case study on psychopaths

The Neuroscientist Who Discovered He Was a Psychopath

While studying brain scans to search for patterns that correlated with psychopathic behavior, James Fallon found that his own brain fit the profile

Joseph Stromberg

One afternoon in October 2005, neuroscientist James Fallon was looking at brain scans of serial killers. As part of a research project at UC Irvine, he was sifting through thousands of PET scans to find anatomical patterns in the brain that correlated with psychopathic tendencies in the real world.

“I was looking at many scans, scans of murderers mixed in with schizophrenics, depressives and other, normal brains,” he says. “Out of serendipity, I was also doing a study on Alzheimer’s and as part of that, had brain scans from me and everyone in my family right on my desk.”

James Fallon’s new book,  The Psychopath Inside

“I got to the bottom of the stack, and saw this scan that was obviously pathological,” he says, noting that it showed low activity in certain areas of the frontal and temporal lobes linked to empathy, morality and self-control. Knowing that it belonged to a member of his family, Fallon checked his lab’s PET machine for an error (it was working perfectly fine) and then decided he simply had to break the blinding that prevented him from knowing whose brain was pictured. When he looked up the code, he was greeted by an unsettling revelation: the psychopathic brain pictured in the scan was his own.

Many of us would hide this discovery and never tell a soul, out of fear or embarrassment of being labeled a psychopath. Perhaps because boldness and disinhibition are noted psychopathic tendencies , Fallon has gone all in towards the opposite direction, telling the world about his finding in a TED Talk , an NPR interview and now a new book published last month, The Psychopath Inside .  In it, Fallon seeks to reconcile how he—a happily married family man—could demonstrate the same anatomical patterns that marked the minds of serial killers.

“I’ve never killed anybody, or raped anyone,” he says. “So the first thing I thought was that maybe my hypothesis was wrong, and that these brain areas are not reflective of psychopathy or murderous behavior.”

But when he underwent a series of genetic tests, he got more bad news. “I had all these high-risk alleles for aggression, violence and low empathy,” he says, such as a variant of the MAO-A gene that has been linked with aggressive behavior. Eventually, based on further neurological and behavioral research into psychopathy, he decided he was indeed a psychopath—just a relatively good kind, what he and others call a “ pro-social psychopath ,” someone who has difficulty feeling true empathy for others but still keeps his behavior roughly within socially-acceptable bounds.

It wasn’t entirely a shock to Fallon, as he’d always been aware that he was someone especially motivated by power and manipulating others, he says. Additionally, his family line included seven alleged murderers , including Lizzie Borden , infamously accused of killing her father and stepmother in 1892.

But the fact that a person with the genes and brain of a psychopath could end up a non-violent, stable and successful scientist made Fallon reconsider the ambiguity of the term. Psychopathy, after all, doesn’t appear as a formal diagnosis in the  Diagnostic and Statistical Manual of Mental Disorders  in part because it encompasses such a wide range of symptoms. Not all psychopaths kill; some, like Fallon, exhibit other sorts of psychopathic behavior.

“I’m obnoxiously competitive. I won’t let my grandchildren win games. I’m kind of an asshole, and I do jerky things that piss people off,” he says. “But while I’m aggressive, but my aggression is sublimated. I’d rather beat someone in an argument than beat them up.”

Why has Fallon been able to temper his behavior, while other people with similar genetics and brain turn violent and end up in prison? Fallon was once a self-proclaimed genetic determinist , but his views on the influence of genes on behavior have evolved. He now believes that his childhood helped prevent him from heading down a scarier path.

“I was loved, and that protected me,” he says. Partly as a result of a series of miscarriages that preceded his birth, he was given an especially heavy amount of attention from his parents, and he thinks that played a key role.

This corresponds to recent research: His particular allele for a serotonin transporter protein present in the brain, for example, is believed to put him at higher risk for psychopathic tendencies. But further analysis has shown that it can affect the development of the ventromedial prefrontal cortex (the area with characteristically low activity in psychopaths) in complex ways: It can open up the region to be more significantly affected by environmental influences, and so a positive (or negative) childhood is especially pivotal in determining behavioral outcomes.

Of course, there’s also a third ingredient, in addition to genetics and environment: free will. “Since finding all this out and looking into it, I’ve made an effort to try to change my behavior,” Fallon says. “I’ve more consciously been doing things that are considered ‘the right thing to do,’ and thinking more about other people’s feelings.”

But he added, “At the same time, I’m not doing this because I’m suddenly nice, I’m doing it because of pride—because I want to show to everyone and myself that I can pull it off.”

Get the latest Science stories in your inbox.

Joseph Stromberg | | READ MORE

Joseph Stromberg was previously a digital reporter for Smithsonian .

Featured Topics

Featured series.

A series of random questions answered by Harvard experts.

Explore the Gazette

Read the latest.

‘The scientist is not in the business of following instructions.’

Glimpse of next-generation internet

Science is making anti-aging progress. But do we want to live forever?

Psychopaths are not incapable of feeling emotions, like regret and disappointment, but what they cannot do is make accurate predictions about the outcomes of their choices, according to a study co-authored by Joshua Buckholtz, associate professor of psychology at Harvard.

File photo by Stephanie Mitchell/Harvard Staff Photographer

A revised portrait of psychopaths

Peter Reuell

Harvard Staff Writer

Study finds that they do feel regret, but it doesn’t affect their choices

When most people hear the word psychopath, they immediately think of a Hannibal Lecter–style serial killer who is cold, calculating, emotionless, willing to do or say anything to get their desire.

More like this

Pinpointing punishment

And they’re not alone. For decades, researchers studying psychopathy have characterized the disorder as a profound inability to process emotions such as empathy, remorse, or regret.

A recent study , though, suggests that psychopaths are not incapable of feeling emotions like regret and disappointment. What they cannot do, it seems, is make accurate predictions about the outcomes of their choices.

The study, co-authored by Joshua Buckholtz, associate professor of psychology at Harvard, and Arielle Baskin-Sommers, assistant professor of psychology and of psychiatry at Yale University, offers a new model of the disorder that could shed important light on the decision-making process of psychopaths. The study was published in the Proceedings of the National Academy of Sciences.

“The assumption has always been that they make these bad choices because they can’t generate negative emotions like fear, or appropriately respond to emotional signals generated by other people … but we turned that idea on its head.”

Using an economic game, Buckholtz and Baskin-Sommers were able to show that while psychopaths have normal, or even enhanced, emotional responses in situations that typically elicit regret, they have trouble extracting information from the environment that would indicate that an action they’re about to take will result in the experience of regret.

“There are two components to regret,” Buckholtz explained. “There is retrospective regret, which is how we usually think about regret — the emotional experience after you learn you could have received a better outcome if you had made a different choice. But we also use signals from our environment to make predictions about which actions will or won’t result in regret. What differentiated psychopaths from other people was their inability to use those prospective regret signals, to use information about the choices they were given to anticipate how much regret they were going to experience, and adjust their decision-making accordingly.

“It’s almost like a blindness to future regret,” he added. “When something happens, they feel regret, but what they can’t do is look forward and use information that would tell them they’re going to feel regret to guide their decision-making.”

“These findings highlight that psychopathic individuals are not simply incapable of regret [or other emotions], but that there is a more nuanced dysfunction that gets in the way of their adaptive functioning,” Baskin-Sommers said. “By appreciating this complexity, we are poised to develop more accurate methods for predicting the costly behavior of psychopathic individuals.”

Using a measure of prospective regret sensitivity, Buckholtz and Baskin-Sommers were also able to predict whether and even how many times study participants had been incarcerated.

“Contrary to what you would expect based on these basic emotional-deficit models, their emotional responses to regret didn’t predict incarceration,” Buckholtz said. “We know psychopathy is one of the biggest predictors of criminal behavior, but what we found was that behavioral regret sensitivity moderated that, raising the suggestion that intact behavioral regret sensitivity could be a protective factor against incarceration in psychopathic individuals.”

While the study upends the pop-culture image of psychopaths, Buckholtz is hopeful that it will also provide a new direction for scientists who hope to understand how psychopaths make decisions.

“We actually know very little about how psychopaths make choices,” he said. “There have been all sorts of research into their emotions and emotional experience, but we know next to nothing about how they integrate information that we extract from the world as a matter of course and use it to make decisions in daily lives. Getting better insight into why psychopaths make such terrible choices, I think, is going to be very important for the next generation of psychopathy research.”

Share this article

You might like.

George Whitesides became a giant of chemistry by keeping it simple

Physicists demo first metro-area quantum computer network in Boston

Nobel laureate details new book, which surveys research, touches on larger philosophical questions

Six receive honorary degrees

Harvard recognizes educator, conductor, theoretical physicist, advocate for elderly, writer, and Nobel laureate

When should Harvard speak out?

Institutional Voice Working Group provides a roadmap in new report

Day to remember

One journey behind them, grads pause to reflect before starting the next

• Your details
• Account settings
• Mini-site Builder
• Add an article
• Edit an article

Register your practice / org.

Submit your practice | Attract referrals

Find a therapist near you

{{pageh1title}}.

Find a therapist

What is therapy, who needs therapy, how to choose a therapist, publish an article on therapyroute, what is a psychopath signs, causes, treatments.

TherapyRoute

., South Africa

Want to know what psychopathy really means? Learn the key differences between psychopathy and sociopathy, discover the causes, and explore treatment options.

You've probably heard the term "psychopathy" in movies or TV shows, often associated with chilling villains or complex characters. But what does it mean in a medical or psychological context?

Psychopathy is a profound mental health condition marked by a striking lack of empathy and emotional depth, which can lead to dangerously antisocial behaviours. Despite its frequent portrayal in popular culture, psychopathy is a real and serious disorder known in the medical community as Antisocial Personality Disorder (ASPD).

Understanding psychopathy involves examining how a person’s mind can diverge so drastically from the norm, leading to behaviours that can seem both calculated and deeply unsettling. This guide will explore the nuances of psychopathy, its causes, symptoms, and the challenges involved in its treatment, providing you with a comprehensive view of this complex condition.

Table of Contents   

What is Psychopathy?

Psychopathy vs. Sociopathy: What's the Difference?

Are Psychopaths Born or Made? Causes and Risk Factors

Signs and symptoms, therapy and other treatment options, key takeaways.

At its core, psychopathy involves a profound inability to empathise with others. This absence of empathy results in significant challenges in emotional regulation, often manifesting in behaviours that are harmful to others. It’s important to note that while all individuals diagnosed as psychopaths would meet the criteria for ASPD, not everyone with ASPD is considered a psychopath.

Psychopathy vs. Sociopathy: What's the Difference? 

Behavioural differences  .

• Psychopathy: Individuals with psychopathy are often calculated and manipulative. They are skilled at planning their actions and can control their behaviour to achieve specific goals.  
• Sociopathy: Sociopaths tend to be more impulsive and less calculated. They are prone to emotional outbursts and struggle to plan actions in detail.

