Why is it important for clinical researchers to examine psychopathology from a perspective of lifespan?

Formal psychopathology among patients interested in cosmetic surgical and minimally invasive treatments

Introduction

Psychopathology and its associated interpersonal, emotional, and financial costs impact society at multiple levels and across a variety of domains. Research investigating the causes, course, and outcome of psychopathology has the potential to provide enormous benefits to afflicted individuals, their families, and society in general by informing innovative and specialized prevention and treatment strategies for a variety of different disorders. Developmental psychopathology has emerged as a leading scientific framework for identifying the dynamic exchange processes that influence both adaptive and maladaptive behavior.

The developmental psychopathology perspective represents an integration of several distinct scientific disciplines, including genetics, neuroscience, and psychiatry, as well as experimental, clinical, and developmental psychology. Scientists working within this framework aim to use these multiple levels of analysis in order to uncover the mechanisms that give rise to and maintain psychological disorders. This work is anchored on the perspective that the processes underlying typical and atypical development are mutually informative. That is, the continuity between normality and pathology (or adaptive and maladaptive behavior) as well continuity among the underlying causal mechanisms is emphasized.

This article aims to provide an introduction to the developmental psychopathology framework, including discussion of its key concepts and principles, as well as potential challenges to psychopathology research. Antisocial behavior is then discussed as an example, in order to further illustrate the ways in which developmental psychopathology research is advancing knowledge regarding the phenomenology, etiology, and treatment of psychiatric disorders.

10.02.1 Introduction

While psychopathology is embedded in the wider cultural context, theories of clinical psychology have generally been ethnocentric in nature. Cross-cultural studies in psychopathology often started with the assumption of the universality of these theories and attempted to compare the similarities and differences between cultural groups on aspects of these theories. Earlier interests in culture-specific aspects of psychopathology were related to peripheral curiosities about bizarre phenomena in exotic cultures. Because of their peripheral status, culture-bound syndromes were identified without much systematic research into the cultural dynamics of these syndromes. While they may have clinical meaning to the specific cultures, there is little relevance to the mainline theories. In this chapter, some of the culture-bound syndromes are demystified. The roles played by cultural factors in the presentation and interpretation of psychopathology are examined. Recent research is incorporating the universalist and relativist approaches of cross-cultural psychology and bringing cultural dimensions of psychopathology into the mainstream.

Abstract

Psychopathology in general and anxiety disorders in particular represent massive public health burdens due to their prevalence and chronicity, which results in substantial impairment across the lifespan. A multifaceted approach is needed to effectively address issues that require increased attention to prevention efforts. Indeed, there have been numerous calls to increase efforts to address mental health problems from a preventive perspective (e.g., American Academy of Child and Adolescent Psychiatry, 1990). In a review of prevention for anxiety and related psychopathology, Feldner and Zvolensky concluded that most existing prevention efforts fail to investigate the effects of modifying specific risk factors on the incidence of anxiety psychopathology. Instead, prevention programs for anxiety disorders have typically modified existing treatment strategies rather than targeting a specific risk factor or collection of theorized risk factors. Thus, prevention approaches tend to be symptom driven versus being based on theoretical models of psychopathology. These authors argued that there are several key reasons to incorporate risk-factor research into prevention programs but foremost is that prevention programs designed to target specific risk factors could be enormously helpful in providing causal tests of putative risk factors and thereby directly inform our understanding of these conditions. Work on anxiety sensitivity represents one such opportunity for risk factor focused preventative efforts.

Introduction

Psychopathology in later life occurs in the context of lifelong patterns of coping, social support, and connectedness, accumulated resources such as education and income, and characteristic late-life changes in physical health, cognition, and social relationships. This chapter presents a life-span perspective on psychopathology in late life, considering the interactions of specific manifestations of psychological disorders with the biopsychosocial and personal historical contexts within which they occur. We will focus on major clinical syndromes that fall within the categories of mood disorders, anxiety disorders, schizophrenia, and substance abuse disorders. We will also examine the role of bereavement as a common late life stressor.

What Is Psychopathology?

