45 9 (22.5%) 10 (25%) 47.25 33.75 2.773 0.006* Concentration Male 23 (57.5%) 20 (50%) Sex 0.453 1 0.501 Delayed Recall 43.55 37.45 1.250 0.211 Female 17 (42.5%) 20 (50%) Immediate 45.83 35.17 2.241 0.025* Hindu 35 (87.5%) 37 (92.5%) Recall Religion 0.556 1 0.456 Retention for Muslim 5 (12.5%) 3 (7.5%) 43.73 37.28 1.556 0.120 Similar Pairs Matriculation 18 (45%) 11 (27.5%) Retention for Intermediate 10 (25%) 9 (22.5%) 3.74 2 0.154 45.13 35.88 1.888 0.059 Dissimilar Pairs

Education Graduation 12 (30%) 20 (50%) Visual Retention 47.84 33.16 3.011 0.003* Married 25(62.5%) 20 (50%) Recognition 47.34 33.66 2.839 0.005* Marital *3  6LJQL¿FDQWDWOHYHO 1.27 1 0.260 Status Un- 15 (37.5%) 20 (50%) 9DOXHVDUHVKRZQDV0HDQ5DQNV married DISCUSSION Domi- Rural 20 (50%) 15 (37.5%) 1.27 1 0.260 In the present study it is found that the cile Urban 20 (50%) 25(62.5) schizophrenic patients have more remote memory 3! 6LJQL¿FDQWDWOHYHO impairment than the OCD patients in the chronic 9DOXHVDUHVKRZQDVWKHQXPEHU  RISDWLHQWV FRXUVHRIWKHGLVHDVH7KH¿QGLQJVRIWKHSUHVHQWVWXG\ DUHFRQVLVWHQWZLWKWKH¿QGLQJVRI7ULYHGL  ,Q Immediate recall is found to be impaired most of the studies done so far, the remote memory more in schizophrenic patients as compared to OCD component of cognitive domain is impaired in the SDWLHQWV7KLV¿QGLQJLVFRUURERUDWHGZLWKWKH¿QGLQJV of Srivastava et al., 2004; Deckersbach et al., 2000. later stages of life, but in the present study it is seen that remote memory may be too impaired in early It is found from the study that schizophrenics stages. It also reveals that schizophrenic patients have are remote memory, recent memory, attention & more recent memory impairment than OCD patients. concentration, immediate recall, visual retention and recognition. These are the most essential components 7KLV¿QGLQJLVFRUURERUDWHGZLWKWKH¿QGLQJVRIWKH of working memory for information processing and study conducted by Zaytseva et al. ( 2012). learning process, which maintains the quality of life Attention and concentration is found to be of patients and impairments of these components, more affected in schizophrenic patients than the OCD ultimately causes mental disability. Remote memory, SDWLHQWV7KLV¿QGLQJLVFRQVLVWHQWZLWKWKH¿QGLQJV recent memory, attention & concentration, immediate of Talreja et al., 2013; Comparelli et al., 2012; Martin recall, visual retention and recognition. These are et al., 2008; Kitis et al., 2007 & Krishnadas et al., the most essential components of working memory 2007. Hence, this may be one of the probable causes for information processing and learning process, EHKLQG WKH LQHI¿FLHQF\ RI FKURQLF VFKL]RSKUHQLF which maintains the quality of life of patients and patients to manage their effective work schedule in impairments of these components, ultimatel y causes long term course of the illness. Immediate recall is mental disability. found to be impaired more in schizophrenic patients.

35 Jashobanta Mahapatra et al. / Memory Functioning In Patients with Schizophrenia and obsessive Disorder ......

VLJQL¿FDQWGLIIHUHQFHEHWZHHQWKHVHWZRJURXSV disorder. The Journal of Clinical Psychiatry, 74 (7), with respect to socio-demographic variables 685-690. Green, M. F., Kern, R. S., Braff, D. L., & Mintz, J. (2000). (Table-1). 7KH ¿QGLQJV DUH FRQVLVWHQW ZLWK WKH 1HXURFRJQLWLYH GH¿FLWV DQG IXQFWLRQDO RXWFRPH LQ ¿QGLQJVRI6ULYDVWDYDHWDO   VFKL]RSKUHQLD DUH ZH PHDVXULQJ WKH ULJKW VWXII" In preset study it is found that schizophrenics Schizophrenia Bulletin, 26 (1), 119. have more impairment in visual retention as +HDG ' %ROWRQ '  +\PDV 1   'H¿FLW LQ cognitive shifting ability in patients with obsessive- FRPSDUHG WR 2&' SDWLHQWV 7KHVH ¿QGLQJV DUH compulsive disorder. Biological Psychiatry, 25 (7), consistent with the Savage et al., 1996; Christensen 929-937.. et al., 1992. Result of this study shows that Keefe, R. S., & Fenton, W. S. (2007). How should schizophrenic patients have more impaired DSM-V criteria for schizophrenia include cognitive recognition than OCD patients. Findings of the LPSDLUPHQW" Schizophrenia Bulletin, 33 (4), 912-920. studies conducted by Comparelli et al. (2012); Kitis, A., Akdede, B. B. K., Alptekin, K., Akvardar, Y., Zystseva et al. (2012) are in same line. Arkar, H., Erol, A., & Kaya, N. (2007). Cognitive dysfunctions in patients with obsessive–compulsive CONCLUSION disorder compared to the patients with schizophrenia 2YHUDOO¿QGLQJVRI3*,0HPRU\VFDOHVXJJHVWV patients: relation to overvalued ideas. Progress in Neuro-Psychopharmacology and Biological that impairment of various component of memory Psychiatry, 31 (1), 254-261. occurred in both schizophrenia and OCD throughout Krishnadas, R., Moore, B. P., Nayak, A., & Patel, R. R. the course of disease especially in the long run. (2007). Relationship of cognitive function in patients But schizophrenic subjects have ore disturbances with schizophrenia in remission to disability: a in various component of memory than the OCD cross-sectional study in an Indian sample. Annals of patients. Various components that are mostly affected General Psychiatry, 6 (1), 1.378-377. are remote memory, recent memory, attention & Lucey, J. V., Burness, C. E., Costa, D. C., Gacinovic, S., Pilowsky, L. S., Ell, P. J., & Kerwin, R. W. (1997). concentration, immediate recall, visual retention and Wisconsin Card Sorting Task (WCST) errors and recognition. These are the most essential component FHUHEUDOEORRGÀRZLQREVHVVLYHFRPSXOVLYHGLVRUGHU of memory for information processing and learning (OCD). British Journal of Medical Psychology, 70 process, which maintain the quality of life of patients (4), 403-411. and impairment of these components, ultimately Martin, V., Huber, M., Rief, W., & Exner, C. (2008). causes mental disability. &RPSDUDWLYH FRJQLWLYH SUR¿OHV RI REVHVVLYH compulsive disorder and schizophrenia. Archives of REFERENCES Clinical Neuropsychology, 23 (5), 487-500. Andreasen, N. C., Carpenter Jr, W. T., Kane, J. M., Lasser, Savage, C. R., Keuthen, N. J., Jenike, M. A., & Brown, H. D. R. A., Marder, S. R., & Weinberger, D. R. (2005). (1996). Recall and recognition memory in obsessive- Remission in schizophrenia: proposed criteria compulsive disorder. The Journal of Neuropsychiatry and rationale for consensus. American Journal of and Clinical Neurosciences, Vol. 39 (3), 315-19. Psychiatry , 162 (3), 441-449. Sharma, T., & Antonova, L. (2003). Cognitive function in Christensen, K. J., Kim, S. W., Dysken, M. W., & Hoover, schizophrenia: deficits, functional consequences, K. M. (1992). Neuropyschological performance and future treatment. Psychiatric Clinics of North in obsessive-compulsive disorder. Biological America , 26 (1), 25-40. Psychiatry , 31 (1), 4-18. Talreja, B. T., Shah, S., & Kataria, L. (2013). Cognitive Comparelli, A., De Carolis, A., Corigliano, V., Romano, S., function in schizophrenia and its association w i t h Kotzalidis, G., Brugnoli, R., & Girardi, P. (2012). socio-demographics factors. Industrial Psychiatry Neurocognition, psychopathology, and subjective Journal, 22 (1), 47-51. disturbances in schizophrenia: a comparison between 7ULYHGL - .   &RJQLWLYH GH¿FLWV LQ SV\FKLDWULF short-term and remitted patients. Comprehensive disorders: Current status. Indian Journal of Psychiatry , 53 (7), 931-939. Psychiatry, 48 (1), 10. Deckersbach, T., Otto, M. W., Savage, C. R., Baer, Veale, D. M., Sahakian, B. J., Owen, A. M., & Marks, I. M. L., & Jenike, M. A. (2000). The relationship   6SHFL¿F FRJQLWLYH GH¿FLWV LQ WHVWV VHQVLWLYH between semantic organization and memory in to frontal lobe dysfunction in obsessive–compulsive obsessive-compulsive disorder. Psychotherapy and disorder. Psychological Medicine , 26 (6), 1261-1269. Psychosomatics, 69 (2), 101-107. Zaytseva, Y., Gurovich, I. Y., Goland, E., & Storozhakova, Farris, S. G., McLean, C. P., Van Meter, P. E., Simpson, H. B., Y. A. (2012). Recovery in schizophrenia: focus on & Foa, E. B. (2013). Treatment response, symptom neurocognitive functioning. Psychiatria Danubina , remission, and wellness in obsessive-compulsive 24 (1), 172-175.

36 Indian Journal of Clinical Psychology Copyright, 2015 Indian Association of 2016, Vol. 42, No. 1, 37-45 Clinical Psychologists (ISSN 0303-2582) Research Article Role of Memory Rehabilitation on Persons with Alcohol Dependence

Sheril Elizabeth Jose 1, *K. S. Sengar 2 and Archana Singh 3

ABSTRACT Alcohol is probably the most commonly used abused substance in the world, with the U.N. World Drug Report (1997) estimating 140 million daily users. There are various cognitive problems/ dysfunctions associated with alcohol abuse. The present study focuses on the assessment and rehabilitation of memory problems for the alcoholics. Samples was consisted of ‘20’alcohol dependent cases (10’ control group and ‘10’ experimental group). Both were assesses (pre & post) on PGI memory scale. The intervention was done with strategies immediate memory improving and rehearsal strategies by using memory games. The results indicates that there ZDVDVLJQL¿FDQWLPSURYHPHQWLQGLIIHUHQWGRPDLQVRIPHPRU\RI3*,PHPRU\VFDOHDIWHUWKH intervention programme. Data was analysed by using nonparametric statistics. There was a VLJQL¿FDQWGLIIHUHQFHLQWKHDUHDVRIUHFHQWPHPRU\UHPRWHPHPRU\YLVXDOUHWHQWLRQYHUEDO retention between experimental group and control group. Key Words: Alcohol, Memory, Remediation Programme, Substance Abusers, Alcohol Dependent.

INTRODUCTION Memory problems associated with alcoholism Substance abuse is a maladaptive pattern consists of global loss of intellectual abilities with RI VXEVWDQFH XVH OHDGLQJ WR VLJQL¿FDQW DGYHUVH an impairment in memory function, together with consequences manifested by psychosocial, medical, disturbance (s) of abstract thinking, judgment, other or legal problems or use in situations in which it higher cortical functions, or personality change is physically hazardous that must recur during a without a clouding of consciousness. The toxic 12-month period. Substance dependence, commonly effects of alcohol on the brain may cause impairment known as addiction, is characterized by physiological directly. In addition, some alcoholics may exhibit and behavioural symptoms related to substance impairment as an indirect result of alcohol abuse, use. Alcohol is the commonly abused substance. e.g., they may have experienced a craniocerebral Alcoholism, also known as Alcohol Addiction, trauma may be eating poorly and suffering nutritional is a broad term for problems with alcohol, and is GH¿FLWV VXFKDVWKLDPLQHRUQLDFLQGH¿FLHQFLHV RU generally used to mean compulsive and uncontrolled they may have cognitive impairments associated consumption of alcoholic beverages, usually to with liver disease. Some researchers have observed the deterioration of the drinker’s health, personal WKDW FRJQLWLYH GH¿FLWV LQ VRPH DOFRKROLFV UHVHPEOH relationships, and social standing. those seen in normal elderly persons, leading to Structural changes in the brains of alcoholics speculation that alcohol's effect on cognition may have been reported (Ron, 1979), as well as reduced be explained as premature aging. However, it is FHUHEUDOEORRGÀRZDQGDOWHUHGHOHFWULFDODFWLYLW\)RU PRUH OLNHO\ WKDW VXFK GH¿FLWV DUH LQGHSHQGHQW RI the most severe alcoholics, serious organic cerebral DQ\GH¿FLWVDVVRFLDWHGZLWKQRUPDODJLQJ 7DUWHU  impairment is a common complication, occurring Edwards, 1986). in about 10 percent of patients (Horvath, 1975). Alcohol acts as a general central nervous The diverse signs of severe brain dysfunction that V\VWHPGHSUHVVDQWEXWLWDOVRDIIHFWVVSHFL¿FDUHDV persist after cessation of alcohol consumption have of the brain to a greater extent than others. Memory been conceptualized in terms of two organic mental impairment due to alcohol has been linked to disorders: alcohol amnestic disorder (memory disruption of hippocampal function—in particular disorder) and dementia associated with alcoholism. affecting gamma-Aminobutyric acid (GABA) and

1. M Phil Trainee, 2. Additional Professor, Dept. of Clinical Psychology, 3. Psychiatric Social Worker, Dept. of PSW, RINPAS, Kanke, Ranchi, Jharkhand (India) 834006. *Corresponding Author: Dr. K S Sengar; E Mail: [email protected]

37 Sheril et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ......

N-methyl-D-aspartate (NMDA) neurotransmission dependence and for that it was hypothesized that which negatively impacts long-term potentiation WKHUHZLOOEHQRVLJQL¿FDQWGH¿FLWLQYLVXDOUHWHQWLRQ (LTP).The molecular basis of LTP is associated verbal retention, immediate recall, recent memory with learning and memory particularly, damage to and there will be no effect of cognitive remediation hippocampal CA1 cells adversely affects memory programme on memory of the persons with alcohol formation and this disruption has been linked to dependence. dose-dependent levels of alcohol consumption at KLJKHUGRVHVDOFRKROVLJQL¿FDQWO\LQKLELWVQHXURQDO Sample: activity in the CA1 and CA3 pyramidal cell layers The study was conducted at the Ranchi Institute of the hippocampus and impairs memory encoding of Neuro-Psychiatry and Allied Sciences (RINPAS), as it plays an important role in the formation of Kanke, Ranchi. The sample was collected from new memories. Neurochemical changes occurring the drug de addiction ward of the institute. Sample in the anterior cingulate are correlated with altered consist of 20 diagnosed cases of alcohol dependence short-term memory functions in the brains of young dignosed according to the DCR of ICD-10 criteria, alcoholic men. FMRIs of alcohol-dependent women having H/o of Alcohol intake since more than ‘7’ years GLVSOD\HG VLJQL¿FDQWO\ OHVV EORRG R[\JHQ LQ WKH and less than 10 years, with age range of 20-45 years, frontal and parietal regions, especially in the right gave informed consent to participate in the study and KHPLVSKHUH7KLVLVVXSSRUWHGE\¿QGLQJVRIVKRUW have completed four weeks of hospitalization or term memory impairment by lesions of the parietal abstinence from alcohol were selected. The subjects lobe and prefrontal cortex. Associations between of the study were further divided in two groups as 10 third ventricular volume and cognitive performance cases in each called experimental group and control on memory tests have been found in alcoholics group in present study. VSHFL¿FDOO\ LQFUHDVHV LQ WKLUG YHQWULFXODU YROXPH The Persons who were having comorbid correlate with a decline in memory performance psychiatric disorder, vision, hearing and / or loco Godfrey et al. (1985). Findings of study conducted motor impairment, having organic pathology, mental E\1DUDQJHWDO  VKRZHGVLJQL¿FDQWGLIIHUHQFH UHWDUGDWLRQ RU VLJQL¿FDQW SK\VLFDO LOOQHVV DQG  RU on cognitive functions in alcoholics as compared to having presence of withdrawal symptoms during pre- control. The cognitive impairment increases with assessment were excluded from study. The present the duration of alcohol use. Bondi et al. (2006) study is a hospital based comparative study using the FRQGXFWHGWKHVWXG\WRGH¿QHWKHFRPELQHGHIIHFWV pre and post treatment with control group design. of drug and alcohol abuse on verbal learning and memory on 70 alcoholic and 80 poly substance Tools: abuse (PSA) individuals with concurrent alcohol Socio demographic and Clinical Data Sheet: abuse. They were compared on a list of learning task It was semi-structured Performa specially of California Learning Test (CVLT).The PSA group designed for this study. It contains information about QRQHWKHOHVV H[KLELWHG VLJQL¿FDQWO\ JUHDWHU GH¿FLWV socio-demographic variables like age, sex, education, on recall than the alcoholic group on the CVLT. residential area, monthly family income. It also The combined use of alcohol and drugs, cocaine includes clinical details e.g. diagnosis, duration of LQ SDUWLFXODU PD\ FRPSRXQG PHPRU\ GLI¿FXOWLHV LOOQHVVKLVWRU\RIVLJQL¿FDQWKHDGLQMXU\VHQVRU\DQG beyond what is typically observed in alcoholic motor impairment, seizures, mental retardation and individuals. The previous studies highlighted the DQ\RWKHUVLJQL¿FDQWSK\VLFDORUJDQLFRUSV\FKLDWULF effects of alcoholism on organisational ability and illness and withdrawal symptoms. inhibition ability, chronic alcoholism leads to a PGI-Memory Scale (PGIMS; Pershad & GH¿FLW LQ XSGDWLQJ DELOLWLHV LQ ZRUNLQJ PHPRU\ (Pitel et al., 2000). Verma, 1977) The PGI memory scale was used as research METHOD tool to evaluate different domains of memory. The present study was aimed to study the effect The scale is frequently being used for clinical and of memory rehabilitation on persons with alcohol research purposes in India. It has ten sub scales

38 Sheril et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ...... dealing with different aspect of memory namely more words that did not belonged to any particular Remote Memory, Recent Memory, Mental Balance, category in a way non sense syllabus (for e.g.- rat, Delayed Recall , Attention & Concentration, Immediate apple, table etc.). At the initial level the target was the Recall, Retention for Similar Pairs , Retention for recall of 3 words. The patients regularly rehearsed to Dissimilar Pairs, Visual Retention , Recognition. The recall of at least 3 words at a time. Also initially the scale has high reliability ranging from .91 and .83 and recall was made immediately after the presentation satisfactory cross validity (Pershad, 1977, Pershad & of words, then the duration of retaining the words Wig, 1976, 1988) LQFUHDVHGWRVHFVHFVHFVHFDQG¿QDOO\ to 60 seconds. Procedure Initially 20 patients were selected for study 6HQWHQFH5HSHWLWLRQ who were further divided in two groups (10 were In this exercise few sentences that were control group and 10 were experimental group). All broken down in small parts were spoken aloud to the 20 cases was assessed on PGI Memory Scale. the patients the patient were asked to repeat these on baseline and after completion (Pre & Post) of sentences correctly. The patient’s performance lied memory remediation programme. The memory in their correct recall of each part of the sentence. rehabilitation programme was given only to the Initially the practice started with the recall of single experimental group along with the treatment as VHQWHQFHWKHUHE\LQFUHDVLQJWKHGLI¿FXOW\OHYHOWR usual and control group received only treatment as 3 and 4 sub parts of the sentence. usual. Weekly three sessions were conducted for 13 weeks continuously from the months of September 6LQJOH6WHS%RG\3DUW&RPPDQG WR 'HFHPEHU ,Q WKH ¿UVW  VHVVLRQV SDWLHQWV ZHUH In the next phase the patients were asked to given information about the study and rationale of recall and perform single step body part command the study. Patients were also asked for the consent to VXFKDV¿UVWFORVH\RXUH\HV 7KHWDUJHWZDVWRKHOS participate in the study. The PGI- memory scale was the patient to retain these steps for at least 10 seconds. administered before starting the study and was taken Initially the exercise started with immediate recall as baseline scores and after the intervention they RI WKH VWHSV WR EH SHUIRUPHG 7KH GLI¿FXOW\ OHYHO were assessed again on the same scale (PGI- memory was increased to perform the steps after 2 seconds scale) for post intervention scores. The procedure for followed by 3 seconds, 5 seconds and 8 seconds memory remediation tools is as follows. DQG¿QDOO\XSWLOOVHFRQGV2QFHWKHSDWLHQWVKDG mastered to recall and perform single step body part Memory Remediation Tools: FRPPDQGWKHGLI¿FXOW\OHYHOZDVLQFUHDVHGWRWZR ,PPHGLDWH0HPRU\,PSURYLQJ6WUDWHJLHV and three step body part command, similar procedure The following memory remediation package as before were employed until the patients were able adapted from “Neuropsychological Rehabilitation to retain the steps for 10 seconds. Theory, Models, Therapy and Outcome’’ was used (Wilson et al., 2009). *HRPHWULFDO)LJXUHV In the next phase, the target was to strengthen 'LJLW5HSHWLWLRQ the visual retention of the patient. Initially single The rehearsal started with three digits. Initially JHRPHWULF¿JXUHVZHUHSUHVHQWHGWRWKHSDWLHQWDQG the patient’s showed variable performance, they were WKH\ZHUHDVNHGWRFRS\WKH¿JXUHQH[WWKH¿JXUHV sometimes able to recall the numbers but unable to were exposed for 30 seconds and then the patients recall at other time. In each session they practiced to ZHUH DVNHG WR GUDZ WKH ¿JXUH LPPHGLDWHO\ EXW recall at least ‘3’ digits. Once they all had mastered without seeing it. WRUHFDOOµ¶GLJLWWKHGLI¿FXOW\OHYHOZDVLQFUHDVHG to 4, 5 and 6. 5HFDOORI'LJLW%DFNZDUG Initially the patients were made to recall of 2 :RUG5HSHWLWLRQ GLJLWVEDFNZDUG7KHGLI¿FXOW\OHYHOZDVLQFUHDVHG This task required the repetition of ‘3’ or to 3 digits only.

