Advanced Psychological Issues

Names that open the right door : Dissociation, Obsessive-Compulsive Disorder (OCD), eating disorders, personality patterns, and substances are treatable. They are not character verdicts.

22.1 Dissociation

Dissociation is a mental process of disconnecting from thoughts, feelings, memories, or sense of identity. It exists on a spectrum from normal to pathological.

Normal: daydreaming; highway hypnosis; getting absorbed in a book or movie.

Pathological: depersonalisation (disconnected from the body); derealisation (world feels unreal); memory gaps (dissociative amnesia); identity fragmentation Dissociative Identity Disorder (DID).

Depersonalisation / derealisation disorder

Persistent feeling of being detached from body or thoughts; like an outside observer; world feels unreal, dreamlike, or distorted. Reality testing remains intact — the person knows it is a feeling, not a fact.

Dissociative amnesia

Inability to recall important personal information, usually related to trauma or stress, more than normal forgetting. Can be localised (a specific event), selective (parts of an event), or generalised (entire life).

Dissociative identity disorder (DID)

Formerly called multiple personality disorder. Two or more distinct personality states; gaps in memory for everyday events, personal information, or trauma. Usually develops from severe childhood trauma. Controversial diagnosis; requires specialised assessment. Not the same as schizophrenia.

Causes: often trauma, especially childhood trauma; a coping mechanism that can persist as a maladaptive pattern.

Treatment: trauma-informed therapy; grounding; building safety and stability; processing traumatic memories when ready; integration work for DID.

22.2 Obsessive-compulsive disorder

OCD is characterised by obsessions (intrusive thoughts) and compulsions (repetitive behaviours or mental acts).

Obsessions: intrusive, unwanted thoughts, images, or urges that cause anxiety; the person tries to ignore or suppress them. Themes: contamination, harm, symmetry, forbidden thoughts.

Compulsions: repetitive behaviours or mental acts performed to reduce anxiety; often excessive or not realistically connected to what they are meant to prevent. Examples: washing, checking, counting, ordering, mental rituals.

Common themes

Contamination: fear of germs, dirt, chemicals; washing, cleaning, avoidance.
Harm: fear of harming self or others; intrusive violent thoughts; checking, reassurance, avoidance.
Symmetry / ordering: need for things to be just right; arranging, repeating.
Forbidden thoughts: intrusive sexual, religious, or aggressive thoughts; mental rituals, prayer, reassurance.
Responsibility: excessive fear of being responsible for something bad; checking, lists, reassurance.

Treatment

Exposure and Response Prevention (ERP): gold standard. Face fears without performing compulsions; learn that anxiety decreases; build tolerance for uncertainty.
Medications: SSRIs, often at higher doses than for depression.
ACT: accept thoughts without engaging them.
Support groups: reduce shame and isolation.

22.3 Eating disorders

Eating disorders are serious mental-health conditions involving disturbed eating behaviours and preoccupation with food, weight, and body image. They have physical and psychological components and can be medically dangerous.

Anorexia nervosa

People with anorexia eat far too little and become dangerously thin. They are very afraid of gaining weight, see their body wrongly and often over-exercise. It can damage the heart, bones and fertility, and it has the highest death rate of any mental illness. Treatment first makes the body safe, then rebuilds healthy eating and adds therapy; teenagers do best with family-based treatment.

Bulimia nervosa

Recurrent binge eating with a sense of loss of control; compensatory behaviours; self-evaluation unduly influenced by body shape and weight; often normal or above-normal weight. Complications: electrolyte imbalance, dental erosion, oesophageal and heart problems. Treatment: CBT-E, SSRIs, nutritional counselling.

Binge-eating disorder

Recurrent binge eating without regular compensatory behaviours; eating rapidly, until uncomfortably full, when not hungry; disgust, depression, or guilt afterwards; often leads to obesity. Treatment: CBT, interpersonal therapy, sometimes medicines.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Limited food intake due to lack of interest, sensory issues, or fear of consequences. Not driven by body-image concerns. Can lead to malnutrition. Common in children and autism spectrum. Treatment: nutritional support, exposure, family involvement.

OSFED (Other Specified Feeding or Eating Disorder) Symptoms cause significant distress but do not meet full criteria for the disorders above. Still serious and requires treatment.

Underlying factors: genetic predisposition; cultural pressure about thinness; perfectionism, low self-esteem; trauma; co-occurring anxiety, depression, OCD; family dynamics.

Treatment principles: medical monitoring; multidisciplinary team (therapist, dietitian, physician, psychiatrist); address underlying psychology; nutritional rehabilitation; family involvement for adolescents; support groups.

22.4 Personality disorders

Enduring patterns of thinking, feeling, and behaving that differ from cultural expectations, are inflexible, and cause distress or impairment.

Cluster A (odd / eccentric)

Paranoid: pervasive distrust; motives read as malevolent; reluctant to confide; hidden meanings in benign remarks.
Schizoid: detachment from relationships; limited emotional expression; prefers solitude; indifferent to praise or criticism.
Schizotypal: social deficits with cognitive distortions; odd beliefs, magical thinking; unusual perceptual experiences; eccentric behaviour.

Cluster B (dramatic / emotional / erratic)

Antisocial: disregard for others' rights; deceitful, impulsive, aggressive; lack of remorse; often conduct disorder in childhood.
Borderline (BPD): instability in relationships, self-image, emotions; fear of abandonment; impulsivity; recurrent suicidal behaviour or self-harm in some people; chronic emptiness; intense anger. DBT is the gold-standard therapy.
Histrionic: excessive emotionality and attention-seeking; uncomfortable when not the centre; shallow, rapidly shifting emotions.
Narcissistic: grandiosity, need for admiration, lack of empathy; fantasies of success; exploitative; fragile self-esteem.

Cluster C (anxious / fearful)

Avoidant: social inhibition, inadequacy, hypersensitivity to criticism; avoids contact despite wanting connection; fear of rejection.
Dependent: excessive need to be taken care of; submissive, clinging; fear of separation; difficulty deciding without reassurance.
Obsessive-Compulsive Personality Disorder (OCPD): preoccupation with orderliness, perfectionism, control; ego-syntonic (feels like 'me'), unlike OCD which is ego-dystonic; rigid; workaholic; neglects leisure and relationships.

Treatment: long-term psychotherapy; Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder (BPD); schema therapy; mentalisation-based treatment; medicines for specific symptoms, not for the personality disorder itself. Challenging but treatable with commitment.

22.5 Substance use disorders

A substance use disorder is a pattern of using alcohol or drugs that causes harm or distress. Signs include: using more than intended; wanting to cut down but not managing to; spending a lot of time getting, using or recovering; cravings; failing at work, study or home; carrying on despite problems; giving up other activities; using in dangerous situations; needing more for the same effect (tolerance); and feeling unwell when stopping (withdrawal).

Substances named: alcohol; opioids (heroin, prescription painkillers); stimulants (cocaine, methamphetamine, ADHD medicines); cannabis; sedatives (benzodiazepines, sleep medicines); hallucinogens; tobacco/nicotine.

Treatment: medically supervised detoxification; rehabilitation; medication-assisted treatment for opioids and alcohol; CBT and motivational interviewing; support groups AA (Alcoholics Anonymous), NA (Narcotics Anonymous), SMART Recovery (Self-Management and Recovery Training) Recovery; relapse prevention; treat co-occurring mental-health conditions.

Reflection activity

Which of these conditions have you encountered (personally or in others)?
How does understanding these conditions reduce stigma?
What would you say to someone struggling with these issues?
Where could they seek help?
How can you be supportive without enabling?