Going to university can lead to depression

Mental disorders and the psychotherapeutic diagnostic process

Table of Contents

List of figures

List of tables

1 Sub-task 1: Risk and protective factors
1.1 Risk factors for the development of mental disorders
1.1.1 Internal Risk Factors
1.1.2 External risk factors
1.2 Protective factors against mental disorders

2 Sub-task 2: Development and maintenance of mental disorders
2.1 The influence of social support
2.2 The importance of dysfunctional cognitions

3 Sub-task 3: Diagnostics in the process of psychotherapy
3.1 Introduction to diagnostics
3.2 Start of therapy - indication-oriented diagnostics
3.3 Course of therapy - process and course diagnostics
3.4 End of therapy - evaluation diagnostics


Web sources

List of figures

Figure 1: Vulnerability-stress model of mental disorders

Figure 2: Model of dysfunctional cognitions and schemas

List of tables

Table 1: Behavioral analysis according to the SORKC scheme

1 Sub-task 1: Risk and protective factors

The following chapter explains the importance of risk and protective factors for the development of mental disorders with reference to empirical results. Subsection 1.1 deals with the various risk factors that can drastically increase the likelihood of developing a mental disorder. The protective factors, on the other hand, have a preventive effect and reduce the likelihood of developing a mental disorder.1 They are defined in more detail in subsection 1.2.

1.1 Risk factors for the development of mental disorders

Various conditions are considered to be risk factors, which usually occur in childhood or adolescence and have a negative impact on development, so that the likelihood of a subsequent disorder is increased. These can be specific features such as a premature birth, a significant life experience such as drug use, or formative events such as the death of a caregiver. This allows a distinction to be made between internal, personal and external, environmental risk factors.2 A study by Laucht, Schmidt and Esser (2000) showed that biological and psychosocial factors reinforce each other in the course of development and that there is less danger from individual risk factors. 80 percent of the variance in mental disorders could be ascribed to later psychosocial influencing variables in the study.3

1.1.1 Internal Risk Factors

Internal factors relate to a person's biological characteristics and in children and adolescents often include a difficult temperament, low intelligence, genetic disposition, or organic disease.4

The temperament already develops in toddler age and, in addition to the quality and intensity of emotional reactions and self-regulation, also determines the activation level of attention.5 According to the Thomas and Chess Model of Temperament (1977), three types of children can be identified: the simple, the difficult and the slowly becoming active child.6 In connection with mental disorders, the difficult and slowly becoming active children are of particular importance. While the difficult child reacts negatively to new stimuli, is inattentive or restless and has an irregularity in the rhythm, i.e. the body functions in the sleep-wake rhythm, in becoming hungry as well as in excretions, the child who only becomes active slowly behaves inactive, fearful and introverted, which makes it slow to adapt to new situations7. The connection between the child's temperament and psychological development can be demonstrated with several findings in this area. Kagan (1998) was able to determine in a study of the modes of reaction to auditory and visual stimuli in 16-week-old infants that 45 percent of the highly reactive test subjects with a difficult temperament developed anxiety symptoms later in school age8. Furthermore, Thomas and Chess (1977) were able to show in a study that 71 percent of the infants with a difficult temperament were affected by a mental disorder later in middle childhood.9 Similar studies have also shown that in the course of development, more externalizing disorders have developed in difficult children and increasingly internalizing disorders have developed in children who only become active slowly.10 In general, a high degree of anxiety and introversion and low self-esteem are considered risk factors for developing mental disorders.11

A person's genetic predisposition can also have a major influence on certain mental disorders, but they should not be seen as the only responsible risk factors. In several twin studies it has become clear that identical twins with a much higher degree of correspondence with one another develop schizophrenia and bipolar disorders than dizygoti twins. Various gene analyzes have also shown that a mental disorder cannot be traced back to individual genes, but rather to a number of genes that, together with external factors, disrupt health-relevant body systems. In contrast to a genetic disposition, an organic disease that arises before, during or after the birth and can have different causes can lead to mental disorders. Depending on the type and severity of the damage, the children affected can develop cerebral paralysis affecting the cerebrum, cognitive dysfunction or intellectual and linguistic impairments. A common cause of pre- and perinatal damage is, for example, the mother's consumption of harmful substances during pregnancy, such as alcohol or nicotine.12 A meta-analysis by Flak et al. (2014), a high level of maternal alcohol consumption, in this case four or more glasses in one situation, is directly related to the child's cognitive abilities. Studies with children between the ages of six months and 14 years have also shown that children whose mothers consumed excessive amounts of alcohol during pregnancy performed worse on cognition tests than normal children.13