Psychopathology is the study of the experience and expression of abnormalities of mind. Hence, it inevitably involves a dynamic interaction between the person and their surroundings, the subject (or patient) and their witness (the observer).

Psychopathology has been approached in three different ways over the last 150 years:

Descriptive psychopathology involves the careful description of mental states of closely observed human experiences, without recourse to explanation (this has been called ‘phenomenology’ and is exemplified by the classic contributions of Karl Jaspers). This form of psychopathology is a prerequisite to accurate diagnosis; it requires time spent listening to subjects; and, by definition, the mental phenomena examined are conscious: they comprise what the subject experiences (and can describe). The formal, structured description of mental symptoms probably began in the 1860s.

Interpretative psychopathology also involves the careful description and understanding of human subjective experience, but seeks to explain it mainly through recourse to hypothesized unconscious mechanisms (this has been called psychodynamic psychopathology and is exemplified by the classic contributions of Sigmund Freud). Hence, much of what might be discussed in psychodynamic psychopathology concerns what the subject herself is unaware of (that which is ‘unconscious’ and initially unknown to her); part of the purpose of therapy is to understand recurring patterns of behavior that might, until then, have eluded recognition.

Experimental psychopathology has sought to understand subjective phenomena mainly in terms of brain processes; it currently constitutes the dominant paradigm and might subsume a host of investigators using a variety of physical methodologies to examine the biological processes supporting disordered mental life (e.g., Wilder Penfield’s pioneering use of direct electrical stimulation of the human cerebral cortex to elucidate the focal correlates of subjective experience (voices were heard by subjects when their temporal lobes were stimulated); or the discovery of the huntingtin gene by the Huntington’s Disease Collaborative Research Group in 1993, the latter indicative of a similarly mechanistic approach, albeit applied at a radically different level of explanation: genes rather than anatomically specified cerebral systems).

Hence, contemporary psychiatric practice requires the ability to retain an understanding of, and relationship with, individual human subjects, to help them attain autonomy (i.e., to effect change in the real-world) while simultaneously incorporating into their clinical care knowledge gleaned from experiments conducted at many different levels of mechanistic understanding (from genes to communities). This may precipitate tensions and, indeed, within scientific academic psychiatry, there is currently a search for endophenotypes, brain markers that may be objectively diagnostic of specific neuropsychiatric disorders, which could effectively circumvent the need for prolonged, detailed description of individual mental states. These approaches raise ethical issues that have yet to be fully explored.

1.07.1.1 What is Experimental Psychopathology?

Experimental Psychopathology (EP) has a long tradition as a research field. The earliest use of the term that we came across is in the title of a book from 1910: “Leitfaden der experimentellen Psychopathologie” by Adalbert Gregor. At that time, experimental psychopathology was seen a research field that links psychiatry and psychology, with a “chief interest in the investigation of the development or interrelations of mental symptoms” (Franz, 1912).

More recent definitions state that “Experimental psychopathology is the psychological science discipline that uses the methods of the experimental psychology laboratory in conjunction with quantitative analytic approaches to gain leverage on the etiology and pathogenesis of psychopathology, within a brain-based (genomic, endophenotype, neurobiological) diathesis-stressor matrix” (Lenzenweger, 2020). Thus, the emphasis is on the use of experimentation to better understand the mechanisms of mental disorders. In recent years, this emphasis also encompasses the improvement of treatments for those disorders, as is mirrored by this definition: “Experimental psychopathology researchers are devoted to understanding the causes and mechanisms of psychological disorders, with the central goal of developing and improving effective interventions” (Ouimet et al., 2021). In sum, experimental psychopathology is a field that is defined by the method used, experimentation, and by the subject studied, psychopathology. It is assumed that experiments allow for a precision in measurement of the dependent variables not attainable through usual clinical rating approaches. Moreover, truly experimental designs allow us to identify causal and maintaining factors in psychopathology, different from observational, correlational, or quasi-experimental research designs. Nevertheless, it must be admitted that as a research field, EP has had limited impact on main stream mental health care. This may be the case because the implications and applications of the results of EP studies, with their emphasis on discovering and elucidating the etiology and maintenance of psychological disorders, do not seem to translate easily into clinical practice. Still, we would assume that almost everyone has heard of “little Albert”, the boy who was reportedly conditioned to fear white rats (Watson and Rayner, 1920). This is one of the most famous experiments in psychopathology, but also an ethically very problematic one with many non-replications (e.g., Bregman, 1934). And many are also familiar with Martin Seligman's studies of “learned helplessness” (Seligman, 1975; reviewed by Maier and Seligman, 1976), which was based on experimental animal research and had great impact on how we think about depression today. Thus, EP is often at the basis of our theories of psychopathology, even if we do not immediately connect them with the name EP.

