Week 1 – NRNP 6635 – Discussion Factors That Influence the Development of Psychopathology

Please review the complete instructions and the resources provided by school to complete this week discussion.

**THIS DISCUSSION IS DIVIDE IN TWO PARTS –

1. MAIN DISCUSSION POST BY Tuesday March 1 BEFORE 8:00 PM EST

2. TWO REPLIES BY Thursday March 3 BEFORE 8:00 PM EST

Discussion: Factors That Influence the Development of Psychopathology

In many realms of medicine, objective diagnoses can be made: A clavicula is broken.  An infection is present. TSH levels meet the diagnostic criteria for hypothyroidism. Psychiatry, on the other hand, deals with psychological phenomena and behaviors. Can these, too, be “defined objectively and by scientific criteria (Gergen, 1985), or are they social constructions?” (Sadock et al., 2015).

Thanks to myriad advances during recent decades, we know that psychopathology is caused by many interacting factors. Theoretical and clinical contributions to the field have come from the neural sciences, genetics, psychology, and social-cultural sciences. How do these factors impact the expression, classification, diagnosis, and prevalence of psychopathology, and why might it be important for a nurse practitioner to take a multidimensional, integrative approach?

To Prepare:

· Consider how theoretical perspective on psychopathology impacts the work of the PMHNP.

Instructions – Discussion

1. Explain the biological (genetic and neuroscientific); psychological (behavioral and cognitive processes, emotional, developmental); and social, cultural, and interpersonal factors that influence the development of psychopathology.

2. APA

3. At least five resources. Please use the resources provided by school. ( see attached PDF documents)

127

http://dx.doi.org/10.1037/0000064-006
APA Handbook of Psychopathology: Vol. 1. Psychopathology: Understanding, Assessing, and Treating Adult Mental Disorders, J. N. Butcher (Editor-in-Chief)
Copyright © 2018 by the American Psychological Association. All rights reserved.

Sociocultural factors influence the development,
presentation, classification, and assessment of psy-
chological disorders. Emotional and behavioral dis-
orders are closely tied to the social world. Although
mental disorders have universal commonalities, psy-
chopathology is embedded in socioculturally based
systems of meaning and values. Social and cultural
variations are found in the formation, expression,
labeling, and treatment of symptom experiences.

SOCIOCULTURAL PERSPECTIVES
IN DIAGNOSTIC SYSTEMS

Sociocultural factors influence the development, pre-
sentation, classification, and assessment of psycho-
logical disorders. Emotional and behavioral disorders
are closely tied to the social world. While there are
universal commonalities in mental disorders, psy-
chopathology is embedded in socioculturally based
systems of meaning and values. Social and cultural
variations are found in the formation, expression,
labeling, and treatment of symptom experiences.

Sociocultural Influences as Determinants
of Mental Health Disparities
In any society, mental health disparities have been
well documented across class, race/ethnicity, gen-
der, and sexual orientation, among many other
sociocultural determinants in prevalence and clini-
cal diagnosis (Garb, 1997). Across epidemiological

studies conducted in the United States and in the
United Kingdom, less privileged social position
was found to be associated with higher prevalence
of common mental disorders among women and
men, with unemployment, less education, and
lower income having stronger association than
occupational status with common mental disor-
ders (Fryers, Melzer, & Jenkins, 2003). Such social
gradient was also found across both genders on
depression, psychological well-being, self-reported
health, and smoking, with employment grade and
years of education showing a stronger relationship
than most recent occupational status (Marmot, Ryff,
Bumpass, Shipley, & Marks, 1997). As to sexual
orientation, based on the National Survey of Midlife
Development conducted in the United States, gay
and bisexual men were found to have higher preva-
lence of depression, panic attacks, and overall psy-
chological distress than heterosexual men; lesbian
and bisexual women were found to have a higher
prevalence of generalized anxiety disorder than
heterosexual women (Cochran, Sullivan, & Mays,
2003). A systematic review showed that lesbian, gay,
and bisexual individuals have higher risk for mental
disorder, suicidal ideation, substance misuse, and
deliberate self-harm (King et al., 2008). Consider-
ing sexual orientation along with ethnicity, find-
ings from the National Latino and Asian American
Survey showed a higher prevalence of depressive
disorders among Latino and Asian American lesbian

C h a P t e r 6

Sociocultural FactorS in
PSychoPathology

Fanny M. Cheung and Winnie W. S. Mak

The writing of this chapter was partially supported by the Hong Kong Research Grants Council General Research Fund (Nos. CUHK4333/00H,
CUHK4326/01H, and CUHK449312) as well as the Chinese University of Hong Kong Direct Grant (Nos. 2020662, 220202030, and 4052103).

APA Handbook of Psychopathology: Psychopathology: Understanding, Assessing, and
Treating Adult Mental Disorders, edited by J. N. Butcher and J. M. Hooley
Copyright © 2018 American Psychological Association. All rights reserved.

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Cheung and Mak

128

and bisexual women than among their heterosexual
counterparts (Cochran, Mays, Alegria, Ortega, &
Takeuchi, 2007). Such heightened risk for nonhet-
erosexual individuals has been found to be related to
perceived discrimination (Mays & Cochran, 2001)
and minority stress (Meyer, 2003).

Intersectional effects among sociocultural sta-
tuses on mental health were also found. On the basis
of data from the Behavioral Risk Factor Surveillance
System surveys from 1993 to 2001, although indi-
viduals with high socioeconomic status reported the
lowest level of frequent mental distress, prevalence
differed by race/ethnicity, being highest among non-
Hispanics of other race (7.9%), followed by Ameri-
can Indians/Alaska Natives (7.7%), non-Hispanic
Blacks (6.1%), Hispanics (5.9%), non-Hispanic
Whites (4.7%), and Asians/Pacific Islanders (3.8%;
Muntaner, Ng, Vanroelen, Christ, & Eaton, 2013;
Zahran et al., 2005). In another study (Williams,
Yu, Jackson, & Anderson, 1997), racial differences
in psychological well-being were accounted for by
economic status (income, education), race-related
stressors (e.g., major experiences of discrimination
and everyday discrimination), and general stress-
ors (e.g., chronic stress, financial stress, and life
events), with African Americans reporting higher
levels of well-being than Whites. Thus, rather than
investigating mental health disparities by any single
identity or status, the intersectionality of multiple
sociocultural identities or statuses should be consid-
ered simultaneously to capture the nuances of and
unique impact that multiple categories of identity,
difference, and disadvantage have on individuals
(Cole, 2009). Moreover, theoretical models such as
social stress models should be applied and tested to
disentangle the within- and between-group varia-
tions that social inequalities have on mental health
disparities (Aneshensel, 2009; Schwartz & Meyer,
2010). Disparities in the access to, utilization of, and
outcomes of services should be considered, along
with sociocultural biases in diagnosis and preva-
lence of mental disorders (McGuire, Alegria, Cook,
Wells, & Zaslavsky, 2006).

Culture and Psychopathology
From an international perspective, theories of cul-
ture and psychopathology have compared diversities

of psychopathology across cultures and examined
the role of culture (including all the nonbiological
aspects of the human social world) in causing or
determining the conditions that lead to psychiatric
disorders (Spiro, 2001). Other than the theory of
cultural determinism, the concept of cultural relativ-
ism proposes that the diversity in a mental disorder,
the variability of symptoms presented in that disor-
der, or the judgment of what constitutes pathology
may be explained by cultural diversity.

Since Kleinman (1977) heralded the interdis-
ciplinary research approach of cross-cultural psy-
chiatry, Western diagnostic systems have begun to
pay attention to indigenous illness categories and to
recognize cultural limitations of some of the existing
diagnostic nosologies that aim to provide a common
language for mental health professionals to commu-
nicate across cultural and social contexts. Kirmayer
(2005) unequivocally warned that

psychiatric nosology and the process
of clinical assessment must consider
the ways in which psychopathology is
shaped by social and cultural contexts
including those of the family, workplace,
and health care system as well as global
professional, economic and political
interests. (p. 192)

López and Guarnaccia (2000) summarized two
major recent advances in the study of culture and
psychopathology: the establishment of the task force
funded by the National Institute of Mental Health to
develop cultural materials to be incorporated into
all sections of the fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM–IV;
Mezzich et al., 1997), and the publication of the
World Mental Health Report (Desjarlais, Eisenberg,
Good, & Kleinman, 1996). Although these devel-
opments advance the range of conceptualization
of cultures and the importance of social domains,
cultural psychopathology remains in the periphery
of mainstream epistemology. Culture continues to
be disconnected from theory, research, training, and
intervention (Causadias, 2013).

Because a psychiatric diagnostic system aims to
provide a universal nomenclature for clinicians and
researchers across different settings to collect and

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Sociocultural Factors in Psychopathology

129

communicate information, cultural considerations
are requisite for the diagnostic classifications to be
accurate and valid. The two most commonly adopted
systems are the American Psychiatric Association’s
Diagnostic Statistical Manual of Mental Disorders
(DSM) and the World Health Organization’s Interna-
tional Classification of Diseases (ICD) mental disorder
section. These contemporary systems are based in
Western models of medicine, taking into account
comprehensive reviews of the published literature and
data sets, as well as extensive field tests on selected
issues. Both systems have undergone periodic reviews
and revisions. Instead of describing the classifications
of these diagnostic systems, we focus on the cultural
and sociocultural perspectives incorporated into the
latest versions and discuss the critiques of the inad-
equacies of and improvements in incorporating socio-
cultural considerations into these systems.

Inclusion of Culture in DSM–IV
and DSM–5
Early versions of the DSM have been criticized for
their neglect of cultural relevance. Bias on the basis
of a person’s race, ethnicity, class, gender, age, sexual
orientation, religion, and other sociocultural influ-
ences affects the accuracy of clinical judgment if the
diagnosis is more valid for one group of persons than
for other groups (Garb, 1997). These biases may
arise from the lack of sensitivity to diversity issues in
the diagnostic criteria, as well as from the clinicians’
lack of sensitivity when gathering and integrating
the clinical information. In an effort to increase its
cultural sensitivity, the text revision of the DSM–IV
included an Outline for Cultural Formulation (OCF)
of a person in the appendix, which includes the
“cultural identity of the individual,” “cultural expla-
nations of the individual’s illness,” “cultural factors
related to the psychosocial environment and levels of
functioning,” “cultural elements of the relationship
between the individual and clinician,” and “overall
cultural assessment for diagnosis and care” (Ameri-
can Psychiatric Association, 2000, pp. 843–844).
The appendix also included a glossary of 25 com-
mon culture-bound syndromes to denote “recurrent,
locality-specific patterns of aberrant behavior and
troubling experience that may or may not be linked
to a particular DSM–IV diagnostic category” (p. 844).

On the basis of an extensive literature review by
experts in the field of cultural and mental health,
materials related to the OCF written in English,
Danish, Dutch, French, Norwegian, Spanish, and
Swedish were accessed (Lewis-Fernández et al.,
2014). The OCF was found to be useful in improv-
ing the clinicians’ and psychiatrists’ accuracy in
making clinical diagnoses and reducing the over-
diagnosis of psychotic disorders among ethnocul-
tural minorities. For example, findings in Canada
demonstrated that the use of the OCF resulted
in rediagnosis of 60% of 400 referrals (Kirmayer,
Guzder, & Rousseau, 2014). In another study, 49%
(34 of 70) of the patients were rediagnosed from
psychotic disorder to non-psychotic disorder and
5% (12 of 253) patients from non-psychotic disor-
der to psychotic disorder on the use of OCF-based
assessment (Adeponle, Thombs, Groleau, Jarvis, &
Kirmayer, 2012). Similar results were found in the
Netherlands, where the OCF-based assessment was
found to increase the validity of the Comprehensive
Assessment of Symptoms and History in diagnosing
schizophrenia and related disorders. Specifically,
among Moroccan patients, the OCF-based Com-
prehensive Assessment of Symptoms and History
reached a 93% diagnostic agreement (κ= .79) com-
pared with a 48% diagnostic agreement (κ = −.49)
using the assessment without consideration of cul-
tural factors (Zandi et al., 2008).

Moreover, the OCF has been used in medical
training programs in Canada, Denmark, India, the
Netherlands, Norway, Spain, Sweden, the United
Kingdom, and the United States. Despite its wide
adoption, difficulties were reported in determin-
ing how to use the OCF in actual practice with
which populations and at what times. Furthermore,
how the information gathered can be effectively
integrated within psychiatric formulation and for
adaptation of clinical approaches to varied popula-
tions was not clear (Lewis-Fernández et al., 2014).
In addition, the application of the OCF took much
more time, with some areas being redundant with
standardized diagnostic assessment.

To address these concerns, the fifth edition of the
DSM (DSM–5) has incorporated more extensive con-
sideration of cultural perspectives by introducing
a Cultural Formulation Interview to operationalize

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Cheung and Mak

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the revised OCF for the facilitation of actual gather-
ing of cultural information for a systematic assess-
ment. The DSM–5 Cross-Cultural Issues Subgroup
used a person-centered, ethnographic approach in
the development of a semistructured interview to
guide the use of the OCF (Lewis-Fernández et al.,
2014). It consists of a 16-item questionnaire along
with 12 modules to address the issues raised in the
OCF. It also includes an informant version to obtain
sociocultural information from caregivers and fam-
ily members (American Psychiatric Association,
2013). The Cultural Formulation Interview has
gone through a field trial for further refinement in
terms of conceptual relevance between patients and
clinicians, fidelity to the format, and repetition in
the questions (Aggarwal, Nicasio, DeSilva, Boiler, &
Lewis-Fernández, 2013). Despite the subgroup’s
efforts in reviewing previous practice and training in
the development of Cultural Formulation Interview,
it is noted that the viewpoints from Asian countries,
specifically those from East Asian and Southeast
Asian countries, were underrepresented in the dis-
cussion. Stronger efforts should be made to include
core representatives from this part of the world to
consider varied sociocultural perspectives of differ-
ent countries.

In discussing the cross-cultural use of the DSM–5
constructs, norms, and guidelines, Rounsaville
et al. (2005) recognized the importance of paying
attention to cultural perspective in the meaning of
statements reflecting diagnostic or clinical criteria
in different parts of the world. As a key “conceptual
scaffolding” of environmental factors that act on
genetic or neurobiological predispositions in a per-
son’s life, culture is considered to be a contributing
factor to the pathogenesis of mental disorders
(p. 17). It is acknowledged that although core diag-
nostic criteria may be universally applicable, there
are cross-cultural variations in symptom definition
and symptomatic manifestations.

Alarcón et al. (2005) presented the current cul-
tural perspective that conceptualizes psychiatric
knowledge and practice from a more comprehensive
perspective of social, cultural, economic, politi-
cal, and historical factors in the DSM–5 research
agenda. The cultural variables proposed include
ethnicity, language, education, religion, gender and

sexuality roles, values, migration and acculturation,
socioeconomic status, and occupational hierarchies.
They proposed five interrelated questions to guide
the thematic research on the cultural perspective of
diagnosis:

1. Has the right nosologic system been
conceptualized?

2. Are the right diagnostic categories and criteria
being used?

3. Has the diagnostic threshold been set at the right
level?

4. Have the course and characteristics of disorders
been correctly typified?

5. Are existing diagnostic criteria being employed
in an unbiased and culturally appropriate way?
(pp. 223–225)

These are useful questions not only to guide
research but also in the diagnostic criteria and pro-
cesses. However, the usefulness of these guiding
questions depends on the sensitivity of researchers
and practitioners to the importance of addressing
these concerns.

Inclusion of Culture in ICD–10 and
Revision
As a member of the World Health Organization’s
“family” of international classifications, the ICD
provides a global standard for a health information
system that facilitates international communication
across the health sector. It is periodically reviewed
with the aim of updating the scientific evidence,
clinical utility, and public health usefulness. The lat-
est version, the ICD–10, was adopted by the World
Health Assembly in 1990.

The ICD–10 Classification of Mental and Behav-
ioural Disorders (World Health Organization,
1993) took into account the viewpoints of the dif-
ferent psychiatric traditions and involved exten-
sive consultation with international psychiatric
societies and experts. International field trials were
conducted in about 40 countries to improve the
psychiatric diagnostic criteria. Associated diag-
nostic instruments with training tools in different
languages were developed, and a set of Diagnostic
Criteria for Research was designed for research use
in different countries.

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Sociocultural Factors in Psychopathology

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In addition to the universal diagnostic catego-
ries, the annex in the ICD–10 lists 12 frequently
described culture-specific disorders that share the
following characteristics:

(1) they are not easily accommodated by the cat-
egories in established and internationally used
psychiatric classifications;

(2) they were first described in, and subsequently
closely or exclusively associated with, a particu-
lar population or cultural area. (World Health
Organization, 1993, p. 213)

Recognizing the skepticism of some researchers
toward the culture specificity of these culture-bound
syndromes, ICD–10 provides a description of the
clinical features for each of these disorders, sug-
gested ICD–10 codes that may be related to these
labels, and identified potentially related syndromes
in other cultures. Noting the lack of reliable clini-
cal, anthropological, epidemiological, and biologi-
cal information on these culture-specific disorders,
further cultural and cross-cultural research is rec-
ommended before clear diagnostic criteria can be
established. This approach to culture-specific disor-
ders provides a useful framework to facilitate further
research on cultural variations in the clinical mani-
festations, distributions, frequency, and course of
these syndromes, so as to fine tune the lexical defini-
tions of the taxonomy in cross-cultural psychiatry.

Preparation for the 11th revision of the ICD
(ICD–11) has involved input from international
stakeholders. The framework for the deliberation of
the topical advisory groups includes greater atten-
tion to cultural elements and how the presentation
of disorders varies across cultures. The work groups
have also been directed to “identify ways to achieve
cross-cultural comparability and utility of diagnostic
criteria rather than listing separate culture-bound
syndromes or formulations” (WHOFIC Network,
2007, p. 15). International teams conduct field tri-
als to test the provisional revised diagnostic criteria.
This iterative process is intended to broaden the cul-
tural perspective of the diagnostic taxonomy and the
universal applicability of the diagnostic criteria. The
ICD–11 is due to be published by 2018.

