Theories of Psychopathology

Lectured by Leila T. Salera, RN, MD,

DPSP
 Theories of Psychopathology
• Psychoanalytic theory – Sigmund Freud
• Developmental Theories
1. Psychosocial Stages – Erik Erikson
2. Cognitive Stages – Jean Piaget
• Interpersonal Theories
1. Harry Stack Sullivan
2. Hildegard Peplau
• Humanistic Theories
1. Hierarchy of Needs - Abraham Maslow
2. Client-centered Theory - Carl Rogers
• Behavioral Theories
• Classical Conditioning - Ivan Pavlov
• Operant Conditioning – Burrhus F. Skinner
 Theories of Psychopathology
• Existential Theories
1. Cognitive therapy
2. Rational emotive therapy
3. Viktor Frankl and Logotherapy
4. Gestalt therapy
5. Reality Therapy
• Biomedical Theory
• Spiritual Theory
 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 awareness
b. Preconscious - Preconscious – thoughts and emotions are not
currently in the person’s awareness, but can be recalled at will
with some effort
c. Unconscious - the realm of thoughts and feelings that motivate a
person even though he or she is totally unaware of them
 Psychoanalytic Theory
• Structural theory of the mind
a. Id
b. Ego
c. 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)
 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
 Ego defense mechanisms
Defense Mechanism Definition
Compensation Covering up a real or
perceived weakness by
emphasizing a trait one
considers more desirable
Denial Refusing to acknowledge the
existence of a real situation
or the feelings associated
with it
Displacement The transfer of feelings from
one target to another that is
considered less threatening
or that is neutral
(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
Example
A physically handicapped
boy is unable to participate
in football, so he
compensated by becoming a
great scholar
A woman drinks alcohol
every day and cannot stop,
failing to acknowledge that
she has a problem
A client is angry with his
physician, does not express
it, but becomes verbally
abusive with the nurse
 Ego defense mechanisms
Defense Mechanism Definition
Rationalization Attempting to make excuses
or formulate logical reasons
to justify unacceptable
feelings or behaviors
Reaction Formation Preventing unacceptable or
undesirable thoughts or
behaviors from being
expressed by exaggerating
opposite thoughts or types
of behaviors
((Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
Example
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.”
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
 Ego defense mechanisms
Defense Mechanism Definition
Regression Retreating in response to
stress to an earlier level of
development and the
comfort measures
associated with that level of
functioning
Identification An attempt to increase self-
worth by acquiring certain
attributes and characteristic
of an individual one admires
(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
Example
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
A teenager who required
lengthy rehabilitation after
an accident decides to
become a physical therapist
as a result of his experiences
 Ego defense mechanisms
Defense Mechanism
Intellectualization
Introjection
Definition Example
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 move
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)

 Ego defense mechanisms
Defense Mechanism Definition
Isolation Separating a thought or
memory from the feeling
tone or emotion associated
with it
Projection Attributing feelings of
impulses unacceptable to
one’s self to another person
Repression Involuntarily blocking
unpleasant feelings and
experiences from one’s
awareness
(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)
Example
A young woman describes
being attacked and raped
without showing any
emotion
Sue feels a strong sexual
attraction to her track coach
and tells a friend, “He’s
coming on to me!”
An accident victim can
remember nothing about
the accident
 Ego defense mechanisms
Defense Mechanism Definition Example
Sublimation 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 Drivers
Suppression 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.”
awareness
Undoing 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)
 Psychoanalytic Theory
• The Stages of Psychosexual Development
1. Oral stage
2. Anal stage
3. Urethral stage
4. Phallic stage
5. Latency stage
6. Genital stage
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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 Nurses with postgraduate training can conduct psychodynamic
responsibilities therapy
Nurse can use this theory in interpreting client’s behavior
Nurses’ must give attention to the client’s defense mechanisms
 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
 Psychosocial Stage Associated Virtue Related Forms of
Psychopathology

Trust vs. mistrust Hope Psychosis

Addictions
Depression
Autonomy vs. shame and Will Paranoia
doubt 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
 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
 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
Age Period Cognitive Developmental Characteristics

0 – 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 objects
7 - 11 Concrete operations application of logic to thinking, but
thinking is still concrete
11 – end of Formal operations more abstract thinking
adolescence
Nursing Useful when nurses work with children
responsibilities 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
 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
 Harry Stack Sullivan
• Interpersonal theory
• Milieu therapy
• Three modes of experiencing and thinking:
1. Protaxic mode – undifferentiated thought
that
2. cannotmode
Parataxic separate the whole
– events into parts
are casually or
related
useofsymbols;
temporaloccurs
or serial connections;
normally no and
in infants
perception
also appears inofpatients
logical relatonships
with schizophrenia
3. Syntaxic mode – logical, rational, and most
mature type of cognitive functioning of which
 Harry Stack Sullivan
• The three personifications of me:
1. Good me – everything that you like about
yourself that you let others see
2. 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
3. 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
 Harry Stack Sullivan
• Mental health alterations:
1. Anxiety disorders
2. Personality disorders
 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
 Nursing Implications
• Hildegard Peplau
• Harry Stack Sullivan
1. Nurse focuses on the nurse-patient
relationship, the vehicles through which the
patient becomes healthy
2. Nurse counsel patients by developing
therapeutic relationship
3. Anxiety interventions is an important nursing
role
4. Nurses use the nurse-patient relationship as a
 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
 Carl Rogers
• Nurse-patient interaction is based on
humanistic principles:
a. Positive regard
b. Empathy
c. Geunineness
 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
 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 regard
b. Empathy
c. Geunineness
 Theory Focus Mental Health Nursing
Alterations Responsibilities

Cognitive 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 listening
Rational emotive Identifies irrational approaches to help
therapy beliefs that people the patient gain self-
use to make understanding
themselves unhappy The nurse helps the
patient examine
Viktor Frankl and Search for meaning alternative choices
Logotherapy (logos) is the central
theme
Spirituality and grief
counseling

(Videbeck, pages 17 to 24 and 44 to 56 Student Guide, pages 83 to 90)

 Theory Focus Mental Health Nursing
Alterations Responsibilities

Frederick “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 the
William Glasses - Person’s behavior reflective listening
Reality 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)

 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
Review of nervous system -
neuroanatomy
 Major Neurotransmitters
Type Mechanism of Action Physiologic Effects

Dopamine Excitatory Controls complex

movements, motivation,
cognition, regulates
emotional response
Norepeniphrine or Excitatory Causes changes inattention,
noradernaline 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
 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 Inhibitory Modulates other
(GABA) neurotransmitters
Videbeck, page 21
 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
 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
 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
•1.Limitations
The use ofofradioactive substances
brain imaging in PET and
techniques
SPECT is frightening to some people
2. Expensive
3. Some clients cannot tolerate the procedure
4. Many changes in some disorders like
 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)
 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)
 Spiritual Theory
Spirituality
• things beyond biological experience
• Gives depth and meaning to life
• Presence of higher power
• Higher purpose
• Higher principles
• “Spirituotherapy”
 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.”
 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.
 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)
 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.
 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
 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.
 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
 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