Theories of Psychopathology

Theories of Psychopathology

Psychoanalytic theory – Sigmund Freud
Developmental Theories
Psychosocial Stages – Erik Erikson
Cognitive Stages – Jean Piaget
Interpersonal Theories
Harry Stack Sullivan
Hildegard Peplau
Humanistic Theories
Hierarchy of Needs - Abraham Maslow
Client-centered Theory - Carl Rogers
Behavioral Theories
Classical Conditioning - Ivan Pavlov
Operant Conditioning – Burrhus F. Skinner

1. Theories of Psychopathology Lectured by Leila T. Salera , RN, MD, DPSP

2. Theories of Psychopathology Psychoanalytic theory – Sigmund Freud Developmental Theories Psychosocial Stages – Erik Erikson Cognitive Stages – Jean Piaget Interpersonal Theories Harry Stack Sullivan Hildegard Peplau Humanistic Theories Hierarchy of Needs - Abraham Maslow Client-centered Theory - Carl Rogers Behavioral Theories Classical Conditioning - Ivan Pavlov Operant Conditioning – Burrhus F. Skinner

3. Theories of Psychopathology Existential Theories Cognitive therapy Rational emotive therapy Viktor Frankl and Logotherapy Gestalt therapy Reality Therapy Biomedical Theory Spiritual Theory

4. Psychoanalytic Theory Behavior motivated by subconscious thoughts and feelings Discovering client’s unconscious and repressed thoughts, feelings, and conflicts believed to cause anxiety and on helping the client to gain the insight into and resolve these conflicts and anxieties (Theory of Anxiety) Topographical model of the mind: Conscious - perceptions, thoughts, and emotions that exist in the person’s awareness Preconscious - Preconscious – thoughts and emotions are not currently in the person’s awareness, but can be recalled at will with some effort Unconscious - the realm of thoughts and feelings that motivate a person even though he or she is totally unaware of them

5. Psychoanalytic Theory Structural theory of the mind Id Ego Superego Transference (client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships) and Countertransference (when the therapist displaces onto the client attitudes or feelings from his or her past)

6. Psychoanalytic Theory Ego defense mechanisms Psychosis versus neurosis Psychosis – defined grossly as impaired reality testing; severe impairment of social and personal functioning characterized by social withdrawal and inability to perform the usual household and occupational roles Neurosis – defined as a chronic or recurrent disorder that is characterized mainly by anxiety, which appears alone or as a symptom such as obsession, compulsion, phobia, or a sexual dysfunction

7. Ego defense mechanisms (Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Compensation Covering up a real or perceived weakness by emphasizing a trait one considers more desirable A physically handicapped boy is unable to participate in football, so he compensated by becoming a great scholar Denial Refusing to acknowledge the existence of a real situation or the feelings associated with it A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem Displacement The transfer of feelings from one target to another that is considered less threatening or that is neutral A client is angry with his physician, does not express it, but becomes verbally abusive with the nurse

8. Ego defense mechanisms ((Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Rationalization Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors John tells the rehab nurse “I’ll drink because it’s the only way I can deal with my bad marriage and my worse job.” Reaction Formation Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors Jane hates nursing and attends nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career

9. Ego defense mechanisms (Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Regression Retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning A 2-year-old boy is hospitalized and he only drinks from a bottle, even though his mom says that he has been drinking from a cup for 6 months Identification An attempt to increase self-worth by acquiring certain attributes and characteristic of an individual one admires A teenager who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences

10. Ego defense mechanisms (Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Intellectualization An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis S’s husband is being transferred with his job to city far away from her parents. She hides the anxiety by explaining to her parents the advantages associated with the move Introjection Integrating the beliefs and values of another individual into one’s own ego structure Children integrate their patents’ value system into the process of conscience formation. A child says to a friend, “Don’t cheat. It’s wrong.”