Notwithstanding the recent efforts to broaden
the cultural perspectives in the diagnostic criteria

of the DSM–5 and ICD–11, greater attention is
also needed to enhance the cultural sensitivity of
practitioners and researchers in their diagnosis and
clinical assessment of individuals from diverse back-
grounds. We discuss these training needs in the last
section of this chapter.

Culture-Bound Syndromes: Controversies
and Resolutions
The inclusion of culture-bound syndromes in the
annexes of the DSM–IV and ICD–10 is perceived
to be the primary cultural focus of these diagnostic
systems. These indigenous expressions of mental
afflictions usually have local names that may not be
found in Western psychiatric lexicons. The topic of
culture-bound syndromes has its own controversies.
On one hand, some researchers have challenged
whether culture-bound syndromes can be seen as
variants of Western disorders contextualized in
non-Western cultures and not as special categories
indigenous to specific cultures. On the other hand,
putting these culture-bound syndromes in the
annexes gives the impression that they are relegated
to an exotic category of curiosity.

Marsella and Yamada (2010) questioned why
“those identified and coded in the West in DSMs and
ICDs are considered the real thing” (p. 107), whereas
both could be considered cultural products in their
respective cultures. Cheung (1998) discussed the
controversy of these culture-bound syndromes in
the context of emic versus etic approaches. Instead
of being engulfed in the emic-versus-etic debate
(Cheung, 2012) and regarding culture-specific disor-
ders as bound to a particular culture, she suggested
that the usefulness of these culture-related syndromes
lies in their provision of better understanding of the
cultural context of psychopathology, particularly
those that are unfamiliar to Western models. She
cited the transformation of neurasthenia from an out-
dated Western psychiatric nomenclature to a popu-
lar diagnostic term in Chinese, shenjing shuairuo,
adopted in traditional Chinese medicine as well as in
Chinese psychiatry, until recent years when literacy
on emotional disorders increased with the modern-
ization of Chinese societies (Cheung, 1989). Through
the attention to less stigmatizing somatic symptoms
attributed to socially acceptable causes of overwork

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Cheung and Mak

132

and bodily imbalance, the adoption of this diagnos-
tic label provides useful clinical understanding of
patients’ illness experience and their social contexts
(Cheung, 1998).

In the DSM–5 (American Psychiatric Association,
2013), culture-bound syndromes are replaced by
cultural syndromes, cultural idioms of distress, and
cultural explanations to further delineate the impact
of sociocultural factors in the expression and com-
munication of distress that reflect specific symptom
clusters (syndromes), common expressions of dis-
tress that may not have specific symptoms (idioms),
and causal models that are used to understand and
interpret their experience (cultural explanations;
Lewis-Fernández et al., 2014). In the next section,
we further discuss the phenomenon of somatization
among Chinese patients to illustrate the cultural
contextualization of mental distress.

Example of Chinese Somatization
Tendency
The phenomenon of Chinese somatization serves
as an illustrative example of the potential pitfalls of
“category fallacy,” the unwarranted assumption that
a Western psychiatric diagnosis carries the same
meaning when extended to another cultural context
(Kleinman, 1986). The understanding of how cul-
ture interacts with formal diagnostic categories to
create alternative frames of meaning would enhance
practitioners’ and researchers’ clinical sensitivity.

In the early stage of cultural psychiatry, the
tendency of Chinese patients to present their
depression in the form of somatic symptoms was
highlighted (Kleinman, 1977). References were
then made to various aspects of Chinese culture
to attribute this somatic tendency without strong
empirical evidence. Cheung (1998) disputed these
post hoc cultural hypotheses and showed through
various studies that Chinese patients were cogni-
zant of their emotional distress but would report
their somatic symptoms as “idioms of distress”
(Kleinman, 1986) to doctors in the context of
medical consultation. They would acknowledge
their emotional symptoms when asked and pre-
ferred to seek emotional support from their peers
and family instead of from medical professionals
(Cheung, Lau, & Wong, 1984). In another study

among Chinese American patients in primary care,
although most of them (93%) endorsed depressed
mood using the Beck Depression Inventory, only
10% labeled their experience as psychiatrically
related (Yeung, Chang, Gresham, Nierenberg, &
Fava, 2004). Thus, patients’ illness experience
depends on the contextual factors that affect how
they seek help for it. Instead of replacing their
psychological distress with somatic symptoms,
Chinese are reporting different types of symptoms
depending on the reporting situation and their
routes of help seeking (Mak & Chen, 2010). Such
tendencies are more salient among immigrant
populations and those with lower socioeconomic
status who have not been “psychologized” by the
Western cultures. Chinese who somatized were
also found to experience more stressors and less
social support than their counterparts (Mak &
Zane, 2004). Thus, the experience of somatization
might be an idiom of distress resulting from exces-
sive stressors and a lack of social support in coping
with them. It also hinges on the explanatory mod-
els used by Chinese who somatized in attributing
their symptoms.

The somatization tendencies observed among
the Chinese may also be related to a distinct cul-
tural syndrome, referred to as neurasthenia or shen-
jing shuairuo. In the Chinese American Psychiatric
Epidemiological Study, 6.4% of a random sample
of 1,747 Chinese Americans living in Los Angeles
were found to have neurasthenia, according to the
ICD–10 (Zheng et al., 1997). Among them, the
majority (56.3%) did not meet any current or lifetime
DSM-defined mood or anxiety disorder diagnosis. In
another study, Chang et al. (2005) found that 44.9%
of Chinese patients with shenjing shuairuo did not
meet the criteria for any DSM diagnosable disorders.
Thus, shenjing shuairuo is a distinct clinical syndrome
experienced by Chinese, rather than an alternative
expression of any Western diagnosis. The phenom-
enon of somatization is heterogeneous among Chi-
nese, which can be a cultural syndrome in the form of
shenjing shuairuo, a cultural idiom of distress contin-
gent on the context in which they seek help and their
cultural explanation of the symptoms they experience
in response to their stress and sociocultural experi-
ence (Mak, Cheung, & Leung, 2012).

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Sociocultural Factors in Psychopathology

133

Finally, it must be emphasized that such report-
ing of somatic symptoms was not specific to Chi-
nese. Studies found no significant differences in
the reporting of somatic systems across ethnic
groups in general practice and that the reporting
of somatic symptoms was very common among
nonclinical populations across cultural groups
(Simon, VonKorff, Piccinelli, Fullerton, & Ormel,
1999). Furthermore, the prevalence of somatiza-
tion disorder was low among Chinese populations
(1.5% in Shanghai, China) and was comparable to
that among other Western populations (i.e., 1.7%
in Seattle, Washington; 1.3% in Berlin, Germany;
and 2.8% in Groningen, the Netherlands; Gureje,
Simon, Ustün, & Goldberg, 1997). In a review of
epidemiological studies examining the prevalence of
somatization across different Asian regions or coun-
tries (Mainland China, Taiwan, Hong Kong, Korea),
the lifetime prevalence rates of somatization were
very low (0–0.2%) and were comparable to that
found among Asian Americans in the Epidemiologic
Catchment Area Study (Chang, 2002).

This discussion of the Chinese somatization
tendency illustrates how individuals’ beliefs, help-
seeking behaviors, and symptom presentation,
together with practitioners’ clinical and cultural sen-
sitivity to these contexts, may affect their diagnostic
classification. Likewise, the need for cultural sensi-
tivity in psychological assessment in making clinical
diagnosis and intervention decisions is evident. In
the next section, we discuss issues related to cross-
cultural validity of psychological assessment.

CROSS-CULTURAL PSYCHOLOGICAL
ASSESSMENT

Psychological assessment forms a major part of
the diagnostic process of psychopathology. The
most common tools for clinical assessment include
observation, interview, and testing. Psychological
tests have become a standard method to evalu-
ate psychopathology and responses to treatment.
Among the psychological tests developed in the
20th century, standardized objective personality and
cognitive tests with demonstrated reliability, valid-
ity, and reference norms are the most commonly
used tools in clinical assessment (Butcher, 2009).

Most of these tests were developed in the English
language and assumed to be universally applicable.
Many major clinical tests were translated and trans-
ported to other language and cultural settings as
though they were equivalent to the original tests.
The translated tests were interpreted in the same
way as though they were the original tests (Cheung,
2009). The universal assumption has been chal-
lenged in cross-cultural assessment. Even when
item translation is not involved, such as with projec-
tive tests in which the test stimuli are not language
based, cultural biases may arise from the assessment
method itself as well as the uncertain cross-cultural
validity of the imported tests (Church, 2001; Van
de Vijver & Hambleton, 1996). With increasing
cross-cultural interactions through globalization,
migration, and population diversity, challenges of
multicultural assessment are not limited to settings
in which imported translated tests are used, but also
when using same-language tests within geographi-
cal boundaries with ethnocultural, gender, and
class diversities (Van de Vijver & Poortinga, 1997).
Cultural biases may result in misdiagnosis and mis-
guided treatment decisions.

Cultural Biases and Cross-Cultural
Equivalence in Psychological Assessment
With the advances in international and cross-
cultural psychology since the 1970s, there has been
more focused discussion of the methodological
issues in cross-cultural assessment (Cheung, 2009;
Marsella, Dubanoski, Hamada, & Morse, 2000;
Marsella & Leong, 1995; Van de Vijver & Leung,
1997; Van de Vijver & Poortinga, 1997). Marsella
and Leong (1995) discussed two major ethnocen-
tric errors in cross-cultural assessment. In the early
stage of cross-cultural assessment, many research-
ers directly applied the conclusions drawn from
the original Western studies to represent universal
human behaviors without conducting any cross-cul-
tural comparisons, resulting in an error of omission.
With this error of omission, it is assumed that there
are no cultural variations in the observed results.
Even when different cultural groups were included
for comparison, the original Western measures were
imposed on the other cultural groups as though
they would be valid for all groups, resulting in an

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error of commission. Even when cultural variations
are obtained, it is unclear whether the observed
variations are substantive or the result of biases of
imposed measurement.

Van de Vijver and Poortinga (1997) summarized
three forms of bias in cross-cultural assessment:
construct bias, method bias, and item bias. Construct
bias refers to the variations or insufficient overlap
in the definition of the construct being measured
across cultures. The measurement of culture-bound
syndromes would be illustrative. Culture-bound
syndromes are generally limited to local cultures
and may not have equivalent diagnostic categories
in the DSM or ICD classification systems. So a mea-
sure of these syndromes may not be meaningfully
transported to another culture. Even with com-
mon diagnostic categories, the inclusion or exclu-
sion of specific behavioral manifestations may vary
across cultures such that what are included in the
measure may affect the definition of that construct.
For example, not sitting still in a classroom may
be considered hyperactivity for children in a dis-
ciplined cultural environment, but it may not be
considered as such for children in a freer and active
environment.

Method bias refers to the procedure in the assess-
ment that may give rise to cultural differences. The
bias may arise from the nonequivalence in the back-
ground of the cultural samples involved, which may
affect their familiarity with the assessment method
or the administration procedures. Cultural groups
may differ in their response styles or social desirabil-
ity tendencies toward the test stimuli.

Item bias may arise from nonequivalence between
the original and the translated items, which may be
due to inclusion of items that are irrelevant to the
local culture, as well as translation errors or differ-
ential item functioning, resulting in different item
endorsement rates or different discriminatory power
of the item across cultural groups.

Bias affects the comparability of test scores across
cultures. To ascertain cross-cultural comparabil-
ity, equivalence between the measures used for
the different cultural groups has to be established.
Researchers have discussed various forms of equiva-
lence in cross-cultural research methodology (e.g.,
Van de Vijver & Leung, 1997; Van de Vijver &

Poortinga, 1997). Cheung (2009) summarized four
levels of equivalence between the original measure
and its adapted versions in personality assessment:
linguistic equivalence, construct equivalence, psy-
chometric equivalence, and psychological equiva-
lence. Other authors may use different terms to
describe these concepts.

Linguistic equivalence refers to equivalence at the
basic level of item and instructions in which both
language versions should convey the same literal
meaning. Cross-cultural psychologists have recom-
mended multiple translation methods to obtain
accurate and appropriate translation.

Construct equivalence refers to the extent to
which the psychological construct in the original
culture is generalizable to the new culture.
A personality construct may differ in form and level
across cultures, and a literal translation may not
capture the meaning of the underlying construct. So
linguistic equivalence may not necessarily ensure
construct equivalence.

Psychometric equivalence refers to the similarity
in the psychometric properties of different language
versions of the test. Differences in item endorsement
rates, reliability, score level, and factor structure
affect the confidence in whether the translated ver-
sion can rely on the scientific evidence established
for the original measure.

Psychological equivalence refers to the experien-
tial familiarity, cultural relevance, or functional util-
ity of the translated items or test in the target culture
as demonstrated by the original test in the source
culture. Demonstrating cross-cultural validity of the
predictive functions of the translated test will sup-
port the usefulness of the translated test in assessing
similar diagnoses or predicting similar outcomes as
intended by the original test.

A systematic approach to translation, adap-
tation, and validation is particularly crucial in
clinical assessment when tests from another cul-
ture are adopted for diagnosis, treatment, and
forensic evaluation (Cheung, 2009). Ensuring
equivalence is an important part of the process of
adapting tests to another culture. Recent advances
in research methodology offer new statistical tools
such as hierarchical multilevel analysis to compare
cross-cultural similarities and differences at the

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Sociocultural Factors in Psychopathology

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individual level as well as at the multicultural level
(van de Vijver & Leung, 2001). A good example
of test translation and adaptation may be found
in the international adaptation of the Minnesota
Multiphasic Personality Inventory (MMPI) and the
MMPI–2 (Butcher et al., 2001).

Example of the Chinese Minnesota
Multiphasic Personality Inventory
The MMPI and MMPI–2 are the most widely used
personality assessment tests in clinical settings in
the world. More than 33 translations of the MMPI–2
are in use, and 22 language versions are currently
available from the University of Minnesota Press
(https://www.upress.umn.edu/test-division/
translations-permissions/available-translations).
Butcher, Mosch, Tsai, and Nezami (2006) reminded
practitioners about possible cultural influences on
testing that may affect the accuracy of diagnosis and
treatment, and they highlighted the cultural factors
that should be considered when interpreting the
MMPI–2 with clients from different cultural back-
grounds (p. 510). In addition, Butcher and his asso-
ciates (Butcher & Han, 1996; Butcher et al., 2006)
have formulated a comprehensive system of cross-
cultural adaptation of objective personality tests
with technical solutions. The quality of international
adaptations of the MMPI–2 should be evaluated
against these parameters.

To achieve linguistic equivalence, Butcher, Lim,
and Nezami (1998) advocated using multiple inde-
pendent translators who are bilingual and bicultural
to translate and back-translate the items. The pro-
cess is repeated to reduce discrepancies to the mini-
mum, paying attention to equivalence in vocabulary,
idiom, and grammar.

To test for construct equivalence, Butcher and
Clark (1979) recommended evaluating the bilingual
test–retest reliabilities of both language versions
taken by bilingual participants within 1 to 2 weeks
and comparing these with the test–retest reliabilities
of the single-language versions. Further validation
studies should be conducted with monolingual par-
ticipants in that culture.

A variety of statistical methods are used to pro-
vide objective indices to demonstrate the psychomet-
ric equivalence between different language versions,

including reliability, item-scale correlation, item
endorsement frequencies, interitem correlations,
interscale correlations, and factor congruence. The
MMPI–2 Content Scales book (Butcher, Graham,
Williams, & Ben-Porath, 1990) and MMPI–2 manual
(Butcher et al., 2001) provide useful psychometric
information on the English version to which the psy-
chometric properties of the translated versions may
be compared. By comparing the American norma-
tive sample’s overall scores on the scale items with
those of comparable samples in the target culture
and determining whether responses to the items dif-
fer widely, it can be established whether American
norms can be appropriately applied or whether new
set of local norms should be established through a
restandardization study.

To determine psychological equivalence, empiri-
cal studies are conducted to examine whether the
pattern of test results with similar samples would
predict outcomes similar to those of the original
American studies. These local studies are needed
to establish the cross-cultural validity of the inter-
national versions of the MMPI–2 and confirm the
usefulness of carefully adapted versions of MMPI–2
in clinical assessment when appropriate norms are
used.

The Chinese translation of the MMPI–2 has fol-
lowed closely these adaptation procedures. Cheung
(2009) began the Chinese translation in the late
1970s in Hong Kong. Her Chinese version was
introduced to the Institute of Psychology of the
Chinese Academy of Science by the late Raymond
Fowler, who led the first American Psychological
Association (APA) delegation to visit the institute
on its resumption of scientific activities after the
end of the Cultural Revolution in 1980. The Chi-
nese University of Hong Kong and the Institute of
Psychology embarked on a long-term collaboration
to translate and standardize the Chinese MMPI and
then the MMPI–2. In addition to using bilingual
translators and back-translators, Cheung and her
team consulted with the original authors to capture
the nuances of the language and the appropriate
meaning of idioms in the English items (Cheung,
2009). They found that direct translation with
accurate back-translation may not always capture
the meaning of the emotional state highlighted in

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some English items, for example “I feel blue,” if
they are literally translated. Particularly for idioms
that are embedded in a particular culture, such
as superstitious behavior, as in the item about
being “careful to step over sidewalk cracks when
walking,” literal translation of the item would not
achieve psychological meaning or functional utility
in the other culture. Similarly, interest in particular
occupations or novels may not be experientially
familiar to other cultures or shared across socio-
cultural groups, reducing the functional utility of
these items. In these cases, they have to be replaced
with comparable items that are relevant to the
local context. Empirical studies were conducted
throughout the development and the refinement of
the Chinese MMPI and MMPI–2 to establish their
equivalence and cross-cultural validity. Large-scale
standardization studies with representative sam-
ples were conducted in China and Hong Kong to
develop the Chinese norms. Clinical studies were
undertaken to ascertain the usefulness of the Chi-
nese MMPI and MMPI–2 in differentiating between
psychiatric patients and the normative sample
(Cheung & Song, 1989; Cheung, Zhao, & Wu,
1992). These studies are documented in the man-
ual for the Chinese MMPI–2 (Cheung, Zhang, &
Song, 2003).