1.1.2 External risk factors

In addition to the internal risk factors that relate to oneself, external factors describe the psychosocial stressors from a person's environment. These can be divided into distal and proximal factors, with the distal factors influencing child development in an indirect way and the proximal factors in a direct way. Distal risk factors can be, for example, a low socio-economic status, a low level of education of the parents, a larger than average family or the psychological well-being of the parents. Proximal risk factors, on the other hand, depend on the parent-child interaction and the communication and parenting behavior of the parents.14

Various epidemiological studies show that a low socio-economic status generally poses a high risk of developing mental disorders. In this context, three assumptions can be made, namely on the one hand the so-called stress-and-strain hypothesis and the social drift hypothesis and on the other hand the transaction model. The stress-and-strain hypothesis states that low social, financial and educational status comes with multiple stresses and can lead to mental illness. The social drift hypothesis, on the other hand, assumes that a low socio-economic status is a direct consequence of a mental disorder. These two assumptions are combined in the transaction model, which sees the low status as the reason for the development of mental illnesses, which in turn lead to a renewed loss of status.15

In a study by Paykel et al. (2003) were included in the National Morbidity Survey of Great Britain examined the differences between rural and urban populations, which found that urban populations were more likely to be affected by mental illness. The researchers attributed the result to the lower average quality of life of the urban population.16

Furthermore, possible mental disorders of the parents can affect the mental development of the child, as in a study by Wiegand-Grefe et al. (2009) could be proven. According to the results, the probability that the children of mentally ill parents will develop internalizing and externalizing disorders was three to seven times higher than that of the normal population.17 In another study by Lieb et al. (2002) also showed that depressed parents significantly increase their children's risk of depression.18 But also negative attachment experiences, such as excessive criticism from a caregiver, can lead to a negative self-image solidifying, which increases the child's risk of depression.19

The psychological conditions of the parents alone do not act as a direct risk factor on the child's development, but rather the disrupted parent-child interaction.20 A lack of emotional warmth and care in parental upbringing, combined with excessive, harmful caring for the child in adolescence, can lead to mental disorders.21 Severe neglect and sexual and emotional abuse of children by caregivers have a far greater negative impact on the development of mental disorders. As profoundly traumatic experiences, they drastically increase the risk of several, even serious, mental disorders.22

1.2 Protective factors against mental disorders

Even if a child is exposed to several risk factors in development, this does not automatically mean that they have to develop a possible mental disorder. The so-called protective factors exist even before the development of a mental illness and are responsible for either mitigating the previously occurring risk factors or eliminating them completely. The characteristics of the protective factors depend on the protective factors in the child, in the family and external influences. Thus, on the one hand, a pronounced self-esteem, a simple temperament and a high level of intelligence and, on the other hand, positive relationships within the family and the social environment are good indicators of a strong protective factor.23

These protective factors are also known as resilience and are the result of development and experience.24 It describes a person's ability to deal appropriately with negative environmental situations and to develop coping skills. Resilience depends on vulnerability, i.e. sensitivity to external conditions. On the one hand, it can be divided into primary vulnerability factors that already exist at birth and, on the other hand, into secondary vulnerability factors that only develop in the course of life.25

Children who are exposed to an increased rate of risk factors during their development show positive prognoses in adulthood, for example if they have been supported in their development by adults, which could boost their confidence. In addition, a qualitative parenting style has a positive effect on the child's self-esteem and positive temperament characteristics are manifested. In the same way, far-reaching possibilities of life transitions, such as going to university, promote a person's resilience.26

2 Sub-task 2: Development and maintenance of mental health

In the following chapter, in addition to the previous explanations on the development and maintenance of mental disorders, the influence of social support and dysfunctional cognitions on the psychological development of a person is discussed using theoretical models and empirical results. In subchapter 2.1, the role of social support is to be examined in more detail in theory, before examples are used to show to what extent it can serve as a positive protective factor. The influence of dysfunctional cognitions, which can also be referred to as thinking errors and represent a risk factor for mental health, is highlighted in the following subsection 2.2.

2.1 The influence of social support

Social support is an important protective factor in relation to the development of mental disorders and if it is not given it can lead to depression, among other things, which has been sufficiently proven in several empirical studies.27 The greatest preventive effect a person experiences from helping other people is protection from main effects and interactions with stressors. So when a stressor occurs, social contacts can represent the necessary contact persons who not only show understanding for the problem situation, but can also submit practical coping strategies so that the person concerned does not feel isolated from their environment. If there is no social support for a long time, it becomes a risk factor for mental disorders, since social loss events as permanent stressors play an important role in most mental illnesses.28 This conclusion can be traced back to the vulnerability-stress model, which states that the combination of a person's vulnerability and external stressors can result in a mental disorder (see Figure 1).29 In the context of social factors, the absence of social support constitutes vulnerability. The simultaneous connection with current stressors activates this vulnerability, which causes a disruption30.