39 Sheril et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ......

Rehearsal Strategies: to remember the number of occurrences in several Card games (Parente & Anderson, 1991) GLIIHUHQW FDWHJRULHV  +HUH LQ WKH ¿UVW SKDVH RI WKH were employed in the intervention for maintenance game three cards were shown to the subject one at rehearsal. Games that were employed are as follows - a time and they were asked to remember how many cards are there of each suit. Then they were asked Maintenance Rehearsal to read aloud the number of cards they recalled *DPH,QWHUIHUHQFH5HVLVWDQFH from each suit. In the rehearsal phase, cumulative Interference refers to a situation in which a rehearsal was used. The subjects were shown the person is experiencing one event, but a second event cards and they were said to read aloud the face of the occurs and interrupts the person’s memory for the card. When they were shown the next card then they ¿UVW)RUH[DPSOHDULQJLQJWHOHSKRQHPD\LQWHUUXSW ZHUHVDLGWRVD\WKHIDFHRIWKH¿UVWFDUGDOVRDORQJ a person’s memory for what he/she was doing while with the second one. cooking dinner. In general, this card game trains the *DPH6SDWLDO5HKHDUVDO client to rehearse in situation where the second of two sequential activities interferes with memory for Spatial rehearsal refers to memory for people or things in a three dimensional space. This common WKH¿UVW7KHSDWLHQWVZHUHVKRZQDFDUGIURPDGHFN and asked to say aloud the number or face and suit activity of daily living involves recalling where RIWKHFDUG HJµ¶¿YHRIKHDUWV 7KHFDUGZDVWKHQ VRPHWKLQJ LV ORFDWHG RU ZKHUH WR ¿QG VRPHWKLQJ placed down on the table in front of the patient. The similar. The game began with 16 cards, 4 from each second was drawn again and the patient again stated VXLW 7KH FDUGV ZHUH VKXIÀHG DQG DUUDQJHG LQWR its number or face and suit (e.g. ‘’jack of diamonds’’) square grid. The subjects turned over any four cards and then second card was also placed face down next leaving them in the same position in the grid. If the WRWKH¿UVW7KHSDWLHQWZDVWKHQDVNHGWRUHFDOOWKH four cards had the same suit, the cards were removed QXPEHURIIDFHDQGVXLWRIWKH¿UVWFDUG,IFRUUHFW from the grid otherwise they were left in the same the card was placed in a pile to his or her right side. If place. Again four cards were turned over and if they incorrect, the card was placed in a pile to his/her left were same then they were also removed from the side. Then third card was displayed and, once again, grid. This procedure was continued till all the cards the patient said the number and suit aloud. The card were removed from the grid. was placed face down next to the second card, and *DPH5HKHDUVLQJ&KDQJLQJ6HWV then the patient was asked to recall the number and In this game the subjects saw three cards one at suit of the second card. In other words, after saying the number and of one card, the patient was asked to a time and named each one aloud as they were placed recall the number and suit of the card that they saw face down the table. Then they were showed other immediately before. The process continued until the FDUGVIURPWKHGHFNRQHDWDWLPHXQWLOWKH\LGHQWL¿HG deck was exhausted. the face or number of the shown cards. If the match is correct. Then the cards were put in the right pile 5HKHDUVDO3KDVH otherwise in the wrong pile of cards. When the match The game was repeated and thus forcing the was made then the matched card was replaced by patient to rehearse. After the patient said the name another card from the deck. This process continued DQGVXLWRIWKH¿UVWFDUGWKHFDUGZDVSODFHGIDFH until the deck was exhausted. down (as before). However, this time, the patient *DPH5HKHDUVLQJ6HTXHQFH UHKHDUVHGWKH¿UVWFDUGEHIRUHKHZDVVKRZQDVHFRQG FDUG7KLVPRGL¿FDWLRQIRUFHGWKHSDWLHQWWRUHKHDUVH ,Q WKLV JDPH WKH VXEMHFWV ZHUH VKRZQ ¿YH WKHLGHQWL¿FDWLRQRIWKHGRZQIDFHFDUGEHIRUHVHHLQJ cards one at a time and then they were placed down another. If the patient continued to make mistakes RQWKHWDEOHLQDUDQGRPRUGHUXQWLODOOWKH¿YHFDUGV more than one rehearsal was given. are turned face down. Then the subjects were said to arrange the cards in numerical order from left to *DPH5HKHDUVLQJ0XOWLSOH6HWV right and lowest to highest. The task required them to Rehearsing multiple sets requires a person remember the cards so that they can arrange them in

40 Sheril et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ...... the proper order. If the cards were arranged correctly Table -1: Showing Comparison of PGI – then they were placed in the right pile otherwise in Memory Scale Scores of Control Group the wrong pile. The game continued until the deck and Experimental Group at Baseline. was exhausted. Conditions Mann Whitney U test Areas of Experi Control Mean Rank Internal Aids Assess mental Group U Z ment Group (M±SD) Exp. Control Value Value 5HFRJQL]LQJ)DFHV (M±SD) Group Group In this patients were asked to sit down in a Remote 3.4±2.11 3.6±0.96 10.70 10.30 48.00 .160 separate room and try to remember the face of any Memory one person Recent 2.10±0.99 3.00±1.15 8.35 12.65 28.50 1.70 Memory )LUVW/HWWHU&XHV Mental 2.90±1.44 2.60±2.22 11.15 9.85 43.50 .517 A First letter cue is the strategy that prompts Balance WKHSHUVRQWRSD\DWWHQWLRQWRWKH¿UVWOHWWHUVRIWKH Delayed 5.80±2.39 5.20±1.39 12.85 8.75 32.50 1.34 words to be learned and memorized. These letters Recall can be arranged into an alphabetical list. Attention & Concen 5.60±0.96 6.50±2.17 7.85 13.15 23.50* 2.05 5HKHDUVDO tration Immediate Rehearsal strategy involves repeating 5.80±2.09 3.60±1.89 13.40 7.60 21.00* 2.22 information silently in the mind, quietly to oneself or Recall aloud. Retention for Similar 2.30±1.05 3.20±1.22 8.55 12.45 30.50 1.61 Visual Imagery: Pairs Visual imagery is a strategy that involves Retention for Dissim 4.30±4.34 4.50±3.02 10.45 10.55 49.50 .038 creating in the mind of something the person would ilar Pairs like to remember. Visual 6.20±3.01 7.90±3.17 8.80 12.20 33.00 1.29 Retention 6WRU\0HWKRG Recog - 8.30±1.88 8.9±1.16 12.00 9.00 35 1.16 The story strategy involves making up a story nition (something silly) that incorporates the entire thing Total 46.40±12.62 48.10±7.37 10.75 10.25 47.50 .189 that have to remember. The simpler the story the *P<.05, **P<.01 more likely it to be remembered. To ensure the experimental group and control ([WHUQDO$LGV group were similar at baseline score for different Although there are many strategies that can be domains of memory, both groups were compared using employed as an external aids such as alarms, timers, Mann Whitney U test. Analyzing the result in table-1 calendar, tape, recorder etc. but only few techniques it is apparent that at baseline level both experimental were used in the present study due to lack of such group and control group were having tentatively instrument for in patient. Few techniques that were similar range for remote memory, recent memory, used are as follows Patients were given NOTE mental balance, delayed recall, retention for similar BOOKS to record the description of all the events pairs, retention for dissimilar pairs, visual retention that happened the day before from memory. Patients and recognition. The score ranges for attention and were trained to use CALENDAR to remember concentration and immediate recall were having important events in day to day life. VLJQL¿FDQW GLIIHUHQFH DW EDVHOLQH DVVHVVPHQW WKH score range is 5.6 ±.966, 6.500± 2.17 for intervention RESULTS and control group in attention and concentration and The data was obtained, organized/ tabulated the score range for immediate recall is 5.80± 2.09, and processed. The obtained results are being 3.60±1.89 for intervention group and control group presented below in tabular form. respectively

41 Sheril Elizabeth Jose et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ......

Table - 2: Showing Comparison of PGI – Memory Results presented in Table 3 shows that there Scale Scores of Control Group Baseline ZDVDVLJQL¿FDQWGLIIHUHQFHDWOHYHOVLQVFRUHV and Post Assessment: of remote memory, recent memory, mental balance, Wilcoxon Signed Rank Test Areas of Baseline Post Inter- Mean Rank Z. attention and concentration, delayed recall, retention Assessment Scores vention Value for similar pairs, retention for dissimilar pairs, and (M±SD) Scores (M ± SD) +Ve -Ve DOVR VLJQL¿FDQW GLIIHUHQFH DW  OHYHO LQ VFRUHV RI Remote visual retention indicate that remediation process 3.6 ± 0.96 5.5 ± 0.52 5.94 1.50 2.69** Memor y ZDV VLJQL¿FDQWO\ DIIHFWLYH RQ DOFRKRO GHSHQGHQW Recent Memory 3.0 ±1.15 3.7 ± 1.63 4.50 6.75 1.078 FDVHVRQLPSURYLQJWKHLUPHPRU\VWDWXV7R¿QGRXW WKH HI¿FDF\ RI LQWHUYHQWLRQ SURJUDPPH PHPRU\ Mental 2.6 ±2 .22 4.7 ± 3.71 5.17 2.50 1.83 Balance training) differences between experimental group Attention and Concentration 6.5 ± 2.17 7.6 ± 1.26 3.60 3.00 1.58 and control group after intervention was calculated Delayed recall 5.2 ± 1.39 6.4 ± 1.77 5.14 4.50 1.61 using Mann Whitney U test. Immediate Recall 3.6 ± 1.89 5.6 ± 3.94 5.33 2.00 1.98 Table -4: Showing Comparison of Post Assessment Retention for PGI – Memory Scale Scores between 3.2 ± 1.22 4.6 ± 0.96 4.93 1.50 2.37* Similar Pairs Experimental Group and Control Group Retention for 4.5 ± 3.02 6.9 ± 4.06 5.40 3.00 1.26 Dissimilar Pair s Condition Mann Whitney U test Visual Retention 7.9 ± 3.17 9.4 ± 3.59 4.71 6.00 1.24 Mean Rank Areas of Control Exp. Recognition 7.6 ± 1.57 8.7 ± 1.05 3.70 2.50 1.68 Assessment Group Group Z Value Z U Value U Total 48.1 ±7.37 63.1 ± 17.2 6.57 3.00 1.88 (M ±SD) (M±SD ) Exp. Group Group * P<.05, **P<.01 Control Remote 5.50± 5.70 ± 11.25 9.75 42.50 0.64 Table 2 shows that control group was having Memory 2.52 0.67 VLJQL¿FDQW GLIIHUHQFH LQ UHPRWH PHPRU\ DQG Recent 3.70± 4.50± 11.90 9.10 23.51* 2.45 retention for similar pairs. In other areas control Memory 1.63 0.70 group was not having a Q\VLJQL¿FDQWGLIIHUHQFH Mental 4.70± 5.80± 11.10 9.90 44.00 0.46 Table –3: Showing the Score of PGI – Memory Scale of Balance 3.71 1.47 Experimental Group before and after Intervention 6.40± 8.40± Delayed Recall 13.50 7.50 20.00* 2.33 Wilcoxon Signed Experimental Group 1.77 1.34 Rank Test Attention & 7.60± 8.00± Post Inter 11.05 9.95 14.50 0 .48 Areas of Baseline vention Mean Rank Concentration 1.26 0.47 Scores Z Assessment Scores Value Immediate 5.60± 8.30± (M ± SD ) (M± SD) +Ve -Ve 12.10 8.90 20.51* 2.50 Remote Recall 3.94 2.00 3.4 ± 2.11 5.7 ±0.67 4.50 0.00 2.53** Memory 4.60± 3.90± Retention for 7.75 13.25 22.50* 2.25 Recent Memory 2.10 ± 0.99 4.50 ± .70 5.50 0.00 2.84** Similar Pairs 0.96 0.73 Mental Balance 2.90 ± 1.44 5.80 ±1.47 5.00 0.00 2.71** Re tention for 6.90± 7.80± Attention & 11.20 9.80 25.51* 2.32 5.60 ± 0.96 8.00 ± 0.47 5.50 0.00 2.83** Dissimilar Pairs 4.06 3.88 Concentration 9.40± 10.40± Delayed Recall 5.80 ± 2.39 8.40 ± 1.34 5.00 0.00 2.71** Visual Retention 11.80 9.20 24.01* 2.55 Immediate 3.59 3.71 5.80 ± 2.09 8.30 ± 2.00 6.50 3.17 1.84 8.70± 9.100± Recall Recognition 11.90 9.10 36.00 1.14 Retention for 1.05 1.28 2.30 ± 1.05 3.90 ± 0.73 4.50 0.00 2.54** Similar Pairs 63.10± 71.00± Retention for Total 11.75 9.25 37.50 0 .94 4.30 ± 4.34 7.80 ± 3.88 6.00 1.00 2.71** 17.25 10.42 Dissimilar Pairs Visual Retention 6.20 ± 3.01 10.40±3.71 5.12 4.00 2.20* * P<.05, **P<.01 Recognition 8.30 ± 1.88 9.10 ± 1.28 3.83 5.00 1.55 7DEOH  VKRZV WKDW WKHUH ZDV D VLJQL¿FDQW Total 46.40 ±12.62 71.0 ±10.42 5.50 0.00 2.80** difference at .05 level in recent memory, delayed *P<.05, ** P<.01 recall, immediate recall, retention for similar pairs,

42 Sheril Elizabeth Jose et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ...... dissimilar pairs, and visual retentions in experimental taking behavior. The person will have a physiological group than control group after intervention. The withdrawal state when substance use has ceased mean scores of interventional group in other areas or been reduced. The other symptoms present are also higher than control group shows that there are progressive neglect of alternative pleasures is improvement though that improvement is not persisting with alcohol intake. Heavy alcohol use VLJQL¿FDQW damages memory (Buddy et al., 2008). A typical heavy user of alcohol reported over 30 percent Table – 5: Showing Comparison of Difference more memory related problems than someone who in PGI- Memory Scale Scores between reportedly did not drink and almost 25 percent more Intervention Group and Control Group problems than those who stated they drank only at Baseline and after Intervention. small amounts of alcohol. Memory rehabilitation in alcoholics made a noticeable improvement in Intervention Group Control Group MANN WHITNEY (Mean ±SD) (Mean ±SD) U TEST the memory of the alcoholic dependent individuals. Area of Mean Godfrey et al. (1985), Patel et al. (2000), Goldstein Assess- Diff. Diff. Ranke et al. (2005), Scheurich et al. (2004), Grohman et al. ment Pre Post (Pre- Pre Post (Pre- U Post) Post) Exp. Cont Value (2003), Bates et al. (2002). Gr. Grou From table 4 in the result section there Remote 3.4 ± 5.7± 2.3± 3.6± 5.50± 1.90± Memory 2.11 0.674 1.76 0.966 0.527 1.197 10.10 10.90 21.15* LV VLJQL¿FDQW LPSURYHPHQW LQ  DOO WKH  DUHDV  RI Recent 2.10± 4.50± 2.4± 3± 3.70± .700± memory as remote memory, recent memory, mental Memory 0.99 0.707 0.843 1.15 1.63 2.49 8.15 12.85 20.00** balance, attention and concentration, delayed