The Chinese MMPI–2 is published by the
Chinese University Press and the Institute of Psy-
chology of the Chinese Academy of Science with
permission from the University of Minnesota Press
(https://www.chineseupress.com/mmpi). It is used
by clinical psychologists for clinical and forensic
assessment in Hong Kong, China, and Taiwan and
by psychologists working with monolingual Chinese
Americans in North America.

Development of Indigenously Derived
Measures: The Example of the Chinese
Personality Assessment Inventory and
the Chinese Personality Assessment
Inventory—2
The use of common psychological measures such
as the MMPI–2 that have been properly adapted
across cultures provides international research-
ers and practitioners with valuable access to the
research database supporting these measures’

clinical interpretation and facilitates cross-cultural
comparisons of common psychological constructs.
What may be amiss in adopting imported tests,
however, is that understanding of the local con-
ceptualization of personality constructs may be
submerged when an etic structure is imposed on
the local context. The constellation of personal-
ity facets in complex constructs and the behavioral
manifestation of these constructs may vary across
cultures. For example, “just sitting and doing noth-
ing,” which may be a sign of depression in the more
action-oriented American culture, would be consid-
ered a form of desirable relaxation in the Chinese
context. Comparing endorsement frequency and
social desirability of this item between normal col-
lege samples in the United States and Hong Kong
confirmed the discrepancy in the psychological
equivalence of this item. Similarly, refraining from
asserting confidence about one’s achievements may
be expected in conformance with the Confucian
value of modesty. Inclusion of many items of this
nature would increase the scale score on depression
for normal Chinese respondents when in fact they
are not depressed. Alternatively, studies on Chinese
psychopathology have shown that patients tend
to present their depression in somatic symptoms,
such as lost appetite, sleep problems, and fatigue
(Cheung, 1998). Should some of the irrelevant items
be replaced by more culture-specific items? Going
further, would an indigenously derived measure
more accurately capture the local illness experi-
ence and identify gaps in understanding important
culture-specific personality factors contributing to
psychopathology?

Development of indigenous measures requires
the same scientific rigor as in all assessment mea-
sures. In non-Western cultures in which the profes-
sion of psychology is still emerging, the expertise
and resources required for such endeavors may be
inadequate. The early attempts to develop indig-
enous personality measures in Asia adopted an
indigenization-from-without approach (Enriquez,
1993) by translating and adapting items from
familiar Western instruments and then adding
indigenous items or subscales (Cheung, Cheung,
Wada, & Zhang, 2003). With the growth of indig-
enous psychology, there is a stronger emphasis on

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Sociocultural Factors in Psychopathology

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the indigenization-from-within approach (Enriquez,
1993) to develop theories, methods, and measures
using emic concepts and knowledge from within the
local context.

Cheung, Fan, and Cheung (2017) reviewed some
of the Asian indigenous personality measures and
identified limitations in adopting an entirely indige-
nous approach. In addition to the shortfall in theory
and scope of the research framework supporting the
applications of these early measures, the focus on
only culture-unique constructs restricts understand-
ing of personality from a pan-cultural perspective.
The combined emic–etic approach was advocated
as an alternative paradigm for deriving culturally
relevant measures, citing the example of the Chinese
Personality Assessment Inventory (CPAI; Cheung,
Cheung, Zhang, et al., 2008; Cheung et al., 1996).

The CPAI was developed by the research team
from the Chinese University of Hong Kong and the
Institute of Psychology at the Chinese Academy of
Science who worked on translation and standard-
ization of the Chinese MMPI–2. The research team
adopted an empirical approach to identify cultur-
ally relevant Chinese personality constructs from
person descriptions in everyday life using multiple
sources and generated items on the behavioral mani-
festations of these constructs. Large samples of the
general population were tested to select items and
finalize scales on the basis of their psychometric
properties. The CPAI and its revised version, the
CPAI–2, were standardized using representative
normative samples from different parts of China and
Hong Kong. The CPAI–2 consists of 28 normal per-
sonality scales, 12 clinical scales, and three validity
scales. Four factors were extracted from the normal
personality scales: Social Potency, Dependability,
Accommodation, and Interpersonal Relatedness.
Two factors, Emotional Problems and Behavioral
Problems, were extracted from the clinical scales.
A more detailed description of the CPAI may be
found in Cheung, Fan, and Cheung (2013).

An extensive research program was conducted
to validate the CPAI. The CPAI was compared with
the Chinese MMPI–2 to establish its concurrent
validity (Cheung, Cheung, & Zhang, 2004). The
CPAI clinical scales were highly correlated with
the corresponding clinical and content scales of the

MMPI–2. Studies with large samples of psychiatric
patients were conducted to validate the clinical util-
ity of the CPAI and CPAI–2 (Cheung, 2007; Cheung,
Cheung, & Leung, 2008; Cheung, Gan, & Lo, 2005;
Cheung, Kwong, & Zhang, 2003). These studies
showed that the clinical scales discriminated among
different psychiatric diagnostic groups. The normal
personality scales also supplement the clinical pro-
files by presenting long- standing personality dynam-
ics and defense mechanisms with implications for
psychological treatment.

With the combined emic–etic approach, it is pos-
sible to evaluate the incremental validity of indig-
enous constructs in understanding psychopathology
and predicting outcomes. A joint factor analysis
of the CPAI–2 and the NEO Five Factor Inventory
(Costa & McCrae, 1992), a measure of the five-factor
model, which has been regarded as a universal factor
structure, found that three of the normal personal-
ity factors overlap with the Big Five (Social Potency
with Extraversion and Openness, Dependability with
Neuroticism and Conscientiousness, Accommoda-
tion with Agreeableness). An indigenous personality
factor, Interpersonal Relatedness, was identified as
being independent of the existing universal personal-
ity structure subsumed under the five-factor model
(Cheung, Cheung, Zhang, et al., 2008). In addition to
the Dependability factor scales (such as Emotionality,
Inferiority vs. Self-Acceptance) that were associated
with clinical features, the emic scales also provided
useful cultural perspectives in understanding psycho-
pathology in the Chinese context.

For example, high scores on Face and Harmony,
two of the emic scales on the Dependability factor
and the Interpersonal Relatedness factor, respec-
tively, predicted the clinical Somatization scale. The
tendency to avoid shame and disruptions in social
harmony may explain the Chinese inclination to
present stigmatized mental problems in the form of
somatic complaints. Lower scores among psychiatric
patients on other emic scales included in the univer-
sal personality factors, such as Family Orientation
on the Dependability factor, showed the breakdown
in family support among these Chinese patients,
given the family plays a central role in Chinese
culture (Cheung, Cheung, & Leung, 2008). Low
scores on the Harmony, Renqing (reciprocal social

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exchange), and Family Orientation scales and high
scores on the Face scale reflect risks in social mal-
adjustment that form an important consideration
of normality in collectivistic cultures. These emic
dimensions are not intended to replace the well-
tested universal dimensions of personality but can
provide important cultural perspectives to supple-
ment understanding of psychopathology beyond the
universal dimensions.

International Best Practices
Practitioners and researchers in cross-cultural
assessment need to decide how they should choose
the most appropriate assessment tools. If they
adopt translated versions of existing measures, they
should evaluate how well the measures have been
translated and adapted. Since the 1980s, psycholo-
gists engaged in assessment and national profes-
sional associations have raised attention about the
need for standards in test translation and adaptation
(Geisinger, 1994). For example, the Standards for
Educational and Psychological Testing (American
Educational Research Association, APA, & National
Council on Measurement in Education, 1985)
included a chapter that outlined standards for test-
ing individuals who are linguistic minorities. The
call for a common set of international guidelines
for cross-cultural assessment culminated in the col-
laboration among international psychological asso-
ciations and international psychologists to prepare
guidelines for translating and adapting psychologi-
cal instruments and to establish score equivalence
across language and cultural groups The Interna-
tional Test Commission (ITC) published its pre-
liminary set of guidelines in 1996 and conducted
field testing to evaluate their applications. These
guidelines were formally adopted by ITC in 2005
and distributed to national psychological societies,
test publishers, and researchers. Van de Vijver and
Hambleton (1996) elaborated on how the guide-
lines can be applied. The 22 guidelines cover four
domains:

1. Context guidelines describe the basic principles
of multilingual measurement in which cultural
bias should be identified and assessed before test
translation and adaptation are undertaken.

2. Guidelines on instrument development consist
of recommended practices in the translation
process and evaluation to ensure appropriate
translation and adaptation when developing
multilingual instruments.

3. Administration guidelines address issues in
administering the instrument in a new cultural
context.

4. Documentation and score interpretation guide-
lines recommend that test translators maintain
careful documentation of changes made and
observed intergroup differences that may affect
the interpretation and cross-cultural compari-
sons of scores.

With the expanding domain of testing in multicultural
groups, ITC (2016) further updated the guidelines in
a second edition, incorporating new methodology and
technological advances for test adaptation and adding
requirements on observing intellectual property rights
of published tests. The revision includes 18 guidelines
grouped under six categories: precondition, test devel-
opment, confirmation, administration, scoring and
interpretation, and documentation. Clearer explana-
tions on the rationale and suggested practice for each
guideline are included.

The extensive efforts in developing and promot-
ing international guidelines on test adaptation point
to the importance of ensuring fairness and accu-
racy in cross-cultural assessment. Unfortunately,
many practitioners and researchers have adopted
tests across cultures without paying attention to
these guidelines. It should be further emphasized
that testing across cultures is not simply a mat-
ter of test translation and adaptation from one
culture to another. Should an indigenous test be
used? How should indigenous measures be evalu-
ated? It involves a deliberate consideration to select
the approach best suited for the purpose of the
assessment.

Using Church’s (2001, p. 984) classification,
the level of indigenization ranges from “imposed
etic” (tests are adopted in non-native languages
or are translated literally) through indigenization
from without (items are modified, local norms
are collected, or new items are generated to fit the
imported constructs) to indigenization from within

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Sociocultural Factors in Psychopathology

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(local constructs are identified and measures to
assess them are investigated to establish their reli-
ability, validity, and utility according to indigenous
criteria). Church raised several pertinent questions
in addressing the issue of choosing imported versus
indigenous measures: “How well do the dimensions
and their behavioral exemplars in imported mea-
sures replicate in the local culture?” “Can imported
measures predict relevant criteria in the local cul-
ture?” “Are the indigenous measures and their
constructs indeed culture-specific?” and “Do these
indigenous measures contribute incremental valid-
ity beyond that of existing imported measures?”
(pp. 986–987). Researchers and practitioners should
familiarize themselves with the measures under con-
sideration, evaluate their psychometric properties,
and balance the need for cross-cultural comparison
against the need for culturally relevant assessment
(Cheung et al., 2017).

Given the importance of cross-cultural and
intersectional considerations in understanding
individuals’ illness experience, the diagnosis of psy-
chopathologies, and the assessment of culturally
diverse populations, in the next section we review
how psychology departments and psychology gradu-
ate training programs have adopted multicultural
and social justice perspectives in their training and
the ways forward in preparing the profession for an
international mental health agenda.

MULTICULTURAL PERSPECTIVES
IN CLINICAL AND COUNSELING
PSYCHOLOGY CURRICULUM AND
TRAINING

Decades have passed since the initial assertion was
made by D. W. Sue and his colleagues that cross-
cultural competence is essential for the practice of
counseling psychologists (D. W. Sue et al., 1982);
APA has issued various guidelines on psychological
practice for ethnic, linguistic, and culturally diverse
populations (APA, 1993), older adults (APA, 2004,
2014), and lesbian, gay, and bisexual individuals
(APA, 2012; Division 44/Committee on Lesbian,
Gay, and Bisexual Concerns Joint Task Force on
Guidelines for Psychotherapy with Lesbian, Gay, and
Bisexual Clients, 2000). APA launched guidelines

on multicultural education, training, research, prac-
tice, and organizational change in 2003 and passed a
resolution on culture and gender awareness in inter-
national psychology in 2010. In addition, it has set
up a joint Division 52 (International Psychology)/
Division 5 (Evaluation, Measurement, & Statistics)
Task Force to identify updates for the methodologi-
cal aspects of cross-cultural research and pinpoint
the need for training in cross-cultural methodol-
ogy in research and assessment (Byrne et al., 2009).
Researchers and practitioners in cross-cultural
assessment need to familiarize themselves with
international best practices and the research base of
translated versions of standard psychological tests.
Furthermore, psychologists need to be trained in
multicultural competence and social justice to effec-
tively serve culturally diverse populations.

Need for Cross-Cultural Perspectives
in Training
Since the 1960s, researchers and practitioners have
advocated for cross-cultural considerations in the
delivery of mental health services and counseling
practices. Many have lamented the lack of atten-
tion to culturally diverse populations and the
biased claims made against certain ethnic groups
as either genetically deficient or culturally deprived
as explaining the observed negative outcomes (e.g.,
genetic deficient model, culturally deficient model),
neglecting the prevailing social oppression in society
(D. W. Sue et al., 1982). Training and practice in
psychology assumed an etic or Eurocentric perspec-
tive, which places cultural concerns at the periph-
ery, with little regard to how people’s personal,
professional, and societal value systems affect the
way researchers and practitioners understand and
interpret psychological and social phenomena. In
response to these biased assumptions and stereotyp-
ing, D. W. Sue et al. issued a position paper in 1982
defining cross-cultural counseling and therapy and
cross-cultural competencies.

Tripartite Model: A Theoretical
Framework for Culturally Competent
Counseling
According to D. W. Sue, Arredondo, and McDavis
(1992), “Cross-cultural counseling/therapy may be

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defined as any counseling relationship in which two
or more of the participants differ with respect to
cultural background, values, and lifestyle”
(p. 47). They also delineated the tripartite model of
beliefs–attitudes, knowledge, and skills in the devel-
opment of a culturally competent counseling psy-
chologist. In this model, beliefs–attitudes are defined
as being aware of and valuing cultural differences
between therapists and their clients. Therapists
are aware of how their own values and biases may
affect their effectiveness with their clients, and they
actively seek consultation and supervision and pro-
vide referral to a more culturally competent thera-
pist as necessary.

Regarding knowledge, therapists should acquire
knowledge specific to the cultural groups with
whom they work, including their history, cultural
values, and lifestyles. Moreover, therapists should be
cognizant of the various levels of oppression and dis-
crimination that affect cultural groups’ identity and
worldviews and the access to and quality of services
received by different cultural groups in the service
systems and in the community. Therapists should
also be aware of possible biases and limitations in
their professional training and knowledge with
respect to the treatment of culturally diverse groups.

Finally, skills refers to adopting a broad repertoire
of nonverbal and verbal responses to appropriately
communicate with culturally diverse clients. Thera-
pists should not be confined to the intrapsychic
model and traditional one-to-one office-based coun-
seling but be ready to outreach and expand their
roles as social change agent and ombudsman outside
of the counseling room in the clients’ natural setting
and indigenous culture (D. W. Sue et al., 1982).

Since D. W. Sue et al.’s (1982) seminal article,
the tripartite model has commonly been adopted
as the standard in training, particularly within the
counseling psychology profession. Pedersen (2000)
adopted the tripartite model in cross-counseling
training during which a problem or anticounselor
role is added to role-play sessions to highlight the
neglected or subconscious cultural dimensions
that interfere with the communication between
the counselor and the client. D. W. Sue et al.
(1992) further expanded and detailed the tripartite
model to recognize the intersectionality of various

sociocultural factors and sociopolitical contexts on
a particular client, including immigration status,
poverty, and racism. The model was later adopted
by the APA when it issued the Guidelines on Mul-
ticultural Education, Training, Research, Practice,
and Organizational Change for Psychologists in
2003. Despite its comprehensiveness in addressing
the importance of multiculturalism across domains
in teaching, training, research, practice, and organi-
zational change, the guidelines remain aspirational.

To operationalize multicultural competence
for research and practice, scholars have tried to
delineate the essential elements in cultural com-
petency. S. Sue and Zane (1987) proposed the
proximal–distal model to explain cultural difference.
Rather than resorting to simply explaining group
differences as the result of racial or ethnic differ-
ences, they proposed identifying proximal factors
such as therapist or client attitudes in explaining
the observed outcomes. S. Sue (1998) also proposed
the importance of having scientific mindedness
(forming and testing hypotheses about the status
of culturally diverse clients rather than making
assumptions and drawing premature conclusions),
dynamic sizing (being flexible in knowing when to
generalize or individualize according to the specific
context), and culture-specific skills (being able to
translate interventions into culturally appropriate
strategies) in the process of working with cultur-
ally diverse clients. Besides these general processes,
S. Sue (1998) also proposed specific concrete steps
that therapists can take to improve their cultural
competency, including self-awareness and aware-
ness of their own stimulus value, assessment of
clients, pretherapy intervention, hypothesizing and
testing specific hypotheses, credibility and giving,
understanding discomfort and resistance, under-
standing clients’ perspective, intervention planning
and strategy, session assessment, and willingness
to consult. All of these efforts aim to clarify and
operationalize what it takes to become culturally
competent.