Prevalence   

• ​​Psychopathy: This condition is relatively rare, affecting less than 1% of the general population . Its rarity makes it a frequent subject of extensive research and public fascination.  
• Sociopathy: Sociopathy is more common than psychopathy, though exact numbers are difficult to determine. It's frequently observed in dysfunctional societal settings due to its strong ties to environmental factors.

The causes of psychopathy are complex and typically involve a mix of genetic and environmental factors. There isn’t a single "psychopathy gene" or definitive event that causes someone to become a psychopath, but several risk factors can increase the likelihood of developing this condition.  

Genetic Influences

Genetics play a significant role in psychopathy, with research indicating it can run in families. Having a family member with psychopathy increases your likelihood of developing it, but genetics alone are not sufficient to cause the disorder.  

Brain Structure and Chemistry

Differences in brain structure and function also contribute to psychopathy. Brain scans of individuals with psychopathy often reveal variations in regions responsible for empathy, fear, and anxiety. These differences affect how people process emotions and make decisions, making them more prone to antisocial behaviour.  

Environmental Factors

Environmental factors, such as a dysfunctional family environment characterised by neglect or abuse, also play a critical role in developing psychopathic traits. Adverse experiences during formative years can impact emotional development and behaviour.  

Childhood Behavioural Disorders

Early behavioural issues can be a significant red flag. Childhood conditions like conduct disorder or oppositional defiant disorder (ODD) increase the risk of developing psychopathy later in life. These early signs often include a blatant disregard for rules and a lack of empathy, which can escalate into more severe behaviours as the individual matures.

Recognising the signs of psychopathy can be challenging, especially because individuals with this condition can often be charming and manipulative. However, certain behaviours can serve as red flags:  

• Lack of Empathy: One of the most telling signs is a lack of empathy or understanding of other people's feelings. This often manifests as a disregard for the emotions and well-being of others.  
• Manipulative Behaviour: Psychopaths are often skilled manipulators. They can deceive and manipulate others to get what they want, showing little to no remorse for their actions.  
• Impulsivity: While they can be calculating, psychopaths also exhibit impulsive behaviours. They may make rash decisions without considering the consequences.  
• Narcissism: A heightened sense of self-importance and a constant need for admiration are also common traits. This narcissistic behaviour often masks fragile self-esteem.  
• Chronic Lying: Frequent and pathological lying is another sign. They can lie effortlessly and manipulate facts to suit their narrative.

The treatment of psychopathy presents a unique challenge in mental health care. Historically, there has been scepticism about the effectiveness of treatment for psychopathy, with concerns that it might be untreatable or that intervention could worsen the condition. However, recent research and clinical practices provide new perspectives on this issue.  

Cognitive Behavioural Therapy (CBT)

CBT has shown potential in treating psychopathy, particularly in helping individuals recognise and change harmful thought patterns and behaviours. It focuses on developing empathy and understanding the consequences of actions.  

• Population-Specific Approaches: The effectiveness of CBT may vary depending on the population. Studies indicate that strategies effective for specific groups, like sex offenders, might not be universally applicable to all individuals with psychopathy.

Schema Therapy (ST)

Developed for patients challenging to treat with traditional therapy, ST has been increasingly considered for psychopathy . It emphasises understanding the childhood origins of psychological issues, experiential techniques, and the therapist-client relationship.  

• Forensic Settings: In forensic hospitals, particularly in the Netherlands, ST has been adapted for severe personality disorders, including psychopathy. This therapy shows promise in reducing violence risk and enhancing openness and vulnerability in therapy sessions.  
• Case Studies: Early case studies, such as the treatment of a forensic inpatient with psychopathic features using ST, suggest that it may enhance treatment motivation and responsiveness in individuals with psychopathy or ASPD.  

Challenges and Considerations

The debate continues regarding the overall effectiveness of therapy for psychopathy. While some researchers report limited benefits, others argue for the potential of specific treatments to reduce behaviours like violence. Treatment approaches may need to be adjusted based on gender, as female psychopaths, generally less violent, might require different strategies than males.

There is a notable lack of controlled studies on the treatment of psychopathy, particularly randomised controlled trials, which limits definitive conclusions about the most effective approaches.  

Barriers to Treatment  

• Lack of Insight: One of the biggest challenges in treating psychopathy is the individual's lack of insight into their condition. They often don't see a need for treatment, making engagement difficult.  
• Manipulative Behaviour: Their manipulative tendencies can also extend into the therapeutic relationship, making it challenging for healthcare providers to establish a genuine connection.  
• Treatment Resistance: Even when they do engage in treatment, psychopaths are often resistant to change, which can make long-term management challenging.  

In sum, psychopathy is a complex condition characterised by a blend of behavioural, emotional, and interpersonal challenges. While treatment can be difficult, understanding the signs and engaging in comprehensive therapeutic approaches can help manage some symptoms.

Early intervention, particularly in cases where psychopathic traits are identified in childhood, can be crucial. The societal and clinical understanding of psychopathy requires continuous evolution and sensitivity, emphasising the need for ongoing research and education in this field.

• Understanding Psychopathy: Psychopathy is a severe form of Antisocial Personality Disorder (ASPD) characterised by a lack of empathy and manipulative behaviour.  
• Differentiating Terms: Psychopathy and sociopathy, while related, are distinct; the former is more calculated and less impulsive than the latter.  
• Causes: Both genetic and environmental factors contribute to the development of psychopathy.  
• Treatment Challenges: Psychopathy is difficult to treat, with therapies like CBT and Schema Therapy showing some promise, but success varies.  
• Early Intervention: Identifying and addressing psychopathic traits early, especially in childhood, can be crucial for better management.  
• Signs and Symptoms: Key indicators include a lack of empathy, manipulative behaviour, impulsivity, narcissism, and chronic lying.  
• Professional Help: Accurate diagnosis and treatment should involve mental health professionals, emphasising safety and appropriate intervention strategies.

What is the difference between a psychopath and a sociopath?

While both psychopathy and sociopathy fall under the broader category of Antisocial Personality Disorder (ASPD), they are distinct. Psychopaths typically have a genetic predisposition to the disorder and exhibit calculated, manipulative behaviour. Sociopaths, on the other hand, are more likely influenced by environmental factors and are generally more impulsive and emotionally volatile.

Can psychopathy be treated or cured?

Treatment of psychopathy is challenging, and there is no known cure. However, certain therapeutic approaches, such as Cognitive Behavioural Therapy (CBT) and Schema Therapy, can help manage some symptoms. The effectiveness of treatment varies based on the individual and the severity of their condition.

How is psychopathy diagnosed?

Psychopathy is often assessed using specialised tools like the Psychopathy Checklist-Revised (PCL-R). This involves a detailed evaluation of the individual's history and behaviour to identify psychopathic traits. Psychopathy is not a distinct diagnosis in the DSM-5 but is seen as a severe form of ASPD.

Are psychopaths b orn or made?

Psychopathy is believed to result from a combination of genetic and environmental factors. While some individuals may have a genetic predisposition to psychopathy, environmental factors such as childhood trauma can also play a significant role in its development.

Can psychopaths feel emotions or empathy?

Psychopaths can experience emotions, but these are often shallow and short-lived. They typically lack empathy, which is the ability to understand and share the feelings of others. This lack of empathy is a core characteristic of psychopathy and contributes to the manipulative and antisocial behaviours associated with the disorder.

Is my child a psychopath?

Diagnosing psychopathy in children is complex and controversial. Warning signs can include a severe lack of empathy, manipulative behaviour, and callousness. However, it's important to consult a mental health professional for an accurate assessment. Many factors can influence children's behaviours, and a professional can help differentiate between normal developmental stages and more serious concerns.

What should I do if I suspect someone is a psychopath?

If you suspect someone may be a psychopath, it is important to approach the situation with caution. Professional help from a mental health expert is crucial. They can provide an accurate diagnosis and suggest appropriate interventions. It’s also important to ensure your safety, especially if the individual's behaviour is harmful or threatening.

Produced By: TherapyRoute is based in ., South Africa.

Click to visit TherapyRoute .

Join the discussion or add your comment below.

Find a Therapist

Find skilled psychologists, psychiatrists, and Counselor near you.

You may like

Mental health professional? Add your practice.

© 2024 THERAPYROUTE PTY LTD

The Psychopathic Patient - A Case Study

Therapy session notes provide insight into living with Antisocial Personality Disorder (AsPD) - psychopaths and sociopaths.

• Watch the video on A Psychotherapist and the Psychopath  

Notes of first therapy session with Ani Korban, male, 46, diagnosed with Antisocial Personality Disorder (AsPD), or Psychopathy and Sociopathy

Ani was referred to therapy by the court, as part of a rehabilitation program. He is serving time in prison, having been convicted of grand fraud. The scam perpetrated by him involved hundreds of retired men and women in a dozen states over a period of three years. All his victims lost their life savings and suffered grievous and life-threatening stress symptoms.

He seems rather peeved at having to attend the sessions but tries to hide his displeasure by claiming to be eager to "heal, reform himself and get reintegrated into normative society". When I ask him how does he feel about the fact that three of his victims died of heart attacks as a direct result of his misdeeds, he barely suppresses an urge to laugh out loud and then denies any responsibility: his "clients" were adults who knew what they were doing and had the deal he was working on gone well, they would all have become "filthy rich." He then goes on the attack: aren't psychiatrists supposed to be impartial? He complains that I sound exactly like the "vicious and self-promoting low-brow" prosecutor at his trial.

He looks completely puzzled and disdainful when I ask him why he did what he did. "For the money, of course" - he blurts out impatiently and then recomposes himself: "Had this panned out, these guys would have had a great retirement, far better than their meager and laughable pensions could provide." Can he describe his typical "customer"? Of course he can - he is nothing if not thorough. He provides me with a litany of detailed demographics. No, I say - I am interested to know about their wishes, hopes, needs, fears, backgrounds, families, emotions. He is stumped for a moment: "Why would I want to know these data? It's not like I was their bloody grandson, or something!"

Ani is contemptuous towards the "meek and weak". Life is hostile, one long cruel battle, no holds barred. Only the fittest survive. Is he one of the fittest? He shows signs of unease and contrition but soon I find out that he merely regrets having been caught. It depresses him to face incontrovertible proof that he is not as intellectually superior to others as he had always believed himself to be.

Is he a man of his word? Yes, but sometimes circumstances conspire to prevent one from fulfilling one's obligations. Is he referring to moral or to contractual obligations? Contracts he believes in because they represent a confluence of the self-interests of the contracting parties. Morality is another thing altogether: it was invented by the strong to emasculate and enslave the masses. So, is he immoral by choice? Not immoral, he grins, just amoral.

How does he choose his business partners? They have to be alert, super-intelligent, willing to take risks, inventive, and well-connected. "Under different circumstance, you and I would have been a great team" - he promises me as I, his psychiatrist, am definitely "one of the most astute and erudite persons he has ever met." I thank him and he immediately asks for a favor: could I recommend to the prison authorities to allow him to have free access to the public pay phone? He can't run his businesses with a single daily time-limited call and this is "adversely affecting the lives and investments of many poor people." When I decline to do his bidding, he sulks, clearly consumed by barely suppressed rage.