Mental 2.90± 5.80± 2.9± 2.60± 4.70± 2.10± 9.90 11.10 22.60* recall, immediate recall, retention for similar pairs, Balance 1.44 1.47 2.37 2.22 3.71 3.07 retention for dissimilar pairs, visual retention Attention and recognition after rehabilitation training. This & Concen- 5.60± 8.30± 2.40± 6.50± 5.60± 1.10± 8.30 12.70 23.00 tration 0.966 2.00 0.96 2.17 3.94 1.96 VXJJHVWV WKDW FRJQLWLYH UHWUDLQLQJ LV VLJQL¿FDQWO\ Delayed 5.80± 8.40± 2.60± 5.20± 6.40± 1.20± useful on improving the various cognitive 8.65 12.35 21.66** Recall 2.39 1.34 1.57 1.39 1.77 2.09 functions, which is very essential for the day to day Immediate 5.80± 8.30± 2.50± 3.60± 5.60± 2.00± 10.25 10.75 24.00** activities, problem solving skills, coping skills and Recall 2.09 2.02 3.68 1.89 3.94 2.788 getting employment. Findings of the present study Retention 2.30± 3.90± 1.60± 3.20± 4.60± 1.40± are consistent with much of the literature presently for Similar 1.05 0.737 10.25 10.75 20.00** Pairs 1.26 1.22 0.966 1.42 available on memory rehabilitation in alcohol Retention 4.30± 7.80± 3.50± 4.50± 6.90± 2.40± dependent cases. Literature available in this area for Dissim 9.95 11.05 21.00** ilar Pairs 4.34 3.88 2.91 3.027 4.06 5.16 suggests that the memory training such as memory Visual 6.20± JDPHVIRXQGKHOSIXORQVLJQL¿FDQWLPSURYHPHQWRI 10.40± 4.20± 7.90± 9.40± 1.50± 8.35 12.65 22.50* Retention 3.01 3.71 4.21 3.17 3.59 3.86 different domains of memory in alcohol dependent Recog- 8.30± 9.10± 800± 7.60± 8.70± 1.10± cases. In present study experimental group and 10.75 10.25 47.5 nition 1.88 1.28 1.75 1.57 1.054 1.85 control group were compared and noticed that in * P<.05, **P<.01 SRVW LQWHUYHQWLRQ VLJQL¿FDQW LPSURYHPHQW ZDV Overall the results shows that the intervention found in verbal memory, immediate memory, JURXS LPSURYHG VLJQL¿FDQWO\ LQ UHPRWH PHPRU\ GHOD\HG PHPRU\ DQG UHSURGXFWLRQ RI ¿JXUHV recent memory, mental balance, attention and in experimental group (Steingass et al., 1994). concentration, delayed recall, retention for similar Greenaway et al. (2012) also in favour of the similar pairs, retention for dissimilar pairs, visual retention ¿QGLQJVDVUHSRUWHGLQKLVVWXG\IRUUHPHGLDWLRQRI than control group. memory process in the area of attention training, visual imagery, verbal strategies, and external use DISCUSSION strategies, recognition and immediate memory. The Alcohol dependence is a state where the ¿QGLQJVRISUHVHQWVWXG\DUHFRQVLVWHQWZLWK7UR\HU individual has a strong desire or sense of compulsion HWDO  ZKRUHSRUWHGVLJQL¿FDQWLPSURYHPHQW WR WDNH DOFRKRO GLI¿FXOWLHV LQ FRQWUROOLQJ DOFRKRO after ‘6’ weeks of intervention. The strategies used

43 Sheril Elizabeth Jose et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ...... were internal visual imagery, chunking and external visual retention and recognition were not found VWUDWHJLHV7KHUHZDVDVLJQL¿FDQWLPSURYHPHQWLQ VLJQL¿FDQW 7KHVH FKDQJHV ZKLFK KDYH RFFXUUHG prospective memory for experimental group while in those two areas might be due to reason that there was no improvement in control group. Results control group was also in abstinent phase and were presented in table no 4 deals with the control group on treatment as usual. In general it is anticipated and experimental group after intervention. Table that cognitive functions would improve over the UHYHDOV WKDW WKHUH ZDV D VLJQL¿FDQW GLIIHUHQFH FRXUVH RI GHWR[L¿FDWLRQ DQG KRVSLWDOL]DWLRQ DV D between control group and experimental group function of severity and adequate nutrition along in the areas of recent memory, delayed recall, with administration of traditional psychiatric, immediate recall, retention for dissimilar pairs, GHWR[L¿FDWLRQ DQG UHKDELOLWDWLRQ WUHDWPHQW EXW the difference in both the groups was also noticed here the interesting phenomenon is that the gains in the area of remote memory, mental balance, obtained by the control group in these areas are attention and concentration and recognition as much lower than the experimental group as it is very obtained mean value in these areas was found FOHDUO\ UHÀHFWHG IURP WKH GLIIHUHQFH LQ WKH PHDQ higher in intervention group when compared to value of both groups, as the experimental group control group who were not given the memory scored higher (2.13) in comparison to control group rehabilitation programme and were on treatment as (1.9) in the area of remote memory and retention usual. Other conditions were also similar for both for similar pairs is also superseded with the ‘1.6’ the groups as participation in the ward activities gain than the ‘1.4’ of the control group. This further and recreation etc. but this difference was not found strengthened the view that neuropsychological VLJQL¿FDQW ZKLFK VXJJHVWV WKDW WKH JDLQ DFTXLUHG UHKDELOLWDWLRQ RQ GHWR[L¿HG VXEMHFWV ZLWK DOFRKRO through rehabilitation programme in these areas GHSHQGHQFHLVVLJQL¿FDQWO\HIIHFWLYHRUUHEXLOGLQJ DUH LGHQWL¿DEOH EXW QRW DERYH WKH PDUN  9LVXDO the cognitive functions. retention and Retention for similar pairs, shows that Overall result showed that the intervention H[SHULPHQWDO JURXS ZDV VLJQL¿FDQWO\ EHWWHU WKDQ JURXSLPSURYHGVLJQL¿FDQWO\LQGLIIHUHQWGRPDLQV control group after intervention. Memory training of memory as remote memory, recent memory, was given to the patients by using strategies of mental balance, attention and concentration, elabourative processing, verbal memory tasks and delayed recall, retention for similar pairs, retention visual memory tasks and rehearsal. Results shows for dissimilar pairs, visual retention than control that there was improvement in the recall of the group indicate that the remediation program has words which were more rehearsed and there was SOD\HGVLJQL¿FDQWSRVLWLYHUROHLQWKHPDQDJHPHQW VLJQL¿FDQWLPSURYHPHQWRQLQIRUPDWLRQSURFHVVLQJ of various cognitive decline caused by alcohol memory and reduction of neuropsychological intake and otherwise also. GH¿FLWV UHVXOWHG IURP WUDLQLQJ 0DWKDL   Memory remediation strategies like errorless REFERENCES: learning, letter fragment cueing, verbal prompting Bates, M.E. Bowden, S. C., & Barry, D. (2002). DQGUHLQIRUFHPHQWIRUVSHFL¿FRXWFRPHKDYHEHHQ Neurocognitive impairment associated with IRXQG VLJQL¿FDQWO\ DIIHFWLYH LQ LPSURYHPHQW LQ alcohol use disorders: Implications for treatment. different domains of memory like delayed recall, Experimental and Clinical Psychopharmacology, retention for similar pairs. 10 (3), 193-212. Table no 5 presented in the result section shows Bates, M.E., Bowden, S. C., & Barry, D. (2002). that the scores of control group on Baseline and post Neurocognitive impairment associated with assessment. The results of the table shows that the alcohol use disorders: Implications for treatment. FRQWUROJURXSZDVIRXQGVLJQL¿FDQWO\LPSURYHGLQ Experimental and Clinical Psychopharmacology, the area of remote memory and retention for similar 10, (3), 193-212. pairs, rest of the areas like recent memory, mental Bondi, S., Bates, M E., Pawlak, A,P., & Tomgan, J S et al. balance, attention and concentration, delayed recall,   FRJQLWLYH ,PSDLUPHQW LQÀXHQFHV GULQNLQJ immediate recall, retention for dissimilar pairs, outcome by altering therapeutic mechanism of

44 Sheril Elizabeth Jose et al. / Role of Memory Rehabilitation on Persons with Alcohol Dependence ......

change. Psychology of Addiction Behavior, 20, 40 (3), 280-288. 241-53. Narang, J.D., Schrimsher, G.W., & Burke, R.D. (1991). Buddy, K.R., Pihl, R.O,. Mayerovitch, J.I., & Shestowsky, Relation between cognitive testing performance J.S. (1999). Alcohol and retrograde memory and pattern of substance use in Males at treatment effects: Role of individual differences. Journal of entry. The Clinical Neuropsychologist , 21, 498 - Studies on Alcohol, 60 (1), 130-136. 510. Godfrey, H.P., & Knight, R. G. (1985).Cognitive Pitel, A., Evans, J J., Wilson, B A., & Schuri, U, et al rehabilitation of memory functioning in amnesiac (2000). “A comparison of errorless’ and ‘trial and alcoholics. Journal of Consulting and Clinical error’ learning methods for teaching individuals Psychology, 53 (4), 555-557. ZLWKDFTXLUHGPHPRU\GH¿FLWV Neuropsychological Goldstein, G., Gretehen., L. H., Shemasky, W.J., & Rehabilitation, 39, 75-94. Barnett, B. (2005). Rehabilitation during alcohol Ron, Wilkinson. (1979). Experience dependent GHWR[L¿FDWLRQ LQ FRPRUELG QHXURSV\FKLDWULF neuropsychological recovery and the treatment of patients. Journal of Rehabilitation Research & alcoholism. Journal of Consulting and Clinical Development, 42, 2, 225-234. Psychology, 61 (5), 812-821. Goldman, S., & Bowden, S C. (2010). “Alcohol related Scheurich A., Muller, M. J., Szegedi. A., Angheleseu, dementia and Wernicke Korsakoff Syndrome.” I., Klawe, C., Lorch, B., et al. (2004). Dementia, Vol. 4, 238-251. Neuropsychological status of alcohol dependent Greenaway, E., Nimura, N., Komatsu, S C., & Kato, M. patients: increased performance through goal et al. (2012). “Memory for subject performed tasks setting instructions. Alcohol and Alcoholism , 39 in patients with Korsakoff syndrome. Cortex, 34, (2), 119-25. 297-303. Steingass, P.,Bobring K.H., Burgart, F., Sartory, G., Grohman, K., Fals-Stewart, W., & Donnelly, K. (2006). & Schugens, M. (1994). Memory training in Improving treatment response of cognitively alcoholics. . Neuropsychological Rehabilitation, 4, impaired veterans with neuropsychological 1, 1994. rehabilitation. Brain and Cognition, 60 (2), 203-4. Tarter, R.E. Allernan, A. I. & Edwards, K.L. (1985). Horvath, A K., & Joseph B. (1975). Differential outcomes Vulnerability to alcoholism in men: A behaviour training facilitates memory in people with genetic Perspective. Journal of Studies on Alcohol , Korsakoff and Prader – Willi Syndromes. Integer 46, 329-356. Physiol. Behav. Sci, 36, 196-204. Troyer, Van Oart R, & Kessels R. (2009).“Executive Mathai, G., Rao. S.L., & Gopinath, P. S. (1998). dysfunction in Korsakoff Syndrome”. International Neuropsychological rehabilitation of alcoholics: a Journal of Psychiatry Clinical Practice 13, 78-81. preliminary report. Indian Journal of Psychiatry,

45 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 46-50 Clinical Psychologists (ISSN 0303-2582) Research Article A Comparative Study of Receptive Speech among Male and Female Cases with Schizophrenic Illness

Riju Raj Roy 1*, Anand Manjhi 2, and J. Mahto 3

ABSTRACT 6SHHFK GLVRUGHU LV LQFUHDVLQJO\ XQGHUVWRRG WR EH D VLJQL¿FDQW LQGLFDWRU DQG FKDUDFWHULVWLF RI schizophrenia. Abnormalities in receptive language processes are also reliably detected for patients with schizophrenia including disturbances to word perception, sentence comprehension, and semantic and syntactic processing. Thus the objective of the study was to assess receptive speech among male and female patients suffering from schizophrenia using Receptive Speech Function Scale of AIIMS comprehensive neuropsychological battery in Hindi (Adult form). 7KLUW\SDWLHQWVLH¿IWHHQPDOHDQG¿IWHHQIHPDOHSDWLHQWVDOUHDG\GLDJQRVHGDVKDYLQJSDUDQRLG schizophrenia (as per ICD-10 DCR) were selected from outpatient and inpatient department of PGIBAMS, Raipur, through purposive sampling. The result of the study concluded that there ZHUHRQO\VLJQL¿FDQWGLIIHUHQFHVIRXQGEHWZHHQPDOHDQGIHPDOHVXEMHFWVRQFHUWDLQDVSHFWVRI receptive speech like understanding of commands that involves exhibiting motor responses and to identify non-sensible words. Key Words: Schizophrenia, Receptive Speech, Neuropsychological Battery, Comprehension INTRODUCTION cause receptive language disorder in schizophrenia. Speech and language disorders have been Receptive speech is the skill to listen to demonstrated to coexist with a wide range of the sounds one hears and then giving one’s own childhood and adolescent psychiatric conditions, interpretation followed by expressive speech which including infantile autism (Baltaxe & Simmons involves making one’s own sounds to communicate 3UL]DQWHWDO DWWHQWLRQGH¿FLWGLVRUGHU with others. Receptive skill is developed by listening (Baker & Cantwell, 1992), and other behavioural and learning the rules of language. Speech production and emotional disorders (Beitchman et al. 1986; abnormalities currently serve as obvious diagnostic Baltaxe & Simmons, 1988; 1990). Although speech symptoms (American Psychiatric Association, production abnormalities are more obvious as 2000). And also abnormalities in receptive language clinical signs and have been more commonly targeted processes are reliably detected for patients and their for empirical study (Docherty et al. 1999; Docherty nonpsychotic family members, including disturbances et al., 2000), dysfunction in receptive language has to word perception, sentence comprehension, and also been consistently observed for patients and their semantic and syntactic processing (Condray et ¿UVWGHJUHHIDPLO\PHPEHUVLQFOXGLQJGLVWXUEDQFHV al., 2002; De Lisi, 2001; Minzenberg et al., 2002). in the perception of words presented aurally at Cannon et al. (2002) found receptive language various levels of intensity (Bull & Venables, 1974) dysfunction during early childhood for individuals and background noise (De Lisi et al., 1997; Shedlack who later developed schizophrenia form disorder et al., 1997) and reduced comprehension accuracy during early adulthood. But expressive language for information in sentences (Thomas & Huff, 1971; dysfunction during childhood was not related with Faber & Reichstein, 1981; Morice & Mc Nicol, adulthood schizophrenia form disorder. 1985; Condray et al., 1992, 1995, 1996; Landre et al., 1992; Goldberg et al., 1998). The language Two of the systems may play key roles in the dysfunction related to schizophrenia may involve a language disorders of schizophrenia i.e. perceptual QHXURGHYHORSPHQWHWLRORJ\$SULPDU\GH¿FLWLQWKH representation system (orthography and phonology temporal dynamics of brain function is assumed to of words) and semantic memory (meaning of words).

1 & 2, M Phil Clinical Psychology Trainee, 3. Professor of Clinical Psychology, , Post Graduate Institute of Behavioural and Medical Sciences, Raipur (C.G) . *Correspondig Author: Riju Raj Roy, PGIBMS, Raipur.

46 Riju Raj Roy et al. / A comparative study on receptive speech among patients suffering from Schizophrenia ......

Semantic memory represents factual knowledge conditions were excluded from this study. about the w orld. Language is one medium for the x 3DWLHQW ZLWK VLJQL¿FDQW RWKHU PHGLFDO contact between environment, learning, and semantic conditions were excluded from this study. memory. The logical extension of this circumstance is Tools: that relation between receptive language function and FOLQLFDOSUHVHQWDWLRQZLOOUHÀHFWWKHFRPSOH[LQWHUSOD\ Socio-demographic Data Sheet: between environment, learning, and memory. It is now The present data sheet was prepared for this clear that schizophrenia is directly associated with study to obtained the relevant demographic disturbance to semantic memory function, although it information as age, occupational, marital status is not yet fully understood whether this dysfunction is education etc. GXHWRGH¿FLHQWHQFRGLQJVWRUDJHDFFHVVRUUHVSRQVH AIIMS Comprehensive Neuropsychological selection processes, and/or some combination of those Battery in Hindi (Adult Form): functions. The data are suggestive, although preliminary, with respect to perceptual memory disturbance Th e All India Institute of Medical Sciences (Schacter & Tulving, 1994; Schacter et al., 2000; Squire Comprehensive Neuropsychological Battery & Zola-Morgan, 1991; Squire & Zola, 1998). was developed in Hindi (Gupta et al., 2000). This consists of 160 items subdivided into 10 basic METHODOLOGY scales and 4 secondary scales including motor, Objective: tactile, visual, receptive speech and expressive The objective of the present study is to speech, reading, writing, arithmetic, memory assess receptive speech among male and female and intellectual process. Each scale is rated on patients suffering from schizophrenia using AIIMS a 5 point rating from 0-4 with 0 indicating no Comprehensive neuropsychological battery. impairment and 4 indicating severe impairment. The reliability of the 10 scales ranges from 0.79 It was hypothesise that there will be a to 0.98. In this study only receptive speech scale VLJQL¿FDQW GLIIHUHQFH EHWZHHQ PDOH DQG IHPDOH has been used. The reliability of this test is 0.98 schizophrenic patients on receptive speech. DOSKDFRHI¿FLHQWV7KHVWXG\ZDVDSSURYHGE\ Sample: ethical committee of the institute. The study was conducted on the outpatient Procedure: and inpatient department of PGIBAMS, Raipur. Data was collected with the permission of the 30 patients i.e. 15 male and 15 females diagnosed director of PGIBAMS, Raipur. Initially subjects as having schizophrenia (as per ICD-10 DCR) were informed about the study and the purpose of the were selected for study using purposive sampling study. Their consent was taken in the consent form. techniqu e. Initially the patients were screened out After that demographic information were collected in the different wards of the institute and researcher and following that Receptive Speech Scale of AIIMS HQVXUHWKHGLDJQRVWLFFRQ¿UPDWLRQDVSHUWKHFULWHULD comprehensive neuropsychological battery in Hindi opted for the study. The all patients were told about (Adult form) was administered. Later on the obtained the purpose of the study and consent to participate in data was taken for statistical analysis. The study was the study was taken from all the participants. approved by ethical committee of the institute. Inclusion Criteria: Statistical Measures: x Patients diagnosed as paranoid schizophrenia In this study the date has been analysed on the according to ICD-10 DCR were included. basis of t-test and chi-square, using IBM SPSS-16 x Patients with insidious onset only were software. included in this study. RESULT Exclusion Criteria: Following tables show the result analysed x Patients with any other comorbid psychiatric from the data. 47 Riju Raj Roy et al. / A comparative study on receptive speech among patients suffering from Schizophrenia ......