11. Ego defense mechanisms (Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Isolation Separating a thought or memory from the feeling tone or emotion associated with it A young woman describes being attacked and raped without showing any emotion Projection Attributing feelings of impulses unacceptable to one’s self to another person Sue feels a strong sexual attraction to her track coach and tells a friend, “He’s coming on to me!” Repression Involuntarily blocking unpleasant feelings and experiences from one’s awareness An accident victim can remember nothing about the accident

12. Ego defense mechanisms (Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16) Defense Mechanism Definition Example Sublimation Rechanneling of drives or impulse that are personally or socially unacceptable into activities that are constructive A mother whose s on was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Drivers Suppression The voluntary blocking unpleasant feelings and experiences from one’s awareness “I don’t want to think about that now. I’ll think about that tomorrow.” Undoing Symbolically negating or cancelling out an experience that one finds intolerable Joe is nervous about his new job and yells at his wife. On his way home he stops and buys her flowers.

13. Psychoanalytic Theory The Stages of Psychosexual Development Oral stage Anal stage Urethral stage Phallic stage Latency stage Genital stage

14. Oral Stage Objectives To establish a trusting dependence on nursing and sustaining objects, to establish comfortable expression and gratification of oral libidinal needs without excessive conflict or ambivalence from oral sadistic wishes Patholological traits Excessive optimism, narcissism, pessimism (often seen in depressive states), and demandingness Oral characters are often excessively dependent and require others to give to them and to look after them Oral characters are often extremely dependent on objects for the maintenance of their self-esteem Envy and jealousy are often associated with oral traits Character traits Successful resolution leads to capacities to give and receive from others without excessive dependence or envy and capacity to rely on others with a sense of trust, as well as with a sense of self-reliance and self-trust Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

15. Anal Stage Objectives Essentially a period of striving for independence and separation from the dependence on and control by the parent Patholological traits Orderliness, obstinacy, stubbornness, willfulness, frugality, and parsimony Heightened ambivalence, lack of tidiness, messiness, defiance, rage, and sadomasochistic tendencies Most typically seen in obsessive-compulsive neuroses Character traits Successful resolution provides the basis for the development of personal autonomy, a capacity for independence and personal initiative without guilt, a capacity for self-determining behavior without a sense of shame or self-doubt, a lack of ambivalence and a capacity for willing cooperation without either excessive willfulness or sense of self-diminution or defeat Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

16. Urethral Stage Objectives Issues of control and urethral performance and loss of control Patholological traits Competitive, ambitious, penis envy, issues in control and sharing Character traits Provides a sense of pride and self-competence derived from performance. This is when a small boy can imitate and match his father’s more adult performance. The resolution sets the stage for budding gender identity and subsequent identifications Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

17. Phallic Stage Objectives Focus erotic interest in the genital area and genital functions, which lays the foundation for gender identity and serves to integrate the residues of previous stages of psychosexual development into a predominantly genital-sexual orientation Patholological traits Oedipal complex Castration complex in males and penis envy in females Conflicts in the previous stages may resume, so that fixations or conflicts that derive from any of the preceding stages can contaminate and modify the oedipal resolution Character traits Provides the foundation for an emerging sense of sexual identity; a sense of curiosity without embarrassment, initiative without guilt, as well as a sense of mastery not only over objects and persons in the environment but also over internal processes and impulses Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

18. Latency Stage Objectives Further integration of oedipal identifications and a consolidation of sex-role identity and sex roles Mastery of skills Broadening of significant figures outside the family, such as teachers, coaches, and other adults Patholological traits Lack of development of inner controls or an excess of them. The lack of control can lead to a failure of the child to sufficiently sublimate energies in the interests of learning and development of skills; an excess of inner control can lead to premature closure of personality development and the precocious elaboration of obsessive character traits Character traits The child can develop a sense of industry and a capacity for mastery of objects that allows autonomous function with a sense of initiative without running the risk of failure or defeat or a sense of inferiority Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

19. Genital Stage Objectives The ultimate separation from dependence on and attachment to the parents and the establishment of mature, nonincestuous , object relations Patholological traits Fixations Personality disorders Identity diffusion in Erik Erikson’s Psychosocial Stages Character traits Sets the stage normally for a fully mature personality with a capacity for a full and satisfying capacity for self-realization and meaningful participation in the areas of work and love and in the creative and productive application to satisfying and meaningful goals and values Nursing responsibilities Nurses with postgraduate training can conduct psychodynamic therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms

20. Psychosocial Stages of Development Erik Homburger Erikson The eight stages represent points along a continuum of development in which physical, cognitive, instinctual, and sexual changes combine to trigger an internal crisis whose resolution results in either psychosocial regression or growth and the development of specific virtues

21. Psychosocial Stage Associated Virtue Related Forms of Psychopathology Trust vs. mistrust Hope Psychosis Addictions Depression Autonomy vs. shame and doubt Will Paranoia Obsessions Compulsions Impulsivity Initiative vs. guilt Purpose Conversion disorder Phobia Psychosomatic disorder Inhibition Industry vs. inferiority Competence Creative inhibition Inertia Identity vs. role confusion Fidelity Delinquent behavior Gender-related identity disorders Borderline psychotic episodes

22. Psychosocial Stage Associated Virtue Related Forms of Psychopathology Intimacy vs. isolation Love Schizoid personality disorder Generativity vs. stagnation Care Mid-life crisis Premature invalidism Integrity vs. despair Wisdom Extreme alienation Despair Nursing responsibilities Nurses commonly perform Erikson’s developmental stages

23. Jean Piaget’s Cognitive Development Four stages Each stage is a prerequisite for the following one, but the rate at which different children move through different stages varies with their native endowment and environmental circumstances

24. Age Period Cognitive Developmental Characteristics – 1.5 (to 2) Sensorimotor child develops a sense of self separate from the environment and the concept of object permanence ( an object does not cease to exist just because they are out of sight (formation of mental images) ) 2 – 7 Preoperations subperiod ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects 7 - 11 Concrete operations application of logic to thinking, but thinking is still concrete 11 – end of adolescence Formal operations more abstract thinking Nursing responsibilities Useful when nurses work with children Nurse may better understand what the child means if the nurse is aware of his or her own level of cognitive development Teaching children is often structured with their cognitive development in mind

25. Harry Stack Sullivan Interpersonal Relationship and Milieu therapy Nurse focuses on the nurse-patient relationship, the vehicles through which the patient becomes healthy Nurse counsel patients by developing therapeutic relationship Anxiety interventions is an important nursing role Nurses use the nurse-patient relationship as a corrective interpersonal experience for patient

26. Harry Stack Sullivan Interpersonal theory Milieu therapy Three modes of experiencing and thinking: Protaxic mode – undifferentiated thought that cannot separate the whole into parts or use symbols; occurs normally in infants and also appears in patients with schizophrenia Parataxic mode – events are casually related of temporal or serial connections; no perception of logical relatonships Syntaxic mode – logical, rational, and most mature type of cognitive functioning of which a person is capable

27. Harry Stack Sullivan The three personifications of me: Good me – everything that you like about yourself that you let others see Bad me – things that you don’t like about yourself that you would prefer others not to see, but you accept them as a part of you Not me – all the negative aspects of yourself, from feelings, thoughts, experiences that you do not accept as a part of you, and as a result these are buried deep within the subconscious/unconscious (e.g., repressed memories)

28. Harry Stack Sullivan Mental health alterations: Anxiety disorders Personality disorders

29. Hildegard Peplau Therapeutic Nurse-Client Relationship Phases of the Nurse-Patient Relationship Roles of the nurse in the therapeutic relationship: stranger, resource person, teacher, leader, surrogate, counselor Four levels of anxiety

30. Nursing Implications Hildegard Peplau Harry Stack Sullivan Nurse focuses on the nurse-patient relationship, the vehicles through which the patient becomes healthy Nurse counsel patients by developing therapeutic relationship Anxiety interventions is an important nursing role Nurses use the nurse-patient relationship as a corrective interpersonal experience for patients

31. Carl Rogers Client-centered theory Or person-centered theory The major concepts are self-actualization and self-direction Persons are born with the capacity to direct themselves in the healthiest way toward a level of completeness called self-actualization Focus is on the client rather than the therapist Each client experiences the world differently and he or she knows this the best Mental health alterations: anxiety and personality disorders

