1.A.5
Models of psychopathology and their effect on functioning
ASPPB's competency statement 1.A.5: Psychopathology (e.g., evidence-based theories and models of psychopathology, influence on functional abilities)
This statement covers evidence-based models of how mental disorders arise, persist and recur, and how they affect daily functioning. Diathesis-stress, developmental pathways, family environment and dimensional classifications explain why the same risk leads to different outcomes, why disorders co-occur and why the setting after an episode matters. A good model tells the clinician what to assess and what to change.
Key ideas
- Diathesis-stress
- A vulnerability (diathesis), biological or psychological, raises risk, and stress helps determine whether and when a disorder appears. Zubin and Spring's vulnerability model of schizophrenia is an early, influential statement of this idea.
- Equifinality and multifinality
- Different pathways can lead to the same disorder (equifinality), and one risk factor can lead to many outcomes, including none (multifinality). Developmental psychopathology therefore treats risk factors as probabilities, not destinies.
- Expressed emotion
- Expressed emotion (EE) is a measure of the family environment, reflecting relatives' criticism, hostility and emotional overinvolvement. A meta-analysis found high EE a robust predictor of relapse in schizophrenia, with even larger effects for mood and eating disorders.
- Dimensional models
- The Hierarchical Taxonomy of Psychopathology (HiTOP) groups co-occurring symptoms into syndromes and spectra measured as dimensions. A general factor, called p, captured liability across many disorders and was linked to greater life impairment.
- Functional impairment
- Most DSM-5-TR diagnoses require that symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Symptoms without such effects may not amount to a disorder, and impairment is often a central treatment target.
Worked example
A 24-year-old man is leaving the hospital after his first manic episode and will live with his parents. In a family meeting, his father repeatedly calls him lazy and irresponsible, and his mother says she will check his phone and run his schedule from now on. He is taking a mood stabilizer and wants to return to college part time.
- Identify the model: frequent criticism and emotional overinvolvement are core features of high expressed emotion, a family climate that predicts relapse in mood disorders as well as schizophrenia.
- Frame it without blame: EE predicts relapse after an episode, so it is a target for change, and the parents' reactions can be explored as fear and strain rather than judged.
- Draw on treatment evidence: in a randomized trial with bipolar disorder, family-focused therapy (psychoeducation, communication training and problem solving) plus medication led to fewer relapses and better adherence than brief crisis management.
- Keep functioning in view: make his return to college a shared goal, with the family agreeing how to notice and respond to early signs of relapse.
A model of what drives relapse tells the clinician which part of the environment to work with.
Check yourself
A man checks that his front door is locked two or three times before leaving home. He finds this mildly silly, it takes about a minute, and it causes no distress or problems at work or home. What is missing for a diagnosis of obsessive-compulsive disorder?
Sources
- Zubin and Spring (1977), Vulnerability: a new view of schizophrenia, Journal of Abnormal Psychology (PMID 858828), Whole article
- Cicchetti and Rogosch (1996), Equifinality and multifinality in developmental psychopathology, Development and Psychopathology, Whole article
- Butzlaff and Hooley (1998), Expressed emotion and psychiatric relapse: a meta-analysis, Archives of General Psychiatry (PMID 9633674), Abstract, Results and Conclusion
- Miklowitz, George, Richards, Simoneau and Suddath (2003), A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder, Archives of General Psychiatry (PMID 12963672), Abstract, Methods and Results
- Kotov, Krueger, Watson and colleagues (2017), The Hierarchical Taxonomy of Psychopathology (HiTOP): a dimensional alternative to traditional nosologies, Journal of Abnormal Psychology (PMID 28333488), Abstract
- Caspi, Houts, Belsky and colleagues (2014), The p factor: one general psychopathology factor in the structure of psychiatric disorders?, Clinical Psychological Science (PMID 25360393), Abstract
- American Psychiatric Association (2022), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Obsessive-compulsive disorder, Criterion B and insight specifier; the clinical significance criterion