How is he adapting to being incarcerated? He is not because there is no need to. He is going to win his appeal. The case against him was flimsy, tainted, and dubious. What if he fails? He doesn't believe in "premature planning". "One day at a time is my motto." - he says smugly - "The world is so unpredictable that it is by far better to improvise."

He seems disappointed with our first session. When I ask him what his expectations were, he shrugs: "Frankly, doctor, talking about scams, I don't believe in this psycho-babble of yours. But I was hoping to be able finally communicate my needs and wishes to someone who would appreciate them and lend me a hand here." His greatest need, I suggest, is to accept and admit that he erred and to feel remorse. This strikes him as very funny and the encounter ends as it had begun: with him deriding his victims.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next: The Narcissistic Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Psychopathic Patient - A Case Study, HealthyPlace. Retrieved on 2024, May 30 from https://www.healthyplace.com/personality-disorders/malignant-self-love/psychopathic-patient-a-case-study

Medically reviewed by Harry Croft, MD

Related Articles

Restrained narcissist - excerpts part 24, the two loves of the narcissist, depression and the narcissist, the narcissist in court, the cyber narcissist, negativistic (passive-aggressive) personality disorder, the narcissist and psychopath getting better.

2024 HealthyPlace Inc. All Rights Reserved. Site last updated May 30, 2024

Treating the untreatable: a single case study of a psychopathic inpatient treated with schema therapy

Affiliations.

• 1 Department of Clinical Psychological Science.
• 2 Forensic Psychiatric Centre de Rooyse Wissel.
• PMID: 24684220
• DOI: 10.1037/a0035773

From its first conceptualization in modern psychiatry, psychopathy has been considered difficult if not impossible to treat. Schema Therapy (ST) is a psychotherapeutic approach that has shown efficacy in patients with borderline personality disorder. ST has recently been adapted for personality disordered forensic patients, including patients with high levels of psychopathy. The present case study examined the process of individual ST, combined with movement therapy and milieu therapy by the nursing staff, with a forensic inpatient with psychopathic features (Psychopathy Checklist-Revised total score = 28.4). The patient had been sentenced to a mandatory treatment order in relation to a sexual assault. We assessed change using independent assessments of psychopathic traits, cognitive schemas, and risk-related behaviors over the 4-year treatment period and a 3-year follow-up. We also assessed the quality of the working alliance. Reliable change analyses showed significant improvements in psychopathic traits, cognitive schemas, and risk-related outcomes. At 3 years posttreatment, the patient was living independently outside of the forensic institution without judicial supervision and he had not reoffended. While many questions remain about the effectiveness of psychotherapeutic treatment for psychopathic patients, our study challenges the view that they are untreatable.

PsycINFO Database Record (c) 2014 APA, all rights reserved.

Publication types

• Case Reports
• Aggression / psychology
• Antisocial Personality Disorder / therapy*
• Criminal Psychology / methods
• Evidence-Based Medicine / methods
• Follow-Up Studies
• Hospitals, Psychiatric
• Inpatients / psychology*
• Netherlands
• Prisoners / psychology
• Professional-Patient Relations*
• Psychotherapy / methods*
• Sex Offenses / psychology*
• Treatment Outcome

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

Related Articles

Research Methodology

Qualitative Data Coding

What Is a Focus Group?

Cross-Cultural Research Methodology In Psychology

What Is Internal Validity In Research?

Research Methodology , Statistics

What Is Face Validity In Research? Importance & How To Measure

Criterion Validity: Definition & Examples

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Best Family Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

What Is a Case Study in Psychology?

Categories Research Methods

A case study is a research method used in psychology to investigate a particular individual, group, or situation in depth . It involves a detailed analysis of the subject, gathering information from various sources such as interviews, observations, and documents.

In a case study, researchers aim to understand the complexities and nuances of the subject under investigation. They explore the individual’s thoughts, feelings, behaviors, and experiences to gain insights into specific psychological phenomena. 

This type of research can provide great detail regarding a particular case, allowing researchers to examine rare or unique situations that may not be easily replicated in a laboratory setting. They offer a holistic view of the subject, considering various factors influencing their behavior or mental processes. 

By examining individual cases, researchers can generate hypotheses, develop theories, and contribute to the existing body of knowledge in psychology. Case studies are often utilized in clinical psychology, where they can provide valuable insights into the diagnosis, treatment, and outcomes of specific psychological disorders. 

Case studies offer a comprehensive and in-depth understanding of complex psychological phenomena, providing researchers with valuable information to inform theory, practice, and future research.

Table of Contents

Examples of Case Studies in Psychology

Case studies in psychology provide real-life examples that illustrate psychological concepts and theories. They offer a detailed analysis of specific individuals, groups, or situations, allowing researchers to understand psychological phenomena better. Here are a few examples of case studies in psychology: 

Phineas Gage

This famous case study explores the effects of a traumatic brain injury on personality and behavior. A railroad construction worker, Phineas Gage survived a severe brain injury that dramatically changed his personality.

This case study helped researchers understand the role of the frontal lobe in personality and social behavior. 

Little Albert

Conducted by behaviorist John B. Watson, the Little Albert case study aimed to demonstrate classical conditioning. In this study, a young boy named Albert was conditioned to fear a white rat by pairing it with a loud noise.

This case study provided insights into the process of fear conditioning and the impact of early experiences on behavior. 

Genie’s case study focused on a girl who experienced extreme social isolation and deprivation during her childhood. This study shed light on the critical period for language development and the effects of severe neglect on cognitive and social functioning. 

These case studies highlight the value of in-depth analysis and provide researchers with valuable insights into various psychological phenomena. By examining specific cases, psychologists can uncover unique aspects of human behavior and contribute to the field’s knowledge and understanding.

Types of Case Studies in Psychology

Psychology case studies come in various forms, each serving a specific purpose in research and analysis. Understanding the different types of case studies can help researchers choose the most appropriate approach. 

Descriptive Case Studies

These studies aim to describe a particular individual, group, or situation. Researchers use descriptive case studies to explore and document specific characteristics, behaviors, or experiences.

For example, a descriptive case study may examine the life and experiences of a person with a rare psychological disorder. 

Exploratory Case Studies

Exploratory case studies are conducted when there is limited existing knowledge or understanding of a particular phenomenon. Researchers use these studies to gather preliminary information and generate hypotheses for further investigation.

Exploratory case studies often involve in-depth interviews, observations, and analysis of existing data. 

Explanatory Case Studies

These studies aim to explain the causal relationship between variables or events. Researchers use these studies to understand why certain outcomes occur and to identify the underlying mechanisms or processes.

Explanatory case studies often involve comparing multiple cases to identify common patterns or factors. 

Instrumental Case Studies

Instrumental case studies focus on using a particular case to gain insights into a broader issue or theory. Researchers select cases that are representative or critical in understanding the phenomenon of interest.

Instrumental case studies help researchers develop or refine theories and contribute to the general knowledge in the field. 

By utilizing different types of case studies, psychologists can explore various aspects of human behavior and gain a deeper understanding of psychological phenomena. Each type of case study offers unique advantages and contributes to the overall body of knowledge in psychology.

How to Collect Data for a Case Study

There are a variety of ways that researchers gather the data they need for a case study. Some sources include:

• Directly observing the subject
• Collecting information from archival records
• Conducting interviews
• Examining artifacts related to the subject
• Examining documents that provide information about the subject

The way that this information is collected depends on the nature of the study itself

Prospective Research

In a prospective study, researchers observe the individual or group in question. These observations typically occur over a period of time and may be used to track the progress or progression of a phenomenon or treatment.

Retrospective Research

A retrospective case study involves looking back on a phenomenon. Researchers typically look at the outcome and then gather data to help them understand how the individual or group reached that point.

Benefits of a Case Study

Case studies offer several benefits in the field of psychology. They provide researchers with a unique opportunity to delve deep into specific individuals, groups, or situations, allowing for a comprehensive understanding of complex phenomena.

Case studies offer valuable insights that can inform theory development and practical applications by examining real-life examples. 

Complex Data

One of the key benefits of case studies is their ability to provide complex and detailed data. Researchers can gather in-depth information through various methods such as interviews, observations, and analysis of existing records.

This depth of data allows for a thorough exploration of the factors influencing behavior and the underlying mechanisms at play. 

Unique Data

Additionally, case studies allow researchers to study rare or unique cases that may not be easily replicated in experimental settings. This enables the examination of phenomena that are difficult to study through other psychology research methods . 

By focusing on specific cases, researchers can uncover patterns, identify causal relationships, and generate hypotheses for further investigation.

General Knowledge

Case studies can also contribute to the general knowledge of psychology by providing real-world examples that can be used to support or challenge existing theories. They offer a bridge between theory and practice, allowing researchers to apply theoretical concepts to real-life situations and vice versa. 

Case studies offer a range of benefits in psychology, including providing rich and detailed data, studying unique cases, and contributing to theory development. These benefits make case studies valuable in understanding human behavior and psychological phenomena.

Limitations of a Case Study

While case studies offer numerous benefits in the field of psychology, they also have certain limitations that researchers need to consider. Understanding these limitations is crucial for interpreting the findings and generalizing the results. 

Lack of Generalizability

One limitation of case studies is the issue of generalizability. Since case studies focus on specific individuals, groups, and situations, applying the findings to a larger population can be challenging. The unique characteristics and circumstances of the case may not be representative of the broader population, making it difficult to draw universal conclusions. 

Researcher bias is another possible limitation. The researcher’s subjective interpretation and personal beliefs can influence the data collection, analysis, and interpretation process. This bias can affect the objectivity and reliability of the findings, raising questions about the study’s validity. 

Case studies are often time-consuming and resource-intensive. They require extensive data collection, analysis, and interpretation, which can be lengthy. This can limit the number of cases that can be studied and may result in a smaller sample size, reducing the study’s statistical power. 

Case studies are retrospective in nature, relying on past events and experiences. This reliance on memory and self-reporting can introduce recall bias and inaccuracies in the data. Participants may forget or misinterpret certain details, leading to incomplete or unreliable information.

Despite these limitations, case studies remain a valuable research tool in psychology. By acknowledging and addressing these limitations, researchers can enhance the validity and reliability of their findings, contributing to a more comprehensive understanding of human behavior and psychological phenomena. 

While case studies have limitations, they remain valuable when researchers acknowledge and address these concerns, leading to more reliable and valid findings in psychology.

Alpi, K. M., & Evans, J. J. (2019). Distinguishing case study as a research method from case reports as a publication type. Journal of the Medical Library Association , 107(1). https://doi.org/10.5195/jmla.2019.615

Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., & Sheikh, A. (2011). The case study approach. BMC Medical Research Methodology , 11(1), 100. https://doi.org/10.1186/1471-2288-11-100

Paparini, S., Green, J., Papoutsi, C., Murdoch, J., Petticrew, M., Greenhalgh, T., Hanckel, B., & Shaw, S. (2020). Case study research for better evaluations of complex interventions: Rationale and challenges. BMC Medicine , 18(1), 301. https://doi.org/10.1186/s12916-020-01777-6

Willemsen, J. (2023). What is preventing psychotherapy case studies from having a greater impact on evidence-based practice, and how to address the challenges? Frontiers in Psychiatry , 13, 1101090. https://doi.org/10.3389/fpsyt.2022.1101090

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Eur J Psychotraumatol

Traumatic experiences in childhood and psychopathy: a study on a sample of violent offenders from Italy

Giuseppe craparo.

