Etiology and Analysis of Dysfunction Notes
Etiology and Analysis of Dysfunction: Methodological Viewpoints
1. Notions and Terms
The origin/cause of phenomena is central to scientific inquiry.
Chapter 2.1 discusses different forms of causal explanations from a scientific perspective.
Etiology, the study of the causes of psychological disorders, is both a theoretical and practical concern.
Psychotherapy, rehabilitation, and especially primary prevention rely on etiological knowledge.
Symptom-oriented therapy can proceed without etiological knowledge but is often less satisfactory.
Even if interventions are closely linked to etiological theories, successful interventions do not necessarily validate the adopted etiological theory.
Most psychological disorders are multi-causal, involving a set of causes or a causal chain.
Multi-causality arises when no single cause is proven or when positive evidence supports multiple causes.
Even when a specific cause is known (e.g., chromosomal anomaly), a chain of conditions arising from that cause influences the individual's current state.
A differentiated concept of causality is needed to account for the complexity of psychological disorders.
Conditions favoring a disorder are distinguished from the disorder's direct cause(s).
Multi-causality can involve factors from the same or different levels (multi-modal models).
Psychological disorders can be determined by biological/somatic, psychological, social, or ecological factors.
Causes/conditions cannot be reduced to a single biological level.
Various sources of data influence each other, making factors at each level important.
Conditions of acquisition (etiology in the narrow sense) must be differentiated from conditions of maintenance (evolution of a disorder after its manifestation).
Research on acquisition conditions is central to prevention, allowing targeted reduction or removal of conditions reinforcing the disorder.
Knowledge of acquisition conditions is important for therapeutic indication and prognosis.
Understanding maintenance conditions is particularly important for therapy.
Psychoanalytic hypotheses emphasize the role of current psychodynamics as maintenance conditions.
Psychological concepts related to behaviors and cognitions highlight functional relationships between disturbed behavior and external stimuli, as well as internal cognitive tendencies.
Functional behavior analysis focuses on explanations of maintenance.
Individual factors can serve as both acquisition and maintenance conditions at different phases.
Comorbidity further complicates causal analysis, requiring clarification of the relationships between each disorder in ordered condition chains.
In comorbidity, disorders X and Y may be independent with separate causal chains or have shared causal chains.
2. Vulnerability vs. Protective Factors; Vulnerability vs. Resilience
Psychological disorders should be considered from a temporal perspective.
The emergence and evolution of disorders is generally accepted as a dynamic and interactive process.
Dynamic: the probability of illness is not stable but can change due to internal and external influences.
Interactive: the evolution of the illness occurs in the interaction between individuals and their environment.
Terms differentiate conditions/characteristics that facilitate illness (risk, risk factors, vulnerability, vulnerability factors, markers) from those that protect against it (protective factors, resilience, resources).
These influences are primarily considered according to pathogenesis (disease/disorder development).
If health includes more than the absence of disease, salutogenesis is also important (Antonovsky).
Salutogenesis refers to the emergence and maintenance of health; Antonovsky emphasizes the importance of the sense of coherence.
Conceptually differentiate:
Input: influences that are either destructive (risk factors, vulnerability factors) or protective (protective factors, resources).
Factors can be external (material, social) or internal (personal) and assigned to different data levels.
Marker: clinical research describes indicators or risk factors for a disorder.
Trait-Marker: Characteristics present at the first appearance of the disorder.
Allowing vulnerability to measured.
State-Marker: indicators measured only during an episode, predicting later evolutions.
Output: result (vulnerability vs resilience). Vulnerability, as a characteristic, includes the result of influences and the probability of illness.
Vulnerability can be genetic or environmental.
Distinction between primary vulnerability (present at birth) and secondary (acquired after birth).
Vulnerability is a key concept in schizophrenia research but is used generally.
Resilience: The level of resistance to stressors.
Also a characteristic of the person, resulting from transactional processes.
Some authors conflate resilience with protective factors, blurring the distinction from internal protective factors.
Diathesis-stress or vulnerability-stress models suggest that a predisposition (diathesis/vulnerability) – innate or acquired early – must be present for a stressor to trigger a psychological disorder.
A stronger predisposition requires fewer triggers; a weaker one needs more stressors.
Disposition implies a fixed characteristic established early.