Table 1: Showing Mean, Standard Deviation Table 2: Showing the Result of Mean, Standard and t-Test Value for Age and Deviation and t Test for Receptive Frequency, Percentage and Chi Square Speech Scale Items for Male and Female. for Occupation, Marital Status and RSS Male Female Education among Male and Females: t Value Items Mean SD Mean SD Male Female t -test 63 0.000 0.000 0.000 0.000 - Variables Mean SD Mean SD 64 0.000 0.000 0.000 0.000 - Age 37.53 12.87 34.20 7.65 0.86 65 0.000 0.000 0.000 0.000 - Freque- % Freque % X 2 66 0.000 0.000 0.000 0.000 - ncy ncy 67 0.000 0.000 0.400 1.055 1.468 Occupation Employed 10 33.3 2 6.7 8.89*** 68 0.000 0.000 0.000 0.000 - Unemployed 5 16.7 13 43.3 69 0.200 0.560 0.000 0.000 1.382 Marital Married 10 33.3 11 36.7 1.59 70 0.000 0.000 0.133 0.351 1.468 Status Unmarried 5 16.7 4 13.3 71 0.000 0.000 0.133 0.351 1.468 Education >5th Std 0 0 3 10 3.692 72 0.133 0.516 0.000 0.000 1.000 5th-10th Std 7 23.3 7 23.3 73 0.733 0.961 1.266 1.334 1.256 <10th 8 26.7 5 16.7 74 0.266 0.457 0.457 0.593 0.000 SLJQL¿FD nt***> 0.001 level 75 0.866 1.245 0.000 0.000 2.694** Table 1 shows the comparison of socio 76 0.466 0.743 0.733 1.279 0.698 GHPRJUDSKLF SUR¿OH DPRQJ PDOH DQG IHPDOH 77 0.000 0.000 0.200 0.774 1.001 schizophrenia subjects. The mean age for male is DQGIHPDOHLV7KHUHLVQRVLJQL¿FDQW 78 0.066 0.258 0.133 0.351 .592 difference between male and female on age variable. 79 0.066 0.258 1.200 1.897 2.292* In terms of occupation, 33.3% of males were 80 0.000 0.000 0.133 0.351 1.468 employed and 16.7% of males were unemployed 81 0.000 0.000 0.000 0.000 - where as only 6.7% of females were employed Total 2.800 2.704 1.866 2.587 0.966 and 43.3% females were unemployed. There is a Score VLJQL¿FDQWGLIIHUHQFHEHWZHHQPDOHDQGIHPDOHRQ RFFXSDWLRQYDULDEOHDWOHYHO Ȥð   6LJQL¿FDQWDWOHYHODQG 6LJQL¿FDQWDWOHYHO On marital status, 33.3 % males are married Table 2 shows the comparison of male and and 16.7% males are unmarried and 36.7% of female schizophrenia subjects on RSS item. The females were reported to be married and 13.3% of mean score for item 63 to 66, 68 and 81 is 0 for females are unmarried. While making an account both male and female. However in item 67 for male of education level, it has been reported that among subjects the mean score is 0.000 but the mean score males 23.3% were educated between 5th to 10th for female subject is 0.400. In item 69 and 72 mean standard and 26.7% of males were educated above score for male subject is 0.200 and 0.133 and for 10th standard. Among females, 10% of females were female subject is 0.00 for both the items. Following educated less than 5th 23.3% educated between 5th item 70 and 71, the result is indicating 0.000 as grade to 10th grade and 16.7% were educated above mean score for male subjects in both the items and WKJUDGH1RVLJQL¿FDQWGLIIHUHQFHEHWZHHQPDOH 0.133 for females in both the subjects. In item 73 and and female on different demographic variables 74, the mean score for male and female subject is was found. Most of the demographic variable 0.733, 1.266 and 0.266 and 0.457 respectively which ZHUHPDWFKHGH[FHSWRFFXSDWLRQZKHUHVLJQL¿FDQW indicates that female subjects have scored more in difference was noted. item 73 and 74 than male subjects. In 75th item the

48 Riju Raj Roy et al. / A comparative study on receptive speech among patients suffering from Schizophrenia ...... mean score for male is 0.866 and for is 0.000. There (Mean= 0.066). However, to support the present LVDVLJQL¿FDQWGLIIHUHQFHEHWZHHQPDOHDQGIHPDOH ¿QGLQJVUHVHDUFKVWXGLHVDUHQRWDYDLODEOHDVPXFK for item 75 at 0.01 level (t= 2.69). The mean score studies have not been done in this area using AIIMS obtained by male subjects in items 76, 77 and 78 is neuropsychological battery. Thus, this study can be 0.466, 0.000 and 0.066 respectively and by female treated as an attempt to focus on receptive speech subjects in item 76, 77 and 78 is 0.733, 0.200 and among schizophrenia that requires a great amount of 1.200. Taking 79th item in concern, the mean score attention. for male subjects is 0.000 and for female subjects is CONCLUSION 7KHUH LV D VLJQL¿FDQW GLIIHUHQFH DPRQJ PDOH The present study suggests that there is no and female subjects on this item at 0.05 level (t= 2.292). In 80th item the mean score for male subject VLJQL¿FDQW GLIIHUHQFH EHWZHHQ PDOH DQG IHPDOH subject on overall receptive speech of the patients of is 0.000 and for female subject is 0.133. The mean schizophrenia. However, this study found differences score for male and female subjects on total score between male and female subjects on certain aspects came to be 2.800 and 1.866 respectively which of receptive speech like understanding of commands indicated a higher total score scored by male subjects that involves exhibiting motor responses and to in comparison to female subjects. identify non-sense words. DISCUSSIONS REFERENCES The present study was carried out to assess American Psychiatric Association (2000). Diagnostic and receptive speech among patients suffering from Statistical Manual of Mental Disorders, 4th ed., schizophrenia. In this study a comparison was also Text Revision. American Psychiatric Association, done to assess any differences lies between male Washington, DC. and female on socio demographic details like age, occupation, education and marital status, and on %DNHU /  &DQWZHOO '3   $WWHQWLRQ GH¿FLW disorder and speech / language disorder. Receptive Speech Scale of AIIMS neuropsychological Comprehensive Mental Health Care , 2, 3-16. battery. Following the hypothesis it was found that WKHUHLVQRVLJQL¿FDQWGLIIHUHQFHEHWZHHQPDOHDQG Baltaxe, C.A.M., & Simmons, J.Q.(1988). Communication female on age, education and marital status in relation GH¿FLWV LQ SUHVFKRRO FKLOGUHQ ZLWK SV\FKLDWULF disorders. Seminars in Speech and Language, 9, 1, WRUHFHSWLYHVSHHFK+RZHYHUWKHUHLVDVLJQL¿FDQW 81-91. difference found between male and female subjects on occupation at 0.001 levels. Baltaxe, C.A.M., & Simmons, J.Q. (1981). Disorders of Language in Childhood Psychosis: Current Accounting for male and female schizophrenia Concepts and Approaches. In Darby, J (Ed), Speech subjects on RSS, it was found that there is no Evaluations in Psychiatry (pp. 285-328). New VLJQL¿FDQWGLIIHUHQFHRQWRWDOVFRUHRI566*XSWDHW York, NY: Grune & Stratton. al. (2000) compared schizophrenia patients with brain Baltaxe, C.A.M., & Simmons, J.Q. (1990). The GDPDJHGDQGFRQWUROJURXSDQGIRXQGQRVLJQL¿FDQW difference on receptive speech scale. However, there differential diagnosis of communication disorders in child and adolescent psychopathology. Topics in LVDVLJQL¿FDQWGLIIHUHQFHEHWZHHQPDOHDQGIHPDOH Language Disorders , 10, 4, 17-31. VXEMHFWV LQ LWHP  DW  VLJQL¿FDQFH OHYHO ,Q item 75, the subjects were required to identify non- Beitchman, J., Nair, R., Clegg, M., Ferguson, B., & Patel, sense words. The result shows that male subjects P. (1986). Prevalence of psychiatric disorders (mean=0.866) were able to respond on this item in children with speech and language disorders. better as compared to female subjects (mean= 0.000). Journal of the American Academy of Child Psychiatry, 25, 528-535. 7KHUH LV DOVR D VLJQL¿FDQW GLIIHUHQFH EHWZHHQ PDOH and female subjects at 0.05 levels in understanding Bull, H.C., & Venables, P H. (1994). Speech perception in of commands by exhibiting motor responses. The schizophrenia. British Journal of Psychiatry, 125, mean score was found to be more for female subjects 350-354. (Mean= 1.200) as compared to male subjects &DQQRQ 0 &DVSL $ 0RI¿WW 7( +DUULQJWRQ +

49 Riju Raj Roy et al. / A comparative study on receptive speech among patients suffering from Schizophrenia ......

Taylor, A., Murray, R.M., & Poulton, R. (2002). semantic system. American Journal of Psychiatry, Evidence for early-childhood, pan-developmental 155, 1671-1676. LPSDLUPHQWVSHFL¿FWRVFKL]RSKUHQLIRUPGLVRUGHU results from a longitudinal birth cohort. Archives of Landre, N.A., Taylor, M.A., & Kearns, K.P. (1992). General Psychiatry, 59, 449– 456. Language functioning in schizophrenic and aphasic patients. Neuropsychiatry, Neuropsychology, and Condray, R., Steinhauer, S.R., van Kammen, D.P., & Behavioural Neurology, 5,7-14. Kasparek, A. (2002). The language system in schizophrenia: effects of capacity and linguistic Minzenberg, M.J., Ober, B.A. & Vinogradov, S. (2002). structure. Schizophrenia Bulletin , 28, 475– 490. Semantic priming in schizophrenia: a review Condray, R., Steinhauer, S.R., & Goldstein, G. (1992). and synthesis. Journal of The International Language comprehension in schizophrenics and Neuropsychological Society, 8, 699–720. their brothers. Biological Psychiatry , 32, 790-802. Morice, R., & McNicol, D. (1985). The comprehension Condray, R., Steinhauer, S.R., van Kammen, D.P., & and production of complex syntax in schizophrenia. Kasparek, A. (1996). Working memory capacity Cortex , 21, 567-580. predicts language comprehension in schizophrenic Prizant, B., Audet, L., Burke, G., Hummel, L., Maher, S., patients. Schizophrenia Research , 20, 1-13. & Theodore, G. (1990). Communication disorders Condray, R., van Kammen, D.P., Steinhauer, S.R., and emotional/behavioural disorders in children Kasparek, A., & Yao, J. K. (1995). Language and adolescents. Journal of Speech and Hearing comprehension in schizophrenia: Trait or state Disorders, 55, 179-192. LQGLFDWRU" Biological Psychiatry , 38, 287-296. Schacter, D.L. & Tulving, E. (1994). What are the memory DeLisi, L.E. (2001). Speech disorder in schizophrenia: review of the literature and exploration of its V\VWHPV RI " ,Q 6FKDFWHU '/7XOYLQJ ( relation to the uniquely human capacity for (Eds.), Memory Systems. MIT Press, Cambridge, 1 language. Schizophrenia Bulletin , 27, 481– 496. –38. DeLisi, L.E., Sakuma, M., Kushner, M., Finer, D.L., Schacter, D.L., Wagner, A.D. & Buckner, R.L. (2000). Hoff, A. L., & Crow, T. J. (1997). Anomalous Memory systems of 1999. In: Tulving, E., Craik, cerebral asymmetry and language processing in F.I.M. (Eds.), The Oxford Handbook of Memory . schizophrenia. Schizophrenia Bulletin, 23, 255- Oxford Univ. Press, Oxford, 627–643. 271. Shedlack, K., Lee, G., Sakuma, M., Xie, S-H., Kushner, Docherty, N.M., Gordinier, S.W., Hall, M.J., & Cutting, M., Pepple, J., Finer, D L., Hoff, A L., & De Lisi, L.P. (1999). Communication disturbances in L.E. (1997). Language processing and memory relatives beyond the age of risk for schizophrenia in ill and well siblings from multiplex families and their associations with symptoms in patients. affected with schizophrenia. Schizophrenia Schizophrenia Bulletin, 25, 4, 851-862. Research , 25, 43-52. Docherty, N.M.; Hall, M.J.; Gordinier, S.W.; & Cutting, Squire, L.R., & Zola, S.M., (1998). Episodic memory, L.P. (2000). Conceptual sequencing and disordered semantic memory, and amnesia. Hippocampus, 8, speech in schizophrenia. S chizophrenia Bulletin, 205– 211. 26, 3,723-735. Faber, R., & Reichstein, M.B. (1981). Language Squire, L.R., & Zola-Morgan, S., (1991). The medial dysfunction in schizophrenia. British Journal of temporal lobe memory system. Science, 253, Psychiatry , 139, 519-522. 1380– 1386. Goldberg, T.E., Aloia, M.S., Gourovitch, M.L., Missar, Thomas, H.B.G., & Huff, F.J.,(1971). Comprehension and D., Pickar, D., & Weinberger, D.R. (1998). recoding-time of transformed sentences. Language Cognitive substrates of thought disorder: I. The and Speech , 14, 352-372.

50 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 51-57 Clinical Psychologists (ISSN 0303-2582) Research Article Therapeutic Effects of Yoga on Generalized Anxiety Disorder

Laiju S. 1 and Sananda Raj 2 ABSTRACT Generalized Anxiety Disorder (GAD) is a chronic, relatively common psychiatric disorder characterized as an unrealistic, excessive anxiety about two or more life circumstances for a SHULRGRIVL[PRQWKVRUORQJHU3HRSOHZLWK*$'IHHOLUULWDEOHDQGWHQVHDQGKDYHGLI¿FXOW\ concentrating. These mental signs are coupled with physical symptoms such as shortness of breath, increased heart rate, cold clammy hands, dry mouth, nausea, diarrhoea, chills or hot ÀXVKHVPXVFOHWHQVLRQDFKHVDQGVRUHQHVV6LQFH*$'LVFRQFHLYHGDVDVWUHVVUHODWHGGLVRUGHU lessening one’s response to stress by various techniques is helpful for patients to reduce their anxiety. The present study aimed to explore the therapeutic effects of yoga on GAD. The sample of the study was 50 GAD patients, both males and females, in the age range of 20 to 45 years. The sample was taken from the Holistic Medicine and Stress Research Unit, Government Medical College, Thiruananthapuram. The tools used to assess was General Anxiety Scale developed by Laiju and Sananda (2002). The Statistical techniques used for the study were two way repeated measures ANOVA and independent samples t-test. Analysis of the results LQGLFDWHVWKDWWKHVWXG\JURXSVVKRZHGVLJQL¿FDQWUHGXFWLRQLQJHQHUDODQ[LHW\FRPSDUHGWRWKH comparison group. Key Words: Generalized Anxiety Disorder, Yoga Therapy, Holistic Medicine, Posture, Asanas.

INTRODUCTION tension, and sleep disturbance. In addition, GAD Anxiety is a vague uneasy feeling the source patients show physical symptoms such as shortness RI ZKLFK LV RIWHQ QRQVSHFL¿F RU XQNQRZQ WR WKH of breath, increased heart rate, cold clammy hands, individual. Exposure to stressful life situations or GU\ PRXWK QDXVHD GLDUUKHD FKLOOV RU KRW ÀXVKHV events can cause anxiety, an observable reaction, muscle tension, aches, and soreness. or an unpleasant emotional state marked by worry, The treatment of GAD has been subject of apprehension and tension. The amount of anxiety considerable interest and controversy in recent one experiences depends on the intensity of the years. Though, medication has been claimed to be stress producing stimulus or event and the resources, effective in the treatment of anxiety, (Rickels et the defences, and the coping mechanisms of the al, 1987), problems like resistance to medication, person (Spielberger and Sydeman, 1994). intolerance, side effects, and tendency to relapse Generalized Anxiety Disorder (GAD), one are also reported (Telch et al., 1983). Hence, GAD, of the anxiety disorder characterized by persistent, one of the stress related disorders, needs a holistic excessive, unrealistic anxiety about possible treatment approach. Still many patients have been PLVIRUWXQHVVXFKDV¿QDQFLDOORVHVIDPLO\ZRUNLOO treated only with pharmacological treatment which health, the welfare of one’s children, or combination focuses on human body, rather than the mind, and of these misfortunes (Rachman, 1998; Roemer, no step is being taken to manage their stress. As a Molina & Borkovec, 1997). According to DSM – IV result, the patients have to depend on medication criteria, 1994), GAD is an unrealistic anxiety about for a long period of time until, their stress has not two or more circumstances for a period of six months been managed. Further, since the daily hassles and DQGWKDWLWPXVWEHH[SHULHQFHGDVGLI¿FXOWWRFRQWURO stressors cannot be removed from our day-to-day The subjective experience of worry must also be life, lessening one’s response to stress should be accompanied by at least three of the following six worthwhile. Yoga therapy, one of the complementary symptoms: Restlessness, a sense of being easily and alternative therapies targets both physiological IDWLJXHGGLI¿FXOW\FRQFHQWUDWLQJLUULWDELOLW\PXVFOH and psychological manifestations of anxiety

1. Assistant Professor of Psychology, Sree Narayana College, Kollam, 2 Former Professor & Head, Deptt of Psychology University of Kerala

51 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ......

(Braunwald et al., 2001). yoga emerges as a device for controlling stress and Yoga is an ancient form of exercise that can stress related disorders. reduce stress and relieve muscular tension or pain. METHODLOGY Yoga believes in a holistic concept of health and well-being of which the body, mind and spirit are Hypothesis: integral and interdependent parts. We cannot think of Generalized Anxiety Disorder (GAD) patients sound health by taking care of one or two aspects and undergoing yoga therapy combined with medication ignoring the other (Bhushan, 2004). VWXG\ JURXS  ZLOO VKRZ VLJQL¿FDQW UHGXFWLRQ LQ The yoga postures or asanas exercise every general anxiety compared to those (contorl group) part of the body, stretching and toning the muscles undergoing medication only. and joint, the spine and the entire skeletal system. And they work not only on the frame of the body, but Design : on the internal organs, glands, and nerves as well, The pre & post assessment design was opted keeping all systems in radiant health. The yogic for present study. However, to see the progress breathing exercises known as pranayama, revitalize LQ PDQDJLQJ WKH SUREOHP DQG WR ¿QG RXW WKH the body and help to control the mind, leaving one sustainability of the gain achieved in intervention feel calm and refreshed, while the practice of positive mid phase and follow-up assessment was also done. thinking and meditation gives increased clarity, mental power, and concentration (Devananda, 2000). Sample The sample of the study consists of 50 GAD Failure of medicine to render good holistic patients, both males and females, in the age range health, failure of religion to give mental peace, of 21 to 45 years, attending the Holistic Medicine IDLOXUHRIVFLHQWL¿FDGYDQFHPHQWVWRSURPRWHPHQWDO and Stress Research Unit, Government Medical health and material progress to improve quality of College, Thiruananthapuram, were randomly taken life created a need to search for a device that will for the study. Purposive sampling method has been relieve man from sufferings and give positive health, adopted to select the sample for the investigation. mental stability, emotional tranquillity and spiritual 7KHFODVVL¿FDWLRQRIWKHVDPSOHLVJLYHQLQWDEOH well being. 7DEOH*URXSDQG6H[ZLVH&ODVVL¿FDWLRQRI the Sample SEX GROUP Total Male Female Study Group 14 11 25

Group Assessment Pre Intervention Assessment Post Intervention Assessment Mid Intervention Follow-up months) (3 Control Group 12 13 25 Medica- Total 26 24 50 Medication Medication Medica- tion & tion & some Yes & Yoga Yes & Yoga Yes Yoga Study Study Group Inclusion Criteria: Therapy Therapy Therapy Practices of Yoga ‡ Subjects between the age range of 21 to 45. ‡ Subjects willing to participate in the study. Yes Medication Yes Medication Yes Medica- Medica- alone alone tion alone tion alone Group Control Control ‡ Patients met the ICD-10 DCR Criteria for GAD. Moreover, since the prime objective of yoga Exclusion Criteria: is to promote health and quality of life (Bhushan, ‡ Subjects having family history of mental illness. 2003), it would be fruitful for the millions of people who have been under the vicious circle of stress, ‡ Subjects having past history of mental illness. to control their stress and keep it at a manageable ‡ Subjects having GAD with comorbid mental level. Thus they can keep themselves away from the disorders. adverse effects of stress. In this context, the role of ‡ Subjects who are illiterate.

52 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ......