1 Faculty of Human and Social Sciences, University of Enna “Kore”, Enna, Italy

Adriano Schimmenti

Vincenzo caretti.

2 Department of Psychology, University of Palermo, Palermo, Italy

The link between early traumatic experiences of abuse/neglect and criminal behaviour has been widely demonstrated. Less is known, however, about the relationship between these experiences and the development of psychopathic personality.

This study investigated childhood relational trauma in a group of violent offenders from Italy. We hypothesised a higher level of early relational trauma associated with higher scores on psychopathy.

Twenty-two offenders convicted for violent crimes aged 22–60 (M=38, SD=11) participated in this study. Participants were selected by the Italian justice system for an experimental research programme aiming at the evaluation of psychopathic personality traits among violent offenders. Within the group, 14 participants (64%) had committed murder, 4 (18%) had committed rape, and 4 (18%) were convicted child sex offenders. The Traumatic Experience Checklist was used to assess childhood relational trauma; the Hare Psychopathy Checklist—Revised (PCL-R) was used to assess psychopathy.

There was a high prevalence of childhood experiences of neglect and abuse among the offenders. Higher levels of childhood relational trauma were found among participants who obtained high scores on the PCL-R. There was also a significant negative association between age of first relational trauma and psychopathy scores.

Conclusions

Findings of this study suggest that an early exposure to relational trauma in childhood can play a relevant role in the development of more severe psychopathic traits.

Psychopathy is a complex personality disorder, characterising individuals with emotional deficits who lack a regard for social norms, empathy, and remorse (Hare, 1991 , 1993 ). In the early years, Cleckley ( 1976 ) described the inability to participate in, or understand, the emotional aspects of humanity as one of the fundamental factors in psychopathy:

Let us say that, despite his otherwise perfect functioning, the major emotional accompaniments are absent or so attenuated as to count for little …. If we grant the existence of a far reaching and persistent blocking, absence, deficit, or dissociation of this sort, we have all that is needed, at the present level of our inquiry, to account for the psychopath. (p. 371).

Robert Hare shed light on the affective and interpersonal-related issues linked to psychopathy. His approach—operationalised in the golden standard Hare Psychopathy Checklist—Revised (PCL-R; Hare, 2003 )—contributed to the understanding of the origins and maintenance of the disorder leading to the important distinction between psychopathy and antisocial personality disorder (Rutherford, Cacciola, & Alterman, 1999 ). The PCL-R enabled the distinction of psychopathy from antisocial personality disorder through specific traits, such as emotional detachment, grandiose sense of self-worth, manipulativeness, lack of empathy, superficial charm, shallow affect, parasitic lifestyle, irresponsibility, impulsivity, and social deviance (Cooke & Michie, 2001 ).

The characteristics of psychopathy identified by the PCL-R contributed to the understanding of high recidivism rates in psychopathic samples. In their study of 93 released prisoners, Serin and colleagues ( 1990 ) demonstrated that the severity of psychopathy was correlated with recidivism. Hart and colleagues ( 1988 ) showed that out of 231 individuals on parole, only 38% with a diagnosis of psychopathy and only 54% with a mild level of psychopathy were not reconvicted a year after. This finding was corroborated by Hare and colleagues ( 2000 ) who highlighted—in a sample of 728 offenders—that 81.8% of psychopaths were found guilty for another crime within 2 years after release.

Karpman ( 1941 ), Lykken ( 1995 ), and Porter ( 1996 ) put forward the idea of psychopathy as a result of dysfunctional interpersonal exchanges and adverse environmental factors, including child abuse and neglect. This is mirrored in more recent theoretical and clinical research on attachment theory (Bowlby, 1969 , 1973 , 1980 ) suggesting a relationship between child abuse/neglect and psychopathy (Caretti & Craparo, 2010 ). However, research in this field is still scant, and there are few studies demonstrating that psychopathy may be linked to a disruptive developmental history, including experiences of early trauma (Lang, Klinteberg, & Alm, 2002 ; Marshall & Cooke, 1999 ).

Thus, the causal role of early traumatic exposure in predisposing an individual to criminal behaviour has been well demonstrated (Ardino, 2011 Ardino, 2012 ; Caretti, Ciulla & Schimmenti, 2011 ; Craparo, Faraci, Rotondo, & Gori, in press ; Maxfield & Widom, 1996 ; Widom, 1989 ), whereas the link between early adverse childhood experiences and psychopathy remains controversial (DiLalla & Gottesman, 1991 ).

Some literature suggests a specific link between abuse and psychopathic features. More specifically, some authors have hypothesised that abuse results in a diminished capacity to respond with empathy. For example, in discussing the possible mechanisms by which psychopathy mediated the abuse–violence association in their sample, Weiler and Widom ( 1996 ) suggested that as a result of early abuse, “a child might become ‘desensitised’ to future painful or anxiety provoking experiences” and that this desensitisation might make “him or her less emotionally and physiologically responsive to the needs of others, to be callous and lack empathy, and to lack remorse or guilt” (p. 264); similarly, Porter ( 1996 ) indicated that the “capacity for empathetic responding … is ‘turned off’ with repeated disillusionment of the child through physical or sexual abuse or other mistreatment … the child's emotion being dissociated from or unconnected with cognition and behaviour over time” (p. 183). Porter's theorising implies that traumatic events can trigger a dissociation of affective capacities.

The aim of this study was to explore the relationship between an early traumatic exposure and a later development of psychopathy. In detail, the study aims to investigate the prevalence of early traumatic experiences in a group of violent convicted offenders and the association between early traumatic exposure and severity of psychopathy as measured by the PCL-R. It was hypothesised that individuals with an experience of early trauma would have scored higher in psychopathy levels as measured by the PCL-R.

Participants

Participants of this study included 22 convicted male offenders aged between 22 and 60 [mean age (M): 38.05; SD=10.76], all diagnosed with antisocial personality disorder. Among them, 14 had committed murder (64%); 4 had committed rape (18%); and 4 (18%) were convicted child sex offenders. They were selected from a wider sample recruited for a comprehensive research programme commissioned by the Italian Ministry of Justice aimed at the evaluation of psychopathic personality traits within the criminal justice system.

Traumatic Experience Checklist

Traumatic experiences were assessed with the Traumatic Experience Checklist (TEC; Nijenhuis, Van der Hart, & Kruger, 2002), a self-reported measure addressing 29 types of potentially traumatic events. TEC is a reliable and valid self-reported measure that can be used in both clinical practice and research. Different scores can be calculated including a cumulative score, and scores for emotional neglect, emotional abuse, physical abuse, and sexual abuse. The TEC has demonstrated good convergent validity, being associated with alleged reports and official records of traumatic experiences. In this sample, good reliability has been obtained for groups of items related to different types of abuse/neglect with a KR-20 reliability index of 0.65 or even more for groups of only three items.

Hare Psychopathy Checklist Revised

Psychopathy traits were assessed with the PCL-R (Hare, 2003 ), a 20-item measure scored on the basis of an interview and on file information. Each item is scored as 0 (not present), 1 (possibly present), or 2 (definitely present), resulting in total PCL-R scores that range from 0 to 40. The PCL-R has demonstrated good internal consistency, test–retest, and inter-rater reliability across diverse populations (e.g. Alterman, Cacciola, & Rutherford, 1993 ; Hare et al., 1990 ; Vitale, Smith, Brinkley, & Newman, 2002 ). The validation of the Italian version of the PCL-R (Caretti et al. 2011 ) showed similar psychometric properties, with a good internal consistency (all scales had a Cronbach's α >0.85), good inter-rater reliability [all intraclass coefficent correlation (ICC) above 0.90] and good convergent validity with other measures of personality and psychopathy. In this sample, Cronbach's α was 0.93 for the full scale, with α of factors and facets ranging from 0.85 to 0.93. Two independent raters scored the PCL-R, and the ICC for the full scale resulted as 0.94.

All participants were introduced to the aim of the study and were briefed to ensure researchers that they had understood all the steps involved in this research. It was explained to them that data were going to be recorded according to a strict procedure to guarantee the confidentiality of information. Data were kept anonymous by the substitution of the participants’ names with a code. Researchers briefed participants that they had the right to withdraw from the study at any time and to request to delete their responses from the database. All participants had to sign an informed consent prior to undertaking the study.

The study was ethically cleared by the Italian Ministry of Justice and by an ethics committee within the prison. The measures were administered individually in the presence of one of the researchers in a quiet room where prisoners usually receive family visits. For safety reasons, a police officer was available close to the room.

Statistical analyses

Descriptive statistics were computed for all variables investigated in the study. Independent-samples t -test and Pearson's Chi-square test were used to compare participants with high and low scores on the PCL-R. The statistical package SPSS 19.0 for Windows was used for all the analyses (SPSS, Chicago, IL, USA).

We first checked for asymmetry and kurtosis in PCL-R scores; PCL-R scores were normally distributed in the sample. The PCL-R mean score was 19.49 (SD=7.71); median was 20.

Research with PCL-R usually showed three distinct groups, with participants scoring between 0 and 19 considered to have low psychopathy, participants with scores ranging between 20 and 29 considered as having medium psychopathy, and participants obtaining scores of 30 or more considered as severe psychopaths; however, in our sample only one participant obtained a score of 30 on the PCL-R. Thus, due to the reduced sample size, we lowered the PCL-R cut-off score to 25, after plotting the PCL-R scores and splitting the distribution of PCL-R scores at the nearest point to the 50th percentile of PCL-R scores between 20 and 30: we considered scores of 25 or more to the PCL-R as indicating high-risk for psychopathy (HRP). Eight participants (36.4%) scored 25 or more. This high-risk group was made up of five convicted murderers (35.7%, within the murderers sub-group), one rapist (25%), and two paedophiles (50%).

All 22 participants reported having had at least one traumatic experience in their own life. Among them, 17 participants (77.3%) reported early traumatic experiences (emotional neglect and/or physical, sexual, emotional abuse). In more detail, 4 (18.2%) reported sexual abuse, 11 (50%) reported physical abuse, 9 (40.9%) reported emotional abuse, and 15 (68.2%) reported emotional neglect (see Table 1 ). Twelve of the participants (55.5%) experienced at least two forms of abuse.

Descriptive statistics

There was some evidence that the risk for psychopathy increases when trauma occurs early in life. Results showed that people in the HRP subgroup tended to have experienced a relational traumatic event earlier on in life compared to the rest of participants (mean age: 5.6, SD=2.85 vs. 11.5, SD=8.86; t (20)=2.18, p =0.05; Fig. 1 ). Data also showed that seven out of eight participants (87.5%) in the HRP group experienced a relational trauma before the age of 10, which is the age in which children in Italy terminate their primary education. The Chi-square test showed that people in the HRP group were more likely to experience traumatic events before this age, in respect with other participants [χ 2 (1)=4.20, p =0.040; Fig. 2 ]. These were mostly related to abuse and neglect in family environments (6 out of 7).

