NRNP 6635 Week 1: History and Theories of Psychopathology

Factors That Influence the Development of Psychopathology

In most fields of medicine, diagnosis is based on a physical assessment (signs and symptoms), lab and radiology results, and a past medical history.  However, in psychiatry, a diagnosis is based on the clinician’s impression of the patient’s behavior, cross-referenced with a diagnostic or classification manual (Sadock, Sadock, & Ruiz, 2015).  Unlike a medical patient that can be diagnosed with diabetes without having symptoms, a psychiatric patient cannot. For example, a patient with no symptoms cannot be diagnosed with schizophrenia (Sadock, Sadock, & Ruiz, 2015).  Many contributions to the field of psychiatry and the advances in psychopathology have come from biological, psychological, and social-cultural sciences.

Biological (Genetic & Neuroscientific)

According to Sadock, Sadock, and Ruiz (2015), research has shown that 40 to 70 percent of cognition, temperament, and personality aspects (domains that are affected in mentally ill patients) can be attributed to genetic factors. The patient’s environment can also influence what genes are expressed; genetics provide the predispositions while the environment shapes what dispositions are expressed (Butcher & Kendall, 2018).  The neuroscientific aspect also plays a key role in psychopathology.  A table provided in one of our readings this week, showed the direct correlation between different areas of the brain, the associated function of the area, and the relevant mental health disorder.  For example, the frontal cortex is involved in the control of the behavioral response; relevant mental health condition may include depression, bipolar disorder, and/or anxiety disorders (Jackson & Milberg, 2018).  The limbic system, involved in sense and identity and initiating emotional response has been implicated in studies of schizophrenia and anxiety disorders (Jackson & Milberg, 2018).

Psychological (Behavioral and Cognitive Processes, Emotional, Developmental)

Cognitive dysfunction within the context of psychopathology is common and may contribute to the high rates of functional impairment found in many psychiatric patients (Jackson & Milberg, 2018).  Common areas of cognitive dysfunction include memory, attention, and executive functioning.  According to Jackson and Milberg (2018), memory deficits and deficits in cognitive processing speed (executive functioning) have been associated with individuals with social phobia.  Patients with Posttraumatic Stress Disorder (PTSD) commonly have deficits in executive functioning.

Social, Cultural, and Interpersonal Factors

Mental health disparities have been well documented across socioeconomic class, race, gender, and sexual orientation.  Studies have shown, individuals with less privileged social positions, unemployment, and lower income have a high association with common mental disorders (Cheung & Mak, 2018).  According to Cheung and Mak (2018), a systematic review revealed that lesbian, gay, and bisexual individuals have higher risk for mental disorders, suicidal ideations, and substance abuse compared to heterosexual individuals.  According to Sadock, Sadock, and Ruiz (2015), culture is a learned behavior and can play a key role in the patient’s mental health; a cultural assessment should be a part of every psychiatric assessment.  When making a psychiatric diagnosis or developing a treatment plan, clinicians should take into account the behaviorism of the patient’s culture.

References:

Butcher, J. N., & Kendall, P. C. (2018). Introduction to childhood and adolescent psychopathology. In J. N. Butcher & P. C. Kendall (Eds.), APA handbook of psychopathology: Child and adolescent psychopathology., Vol. 2. (pp. 3–14). American Psychological Association. https://doi-org.ezp.waldenulibrary.org/10.1037/0000065-001

Cheung, F. M., & Mak, W. W. S. (2018). Sociocultural factors in psychopathology. In J. N. Butcher & J. M. Hooley (Eds.), APA handbook of psychopathology: Psychopathology: Understanding, assessing, and treating adult mental disorders., Vol. 1. (pp. 127–147). American Psychological Association. https://doi-org.ezp.waldenulibrary.org/10.1037/0000064-006

Jackson, C. E., & Milberg, W. P. (2018). Examination of neurological and neuropsychological features in psychopathology. In J. N. Butcher & J. M. Hooley (Eds.), APA handbook of psychopathology: Psychopathology: Understanding, assessing, and treating adult mental disorders., Vol. 1. (pp. 65–90). American Psychological Association. https://doi-org.ezp.waldenulibrary.org/10.1037/0000064-004