Figure not included in this excerpt

Figure 1: Vulnerability-stress model of mental disorders.

(Source: Wittchen / Hoyer (2011), p. 21.)

A lack of social support often manifests itself as a result of low social status within a group. These people show poorer mental health than higher-status group members because they have to deal with direct rejection and experience little social acceptance.31

The influence that social support can have on a person's psychological state is particularly illustrated by the example of alcoholism. Excessive alcohol consumption is usually associated with some negative social factors, making it difficult to access social support from family or acquaintances. In these cases, self-help groups such as the Alcoholics Anonymous, in which the members give each other mutual support and understanding, are particularly helpful. This can counteract possible depression, anxiety disorders and dissocial personality disorders that are associated with alcohol abuse.

A similar intervention measure are therapeutic residential communities, in which people who were previously drug addicts have the opportunity to integrate into a new social environment in which the members support each other against the background of a shared past, so that a relapse is avoided.32

Another practical and empirically proven example of the positive influence of social support on the development of mental disorders is depression. The majority of people suffering from depression tend to have a small, often defective social environment that cannot offer the required support33. This lack of social support makes it difficult for those affected to deal with difficult life events.34 One study found that women who did not receive social support after a stressful and serious experience had a 40 percent risk of developing depression, while the other women who received the support they needed had a 40 percent risk only had a four percent risk.35

Even in therapeutic work with people at risk of suicide, cognitive behavioral therapy aims to provide greater social support in order to reduce the patient's feeling of hopelessness.36 Adaptive coping strategies, which are often used to successfully cope with post-traumatic stress disorder, are also significantly dependent on a great deal of social support.37


1 See Benecke (2014), p. 217

2 See Petermann (2011), pp. 123-124

3 See Laucht / Schmidt / Esser (2000); quoted from Benecke (2014), p. 217

4 See Benecke (2014), p. 218

5 See Elsner / Pauen (2018), p. 174

6 See Chess / Thomas (1984); quoted from Elsner / Pauen (2018), p. 174

7 See Chess / Thomas (1984); quoted from Elsner / Pauen (2018), p. 174

8 See Kagan (1998); quoted from Benecke (2014), p. 222

9 See Thomas / Chess (1977); quoted from Benecke (2014), p. 222

10 See Zentner (2000), p. 264

11 See Berking (2012), p. 22

12 See Berking (2012), pp. 21-22

13 See Flak / Su / Bertrand / Denny / Kesmodel / Cogswell (2014), p. 222

14 See Petermann (2011), p. 124

15 See Berking (2012), p. 23

16 See Paykel / Abbott / Jenkins / Brugha / Meltzer (2003), p. 104

17 See Wiegand-Grefe / Geers / Plaß / Petermann / Riedesser (2009); quoted from Naab / Kunkel / Fumi / Voderholzer / Chiemsee (2017), p. 28

18 See Lieb / Isensee / Höfler / Wittchen (2002), p. 242

19 See Berking (2012), pp. 23-24

20 See Benecke (2014), p. 224

21 See Schumacher / Eisemann / Brähler (1999)

22 See Maniglio (2010), p. 637

23 See Petermann (2011), p. 126

24 See Benecke (2014), p. 227

25 See Petermann (2011), p. 126

26 See Petermann / Kusch / Niebank (1998); quoted from Petermann (2011), p. 128

27 See Gariepy / Honkaniemi / Quesnel-Vallee (2016), p. 289

28 See Pinquart (2011), pp. 324-325

29 See Wittchen / Hoyer (2011), p. 21

30 See Ingram / Price (2010); quoted from Pinquart (2011), p. 320

31 See Boivin / Hymel / Bukowski (1995), p. 780

32 See Hautzinger / Thies (2009), pp. 48-49

33 See Keltner / Kring (1998), p. 328

34 See Kring / Johnson / Hautzinger (2019), p. 186

35 See Brown / Andrews (1986); quoted from Kring / Johnson / Hautzinger (2019), p. 186

36 See Kring / Johnson / Hautzinger (2019), p. 207

37 See Brewin / Andrews / Valentine (2000); quoted from Kring / Johnson / Hautzinger (2019), p. 268

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