Boxplot representing the age in which participants experienced their first traumatic experience.

Childhood trauma among participants.

Although such findings do not imply a direct cause-effect between experiences of early relational trauma and psychopathy, results suggest a relationship between relational trauma in childhood and the development of psychopathic traits; our study indicates this is an important area (the relationship between early relational trauma and psychopathy) to be further explored in future studies.

Psychopathy represents a complex construct and is the subject of a major clinical debate. Theory and empirical research maintain that psychopathy may be linked to a history of trauma.

Among studies referring to the heterogeneity of psychopathy, Porter ( 1996 )—following Karpman's ( 1941 ) distinction—has proposed that primary psychopathy mainly reflects a congenital affective deficit whereas secondary psychopathy reflects a detachment of emotions resulting from negative childhood experiences and acquired affective disturbances. Also, Blackburn ( 2009 ; Blackburn, Logan, Donnelly, & Renwick, 2008 ) has defined a typology in which two subtypes of psychopaths (secondary psychopaths and inhibited psychopaths) were more associated with high anxiety and withdrawal. These subtypes have been shown to be associated with a history of trauma. Therefore, analysing the relationship between traumatic stress symptoms and the various facets of psychopathy is of particular relevance in terms of clinical assessment and treatment.

The study explored this link by investigating the role of childhood experiences of abuse and neglect in individuals who presented criminal behaviours. Unlike a study published by Pham ( 2012 ), in which psychopaths reported a lower number of traumatic events, our research has shown a higher prevalence of traumatic events in more severe violent offenders.

The main finding of this study was that convicted male offenders with high levels of psychopathic traits were more likely to have experienced abuse and neglect during childhood, and they were even more likely to have experienced relational trauma at an early age.

Indeed, comparing our results to those reported by Nijenhuis and colleagues ( 2002 ) on the subsample of 57 male psychiatric outpatients who participated in the original validation of the TEC, the convicted offenders analysed in this study reported more childhood experiences of emotional neglect ( z =2.7, p =0.008) and sexual abuse ( z =2.2, p =0.027); also, a higher prevalence of physical abuse and emotional abuse was observed in our offender sample, but gender differences on these variables were not reported on the TEC validation article, thus a comparison between the two samples is not possible in this case. However, when considering other robust and well-validated measures of child neglect and abuse, such as the Childhood Experience of Care and Abuse (Bifulco, Brown, & Harris, 1994 ), it was observed that the sample described in this study reported a very higher prevalence of emotional neglect, emotional abuse, physical abuse, and sexual abuse (all p <0.001) with respect to the normal sample who participated in the Italian CECA validation study (Giannone et al. 2011 ).

Furthermore, almost every subject in our HRP group had experienced a trauma before the age of 10, a threshold selected for its consistency with the Italian educational system. It is to be underlined that this result does not mean that child abuse and neglect lead to psychopathy; however, it means that it is very unlikely that subjects who show severe psychopathic traits did not experience abuse and neglect in childhood. This can positively inform their assessment and treatment.

This study has some limitations to be addressed: first, the small sample size prevented the use of more complex statistical analyses, thus not allowing for a generalisation of results. Second, even though the TEC is a valid and reliable measure, the use of a self-reported measure for assessing childhood trauma may produce biased results, although there were alleged reports of adverse childhood experiences for most of the sample. Hence, there is a need for further research on the heterogeneity of psychopaths in relation to a history of trauma.

Despite these limitations, data suggest that exposure to early relational trauma can play a relevant role in the onset of violent offending behaviour, and this can be related to an early age of exposure to abuse and neglect and the subsequent development of psychopathic traits.

It is beyond the scope of this study to advance a deterministic explanation of the link between trauma and psychopathy; however, it may be assumed that traumatic memories built upon abuse, material neglect, and lack of emotional care could be responsible for a fragmented self (Meloy, 2001 ; Schimmenti, 2012 ), which is dysregulated on a psychobiological level and needs to have power and control over others through manipulation, deception and even violence.

For the abstract or full text in other languages, please see Supplementary files under Article Tools online

Conflict of interest and funding

There is no conflict of interest in the present study for any of the authors.

• Alterman A. I, Cacciola J. S, Rutherford M. J. Reliability of the Revised Psychopathy Checklist in substance abusing patients. Psychological Assessment. 1993; 5 :442–448. [ Google Scholar ]
• Ardino V. Post-traumatic stress in antisocial youth: A multifaceted reality. In: Ardino V, editor. Post-traumatic syndromes in children and adolescents. Chichester, UK: Wiley-Blackwell; 2011. pp. 211–229. [ Google Scholar ]
• Ardino V. Offending behaviour: The role of trauma and PTSD. European Journal of Psychotraumatology. 2012; 3 18967, doi: http://dx.doi.org/10.3402/ejpt.v3i0.18967 . [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Bifulco A, Brown G. W, Harris T. O. Childhood Experience of Care and Abuse (CECA): A retrospective interview measure. Journal of Child Psychology and Psychiatry. 1994; 35 :1419–1435. [ PubMed ] [ Google Scholar ]
• Blackburn R. Subtypes of psychopaths. In: McMurran M, Howard R. C, editors. Personality, personality disorder and violence. West Sussex, UK: John Wiley & Sons; 2009. pp. 113–130. [ Google Scholar ]
• Blackburn R, Logan C, Donnelly J, Renwick S. J. D. Identifying psychopathic subtypes: Combining an empirical personality classification of offenders with the Psychopathy Checklist-Revised. Journal of Personality Disorders. 2008; 22 :604–622. [ PubMed ] [ Google Scholar ]
• Bowlby J. New York: Basic Books; 1969. Attachment and loss, Vol. 1: Attachment. [ Google Scholar ]
• Bowlby J. New York: Basic Books; 1973. Attachment and loss, Vol. 2: Separation. [ Google Scholar ]
• Bowlby J. New York: Basic Books; 1980. Attachment and loss, Vol. 3: Loss, sadness and depression. [ Google Scholar ]
• Caretti V, Ciulla S, Schimmenti A. Stalking: Definition of the construct, phenomenological facets, and related behaviors. Italian Journal of Psychopathology. 2011; 17 :5–12. [ Google Scholar ]
• Caretti V, Craparo G. Psychopathic personality. Sistemi Intelligenti. 2010; 2 :229–240. [ Google Scholar ]
• Caretti V, Manzi G. S, Schimmenti A, Seragusa L. PCL-R. Hare Psychopathy Checklist—Revised. Firenze, Italy: OS Giunti; 2011. [ Google Scholar ]
• Cleckley H. The mask of sanity. St. Louis, MO: Mosby; 1976. [ Google Scholar ]
• Cooke D. J, Michie C. Refining the construct of psychopathy: Towards a hierarchical model. Psychological Assessment. 2001; 13 :171–188. [ PubMed ] [ Google Scholar ]
• Craparo G, Faraci P, Rotondo G, Gori A. The Impact of Event Scale—Revised: Psychometric properties of the Italian version in a sample of flood victims. Neuropsychia-tric Disease and Treatment. (in press) [ PMC free article ] [ PubMed ] [ Google Scholar ]
• DiLalla L. F, Gottesman I. I. Biological and genetic contributors to violence—Widom's untold tale. Psychological Bulletin. 1991; 109 :125–129. [ PubMed ] [ Google Scholar ]
• Giannone F, Schimmenti A, Caretti V, Chiarenza A, Ferraro A, Guarino S, et al. Validità , attendibilità e proprietà psicometriche della versione italiana dell'intervista CECA (Childhood Experience of Care and Abuse). [Validity, reliability and psychometric properties of the Italian translation of the CECA interview (Childhood Experience of Care and Abuse)] Psichiatria e Psicoterapia. 2011; 30 :3–21. [ Google Scholar ]
• Hare R. D. The Hare Psychopathy Checklist—Revised. Toronto, ON: Multi-Health Systems; 1991. [ Google Scholar ]
• Hare R. D. Without conscience: The disturbing world of the psychopaths among us. New York: The Guilford Press; 1993. [ Google Scholar ]
• Hare R. D. The Hare Psychopathy Checklist—Revised. 2nd ed. Toronto, ON: Multi-Health Systems; 2003. [ Google Scholar ]
• Hare R. D, Clark D, Grann M, Thornton D. Psychopathy and the predictive validity of the PCL-R: An international perspective. Behavioral Sciences and the Law. 2000; 18 :623–645. [ PubMed ] [ Google Scholar ]
• Hare R. D, Harpur T. J, Hakstian A. R, Forth A. E, Hart S. D, Newman J. P. The revised Psychopathy Checklist: Reliability and factor structure. Psychological Assessment. 1990; 2 :338–341. [ Google Scholar ]
• Hart S. D, Kropp P R, Hare R. D. Performance of male psychopaths following conditional release from prison. Journal of Consulting and Clinical Psychology. 1988; 5 :227–232. [ PubMed ] [ Google Scholar ]
• Karpman B. On the need for separating psychopathy into two distinct clinical types: Symptomatic and idiopathic. Journal of Criminology and Psychopathology. 1941; 3 :112–137. [ Google Scholar ]
• Lang S, Klinteberg B, Alm P. O. Adult psychopathy and violent behavior in males with early neglect and abuse. Acta Psychiatricka Scandinavica. 2002; 106 :93–100. [ PubMed ] [ Google Scholar ]
• Lykken D. T. The antisocial personalities. Hillsdale, NJ: Erlbaum; 1995. [ Google Scholar ]
• Marshall L. A, Cooke D. J. The childhood experiences of psychopaths: A retrospective study of familial and societal factors. Journal of Personality Disorders. 1999; 13 :211–225. [ PubMed ] [ Google Scholar ]
• Maxfield G. M, Widom C. The cycle of violence revisited 6 years later. Archives of Pediatric & Adolescent Medicine. 1996; 150 (4):390–395. [ PubMed ] [ Google Scholar ]
• Meloy J. R. The mark of Cain. Hillsdale, NJ: The Analytic Press; 2001. [ Google Scholar ]
• Nijenhuis E. R. S, Van der Hart O, Kruger K. The psychometric characteristics of the traumatic experiences questionnaire (TEC): First findings among psychiatric outpatients. Clinical Psychology and Psychotherapy. 2002; 9 :200–210. [ Google Scholar ]
• Pham H. T. Psychopathy and traumatic stress. Journal of Personality Disorders. 2012; 26 :213–225. [ PubMed ] [ Google Scholar ]
• Porter S. Without conscience or without active conscience? The etiology of psychopathy revisited. Aggression and Violent Behavior. 1996; 1 :179–189. [ Google Scholar ]
• Rutherford M. J, Cacciola J. S, Alterman A. I. Antisocial personality disorder and psychopathy in cocaine-dependent women. American Journal of Psychiatry. 1999; 156 :849–856. [ PubMed ] [ Google Scholar ]
• Schimmenti A. Unveiling the hidden self: Developmental trauma and pathological shame. Psychodynamic Practice. 2012; 18 :181–194. [ Google Scholar ]
• Serin R. C, Peters R. D, Barbaree H. E. Predictors of psychopathy and release outcome in a criminal population. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1990; 2 :419–422. [ Google Scholar ]
• Vitale J. E, Smith S. S, Brinkley C. A, Newman J. P. The reliability and validity of the Psychopathy Checklist- Revised in a sample of female offenders. Criminal Justice and Behavior. 2002; 29 :202–231. [ Google Scholar ]
• Weiler B, Widom C. S. Psychopathy and violent behaviour in abused and neglected young adults. Criminal Behaviour and Mental Health. 1996; 6 :253–271. [ Google Scholar ]
• Widom C. S. Child abuse, neglect, and adult behavior: Research design and findings on criminality, violence, and child abuse. American Journal of Orthopsychiatry. 1989; 59 (3):355–367. [ PubMed ] [ Google Scholar ]

Feel Like an Imposter?