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

 

Responses

Post Reply 

The nurse practitioner should adopt a multidimensional, integrative model of psychopathology because psychiatric diagnoses are not unidimensional. Psychopathology is exhibited by many factors, social, cultural, behavioral, cognitive, and biological (Sadock, et al., 2015). For example, obesity can be caused by genetics (biological), environmental, cultural, and social factors. According to Micanti et al. (2016), eating disorders are both pathological and psychological development. It would be important for the nurse practitioner to adopt the view of multidimensional psychopathology to accurately assess patients on a deeper level than just biological. Psychiatry is unique as psychiatric diagnoses are multidimensional; they show both biological symptoms, however, can be developed or exasperated by other factors leading to physical symptoms. Learning multidimensional psychopathology will allow me as a practitioner to understand the psychiatric patient population better and will allow me to diagnose more accurately. 

                                                                             References

Micanti, F., Iasevoli, F., Cucciniello, C., Costabile, R., Loiarro, G., Pecoraro, G., Pasanisi, F., Rossetti, G. L., & Galletta, D. (2016). The relationship between emotional regulation and eating behaviour: a multidimensional analysis of obesity psychopathology. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity22(1), 105–115. https://doi.org/10.1007/s40519-016-0275-7

Sadock, B. J., Sadock, V. A., & Ruiz, R. P. (2015). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (Eleventh ed.). Wolters Kluwer.

 

I really like the statement from Butcher & Kendall (2018) that talks about how genetics determine predispositions for mental health, whereas the environment affects what predispositions are expressed. I struggled to understand the concept of gene expression and its effect on mental health until I saw this same passage. This is why it is so important to have a multidisciplinary approach to the many facets of mental health predisposition. We as APRN’s are not going to have imaging that tells us a patient has schizophrenia. Lab work will not tell us how depressed a patient is. We must use the tools at are disposal – mainly, in-depth and accurate assessments. An accurate assessment involves being thorough and addressing all possible internal and external forces that could have led to a mental health disorder. Trauma is one of those external forces. Mental health providers cannot treat depression without treating the trauma that led to its expression. People accessing mental health services are much more likely to have experienced violence and/or trauma in within the last year than the overall population (Sweeney et al., 2018). While also needing to consider precipitating factors, the APRN should also consider the access to care. Far too many people in the US experience a significant lack of mental health services. The APRN may provide some limited therapy and prescriptions, but how easily can the patient access other mental health services so that they can continue mental health care once they are stabilized on medications? Therefore, the APRN must be knowledgeable about community services as well. Access to appropriate mental health services in communities can be linked to reduced stigma, reduced cost, and a wider range of services, as well as promoting care adherence and improved patient outcomes (Khort et al., 2018).

References

Kohrt, B. A., Asher, L., Bhardwaj, A., Fazel, M., Jordans, M., Mutamba, B. B., Nadkarni, A., Pedersen, G. A., Singla, D. R., & Patel, V. (2018). The Role of communities in cental health care in low- and middle-income countries: A meta-review of components and competencies. International Journal of Environmental Research and Public Health15(6), 1279. Accessed December 5, 2020 from https://doi.org/10.3390/ijerph15061279

Sweeney, A., Filson, B., Kennedy, A., Collinson, L., & Gillard, S. (2018). A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances24(5), 319–333. Accessed December 5, 2020 from https://doi.org/10.1192/bja.2018.29

 

Week 1: History and Theories of Psychopathology

The history of the diagnosis of mental disorders is fraught with examples of how cultural norms and prejudices interfere with and warp a diagnosis. The result is that normal behavior and orientations have been pathologized as an illness or disease. An example of this would be the story of Alan Turing, the famous British computer scientist of the 20th century, who was instrumental in inventing modern computers and deciphering German code in World War II. He was convicted in 1952 in England of gross indecency for being gay. Turing was forced by the courts to undergo 12 months of hormone therapy and could no longer work for the British government. At the time, homosexuality was pathologized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders and was criminalized in most Western countries. It was not until 1973 that the American Psychiatric Association (APA) finally removed homosexuality from the DSM.

