Reconceptualising the Case of Peter Alan Using a Biopsychosocial Framework
This essay will be reconceptualising the case study of Peter Alan using a developmental psychopathology approach. Developmental psychopathology differs from the more traditional, diagnostic framework as it takes a broad and holistic approach to the study of individuals. Rather than viewing maladaptation as inherent to the individual, the understanding is that multiple levels of analysis are needed, and maladaptation should be placed within a dynamic relationship between the individual and their internal and external contexts (Cicchetti & Cohen, 2016).
As a result of using this approach, the focus will not be on formal diagnosis, instead, Peter’s presenting symptoms will be analysed by exploring the interplay of potential risk and protective factors. To support a developmental psychopathology reconceptualisation of Peter’s case, the essay will use the biopsychosocial (BPS) framework which was formulated by Engel in 1977. The BPS framework demonstrates how interactions between biological, psychological, and social factors determine the cause, manifestation, and outcome of wellness and disease (Engel, 1977). Through this framework, the interaction between biological risk factors and the social and environmental context which have shaped Peter’s development will be explored.
Peter is a 16-year-old boy who has been described as having concerning “episodes”. These episodes occur about two times per year and last between 14-17 days. During this time, Peter becomes passive and apathetic, losing interest in his usual hobbies and demonstrating regression in areas such as bladder and bowel control. Although the episodes began at the age of 10, they increased in severity after the death of his father at 11 and again at the onset of puberty at 14. His last episode showed most disturbance, as described by his mother: Peter wet his pants, masturbated in public and walked with his clothes on straight out into the sea, seemingly unaware of his surroundings. Peter’s personality is described as extremely reserved and pedantic while he is insistent on the maintenance of sameness. He is also said to be passive and unable to plan constructively. Peter is reported as having a very limited social network. His mother suggested he did not like other people around him and appeared un-interested in making friends. At home, Peter does not interact much with his siblings, preferring to stay in his room. His four older siblings tease him and try to provoke angry responses from him regularly.
It could be seen that Peter Alan has two main presenting challenges: the first is a difficulty in interacting with others and forming relationships. The second is the more recent experience of “episodes” in which he displays both internalising and externalising maladaptive behaviours. Both challenges will now be examined from a BPS perspective.
Peter is likely to have a genetic predisposition to both of his presenting difficulties. When we examine his family background, we can see a number of risk factors on his paternal side. Two of Peter’s paternal first cousins are described as being much like Peter with regard to personality, “though not as pronounced.” Peter’s father was also “a bit like him, reserved and with circumscribed interests.” Peter’s mother reported that two of Peter’s father’s paternal relatives had committed suicide and that four of the father’s relatives suffered from manic-depressive illness. One paternal relative suffered from recurrent depression. Within the BPS model, the role of particular genetic biomarkers and their links with maladaptive outcomes form the basis of the research in the biological domain (Rolland & Williams, 2005). With advances in genetic research, many disorders have been found to share a common genetic basis (Sanchez- Roige et al., 2017). Consequently, Peter’s paternal history brings a heightened risk to develop a disorder, even if it does not present itself in the same way.
Peter is described as having a tendency for ‘sameness’ with pedantic and stereotyped actions. He is also reported to have a fanatical interest in meteorology. These traits, alongside his deficits in social interaction, are typical of Autistic Spectrum Disorder (ASD). Although the purpose of reconceptualisation using the developmental psychopathology approach is not to offer a diagnosis, it may be helpful to understand the implications that Peter’s ASD type traits can have by making reference to research in this area. There are also genetic implications as both Peter’s father and two other paternal relatives ‘were a bit like Peter’ and his father in particular had ‘circumscribed interests’. Many studies have shown that personality traits have a strong genetic component (Sanchez-Roige et al., 2017). A 2015 meta-analytic study suggested that genes can account for approximately 40% of differences in personality (Vukasović & Bratko, 2015).
However, it should be noted that epigenesis is probabilistic but does not predict outcome. The concept of equifinality demonstrates that different biological factors or experiences in life may result in the same outcome (for example, social isolation). The concept of multifinality states that people can have similar biological factors or experiences (for example, the loss of a parent) that can result in varied outcomes. It is through coaction, transaction, and interaction across various levels of influence which characterise development in a BPS informed model. The interaction of genetic biomarkers and the specific environmental and social contexts they are exposed to is what can cause genes to become expressed as maladaptation and disorder (Cicchetti, 2016).