Congratulations!

• Find a Therapist

Verified by Psychology Today

• Psychiatrists
• Treatment Centers
• Support Groups

Professionals

Therapists Sign Up | Login

Psychology Today: Health, Help, Happiness + Find a Therapist

Today’s essentials today’s essential reads.

Forgiveness

6 ways to temper your partner’s tantrums.

Robert Enright Ph.D. on May 29, 2024 in The Forgiving Life

The path of reducing rather than only controlling a partner's tantrums includes the challenge of growing together, forgiving those who have been unfair, and practicing humility.

Animal Behavior

How a puppy whines affects their mother's behavior.

Stanley Coren PhD., DSc, FRSC on May 29, 2024 in Canine Corner

Canine mothers can recognize the whines and whimpers of puppies from their own litter, and they trigger a strong caregiving response.

What Is the Format of Human Thought?

Barbara Blatchley Ph.D. on May 28, 2024 in What Are the Chances?

Do you think in pictures or in words? Maybe you think in both, or neither. Here I discuss two thought format variations: anendoaphasia and aphantasia.

Family Dynamics

Improving family and romantic relationship through listening.

Guy Itzchakov Ph.D. on May 28, 2024 in The Listening Lens

Struggling to connect with your kids or partner in today's busy world? Discover how simple listening techniques can transform family communication.

5 Things Special Needs Siblings Want You to Know

Gina DeMillo Wagner on May 29, 2024 in Forces of Nature

Personal Perspective: Growing up alongside a sibling with a disability or special need has its joys and challenges. Here's what we wish more people understood about the experience.

Introversion

Introverts aren't who you think they are.

Blake Griffin Edwards LMFT on May 29, 2024 in Progress Notes

Introverts often face biases at work. Research examines specific beliefs about and responses to introversion that can create challenges for quiet professionals.

Are You More Insightful Than Other People?

Temma Ehrenfeld on May 29, 2024 in Open Gently

Be cautious if you feel you are more insightful than other people or other groups. This is a standard human cognitive bias.

The End of Reading

Liz Stillwaggon Swan PhD on May 29, 2024 in College Confidential

College students aren't reading anymore, unless you count texts, tweets, and social media comments (but I don't and here's why).

• Relationships

How to Exit a Relationship Properly and Respectfully

Bruce Y. Lee M.D., M.B.A. on May 29, 2024 in A Funny Bone to Pick

The real measure of you as a person is how you behave when you are leaving a relationship, whether personal or professional. Here's how to break up the right way. 

From Conversion to FND: An Interview With Anton Scamvougeras

Mark L. Ruffalo M.S.W., D.Psa. on May 29, 2024 in From Freud to Fluoxetine

The recent shift away from psychological explanations of conversion disorder/FND to neurobiological ones reflects a basic misunderstanding of the disorder, says Anton Scamvougeras.

How to Cope with Misophonia During the Summer

Shaylynn Hayes-Raymond MA on May 29, 2024 in Eclectic Approaches

Misophonia can be harder to manage in the summer months. Certain triggers such as lawn and garden machinery are difficult to mask with traditional white and pink noise.

Understanding Twins

Why twin families disagree and fight so intensely.

Barbara Klein Ph.D., Ed.D. on May 29, 2024 in Twin Dilemmas

Simply stated, twins can and do outsmart their parents and grandparents.

Divert Worry With Distraction

Polly Campbell on May 29, 2024 in Imperfect Spirituality

Worry was taking hold, my thoughts were spiraling into all the things that could go wrong until I took charge of the one thing I could control—myself.

Adolescence

Teen tech time: a new approach to dinner etiquette.

Sarah M. Coyne Ph.D. on May 29, 2024 in The Right Media Mindset

Have you ever wondered how to make smartphones at mealtimes less of a battle with your teen? Here are three ways to improve dinnertime habits and strengthen your relationships.

Celebrating the Sabbath with Family Stories

Robyn Fivush Ph.D. on May 29, 2024 in The Stories of Our Lives

Personal Perspective: Family stories are powerful because they provide us with roadmaps for perseverance and strength.

What All Partners Can Learn About Orgasms From Queer Couples

Sari Cooper, CST, LCSW on May 29, 2024 in Sex Esteem

A 2024 study highlights a significant orgasm gap between heterosexual women and men. Addressing this gap is crucial for promoting wider access to orgasm for women.

• Emotional Intelligence

3 Emotionally Intelligent Techniques for Any Relationship

Erin Leonard Ph.D. on May 29, 2024 in Peaceful Parenting

These techniques can help you maintain closeness with the people in your life. They may also protect you from being manipulated and exploited by others.

Does the Summertime Make Grief Go Away?

Dee Stern Psy.D. on May 29, 2024 in Navigating Grief and Loss

When you have lost a part of your heart, there is no time limit to your grief. And the season, weather, and time of day do not matter to grief.

Perfectionism

Healing yourself with greatness.

Leon Garber LMHC on May 29, 2024 in Perfectionism

Some chase success as a way of resolving trauma, but it often feels empty anyway. Yet, perfectionism doesn't have to be eliminated—just reframed into a healthier version of it.

Why Is Sisterhood So Special?

A Unique Bond

Personality Change

Can we change our nature.

Leon F Seltzer PhD on May 29, 2024 in Evolution of the Self

Often inborn tendencies don’t evolve according to your nature because of such factors as parental abuse, bullying experiences, and traumas altering your perception of reality.

Artificial Intelligence

Grappling with self-aware ai—i think, therefore.

John Nosta on May 29, 2024 in The Digital Self

Powerful AI language models may be exhibiting behaviors suggestive of primitive self-awareness and existential dread, raising critical ethical and moral questions.

Ethics and Morality

Fighting greed makes for great theatre and film.

Joanne Intrator M.D. on May 29, 2024 in Breaking Down the Walls

Personal Perspective: Corporations' legal protections tend to overwhelm the struggle for social justice. It takes a brave person, a hero, to go against the odds.

• Child Development

Guardians of Health: Vaccines Are a Medical Success Story

The Research Room on May 29, 2024 in The Inflamed Brain

On current vaccine controversies and the challenges confronting low-to-middle-income countries.

How to Give Birth Is an Important Parenting Decision

Calvina Ellerbe Ph.D. on May 29, 2024 in The Parenting Playbook

Birth is a life-changing experience. Parents should play a pivotal role in making decisions about how they bring their children into the world.

A World Without Grandmothers: What Would We Lose?

Dale M. Kushner on May 29, 2024 in Transcending the Past

In our collective experience, grandmothers provide wisdom, comfort, and support. What impact will declining fertility rates have on the role and appreciation of grandmothers?

Growth Mindset

Cultivating a lucky mindset.

Dayna Lee-Baggley Ph.D. on May 29, 2024 in The Psychology of Weight Loss

Whenever you encounter challenges, make it a habit to finish the sentence with: “How lucky am I?" Watch how it transforms your perception and experience.

Mental Health Stigma

Why mental health awareness month matters.

Sarah A. Benton LMHC, LPC, LCPC, AADC on May 29, 2024 in The High-Functioning Alcoholic

May is Mental Health Awareness Month, and while many people hear or read references to it, who does it apply to?

Parental Alienation

Do you use the term parental alienation in court.

Amy J.L. Baker Ph.D. on May 29, 2024 in Caught Between Parents

Just because you think parental alienation is taking place doesn’t mean you should talk about it. With all aspects of your high-conflict custody case, you need to be strategic.

The Siren Song of "Evidence-Based" Instruction

Alfie Kohn on May 29, 2024 in The Homework Myth

Educational traditionalists and behaviorists like to invoke "evidence" or the "science of learning," but those terms are often misleading.

Reclaim Your Existence in an Anti-Human World—I, Exist

Derek Lusk Ph.D. on May 29, 2024 in Unnatural Selection

Personal Perspective: The death of meaning is the fundamental problem of our time in a technology-driven, anti-human world.

From Curiosity to Dependence: The 4 Stages of Alcohol Misuse

Jeanette Hu AMFT on May 29, 2024 in Sober Curiosity

How does casual drinking spiral into a daily routine? Discover the stages of alcohol misuse and how to recognize the signs before it's too late.

People-Pleasing

Ditch people-pleasing with smile-seeking.

Jennifer Gerlach LCSW on May 29, 2024 in Beyond Mental Health

Six differences between people-pleasing and smile-seeking.

The Secret of Successful Goal-Setting at the Workplace

Gil Winch Ph.D. on May 29, 2024 in Caring Leadership

Employers often craft goals aimed at placating the emotional needs of C-suite executives, and consequently, get less.

• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

• Gaslighting
• Affective Forecasting
• Neuroscience

Trajectories and predictors of emotional exhaustion in clinical nurses in the context of healthcare crisis: a case study in Xi’an, China

• Open access
• Published: 28 May 2024

Cite this article

You have full access to this open access article

• Chao Wu 1   na1 ,
• Chunyan He 2   na1 ,
• Hongli Zhang 1 , 3   na1 ,
• Yawei Lin 4 ,
• Jing He 6 ,
• Feixia Cheng 7 ,
• Zhaohua Ji 8 &
• Hongjuan Lang 1  

This study investigated the growth trajectory of emotional exhaustion and its predictors in clinical nurses in the context of healthcare crisis in the post pandemic era. A total of 422 Chinese clinical nurses were followed up three times over two months from December 2022 to January 2023, and data from the final 358 clinical nurses were analyzed. The growth mixed model was used to identify the trajectory categories, and the predictive factors of the trajectory types were analyzed by logistic regression. The relationship of the trajectory types of emotional exhaustion with psychological capital were analyzed by variance analysis. The best-fit growth mixture modeling revealed three class models: Class 1 characterized by high and increasing levels of emotional exhaustion, Class 2 characterized by moderate and decreasing levels of emotional exhaustion, and Class 3 characterized by low and decreasing levels of emotional exhaustion. These classes accounted for 9.78%, 83.52%, and 6.70% of clinical nurses, respectively. The results of the univariate analysis indicated that age, years of working experience, gender, past participation in emergency public health event rescue, and sleep quality were associated with the trajectory of emotional exhaustion. Logistic regression analysis revealed that gender, past participation in emergency public health event rescue, and sleep quality were independent predictors of the emotional exhaustion trajectory. The variance analysis of the four dimensions of psychological capital showed that there were statistically significant differences in scores of self-efficacy and hope dimensions among the three groups of emotionally exhausted individuals. Our study demonstrated the heterogeneity of emotional exhaustion among clinical nursing personnel in coping with healthcare system overload. The psychological capital of nursing staff with different categories of emotional exhaustion varies. Managers should actively pay attention to the predictive role of gender, past participation in emergency public health event rescue, and sleep quality on the development of emotional exhaustion in clinical nurses.