Historically, the process of rendering a diagnosis has been used to pathologize those who fell outside what was considered the cultural norm of human behavior. This process often marginalized diagnosed populations and prevented individuals from receiving appropriate care. It is of utmost importance to consider cultural issues that influence how you as a clinician interpret a client’s behavior and how cultural issues influence how a client may express behavior. This week, you explore the history of psychopathology and the evolution of theoretical perspectives in the field.

Learning Objective

Students will:

  •  Analyze historical and currently recognized biological, psychological, and sociocultural factors that inform the expression, course, and prevalence of psychopathology

Learning Resources

Required Readings (click to expand/reduce)

Assignment

Practicum Manual Acknowledgment

The Practicum Manual describes the structure and timing of the classroom-based and practicum experiences and the policies students must follow to be successful in the nurse practitioner (NP) specialties.

Click here and follow the instructions to confirm you have downloaded and read the entire MSN Nurse Practitioner Practicum Manual and will abide by the requirements described in order to successfully complete this program.


Optional Discussion Forum: PMHNP Study Support Lounge

The PMHNP Study Support Lounge is offered throughout the course as a place of academic refuge, where you can ask questions, offer insights, and interact with your peers. Your Instructor may also weigh in to provide global feedback to the group based on trends, common problems, and common strengths in student posts.

As a peer, you are encouraged to provide constructive, helpful feedback to your peers. Advanced practice nurses always benefit from the feedback of others. Your Study Support Lounge posts may be procedural (“How do I attach a Kaltura video to a Discussion post?”), conceptual (“How does this relate to the other therapy approaches we have studied?”), or analytical (“What do these diagnostic results actually mean in the context of this specific patient case?”). Although not mandatory, this is an opportunity to interact and study together as you navigate the assignments, so you are highly encouraged to take part in this activity. Full participation in activities like these is a statistically significant predictor of success.

To Participate in this Optional Discussion:

PMHNP Study Support Lounge


Discussion: Factors That Influence the Development of Psychopathology

Photo Credit: Getty Images/Blend Images

In many realms of medicine, objective diagnoses can be made: A clavicula is broken.  An infection is present. TSH levels meet the diagnostic criteria for hypothyroidism. Psychiatry, on the other hand, deals with psychological phenomena and behaviors. Can these, too, be “defined objectively and by scientific criteria (Gergen, 1985), or are they social constructions?” (Sadock et al., 2015).

Thanks to myriad advances during recent decades, we know that psychopathology is caused by many interacting factors. Theoretical and clinical contributions to the field have come from the neural sciences, genetics, psychology, and social-cultural sciences. How do these factors impact the expression, classification, diagnosis, and prevalence of psychopathology, and why might it be important for a nurse practitioner to take a multidimensional, integrative approach?

To Prepare:

  • Review this week’s Learning Resources, considering the many interacting factors that contribute to the development of psychopathology.
  • Consider how theoretical perspective on psychopathology impacts the work of the PMHNP.
By Day 3 of Week 1

Explain the biological (genetic and neuroscientific); psychological (behavioral and cognitive processes, emotional, developmental); and social, cultural, and interpersonal factors that influence the development of psychopathology.

Read
 a selection of your colleagues’ responses

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days by explaining the implications of why, as an advanced practice nurse, it is important to adopt a multidimensional, integrative model of psychopathology.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 1 Discussion Rubric

Post by Day 3 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:

Week 1 Discussion


What’s Coming Up in Week 2?

In Week 2, you will be introduced to assessment and diagnosis of the psychiatric patient. You will explore elements of the psychiatric interview, history, and examination as well as psychiatric rating scales. You also will review the classification system of psychiatric disorders in the DSM-5 and the role the DSM-5 plays in diagnosis.

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Practicum – Upcoming Deadline

In the Nurse Practitioner programs of study (FNP, AGACNP, AGPCNP, and PMHNP) you are required to take several practicum courses. If you plan on taking a practicum course within the next two terms, you will need to submit your application via Meditrek .

For information on the practicum application process and deadlines, please visit the Field Experience: College of Nursing: Application Process – Graduate web page.