In addition to elaborating on the conceptualiza-
tions of cultural competence, research was in place
to demonstrate its significance to client outcomes.
For example, among a multiethnic sample of cli-
ents served by a community mental health agency

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Sociocultural Factors in Psychopathology

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in San Francisco, ethnic match was predictive of
session comfort, positivity, and arousal, and cogni-
tive match was predictive of session depth. As to
treatment outcomes, cognitive match on avoidant
coping and on problem distress between therapist
and client was predictive of more favorable out-
comes on psychological symptoms and functioning
(Zane et al., 2005). Rather than being limited to
the provider–client level, multicultural compe-
tence needs to be achieved at the agency level as
well. In other words, cultural diversity should be
considered in the hiring, organizational structure,
program development and evaluation, outreach,
access, availability, utilization, and quality of ser-
vices to ensure that the agency is effective in serving
a culturally diverse clientele. More broadly speak-
ing, the systems of care need to be multiculturally
competent through collaboration across service
agencies in the community and with various institu-
tions in the community (e.g., schools, churches, law
enforcement) to provide equitable and culturally
appropriate services (S. Sue, 2006). These elements
of multicultural competence across levels of inter-
ventions and diverse cultural groups were mapped
onto the multidimensional model of cultural com-
petence by D. W. Sue (2001).

Despite all these efforts, multicultural compe-
tence training has still fallen short in actual prac-
tice. An earlier study showed that about one third
of clinical and counseling psychology graduates
had received training in serving culturally diverse
populations (Allison, Crawford, Echemendia, Rob-
inson, & Knepp, 1994). Moreover, compared with
counseling psychology training programs, signifi-
cantly fewer clinical psychology training programs
required a multicultural competence course for
their students (Mintz, Bartels, & Rideout, 1995),
and counseling psychology students reported a
higher level of multicultural competence than
clinical psychology students (Pope-Davis, Reyn-
olds, Dings, & Nielson, 1995). Although the APA
requires all accredited doctoral clinical and counsel-
ing psychology training programs to include courses
covering multicultural issues, only 67.6% of the
APA- accredited programs have made a multicul-
tural competence course a mandatory requirement
(Sherry, Whilde, & Patton, 2005).

Research has also found that compared with
psychologists who are experienced in multicultural
counseling, clinical psychology students have a sig-
nificantly lower level of multicultural competence,
endorsement of multiculturally competent strate-
gies, and actual engagement in such multiculturally
competent practices (Sehgal et al., 2011). Despite
inconsistent training in and practice of multicultural
competence, a meta-analysis of 45 retrospective sur-
vey studies showed that individuals who reported
completing multicultural education had a weighted
average effect size of 0.49 on multicultural counsel-
ing competence measures compared with those who
did not (Smith, Constantine, Dunn, Dinehart, &
Montoya, 2006). Another meta-analysis based on 37
studies that evaluated an actual multicultural educa-
tion intervention demonstrated an average effect size
of 0.92 before and after the training. Specifically,
education that was explicitly based on extant theory
showed a significantly larger effect size (d = 1.13)
than education that was not theoretically based
(d = 0.61; Smith et al., 2006). These findings point
to the effect of multicultural education and the need
for more consistent training in multicultural compe-
tence across all clinical and counseling psychology
training programs.

In addition to advocating for training in mul-
ticultural competence, the format in which such
training should be delivered and the scope such
training should cover have also been much debated
and discussed. Going beyond the one-course prac-
tice in offering only one didactic course in the entire
course of clinical and counseling psychology train-
ing, scholars have recommended that multicultural
issues should be integrated throughout the curricu-
lum across courses in assessment, psychotherapy,
practice, and supervision with the infusion approach
(Abreu, Chung, & Atkinson, 2000). In addition,
rather than using such traditional pedagogical
strategies as lectures and readings, students should
be involved in participatory methods, including
simulations and role-plays, and have opportunities
to be immersed in culturally diverse communities
and provide services to culturally diverse popula-
tions with culturally competent supervision to
translate their knowledge into actual practice and
to foster their multicultural attitudes and mindset

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Cheung and Mak

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(Dickson & Shumway, 2011). Borrowing from the
gender mainstreaming concept, Cheung (2012)
recommended “regular cultural analysis and audits
. . . to review the extent to which cultural consider-
ation is incorporated in the research and practice of
psychology. This culture-grounded knowledge base
should constitute an integral component of basic
training in psychology” (p. 728).

Social Justice Training
Beyond multicultural competence as captured by the
tripartite model of knowledge, awareness, and skills,
a focus on social justice advocacy and leadership has
been emphasized, especially in community psychol-
ogy and counseling psychology training (Kumagai &
Lypson, 2009; Vera & Speight, 2003). Social justice
training focuses on raising the critical consciousness
of psychology students in recognizing the oppression
that limits access and opportunities in society because
of one’s sociocultural characteristics (i.e., race/ethnic-
ity, gender, class, sexual orientation, age, education,
ability, religion). It emphasizes the importance of rais-
ing individuals’ critical reflection on societal inequali-
ties, enhancing their political efficacy to initiate and
participate in social change and collective action,
and encouraging them to take critical action to effect
change in institutional policies and practices that per-
petuate injustice (Watts, Diemer, & Voight, 2011).

A review of 47 texts and 54 syllabi of multicul-
tural and diversity-related courses in counseling
psychology showed that although 96% of the syllabi
incorporated some aspects of knowledge aware-
ness and skills from the tripartite model, 59% of
the goal statements and objectives mentioned social
justice and 48% included social justice concepts
(Pieterse, Evans, Risner-Butner, Collins, & Mason,
2009). With this social justice perspective, clini-
cal and counseling psychologists no longer relegate
their roles to understanding and facilitating changes
to clients’ presenting issues; they can also become
advocates for clients’ rights within and beyond the
service system, enable self-advocacy by their clients
and families, and act as change agents in the society
to level injustices and social inequalities that con-
tinually oppress disadvantaged groups (Constantine,
Hage, Kindaichi, & Bryant, 2007). Social justice
training can also broaden clinical, counseling, and

community psychology students’ appreciation of
the social oppression is going on internationally,
facilitating the improvement of global mental health
and setting mental health as a global agenda. These
directions echo with the World Health Organiza-
tion’s (2013) Mental Health Action Plan 2013–2020,
which emphasizes a human rights approach to
mental health and empowerment of individuals with
mental disorders in advocacy, policy, legislation,
service provision, monitoring, research, and evalu-
ation, among other strategies to eradicate mental
health disparities globally.

CONCLUSION

Culture is in the fabric of human experience. In
understanding assessment, diagnosis, and treatment
of psychopathology, the intersectionality of vari-
ous sociocultural factors and sociopolitical contexts
must be carefully considered to effectively facilitate
clients’ change and growth. As such, solid and inte-
grated multicultural competence training must be
implemented throughout the curriculum of clinical,
counseling, and community psychology training to
effect changes in research and practice. Moreover,
going beyond the individual level, psychologists
should recognize and engage in multicultural com-
petence and social justice strategies at the organiza-
tional, service systems, and community and societal
levels to avert social oppression and promote human
rights to mental health for all individuals. These
efforts are imperative in actualizing the international
agenda of global mental health.

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http://dx.doi.org/10.1037/0000064-004
APA Handbook of Psychopathology: Vol. 1. Psychopathology: Understanding, Assessing, and Treating Adult Mental Disorders, J. N. Butcher (Editor-in-Chief)
Copyright © 2018 by the American Psychological Association. All rights reserved.

Neuropsychology is commonly defined as the study
of brain–behavior relationships. Although the field
of neuropsychology was once based in the assess-
ment of individuals with neurological disorders,
the need and usefulness of neuropsychological
assessment in the mental health field has gained
widespread acceptance (Yozawitz, 1986). With the
increased use of neuropsychological assessment
with psychiatric populations came a growing appre-
ciation of the cognitive sequelae, both subtle and
profound, within psychiatric conditions (Heaton,
Baade, & Johnson, 1978). Today, neuropsycho-
logical assessment is commonly used to inform
diagnostic and treatment outcomes in neurological,
psychiatric, and mixed populations (Hebben &
Milberg, 2009).

The sheer number of individuals affected by
psychiatric conditions is striking, particularly
when considered within the context of substantial
disability associated with mental illness. Recent
published figures from the World Health Organiza-
tion (2001) estimate that 450 million individuals
are affected by a mental or behavioral disorder;
however, this figure is likely now far surpassed.
Updated prevalence figures (Kessler et al., 2009)
suggest that, although variable across countries, a
diagnosis of any Diagnostic and Statistical Manual
of Mental Disorders (4th ed.; American Psychiat-
ric Association, 1994) condition was present for
18.1%–36.1% of those assessed. The pervasiveness

of cognitive impairment associated with psychiatric
conditions underscores the need to understand and
intervene with what is likely to be a major cause of
disability in these conditions.

INTRODUCTION

In this chapter, we present numerous men-
tal health conditions with associated cognitive
impairment. However, the reasons why these
conditions are associated with cognitive impair-
ment is less clear. In the attempt to understand
cognitive impairment within the context of psy-
chopathology, one is faced with the challenge of
considering whether measurable cognitive impair-
ment is the result of fundamental neuropathology
due to the mental health condition or, alterna-
tively, whether cognitive impairment in one or
more domains is reflective of more diffuse impair-
ment co-occurring with the psychiatric condi-
tion. For example, many of the mental health
disorders discussed in this chapter are associated
with memory dysfunction. However, is memory
impairment fundamental to, and reflective of neu-
robiological dysfunction in, these disorders? Or
are these problems indicative of a deficit in core
cognitive functions (e.g., attention, information
processing) resulting in bottom-up dysfunction?
Or do more generalized cognitive deficits perhaps
commonly co-occur with, yet are in fact separate

C h a P t e r 4

Examination of nEurological
and nEuropsychological

fEaturEs in psychopathology
Colleen E. Jackson and William P. Milberg

Dr. Jackson was supported by a Department of Veterans Affairs Fellowship in Advanced Geriatrics during a portion of her work on this chapter. This
chapter was authored by employees of the United States government as part of official duty and is considered to be in the public domain. Any views
expressed herein do not necessarily represent the views of the United States government, and the authors’ participation in the work is not meant to
serve as an official endorsement.

APA Handbook of Psychopathology: Psychopathology: Understanding, Assessing, and
Treating Adult Mental Disorders, edited by J. N. Butcher and J. M. Hooley
Copyright © 2018 American Psychological Association. All rights reserved.

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Jackson and Milberg

66

from, these conditions? We raise this as a criti-
cal point in interpreting the neuropsychological,
neurological, and neuropathological literature as
it relates to psychopathology.

Because many different mental health condi-
tions may present with one or more similar areas of
cognitive dysfunction, neuropsychological results
cannot be used to diagnose mental disorders.
Rather, the information obtained through a neu-
ropsychological evaluation may offer significant
insight into an individual’s cognitive strengths and
weaknesses and may be used to inform treatment
recommendations and guide educational and voca-
tional planning.

Evolving conceptualizations of psychopathol-
ogy and neuroscience have transitioned focus from
symptom-based diagnoses to a greater emphasis on
transdiagnostic commonalities (i.e., shared dimen-
sions of brain–behavior relationships; McTeague,
2016). Although not the focus of this chapter, we
believe that the evolving diagnostic approaches
described in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM–5;
American Psychiatric Association, 2013) and the
Research Domain Criteria (see Krueger &
DeYoung, 2016) have relevance to the broader issue
of conceptualizing cognition and neuropathology
across psychopathological conditions. Evidence
supports common neurobiological abnormalities
in related disorders (Baker et al., 2014; Etkin &
Wager, 2007) as well as across more diverse diag-
nostic groups (Goodkind et al., 2015). Common
genetic polymorphisms are also associated with a
number of different psychiatric conditions
(Cross-Disorder Group of the Psychiatric Genomics
Consortium, 2013).

This chapter presents an up-to-date review of the
most common mental health conditions presenting
with cognitive dysfunction using a DSM–5 frame-
work. Chapter sections are separated by diagnosis,
with associated cognitive, neurological, and neu-
ropathological dysfunction. Although we strive to
present the most relevant evidence of impairment
associated with the individual conditions presented
in this chapter, we strongly encourage the reader to
consider all evidence within a broader, transdiag-
nostic framework.

Challenges in the Assessment
of Cognition
The assessment of cognition has a number of chal-
lenges. These challenges exist in all assessment
contexts; however, they may be particularly salient
when working with individuals with a mental health
condition.

Motivation and effort are of particular concern
in neuropsychological assessment. Suboptimal
motivation can potentially complicate interpretation
of assessment results and in some instances lead
to an invalid examination. The role of secondary
gain, including internal (e.g., receiving attention or
care) or external factors (e.g., financial compensa-
tion, reduced obligations at work), should also be
considered. These factors may reduce a person’s
motivation to perform in a manner consistent with
his or her true capabilities (Heilbronner, Sweet,
Morgan, Larrabee, & Millis, 2009). In the field of
neuropsychology, measures of symptom validity
(symptom validity tests) and performance valid-
ity (performance validity tests) are used to provide
an objective assessment of motivation and effort
(Larrabee, 2012). Similarly, the use of embedded
symptom validity test measures in psychological
assessment (e.g., the Minnesota Multiphasic Person-
ality Inventory—2—Restructured Form) also offers
standardized, objective measurement of motivation
and effort. Standardized assessment of motivation
and effort is of particular importance with psychiat-
ric populations because factors related to psychiatric
conditions may affect an individual’s ability to put
forth full and consistent effort.

Neuropsychological assessment must also con-
sider the extent to which an individual’s perfor-
mance is reflective of his or her current pathology
versus baseline cognitive abilities. This is typically
described in terms of a deficit in one or more cog-
nitive domains relative to estimated baseline (i.e.,
premorbid) abilities. Such abilities may be predicted
on the basis of sociodemographic information
(e.g., Barona equation, which incorporates patient
age, sex, race, education, occupation, geographic
region of residence, and urban vs. rural residence;
Barona, Reynolds, & Chastain, 1984) or objective
assessment (e.g., Wechsler Adult Intelligence Scale;
Wechsler, 1987). The process of distinguishing

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Examination of Neurological and Neuropsychological Features in Psychopathology

67

between baseline functioning and cognitive changes
attributable to a psychiatric disorder may be espe-
cially complicated because many psychiatric condi-
tions begin early in life and may lack a clear point
of onset, making it difficult to estimate premorbid
cognitive abilities.

Using neuropsychological assessment to clarify
cognitive functioning is further complicated when
two or more psychiatric conditions co-occur (e.g.,
anxiety and depression). As discussed further later
in this chapter, many psychiatric conditions produce
similar cognitive profiles, making it challenging to
attribute specific deficits to a particular disorder
in cases of multiple co-occurring conditions. We
encourage readers to reflect on these challenges as
they consider neuropsychological and neurological
findings within psychiatric populations.

Cognitive Domains and Associated
Brain Regions
Before discussing the unique, and at times overlap-
ping, cognitive impairments associated with mental
health conditions, we feel it is pertinent to present
descriptions of the cognitive domains included in
this chapter. Although we briefly mention relevant
brain structures associated with cognitive domains,
this summary is not intended to be exhaustive.
Readers are reminded that cognitive functions exist
within a highly networked system, and although
damage in a particular region may result in cogni-
tive dysfunction, this does not necessarily indicate a
direct structure-to-function relationship (Hebben &
Milberg, 2009).

Attention. Attention extends well beyond the
fundamental ability to encode information. Rather,
attention is more appropriately defined and concep-
tualized as a multipart process that includes (a) sen-
sory selection, described as the filtering of relevant
and irrelevant information, as well as the focusing
and automatic shifting between incoming informa-
tion; (b) response selection, which includes initiat-
ing a response, inhibition of unselected responses,
and active switching; (c) attentional capacity, which
is dependent on arousal, effort, and motivation; and
(d) sustained performance, which describes the
ability to maintain attention, although performance

is influenced by vigilance and fatigability (Strauss,
Sherman, & Spreen, 2006).

Assessment and description of attentional
processes is complicated by a number of factors,
including inconsistent use of terminology and
overlap in attentional processes both conceptually
(i.e., attentional processes cannot be evaluated in
isolation and there is frequent overlap with other
neurocognitive domains, such as executive func-
tion) and in practice (i.e., frequent overlap in atten-
tional processes assessed in a given test; Strauss
et al., 2006).

Executive functioning. Perhaps even more so
than attention, executive functioning represents the
use of a single term to describe a multitude of func-
tions. Multiple authors in the past 10 to 15 years
have attempted to define the core aspects of execu-
tive functioning (e.g., Baron, 2004; Gioia, Isquith,
Guy, & Kenworthy, 2000; Lezak, Howieson, &
Loring, 2004), with most authors describing a
system that functions in a supervisory capacity
and enables the execution of purposeful and goal-
directed actions. This type of functioning is
dependent on the ability to plan, respond, and flex-
ibly adjust in response to changing information.
Consequently, impairments in executive function-
ing may result in alterations in social comportment,
judgment, decision making, organizing and execut-
ing behaviors, modifying and switching, and aspects
of memory (J. G. Scott & Schoenberg, 2011).

Damage to the prefrontal lobes, particularly the
orbital and medial regions, has consistently been
associated with behavioral and personality changes.
However, damage to limbic structures (e.g.,
amygdala), thalamic nuclei, and right hemisphere
structures may also result in notable changes in per-
sonality (e.g., apathy) and behavior (e.g., planning,
organization, and execution).

Verbal and nonverbal memory. Memory includes
three component processes: (a) encoding (the pro-
cessing of information to be stored), (b) consolida-
tion (strengthening of representations while stored),
and (c) retrieval (accessing stored information). The
studies included in this chapter typically focus on
the encoding and retrieval of consciously learned
and recalled information (i.e., declarative memory).

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Jackson and Milberg

68

Multiple brain regions are implicated in memory,
including the temporal lobes, medial temporal struc-
tures (i.e., hippocampus, entorhinal and perirhinal
cortices, amygdala), diencephalon (i.e., thalamus,
hypothalamus), and basal forebrain (see Kolb &
Whishaw, 2003).