Similar content being viewed by others

Patient mistreatment, social sharing of negative events and emotional exhaustion among Chinese nurses: the combined moderating effect of organizational support and trait resilience

Factors associated with clinical nurse’s mental health: a qualitative study applying the social ecological model

The prevalence and risk factors for depressive symptoms in frontline nurses under COVID-19 pandemic based on a large cross-sectional study using the propensity score-matched method

Avoid common mistakes on your manuscript.

Introduction

The novel coronavirus pneumonia, as the most widespread and impactful public health emergency (Sharma et al., 2021 ), has posed a serious threat to the lives, health, and property safety of people worldwide (Dubin et al., 2022 ; Olson et al., 2022 ). Since the outbreak of COVID-19 pandemic, China has taken strict control and prevention measures and followed the dynamic zero-COVID policy (Cheng et al., 2021 ). It was not until late 2022, when the Omicron variant with the waning virulence became prevalent, that China chose to “coexist” with the virus, thus avoiding a massive epidemic-related death (Lyu et al., 2023 ). The relaxation of epidemic control measures led to a large-scale infection within a short period of time. Hospitals experienced different degrees of medical overcrowding, especially during the first two weeks of endzero-COVID policy, with a high patient volume in the emergency departments and a significant lack of beds in the medical wards, particularly in the respiratory intensive care unit and emergency treatment (Lei et al., 2023 ). As frontline healthcare workers, they faced high work pressure and the risk associated with the healthcare system’s openness and overcrowding, which increased their vulnerability to both physical and psychological stress. The combination of intense work demands and the risk of infection elevated the risk of developing mental health disorders (Costantini et al., 2022 ; Kang et al., 2023 ).

The occurrence of emotional exhaustion among nursing staff, who were the main body of healthcare workers and directly in contact with patients, was not optimistic under the impact of healthcare system overload (Ding & Wu, 2023 ; Kumar & Jin, 2022 ). They not only needed to overcome their own fears and risks of being infected with infectious diseases but also had to deal with the transmission of negative emotions from patients who were affected by the infection, such as anxiety and irritability (Sexton et al., 2022 ). Previous research showed that high workload and emotional job demands increased the risk of emotional exhaustion (Alonso et al., 2020 ). In this situation, nursing staff were prone to experiencing feelings of stress and intense work pressure, which resulted in a more pronounced issue of emotional exhaustion among them (Sagherian et al., 2023 ).

Emotional exhaustion referred to an extreme state of emotional fatigue and depletion that occurred when individuals experienced excessive emotional demands and over-extension in their work. It reflected a sense of helplessness and psychological burnout in the individual’s professional role (Petersen et al., 2023 ). The study revealed a close association between emotional exhaustion and negative emotions such as insomnia and impaired attention (Abusamra et al., 2022 ). Emotional exhaustion was also considered a risk factor for cardiovascular diseases, gastrointestinal disorders, and other related illnesses (Malik et al., 2022 ; Seiça et al., 2023 ). Once nursing staff experienced emotional exhaustion, it not only affected their physical and mental well-being but also impacted their treatment to the patients, leading to a decrease in work efficiency. This had serious implications for the nursing staff themselves, the hospital, and society as a whole (Hong et al., 2023 ). Moreover, emotional exhaustion, as a core component of occupational burnout, was considered an initial stage in the process, which only developed into full-blown burnout when individuals did not cope effectively with work-related stressors (Coelho et al., 2023 ; Yuguero et al., 2022 ). Therefore, preventing emotional exhaustion was crucial for maintaining the physical and mental well-being of individuals as well as preventing occupational burnout (Zhang et al., 2023 ).

Psychological capital referred to a positive psychological state developed by individuals during their growth and developmental process (Chiang et al., 2023 ). It encompassed four core components: hope, self-efficacy, resilience, and optimism (Flinkman et al., 2023 ; Yuan et al., 2023 ). Previous studies have indicated that psychological capital had a significant positive impact on individuals’ attitudes, behaviors, and performance (Lee et al., 2022 ). It also demonstrated a beneficial buffering effect on negative emotions, such as emotional exhaustion and burnout (Tang et al., 2023 ). The research showed that psychological capital attenuated the workload-exhaustion relationship (Solms et al., 2023 ). Therefore, we speculated that it also had a certain buffering effect on individuals’ emotional exhaustion.

It was well known that individual emotions were not stable and unchanging, but rather dynamically fluctuated over time (Khatin-Zadeh et al., 2023 ). Therefore, in the context of healthcare system overload, emotional exhaustion among nursing staff was not a stable and unchanging state but rather a potentially modifiable and dynamic developmental process. Therefore, we hypothesized that emotional exhaustion in different clinical nurses may develop different trajectories over time. Despite scholars conducting relevant studies on the emotional exhaustion of nursing staff, most of the studies were mainly cross-sectional (Hong et al., 2023 ; Pohl et al., 2023 ). As a result, these research methods were unable to fully reflect the trajectory of changes in emotional exhaustion in clinical nurses (Ding & Wu, 2023 ; Karaca et al., 2023 ; Zhang et al., 2023 ), and overlook the dynamic temporal variations in emotional exhaustion experienced by nursing staff over time. Besides, previous studies on the changes in emotional exhaustion often treated the psychological states of nurses as uniformly distributed, overlooking the issue of individual differences (Gedik et al., 2023 ; Rink et al., 2023 ). There was a lack of longitudinal exploration regarding the differential impact factors among different developmental trajectories. Therefore, there is an urgent need for a new approach to address the shortcomings in previous studies, and the growth mixture model (GMM) offers a promising approach to address these deficiencies (McNeish et al., 2023 ). GMM is a common statistical method that groups heterogeneous populations according to their development trajectories (McNeish et al., 2023 ). It can provide methods to identify which subset of a variable based on the trajectory distinction is more susceptible to the influence of another variable and to clarify the nonlinear relationship between these variables (Gebauer et al., 2023 ).

The results of this research are expected to provide important theoretical references and practical guidance for the protection against emotional exhaustion and the adjustment of psychological well-being among nursing staff in the post-pandemic era. Additionally, it will also have theoretical implications and practical significance for the future maintenance of psychological health among all healthcare workers in responding to major outbreaks of infectious diseases in public health emergencies. The findings can serve as empirical evidence for preventing occupational burnout among nursing staff, reducing attrition rates, ensuring a stable workforce, improving the quality of clinical nursing, and enhancing team effectiveness.

Participants and methods

Participants.

In this study, convenience sampling was used to choose the clinical frontline nurses after the relaxation of epidemic control policies. The inclusion criteria were as follows: nursing personnel who have obtained nursing qualification certificates and are engaged in frontline clinical nursing work, voluntarily participate in the research and ensure their continuous participation in the study. Exclusion criteria: Those who have recently experienced significant life events.

This prospective study investigated eligible clinical nurses at three time points. The calculation of the sample size refers to the table used for sample size estimation in the design of single-group repeated measurements. We selected with a mean correlation coefficient of r = 0.5, f = 0.14 (weak effect), α = 0.05, and a sample size of 142 nurses was required under conditions that ensured 1-β = 0.8. Considering a potential dropout rate of 20%, the minimum sample size for this study is 178 participants.

A total of 358 cases of clinical nurses were included in this study. The participants involved had an age range of 22 to 52 (31.70 ± 5.25), with a range of work experience from 1 to 35 years (8.79 ± 5.63). Among them, there were 65 male nurses (18.16%) and 293 female nurses (81.84%). In terms of professional titles, there were 223 primary-level, 129 intermediate-level, and 6 senior-level title holders, accounting for 62.29%, 36.03%, and 1.68% respectively. Regarding marital status, there were 109 unmarried individuals (30.45%), 247 married individuals (68.99%), and 2 divorced or widowed individuals (0.56%). In terms of educational background, there were 28 individuals with a junior college degree (7.82%), 326 individuals with a bachelor’s degree (91.06%), and 4 individuals with a master’s degree or above (1.12%). Furthermore, 103 participants (28.77%) had previously participated in emergency public health event rescue, while 87 individuals (24.30%) reported poor sleep quality, 202 individuals (56.42%) reported average sleep quality, and 69 individuals (19.27%) reported good sleep quality.

General information survey form

The questionnaire was designed by the researcher, including demographic characteristics such as gender, age, professional title, marital status, years of work experience, department, involvement in emergency public health event rescue, and educational level.

Maslach burnout inventory

Maslach Burnout Inventory was developed by American social psychologists Maslach and Jaskson in 1981, which included three dimensions: Emotional Exhaustion, Depersonalization, and Personal Accomplishment (Rotstein et al., 2019 ). For this research, the emotional exhaustion subscale was selected, consisting of 5 items, including “I feel very exhausted,” “I worry that work affects my mood,” “I often feel worn out,” “At the end of the day, I feel extremely fatigued,” and “I have been feeling somewhat depressed lately.” The scale was rated on a 7-point Likert scale, ranging from “completely not applicable” to “extremely applicable,” with scores ranging from 1 to 7. Higher scores indicated a higher level of emotional exhaustion in individuals. The scale is widely used among the nursing population in China (Hong et al., 2023 ; Xu et al., 2020 ), and had demonstrated good reliability and validity. The reliability of the scale in the original study was 0.818. The Cronbach’s α coefficients of the scale used in this study at the three time points were 0.814, 0.849 and 0.823 respectively.

Psychological capital scale

The Psychological Capital Scale was developed by Luthans, which consisted of 24 items (such as “I can analyze problems and find solutions”, “I can achieve work goals” and “I am able to cope with work pressure”), including 4 dimensions: self-efficacy, hope, resilience, and optimism (Wang et al., 2023 ). Each dimension contained six items, rated on a 6-point Likert scale, ranging from “strongly disagree” to “strongly agree,” with scores ranging from 1 to 5. The overall level of psychological capital was determined by the total scores of each dimension, with higher scores indicating higher levels of psychological capital in the respondents. The scale was widely used among the nursing population in China (Liu et al., 2021 ; Yan et al., 2020 ), and had demonstrated good reliability and validity. The Cronbach’s α coefficients of the Psychological Capital Scale used in this study at the three time points were 0.864, 0.857 and 0.873 respectively.