Please take the time to review the Appropriate Preceptors and Field Sites for your courses.

Please take the time to review the practicum manuals, FAQs, Webinars and any required forms on the Field Experience: College of Nursing: Student Resources and Manuals web page.

Discussion 1: Factors Related to Psychopathology

 

The need for psychiatric providers in the United States is high, while the availability of service providers is generally lacking. Worldwide, the mental health burden (cost) is estimated to be 13% of the total burden of health care (Samartzis & Talias, 2019). While this issue is not likely to fix itself any time soon, the psychiatric provider can assist with the global burden of mental health disease through an accurate and thorough assessment of symptoms for diagnosis and treatment. The first step in this process is the recognition of influences behind the development of mental illness. This discussion will provide an explanation for the biological, psychological, social, cultural, and interpersonal factors that influence the development of psychopathology.

Genetic

The genetic factors that influence the development of psychopathology is still a matter of intense debate and research. Typically, researchers discover the relative likelihood of genetic predisposition to certain diseases by studying monozygotic and dizygotic twins; monozygotic twins would both develop a given disease if it is strictly genetic/inherited in nature (Sadock et al., 2015). Researchers are also using family studies (to discover any increased rates of specific disorders among relatives when compared to a control group) as well as adoption studies (to investigate how similar genetically-related individuals express disease when compared to adoption-related individuals) to further assess the degree of inheritability of certain diseases (Thapar & Stergiakouli, 2008). Many illnesses may have a genetic predisposition or risk, but environmental influences are still considered to be a significant factor in the majority of psychiatric disorders.

Neuroscientific

The neuroscientific factors that influence the development of psychopathology is still unproven, however, gene expression is one generally accepted theory. The main goal of neurotransmission is often gene expression – that is, turning a gene on or off (Stahl, 2013). Through a very elaborate cascade of events, specifically through enzymes and ultimately the acetylation and demethylation of histones, genes are able to be expressed or silenced (Stahl, 2013). Therefore, it is easy to infer that perhaps a patient may already be genetically susceptible to bipolar disorder thanks to a long family history of mood disorders, but nurture and environment can trigger a cascade of events that could “turn on” the genes that encode for bipolar disorder.

Psychological

Risk factors for the development of mental illness begin in childhood. Attachment disorders and anxiety can develop without a strong and consistent maternal figure in the early stages of life (Sadock et al., 2015). Traumatic events experienced in childhood no doubt have a significant impact on mental health in later years. Stahl (2013) notes that experiences from the external environment can impact which genes are expressed and therefore cause a change in neuronal connections; human experiences may change the expression of genes. One can then deduce that traumatic events experienced at any point in life, but especially childhood, can have a significant impact on mental health secondary to the environment and its impact on gene expression. Other psychological factors that have been associated with a higher risk for developing mental illness include personal beliefs, self-esteem, personality, temperament, self-control, emotional regulation, cognitive functioning, fear conditioning, childhood aggression, trait resilience, compassion, childhood social withdrawal, and a whole host of other traits (Furber et al., 2017).

Social, Cultural, & Interpersonal

Evidence has shown a correlation between lifestyle risk factors and mental illness; specifically: poor diet, irregular sleeping patterns, sedentary lifestyle, and tobacco use (Firth et al., 2020). I did not find any articles that specifically linked culture to the propensity for psychopathology, however, culture has been directly linked to the type and quality of care provided for mental health. Access to and barriers to care, perceived need for mental health assistance, and likelihood of medication adherence can all be linked to culture and/or socioeconomic factors (McIntyre et al., 2017). The stigma of mental health is deeply rooted in culture all over the world, and how others perceive mental illness (interpersonal relationships) can impact how those with mental illness feel about themselves, and may also impact how likely they are to get treatment.

In conclusion, the skilled and knowledgeable provider would best meet the needs of the mental health population by having a firm understanding of the factors that influence mental health illness. Psychopathology is not limited to genetics, or trauma, or childhood abuse. Psychopathology can be indicated by a significant number of circumstances, personality traits, inherited genetics, and more. Through the accurate assessment and recognition of risk factors, a more accurate diagnosis can be obtained; this will allow for appropriate treatment planning and interventions.