Visuospatial functioning. Visuospatial functioning
encompasses higher order vision abilities, includ-
ing visuoperception (i.e., identifying the object) and
spatial processing (i.e., identifying the location of
the object). A dorsal visual pathway, projecting from
the primary visual field through the parietal lobe,
has been shown to be involved in spatial process-
ing, resulting in deficits in locating objects in space
and hemispatial neglect. In contrast, a ventral visual
pathway, connecting the striate and temporal lobe,
has been associated with object identification; dam-
age to this pathway results in impairments in face
and object recognition.

Language. The assessment of language typically
includes evaluation, whether formal or informal, of
fluency, comprehension, and repetition. In addition,
assessment of receptive and expressive vocabulary,
naming, and word generation (i.e., phonemic [let-
ter] and semantic [category] fluency) are commonly

included. The left hemisphere contains many of the
critical areas for language production, including
speech output (e.g., Broca’s area in the left prefrontal
region) and comprehension (e.g., Wernicke’s area in
the left temporoparietal region). Access to semantic
information, on which naming tasks and semantic
word generation tasks are dependent, is commonly
associated with the functioning of the left anterior
temporal lobe. In contrast, phonemic generation
tasks are more broadly mediated by frontal-
executive systems.

Motor functioning. Motor functioning is com-
monly assessed via standardized tasks requiring
manual dexterity and motor speed. However, it
should also be noted that many motor tasks are also
affected by attention, executive functioning, and
visuospatial abilities.

Neurological and Neuropathological
Factors Associated With Psychopathology
In an effort to provide relevant background to
understanding associated neuropathological cor-
relates of psychiatric disorders, we present a brief
reference table that provides an overview of relevant
brain regions and associated functions and disorders
(Table 4.1). Readers are encouraged to refer back to

TABLE 4.1

Relevant Brain Regions and Associated Functions and Disorders

Brain region and structure Function and involvement in mental

health conditions

Relevant mental health conditions

Limbic system
Amygdalaa Sense and identify fear and anxiety; initiate

emotional response
Anxiety disorders

Anterior cingulate cortexb Self-monitoring; motivation; sustained attention Depression; bipolar disorder; schizophrenia
Cingulate gyrusa Involved in the emotional response Anxiety disorders
Hippocampusa Potentially affected by neurochemical alterations Depression; bipolar disorder; posttraumatic stress

disorder
Insular cortex Internal regulation system controlling

visceromotor, neuroendocrine, pulmonary
systems, pain

Posttraumatic stress disorder; social anxiety
disorder

Orbitofrontal cortexb Involved in the emotional response Depression; bipolar disorder; anxiety disorders
Thalamusb Involved in emotional responding, homeostasis Depression; bipolar disorder
Frontal cortexb Involved in control of the behavioral response;

social awareness
Depression; bipolar disorder; anxiety disorders

Note. aBlumenfeld (2010). bHarrison (2002).

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this table as they progress through the neurological
and neuropathological subsections relevant to each
disorder. In addition, the role of soft neurologi-
cal signs, describing abnormal motor, sensory, or
integrative motor–sensory presentations that do not
localize to a central nervous system lesion (Rossi,
De Cataldo, et al., 1990), are also presented when
relevant. Examples include motor impairments, such
as dyspraxia (difficulty carrying out voluntary move-
ments), dyskinesia (problems in movement), and
impairments in sensory abilities such as left–right
discrimination and stereognosis (the ability to per-
ceive and recognize the form of an object without
seeing it).

In the sections that follow, we describe several
psychiatric conditions with prominent neuropsy-
chological and neurological features: major depres-
sive disorder, bipolar disorder, panic disorder, social
phobia, generalized anxiety disorder, posttraumatic
stress disorder (PTSD), and schizophrenia.

MAJOR DEPRESSIVE DISORDER

Major depressive disorder (MDD) is one of the most
common mental health conditions in the United
States, with a prevalence estimate of 6.7% among
all U.S. adults (Substance Abuse and Mental Health
Services Administration, 2014). Cognitive deficits
associated with MDD, including attention, executive
functioning, psychomotor and processing speed,
and verbal and visual memory (immediate and
delayed) are associated with psychosocial impair-
ment (see Evans, Iverson, Yatham, & Lam, 2014, for
a review).

Neuropsychological Findings

Intellectual functioning. The effect of MDD on
intellectual functioning has been a topic of uncer-
tainty for decades. Inconsistent findings may be, at
least in part, attributable to variability in the clini-
cal severity of the patient group, use of measures to
assess intellectual functioning, and poorly matched
control samples. The existence of intellectual dif-
ferences between patients with MDD and healthy
controls is equivocal; patients with MDD have been
found to have IQs lower than (Sørensen, Sæbye,
Urfer-Parnas, Mortensen, & Parnas, 2012), equal

to (Granick, 1963), and greater than (Robertson &
Taylor, 1985) normal controls. In addition, research
comparing currently depressed individuals, previ-
ously depressed but currently euthymic individuals,
and controls who have never been depressed has
found that a history of depression (either current or
lifetime) was associated with significantly worse per-
formance on tests of global cognition (i.e., Dementia
Rating Scale and Mini-Mental State Examination;
Koenig et al., 2015).

The role of premorbid intellectual functioning
on conferring risk for the development of depres-
sion is also an area of extensive study. Higher child-
hood cognitive abilities have been associated with
fewer symptoms of depression and anxiety during
adulthood (Hatch et al., 2007; Koenen et al., 2009).
Cognitive reserve, conceptualized as a factor that
may confer protection from or vulnerability for the
clinical expression of sequelae associated with brain
pathology (Stern, 2009), has been proposed as a fac-
tor influencing risk for the development of depres-
sion and other neuropsychiatric disorders (Barnett,
Salmond, Jones, & Sahakian, 2006).

Attention and executive functioning. Attention
and executive functioning are consistently identi-
fied as areas of impairment among individuals with
MDD. A systematic review and meta-analysis identi-
fied high rates of reduced concentration and inde-
cisiveness among individuals with MDD (Trivedi &
Greer, 2014). This study also noted the not incon-
sequential effects on function associated with these
attentional impairments. Specific effects on selective
attention (Landrø, Stiles, & Sletvold, 2001), work-
ing memory (Cotrena, Branco, Shansis, & Fonseca,
2016; Landrø et al., 2001), focused and divided
attention (Cotrena et al., 2016), and processing
speed (Koenig et al., 2015) have also been identified.

MDD is also associated with deficits in aspects
of executive functioning (e.g., Gohier et al., 2009).
For example, Lee, Hermens, Porter, and Redoblado-
Hodge (2012) identified small to medium effect size
differences between patients experiencing their first
episode of MDD and healthy controls on measures
of attentional switching (Hedges’s g = .22) and cog-
nitive flexibility (Hedges’s g = .53). Similarly, other
meta-analyses have found MDD to be reliably asso-
ciated with impaired performance on measures of

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executive functioning (Snyder, 2013; Wagner, Doer-
ing, Helmreich, Lieb, & Tadić, 2012). There is also
evidence that greater depression symptom severity
may be associated with more impaired executive
functioning (McDermott & Ebmeier, 2009).

Learning and memory. Reductions in learning and
memory are prominent cognitive effects associated
with MDD (Koenig et al., 2015). In fact, deficits in
episodic memory are arguably the most prominent
disturbance associated with depression (Zakzanis,
Leach, & Kaplan, 1998). For example, Landrø et al.
(2001) identified significantly worse verbal delayed
memory (i.e., worse performance on seven sub-
tasks, including a list learning paradigm, associative
learning task, and short story, with delayed recall
4–5 minutes and 24 hours after initial exposure)
among MDD patients compared with controls. Meta-
analytic findings based on 14 studies of patients
who varied in MDD duration also identified a posi-
tive relationship between symptom severity and
worse verbal episodic memory (weighted M = .31),
but not visuospatial memory (weighted population
effect size r = .11; McDermott & Ebmeier, 2009).
In contrast, Lee et al. (2012) identified significant
deficits in visual learning and memory in a
sample of individuals in a first episode of MDD
(Hedges’s g = .53)

Visuospatial functioning. Visuospatial impair-
ment is less commonly identified among individuals
with MDD; however, Koenig et al. (2015) reported
significantly worse visuospatial abilities, includ-
ing construction using colored blocks and drawing
of simple and complex figures, among a sample of
older adults (mean age = 72.51 years) with a history
of depression, either current or lifetime, than among
individuals without a history of depression. In addi-
tion, Rossi, Stratta, et al. (1990) identified signifi-
cantly worse performance among young to middle
aged (mean age = 47 years) severely depressed
patients than among controls on the Rey Complex
Figure Task (J. E. Meyers & Meyers, 1995) copy and
immediate recall trials.

Language. Phonemic fluency (i.e., a measure of
the ability to generate words beginning with an
identified letter; also referred to as letter fluency) has
repeatedly been identified as an area of impairment

among individuals with MDD (Koenig et al., 2015;
Landrø et al., 2001; Lee et al., 2012). Cross-sectional
(Fossati, Amar, Raoux, Ergis, & Allilaire, 1999) and
meta-analytic (Wagner et al., 2012) findings with
patients with unipolar depression identified signifi-
cant impairment in semantic fluency (i.e., a measure
of the ability to generate words belonging to a spe-
cific category). However, there is noted variability
across studies, including assessment of verbal flu-
ency (see Henry & Crawford, 2005, for a review and
meta-analysis). Specifically, Henry and Crawford
(2005) identified generally greater impairment on
measures of semantic relative to phonemic fluency.
However, when examining studies in which assess-
ment of both semantic and phonemic fluency were
included for the same participants, the deficit for
semantic fluency was only marginally larger than the
deficit for phonemic fluency (rs = .43 for semantic
fluency and .39 for phonemic fluency), which was
interpreted as suggesting a more generalized flu-
ency deficit. Notably, a meta-analysis of 14 studies
concluded that symptom severity is not significantly
associated with poorer semantic memory (weighted
population effect size r = .17; McDermott &
Ebmeier, 2009).

Motor and sensory functioning. Psychomotor dis-
turbance (i.e., slowing or retardation vs. agitation) is
one of the only objectively measurable symptoms of
endogenous depression (see Schrijvers, Hulstijn, &
Sabbe, 2008, and Sobin & Sackeim, 1997, for
reviews). Psychomotor retardation and agitation
are not mutually exclusive. For example, a study
of 23 hospitalized depressed patients identified
increased frequency of self-touching but decreased
direct eye contact, smiling, and eyebrow movement
(Jones & Pansa, 1979). In addition, task complex-
ity does not appear to modulate psychomotor
symptoms, because Sabbe, Hulstijn, van Hoof, and
Zitman (1996; Sabbe, Hulstijn, van Hoof, Tuynman-
Qua, & Zitman, 1999) identified fine motor slowing
on both less demanding tests (e.g., drawing lines
and simple figures) and tests with greater cognitive
effort (e.g., tasks requiring coordination, visuospa-
tial storage, planning, and sequencing).

Evidence has suggested that age may influ-
ence psychomotor disturbances, such that patients
younger than age 40 are more likely to experience

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psychomotor retardation, and patients older than
age 40 are more likely to experience agitation
(Hamilton, 1967; Winokur, Morrison, Clancy, &
Crowe, 1973). Sex may also affect psychomotor
symptoms, although the findings are equivocal, and
evidence ranges from suggesting that males experi-
ence greater psychomotor retardation than females
(Avery & Silverman, 1984; Winokur et al., 1973),
females experience greater psychomotor retardation
than males (Khan, Gardner, Prescott, & Kendler,
2002; Kornstein et al., 2000), to a lack of sex-
dependent differences (Hildebrandt, Stage, &
Kragh-Soerensen, 2003a, 2003b).

Changes in speech output are also commonly
noted among depressed patients. Increased speech
pause time (Greden, Albala, Smokler, Gardner, &
Carroll, 1981; Hoffmann, Gonze, & Mendlewicz,
1985; Nilsonne, 1987; Szabadi, Bradshaw, & Besson,
1976), paucity of speech, slowed responses, mono-
tonic phrases, and poor articulation (Hoffmann
et al., 1985) are more frequently seen in depressed
patients than in controls. Cannizzaro, Harel, Reilly,
Chappell, and Snyder (2004) also identified a cor-
relation between Hamilton Depression Rating Scale
score (Hamilton, 1967) and slower speaking rate
and reduced pitch variation.

One of the greatest concerns related to psycho-
motor slowing among depressed individuals may
be the association between psychomotor retarda-
tion and slowed motor response and decision times
(Lapierre & Butter, 1980). This finding may have
real-world application in the performance of tasks
such as driving, which requires rapid cognitive and
motor responses. Bulmash et al. (2006) found that,
after controlling for age and sleepiness, depressed,
nonmedicated outpatients exhibited slower steering
reaction times than did controls. They also had an
increased number of crashes when tested on a driv-
ing simulator.

Cognitive Functioning After Major
Depressive Disorder Remission
Findings reflect a persistence of cognitive deficits
during MDD remission (Hammar, Lund, & Hugdahl,
2003; Neu, Kiesslinger, Schlattmann, & Reischies,
2001). Specific findings have identified continued
impairment in attention (Bora, Harrison, Yücel, &

Pantelis, 2013; Paelecke-Habermann, Pohl, &
Leplow, 2005) and executive functioning (Boeker
et al., 2012; Paelecke-Habermann et al., 2005). The
persistence of cognitive deficits after remission has
been hypothesized to reflect trait features associ-
ated with chronic MDD (e.g., Hammar et al., 2003;
Paelecke-Habermann et al., 2005). In addition,
others have proposed possible relations between the
duration of illness and structural brain changes (e.g.,
Sheline, Sanghavi, Mintun, & Gado, 1999), which
may also explain persisting deficits.

Interestingly, there is also evidence to support
improvement in some aspects of cognitive function-
ing during MDD remission. For example, memory
deficits appear to be related to depression severity
and, as a result, performances improve after remis-
sion (Biringer et al., 2007; Boeker et al., 2012;
Gualtieri, Johnson, & Benedict, 2006; Paelecke-
Habermann et al., 2005). Notably, the literature
examining cognitive functioning during remission is
complicated by variable definitions to establish the
extent of symptom remission, diverse methodological
strategies, and heterogeneous clinical characteristics
of patients (see Hasselbalch, Knorr, & Kessing, 2011,
for a review).

Cognitive Effects Associated With
Late-Life Major Depressive Disorder
Late-life depression, defined as MDD in adults
older than age 60, is of tremendous clinical con-
cern. These individuals present with notable cogni-
tive impairment that is significant in its own right.
Impairments related to depression may also mask
or confound the assessment and diagnosis of other
neurological conditions affecting cognition (e.g.,
dementia). The nature of cognitive impairments
associated with the onset of depression after age 60
appears to be broad, with noted deficits in process-
ing speed and executive functioning (Alexopoulos,
2002). Additional deficits in psychomotor impair-
ment (Beheydt et al., 2015), episodic memory, and
visuospatial abilities are also commonly identified
(Butters et al., 2004).

As with their younger counterparts, depressed
older adults continue to experience cognitive symp-
toms, particularly on executive tasks, processing
speed, and working memory, after remission of

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mood symptoms (Butters et al., 2000; Nebes et al.,
2003). In fact, treatment with pharmacotherapy
has been found to have a limited effect on cogni-
tion in depressed older adults (B. S. Meyers, Mattis,
Gabriele, & Kakuma, 1991). Cognitive abilities also
appear to be related to future symptomatology and
functional outcomes; poor executive functioning in
depressed older adults has been shown to predict
greater functional disability (Kiosses & Alexopoulos,
2005).

Neurological and Neuropathological
Findings

Neuropathology. Multiple neuropathological
changes have been associated with MDD in adults.
Frontal, midbrain, and limbic regions are most
consistently implicated, with evidence of decreased
volume in the frontotemporal region (Vasic et al.,
2015), prefrontal cortex (PFC), dorsolateral prefron-
tal cortex (DLPFC), subgenual region of the anterior
cingulate cortex (ACC), basal ganglia, amygdala,
and hippocampus (Campbell & MacQueen, 2006).
There is also decreased density of neurons in
the hippocampus (Tsopelas et al., 2011), orbito-
frontal cortex (Cotter, Hudson, & Landau, 2005;
Rajkowska et al., 1999), and PFC (Cotter et al.,
2002; Rajkowska et al., 1999). In addition, a reduc-
tion in the number and density of pyramidal cells
in the orbitofrontal cortex and ACC and reductions
in pyramidal cell volumes in the DLPFC (see Kim,
Nunes, Oliveira, Young, & Lafer, 2016, for a review)
have been described.

MDD has also been associated with altered brain
network functioning. Specifically, relative to control
participants, functional neuroimaging with individ-
uals with MDD has demonstrated decreased activity
in the DLPFC and increased activity in the ventro-
lateral PFC (Brody, Barsom, Bota, & Saxena, 2001).
Furthermore, there is evidence of particular abnor-
malities in ACC and DLPFC inputs from the amyg-
dala (Drevets, 2000), as well as reduced cerebral
blood flow in the ACC and bilateral parahippocam-
pal areas, with increased blood flow in the frontopa-
rietal and striatal regions (Vasic et al., 2015).

Meta-analytic findings from fluorodeoxyglucose–
positron emission tomography studies identified

lower metabolism in bilateral insula, left lentiform
nucleus putamen, and right caudate and cingulate
gyrus; however, right thalamus pulvinar and declive
of the posterior limb and left culmen of vermis in
the anterior lobe were significantly increased (Su
et al., 2014). Furthermore, evidence of decreased
metabolic activity during depressive episodes has
also been identified in the DLPFC, dorsomedial
PFC, subgenual region of the ACC, basal ganglia,
and hippocampus, and increased activity has been
identified in the ventrolateral and orbital PFC and
amygdala (Davidson, Pizzagalli, Nitschke, &
Putnam, 2002).