Vulnerability and resilience are dynamic characteristics; constructs can increase or decrease in different phases.
The relationship between harm and protection is not always clear.
Protective factors are not simply the opposite of risk factors.
Interaction between risk and protective factors must be analyzed for a complete analysis of psychological disorders.
This interaction is important for each of the four phases of a disorder's evolution.
3. Phases of Disorder Evolution
3.1 Separation of Phases
To clarify the term "cause," a disorder's evolution is divided into four successive phases.
Different risk or protective factors can influence each phase, affecting vulnerability and resilience.
This division schematizes possible evolutions.
In individual cases or specific disorders, transitions may be indistinct.
The importance of each phase varies for explaining a specific disorder.
Etiological research must differentiate these phases:
3.2 Phase 1: Pre- and Perinatal Phase
Factors of influence:
Genetics (hereditary factors).
Prenatal influences (during pregnancy).
Perinatal influences (time of birth; from the 28th week of pregnancy to the 7th day of life).
Conditions present at birth are described as "innate" or "congenital."
The question remains open whether they are genetically or intra-uterinely conditioned.
The sum of these influences introduces different circumstances for later evolution in each individual.
The result of influences in phase 1 related to a psychological disorder are called: disposition, predisposition, diathesis, or primary vulnerability.
3.3 Phase 2: Socialization and Development Phase
Socialization includes personality changes based on influences from others and institutions (social environment).
Development focuses on intra-individual changes.
Development also used for all changes.
Psychoanalytic and attachment theories have closely linked socialization with early childhood (0-5 years).
This position is now replaced by the lifespan perspective: humans change throughout life due to various influences.
This perspective has also been fruitful in gerontology research.
The psychoanalytic view, with early childhood as the main determinant of psychological disorders, is no longer dominant, although early childhood is still considered a key phase of socialization.
3.4 Phase 3: Preceding the Appearance of a Disorder (Prodromal Phase)
Variable transitions between phases 2 and 3 exist for different disorders and individuals.
Despite often insidious onset, an attempt is made to pinpoint the start of the disorder's manifestation.
Determination of illness, desire for change, and seeking help can aid in dating.
The pre-existing state is important for identifying triggers.
Stress research (especially life events) has highlighted that stressful events (acute and chronic) can trigger disorders.
The question of cause and effect is difficult to answer.
For example, is the frequency of critical life events before the eruption of the disorder is an index of increased stress, the consequence of a disorder in the process of establishing itself, or a disturbance of perception?
3.5 Phase 4: Evolution Following the Eruption of the Disorder
Focus shifts to conditions maintaining the disorder.
Both worsening (e.g., stressful relationship) and protective (e.g., social support) factors influence subsequent evolution.
Expressed Emotions research has shown that specific family constellations and interactions increase the risk of relapse in schizophrenic patients.
3.6 Acquisition and Maintenance Conditions
Factors in phases 1 and 2 (partly phase 3) are described as acquisition conditions; phase 4 factors as maintenance conditions.
Etiological knowledge (acquisition conditions) informs therapeutic strategies for psychological disorders.
Etiological theories in the strict sense (phases 1 and 2) are still limited; knowledge of conditions maintaining the present disorder (phase 4) is more important.
4. Forms of Evolution of Episodes of Certain Disorders
The term "cause" often implies an initial acute appearance of a disorder that disappears after a period with or without treatment.
This form of evolution along with others can be seen in psychological disorders.
Referring to Zerssen (1987) and the CIM-10 and DSM-IV-TR classification systems, different forms of evolution can characterize a disorder's progression, individually or in combination:
When considering the particular manifestation of a disorder, we speak of an episode (disease episode; sometimes also phase).
The latter is characterized by the appearance of a disorder with a minimum manifestation (see the criteria of the CIM-10 or the DSM-IV-TR) and a minimum duration (for example the manic episode according to the DSM-IV-TR: at least one week of symptom manifestation).
Evolutionary forms of a disorder:
Paroxysmal evolution: a punctual evolution, in the form of access or crisis, of a disorder episode;
In a few minutes, the maximum value of extreme functioning is very often reached, and returns in a few minutes or hours to the starting value (for example, in panic attacks, the symptoms must, according to the DSM-IV-TR reach their maximum in 10 minutes).