32. Carl Rogers Nurse-patient interaction is based on humanistic principles: Positive regard Empathy Geunineness

33. Abraham Maslow A leader in humanistic psychology Hierarchy of needs As the more primitive needs, such as hunger and thirst are satisfied, more advanced psychological needs, such as affection and self-esteem, become the primary motivators Self-actualization is the highest need

34. Abraham Maslow Anxiety disorders as well as behavioral problems may arise if needs are not met Nurse-patient interaction is based on humanistic principles: Positive regard Empathy Geunineness

35. Theory Focus Mental Health Alterations Nursing Responsibilities Cognitive therapy How the person perceives or interprets his or her experience and determines how he or she feel and behaves Anxiety disorders Client is encouraged to initiate topics of concern Nurse listens carefully to the client The nurse uses the reflective listening approaches to help the patient gain self-understanding The nurse helps the patient examine alternative choices Rational emotive therapy Identifies irrational beliefs that people use to make themselves unhappy Viktor Frankl and Logotherapy Search for meaning (logos) is the central theme Spirituality and grief counseling ( Videbeck , pages 17 to 24 and 44 to 56 Student Guide, pages 83 to 90)

36. Theory Focus Mental Health Alterations Nursing Responsibilities Frederick “Fritz” Perls - Gestalt Therapy Emphasis is on identifying the person’s feelings and thoughts in the here and now – increase self-awareness Anxiety disorders Client is encouraged to initiate topics of concern Nurse listens carefully to the client The nurse uses the reflective listening approaches to help the patient gain self-understanding The nurse helps the patient examine alternative choices William Glasses - Reality therapy Person’s behavior and how that behavior keeps him or her from achieving life goals ( Videbeck , pages 17 to 24 and 44 to 56 Student Guide, pages 83 to 90)

37. Biomedical Theory Mental illness can be a result of something physical Mental illness may be a symptom of an organic disease Mental illness has an organic basis

38. Review of nervous system - neuroanatomy

39. Major Neurotransmitters Type Mechanism of Action Physiologic Effects Dopamine Excitatory Controls complex movements, motivation, cognition, regulates emotional response Norepeniphrine or noradernaline Excitatory Causes changes inattention, learning and memory, sleep and wakefulness, mood Epinephrine or adrenaline Excitatory Controls fight or flight response Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Videbeck , page 21

40. Major Neurotransmitters Type Mechanism of Action Physiologic Effects Histamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses Acetylcholine Excitatory or inhibitory Controls sleep and wakefulness cycle, signals muscles to become alert Neuropeptides Neuromodulators Enhance , prolong, inhibit, or limit the effects of principal neurotransmitters Glutamate Excitatory Results in neurotoxicity if levels are too high Gamma- aminonutytic acid (GABA) Inhibitory Modulates other neurotransmitters Videbeck , page 21

41. Proposed Clinical Relevance of Neurotransmitters Serotonin – antidepressant action; anxiolytic ; possible role in locomotor activity, aggression; regulation of appetite, anxiety, seizures; target of hallucinogens, antipsychotics; cognitive enhancement Histamine – produce sedation as well as arousal; weight gain as well as appetite suppression Dopamine – D1 and D2 receptor stimulation synergistic; required for stimulant effects of cocaine; target of therapeutic and extrapyramidal effects of dopamine receptor antipsychotics (typical antipsychotics)

42. Brain Imaging Techniques Computed tomography (CT) – also called computed axial tomography (CAT), is a procedure in which a precise x-ray beam takes cross sectional images (slices) layer by layer Magnetic resonance imaging MRI) – a type of body scan, an energy field is created with a huge magnet and radio waves and the energy field is converted to visual images or scan ( Videbeck , pages 21 to 23)

43. Brain Imaging Techniques Positron emission tomography (PET) and single positron emission computed tomography) – are used to examine the function of the brain, where radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the client performs cognitive activities instructed by the operator Limitations of brain imaging techniques The use of radioactive substances in PET and SPECT is frightening to some people Expensive Some clients cannot tolerate the procedure Many changes in some disorders like schizophrenia which are at a molecular and chemical level cannot be detected by current imaging techniques ( Videbeck , pages 21 to 23)

44. Spirituality Affirmation of life in relationship with God, self, community, and environment that nurtures and celebrated wholeness ( http://www.rcpsych.ac.uk/pdf/nl6_eagger.pdf )

