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Theories of Psychopathology


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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

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Theories of Psychopathology

  1. 1. Theories of Psychopathology Lectured by Leila T. Salera, RN, MD, DPSP
  2. 2. Theories of Psychopathology• Psychoanalytic theory – Sigmund Freud• Developmental Theories1. Psychosocial Stages – Erik Erikson2. Cognitive Stages – Jean Piaget• Interpersonal Theories1. Harry Stack Sullivan2. Hildegard Peplau• Humanistic Theories1. Hierarchy of Needs - Abraham Maslow2. Client-centered Theory - Carl Rogers• Behavioral Theories• Classical Conditioning - Ivan Pavlov• Operant Conditioning – Burrhus F. Skinner
  3. 3. Theories of Psychopathology• Existential Theories1. Cognitive therapy2. Rational emotive therapy3. Viktor Frankl and Logotherapy4. Gestalt therapy5. Reality Therapy• Biomedical Theory• Spiritual Theory
  4. 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:a. Conscious - perceptions, thoughts, and emotions that exist in the person’s awarenessb. Preconscious - Preconscious – thoughts and emotions are not currently in the person’s awareness, but can be recalled at will with some effortc. Unconscious - the realm of thoughts and feelings that motivate a person even though he or she is totally unaware of them
  5. 5. Psychoanalytic Theory• Structural theory of the minda. Idb. Egoc. 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. 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. 7. Ego defense mechanisms Defense Mechanism Definition ExampleCompensation Covering up a real or A physically handicapped perceived weakness by boy is unable to participate emphasizing a trait one in football, so he considers more desirable compensated by becoming a great scholarDenial Refusing to acknowledge the A woman drinks alcohol existence of a real situation every day and cannot stop, or the feelings associated failing to acknowledge that with it she has a problemDisplacement The transfer of feelings from A client is angry with his one target to another that is physician, does not express considered less threatening it, but becomes verbally or that is neutral abusive with the nurse(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  8. 8. Ego defense mechanisms Defense Mechanism Definition ExampleRationalization Attempting to make excuses John tells the rehab nurse or formulate logical reasons “I’ll drink because it’s the to justify unacceptable only way I can deal with my feelings or behaviors bad marriage and my worse job.”Reaction Formation Preventing unacceptable or Jane hates nursing and undesirable thoughts or attends nursing school to behaviors from being please her parents. During expressed by exaggerating career day, she speaks to opposite thoughts or types prospective students about of behaviors the excellence of nursing as a career((Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  9. 9. Ego defense mechanisms Defense Mechanism Definition ExampleRegression Retreating in response to A 2-year-old boy is stress to an earlier level of hospitalized and he only development and the drinks from a bottle, even comfort measures though his mom says that he associated with that level of has been drinking from a functioning cup for 6 monthsIdentification An attempt to increase self- A teenager who required worth by acquiring certain lengthy rehabilitation after attributes and characteristic an accident decides to of an individual one admires become a physical therapist as a result of his experiences(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  10. 10. Ego defense mechanisms Defense Mechanism Definition ExampleIntellectualization An attempt to avoid S’s husband is being expressing actual emotions transferred with his job to associated with a stressful city far away from her situation by using the parents. She hides the intellectual processes of anxiety by explaining to her logic, reasoning, and parents the advantages analysis associated with the moveIntrojection Integrating the beliefs and Children integrate their values of another individual patents’ value system into into one’s own ego structure the process of conscience formation. A child says to a friend, “Don’t cheat. It’s wrong.”(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  11. 11. Ego defense mechanisms Defense Mechanism Definition ExampleIsolation Separating a thought or A young woman describes memory from the feeling being attacked and raped tone or emotion associated without showing any with it emotionProjection Attributing feelings of Sue feels a strong sexual impulses unacceptable to attraction to her track coach one’s self to another person and tells a friend, “He’s coming on to me!”Repression Involuntarily blocking An accident victim can unpleasant feelings and remember nothing about experiences from one’s the accident awareness(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  12. 12. Ego defense mechanisms Defense Mechanism Definition ExampleSublimation Rechanneling of drives or A mother whose son was impulse that are personally killed by a drunk driver or socially unacceptable into channels her anger and activities that are energy into being the constructive president of the local chapter of Mothers Against Drunk DriversSuppression The voluntary blocking “I don’t want to think about unpleasant feelings and that now. I’ll think about experiences from one’s that tomorrow.” awarenessUndoing Symbolically negating or Joe is nervous about his new cancelling out an experience job and yells at his wife. On that one finds intolerable his way home he stops and buys her flowers.(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
  13. 13. Psychoanalytic Theory• The Stages of Psychosexual Development1. Oral stage2. Anal stage3. Urethral stage4. Phallic stage5. Latency stage6. Genital stage
  14. 14. Oral StageObjectives 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 wishesPatholological 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 traitsCharacter 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-trustNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  15. 15. Anal StageObjectives Essentially a period of striving for independence and separation from the dependence on and control by the parentPatholological 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 neurosesCharacter 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 defeatNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  16. 16. Urethral StageObjectives Issues of control and urethral performance and loss of controlPatholological traits Competitive, ambitious, penis envy, issues in control and sharingCharacter 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 identificationsNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  17. 17. Phallic StageObjectives 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 orientationPatholological 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 resolutionCharacter 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 impulsesNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  18. 18. Latency StageObjectives 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 adultsPatholological 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 traitsCharacter 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 inferiorityNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  19. 19. Genital StageObjectives The ultimate separation from dependence on and attachment to the parents and the establishment of mature, nonincestuous, object relationsPatholological traits Fixations Personality disorders Identity diffusion in Erik Erikson’s Psychosocial StagesCharacter 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 valuesNursing Nurses with postgraduate training can conduct psychodynamicresponsibilities therapy Nurse can use this theory in interpreting client’s behavior Nurses’ must give attention to the client’s defense mechanisms