Soft neurological signs associated with MDD.
Evidence has suggested that hypoesthesia of the
malleolus (i.e., reduced sense of touch on the bony
projections on the ankle) may be a soft neurological
sign associated with MDD (Livianos et al., 2015).
However, other studies have failed to identify signifi-
cant differences in soft neurological signs between
individuals with MDD and healthy controls using
standard soft sign assessments, including motor
coordination, sensory integration, and disinhibition
(Zhao et al., 2013).

Conclusions
Interpreting findings from the MDD literature is
complicated by considerable variability in partici-
pant inclusion/exclusion criteria, depression severity
within patient groups, and control of factors with
potential cognitive and/or neurologic sequelae (e.g.,
medications, psychotic symptoms) (Evans et al.,
2014). Additionally, the role of effort and engage-
ment must be considered when evaluating individu-
als with MDD. For example, Rohling, Green, Allen,
and Iverson (2002) found that depression had no
effect on objective cognitive and psychomotor tests
once patients with suboptimal effort were excluded
from analyses.

BIPOLAR DISORDER

Bipolar disorder is a disabling illness (Harvey,
Wingo, Burdick, & Baldessarini, 2010) associated
with significant functional impairment during acute
and remitted stages. In addition, bipolar disorder is

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a challenging condition to treat, and relapse rates
are high even after psychopharmacological interven-
tion. For example, Gitlin, Swendsen, Heller, and
Hammen (1995) found that 37% of participants
diagnosed with bipolar disorder and followed in
an outpatient clinic experienced a recurrence of a
manic or depressive episode within 1 year. More-
over, two thirds of individuals who relapsed experi-
enced multiple relapses.

Per the diagnostic criteria of the DSM–5 (Ameri-
can Psychiatric Association, 2013), bipolar I disor-
der is characterized by the occurrence of at least one
manic episode, with many individuals also experi-
encing one or more depressive episodes. Diagnosis
of bipolar II requires current or past hypomanic
episode as well as current or past major depressive
episode.

Cognitive impairment in bipolar disorder is not
a core diagnostic criterion. However, given evidence
of neurocognitive deficits across all stages of bipolar
illness (manic, depressed, and euthymic), neurocog-
nitive deficits have been proposed as an endopheno-
type (Hasler, Drevets, Gould, Gottesman, & Manji,
2006). Further evidence for this proposal comes
from findings indicating that first-degree relatives
of individuals with bipolar disorder, who are pre-
sumably at particularly elevated risk of developing
a mood disorder, perform worse on tasks of verbal
declarative memory as well as on some aspects of
executive functioning (Robinson & Ferrier, 2006).
This finding has been interpreted as suggesting that
cognitive impairment may be a trait vulnerability
factor for bipolar disorder that is present before the
onset of clinical symptoms and that worsens as the
illness progresses.

Neuropsychological Findings

Intellectual functioning. Research on intellectual
functioning among patients with bipolar disorder
has generally suggested that they perform about
as well as healthy controls (e.g., Mann-Wrobel,
Carreno, & Dickinson, 2011). However, some
reports have suggested that bipolar patients may
have premorbid intellectual deficits. For example,
Trotta, Murray, and MacCabe (2015) identified small
yet significant deficits in premorbid intellectual

functioning when it was assessed retrospectively, but
not prospectively.

Attention and executive functioning. Multiple
aspects of attention, including sustained atten-
tion, psychomotor speed, and processing speed,
have consistently been identified as impairments
among individuals with bipolar disorder relative
to healthy control participants (Kurtz & Gerraty,
2009). Vrabie et al. (2015) identified significantly
worse performance on measures of attention, psy-
chomotor speed, and processing speed, regardless
of disease stage (manic–hypomanic, depressed, or
euthymic). In meta-analytic comparisons between
healthy control participants and euthymic bipolar
patients, small effect size differences were identified
for auditory attention, and moderate to large effect
size differences were identified for sustained visual
vigilance and speeded visual scanning (Arts, Jabben,
Krabbendam, & van Os, 2008; Bora, Yucel, &
Pantelis, 2009; Kurtz & Gerraty, 2009). Bonnín et al.
(2012) similarly found that subsyndromic euthymic
bipolar patients demonstrated slower psychomo-
tor speed relative to healthy controls. In this study,
even asymptomatic euthymic patients demonstrated
significantly worse performance, relative to healthy
controls, on measures of psychomotor and process-
ing speed.

Comparisons between healthy controls and
depressed bipolar patients have revealed deficits in
visual scanning (Kurtz & Gerraty, 2009), as well
as large effect size differences in processing speed
(Gallagher, Gray, Watson, Young, & Ferrier, 2014).
Large effect size differences were also found in com-
parisons between healthy controls and individuals
in mixed or manic states for sustained attention and
rapid visual scanning (Kurtz & Gerraty, 2009).

Deficits in working memory have also been con-
sistently identified across different bipolar states,
including euthymia (Bora et al., 2009; Kurtz &
Gerraty, 2009; Vrabie et al., 2015), mania–
hypomania (Vrabie et al., 2015), and depression
(Gallagher et al., 2014; Vrabie et al., 2015). Con-
sistent impairments in executive functioning are
similarly found across bipolar states (Martínez-Aran,
Vieta, Reinares, et al., 2004; Vrabie et al., 2015). Rel-
ative to healthy controls, euthymic bipolar patients

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demonstrated impairments in multiple aspects of
executive functioning, including large effect size dif-
ferences in working memory (Robinson & Ferrier,
2006), inhibition, and set shifting (Arts et al., 2008;
Bora et al., 2009; Kurtz & Gerraty, 2009), as well as
moderate to large effect size differences for concep-
tual shifting, novel problem solving, perseveration
(Bora et al., 2009; Kurtz & Gerraty, 2009; Robinson &
Ferrier, 2006), speeded set shifting, sustained visual
and auditory attention, and response inhibition
(Robinson & Ferrier, 2006). Furthermore, Martínez-
Arán, Vieta, Colom, et al. (2004) reported signifi-
cantly worse performance on multiple measures of
executive functioning among remitted patients in a
euthymic state, even after controlling for the effects
of subclinical symptomatology, age, and premorbid
IQ. Even among subsyndromic euthymic bipolar
patients, Bonnín et al. (2012) identified worse per-
formance on set switching. Moderate effect size
differences in set switching (d = 0.64) have been
identified among depressed and mixed or manic
bipolar patients, and large effect size differences
in perseverations among mixed or manic bipolar
patients have also been noted (Kurtz & Gerraty,
2009).

Learning and memory. Deficits in verbal learn-
ing and memory are commonly and consistently
identified among patients with bipolar disorder,
regardless of their clinical state (Gallagher et al.,
2014; Goswami et al., 2006; Martínez-Arán, Vieta,
Reinares, et al., 2004; Robinson & Ferrier, 2006).
Kurtz and Gerraty (2009) identified large effect size
differences in verbal learning for euthymic, mixed or
manic, and depressed patient groups, as well as large
effect size differences in delayed recall for mixed
or manic patients and moderate differences for
euthymic patients. Bonnín et al. (2012) also identi-
fied verbal learning and recall deficits in subsyn-
dromic euthymic bipolar patients and asymptomatic
patients, relative to healthy controls, and Malhi
et al. (2007) reported more pronounced deficits in
verbal memory during episodes of hypomania and
depression among patients diagnosed with bipolar
I disorder. Interestingly, Vrabie et al. (2015) found
that manic patients showed greater verbal memory
deficits than depressed, mixed, and euthymic

subgroups. Deficits in nonverbal memory have
also been identified in bipolar patient groups (Bora
et al., 2009), and Martínez-Arán, Vieta, Reinares,
et al. (2004) reported differences between depressed
patients and controls in visual learning as well as
differences between both acute clinical groups and
controls in visual recall.

Visuospatial functioning. Deficits in visual per-
ception and visuospatial functioning in individuals
with bipolar disorder are comparatively less severe
relative to well-established attention, executive func-
tioning, and memory deficits. Meta-analytic findings
focused on patients in the euthymic stage of bipolar
disorder have demonstrated small to moderate effect
size differences relative to healthy controls on mea-
sures of visuoperception (i.e., copying a complex
figure and ability to reproduce visually presented
designs using colored blocks; Arts et al., 2008;
Kurtz & Gerraty, 2009). In addition, Gallagher, Gray,
and Kessels (2015) reported differences among indi-
viduals in a depressive episode, relative to healthy
controls, on an object-location binding task.

Language. Impairment within the language
domain is quite variable and dependent on the cog-
nitive task and stage of the disease. For example,
the existence of differences between semantic
and phonemic fluency (ability to generate words
belonging to a particular category or starting with
a particular letter, respectively) among patients in
the euthymic stage of bipolar disorder is equivocal,
with some studies reporting greater impairment in
semantic fluency (Arts et al., 2008; Martínez-Arán,
Vieta, Colom, et al., 2004; Robinson & Ferrier,
2006), some studies reporting greater impairment in
phonemic fluency (Bonnín et al., 2012), and some
studies reporting comparable impairment in both
(Kurtz & Gerraty, 2009). Furthermore, although
Vrabie et al. (2015) reported worse performance on
both semantic and phonemic fluency tasks across
bipolar stages, individuals in a depressive stage were
more impaired relative to other bipolar patients and
healthy controls. Additional findings further sup-
port impairment in both phonemic and semantic
fluency among patients in mixed or manic stages
(Kurtz & Gerraty, 2009), as well as impairment in

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phonemic fluency among patients in a depressed
stage (Kurtz & Gerraty, 2009; Martínez-Arán, Vieta,
Reinares, et al., 2004).

Motor and sensory functioning. Evidence of
structural changes in the cerebellum (Baldaçara
et al., 2011; Moorhead et al., 2007) has supported
recent evidence of impaired implicit motor learning
(i.e., learning a sequence of button presses with-
out instruction) in bipolar patients compared with
healthy controls (Chrobak et al., 2015).

Neurological and Neuropathological
Findings

Neuropathology. Neuropathological changes
in patients with bipolar disorder have implicated
reduced hippocampal volume (Quigley et al.,
2015) and frontal cortical volume (Abé et al., 2015;
López-Larson, DelBello, Zimmerman, Schwiers, &
Strakowski, 2002), as well as reduced gray and
white matter volumes in the posterior cingulate
bilaterally, right thalamus, cerebellum bilaterally,
and left posterior limb of the internal capsule (Sani
et al., 2016; see Haldane & Frangou, 2004, for a
review).

Soft neurological signs associated with bipolar
disorder. Soft neurological signs appear to be
significantly increased among patients with bipolar
disorder compared with healthy controls (Goswami
et al., 2007; Nasrallah, Tippin, & McCalley-Whitters,
1983; Negash et al., 2004). Among a sample of
euthymic patients with bipolar disorder, prevalence
of soft neurological signs was high, with 54% dem-
onstrating parkinsonism, 27% reporting akathisia,
and 11% presenting with dyskinetic movements
(Goswami et al., 2006). In addition, Mrad, Wassim
Krir, Ajmi, Gaha, and Mechri (2016) reported higher
prevalence and scores on a measure of soft neuro-
logical signs among euthymic patients with bipolar
disorder and their psychiatrically healthy siblings,
compared with unrelated control participants.

Conclusions
Multiple clinical factors have been associated with
neuropsychological dysfunction in bipolar disorder.
Broadly, greater cognitive impairment has been
associated with worse course of illness, particularly

with respect to the number of manic episodes,
hospitalizations, and length of illness (Robinson &
Ferrier, 2006), which is likely attributable to a
complex combination of genetic, environmental,
neurodevelopmental, and medication-related fac-
tors, as well as possible medical or psychiatric
comorbidities (Balanzá-Martínez et al., 2010).
Specifically, longer duration of illness and greater
number of hospitalizations, suicide attempts, and
manic episodes have been associated with greater
memory dysfunction, and longer duration of illness
was associated with diminished attention, slowness,
and perseveration (Martínez-Arán, Vieta, Colom,
et al., 2004). Significant clinical heterogeneity,
including symptom severity, predominating symp-
toms (mania or depression), age at symptom onset,
duration of illness (Robinson & Ferrier, 2006),
number of prior manic or depressive episodes
(Nehra, Chakrabarti, Pradhan, & Khehra, 2006),
duration of clinical stages (manic, depression, and
euthymia), and other comorbidities complicate
interpretation of the literature. In addition, many of
these clinical factors, as well as other methodologi-
cal and statistical factors, and within-participant
factors (e.g., engagement, self-esteem, sensitivity to
perceived feedback) may exert a potential influence
on cognitive function (Porter, Robinson, Malhi, &
Gallagher, 2015).

ANXIETY DISORDERS

The DSM–5 includes a number of conditions under
the umbrella of anxiety disorders, including panic
disorder, social phobia, and generalized anxiety
disorder, as well as a number of less commonly
diagnosed or studied conditions not described in
detail here. Anxiety disorders cost the United States
billions in health care costs (Greenberg et al., 1999),
and they are also associated with significant func-
tional disability (e.g., Alonso et al., 2004), particu-
larly among those with social anxiety and multiple
anxiety disorders (Hendriks et al., 2014).

Patients commonly report cognitive symptoms
of varying severity with anxiety. Although the pres-
ence and severity of cognitive problems on formal
objective testing varies, a number of key similarities,
including deficits in complex attention, executive

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Jackson and Milberg

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functioning, encoding, and free retrieval of infor-
mation, are present across the spectrum of anxiety
disorders. We focus our discussion on cognitive
symptoms associated with panic disorder, social
phobia, and generalized anxiety disorder.

Neuropsychological Findings

Intellectual functioning. The evidence support-
ing differences in estimated intellectual functioning
between individuals with anxiety and healthy con-
trols is minimal. In a study comparing individuals
with panic disorder, individuals with social phobia,
and healthy controls, Asmundson, Stein, Larsen,
and Walker (1994) found no difference between
anxiety disorder patients and healthy controls on
measures of vocabulary or similarities as measured
by the Wechsler Adult Intelligence Scales—Revised.
However, this study did identify significant dif-
ferences between the clinical groups and healthy
controls on a measure of visuoconstruction (i.e.,
creating designs using colored blocks; Asmundson
et al., 1994).

Attention and executive functioning. Deficits
in cognitive processing speed on a task requiring
the transcription of digit–symbol pairs has been
identified among individuals with social phobia
(O’Toole, Pedersen, Hougaard, & Rosenberg, 2015).
However, on a less complicated visual process-
ing task (Trails A completion time and accuracy),
Airaksinen, Larsson, and Forsell (2005) found no
differences in performance between individuals with
any anxiety disorder compared with healthy control
participants. Similarly, there were no identified dif-
ferences between anxiety subtypes on this measure
(Airaksinen et al., 2005). It would appear, on the
basis of these findings, that task complexity plays
a role in visual processing performance. Executive
dysfunction, particularly set-shifting completion
time, has also been identified among individu-
als with anxiety more generally (Airaksinen et al.,
2005), as well as specifically among individuals with
panic disorder (L. J. Cohen et al., 1996).

Learning and memory. Verbal memory deficits
have been identified in numerous patient groups,
including individuals with social phobia (Airaksinen

et al., 2005; Asmundson et al., 1994; O’Toole et al.,
2015; although see Sachs et al., 2004), and panic
disorder (Airaksinen et al., 2005; Asmundson et al.,
1994). In fact, in the sample of patients examined
by Asmundson et al. (1994), approximately 22%
of those diagnosed with social phobia and 50% of
individuals diagnosed with panic disorder were at
least 2 or more standard deviations below the mean
on a word-list learning task. Evidence has also sup-
ported deficits in nonverbal memory among patients
with social phobia compared with healthy controls
matched for education and general cognitive ability
(O’Toole et al., 2015).

Visuospatial functioning. Visuospatial deficits,
including construction accuracy (O’Toole et al.,
2015), visuospatial processing (e.g., block design;
Asmundson et al., 1994, L. J. Cohen et al., 1996),
and cube drawing (Hollander et al., 1996), have been
identified among individuals with social phobia.

Language. Decreased verbal fluency, including
reduced phonemic (Airaksinen et al., 2005; O’Toole
et al., 2015) and semantic fluency (O’Toole et al.,
2015), has been identified among individuals with
social phobia.

Motor and sensory functioning. No specific defi-
cits in motor or sensory functioning are commonly
reported among individuals with social phobia or
panic disorder.

Neurological and Neuropathological
Findings

Neuropathology. Structural abnormalities involv-
ing the cingulate cortex, precentral gyrus, precu-
neus, and temporal and frontal gyrus (De Bellis
et al., 2002; Strawn et al., 2013) have been identified
in individuals with generalized anxiety disorder.
Functional abnormalities have also been identi-
fied in this group, including resting state abnor-
malities involving amygdala circuits (Etkin, Prater,
Schatzberg, Menon, & Greicius, 2009; Liu et al.,
2015), as well as task-related changes in PFC and
ACC (see Mochcovitch, da Rocha Freire, Garcia, &
Nardi, 2014, for a review).

Among those diagnosed with panic disorder,
structural changes in the amygdala (Massana et al.,

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2003a), parahippocampal gyrus, caudate nucleus,
basal ganglia, insula (Lai, 2011; Massana
et al., 2003b), ACC, and frontal and temporal areas
(Asami et al., 2008; Han et al., 2008; Sobanski
et al., 2010) have been identified. Functional
abnormalities during functional MRI have also
been identified in many of these regions. Specifi-
cally, increased activation in the amygdala, insula,
and hippocampus during the presentation of ago-
raphobic-specific stimuli (Wittmann et al., 2011),
and increased activation in the right inferior frontal
area and cingulate cortex during panic anticipation
and imagery exposure (Bystritsky et al., 2001) have
been identified. Furthermore, abnormal functional
connectivity within the default mode network
(Y. W. Shin et al., 2013) and salience network
(Pannekoek et al., 2013) have also been high-
lighted. Interestingly, evidence has not pointed to a
clear pattern of structural changes associated with
social phobia (e.g., Potts, Davidson, Krishnan, &
Doraiswamy, 1994).