‡ Subjects who dropped either medicine or yoga in various aspects of the intervention programme therapy during the intervention period. including the procedure. The yoga techniques used in the study were relaxation techniques, breathing Tools: exercises, pranayamas, asanas, and meditation. A Case Record Form was prepared for the study doctor, who had Bachelors Degree in Naturopathy in order to take the case history of subjects. In the and Yogic Sciences, was the therapist for giving yoga present investigation, diagnosis of GAD was made on therapy. Treatment outcomes of the study and the the basis of case history and interview. The interview comparison group were amassed towards the end of focused on eliciting the essential information three assessment phases: (1) Mid assessment phase inevitable for the proper evaluation of GAD. (1/2 months after pre assessment; (2) Post assessment To measure the intensity of GAD, General phase (1.5 months after the mid assessment; and (3) Anxiety Scale developed by Laiju and Sananda follow-up assessment phase (three months after the (2002) was used for the study. The scale consists of post assessment). The procedure adopted for the 31 items, which were highly relevant to elicit general VWXG\LVJLYHQLQ¿JXUHEHORZ anxiety symptoms. Figure - 1: Description of Assessment Procedure: Yoga Techniques Used for Intervention: FIGURE: 3.1 Description of assess ment procedure The major yoga techniques used in the study were: Diagnostic interview and Exclude those who did screening of patients not fit the criteria 1. Relaxation techniques

2. Breathing techniques Case History Exclude those who refused to participate 3. Pranayamas 4. Asanas(12 postures)

5. Meditation Study group Comparison group Procedure: 7KH SDUWLFLSDQWV ZHUH ¿UVW LQWHUYLHZHG E\ Pre-assessment phase Pre-assessment phase the investigator and then they were diagnosed by Underwent medication as a psychiatrist. After the diagnostic interview and Underwent medication only screening of subjects using exclusion-inclusion well as yoga therapy criteria, case records of the subjects were taken using Mid assessment phase the case record form. Subjects who had completed Mid assessment phase ( (m onths after pre test) the case record form and were willing to participate months after pre test) in the study were randomly assigned to the study Medication and yoga therapy group and the comparison group respectively. Pre Medication continuing assessments of the subjects were taken as the initial continuing step, using General Anxiety Scale. Post assessment phase The study group was given Yoga Therapy along Post assessment phase (3months after (3months after pre assessment ) with medication, while the comparison group was pre assessment ) given medication only. The drugs used were Triplent, and Alamo. The duration of the yoga therapy was Medication and yoga therapy Medication continuing one and a half hour daily session for continuous continuing 14 days in the clinic. After that, the patients had to practice the same at home regularly. Review classes Follow-up (3 months after Follow-up ( 3 months after were also arranged once in a month after the 14 days post assessment) post assessment) therapy session, with a view to clarify doubts, if any,

53 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ......

Data Analysis: interaction effect, i.e., the combined effect of yoga The following statistical techniques were used therapy and medicine (group x assessment) is also for the analysis of data. seen in the result (F=26.81, P<0.01). The interaction Preliminary analysis of data was done by using HIIHFWLVVKRZQLQ¿JXUH mean and standard deviation. Independent samples Table 3: Results of the Two Way Repeated Measures t-test and Two-way Repeated measures ANOVA was ANOVA for the Variable General Anxiety applied for anlysing the data. (Group x Assessment) Sum of Mean Sum RESULTS Source df F-value The results of the study are analyzed primarily Squares of Squares comparing the mean and standard deviations of the Between 43991.42 3 14663.81 594.04 ** study group and the control group. The mean scores Assessment of general anxiety revealed that the study group Between Group 6624.01 1 6624.01 35.43 ** shows more reduction in general anxiety than the comparison at mid, post and follow-up assessment Group x 1985.70 3 661.90 26.81 ** phase (Table 2). Assessment Table 2: Comparison of Study Group and Control Error 3554.64 144 24.69 Group for the Variable General Anxiety 1RWH 6LJQL¿FDQWDWOHYHO Disorder at Different Phases. Figure 2: Comparison of Mean Scores of General Assessment Group N Mean /SD Anxiety at Differ ent Assessment Phases of the Study Group 25 88.88 ±7.54 Study Group and the Co ntrol Group. Pre Contorl Group 25 90.52 ±6.80 Study Group 25 63.44 ±7.90 Mid Contorl Group 25 74.32 ±7.20 Study Group 25 51.40 ±7.65 Post Contorl Group 25 66.44 ±7.39 Study Group 25 40.56 ±6.44 Follow-up Contorl Group 25 59.04 ±12.25 Two-way repeated measures ANOVA (Table Figure 2 shows the decrease in mean scores of   ZDV XVHG WR ¿QG RXW WKH HIIHFW RI \RJD WKHUDS\ general anxiety of the study group and the control on subjects’ scores on general anxiety at pre, mid, group obtained for the variable general anxiety from post and follow-up assessment phases (2 groups x baseline assessment to follow-up, the mid phase to 4 assessments). The F-value (F=594.04, P<0.01) for post assessment phases. The study group as well the between assessment phases of general anxiety as the comparison group show decrease in general UHYHDOHGWKDWWKHUHLVVLJQL¿FDQWGLIIHUHQFHEHWZHHQ anxiety. The slope of the lines indicates the rate the study group and the comparison group in mean of improvement found in the study group and the scores of general anxiety among the pre, mid, post comparison group. The line representing the study and follow-up assessment phases. The F-value (F= group shows more slope than the line representing 35.43, P<0.01) for between group (study group the comparison group. This is due to the interaction and comparison groups) indicates that, there is effect, i.e., the combined effect of yoga therapy VLJQL¿FDQW GLIIHUHQFH EHWZHHQ WKH VWXG\ JURXS and medicine. Hence, the study group shows more and the comparison group in general anxiety. The decrease in general anxiety.

54 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ......

To further examine, the effect of yoga therapy symptoms. While comparing the two groups at mid on general anxiety, independent samples t-test was phase to post and follow-up assessment phases, used to assess the changes from pre assessment we can see that the study group showed greater phase to follow-up assessment phases. For this improvement in general anxiety symptoms than purpose, mean difference between the assessment the comparison group. At the follow-up assessment phases were considered for analysis. The results phase, i.e., six months after the pre assessment, the indicate that there was a greater reduction in average general anxiety score has reduced from 88. general anxiety between pre and mid assessment 88 to 40.56. In the comparison group, it has been and mid and post assessment. Between the post reduced from 90.52 to 59.06 only. The results of and follow-up assessment the study group and the the two way repeated measures ANOVA (Table FRQWUROJURXSGRQRWVKRZDQ\VLJQL¿FDQWUHGXFWLRQ 3) and independent samples t-test (Table 4) also in general anxiety. This may be due to the fact that substantiate the results of the preliminary analysis. since the general anxiety scale mainly measures All these results suggest that yoga can be use as an the symptoms of GAD, three months period was alternative or complementary therapy for treating enough for reducing the symptoms. Hence both generalized anxiety disorder. groups do not show much improvement in general Studies suggest that the practice of yoga anxiety between the post and follow-up assessment PD\ EHQH¿W WKH WUHDWPHQW RI DQ[LHW\ LQFOXGLQJ period (Table 4). *$'+RIIPDQHWDO  VWXGLHGWKHHI¿FDF\RI Kundalini Yoga intervention, relative to CBT and Table 4: Results of the t-test: Group Difference a control condition. This randomized controlled in General Anxiety Scores between trial compared yoga (N=95) to both CBT for GAD Different Assessment Periods (N=95) and stress education (N=40), a commonly Assessment Mean used control condition. All three treatments will be Group N SD t-value period difference administered by two instructors in a group format over 12 weekly sessions with four to six patients Study 25 25.44 5.61 per group. Treatment outcome were evaluated bi- Between Pre & Group Mid Assessments 6.67** weekly and at six month follow-up. Furthermore, Comparison (1.5 months) 25 16.20 4.05 potential mediators of treatment outcome will be Group investigated. Given the individual and economic Study burden associated with GAD, identifying 25 12.04 5.13 Between Mid & Group accessible alternative behavioural treatments will Post Assessments 2.72** have substantive public health implications. A Comparison (1.5 months) 25 7.88 5.67 Group study conducted by Crison et al., (1984) support the present result of the study. Their study was Study Between Post 25 10.84 4.52 based on the effect of pranayama on GAD. Other & Follow-up Group 1.70 ns studies that support the present result include, Assessments (3 Comparison studies conducted by Mishra and Sinha (2001); 25 7.40 9.07 months) group Ray et al. (2001). They studied the effect of yoga 6LJQL¿FDQWDWOHYHO RQGHSUHVVLRQDQGDQ[LHW\DQGIRXQGVLJQL¿FDQWO\ effective in reducing the symptoms. DISCUSSION The present study applied breathing exercises, The results of the study indicates that general relaxation techniques, yogic postures, pranayama, DQ[LHW\ZDVVLJQL¿FDQWO\UHGXFHGLQWKHVWXG\JURXS and meditation techniques in GAD patients. compared with the comparison group at mid, post Relaxation techniques and breathing exercises were and follow-up assessment phases. used to calm the mind, relieve stress and lead to The mean scores of the study group increased concentration and equanimity which are (88.88) and the comparison group (90.52) at the the common symptoms found in GAD patients. baseline assessment indicate high level of anxiety The different asanas have been applied to provide

55 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ...... proper energy to the body. It brought a rich supply activity by reducing the ruminative and mind of blood to the glands, brain cells, and to the various wandering activity of the default mode network parts of the spinal column. The yoga postures or (DMN) in the brain (Hansenkamp et al., 2012). asanas worked by exercising every part of the body Broyd and colleagues (2009) found that higher including the internal organs and glands, stretching activity in parts of this network is associated with and toning the muscles and joints, the spine and the depression, anxiety, rumination and other negative entire skeletal system to promote the health and self-referential thoughts. Rumination and self- well-being. Asanas have a particularly powerful focused attention are central features of anxiety DQGEHQH¿FLDOHIIHFWRQRQHRUPRUHRIWKHJODQGV disorders and depression (Rochat, Billieux, & Van When a person is in a particular asana, for example, Der Linden, 2012). LQ VDUYDQJDVDQD WKH ÀRZ RI HQHUJ\ RU SUDQD LV Since the stressors of everyday life cannot concentrated to throat region where the thyroid be eliminated, lessening one’s response to stress gland is located. The thyroid is given good massage, by various techniques is helpful for individuals to and its functioning is greatly improved. By regular reduce physical as well as psychological problems. practice of yoga, there occurs a natural alignment of Yoga therapy targets both physiological and body, which leads to a natural realignment of your psychological management of stress and stress perception of life and who you are. Thus, when related problems such as anxiety and depression. In we reach in an energized state, we can control our short, yoga therapy, one of the complementary and mind, feel calm and refreshed, and increase mental alternative medicines believes in holistic concept of power and concentration. Pranayama is aimed at health and well being of which the body, mind, and stimulating and increasing the vital energy in the spirit are integral and interdependent parts. body and directing it to a particular area of the body. Extra oxygen is introduced and consequently one CONCLUSION can utilize one’s lung capacity. Meditation calms The following conclusions have been drawn the mind, relieves stress, and leads to increased from the present study. concentration and equanimity. It brings peace and harmony, which may be enjoyed throughout the day. ‡ GAD patients who underwent yoga therapy Thus the ultimate result is good physical, mental, combined with medication (study group) emotional, social and spiritual health that is what VKRZHGVLJQL¿FDQWUHGXFWLRQLQJHQHUDODQ[LHW\ we call the holistic concept of health. Since GAD than those underwent medication (comparison is a stress related disorder, reducing one’s stress group) only. through yoga therapy can have a positive impact on ‡ Yoga should be considered as a complementary GAD. Selye (1936) recognizes that exposure to a therapy or alternative therapy in the treatment stressor can increase the body’s ability to cope with of GAD and other anxiety based disorders. that stressor in future by a process of physiological adaptation. Likewise, a person who practices yoga In conclusion the present study suggests that regularly, gradually increases the body’s ability yoga therapy can be used as a complementary or to respond to adaptively and to recover from the alternative therapy to reduce anxiety symptoms in adverse effects of stress and stress related diseases. patients with GAD. Yoga may exert its effect on psychophysiology REFERENCES by invoking the relaxation response, an endogenous, American Psychiatric Association. (1994). Diagnostic and co-ordinated response in which arousal of the Statistical Manual of Mental Disorders, (DSM-IV: autonomic nervous system and activation of the 4th ed.). Washington, DC: American Psychiatric hypothalamic pituitary axis are reduced in direct Press. RSSRVLWLRQ WR WKH ¿JKWRUÀLJKW VWUHVV UHVSRQVH Bhushan, L. I. (2003). Re-emerging yogic Science: (Jacobs, 2001). Furthermore, the meditative Instrument for Individual and Societal component of yoga practice involving relaxed Transformation. Indian Journal of Psychological control of attention has direct effects on cognitive Issues, 11(1), 1-12.

56 Laiju S. et al. / Therapeutic Effects of Yoga on generalized Anxiety Disorder ......

Bhushan, L. I. (2004). Yoga: An instrument for Rachman, S. (1998). Anxiety . Psychology Press Ltd. psychological transformation. Indian Journal of Publishers, UK. Community Psychology , 1 (1) 11-24. Ray, U. S., Mukhopadhyaya, S., Purkayasta, S. S., Braunwald, E., Fauci, A. S., Kasper, D. L., Hauser, S. Asnani, V., Tomer, O. S., Prashad, R., Takur, L., & L., Longo, D. L., & Jameson, J. L. (Eds.), (2001). Selvamurthy, W. (2001). Effect of Yogic exercises Harison’s Principles of Internal Medicine, (15th on Physical and Mental health of young fellowship ed.). New York: McGraw-Hill. course trainees. Indian Journal of Physiological Broyd, S.J., Demanuele, C., Debener, S., Helps, S.K., Pharmacology, 45 (1), 37-53. James, C.J., Sonuga-Barke, E.J. (2009). Default- Rickels, K., Sehweitzer, E. & Lucki, I. (1987). mode brain dysfunction in mental disorders: A Benzodiazepine side effects. In Hales, R. E., systematic review. Neuroscience and Biobehavioral Frances, A. T. (Eds.), Psychiatry Update: APA, Reviews . 33 (3), 279–296. Annual Review. Washington, DC: American Crison, H. G., Nagarathna, R., & Nagendra, H. R. Psychiatric Press, 781-801. (1984). Preliminary Investigation on the Use of Rochat, L., Billieux, J., Van der Linden, M. (2012). Yoga Therapy for Anxiety Neurotics . Bangalore: 'LI¿FXOWLHV LQ GLVHQJDJLQJ DWWHQWLRQDO UHVRXUFHV Vivekananda Kendra Yoga Research Foundation. from self-generated thoughts moderate the link Devananda, S. V. (2000). The Sivananda Companion to between dysphoria and maladaptive self-referential Yoga . New York: Simon and Schuster. thinking. Cognition & Emotion . 26 (4), 748–757. Hasenkamp, W., Wilson-Mendenhall, C.D., Duncan, Roemer, L., Molina, S., & Borkovec, T. D. (1997). An E., Barsalou, L.W. (2012). Mind wandering and Investigation of worry content among generally DWWHQWLRQGXULQJIRFXVHGPHGLWDWLRQ$¿QHJUDLQHG anxious individuals. Journal of Nervous and Mental WHPSRUDO DQDO\VLV RI ÀXFWXDWLQJ FRJQLWLYH VWDWHV Diseases, 185 (5), 314-319. NeuroImage, 59 (1), 750–760. Selye, H. (1936). Thymus and adrenals in the response of Hofmann, S.G., Curtiss, J., Khalsa S.B., Hoge, E., the organism to injuries and intoxications. British 5RVHQ¿HOG ' %XL ( .HVKDYLDK $ 6LPRQ Journal of Experimental Pathology, 17, 234-248. N. (2015). Yoga for generalized anxiety disorder: Spielberger, C. D. & Sydeman, S. J. (1994). State-Trait design of a randomized controlled clinical trial. Anxiety Inventory and State-Trait Anger Expression Contemporary Clinical Trials . 44, 70-76, Inventory. In M. E. Maruish (Ed.), The Use Of Jacobs, G.D. (2001). The physiology of mind–body Psychological Testing for Treatment Planning and interactions: The stress response and the relaxation Outcome Assessment. Hillsdale, NJ: Lawrence response. The Journal of Alternative and Erlbaum Associates. Complementary Medicine. 7 (1), S 83–S92. Telch, M. J., Tearmon, B., Taylor, C. B. (1983). Combined Mishra, M. & Sinha, R. K. (2001). Effect of Yogic practices pharmacological and behavioral treatment for on Depression and Anxiety. Journal of Projective agoraphobia. Behavior Research and Therapy, 23, Psychology and Mental Health, 8(1). 325-335.

57 Indian Journal of Clinical Psychology Copyright, 2016 Indian Association of 2016, Vol. 43, No. 1, 58-64 Clinical Psychologists (ISSN 0303-2582) Research Article Psychometric Properties of Hindi Version of Peace of Mind, Harmony in Life and Sat-Chit-Ananda Scales

Kamlesh Singh 1*, Shambhovi Mitra 2 and Pulkit Khanna 3

ABSTRACT The present research reports the psychometric properties of the Hindi version (translated) of three recently developed scales, namely Peace of Mind Scale (PoM; Lee et al., 2013), Harmony in Life Scale (HILS; Kjell et al., 2015), and Sat-Chit-Ananda Scale (SCA; Singh et al., 2013). All three scales assess well-being in terms of an inner experience as focused in Eastern cultures. The scales were administered to 474 Indian adults aged 18 to 50 years (M Age=25.68, 6'    2YHUDOO ¿QGLQJV FRQ¿UPHG WKH RULJLQDO IDFWRU VWUXFWXUHV DQG UHYHDOHG DFFHSWDEOH psychometric properties for Hindi versions of all three scales. Further, these scales were found to EHVLJQL¿FDQWO\SRVLWLYHO\FRUUHODWHGZLWKHDFKRWKHU7KLVVWXG\KHOSVWREULGJHWKHJDSEHWZHHQ theoretical knowledge and empirical investigation of Eastern concepts of well-being. Key Words: Peace of Mind, Harmony in Life, Sat-Chit-Ananda, Psychometrics, Revalidation INTRODUCTION value different positive feelings (Lee, Lin, Huang, & Well-being is a multi- dimensional concept, one Fredrickson, 2013). Predominant focus has been on that subsumes physiological, psychological, social as Western models of well-being, with relatively less work well as spiritual aspects (Lyubomirsky et al., 2005; in the domain of Eastern cultures. There is a need for McDowell, 2010). Various models describing well-being expanding the discourse beyond Europe and America have emanated from Western literature. According to and taking into account diverse cultural nuances in Younes (2011), the ‘psychological tradition’ emphasises the study of happiness (Banavathy & Choudry, 2014). the area of subjective well-being – an evaluation of Literature suggests that Eastern cultures lay greater one’s life including cognitive satisfaction and affective emphasis on concepts like harmony, peace of mind, evaluations. Furthermore, the model of well-being and inner well-being (Laungani, 2006; Lee et al., is comprised of hedonic or emotional well-being as 2013) which have been subjected to limited empirical well as functional well-being. Functional well-being investigation. The present study deals with three such further consists of psychological well-being and social concepts of well-being and scales to assess them, well-being. Ryff (1989) put forth a six-factor model of namely harmony in life, peace of mind and Sat-Chit- psychological well-being and a model of social well- Ananda. These are described ahead. being was posited by Keyes (1998, 2005), and Keyes ‘Harmony in Life’: Concept and Assessment: and Shapiro (2004). More recently, Seligman (2011) The word ‘harmony’ has its genesis in proposed the PERMA model describing psychological WKH FRQWH[W RI PXVLF DQG KDV EHHQ GH¿QHG DV µD ZHOOEHLQJDORQJWKH¿YHGRPDLQVRISRVLWLYHHPRWLRQV pleasing combination or arrangement of different (P), engagement (E), relationships (R), meaning (M), things’ (‘Harmony’). In the words of Li (2006), and accomplishment (A). ‘philosophically, harmony presupposes the existence While these models capture the essence of well- of different things and implies a certain favourable being in diverse and comprehensive ways, it may be relationship among them’. Thus, harmony erroneous to ignore cultural differences and assume HVVHQWLDOO\ FRQYH\V D VHQVH RI EDODQFH ÀH[LELOLW\ universal applicability of these models. In fact, culture and a holistic view of well-being that encompasses and context may mould the subjective perceptions mutual relations (Li 2008a; 2008b). Harmony is an of happiness and consequently impact people’s important concept in Eastern philosophy, albeit one experience of well-being. There exists evidence that that has been subjected to limited empirical study in SHRSOH LQÀXHQFHG E\ (DVWHUQ DQG :HVWHUQ FXOWXUHV the area of psychology (Kjell, et al., 2015). Moreover,