45. Spiritual Theory Focus: Relationship of Man and God Man’s relationship with God is destroyed because of sin. Restlessness (anxiety)is because man is separated from God. Sin produces fear Sin separates man from God. The only way to have peace is to reestablish relationship with God through Jesus Christ – (Christianity)

46. Spiritual Theory Spirituality things beyond biological experience Gives depth and meaning to life Presence of higher power Higher purpose Higher principles “Spirituotherapy”

47. Spirituotherapy To establish relationship with God there are three things that a man should do: Acknowledge being sinful Repentance Receive God’s offer of salvation through His son, Jesus Christ. “God did not give us the spirit of fear but power, love and SOUND MIND.”

48. Nursing application The nurse should first assess her own relationship with God. Praying and reading the gospel with the patient is one of the functions of the nurse. The nurse must respect his/her patient’s belief but need not sacrifice his/her salvation.

49. Basic Concepts Apart from God , man is not whole. God is able to forgive past experiences( Intrapsychic) and erase painful experiences in the past. The only way man can learn to do good is through God’s grace (unmerited favor) Man cannot be good on His own. “ Its not by might nor by power but by my spirit ,says the Lord.” (the Bible)

50. Actual People in History with Alterations with Mental Health Ted Bundy – born out of wedlock, mother remarried and raised him as her younger brother, had a difficult relationship with his stepfather, became a serial killer who could have been responsible for killing 100 girls and women. A sociopath. Ed Gein – raised by his mother who was a religious fanatic, grew up bashful, fantasized about the female anatomy. After his mother died, he began digging graves of women and wearing their skin. He escalated into killing women, wearing their skin. He wanted to be a woman. Denied being a necrophiliac . Diagnosed with schizophrenia

51. Actual People in History with Alterations with Mental Health Cary Stayner – grew up in a family with a father who worked long hours and a mother who was not affectionate. Was diagnosed with trichotillomania at age 3, became a serial killer during adulthood. Claims he was diagnosed as having OCD. His father once said, he was a good boy who kept to himself and got good grades, and they didn’t know he had problems and that he heard voices. Aileen Wuornos – abandoned by her mother when she was an infant, father was a convicted child molester who committed suicide in prison, raised by her grandparents who mistreated her. Got pregnant at 14 due to rape, became a prostitute, killed 7 men. She was diagnosed as having borderline personality disorder. But there are those who question this diagnosis. " I'm one who seriously hates human life and would kill again ," she told the Florida Supreme Court.

52. Actual People in History with Alterations with Mental Health Dennis Lynn Rader (born March 9, 1945) is an American serial killer who murdered ten people in Sedgwick County (in and around Wichita, Kansas ), between 1974 and 1991. He was known as the BTK killer (or the BTK strangler ). "BTK" stands for "Bind, Torture, Kill", which was his famous signature. He sent letters describing the details of the killings to police and to local news outlets during the period of time in which the murders took place. Rader was a member of Christ Lutheran Church and had been elected president [1][7] of the Congregation Council. He was also a Cub Scout leader. [

53. Actual People in History with Alterations with Mental Health Mary Flora Bell (born 26 May 1957 in Newcastle upon Tyne , England) was convicted in December 1968 of the manslaughter of two boys, Martin Brown (aged four years) and Brian Howe (aged three years). Bell was ten years old when she killed Brown, and eleven when she killed Howe. Independent accounts from family members strongly suggest that Betty had attempted to kill Mary and make her death look accidental more than once during the first few years of her life. [2] [ page needed ] Mary herself says she was subject to repeated sexual abuse , her mother forcing her from the age of four to engage in sex acts with men.

54. Actual People in History with Alterations with Mental Health On 31 July 1968, the pair took part in the death, again by strangling, of three-year-old Brian Howe, on wasteland in the same Scotswood area. Police reports concluded that Mary Bell had later returned to his body to carve an "N" into his stomach with a razor; this was then changed using the same razor but with a different hand to an "M". Mary Bell also used a pair of scissors to cut off some of Howe's hair, scratch his legs, and mutilate his penis