 

 

References

Furber, G., Leach, M., Guy, S., & Segial, L. (2017). Developing a board categorization scheme to describe risk factors for mental illness, for use in prevention policy and planning. Australian and New Zealand Journal of Psychiatry, 51(3), 230-240. Accessed December 1, 2020 from https://doi.org/10.1177/0004867416642844

McIntyre, C., Harris, M. G., Baxter, A. J., Leske, S., Diminic, S., Gone, J. P., Hunter, E., & Whiteford, H. (2017). Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: A rapid review of population surveys. Health Research Policy and Systems15(1), 67. Accessed December 1, 2020 from https://doi.org/10.1186/s12961-017-0233-5

Sadock, B. J., Ruiz, P., & Sadock, V. A. (2015). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Samartzis, L., & Talias, M. A. (2019). Assessing and improving the quality in mental health services. International Journal of Environmental Research and Public Health17(1), 249. Accessed December 2, 2020 from https://doi.org/10.3390/ijerph17010249

Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Application. Cambridge, UK: Cambridge University Press.

Thapar, A., & Stergiakouli, E. (2008). Genetic influences on the development of childhood psychiatric disorders. Psychiatry7(7), 277–281. Accessed December 1, 2020 from https://doi.org/10.1016/j.mppsy.2008.05.009

 

 

Response

 Thank you for such an interesting discussion post this week. I enjoyed reading what you took out of this week’s lessons. I worked at a residential treatment facility for youth with mental illnesses for five years as a nurse. That experience really solidified this week’s readings for me. The children there all had a variety of mental illnesses and most had trauma in their childhood that led to a mental disorder. There were others who simply had genetic ties to a disorder, and others who were known to have been exposed to recreational drugs before being born. In my own family, nearly every female on my mom’s side of the family suffers with anxiety in different forms and severity. 

 I like that you mentioned the symptom of self-control during your discussion. Children present with this symptom in different ways than adults. Masten and Kalstabakken (2018) explained while a child may have poor impulse control demonstrated by taking toys from peers or interrupting adults, an adult may demonstrate this same symptom by engaging in substance abuse or stealing. This symptom, along with not being able to connect cause and effect, was the most common one I saw during my time as psychiatric nurse. 

 Another aspect of psychopathology that interests me is the socioeconomic factors. Kivimäkiet al. (2020) stated that those living in lower income areas are at higher risk for developing psychopathology as children and adults. This could be due to limited access to care, but it also has to do with the cascade of mental and physical disorders that compound when those growing up in poverty then raise their own family in the same fashion. Children and young adults growing up in lower socioeconomic situations first develop psychiatric disorders. Those disorders, if left untreated, soon lead to substance abuse, self-harm, and later in life, liver and renal disease, heart disease, stroke, chronic obstructive pulmonary disease, cancer, and dementia (Kivimäki et al., 2020). I have seen all of this first hand in the community I live in, which does have a large population of homeless and low-income families. Treating children effectively is crucial in breaking this cycle of worsening physical and mental health. I have a passion for working with children and hope to serve my community families when I obtain my license. 

Thank you again for the thought-provoking discussion this week!

References

Kivimäki, M., Batty, G. D., Pentti, J., Shipley, M. J., Sipilä, P. N., Nyberg, S. T., Suominen, S. B., Oksanen, T., Stenholm, S., Virtanen, M., Marmot, M. G., Singh-Manoux, A., Brunner, E. J., Lindbohm, J. V., Ferrie, J. E., & Vahtera, J. (2020). Association between socioeconomic status and the development of mental and physical health conditions in adulthood: A multi-cohort study. The Lancet Public Health, 5(3), 140–149. https://doi-org.ezp.waldenulibrary.org/10.1016/S2468-2667(19)30248-8

Masten, A. S., & Kalstabakken, A. W. (2018). Developmental perspectives on psychopathology in children and adolescents. APA handbook of psychopathology: Child and adolescent psychopathology, 2, 15-36. https://doi-org.ezp.waldenulibrary.org/10.1037/00000065-002

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