1. Professor, Deptt. of Humanities and Social Sciences, IIT Delhi *Dr Kamlesh Singh, Email:[email protected];[email protected]

58 Kamlesh Singh et al...... / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

Kjell (2011) noted that traditional measures of well-being. Further, the scale has been validated in well-being such as the Satisfaction with Life Scale cross-cultural settings like European American and 'LHQHU (PPRQV /DUVHQ  *ULI¿Q   DUH Taiwanese culture. limited in terms of their attention only to self-centred expectations with regard to cognitive well-being. Sat-Chit-Ananda: Concept and Assessment: The Indian notion of well-being encompasses With a view to overcome this limitation, Kjell the bio-physical, socio-psychological as well as et al. (2015) put forth the Harmony in Life Scale (HILS) which is focused on psychological balance spiritual realms. In this context, the term Sat-Chit- Ananda with its origin in Sanskrit may be understood DQG ÀH[LELOLW\ LQ OLIH +,/6 LV D XQLIDFWRU LWHP instrument which has been found to be reliable, as the foundation of this holistic approach to well- valid and contributory to a more comprehensive being. Ancient texts suggest that humans seek assessment of well-being (Kjell et al., 2015). Kjell their inner source of happiness or satchidanand and associates further backed HILS by examining (Srivastava & Misra, 2011). According to Campbell its strong positive correlations with other well-being (1988), ‘each person can have his own depth, measures and negative correlations with mental experience, and some conviction of being in touch health problems such as stress and anxiety. The with his own sat-chit-ananda, his own being through VFDOH GHPRQVWUDWHG D UHOLDELOLW\ RI Į   DQG WHVW consciousness and bliss’. re-test reliability of .77 (Kjell et al., 2015). These In order to facilitate empirical assessment ¿QGLQJV KDYH EHHQ UHLQIRUFHG E\ RWKHU VWXGLHV DV of this otherwise abstract concept, Singh et al. well ( Fahlgren et al., 2014). In view of the above, (2013) developed the Sat-Chit-Ananda (SCA) scale HILS may be regarded as a valuable measure of the in English. The creation of this tool was aimed cognitive component of well- being. Being a new at bringing a rich indigenous concept into the scale, further research and adaptation across cultures mainstream. The 17-item SCA scale is comprised of is a step forward in establishing the utility of this scale. four sub-factors. These factors are Chit (pertaining ‘Peace of Mind’: Concept and Assessment: to consciousness of one’s thoughts, feelings, speech etc.), Antahshakti (pertaining to inner strength, ,Q VLPSOLVWLF WHUPV µSHDFH RI PLQG¶VLJQL¿HV a mental state that is free from worry. In the realm even in the face of challenges), Sat (dealing with of psychological research, the construct has been truthfulness, goodness and positivity), and Ananda GH¿QHG DV µDQ LQWHUQDO VWDWH RI SHDFHIXOQHVV DQG (bliss), Singh et al., 2013). The scale demonstrated harmony’ (Lee et al., 2013). Describing this construct alpha rel iabilities ranging from 0.64 – 0.76 for the in the context of Chinese culture, Lee et al. (2013) four factors; with the four factor solution accounting posited that peace of mind characterizes an aspect for 53.82% variance (Singh et al., 2013). Following of affective well-being encompassing states of mind initial test development, this scale has also been such as calmness and serenity. revalidated and its psychometric properties Drawing on the premise that mainstream work UHDI¿UPHGLQWKH,QGLDQFRQWH[W$WWKLVWLPHVFDOH on affective well-being has been dominantly focused reliabilities ranged from 0.66 to 0.84, with the four- on hedonic pleasure, without due consideration factor solution accounting for 58.6% variance (Singh to affect as valued in Chinese and other Eastern et al., under review) . cultures, Lee et al. (2013) developed the Peace of Relevance of the Study: Mind scale (PoM). This 7-item self-report measure As explained in the introduction, there has been has demonstrated good reliability and validity limited work to bridge the gap between theoretical for assessing affective well-being. The item–total knowledge and empirical assessment in the context correlations ranged from .76 to .85, average item–total of inner well-being. Moreover, existing research FRUUHODWLRQZDV7KHDOSKDUHOLDELOLW\FRHI¿FLHQW which has largely emanated from the Western culture RI WKH VFDOH ZDV Į  $ VLQJOH IDFWRU VROXWLRQ has used English language as a dominant medium. accounting for 63.58% variance was obtained (Lee This further accounts for paucity of literature dealing HWDO 3R0VFDOHKDVDOVRVKRZQVLJQL¿FDQW with psychometrically valid tools  ¿W IRU XVH ZLWK correlations with positive and negative indicators of Indian people. Since the present study was set in the

59 Kamlesh Singh et al...... / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

Indian context where nearly 41% population is Hindi &URQEDFK¶VĮ KDVEHHQUHSRUWHGIRUWKLVVFDOH speaking (Census, 2001), it was considered appropriate (Singh et al., 2013). to assess the psychometric properties of Hindi translated versions of the selected scales. To the best Procedure: of our knowledge, these scales are fairly unexplored 3UHSDUDWLRQIRUWKH6WXG\ in Indian literature. The present study investigated the At the outset, the original English scales were psychometric properties of Hindi versions of HILS translated into Hindi by a bilingual expert working (Kjell et al., 2015), PoM scale (Lee et al., 2013), and in the area of psychological assessment. The Hindi SCA scale (Singh, et.al. 2013) with a two-fold purpose translations of the three scales were then evaluated of expanding scholarship about (a) psychometrically by the authors to check for adequacy of translation. valid empirical tools to assess internal well-being in 0RGL¿FDWLRQV ZHUH PDGH ZKHUHYHU WKH +LQGL general, and (b) wider psychometric assessment of translations were not found to adequately capture the selected scales in particular. Additionally, since all the intended meaning. Further, a bilingual expert three constructs are highly correlated with each other, independently back translated these scales from it was hypothesized that the selected scales would be Hindi to English. The back translations were again positively correlated with each other. reviewed by the authors and matched to the original scales. At this stage, most items were found to aptly METHODOLOGY represent the content of the original English scales. Participants: 7KH¿QDOL]HGVFDOHVZHUHXVHGIRUGDWDFROOHFWLRQ Four hundred and seventy four adults (Age range = 18 to 50 years, M Age = 25.68 years and Data Collection and Analysis: SD = 8.10)participated in this study. All participants All potential participants were individually were recruited from urban and semi-urban locations approached, either online or in person. Voluntary in North India. Of them, 53% were males and 47% participation was sought and informed consent was females. Majority of the participants (83%) were taken. Each participant was provided the questionnaire unmarried. All participants were well-versed with booklet containing demographic information schedule, Hindi. consent form and the above mentioned scales. Only For part of this study, the sample was randomly WKRVHSDUWLFLSDQWVZKRUHWXUQHGFRPSOHWHO\¿OOHGXS divided into two parts for the purpose of exploratory questionnaires were included in the study. DQG FRQ¿UPDWRU\ IDFWRU DQDO\VLV UHVSHFWLYHO\ It is noteworthy that the original English Details of each resultant sub-sample are provided version of the SCA scale has been previously subsequently in the paper. H[SORUHGDVZHOODVFRQ¿UPHGLQWKH,QGLDQVHWWLQJ (Singh et. al, 2013). However, the other two scales, Measures Used : i.e. HILS and PoM were previously unexplored Harmony in Life Scale (HILS; Kjell et al. 2015). among Indian participants. Consequently, their It is a 5 item self-report scale scored on a 7 point Likert IDFWRUVROXWLRQZDV¿UVWH[SORUHGDQGWKHQFRQ¿UPHG scale ranging from 1 (strongly disagree) to 7 (strongly in this study. For this purpose, the study sample was agree). The factor loadings of the items ranged from randomly sub-divided into 1/3rd for exploratory WRDQGWKH&URQEDFK¶VĮ IRUWKHRULJLQDO IDFWRU DQDO\VLV ()$  DQG UG IRU FRQ¿UPDWRU\ English version of the scale (Kjell et al., 2015). factor analysis (CFA; Guadagnoli &Velicer,1988; Peace of Mind Scale (PoM; Lee et al., 2013): Mac Callum, Brown & Sugawara, 1996). Thus, data The scale contains 7 items rated on a 5-point Likert of 158 participants (M Age = 28.27 years, SD = scale ranging from 1 (not at all) to 5 (all the time). 8.58)were used for EFA and 316 participants’data /HHHWDOUHSRUWHGĮ IRUWKHRULJLQDOYHUVLRQ (M Age = 24.40 years, SD = 7.54) for CFA. of the scale. RESULTS Sat-Chit-Ananda Scale (SCA; Singh et al., 1. HILS: 2013): This is a 17-item scale comprising four factors, namely Sat, Chit, Ananda and Antahshakti. a) Psychometric Properties :

60 Kamlesh Singh et al...... / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

The mean of the HILS items ranged from 4.71 Fig. 1:Path Diagram for CFA of HILS to 5.70 on 7- point Likert scale. Skewness (-1.08 to -0.45) and kurtosis (-0.76 to 0.53) were found to be within the acceptable range (skewness < 2 and kurtosis < 7; Curran, West & Finch, 1996). Further, alpha if item deleted values of the items ranged from 0.83 to 0.87 and the corrected item total correlation range from 0.59 to 0.75 which is also acceptable. b)  ([SORUDWRU\ DQG &RQ¿UPDWRU\ )DFWRU Analysis : KMO (0.83) was found to be higher than the recommended cut-off point of 0.60 (Kaiser, 2. PoM Scale 1974) and Bartlett's test of sphericity was a) Psychometric Properties: VLJQL¿FDQW S  )DFWRUORDGLQJVIRU¿YH For this scale,mean of the items ranged items of the scale ranged from 0.75 to 0.90. IURP  WR  RQ ¿YH SRLQW /LNHUW VFDOH Factor analysis for more than 1 Eigen value Skewness ranged between -0.03 to -0.38 and (3.59) yielded a one factor solution which kurtosis ranged from -0.64 to -0.80. The item accounted for 71.92% of variance. Exploratory analysis revealed that all the items showed factor solution replicated its original model. acceptable corrected item-total correlation Further, CFA via AMOS 24 using standardized (range r =0.61 to 0.68) except two items (item estimates on the data for HILS yielded values ,WLVGLI¿FXOWIRUPHWRIHHOVHWWOHG´DQGLWHP of x2/ (d.f.) = 2.91, RMSEA= 0.07, CFI = 7- “I feel anxious and uneasy in my mind"). The 0.98, GFI = 0.98, and AGFI = 0.94. All these corrected item total correlation for item 5 and 7 indices were found to be as per the proposed was quite low (r= -0.11 and 0.01 respectively). benchmarks as shown in Table 1. Corrected item total correlation supported the deletion of these two items. Thus these two Table 1: Results of CFA along with Norm Values items were dropped from further analyses. of Reported Indices: E  ([SORUDWRU\ DQG &RQ¿UPDWRU\ )DFWRU Measures Acceptable HILS PoM SCA Analysis: of Goodness Level of Fit (n=316) (n= 316) (n=474) The KMO for this scale was 0.87, which is higher than the recommended cut-off point x2 (2/(d. f.) <5 (Geuens & Pel 2.91 6.54 2.44 Smacker, 2002) ZLWK VLJQL¿FDQW %DUWOHWW V WHVW RI VSKHULFLW\ S  )DFWRUORDGLQJVIRU¿YHLWHPVRIWKH RMSEA <0.10 (Mac Calum 0.07 0.13 0.05 scale ranged from 0.87 to 0.94. Factor analysis et al., 1996) for more than 1 Eigen value (4.03) yielded CFI —Ġ%Q 0.98 0.96 0.95 a one factor solution which accounted for Bentler, 1999) 80.66% of variance. Thus, the factor analysis GFI > 0.90 (Tabachnick 0.98 0.96 0.93 was considered appropriate. & Fidell, 2007) As represented in Table 1, CFA using AMOS AGFI > 0.90 (Tabachnick 0.94 0.87 0.91 24 with standardized estimates command revealed & Fidell, 2007) outcomes of x2/ (d.f.)=6.54, RMSEA= 0.13, CFI= Note. RMSEA = Root Mean Squared Approximation 0.96, GFI=0.96, and AGFI=0.87 for this scale. These of error; NNFI = Non-Normed Fit Index; GFI obtained values met the proposed benchmarks in =Goodness of Fit Index; CFI = Comparative Fit case of CFI and GFI, but were somewhat higher in Index; X2/df = Ratio of Chi-square to Degrees case of the RMSEA, ratio of x2/ (d.f.) and lower in of Freedom. AGFI. Thus, on the whole CFA results indicate a

61 Kamlesh Singh et al...... / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

PRGHUDWHPRGHO¿WIRUWKLVVFDOH  $VVKRZQLQ7DEOHKLJKO\VLJQL¿FDQWSRVLWLYH correlations were observed among all the three VFDOHV3HDFHRIPLQGZDVIRXQGWREHVLJQL¿FDQWO\ correlated with harmony in life as well as with Sat- Chit-Ananda (both composite as well its sub-factors). 6LPLODUO\KDUPRQ\LQOLIHDOVRVKRZHGDVLJQL¿FDQW positive correlation with Sat-Chit-Ananda and its constituents. Further, the sub-factors of Sat-Chit- Ananda were found to be highly correlated with each other and also with the overall factor. Thus, results approved the proposed hypothesis. Table 2: Correlation Matrix between PoM, HILS and Fig. 2: Path Diagram for CFA of PoM Scale SCA Scale (and its sub-factors)   6&$ 6FDOH &RQ¿UPDWRU\ )DFWRU $QDO\VLV RI 1 2 3 4 5 6 7 SCA Scale: PoM 0.78 Since the factor solution for SCA scale has HILS 0.56** 0.90 been previously explored (Singh et.al., 2013) as SCA 0.39** 0.57** 0.90 ZHOO DV FRQ¿UPHG LQ ,QGLD RQ (QJOLVK VSHDNLQJ TOTAL population (Singh et.al, under review), the present CHIT 0.30** 0.57** 0.82** 0.84 VWXG\ RQO\ FRQ¿UPHG WKH IDFWRU VWUXFWXUH RI WKH 5 ANTA 0.27** 0.48** 0.87** 0.70** 0.80 Hindi version of this scale on 474 participants. As SHAKTI shown in Table-1, the CFA using AMOS–24 with SAT 0.29** 0.43** 0.86** 0.56** 0.63** 0.82 standardized estimates command yielded results ANAND 0.44** 0.34** 0.63** 0.32** 0.39** 0.48** 0.66 of x2/(d.f.) = 2.44, RMSEA= 0.05, CFI = 0.95, NRWH 1    &RUUHODWLRQ LV VLJQL¿FDQW DW WKH  GFI = 0.93, and AGFI = 0.91. Thus, Hindi translated level (1-tailed). Numbers in italics along the 6&$VFDOHFRQ¿UPHGLWVIDFWRUVROXWLRQ GLDJRQDOUHSUHVHQWWKH&URQEDFK¶VĮ Correlation among the Scales: DISCUSSION The present study is an incipient step in empirical investigation of well-being as explored in Eastern cultures. The study dealt with psychometric assessment of three self-report scales meant to assess participants’ well-being through the concepts of harmony, peace of mind and sat-chit- ananda respectively. This is a step forward in the realm of comprehensive assessment of well-being among Eastern cultures, instead of sole reliance on Western models. Further, the study looked at Hindi translations of the three selected scales, so as to make them more culturally relevant for Indian participants. This study successfully revalidated the Hindi translations of three contemporary scales –HILS (Lee et al., 2013), PoM scale (Kjell et al., 2015), and SCA scale (Singh et al., 2013) among Indian SDUWLFLSDQWV7KLVZDVSHUKDSVWKH¿UVWSV\FKRPHWULF assessment of HILS and PoM in India; while the Fig. 3: Path Diagram for CFA of SCA Scale English version of the recently developed SCA scale has been previously used with Indian participants.

62 Kamlesh Singh et al. / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

For HILS, good psychometric properties were positive affect, low negative affect). Similarly, obtained. The factor loadings ranged from 0.73 to Fahlgren et al. (2015) reported a positive association 0.86 (original scale) and from 0.75 to 0.90 (Hindi between harmony in life and personality factors such translated version). Further, item-total correlations as maturity, responsibility, purposefulness, optimism ranged from 0.65 to 0.80 (original scale) and from and so on. It is noteworthy that most of these WR +LQGLWUDQVODWHGYHUVLRQ )RUWKH¿YH personality dimensions are also consonant with the LWHPV WKH &URQEDFK¶V DOSKD ZDV Į   RULJLQDO concept of sat-chit-ananda. Further, Xu, Rodriguez, VFDOH DQGĮ  +LQGLWUDQVODWHGYHUVLRQ )DFWRU Zhang and Liu (2015) reported positive association analysis for more than 1 Eigen value yielded a one between peace of mind and mindfulness. Positive factor solution for both original and Hindi translated correlations between sat-chit-ananda and happiness, version;accounting for 62.64 % variance (original life satisfaction and positive experience have been scale) and 71.92% of variance (Hindi translated previously reported by Singh et al. (under review). version). All these indices were found to be within At a broader level, all three scales used herein may their recommended range. be understood as indicators of internal well-being. As regards the 7-item PoM scale, evaluation CONCLUSION and FUTURE DIRECTION revealed poor psychometric properties for two items (item 5 and item 7). Consequently, rest of the analyses In conclusion, the present study is a step were performed on a 5 item Hindi translated version forward in empirical assessment of well-being of the PoM scale. The factor loading was above 0.30 through the lens of Eastern cultures. Future research (original scale) and above 0.87 (Hindi translated using mixed methodology could look at corroborating version); item-total correlation ranged from 0.76 to TXDQWLWDWLYH ¿QGLQJV ZLWK TXDOLWDWLYH DVVHVVPHQW 0.85 (original scale) and from 0.61 to 0.68 (Hindi of these constructs among participants. While sole reliance on self-report measures may be seen as a WUDQVODWHG YHUVLRQ 7KH &URQEDFK¶V DOSKD ZDV Į  potential limitation, it is pertinent to remember  RULJLQDOVFDOH DQGĮ  +LQGLWUDQVODWHG version). Factor analysis for more than 1 Eigen value that all the concepts covered in the purview of the yielded a one factor solution for both original and present study are in fact very subjective and perhaps Hindi translated version, which accounted for 63.58 best assessed by the participants themselves. Further % variance (original scale) and 80.66 % variance research involving these and other such concepts (Hindi translated version). Even after rejecting 2 would work towards more holistic knowledge and items initially due to poor psychometric properties, assessment of well-being while the validation of remaining 5 items have excellent results for the Hindi translated scales would contribute to future scale. Thus, 5 items PoM scale can be used for research on Hindi speaking population. further studies. Acknowledgement: We would like to extend The CFA of the Hindi translation of SCA our thanks to Arpan Das and Gourav Kumar Saini of Indian Institute of Technology Delhi, who were VFDOH UHYHDOHG DQ DFFHSWDEOH PRGHO ¿W DV ZDV WKH case with the English version of SCA (Singh et al., involved at the initial stage of the project. XQGHUUHYLHZ 7KLVIXUWKHUUHLQIRUFHVWKHHI¿FDF\RI REFERENCES this scale in both English and Hindi among Indian Banavathy, V. K., & Choudry, A. (2014). Understanding Happiness: A population. Vedantic Perspective. Psychological Studies, 59 (2), 141 152. A correlation analysis among these three scales Campbell, J. (1988). The Power of Myth . New York: Double day GHPRQVWUDWHGVLJQL¿FDQWSRVLWLYHFRUUHODWLRQVDPRQJ Census of India (2001). Language-2001 Census, Retrieved April 9, these constructs. The observed pattern of correlation 2015, from Census of India online via access: http://www. censusindia.gov.in/Ad_Campaign/press/Data Highlights.pdf was in accordance with the theoretical understanding Curran, P. J., West, S. G, & Finch, J. F. (1996). The robustness of of the conceptual models of the harmony in life, WHVW VWDWLVWLFV WR QRQ QRUPDOLW\ DQG VSHFL¿FDWLRQ HUURU LQ peace of mind and sat-chit-ananda. These results are FRQ¿UPDWRU\IDFWRUDQDO\VLV Psychological Methods, 1, 16-29. DOVRDOLJQHGZLWKSUHYLRXVUHVHDUFK¿QGLQJV*DUFLD 'DPEUXQ0 5LFDUG0  6HOIFHQWHUHGQHVVDQGVHOÀHVVQHVV et al. (2014) reported harmony in life to be positively A theory of self-based psychological functioning and its DVVRFLDWHGZLWKVHOIIXO¿OOLQJDIIHFWLYHSUR¿OH KLJK consequences for happiness. Review of General Psychology,

