2.D.2
Using models of psychopathology to formulate
ASPPB's competency statement 2.D.2: Apply evidence-based theories or models of psychopathology when formulating diagnoses, recommendations, or professional opinions
A model of psychopathology turns a list of findings into an explanation: what made the person vulnerable, what set the problem off and what keeps it going. Evidence-based models, from diathesis-stress and cognitive and behavioral maintenance models to dimensional systems such as HiTOP, guide what to assess, how to understand the pattern and which interventions should help. A formulation is a hypothesis, tested against the data and revised.
Key ideas
- Diathesis-stress
- Vulnerabilities (diatheses), biological or psychological, interact with stressors to produce disorder, and neither alone explains onset. Monroe and Simons urged precision about which stressors interact with which diatheses, noting that a diathesis can also shape the stress a person encounters.
- Cognitive maintenance models
- In the cognitive model of panic, attacks arise from a tendency to misinterpret bodily sensations as signs of imminent catastrophe, and avoidance and within-situation safety behaviors keep those beliefs from being disconfirmed.
- Learning models of avoidance
- Avoidance learning theories explain how avoidance, rewarded by the relief it brings, keeps fear from being unlearned; reviews of these theories draw out clinical strategies for reducing maladaptive avoidance and preventing its return.
- Dimensional and hierarchical models
- The Hierarchical Taxonomy of Psychopathology (HiTOP) groups co-occurring symptoms into dimensional syndromes and broader spectra, addressing the arbitrary boundaries, comorbidity and heterogeneity that limit categorical diagnoses.
Worked example
Ms. Grant, 29, has had repeated panic attacks for six months. When she feels dizzy she believes she is about to faint, so she grips the nearest furniture, sits down at once and carries sugar candy, and she has stopped exercising and going into crowded stores. Her physician found no medical cause.
- The cognitive model of panic directs the psychologist to the appraisal: she reads ordinary dizziness as a sign that she is about to collapse.
- The model also names the maintaining factors to assess: avoidance (exercise, crowded stores) and safety behaviors within the situation (gripping furniture, sitting down, the candy), which keep her from learning that the feared collapse does not happen.
- The formulation is checked against the data: do her attacks follow noticing a bodily sensation, and does her belief that she will faint drop when an attack passes without her fainting?
- The formulation points to treatment that tests the misinterpretation directly, for example by bringing on dizziness deliberately while she drops the safety behaviors.
A good formulation explains onset and maintenance and points to what needs to change.
Check yourself
Which approach classifies psychopathology by grouping symptoms that co-occur into dimensional syndromes and then into broader spectra?
Sources
- Monroe and Simons (1991), Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders, Psychological Bulletin (PMID 1758917), Psychological Bulletin 110, 406-425
- Clark (1986), A cognitive approach to panic, Behaviour Research and Therapy (PMID 3741311), Behaviour Research and Therapy 24, 461-470
- Salkovskis, Clark and Gelder (1996), Cognition-behaviour links in the persistence of panic, Behaviour Research and Therapy (PMID 8687367), Behaviour Research and Therapy 34, 453-458 (misinterpretation of bodily sensations; safety-seeking behaviors maintain catastrophic cognitions)
- Krypotos, Effting, Kindt and Beckers (2015), Avoidance learning: A review of theoretical models and recent developments, Frontiers in Behavioral Neuroscience (PMID 26257618), Frontiers in Behavioral Neuroscience 9, 189
- Kotov, Krueger, Watson and colleagues (2017), The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies, Journal of Abnormal Psychology (PMID 28333488), Journal of Abnormal Psychology 126, 454-477