Soft neurological signs associated with anxiety
disorders. Soft neurological signs, including cube
drawing and mirror movement impairments, have
been identified among individuals with social pho-
bia (Hollander et al., 1996).

Conclusions
Deficits in attention, executive functioning, learning
and memory, visuospatial functioning, and language
have been identified among patients with social
anxiety and panic disorder. However, the literature
examining neurocognitive functioning in these
populations is relatively small and may benefit from
further examination using clinical and experimental
paradigms, with particular attention to symptom
severity and comorbid conditions.

POSTTRAUMATIC STRESS DISORDER

The cognitive sequelae and related neuroimaging
correlates of PTSD have been studied extensively.
We present a brief review here; however, we also
refer the reader to several excellent review references
detailing this topic (Aupperle, Melrose, Stein, &
Paulus, 2012; Hayes, Vanelzakker, & Shin, 2012;
Qureshi et al., 2011; Vasterling & Brewin, 2005).

Neuropsychological Findings

Intellectual functioning. Pretrauma intelligence has
been found to predict PTSD diagnosis after trauma
exposure (see Bomyea, Risbrough, & Lang, 2012, for
a review). In addition, PTSD symptom severity, as
measured by the Clinician Administered PTSD Scale
(Blake et al., 1995), has been found to be negatively
correlated with estimated IQ (Gurvits et al., 2000),
suggesting that it is not simply the dichotomous
diagnosis but rather the potential severity of the
symptoms that may contribute to a reduction in per-
formance on measures assessing intelligence.

Attention and executive functioning. Deficits
in attention and executive functioning are com-
monly identified among individuals with PTSD
(B. E. Cohen et al., 2013; Koso & Hansen, 2006).
For example, Jenkins, Langlais, Delis, and Cohen
(2000) identified worse performance on measures
of sustained attention, digit span, processing speed
(i.e., rapid transcription of digit–symbol pairs), and
set shifting among rape survivors with and without
PTSD. Vasterling et al. (2002) similarly identified
impairments in basic (i.e., Digit Span), and sus-
tained attention on the Continuous Performance
Test among Vietnam veterans with PTSD; sus-
tained attention deficits were similarly found
among Operation Desert Storm (Vasterling, Brailey,
Constans, & Sutker, 1998) and Bosnian combat
veterans with PTSD (Koso & Hansen, 2006).

Learning and memory. Studies have also indicated
that individuals with PTSD performed significantly
worse on verbal learning (B. E. Cohen et al., 2013;
Vasterling et al., 2002; Yehuda, Golier, Tischler,
Stavitsky, & Harvey, 2005) and memory trials
(Yehuda et al., 2005). Nonverbal learning has been
shown to be impaired among veterans with PTSD
(Vasterling et al., 1998), although not consistently
(e.g., Gilbertson et al., 2006).

Visuospatial functioning. Visuospatial functioning
has been less well studied among individuals with
PTSD.

Language. Significantly worse semantic fluency,
relative to healthy controls, has been identified
among adults with PTSD (B. E. Cohen et al., 2013).
In addition, Koso and Hansen (2006) identified

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Jackson and Milberg

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impairment among veterans with PTSD, relative to
age and IQ-matched trauma-exposed veterans with-
out PTSD, on a sentence completion task.

Motor and sensory functioning. Assessment of
motor and sensory functioning that is independent
of processing speed or executive demands has been
less well studied among individuals with PTSD.

Neurological and Neuropathological
Findings

Neuropathology. The literature examining neu-
ropathological markers among individuals with
anxiety has largely focused on those with PTSD.
Structural abnormalities in this diagnostic group are
typified by reduced anterior cingulate (e.g., Rauch
et al., 2003) and hippocampal volumes (Gurvits
et al., 1996; although see Golier et al., 2005). The
literature examining functional changes among indi-
viduals with PTSD is also quite extensive (see Hayes
et al., 2012, for a review). A number of functional
imaging studies have identified increased activ-
ity in the amygdala in response to trauma-related
stimuli (Pissiota et al., 2002; L. M. Shin et al., 2004)
and trauma-unrelated affective stimuli (L. M. Shin
et al., 2005). However, these findings are not uni-
versal (e.g., Hayes et al., 2011). Similarly, findings
are also mixed with regard to hippocampal activity
in those with PTSD, such that there is evidence for
both increased (Thomaes et al., 2009) and decreased
(Bremner et al., 2003; Hayes et al., 2011) activity in
response to emotionally salient stimuli. Dysfunction
in neural circuits involved in attention and emo-
tional processing has also been identified, specifi-
cally increased dorsolateral and ventromedial PFC
activity in response to threat stimuli (Hayes, Labar,
Petty, McCarthy, & Morey, 2009) and reduced dorso-
lateral PFC activity in response to nonthreat stimuli
(Hayes et al., 2009; Morey, Petty, Cooper, Labar, &
McCarthy, 2008).

Soft neurological signs associated with
PTSD. Among both combat veterans and women
with a history of childhood sexual abuse, individu-
als with PTSD had a greater than average number of
soft neurological signs than individuals with similar
trauma exposure without PTSD. Furthermore, PTSD

symptom severity, as assessed using the Clinician
Administered PTSD Scale (Blake et al., 1995), was
significantly correlated with an average number of
soft neurological signs (Gurvits et al., 2000).

Conclusions
Overall, the literature supports significant neuro-
cognitive effects associated with PTSD, including
deficits in verbal learning and memory, rapid infor-
mation processing, attention, and working memory
(J. C. Scott et al., 2015). However, examination of
the PTSD literature highlights several challenges in
interpreting existing findings. The role of symptom
severity is one that must be considered, particularly
because it has been found to be significantly associ-
ated with worse performance on multiple aspects of
cognitive functioning, even after adjusting for demo-
graphics (L. J. Cohen et al., 2013). Furthermore, the
potential influence of comorbid conditions, includ-
ing depression and other anxiety disorders, is one
that must be considered both clinically and in evalu-
ating the literature.

SCHIZOPHRENIA

The literature examining cognitive factors associated
with schizophrenia and psychotic spectrum disor-
ders is extensive; the reader is referred to several
well-written review articles for additional informa-
tion (Barch & Sheffield, 2014; Madre et al., 2016;
Tolman & Kurtz, 2012). The relationship between
cognitive deficits and functional impairment among
individuals with schizophrenia has been well sup-
ported (Green, Kern, & Heaton, 2004), and concep-
tualization of cognitive deficits as discrete areas of
weakness is now being replaced by a view reflect-
ing a more global deficit across cognitive domains
(Gold & Dickinson, 2013).

In addition, although a full review of these find-
ings is outside the scope of this chapter, it is worth
noting that evidence from the second phase of the
North American Prodrome Longitudinal Study
(Seidman et al., 2016) has indicated that attention,
working memory, and declarative memory abilities
may be strong predictors of conversion to psycho-
sis among those considered to be clinically high
risk. Investigators in this study have suggested that

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Examination of Neurological and Neuropsychological Features in Psychopathology

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interventions targeting neurocognitive functioning
may be particularly important among those at high
risk for psychosis.

Neuropsychological Findings

Intellectual functioning. Meta-analysis has dem-
onstrated impairments in premorbid (Woodberry,
Giuliano, & Seidman, 2008) and current intellectual
functioning among individuals with schizophre-
nia. Compared with healthy control participants,
Woodberry et al. (2008) reported a 0.5 standard
deviation impairment in premorbid intelligence in
individuals who went on to develop psychotic symp-
toms. Comparisons between individuals with schizo-
phrenia and control samples have reflected medium
to large effect sizes (Heinrichs & Zakzanis, 1998).

Attention and executive functioning. Impairments
on tasks requiring auditory attention (i.e., Digit
Span), psychomotor speed (i.e., Trails A), rapid
alternation between sets of information (i.e., Trails
B), and sustained attention (e.g., Continuous
Performance Test) are commonly identified among
individuals with schizophrenia (Heinrichs &
Zakzanis, 1998). Deficits in working memory are
among the most commonly reported in schizophre-
nia (see Forbes, Carrick, McIntosh, & Lawrie, 2009,
for a review; Van Snellenberg et al., 2016). Given a
lack of difference between phonological and visuo-
spatial working memory functioning, a more general-
ized deficit in the central executive resource system,
responsible for maintaining and modulating informa-
tion over time, has been proposed to explain working
memory impairments in this population (Barch &
Sheffield, 2014). Finally, performance on more
complex measures of executive functioning requir-
ing novel problem solving, flexibility, and learning
from feedback (i.e., the Wisconsin Card Sorting
Task) is frequently impaired in this clinical group
(Heinrichs & Zakzanis, 1998). However, findings
from this meta-analytic study have also noted a rela-
tionship between the Wisconsin Card Sorting Task
and intelligence, suggesting that impaired perfor-
mance on this test may be a reflection of low general
intellectual abilities (Heinrichs & Zakzanis, 1998).

Learning and memory. Impairments in verbal
declarative memory are consistently reported among

individuals with schizophrenia (see Stone & Hsi,
2011, for a review), with effect sizes ranging from
1.0 to 1.5 standard deviations below comparison
populations (Cirillo & Seidman, 2003; Heinrichs &
Zakzanis, 1998). Deficits are greatest in the learn-
ing and encoding stage of memory (Cirillo &
Seidman, 2003), relative to retrieval and recognition.
Nonverbal memory performance is also impaired
within this group, but greater heterogeneity across
studies suggests that performance within this spe-
cific domain may be less reliable relative to verbal
memory deficits (Heinrichs & Zakzanis, 1998).

Visuospatial functioning. Visuospatial functioning
is less commonly assessed in studies on schizophre-
nia. Heinrichs and Zakzanis (1998) reported moder-
ate effect sizes, in the range of 0.46 for Block Design,
0.60 for Line Orientation (judgment of line angles),
and 0.61 for Facial Recognition, relative to compari-
son groups. Similar effect sizes were also reported by
Dickinson, Ramsey, and Gold (2007).

Language. Performance on verbal fluency mea-
sures is also reflective of significant impairment
(large Cohen’s d; Dickinson et al., 2007; Heinrichs &
Zakzanis, 1998).

Motor and sensory functioning. Dickinson et al.
(2007) reported moderate (finger tapping bilater-
ally) to large (grooved pegboard bilaterally) effect
sizes between individuals with schizophrenia and
control samples. In addition, there is evidence of
greater involuntary dyskinetic movement abnor-
malities among children with multiple antecedents
of schizophrenia (e.g., dyskinetic movements, psy-
chotic-like experiences), who are considered to be
at increased risk of future schizophrenia spectrum
disorders, compared with children without such
antecedents (MacManus et al., 2012).

Neurological and Neuropathological
Findings

Neuropathology. Meta-analysis of 52 cross-
sectional and 16 longitudinal studies identified
reductions in both whole brain and hippocampal
volume, as well as increased ventricular volume,
in individuals with schizophrenia compared with
healthy controls (Steen, Mull, McClure, Hamer, &

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Jackson and Milberg

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Lieberman, 2006). Evidence of abnormal neural
connectivity was identified in both first-episode
and chronic schizophrenia patients; however, there
is considerable heterogeneity between studies (see
Wheeler & Voineskos, 2014, for a review).

Soft neurological signs associated with
schizophrenia. The literature on neurological soft
signs in schizophrenia is extensive, with demon-
strated relationships to structural and functional
abnormalities (see Hüfner, Frajo-Apor, & Hofer,
2015, for a review). Total score on a measure of neu-
rological soft signs, including sensory integration,
motor coordination, motor sequencing, and other
neurological impairments, was positively correlated
with aspects of cognition, including spatial working
memory and complex set shifting in both controls
and individuals with schizophrenia (Arabzadeh
et al., 2014). Furthermore, Bachmann, Degen,
Geider, and Schröder (2014) described variability in
neurological soft signs over the course of the disor-
der, although these soft signs were in almost all cases
found to decrease alongside psychiatric symptoms.

Conclusions
The literature focused on cognitive factors associated
with schizophrenia is rich and evolving. Given the
strong relationship between cognition and functional
impairment within this population, there is a criti-
cal need to improve the ability to address cognitive
deficits and their effects on daily activities and social
functioning (Green, 2016). The development of cog-
nitive remediation programs focused on schizophre-
nia is an area of great interest, and such programs
have demonstrated effectiveness in this population
(see Kaneko & Keshavan, 2012, for a review).

CONCLUSION

Cognitive dysfunction within the context of psy-
chopathology is common and may contribute to the
high rates of functional impairment found within
psychiatric groups. Comparisons across psychiatric
conditions underscore a number of common areas of
cognitive dysfunction, including attention, memory,
and execution of complex cognitive tasks (i.e., exec-
utive functioning). Given these overlapping areas of
dysfunction, neuropsychological assessment cannot,

at this time, function as a diagnostic test for psycho-
pathology. However, neuropsychological assessment
has the potential to clarify cognitive strengths and
weaknesses, inform treatment, and contribute to dif-
ferential diagnosis.

Because future research and clinical efforts are
likely to be informed by a transdiagnostic
approach, understanding common mechanisms
of dysfunction from both cognitive and
neurological–neuropathological views will be of
increasing importance. Incorporating neuropsy-
chological assessment into mental health treatment
has the potential to contribute to improving the
understanding of the cognitive impairments asso-
ciated with psychiatric conditions and to use this
knowledge to inform the treatment of individuals
with these conditions.

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Steen, R. G., Mull, C., McClure, R., Hamer, R. M., &
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sy
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og
ic
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ss
oc
ia
ti
on
.
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t
fo
r
fu
rt
he
r
di
st
ri
bu
ti
on
.

Examination of Neurological and Neuropsychological Features in Psychopathology
89

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bjp.188.6.510

Stern, Y. (2009). Cognitive reserve. Neuropsychologia,
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Stone, W. S., & Hsi, X. (2011). Declarative memory
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j.pnpbp.2012.12.006

Co
py
ri
gh
t
Am
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
.
No
t
fo
r
fu
rt
he
r
di
st
ri
bu
ti
on
.

In

s

t

ruct

i

on

s:

R

e

spon

d

 

to

y

our

c

ol

le

a

gues

by

expla

in

ing

t

h

e

implic

at

ions

of

why

,

as

an

advanced

practice

nurse,

it

is

important

to

adopt

a

multidimensional,

integrative

mo

de

l

of

psychopathology

.

**

minimum of three

(

3

)

scholarly references

are

required

for

each

reply

cited

with

in

the

body of the reply

&

at the end

**

Reply

#

2

SH

A

RON

CAMACHO

 

Top of

For

m

Discussion

Week

1

Initial

Pos

t

Fact

ors

determining

the

Development

of

Mental

Health

Condition

s

The

re

is a

genetic

basis

for

most

mental

health

condition

s

as

shown

by the

presence

of a

predictable

pattern

of

inheritance.

For

instance,

there

is a

50%

chance

of

developing

bipolar

disor

der

if

one

of the

parents

has

a

history

of the

disease

(

Levine,

201

8

).

The presence of mental health conditions is

correlated

to the

distortion

of the

neuroscience

of the

brain.

For

example,

schizophrenia

develops

fol

low

ing

the i

ncrease

in

dopamine

levels

in the brain. 
The

be

havioral

and

cognitive

functioning

is

often

distorted

in mental health

conditions.

For instance, the

development

of

depression

is often

preceded

by a

feeling

of

worthlessness

and low

mood.

The

emotions

of

suc

h a

patient

are

likel

y

to be distorted with

higher

chances

of feeling low and

unhappy.

Developmentally,

mental health

patients

are likely to

have

a history of

trauma.

For instance, the presence of

maltreatment

by

seniors

in the

form

ative

age

(

Sala,

201

9

).
The

social

fact

ors

implicated

in the development of mental health conditions

include

the

inability

to form

friends

and the

lack

of social

support

from

family.

A

single

patient

who

lives

alone

at

home

and

unable

to form

close

relations

is

more

likely to

go

into

depression

compared

to the one with

adequate

social support (de

Figueiredo,

202

1). The presence of

cultural

beliefs

such

as a lack of

appreciation

for mental health conditions

increase

the chances of

delayed

diagnosis

and

treatment.

Inter

person

al

factors

determine

the

onset

of mental health conditions and the

speed

of

progression

of the disease

process.

For example, the lack of

interpersonal

skills

including

communication

makes

it

hard

for the person to

share

inner

feelings.

Such

a person is more likely to

get

a mental health condition compared to

those

who

readily

share

what

they

are

going

through

in

life

.

Reference

s
de Figueiredo,

C.

S.

,

Sandre,

P.

C.,

Portugal,

L.

C.

L.,

Mázala

–

de-

Oliveira,

T.,

da

Silva

Chagas,

L.,

Raony,

Í.,

…

&

Bomfim,

P.

O.

S.

(2021).

COVID

–

19

pandemic

impact

on

children

and

adolescents’

mental

health:

Biological

,

environmental,

and social

factors.

 

Progress

in

Neuro

–

Psychopharmacology

and Biological

Psychiatr

y, 

10

6

,

110171

.
Levine,

J.,

Toker,

L., &

Agam,

G.

(2018).

Dissecting

disease

entities

out

of the

broad

spectrum

of bipolar-

disorders.

 

Psychiatry

Researc

h, 

25

9,

330

–

332

.
Sala,

G.,

Jopp,

D.,

Gobet,

F.,

Ogawa,

M.,

Ishioka,

Y.

,

Masui,

Y., … &

Gondo,

Y.

(2019).

The impact of

leisure

activities

on older

adults’

cognitive

function,

physical

function, and mental

health.

 

PloS

one, 1

4

(11),

e0225006

.

Bottom of Form

Instructions:

Respon
d

to

your

colleagues

by

explaining

the

implications

of

why,

as

an

advanced

practice

nurse,

it

is

important

to

adopt

a

multidimensional,

integrative

model

of

psychopathology
.