63 Kamlesh Singh et al. / Psychometric Properties of Hindi Translated Version of Peace of Mind, Harmony in Life ......

15 (2), 138- 157. Laungani, P. D. (2006). Understanding Cross-Cultural Psychology: De Pelsmacker, P., Geuens, M.,& Anckaert, P. (2002). Media context Eastern and Western Perspectives. Sage South Asia. and advertising effectiveness: the role of context appreciation Lee, Y. C., Lin, Y. C., Huang, C. L., &Fredrickson, B. L. (2013). The and context–ad similarity. Journal of Advertising, 31 (3), 25– construct and measurement of peace of mind. Journal of 37. Happiness Studies , 14 (2), 571-590. 'LHQHU('(PPRQV5$/DUVHQ5- *ULI¿Q6  7KH Li, C. (2006). The Confucian ideal of harmony. Philosophy East and Satisfaction with Life Scale. Journal of Personality Assessment, West, 56(4), 583–603. doi:10.1353/ pew.2006.0055 49 (1), 71-75. Li, C. (2008a). The ideal of harmony in ancient Chinese and Greek Fahlgren, E., Nima, A. A., Archer, T., & Garcia, D. (2015). Person- philosophy, Dao, 7 (1), 81–98. centred osteopathic practice: patients’ personality (body, mind, Li, C. (2008b). The philosophy of harmony in classical Confucianism. and soul) and health (ill-being and well-being). Peer J, 3, Philosophy Compass, 3 (3), 13 e1349. https://doi.org/10.7717/peerj.1349 Lyubomirsky, S., & Sheldon, K. M.(2005). Pursuing Happiness: *DEOH6/ +DLGW-  :KDW DQGZK\ LVSRVLWLYHSV\FKRORJ\" The Architecture of Sustainable Change. Review of General Review of General Psychology, 9 (2), 103-110. Psychology , 9 (2),111-131. *DUFLD'$O1LPD$ .MHOO21  7KHDIIHFWLYHSUR¿OHV MacCallum, R. C., Brown, M. W., and Sugawara, H. M. (1996). In MM psychological well-being, and harmony: environmental Byrne & CM MacNeil (2003). Line Managers: Facilitators of mastery and self-acceptance predict the sense of a harmonious Knowledge Sharing in Teams. Employee Relations , 25 (3), life. PeerJ, 2, e259.https:// doi: 10.7717/peerj.259. 294-307. Geuens, M., & De Pelsmacker, P. (2002). Developing a short affect McDowell, I. (2010). Measures of self-perceived well-being. Journal of intensity scale. Psychological Reports, 91(2), 657-670. Psychosomatic Research, 69, 69–79. Guadagnoli, E., & Velicer, W. F. (1988). Relation to sample size to the Pandey, S. (2011). Positive psychology: Blending strengths of western, stability of component patterns. Psychological Bulletin, 103 eastern and other indigenous psychologies. In 1st International (2), 265-275 Conference on “Emerging Paradigms in Business & Social +X /7  %HQWOHU 3 0   &XWRII FULWHULD IRU ¿W LQGH[HV LQ Sciences” (EPBSS-2011), organized by Middlesex University, covariance structure analysis: Conventional criteria versus new Dubai. alternatives. Structural equation modeling: A Multidisciplinary Ryan, R. M.,& Deci, E. L. (2001). On happiness and human potentials: Journal, 6 (1), 1-55. A review of research on hedonic and eudaimonic well-being. Kabat-Zinn, J. (2004). Bringing mindfulness to medicine: an interview Annual Review of Psychology , 52(1), 141-166. with Jon Kabat-Zinn, PhD. Interview by Karolyn Gazella. 5\II & '   +DSSLQHVV ,V (YHU\WKLQJ RU ,V ,W" ([SORUDWLRQV Advances in Mind-Body Medicine, 21 (2), 22-27. on the Meaning of Psychological Well-Being. Journal of Kaiser, H. F. (1974). An index of factorial simplicity. Psychometrika, Personality and Social Psychology, 57 (6),1069-1081. 39 (1), 31-36. Seligman, M. E. (2011). Flourish: A Visionary New Understanding of Keyes, C. L. M. (1998). Social well-being. Social Psychology Happiness and Well-Being (1st Free Press hardcover ed.). New Quarterly ,61 (2),121-140.http://dx.doi.org/10.2307/ 2787065 York, NY: Free Press. Keyes, C. L. M., & Shapiro, A. (2004). “Social Well-Being in the Seligman, M. E., & Csikszentmihalyi, M. (2014). Positive Psychology: United States: A Descriptive Epidemiology,” pp. 350-372. An Introduction (pp. 279-298). Springer Netherlands. In How Healthy Are We? A National Study of Well-Being at Srivastava, A. K., & Misra, G. (2011) In A. K. Dalal & G. Misra (Eds.), Midlife , Chicago: University of Chicago Press. New Directions in Health Psychology (pp. 109–131). New .H\HV &/ 0   0HQWDO ,OOQHVV DQGRU 0HQWDO +HDOWK" Delhi: Sage. Investigating Axioms of the Complete State Model of Health. Singh, K., Khanna, P., Khosla, M., Rapelly, M. & Soni, A., (under Journal of Consulting and Clinical Psychology, 73 (3), 539- review). Revalidation of the Sat-Chit-Ananda Scale. Journal of 548. Religion and Health. Keyes, C. L. M. (1998). Social well-being. Social Psychology Singh,K.,Khari, C., Amonkar, R.S., Arya, N. K., & Kasav, S. (2013). Quarterly,61 (2), 121-140.http://dx.doi.org/10.2307/2787065 Development and Validation of a New Scale: Sat-Chit- Kjell, O.N.E. (2011). Sustainable well-being: A potential synergy Ananda Scale. International Journal on Vedic Foundations of between sustainability and well-being research. Review of Management, 1 (2), 102-122. General Psychology, 15 (3), 255-266. Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics . Kjell, O.N.E., Daukantaitè, D., Hefferon, K.,& Sikström, S. (2015). Boston: Pearson/Allyn & Bacon. The harmony in life scale complements the satisfaction with Younes, M.S.(2011). Positive Mental Health, Subjective Vitality and life scale: expanding the conceptualization of the cognitive Satisfaction with Life for French Physical Education Students. component of subjective well-being. Social Indicators World Journal of Sport Sciences 4 (2), 90-97. Research , 126 (2), 893-919. Xu, W., Rodriguez, M. A., Zhang, Q., & Liu, X. (2015). The Mediating Kumar, S. K. (2006). Health and Well Being in Indian tradition. Effect of Self-Acceptance in the Relationship between Psychological Studies , 51 (2), 105-112. Mindfulness and Peace of Mind. Mindfulness , 6 (4), 797-802.

64 Indian Journal of Clinical Psychology Copyright, 2016, Indian Association of 2016, Vol. 43, No. 1, 65-72 Clinical Psychologists (ISSN 0303-2582) Research Article (I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU Parents of Children with Mental Retardation Gannavaram Srikrishna 1 S.R. Joshi 2 and B. Surya Prakasam 3

ABSTRACT ,QWURGXFWLRQ5HDULQJDFKLOGZLWKGLVDELOLW\LVDOLIHORQJDFWLYLW\3DUHQWVXQGHUJRWKURXJKYHU\GLI¿FXOW situations as they are forced to readdress their priorities; compromise their personal space; and in number of cases rather unprepared. The costs are not only economical but also psychological and many parents undergo depression as a result. Parents having a child with mental retardation experience a variety of stressors and stress reactions related to the child’s disability. The feeling of depression is common, particularly when realization of WKHFKLOG¶VUHWDUGDWLRQLVUHFHQW$LP7KHDLPRIWKHVWXG\ZDVWRLQYHVWLJDWHWKHHI¿FDF\RIFRJQLWLYHEHKDYLRU therapy in depression for parents of children with mental retardation. Method: It was pre- post comparative experimental design with control group. Experimental and control groups consisted of 24 individual in each group with depression, diagnosed as per ICD-10. Baseline assessment was carried out with the tool of Beck Depression Inventory. The experimental group received cognitive behavior therapy. They received 12 sessions for the period of 3 months. Therapy was conducted in one session per a week with the duration of 1 hour 30 min. Assessment was repeated after 3 months in the last session of therapy program to investigate effectiveness of cognitive behavior therapy. The data were analysed by using appropriate statistical measures. Results: CBT was considerably more effective in depression for parents of children with mental retardation. Key Words: Cognitive Behaviour Therapy, Depression, Parents, Mental Retardation, BDI INTRODUCTION A child with developmental delays poses there is the perennial question of direction of effect multiple parenting challenges. While families ZKHUHDVVSHFL¿FSUREOHPEHKDYLRUDUHSDUWRIWKH generally develop positive ways of coping with phenotype in some genetic disorders (e.g., eating these, and demonstrate considerable resilience, problems in Prader-Willi syndrome and self-inury but in countless studies parents have reported in Lesch-Nyan syndrome; Dykens 2000), and heightened stress, especially in domains related thus, are not likely to be caused by family factors to child rearing. Two issues concerning parenting for most children and most problem behaviours, stress are of particular interest. First, although it is likely that such factors do matter. Parental stress has traditionally been viewed as a result of factors that may be relevant to the emergence, or developmental delays or of the increased demands exacerbation, of behavior problems (Crnic et al., resulting from the child’s support needs, the 1983) since a highly stressed parent may engage LQÀXHQFH RI EHKDYLRU SUREOHPV PD\ KDYH EHHQ in parenting behavior which are less growth- underestimated. In families where a child has promoting. Research studies have found three an intellectual disability, parenting stress levels possible interactions of child behavior problems appears to be highest in the childhood years, and parents’ perception of negative impact or stress: diminishing as the individual ages (Blacher & (a) behavior problems predict subsequent increased %DNHU $UHODWHG¿QGLQJLVWKDWVWUHVVOHYHOV parenting stress; (b) parenting stress predicts ÀXFWXDWHDFFRUGLQJWRWKHGHYHORSPHQWDOVWDJHVDQG demands which parents face, with the highest stress subsequent increased behavior problems; or (c) at the onset of adolescence and transition of young both causal explanations apply. adulthood (Wikler 1986; Blacher 2001). Secondly, Research studies explored family functioning

1. Faculty in Rehabilitation Psychology, 2. Consultant Rehabilitation Psychologist, Deptt. of Rehabilitation Psychology, 3. Statistician, National Institute for the Mentally Handicapped, Seunderabad, AP (India). Corresponding Author: Gannavaram Srikrishna, Email: [email protected] Email: [email protected]

65 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ over time, focusing on parent’s reports of positive or depressed. Thus mothers’ usual coping strategies and negative impact of the target child on the family. may unavailable and their levels of stress may rise From the 36-48 month assessment, positive impact DVDUHVXOW+REGHOO  GHPRQVWUDWHGVLJQL¿FDQW scores were moderately stable and negative impact differences in a study between 63mothers/ fathers scores were highly stable for mothers and fathers and 6 single parents and established a relationship alike. The parents of children with and without between chronic sorrow leading to depressive delays did not differ in their appraisal of positive V\PSWRPVDQGFKURQLFVRUURZPLJKWEHVLJQL¿FDQW impact. Negative impact, or stress, scores were barrier to understand their child’s condition with considerably higher for the parents of children in mental retardation. Glidden and Schoolcraft (2003) WKHGHOD\HGJURXSD¿QGLQJWKDWLVFRQVLVWHQWZLWK have done a 11-year follow up of mothers who have a vast literature on families and disability (Kazak, adopted and biological mothers and concluded 1987; Cameron et al., 1991; Baker et al., 1997). that personality variable of neuroticism was the Following families of children with delays from strongest predictor of depression for both adoptive infancy through 10 years of age, Hauser-Cram et al., and birth mothers. Mallow and Bechtel (1999) (2001) found increasing parental stress such that, have investigated adaptation mechanisms and by child age 10, four times as many parents were demonstrated that fathers and mothers of children reporting stress in the clinical range as parents in the with disability differ with mother’s emotions radiate non-disabled standardization sample. At 36-month into chronic sorrow while father’s reactions move assessment, these differences in negative impact towards resignation. Heaman (1995) inquired into were related much more strongly to the child’s coping strategies between mothers and fathers who maladaptive behavior than to cognitive delay (Baker have children with developmental disabilities and et al., 2002). And despite high stability over time in reported that there were fewer differences between both child behavior problems and negative impact, both groups. They were more concerned with the child problem behavior at 36 months and changes in child’s future and reported stress but with poor child problem behaviours over the one-year period coping strategies. Carver et al., (1985) compared were found to be associated with increases in parent cognitive style and depression and found that self- stress. However, it was also the case that parenting blame was derived cognitive bias which in turn stress at 36 months and changes in parenting stress determined attributional style. Frey et al., (1989) over the one-year period were also associated reported parental belief system predicted coping with increases in child behavior problems. Thus, styles; psychological distress and family adjustment. WKHVH ¿QGLQJV DUH FRQVLVWHQW ZLWK WKH QRWLRQ WKDW Trute (1995) argues self-esteem and strong-tie maladaptive child behavior and parenting stress social support resources like spousal relationship have a mutually escalating effect on each other ZHUH VLJQL¿FDQW SUHGLFWRUV RI GHSUHVVLRQ LQ ERWK (Sameroff & Chandler, 1975; Sameroff et al., 1998). mothers and fathers. Seltzer (1995) compared Hastings (2003) studied that mothers and coping strategies of aging mothers of adults with fathers do not differ in their levels of stress and mental illness and mental retardation and found depression, but mothers reported more anxiety that emotion-focused coping predicted maternal than fathers. Statistical analysis revealed that child depression in mothers of adults with mental behavior problems and fathers’ mental health were illness and depressive symptoms were function associated with mothers’ stress. If mothers are also of their child’s behavior problems. Miller et al., taking more responsibility for other aspects of home (1992) found emotion-focused coping was related and family management, then this may explain why to increased psychological distress in mothers of they are additionally affected by their husbands’ disabled children whereas problem-focused coping mental health symptoms. Alternatively, if they relay was associated with decreased distress. Dyson on their husband for social and practical support, (1997) studied 30 pairs of fathers and mothers then this may reduced when he is feeling anxious and found that they displayed disproportionately

66 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ greater level of stress relating to their children than problems. According to Beck’s model, these those of children without disabilities. Rogner & maladaptive cognitions include general beliefs, or Wessels (1994) was interested to know the coping schemes, about the world, the self, and the future, strategies of mothers and fathers of children with JLYLQJ ULVH WR VSHFL¿F DQG DXWRPDWLF WKRXJKWV LQ mentally handicap and found mothers showed more particular situations. The basic model posits that emotional stress, more self-criticism, searched therapeutic strategies to change these maladaptive PRUHIRUVRFLDOVXSSRUWDQGH[SHULHQFHGGLI¿FXOW\ cognitions lead to changes in emotional distress and in process of adaptation. Olsson and Hwang problematic behaviours. Seltzer et al., (2004) done (2001) studied 216 families having children with DPRUHVSHFL¿FVWXG\LQ³DFFRPPRGDWLYHFRSLQJ´ autism/intellectual disability and compared with strategy and compared with well-being in parents families which have children without disabilities who have a child with severe mental health problem assessing Beck Depression Inventory and reported or a child with a developmental disability and with that Mothers of children with mental retardation a control group of parents whose children have no displayed less depression than mothers of children disability and found that the strategy was effective with autism. Making an important contribution for parents who have children with mental health in regard to therapeutic purposes Krauss (1993) problem than with parents who have children with studied similarities and differences in parenting developmental disability. Murphy et al., (1995), stress between 121 mothers and fathers of children Hensley et al., (2004); Fava et al., (2004) have with disabilities and reported that fathers related investigated with Cognitive Behavioural Therapy stress to their child’s temperament and child- and psychopharmacological therapy and proved the parent relationship; whereas mothers related stress robustness of CBT. from personal consequence of parenting. Fathers were more sensitive to the effects of the family METHODOLOGY environment, whereas mothers were more affected Aim of the study: The aim of the study was by their personal support networks. to investigate the cognitive behavior therapy in 1L[RQ  6LQJHU   UHSRUWHG VLJQL¿FDQW depression for parents of children with mental reduction in measures of guilt, negative automatic retardation. thoughts, internal negative attributions and depression in Group cognitive behavioural Sample: treatment for excessive parental self blame and The sample was selected based on a set guilt in 34 mothers of children with disabilities. of criteria from National Institute for Mentally Reinecke et al., (1998) intervened depression and Handicapped general services from Hyderabad. depressive symptoms in 217 subjects through The sample consisted of 24 parents of children &%7 DQG UHVXOWV VXJJHVW WKH HI¿FDF\ RI &%7 LQ with mental retardation for experimental group, treating depressive symptoms and sustenance of and the control group had 24 parents of children therapeutic intervention. Cognitive behavioural with mental retardation. Sample was taken from therapy (CBT) refers to a popular therapeutic the National Institute for Mentally Handicapped, approach that has been applied to a variety of those whose children were diagnosed as moderate problems. Cognitive-behavioural therapy (CBT) mental retardation as per ICD-10. The age range refers to a class of interventions that share the basic of children with moderate mental retardation premise that mental disorders and psychological is between 8 years to 10 years. The age range of distress are maintained by cognitive factors. mothers of mentally retarded children is 25 years The core premise of this treatment approach, as to 35 years. A comprehensive cognitive behaviour pioneered by Beck (1970) and Ellis (1962), holds therapy was carried out to the experimental group that maladaptive cognitions contribute to the and for the control group there was no additional maintenance of emotional distress and behavioural management except the routine follow up with

67 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ regular services. Written consent was taken from the experimental group. Assessment was repeated the parents of children with mental retardation. using BDI, after 3 months in the last session of Inclusion Criteria: therapy program to investigate effectiveness of The parents of the mentally retarded children cognitive behavior therapy for both the groups. having one child without mental retardation, mothers Statistical analysis being home makers with minimum earnings of the Data were analyzed using the statistical family being INR. 10,000/- per month and who package for social sciences (SPSS) version 10. have attended high school to graduation level were Differences between the two conditions were included in the study. calculated by using t-test for equality of means, and Exclusion Criteria: within group pre and post results were compared, by The children with mild and severe mental SDLUHGµW¶WHVWZLWKFRQ¿GHQFHLQWHUYDOV retardation with behavior problems, physical RESULT & DISCUSSION problems and psychiatric problems, mothers with 7KHVWXG\SURSRVHGWRXQGHUVWDQGWKHHI¿FDF\ chronic physical or mental illness, and children with of CBT by comparing with in groups (pre-post) chronic neurological conditions such as cerebral and between groups (Control and Experimental) palsy, epilepsy etc. were excluded from the study. on BDI scores. Mean and Standard Deviations on Tools Used: BDI were computed for both the groups pre and Demographic data sheet designed for post intervention. Dependent sample t-test was used the purpose of this study, Binet-Kamat Test of IRU WHVWLQJ WKH VLJQL¿FDQFH GLIIHUHQFH EHWZHHQ SUH Intelligence and Beck’s Depression Scale (BDI) and post intervention scores. The effect (difference were used for the study. in pre-post BDI scores) was compared between experimental and control groups using independent Procedure: sample t-test. Those children who were diagnosed as Table-1: Mean, S.D, t, is Calculated for Pre and moderate mental retardation based on the ICD-10 Post-Assessment for Experimental and by psychologist and whose parents were willing Control Group on BDI Scores. participate in the study were included and a sample of 100 was randomly selected for the study. Baseline Beck Depression Inventory Scores assessment was done using Beck’s Depression Scale Level of Group Conditions N Mean SD t for the parents of children with mental retardation Sig and selected 48 parents who were diagnosed with Experi- Baseline 24 22.04 5.56 depression criteria as per ICD-10. All the 48 selected 11.28 0.01** mental parents were randomly grouped into experimental Post-inter 24 14.13 3.54 and control with 24 subjects (12 male and 12 female) Baseline 24 22.88 3.43 Control 6.66 0.01** in each group. Pre-post research design was used Post-inter 24 19.96 2.66 WRVWXG\WKHHI¿FDF\RIFRJQLWLYHEHKDYLRUWKHUDS\ ** P<0.01 The experimental group received cognitive behavior TDEOHVKRZWKHVLJQL¿FDQWFKDQJHLQWKHSUH therapy. They received 12 sessions for the period of and post intervention scores on BDI for experimental 3 months. Therapy was conducted in one session per DQG FRQWURO JURXSV ,W LV VLJQL¿FDQW DW  OHYHO a week with the duration of 1 hour 30 min. For the The mean scores of experimental group on pre and control group, there was no additional management post-test are 22.04 and 14.13 respectively. The mean except the routine follow-up and closely monitored scores of control group on pre and post-test are 22.88 consistently in three month time period along with and 19.96 respectively.