Attachment security is widely recognised to support healthy developmental trajectories in individuals (Allen et al., 2007). Studies have also shown secure attachment to be a protective factor in preventing maladaptive outcomes from biological vulnerabilities as well as supporting the development of other relationships throughout an individual’s life (Antonucci et al., 2018; Brown & Wright, 2001). On the contrary, insecure attachment has been associated with negative outcomes and can be a risk factor for maladaptation (Brown & Wright, 2001). Although there is no information on Peter’s attachment style in infancy, we can glean certain information from his interview. Firstly, his current relationship with his mother suggests an insecure attachment: Both Peter and his mother came across as disconnected emotionally, appearing slightly dissociative at points. Some significant adverse life events were described in a matter-of-fact way and neither Peter nor his mother appeared to check whether the other was OK when these were being recalled.
There are also several other indicators that suggest Peter’s early attachment may have been compromised. Although Peter’s mother described both her pregnancy and delivery with Peter as normal, it is noted that Peter was born with his umbilical cord wound around his neck. Such an occurrence may still have resulted in some level of trauma for his mother and impacted on those first moments when attachment formation begins. Birth trauma has been found to cause mothers to feel disconnected from their infants and lacking confidence in their parental decision making (Molloy et al., 2021).
Peter’s mother described him as being more reserved than his siblings, even in early infancy. This suggests that Peter’s temperament may also have impacted on the attachment relationship. Infant temperament, along with planned pregnancy, have been shown to be key factors in the formation of secure attachment (Abuhammad et al., 2020). As Peter also displays ASD type traits, this may have had an additional impact on attachment formation. Studies have indicated that the impairments children with ASD have in the development of social interaction can have profound effects on the attachment relationship developed with parents and may have an impact on parenting (Rutgers et al., 2007).
Although attachment is more commonly studied in infants, the attachment relationship can serve as an important aspect in the transition from childhood into adolescence and can be integral in formulating a sense of autonomy and developing emotion regulation capabilities (Warren, 2013). Securely attached adolescents display better social and coping mechanisms (Beijersbergen et al., 2012; Brown & White, 2001) and lower incidents of mental health problems (Toth et al., 2009). In the case of insecure attachment, the adolescent transition may be a cause of greater stress and a potential trigger for maladaptive behaviours. This is notable, as Peter’s episodes began at age 10 and became significantly worse at puberty.
Referring back to the BPS framework, it can be seen that Peter’s formation of attachment relationships is likely to have been initiated by biological and psychological factors which have then been further compounded by the interaction of these with his social environment. This demonstrates multifinality as the same risk factors in other individuals are likely to have led to different outcomes depending on other interacting variables. As attachment security has such a known effect on developmental outcomes, it is useful to highlight the significance this could have for Peter and his presenting problems. However, attachment relationships only form part of the bigger picture. Other potential contributing factors, including those with a psychological and social basis, will be explored now.
In Peter’s early childhood, his mother felt there was a delay in his cognitive abilities describing him as “retarded” with regards to both motor and language development at the age of 3. Although at the time a visiting paediatrician felt that everything was normal, on entering school, Peter couldn’t keep pace with his classmates and his IQ was later found to be 65: significantly lower than average. Research suggests a high comorbidity rate between developmental delay and psychopathology (Caplan et al., 2015; Einfeld et al., 2011). In particular, delays in language and other developmental milestones are common in children who later suffer from psychotic illnesses (Bentall et al., 2007; Larson et al., 2017).
Peter’s “episodes” could be seen to be psychotic in nature. Although the term psychosis is broad and cannot be easily defined, there is a general consensus that psychotic episodes involve some loss of contact with reality. They may include behaviour that is inappropriate for the situation and difficulty in functioning overall (National Institute of Mental Health, n.d). Some evidence suggests that individuals with ASD are at greater risk of developing psychotic illnesses than those in the general population (Larson et al., 2017), as Peter shares many ASD type traits, this finding may demonstrate another risk factor.
A possible primary risk factor in Peter’s case is his relationships with others. Peter has very limited social relationships as a result of the many interacting variables already mentioned. However, this is also another potential factor in his “episodes” and extreme withdrawal. It seems that Peter’s relationship with his siblings could be particularly harmful as although Peter’s mother suggests she tries to stop Peter’s elder siblings from picking on him, they do what they want and don’t listen to her. In contrast to peer bullying, sibling bullying has been neglected in research and is often perceived as less severe or even typical of sibling relationships. However, it is worth exploring as the limited studies that exist have shown extensive evidence linking sibling bullying to negative mental health (Toseeb & Wolke, 2021). Good quality sibling relationships are protective as they help children to develop social skills and are a source of emotional support (Toseeb et al., 2020). In contrast, research demonstrates that sibling bullying is associated with internalizing and externalizing problems in early adolescence, psychotic disorder in late adolescence, and depression, self-harm, and suicidal ideation in late adolescence and young adulthood (Toseeb & Wolke, 2021).