**minimum of three
(3)
scholarly references are required for each
reply

cited
within the body of the reply & at the end
**

Reply

#

2

SHARON

CAMACHO

Discussion

Week

1

Initial

Pos
t

Factors

determining

the

Development

of

Mental

Health

Condition
s

There

is

a

genetic

basis

for

most

mental

health

conditions

as

shown

by

the

presence

of

a

predictable

pattern

of

inheritance.

For

instance,

there

is

a

50%

chance

of

developing

bipolar

disorder

if

one

of

the

parents

has

a

history

of

the

disease

(
Levine,

201
8
).

The

presence

of

mental

health

conditions

is

correlated

to

the

distortion

of

the

neuroscience

of

the

brain.

For

example,

schizophrenia

develops

following

the

i
ncrease

in

dopamine

levels

in

the

brain.

The

behavioral

and

cognitive

functioning

is

often

distorted

in

mental

health

conditions.

For

instance,

the

development

of

depression

is

often

preceded

by

a

feeling

of

worthlessness

and

low

mood.

The

emotions

of

suc
h

a

patient

are

likely

to

be

distorted

with

higher

chances

of

feeling

low

and

unhappy.

Developmentally,

mental

health

patients

are

likely

to

have

a

history

of

trauma.

For

instance,

the

presence

of

maltreatment

by

seniors

in

the

formative

age

(
Sala,

201
9
)
.

The

social

factors

implicated

in

the

development

of

mental

health

conditions

include

the

inability

to

form

friends

and

the

lack

of

social

support

from

family.

A

single

patient

who

lives

alone

at

home

and

unable

to

form

close

relations

is

more

likely

to

go

into

depression

compared

to

the

one

with

adequate

social

support

(
de

Figueiredo,

202
1
).

The

presence

of

cultural

beliefs

such

as

a

lack

of

appreciation

for

mental

health

conditions

increase

the

chances

of

delayed

diagnosis

and

treatment.

Interpersonal

fact
ors

determine

the

onset

of

mental

health

conditions

and

the

speed

of

progression

of

the

disease

process.

For

example,

the

lack

of

interpersonal

skills

including

communication

makes

it

hard

for

the

person

to

share

inner

feelings.

Such

a

person

is

more

likel
y

to

get

a

mental

health

condition

compared

to

those

who

readily

share

what

they

are

going

through

in

life
.

Reference
s

de

Figueiredo,

C.

S.,

Sandre,

P.

C.,

Portugal,

L.

C.

L.,

Mázala
–
de
–
Oliveira,

T.,

da

Silva

Chagas,

L.,

Raony,

Í.,

…

&

Bomfim,

P.

O.

S.

(2021).

COVID
–
19

pandemic

impact

on

children

and

adolescents’

mental

health:

Biological,

environmental,

and

social

factors.

Progress

in

Neuro
–
Psychopharmacology

and

Biological

Psychiatr
y
,

10
6
,

110171
.

Levine,

J.,

Toker,

L.,

&

Agam,

G.

(2018).

Dissecting

disease

entities

out

of

the

broad

spectrum

of

bipolar
–
disorders.

Psychiatry

Researc
h
,

25
9
,

330
–
332
.

Sala,

G.,

Jopp,

D.,

Gobet,

F.,

Ogawa,

M.,

Ishioka,

Y.,

Masui,

Y.,

…

&

Gondo,

Y.

(2019).

The

impact

of

leisure

activities

on

ol
der

adults’

cognitive

function,

physical

function,

and

mental

health.

PloS

on
e
,

1
4
(11),

e0225006
.

Instructions:

Respond to your colleagues by explaining the implications of why, as an advanced practice nurse, it

is important to adopt a multidimensional, integrative model of psychopathology.

**minimum of three (3) scholarly references are required for each reply cited

within the body of the reply & at the end**

Reply # 2

SHARON CAMACHO

Discussion Week 1 Initial Post

Factors determining the Development of Mental Health Conditions

There is a genetic basis for most mental health conditions as shown by the presence of a predictable

pattern of inheritance. For instance, there is a 50% chance of developing bipolar disorder if one of the parents

has a history of the disease (Levine, 2018). The presence of mental health conditions is correlated to the

distortion of the neuroscience of the brain. For example, schizophrenia develops following the increase in

dopamine levels in the brain.

The behavioral and cognitive functioning is often distorted in mental health conditions. For instance, the

development of depression is often preceded by a feeling of worthlessness and low mood. The emotions of such

a patient are likely to be distorted with higher chances of feeling low and unhappy. Developmentally, mental

health patients are likely to have a history of trauma. For instance, the presence of maltreatment by seniors in

the formative age (Sala, 2019).

The social factors implicated in the development of mental health conditions include the inability to

form friends and the lack of social support from family. A single patient who lives alone at home and unable to

form close relations is more likely to go into depression compared to the one with adequate social support (de

Figueiredo, 2021). The presence of cultural beliefs such as a lack of appreciation for mental health conditions

increase the chances of delayed diagnosis and treatment. Interpersonal factors determine the onset of mental

health conditions and the speed of progression of the disease process. For example, the lack of interpersonal

skills including communication makes it hard for the person to share inner feelings. Such a person is more

likely to get a mental health condition compared to those who readily share what they are going through in life.

References

de Figueiredo, C. S., Sandre, P. C., Portugal, L. C. L., Mázala-de-Oliveira, T., da Silva Chagas, L., Raony, Í., …

& Bomfim, P. O. S. (2021). COVID-19 pandemic impact on children and adolescents’ mental health:

Biological, environmental, and social factors. Progress in Neuro-Psychopharmacology and Biological

Psychiatry, 106, 110171.

Levine, J., Toker, L., & Agam, G. (2018). Dissecting disease entities out of the broad spectrum of bipolar-

disorders. Psychiatry Research, 259, 330-332.

Sala, G., Jopp, D., Gobet, F., Ogawa, M., Ishioka, Y., Masui, Y., … & Gondo, Y. (2019). The impact of leisure

activities on older adults’ cognitive function, physical function, and mental health. PloS one, 14(11), e0225006.

I

n

s

tructi

on

s:

Respon

d

 

to

y

our

colle

a

gues

by

expla

in

ing

the

implications

of

why,

as

an

advanced

practice

nurse,

it

is

important

to

adopt

a

multidimensional,

integrative

model

of

ps

y

chopathology

.

**

minimum of three

(3)

scholarly refer

ences

are

required

for

each

reply

cited

with

in the body of the reply

&

at the end

**

Reply

#

1

HE

A

THER

GROSSNICKLE

 

Top of Form

Biological

Factors

In

fluencing

the

Developm

ent

of

Psychopatholog

y
Biological

factors

influ

encing

the

developm

ent

of

psy

chopathology

inc

lude

gene

tic

s

and

the development and

function

of the

brain

.

A gen

et

ic

expression

of

psychiatric

illnesses

encompasses

a

complex

of

mutually

relate

d

gene

variations

 

(Kalin,

2

0

19).

Genetic

and

environ

mental

factors

impact

brain

development;

therefore,

any

disruption

of

these

factors

can

negatively

impact the

developing

brain

(Giannopoulou

et

al.,

2018)

.

Various

prenatal

,

intr

apartum,

and

postnatal

events

influence

brain

development,

such

as

drugs,

infections,

prenatal

depression,

fetal

hypoxia

,

hypoxia

during

the

neonatal

period,

and

obstetric

complications

that

result

in

hypoxia.

Studies

have

s

how

n

a

direct

correlation

be

twee

n

complicated

pregnancies

and

deliveries

and

their

impact on

severe

neurodevelopment

disorders

such as

autism,

ADHD,

and

schizophrenia

(Giannopoulou et al., 2018).  

  

Psychological

Factors Influencing the

Development

of Psychopathology

Environmental

influences can influence

rapid

brain development; therefore,

undermining

normal

development for

behavior

al,

emotion

al

,

and

cognitive

abilities.

Studies

support

the

effects

of

child

hood

emotional

abuse

on

psychopathology,

and

adverse

effects

exhibited

in

soc

ial

relationships

and

difficulties

in emotion

regulation

were

found

 

(

Berzenski,

2018).

As

sociations

between

child and

parent

psychopathology, with a

possible

stress

mediator,

are

investigated

to

understand

the

mothers’

and

fathers’

role

s

in

children’s

development of

psychopathology.

The

findings

indicated

that

parenting

stress

harms

their

children.

The

harmful

effects are exhibited

through

abnormal

behavior such as ADHD,

anxiety

disorders,

and

depressive

disorders 

(Weijers,

Steensel,

&

Bogels,

2018).  

Social,

Cultural,

and

Interpersonal

Factors Influencing the Development of Psychopathology

Culture

has

a

prominent

role in

understanding

and

treating

mental

health

disorders.

In a

globalized

world,

cultural

context

is

defined

by

adjusting

human

behavior,

which

inc

ludes

how

individuals

think,

feel,

behave

and relate in

social

situations

 

(Mole

rio,

2018). As

clinicians,

treatment

plans

must

be

tailored

to

patients’

own

cultural

beliefs

and

historical

roots,

impacting

overall

adherence

to

treatment.

Also,

minority

grou

ps such as

migrants

and

members

of the

LGBT

community

may

be

subjected

to

increased

risk

factors for

psychological

distress,

which

increases

their risk for

suicide,

major

depressive disorders, anxiety disorders, and

traumatic

disorders, to

name

a

few

 

(Molerio,

2018).

Additionally,

soc

–

economic

adversities

such as

povert

y

have

been

linked

with

low

life

satisfaction;

therefore,

explain

ing

material

deprivation

increased adverse life

advents

such as

unemployment,

neglect,

and

abuse.

Individuals

living

in poverty are

more

likely

to

suffer

from

mental health

issues

and

less

likely to

seek

treatment and

achieve

full

recovery

from emotional

psychopathological

problems

 (Molerio, 2018).

Reference

s
Berzenski,

S.

R.

(2018).

Distinct

emotion regulation

skills

explain psychopathology and problems in social relationships

following

childhood

emotional abuse and

neglect.

 

Developmental

and

Psychopathology,

31

(2),

483

–

496.

 

https://doi.org/10.1017/S09545794180000

20

Ginnopoulou, I., Pagida, M. A., Briana, D. D., & Panayota, M. T. (2018). Perinatal hypoxia as a risk factor for psychopathology later in life: The role of dopamine and neurotrophins. Hormones, 17, 25-32. https://doi.org/10.1007/s4200-018-007-7

Kalin, N. H. (2019). Early-life environmental factors impacting the development of psychopathology. American Journal of Psychiatry. https://ajp.psychiatryonline.org/14efe0f4-5e9d-43ef-ab80-033

Molerio, C. (2018). Culture and psychopathology: New perspective on research, practice, and clinical training in a globalized world. Frontiers in Psychiatry, 9(366). https://doi.org/10.3389/fpst.2018.00366

Weijers, D., Steensel, F. J., & Bogels, S. M. (2018). Associations between Psychopathology in mothers, fathers and their children: A structural modeling approach. Journal of Child and Family Studies, 27, 1992-2003. htts:/doi.org/10.1007/s10826-018-1024-5

Bottom of Form

Instructions:

Respon
d

to

your

colleagues

by

explaining

the

implications

of

why,

as

an

advanced

practice

nurse,

it

is

important

to

adopt

a

multidimensional,

integrative

model

of

psychopathology
.

**minimum of three
(3)
scholarly references are required for each
reply

cited
within the body of the reply & at the end
**

Reply

#

1

HEATHER

GROSSNICKLE

Biological

Factors

Influencing

the

Development

of

Psychopatholog
y

Biological

factors

influencing

the

development

of

psychopathology

include

genetics

and

the

development

and

function

of

the

brain.

A

genetic

expression

of

psychiatric

illnesses

encompasses

a

complex

of

mutually

related

gene

variations

(Kalin,

2019).

Genetic

and

environmental

factors

impact

brain

development;

therefore,

any

disruption

of

these

factors

can

negatively

impact

the

developing

brain

(Giannopoulou

et

al.,

2018).

Various

prenatal,

intr
apartum,

and

postnatal

events

influence

brain

development,

such

as

drugs,

infections,

prenatal

depression,

fetal

hypoxia,

hypoxia

during

the

neonatal

period,

and

obstetric

complications

that

result

in

hypoxia.

Studies

have

shown

a

direct

correlation

betwee
n

complicated

pregnancies

and

deliveries

and

their

impact

on

severe

neurodevelopment

disorders

such

as

autism,

ADHD,

and

schizophrenia

(Giannopoulou

et

al.,

2018).

Psychological

Factors

Influencing

the

Development

of

Psychopatholog
y

Environmental

influ
ences

can

influence

rapid

brain

development;

therefore,

undermining

normal

development

for

behavioral,

emotional,

and

cognitive

abilities.

Studies

support

the

effects

of

childhood

emotional

abuse

on

psychopathology,

and

adverse

effects

exhibited

in

social

relationships

and

difficulties

in

emotion

regulation

were

found

(Berzenski,

2018).

Associations

between

child

and

parent

psychopathology,

with

a

possible

stress

mediator,

are

investigated

to

understand

the

mothers’

and

fathers’

roles

in

children’s

developm
ent

of

psychopathology.

The

findings

indicated

that

parenting

stress

harms

their

children.

The

harmful

effects

are

exhibited

through

abnormal

behavior

such

as

ADHD,

anxiety

disorders,

and

depressive

disorders

(Weijers,

Steensel,

&

Bogels,

2018).

Social,

Cultural,

and

Interpersonal

Factors

Influencing

the

Development

of

Psychopatholog
y

Culture

has

a

prominent

role

in

understanding

and

treating

mental

health

disorders.

In

a

globalized

world,

cultural

context

is

defined

by

adjusting

human

behavior,

which

inc
ludes

how

individuals

think,

feel,

behave

and

relate

in

social

situations

(Molerio,

2018).

As

clinicians,

treatment

plans

must

be

tailored

to

patients’

own

cultural

beliefs

and

historical

roots,

impacting

overall

adherence

to

treatment.

Also,

minority

grou
ps

such

as

migrants

and

members

of

the

LGBT

community

may

be

subjected

to

increased

risk

factors

for

psychological

distress,

which

increases

their

risk

for

suicide,

major

depressive

disorders,

anxiety

disorders,

and

traumatic

disorders,

to

name

a

few

(Mole
rio,

2018).

Additionally,

soc
–
economic

adversities

such

as

poverty

have

been

linked

with

low

life

satisfaction;

therefore,

explaining

material

deprivation

increased

adverse

life

advents

such

as

unemployment,

neglect,

and

abuse.

Individuals

living

in

povert
y

are

more

likely

to

suffer

from

mental

health

issues

and

less

likely

to

seek

treatment

and

achieve

full

recovery

from

emotional

psychopathological

problems

(Molerio,

2018)
.

Reference
s

Berzenski,

S.

R.

(2018).

Distinct

emotion

regulation

skills

explain

psy
chopathology

and

problems

in

social

relationships

following

childhood

emotional

abuse

and

neglect.

Developmental

and

Psychopathology,

31
(2),

483
–
496.

https://doi.org/10.1017/S09545794180000
2
0

Instructions:

Respond to your colleagues by explaining the implications of why, as an advanced practice nurse, it

is important to adopt a multidimensional, integrative model of psychopathology.

**minimum of three (3) scholarly references are required for each reply cited

within the body of the reply & at the end**

Reply # 1

HEATHER GROSSNICKLE

Biological Factors Influencing the Development of Psychopathology

Biological factors influencing the development of psychopathology include genetics and the development and

function of the brain. A genetic expression of psychiatric illnesses encompasses a complex of mutually related

gene variations (Kalin, 2019). Genetic and environmental factors impact brain development; therefore, any

disruption of these factors can negatively impact the developing brain (Giannopoulou et al., 2018). Various

prenatal, intrapartum, and postnatal events influence brain development, such as drugs, infections, prenatal

depression, fetal hypoxia, hypoxia during the neonatal period, and obstetric complications that result in hypoxia.

Studies have shown a direct correlation between complicated pregnancies and deliveries and their impact on

severe neurodevelopment disorders such as autism, ADHD, and schizophrenia (Giannopoulou et al., 2018).

Psychological Factors Influencing the Development of Psychopathology

Environmental influences can influence rapid brain development; therefore, undermining normal development

for behavioral, emotional, and cognitive abilities. Studies support the effects of childhood emotional abuse on

psychopathology, and adverse effects exhibited in social relationships and difficulties in emotion regulation

were found (Berzenski, 2018). Associations between child and parent psychopathology, with a possible stress

mediator, are investigated to understand the mothers’ and fathers’ roles in children’s development of

psychopathology. The findings indicated that parenting stress harms their children. The harmful effects are

exhibited through abnormal behavior such as ADHD, anxiety disorders, and depressive disorders (Weijers,

Steensel, & Bogels, 2018).

Social, Cultural, and Interpersonal Factors Influencing the Development of Psychopathology

Culture has a prominent role in understanding and treating mental health disorders. In a globalized world,

cultural context is defined by adjusting human behavior, which includes how individuals think, feel, behave and

relate in social situations (Molerio, 2018). As clinicians, treatment plans must be tailored to patients’ own

cultural beliefs and historical roots, impacting overall adherence to treatment. Also, minority groups such as

migrants and members of the LGBT community may be subjected to increased risk factors for psychological

distress, which increases their risk for suicide, major depressive disorders, anxiety disorders, and traumatic

disorders, to name a few (Molerio, 2018). Additionally, soc-economic adversities such as poverty have been

linked with low life satisfaction; therefore, explaining material deprivation increased adverse life advents such

as unemployment, neglect, and abuse. Individuals living in poverty are more likely to suffer from mental health

issues and less likely to seek treatment and achieve full recovery from emotional psychopathological

problems (Molerio, 2018).

References

Berzenski, S. R. (2018). Distinct emotion regulation skills explain psychopathology and problems in social

relationships following childhood emotional abuse and neglect. Developmental and Psychopathology, 31(2),

483-496. https://doi.org/10.1017/S0954579418000020