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Table-2: Mean, Standard Deviation and t is Statistical analysis was done to understand Calculated for Pre and Post-Assessment WKH HI¿FDF\ RI &%7 RQ VSRQWDQHRXV UHPLVVLRQ E\ for Experimental and Control Group on taking the difference/improvement (pre & post) BDI Scores Based on Gender: on BDI scores in both control and experimental groups. That is the Mean improvement in BDI was Beck Depression Inventory Scores compared between control and experimental groups Sig Gender Group Conditions N Mean SD t ZLWK LQGHSHQGHQW VDPSOH WWHVW ,W LV VLJQL¿FDQW DW Level 0.01 level. The table-3 indicated that the average Experi- Pre-inter 12 20 4.65 improvement in experimental group was 7.91 and 7.72 0.01** mental Post-inter 12 12.92 3.05 in control group was 2.91 which shows that the Male Pre-inter 12 22.67 2.53 VLJQL¿FDQW LPSURYHPHQW ZDV VHHQ LQ H[SHULPHQWDO Control 5.61 0.01** group who have received Cognitive Behaviour Post-inter 12 19.25 2.00 Therapy, when compared to control group. Experi- Pre-inter 12 24.08 5.82 In order to study how gender has contributed 8.37 0.01** mental Post-inter 12 15.33 3.71 in responding to therapy, the above analysis was Female done for males and females separately and tested Pre-inter 12 23.08 4.25 Control 3.89 0.01** the improvement in BDI between experimental and Post-inter 12 20.67 3.11 control groups. ** P<0.01 7DEOH  VKRZV VLJQL¿FDQW FKDQJH LQ WKH SUH Table-4: Mean, Standard Deviation and t is and post intervention scores on BDI for experimental Calculated for Improvement on BDI DQGFRQWUROJURXSVEDVHGRQJHQGHU,WLVVLJQL¿FDQW Scores For Experimental and Control at 0.01 level. The mean scores of experimental group Group Based on Gender. of male on pre and post-intervention are 20 and Beck Depression Inventory Scores 12.92 respectively. The mean scores of control group Level of male on pre and post-intervention are 22.67 and Gender Group N Mean SD t 19.25 respectively. The mean scores of experimental of Sig. group of female on pre and post-intervention are Experimental 12 7.08 3.17 24.08 and 15.33 respectively. The mean scores of Male 3.66 0.01** control group of female on pre and post-intervention Control 12 3.41 2.1 are 23.08 and 20.67 respectively. It indicate that there Experimental 12 8.75 3.62 LVDVLJQL¿FDQWUHGXFWLRQRQ%',VFRUHRISRVWWHVWRQ Female 5.209 0.01** experimental group which suggest that experimental Control 12 2.41 2.15 group showed improvement than control group in ** P<0.01 both gender. Table-4 shows the improvement on BDI scores for experimental group and control group based on Table-3: Mean, Standard Deviation and t is JHQGHU,WLVVLJQL¿FDQWDWOHYHO7KHLPSURYHPHQW Calculated for Improvement on BDI score for male on experimental group is 7.08 and for Scores for Experimental and Control control group is 3.41. The improvement score for Group female on experimental group is 7.08 and for control Beck Depression Inventory Scores group is 3.41. In both the gender it is observed Level WKDW WKH VLJQL¿FDQW LPSURYHPHQW ZDV REVHUYHG LQ Group N Mean SD t of Sig. experimental group than the control group. Experi- 24 7.91 3.43 DISCUSSION AND CONCLUSION Improvement mental 6.04 0.01** From the above analysis, it is evident that Control 24 2.91 2.14 &%7 KDG VLJQL¿FDQW HIIHFW RYHU WKH SHULRG RI WLPH ** P<0.01 in experimental group when compared to control

69 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ group to reduce depression among parents of example, Jorm and colleagues (2008) found CBT to children with mental retardation. When the gender be superior to relaxation techniques at post-treatment. was taken into consideration, females have found Heaman (1995) and Hobdell (2004) emphasized on EHQH¿WHGIURP&%7WKDQPDOH1HYHUWKHOHVVPDOHV therapeutic intervention for developing immunity to KDYH EHQH¿WHG PDQ\ RWKHU IDFWRUV DV RFFXSDWLRQ depression and better coping skills. away from house for more hours than females, peer group, opportunity to pursue interesting goals Further Research Direction: could be complementing to improvement. In this The study recommends CBT was an effective sample females are housewives and all of them intervention in family system. However, variables had two children in their families hence, females like family system, older member with ailments, had less social contacts, more responsibilities and siblings without mental retardation or developmental had to maintain emotional harmony within the delays; low socioeconomic group with no or minimal siblings. Mallow and Bechtel (1999) have reported educational back ground, gender of disabled child that adaptation mechanisms differ between mothers demands further need to study the intervention and fathers of developmentally disabled children; outcomes with CBT. mothers' emotions radiate into chronic sorrow while Acknowledgements: fathers' reactions move toward resignation; patterns Parents who are major contributors for this of grief and sadness reemerge and are most often x study precipitated by a health care crisis in women and Sheetal Pal who worked on this project for comparison with social norms in fathers. Glidden and x sometime Schoolcraft (2003) have observed that personality Shri. T.C.Siva Kumar, Director NIMH, who factors and multiple measures for different outcomes x provided intellectual support. are necessary to study reaction over time. Hobdell (2004) concluded that separate assessments of parents and timely interventions are warranted. REFERENCES Furthermore, the extraneous variable ‘spontaneous Baker, B.L., Kopp, C., & Blacher, J. (1997). Parenting remission’ was considerably neutralized by a child with mental retardation. In N. W. Bray dissecting the difference and establishing the (Ed.), International review of research in mental HI¿FDF\ RI &%7 RYHU D SHULRG RI WLPH 7KLV ZDV retardation (Volume 21, p. 1-45). Orlando, FL: done by studying control and experimental groups. Academic Press. CBT for depression was more effective than control Baker, B.L., Blacher, J., Crnic, K. & Edelbrock, C. conditions such as no treatment, with a medium (2002). Behavior problems and parenting stress effect size (van Straten, Geraedts, Verdonck-de in families of three year old children with and Leeuw, Andersson, & Cuijpers, 2010; Beltman, without developmental delays. American Journal Oude Voshaar, & Speckens, 2010). However, studies on Mental Retardation , 107, 433-444. that compared CBT to other active treatments, such Blacher, J. (2001). The transition to adulthood: Mental as psychodynamic treatment, problem-solving Retardation, families and culture. American therapy, and interpersonal psychotherapy, found Journal on Mental Retardation, 106, 173-188. PL[HG UHVXOWV 6SHFL¿FDOO\ PHWDDQDO\VHV IRXQG Blacher, J. & Baker, B.L. (2002). Best of AAMR; Families CBT to be equally effective in comparison to other and Mental Retardation, A collection of Notable psychological treatments (Beltman, Oude Voshaar, AAMR Journal Articles aAcross 20th Century, & Speckens, 2010; Cuijpers, Smit, Bohlmeijer, American Association on Mental Retardation, Washington D.C. Hollon, & Andersson, 2010; Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011). Other studies, however, Beck, A.T. (1970). Cognitive therapy: Nature and relation found favourable results for CBT (Di Giulio, 2010; to behavior therapy. Behavior Therapy, 1, 184–200. Jorm, Morgan, & Hetrick, 2008; Tolin, 2010). For Beltman, M.W., Oude, V. R.C., & Speckens, A.E. (2010).

70 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ

Cognitive-behavioural therapy for depression in Journal for Mental Retardation , 94, 240-9. people with a somatic disease: meta-analysis of Glidden, L.M., & Schoolcraft, S.A. (2003). Depression: randomised controlled trials. The British Journal Its trajectory and correlates in mothers rearing of Psychiatry, 197, 11–19. children with intellectual disability. Journal of Carver, C.S., Ganellen, R.J., & Behar-Mitrani, V. (1985). Intellectual Disabilities Research, 47, 250-63. Depression and Cognitive style: comparisons Hastings, R.P. (2003). Child behaviour problems and between measures. Journal of Personality and partner mental health as correlates of stress in Social Psychology, 49, 722-8. mothers and fathers of children with autism. Cameron, K. S., Freeman, S.J., & Mishra, A.K. (1991). Journal of Intellectual Disabilities Research, 47, “Best Practices in White Collar Downsizing: 231-7. Managing Contradictions”. Academy of +DXVHU&UDP 3 :DU¿HOG 0 ( 6KRQNRII - 3  Management Executive , 5(3), 57-73. Krauss, M. W. (2001). Children with disabilities: Crnic, K.A., Friedrich, W.N., & Greenberg, M.T. (1983). A longitudinal study of child development and Adaptation of families with mentally retarded parent well-being. Society for Research in Child children: A model of stress, coping, and family Development, 66 (206), 1-131. ecology. $PHULFDQ -RXUQDO RI 0HQWDO 'H¿FLHQF\ , Heaman, D. J. (1995). Perceived stressors and coping 88, 125-138. strategies of parents who have children with Cuijpers, P., Smit, F., Bohlmeijer, E., Hollon, S.D., & developmental disabilities: a comparison of $QGHUVVRQ *   (I¿FDF\ RI FRJQLWLYH mothers with fathers. Journal of Pediatric Nursing , behavioural therapy and other psychological 10, 311-20. treatments for adult depression: meta-analytic Hensley, P.L., Nadiga, D., & Uhlenhuth, E.H. (2004). study of publication bias. The British Journal of Long-term effectiveness of cognitive therapy in Psychiatry , 196, 173–178. major depressive disorder. Depression and Anxiety , Di Giulio, G. (2010). Therapist, Client Factors, and 20, 1-7. (I¿FDF\   LQ &RJQLWLYH %HKDYLRXUDO 7KHUDS\ Hobdell, E. (2004). Chronic sorrow and depression A Meta-Analytic Exploration of Factors that in parents of children with neural tube defects. Contribute to Positive Outcome . Ottawa: Journal of Neuroscience and Nursing , 36, 82-8. University of Ottawa. Jorm, A.F., Morgan, A.J., & Hetrick, S.E. (2008). Dykens, E.M. (2000). Psychopathology in children with Relaxation for depression. Cochrane Database of intellectual disability. Journal of Child Psychology Systematic Reviews , 4, CD007142. and Psychiatry, 41, 407-417. Kazak, A.E. (1987). Families with disabled children: Dyson, L.L. (1997). Fathers and mothers of school-age Stress and social networks in three samples. children with developmental disabilities: parental Journal of Abnormal Child Psychology , 15, 137- stress, family functioning, and social support. 146. American Journal for Mental Retardation , 102, Krauss, M.W. (1993). Child-related and parenting stress: 267-79. similarities and differences between mothers and Ellis, A. (1962). Reason and Emotion in Psychotherapy . fathers of children with disabilities. American New York: Lyle Stuart. Journal for Mental Retardation, 97, 393-404. Fava, G.A., Ruini, C., Rafanelli, C., Finos, L., Conti, S., Mallow, G.E., & Bechtel, G.A. (1999). Chronic Sorrow: & Grandi, S. (2004). Six-year outcome of cognitive The experience of parents with children who are behavior therapy for prevention of recurrent developmentally disabled. Journal of Psychosocial depression. American Journal of Psychiatry, 161, Nursing and Mental Health Service , 37, 31-5. 1872-6. Miller, A.C., Gordon, R.M., Daniele, R.J., & Diller, L. Frey, K.S., Greenberg, M.T., & Fewell, R.R. (1989). (1992). Stress, appraisal and coping in mothers Stress and coping among parents of handicapped of disabled and nondisabled children. Journal of children: a multidimensional approach. American Pediatric Psychology, 17, 587-605.

71 *DQQDYDUDP6ULNULVKQDHWDO(I¿FDF\RI&RJQLWLYH%HKDYLRU7KHUDS\ &%7 LQ'HSUHVVLRQIRU3DUHQWVRI&KLOGUHQ

Murphy, G.E., Carney, R.M., Knesevich, M.A., & Seltzer, M.M., Greenberg, J.S., & Floyd, F.J., & Hong, Wetzel, R.D., & Whitworth, P. (1995). Cognitive J. (2004). Accommodative coping and well-being behavior therapy, relaxation and training and of midlife parents of children with mental health tricyclic antidepressant medication in treatment of problems or Developmental Disabilities. American depression. Psychological Reports, 77,403-20. Journal of Orthopsychiatry, 74, 187-95. Nixon, C.D., & Singer, G.H. (1993). Group cognitive Seltzer, M.M., Greenberg, J.S., & Krauss, M.W. (1995). A behavioural treatment for excessive parental self comparison of coping strategies of aging mothers blame and guilt. American Journal for Mental of adults with mental illness or mental retardation. Retardation , 97, 665-72. Psychology and Aging , 10, 64-75. Olsson, M.B., Hwang, C.P. (2001). Depression in mothers Tolin, D.F. (2010). Is cognitive-behavioural therapy more and fathers of children with intellectual disability. HIIHFWLYH WKDQ RWKHU WKHUDSLHV" $ PHWDDQDO\WLF Journal of Intellectual Disability Research, 45, review. Clinical Psychology Review , 30, 710–720. 535-43. Trute, B. (1995). Gender differences in the psychological Reinecke, M.A., Ryan, N.E., & DuBois, D.L. (1998). adjustment of parents of young, developmentally Cognitive Behavioural Therapy of depression and disabled children. Journal of Child Psychology, depressive symptoms during adolescence: a review Psychiatry and Allied Disciplines , 36, 1225-42. and meta analysis. Journal of American Academy Van, S.A., Geraedts, A., Verdonck-de, L. I., Andersson, of Child and Adolescent Psychiatry , 37, 1005-7. G., & Cuijpers, P. (2010). Psychological Sameroff, A. J., & Chandler, M. J. (1975). Reproductive treatment of depressive symptoms in patients with risk and the continuum of caretaking casualty. In F. medical disorders: a meta-analysis. Journal of D. Horowitz, M. Hetherington, S. Scarr-Salapatek, Psychosomatic Research, 69, 23–32. & Siegel, G. Review of Child Development Wikler, L.M. (1986). Family stress theory and research Research (Vol. 4). Chicago: University of Chicago on families of children with mental retardation. In Press. J.J. Gallagher & P. M. Vietze (Eds.), Families of Sameroff, A. J., Bartko, W. T., Baldwin, A., Baldwin, C., Handicapped Persons: Research, Programs and 6LHIHU5  )DPLO\DQGVRFLDOLQÀXHQFHV Policy Issues (pp.167-196). Baltimore: Brookes. on the development of child competence. In M. Lewis & C. Feiring (Eds.), Families, Risk, and Competenc e (pp. 161–185). Mahwah, NJ: Erlbaum.

72 Important Announcement

Invitation and Call for Papers

ICIAHP-2016 2nd International Conference of Indian Academy of Health Psychology

(December 16-18, 2016) Focal Theme Health Psychology: Expanding Horizons Venue: Gautam Buddha University

Organized by: Department of Psychology and Mental Health Gautam Buddha University, Yamuna Expressway, Greater Noida-201312, U.P. E-mail: [email protected] Website: iahp.net.in

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Contact Person : Dr. D. Dhanpal Mob. : 91 8883331732, 91 9788676283 e-mail : [email protected]

73 7KHFRSLHVRIWKH-RXUQDORIIROORZLQJ0HPEHUVKDYHEHHQUHFHLYHGEDFNE\(GLWRULDO2I¿FHGXHWR incorrect Address. The name of the Honourable members along with their membership number is given below. All the concerns are requested to kindly intimate their correct addresses to editor Indian Journal of Clinical Psychology via e-mail: [email protected] 5HDGHUV+RQ EOH0HPEHUVRIWKH$VVRFLDWLRQPD\SOHDVHDOVRLQWLPDWHWR(GLWRULDO2I¿FHWKHFRUUHFW address of members listed below; if someone knows:

1. Saroj Arya F-11 14. Sonali Bhatt Marwah LAM-21 2. Thimappa, M S F-45 15. Saleena Khan LAM-55 3. Ramani Mitra F- 85 16. Renu Joshi LAM-64 4. R S Hegde F-120 17. G P Mathur LAM - 68 5. Urmila George F-137 18. Ravindra Kumar LAM-90 6. Sujeetha B PLM-206 19. N K Taneja LAM-95 7. Nilesh B Wagh PLM-223 20. Ashok Sharma LAM-112 8. Hardeep Lal Joshi PLM-252 21. Anjali Sahai LAM-158 9. Vikash Sharma PLM-239 22. Tharakarni Sree Kumar LAM-203/08 10. Ravi Tiwari PLM-254 23. Chandolu Sudarshan Raju LAM-258/09 11. Chhavi Khanna, PLM-324/07/10 24. Muktalekha Mukhopadhyay LAM-255/09 12. Mercy Sebastian PLM-271 25. P Leelavathamma LAM-304/11 13. Anjali Gupta PLM-323/09/10

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