In addition to the etiology and maintenance of disorders, experimental psychopathology is also addressing clinical interventions, again focusing foremost at a better understanding of the mechanisms of intervention. Recently, Michelle Craske and her colleagues have conducted major experimental work on the learning processes that are involved in exposure therapy. This has led to a better understanding of the underlying processes, and to impressive improvements in the treatment of anxiety disorders (Craske et al., 2014). Moreover, there is now also an impressive number of completely new interventions that are based on experimental work, for instance, so-called “cognitive bias modification” interventions (MacLeod, 2012; Wiers et al., 2013). Nevertheless, the results of experimental psychopathology research often have to be “translated”, so they can be used and tested in applied contexts (see also van den Hout et al., 2017).

Behavioral accounts of novel behavior

Psychopathology often involves novel behavior that does not appear to be directly learned. A simple phobia may clearly involve conditioning (such as a fear of dogs following receipt of a painful dog bite), but even here, there is frequently behavior that has not been directly learned, such as the person's fearful behavior toward dogs who are physically dissimilar to the dog who rendered the bite. Often, there is not even a clear initial conditioning event (for example, when individuals demonstrate phobic responding to benign stimuli, such as flowers), and many disorders, such as generalized anxiety disorders and depression, are diffuse in that they involve behavior in many apparently unrelated environments and responding to disparate stimuli. Most behavior analytic accounts of novel behavior that is not directly taught appeal to one or two learning processes, such as stimulus generalization and reinforcement of novel responding. Derived relationships and transfer of function, however, may also explain many of the novel complex behaviors related to psychopathology.

Abstract

Psychopathology such as depressed mood and anxiety are frequently reported, among other daytime consequences such as excessive sleepiness, impaired occupational and social functioning, and lowered quality of life in individuals with untreated obstructive sleep apnea (OSA). Associations between illness severity or hypoxemic indices and mood symptoms have been identified but daytime sleepiness seems to be a more reliable predictor of emotional functioning of individuals with OSA. Treatment effects on mood functioning vary across studies, and interventions targeting persistent mood symptoms and functional deficits are called for. Behavioral problems and academic difficulties in children with OSA are outlined and discussed.

11.02.4.3 Developmental Psychopathology

The developmental psychopathology framework integrates key theories and methods from the fields of developmental science and psychopathology to understand the etiology and pathogenesis of mental health disorders. Under the lens of developmental psychopathology, normative and atypical development are mutually informative, as maladaptation is considered a deviation from a normal course of development. Each developmental stage presents new challenges related to emotions, cognitions, social interactions, and biology, wherein children must learn to adapt (Cicchetti and Cohen, 1995). When children meet these developmental challenges, success at future developmental stages is expected; however, maladaptation is likely to occur when children fail to master or resolve developmental challenges (Cicchetti and Cohen, 1995). For example, if a child fails to master language acquisition skills during toddlerhood, they have fewer resources to communicate and may display higher frustration and aggression during the next developmental stage of early childhood, when children are tasked with learning self-regulation skills and socio-emotional competencies (Hentges et al., 2021). Developmental psychopathology examines processes and pathways to further understand how, why, when, and for whom psychopathology develops. Developmental pathways are not considered to be deterministic; in the presence of buffering supports, adversity can be overcome. Thus, both risk and resilience factors are considered in this framework. As developmental psychopathology takes a life-span approach to risk and psychopathology, it takes a multigenerational perspective, which includes how parents transmit risk for psychopathology via both genetic and environmental pathways.