Chronic, continuous evolution: the disorder episode remains for a long time (for example one year, two years) with a minimum manifestation.
This characteristic can only be attributed after a longer observation time (for example, according to the DSM-IV-TR: major depression, chronic character: at least two years).
If considering the evolution of a single episode, sequences can be stable, progressive or fluctuating.
Change can be continual or made through flare-ups
Considering the possible final states of an episode for a single disorder, variants can be differentiated:
Cure, recovery (the person is in good health): the same level as when the disorder appeared is reached, in which the disorder, disappeared, no longer occurs for a minimum defined period.
The personality structure present before the onset is described in pre-morbid personality.
Evolution with fluctuating manifestation
Complete Remission – There are no longer any signs or symptoms of the disorder, however it is possible the episode may re-occur
Partial Remission – There are still some minor symptoms of the disorder that do not meet the full criteria.
Chronicization – The disorder remains at a steady minimum level for a long period of time.
Personality Modification – The baseline level of the personality is never reached again after the effects of the disorder have reduced.
Death – There is a high chance of mortality with many psychological disorders through suicide or accidents.
If at least two episodes occur, the evolution is episodic, phases or recurrent (relapse) whether it's the same kind of disorder or completely different.
Long term evolution is described with specific codes in the DSM-IV-TR and the CIM-10.
Given one or more episodes, different evolutions can happen as each episode has its own final state.
5. Research Plans for Etiology and Dysfunction Research
5.1 Overview of Methodological Parameters
Various research strategies can be implemented to find important development and maintenance factors in disorders.
The points of view introduced in table 2 are proposed as systemization criteria for etiological research plans.
The introduced aspects can be combined:
If for instance students are being watched based on their performance in “With or without controllable noise” conditions (Learned helplessness), then there is a transversal study (group study) on a random same of the normal population.
5.2 Number of Measurement Points
5.2.1 Longitudinal Studies
Psychological disorders are to be understood an evolution in time so longitudinal studies are needed for research on etiology.
Experimental damage to research conditional structures of disorders are prohibited because of ethical reasons.
Prospective longitudinal studies: the appearance of a disorder can be seen through natural conditions: people are observed over a long period before disorder eruptions.
Attention is to be payed to the fact that most vast longitudinal studies only select a small park of the set of variables on the time axis.
Another problem is the generation effect.
The causality question in longitudinal studies is not easily explainable because factors only appear in specific combinations.
Today, ethical studies are being combined with intervention studies in order to facilitate causal interpretations.
"Fictious" Longitudinal Studies: Studies on people that differentiate based on the duration of independent variables.
By succession of each group (= cohorts), a temporary sequence is obtained.
Real effects can be emphasized by combining fictitious studies with real ones.
(Longitudinal) Retrospective Studies: Conclusions are made by conclusions drawn from past events (method important to psychoanalysis).
The information can still be useful for therapies;
5.2.2 Transversal Studies
Transversal Studies are often lead as clarification for etiology/conditional structures where two or more samples that differentiate between aspects of theoretical importance are compared.
Experimental studies are experiments where a group with the disorder S is compared to a control group not presenting symptoms in order to draw etiological information.
For example, if comparing two groups with disorders linked to psychotropic substances, you often see difference in age or professional background along with the diagnostic differences in the groups.
Transversal studies create problems of interpretations for the causes and efficiency of the disorder.
In a group with diagnosis X, phenomenon S (For e.g, a reduced number of social contacts) can be interpreted differently:
S belonging to disorder X
S coming from X, which makes it more difficult to recover.
S leading to X alone or with other factors.
S increasing the risk for X
5.3 Sample Selection
Etiology/conditional structures research can have different samples
Random or chosen sample of the normal population: Longitudinal prospective studies are very critical as non selected conditional structures are examined here.
Risk Groups: Research on risk groups are tolerated with smaller sample sizes.
Clinical Groups: Data can be used from all study designs in longitudinal and transversal groups.
5.4 Representivity of the (Clinical) Phenomena / Research
Analog studies refer to studies that only represent partially or in a comparative way the analyzed reality (Kazdin, 1980 ; Sher & Trull, 1996 ; see chapter 16 of the book).
Animal researches are a prototype as an analogous for the hypotheses on human beings (