Sibling bullying occurs more frequently where there are pre-existing social and emotional difficulties or the presence of a neurodevelopmental condition (Toseeb et al., 2020). Households with more children are also more likely to experience sibling bullying with the first-born child/children as the most likely perpetrators. It is suggested that this may be as a result of competition over resources. Access to parental resources such as affection, attention, and material goods become limited as the number of siblings increase (Toseeb et al., 2020). In Peter’s case, as well as being one of six children, his mother may also need to give more care to Peter and his disabled younger brother, making this issue all the more likely. Whereas positive sibling relationships may have offered a protective buffer to Peter at the time of his father’s death, it is likely Peter experienced greater adversity at this time as a result of the increased stress in the household.
It could be suggested that the illness and subsequent death of Peter’s father acted as a catalyst for his current difficulties. Peter’s episodes began at the age of 10 and his father died of leukaemia when Peter was 11. Therefore, it is possible that the onset of his episodes occurred as a result of a decline in his father’s health. The changes and hospitalisations experienced at this time may have been overwhelming for Peter who has a need for sameness. Withdrawing or even disassociating from the experience could be seen to be an adaptive behaviour at the time, but one that has now become maladaptive.
In serious parental illness, there is often an emotional and psychological effect on both the ill and well parents. This can change the emotional availability of the parents, how the family functions and parent-child relationships (Chen & Panebianco, 2020). Since his father’s death it is likely that there have been extensive changes to the family environment which seem to be highlighted in Peter’s mother’s description of their home. Peter’s mother described the household as fraught with high levels of stress. She is a full-time carer for Peter and his younger brother. She does not work and receives benefits for being a carer. She has very little time (and money) to engage in social activities and can’t remember the last time she was able to go out. This account strongly suggests that Peter’s mother is not receiving the social and emotional support needed to manage her family situation effectively, possibly having a detrimental impact on her parenting. A mother who has a positive relationship with her child is a protective factor. But the same mother struggling emotionally and psychologically is a strong proximal risk factor in her child’s life (Shin, Park and Kim, 2006). The stress of being the sole carer is likely to impact on both Peter’s mother’s psychological functioning and feelings of efficacy in parenting (Rutgers et al., 2007).
Perhaps as a result of his sibling relationships and the fraught household, Peter spends much of his time alone in his room. This initial self-protection strategy has the unfortunate consequence of further isolating Peter and posing greater risks to compounding his already limited social skills and relations with others. Although this behaviour may initially have served as an adaptation to stress in the home, it acts as maladaptation when Peter withdraws from social interactions with peers. This was demonstrated when Peter attended a summer camp at the age of 14. During the camp, Peter experienced one of his episodes and was sent home a few days later because of severe negativism, muteness, and lack of initiative. Repeated experiences like these could serve to further Peter’s feelings of isolation and withdrawal from others (Larson & Hartl, 2013).
To summarise Peter’s case, there is evidence that his presenting symptoms could have many contributing factors. His social difficulties are likely to have a biological basis but may have been aggravated by environmental and social factors ranging from insecure attachment, sibling bullying and the death of his father. The experience of his father’s illness and death could be seen to have had a key influence on Peter’s development as it was at this time that he began to experience his first episodes. This adverse experience may have been compounded by his lack of coping mechanisms and inability to seek social support. It is also worth noting that Peter’s episodes also increased in severity at the onset of puberty, suggesting the interplay of developmental processes with environmental and social factors (Laursen & Hartl, 2013). The combination of Peter’s low cognitive development and potential genetic inheritability could mean he may have been more adversely impacted by his father’s illness and death at this pivotal stage in brain development, than if these factors were not to interact (Osei, 2019).
The BPS reconceptualisation moves beyond a clinical diagnosis allowing there to be greater focus on specific behaviours and the underlying factors that cause them. This can be helpful when thinking of potential interventions that could serve to help Peter and his family and may provide more options than plans based solely on diagnosis. From examining Peter’s case, it could be seen that a family intervention may be effective, especially in order to improve family engagement (American Psychological Association, 2011). Family based interventions are recommended and evidence-based treatments for a number of physiological disorders, including emotional, social and behavioural problems as well as symptoms of psychosis (Kaslow et al., 2012; Onwumere et al., 2011). This approach could be especially helpful in supporting his mother’s care role and reducing the stress she is currently under. With additional support, she may also feel more able to address Peter’s sibling bullying and help to create a safer and more supportive home environment where Peter doesn’t feel the need to retreat to his room. Additional strategies focused on supporting Peter’s social skills could also be of benefit. Studies which have explored the use of the Program for the Education and Enrichment of Relational Skills (PEERS) have found it effective for targeting young people with ASD or similar difficulties in the skills of making and keeping friends (McVay et al., 2016). This may be especially valuable in overcoming the impact of both sibling and peer rejection that Peter has experienced in his childhood and adolescent years. Both interventions would develop the potential for Peter to form deeper relationships, a proven protective factor for many psychological disorders (Dodge & Pettit, 2003) and one which particularly targets Peter’s difficulties.
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