  20. 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. 21. Psychosocial Stage Associated Virtue Related Forms of PsychopathologyTrust vs. mistrust Hope Psychosis Addictions DepressionAutonomy vs. shame and Will Paranoiadoubt Obsessions Compulsions ImpulsivityInitiative vs. guilt Purpose Conversion disorder Phobia Psychosomatic disorder InhibitionIndustry vs. inferiority Competence Creative inhibition InertiaIdentity vs. role confusion Fidelity Delinquent behavior Gender-related identity disorders Borderline psychotic episodes
  22. 22. Psychosocial Stage Associated Virtue Related Forms of PsychopathologyIntimacy vs. isolation Love Schizoid personality disorderGenerativity vs. stagnation Care Mid-life crisis Premature invalidismIntegrity vs. despair Wisdom Extreme alienation Despair Nursing responsibilitiesNurses commonly perform Erikson’s developmental stages
  23. 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. 24. Age Period Cognitive Developmental Characteristics0 – 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 ability to express self with language, subperiod understands the meaning of symbolic gestures, and begins to classify objects7 - 11 Concrete operations application of logic to thinking, but thinking is still concrete11 – end of Formal operations more abstract thinkingadolescenceNursing Useful when nurses work with childrenresponsibilities 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. 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. 26. Harry Stack Sullivan• Interpersonal theory• Milieu therapy• Three modes of experiencing and thinking:1. Protaxic mode – undifferentiated thought that cannot separate the whole into parts or use symbols; occurs normally in infants and also appears in patients with schizophrenia2. Parataxic mode – events are casually related of temporal or serial connections; no perception of logical relatonships3. Syntaxic mode – logical, rational, and most
  27. 27. Harry Stack Sullivan• The three personifications of me:1. Good me – everything that you like about yourself that you let others see2. 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 you3. 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
  28. 28. Harry Stack Sullivan• Mental health alterations:1. Anxiety disorders2. Personality disorders
  29. 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. 30. Nursing Implications• Hildegard Peplau• Harry Stack Sullivan1. Nurse focuses on the nurse-patient relationship, the vehicles through which the patient becomes healthy2. Nurse counsel patients by developing therapeutic relationship3. Anxiety interventions is an important nursing role
  31. 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
  32. 32. Carl Rogers• Nurse-patient interaction is based on humanistic principles:a. Positive regardb.Empathyc. Geunineness
  33. 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. 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:a. Positive regardb.Empathyc. Geunineness
  35. 35. Theory Focus Mental Health Nursing Alterations ResponsibilitiesCognitive therapy How the person Anxiety disorders Client is encouraged perceives or to initiate topics of interprets his or her concern experience and Nurse listens determines how he carefully to the client or she feel and The nurse uses the behaves reflective listeningRational emotive Identifies irrational approaches to helptherapy beliefs that people the patient gain self- use to make understanding themselves unhappy The nurse helps the patient examineViktor Frankl and Search for meaning alternative choicesLogotherapy (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. 36. Theory Focus Mental Health Nursing Alterations ResponsibilitiesFrederick “Fritz” Perls Emphasis is on Anxiety disorders Client is encouraged- Gestalt Therapy identifying the to initiate topics of person’s feelings and concern thoughts in the here Nurse listens and now – increase carefully to the client self-awareness The nurse uses theWilliam Glasses - Person’s behavior reflective listeningReality therapy and how that approaches to help behavior keeps him the patient gain self- or her from achieving understanding life goals The nurse helps the patient examine alternative choices(Videbeck, pages 17 to 24 and 44 to 56 Student Guide, pages 83 to 90)
  37. 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. 38. Review of nervous system - neuroanatomy
  39. 39. Major NeurotransmittersType Mechanism of Action Physiologic EffectsDopamine Excitatory Controls complex movements, motivation, cognition, regulates emotional responseNorepeniphrine or Excitatory Causes changes inattention,noradernaline learning and memory, sleep and wakefulness, moodEpinephrine or adrenaline Excitatory Controls fight or flight responseSerotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Videbeck, page 21
  40. 40. Major NeurotransmittersType Mechanism of Action Physiologic EffectsHistamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responsesAcetylcholine Excitatory or inhibitory Controls sleep and wakefulness cycle, signals muscles to become alertNeuropeptides Neuromodulators Enhance, prolong, inhibit, or limit the effects of principal neurotransmittersGlutamate Excitatory Results in neurotoxicity if levels are too highGamma-aminonutytic acid Inhibitory Modulates other(GABA) neurotransmitters Videbeck, page 21
  41. 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
  42. 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
  43. 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 1. The use of radioactive substances in PET and SPECT is frightening to some people 2. Expensive 3. Some clients cannot tolerate the procedure 4. Many changes in some disorders like
  44. 44. Spirituality• Affirmation of life in relationship with God, self, community, and environment that nurtures and celebrated wholeness (
  45. 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. 46. Spiritual TheorySpirituality• things beyond biological experience• Gives depth and meaning to life• Presence of higher power• Higher purpose• Higher principles• “Spirituotherapy”
  47. 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. 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. 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. 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.
  51. 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.
  52. 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.
  53. 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
  54. 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