This study involved frontline clinical nursing staff who were surveyed at three time points with a 2-week interval from December 2022 to January 2023: the first week after the relaxation of COVID-19 control policies in China (Wave 1), the third week after the relaxation of COVID-19 control policies in China (Wave 2), and the fifth week after the relaxation of COVID-19 control policies in China (Wave 3). Researchers informed the eligible clinical nursing staff about the purpose of the study and the subsequent follow-up survey times, ensuring that they had the option to terminate or withdraw from the study at any time. After obtaining informed consent from the participants, baseline data were collected. To ensure the accuracy and reliability of the follow-up survey data, the time points for each follow-up survey were fixed within a three-day interval. In total, 422 clinical nurses were included in the study, and ultimately, 358 (response rate: 84.83%) completed all the surveys. Among them, 57 (13.51%) clinical nurses were on leave due to COVID-19 infection (29 clinical nurses in Wave 1;16 clinical nurses in Wave 2; 12 clinical nurses in Wave 3), while 7 (1.66%) clinical nurses explicitly stated their lack of interest in continuing the study and withdrew from participation (4 clinical nurses in Wave 1; 3 clinical nurses in Wave 2). We have conducted attrition analysis for the dropouts after the first (or second) data collection phase. There were no significant losses in terms of demographic or substantive variables. So, for missing data, we deleted it.

Statistical analyses

The data were analyzed with SPSS 26.0 and Mplus 8.3 software. The unconditioned Latent Class Growth Model (LCGM) and Gaussian Mixture Model (GMM) were used to judge the trajectory categories with Mplus 8.3 software. The baseline model was a single-category model, setting the variance within the category to 0, increasing the number of categories in the model one by one, and then comparing the fitting indexes between the models. The optimal model was determined by combining the practical significance and statistical indices. Fit indicators included the akaike information criterion (AIC), bayesian information criterion (BIC), adjusted BIC (aBIC), entropy, likelihood ratio test (LRT), and bootstrapped likelihood ratio test (BLRT). The smaller the AIC, BIC and aBIC values are, the better the model fit. Entropy represented the accuracy of classification, and the higher the entropy value was, the more accurate the classification was. LRT and BLRT were commonly used to compare fit differences between K-1 and K-category models, with P  < 0.05 indicating that the K-category model was superior to the K-1-category model. The category to which an individual belonged was then determined based on a posterior probability. According to the fitting results of the individual category model, the above indexes were comprehensively evaluated, the best fitting model was selected, and the nurses were divided into different categories. Then, SPSS 26.0 was used for analysis. Data that followed a normal distribution were expressed as the mean and standard deviation, and analysis of variance was used to compare multiple groups. Count data were expressed by frequency and constituent ratio, and the chi-square test was used to compare multiple groups. Logistic regression analysis was used to explore the influence of age, years of working experience, self-efficacy, hope, gender, past participation in emergency public health event rescue, sleep quality on the class of emotional exhaustion. There was a significant difference at P  < 0.05.

Ethical considerations

Prior to the implementation of the study, strict adherence to the principle of informed consent was followed. The participants were introduced to the purpose, methods, and significance of the study and were informed about the principles of voluntary participation and strict confidentiality of their information. Their consent was obtained, and they signed an informed consent form. The research results will not have any impact on them to ensure the authenticity of the study. All data and information pertaining to the study subjects are strictly used for the purpose of this research only.

Common method deviation

We have adjusted the questionnaire to ensure its neutrality, impartiality, and non-threatening. The Harman single-factor method was used to test the common method deviation. The variance explained by the maximum factor variance was 29.2%, less than the critical value of 40% (Wu et al., 2022 ). The statistical test results showed that there was no significant common method bias in the measurement.

Identification of the trajectories of emotional exhaustion in clinical nurses in the context of healthcare crisis

Taking the emotional exhaustion score of clinical nurses at 3 time points as an observation index, data from 358 clinical nurses were included in the model analysis. First, LCGM was used and set as the free estimation of the time parameter, and 1 to 5 categories were extracted in turn. When the number of potential classes increased from 1 to 5, AIC, BIC and aBIC all decreased. However, when the number of categories increased from 3 to 4, entropy decreased, and LRT and BLRT became insignificant, suggesting that the best fit was to retain 3 categories.

To further judge the optimal model, the model was set to GMM, AIC, BIC, aBIC values of the model of Category 2 to 5 were less than the values of LCGM, suggesting that the model was optimized. Following the selection criteria in LCGM, in GMM, the best fit was obtained by retaining 3 categories. Based on the above information, the classification probability of the model and the interpretability of the results, the 3 categories of GMM were retained. The results of model fitting are shown in Table  1 .

Each class was named based on the emotional exhaustion score and its changing trend. Class 1 (9.78%) had consistently higher scores, and was named the “High-level and Continuously Rising Emotional Exhaustion Group”. In Class 2 (83.52%), emotional exhaustion was at a moderate level and gradually decreased over time, so this group was named the “Moderate-level and Continuously Decreasing Emotional Exhaustion Group”. The score of Class 3 (6.70%) was the lowest, and the scores decreased continuously during follow-up, and this group was named the “Low-level and Continuous-Decreasing Emotional Exhaustion Group”. The three trajectories of emotional exhaustion from the model fit are shown in Fig.  1 .

Three classes of growth trajectory of emotional exhaustion

Single factor analysis of influencing factors of emotional exhaustion trajectories in clinical nurses in the context of healthcare crisis

Single factor analysis was used to identify the possible predictive factors according to the different categories determined by GMM, with P  < 0.05 indicating a significant difference. The general data and psychological capital were included in the single factor analysis. The results showed that age (χ 2  = 24.348, P  < 0.001), years of working experience (χ 2  = 12.301, P  = 0.015), gender (χ 2  = 69.709, P  < 0.001), past participation in emergency public health event rescue (χ 2  = 60.967, P  < 0.001) and sleep quality (χ 2  = 24.699, P  < 0.001), were significantly different among the three groups. The difference between the other variables was not significant. The results are shown in Table  2 .

Variance analysis of psychological capital of emotional exhaustion trajectories in clinical nurses in the context of healthcare crisis

The mean scores of psychological capital of the three groups were (101.66 ± 16.12), (103.57 ± 14.94), (112.79 ± 15.01), with F  = 4.636, P  = 0.010. Further pairwise comparisons within the group showed that the comparison of class1 and class3, class2 and class3 were significant ( P  < 0.01). The variance analysis of the four dimensions of psychological capital showed that there were statistically significant differences in scores of self-efficacy and hope dimensions among the three groups of emotionally exhausted individuals. Further pairwise comparisons revealed statistically significant differences in self-efficacy and hope scores between Group 1 and Group 3, as well as between Group 2 and Group 3. The results are shown in Table  3 .

Logistic regression analysis of influencing factors of emotional exhaustion trajectory categories in clinical nurses in the context of healthcare crisis

The emotional exhaustion trajectories of clinical nurses determined by GMM were used as the dependent variable, and Class 3 was the control group. The independent variables were assigned as follows: Gender: 0 = Male, 1 = Female; Have you ever participated in the rescue of public health emergencies: 0 = Yes, 1 = No; Sleep quality: 0 = Poor sleep, 1 = As usual, 2 = Good sleep. Logistic regression analysis of emotional exhaustion trajectory categories in clinical nurses was shown in Table  4 . Compared with Class 1 and Class 2, male nursing staff and those who had participated in public emergency health event rescue were more likely to be grouped into Class 3. Compared with Class 3, nurses with poor sleep were more likely to be grouped into Class 1.

There were different trajectories of emotional exhaustion in clinical nurses in the context of healthcare crisis

Our study identified 3 different trajectories of emotional exhaustion in clinical nurses based on the GMM, namely, “the High-level and Continuously Rising Emotional Exhaustion Group” (Class 1), “the Moderate-level and Continuously Decreasing Emotional Exhaustion Group” (Class 2), and “the Low-level and Continuous-Decreasing Emotional Exhaustion Group”, accounting for 9.78%, 83.52%, 6.70% respectively.

After the relaxation of epidemic control policies, in the context of healthcare crisis, the majority of frontline clinical nursing staff experienced a continuous decline in emotional exhaustion, which was classified as the “the Moderate-level and Continuously Decreasing Emotional Exhaustion Group”, accounting for 83.52%. This indicated that emotional exhaustion was commonly present among nursing staff when dealing with healthcare crisis, which was consistent with the research findings of Crippa et al. (Crippa et al., 2021 ). This required attention from hospital administrators and nursing staff (Galanis et al., 2021 ). In the context of healthcare crisis, a large number of patients were flooding into hospitals, resulting in overloaded operations. Nursing staff were facing the risk of infection while working under immense pressure. In this situation, they were prone to experience emotional exhaustion (Hui et al., 2023 ). The state of emotional exhaustion could have a serious impact on the physical and mental health of nursing staff, as well as their work efficiency and the quality of nursing care (Tomaszewska et al., 2022 ). Paying attention to the emotional state of nurses could improve the care conditions of patients, and nursing managers should actively work towards improving the emotional exhaustion state of nurses in different situations and crises.In our study, we observed that the emotional exhaustion in Class 2 gradually decreased. This may be attributed to the nursing staff gradually adapting and regulating themselves, as well as the proactive attention from hospital managers towards the physical and mental health of the nursing staff. It also correlated with the increasing support and concern from various sectors of society towards healthcare workers. This suggested that in the early stage of healthcare crisis, it was crucial to pay high attention to and address the emotional well-being of this group of nursing staff.

The condition of nursing staff in the High-level and Continuously Rising Emotional Exhaustion Group was worthy of active attention. This group accounted for 9.78% in our study, and their emotional exhaustion levels showed a continuous increase. This suggested that individuals in the high emotional exhaustion state were less likely to regulate themselves effectively. Therefore, it was important to actively address the work and emotional well-being of this group in clinical practice.

The predictive indicators of trajectories of emotional exhaustion in clinical nurses in the context of healthcare crisis

The results showed that age, year of working experience, gender, past participation in emergency public health event rescue, sleep quality, psychological capital were significantly different among the three groups. The variance analysis of the four dimensions of psychological capital showed that there were statistically significant differences in scores of self-efficacy and hope dimensions among the three groups of emotionally exhausted individuals. When individuals have higher psychological capital, they may be better able to cope with stress and challenges in work and life, maintain a positive emotional state, and reduce emotional exhaustion (Ding & Wu, 2023 ). For example, confident people believe more in their abilities, thus having more motivation to overcome difficulties; Optimistic people are more likely to see the positive side of problems and reduce negative emotions. Psychological capital and emotional exhaustion are interdependent (Xue et al., 2023a , b ). Emotional exhaustion may weaken an individual’s psychological capital, and lower psychological capital may also make it easier for individuals to experience emotional exhaustion (Xue et al., 2023a , b ). One can try to alleviate emotional exhaustion by improving psychological capital, such as cultivating a positive mindset, exercising stress management skills, and establishing good social support. At the same time, it is also important to promptly identify and respond to symptoms of emotional exhaustion, such as taking appropriate rest, adjusting work and life rhythm, seeking professional help, etc., to protect mental health.

Further logistic regression analysis demonstrated that compared with Class 1 and Class 2, male nursing staff were more likely to be grouped into Class 3. Male nursing staff and those who had participated in public emergency health event rescue were less likely to experience emotional exhaustion. This finding was consistent with the research results of Clari et al. (Clari et al., 2022 ) According to the study findings, it was revealed that female nurses exhibited elevated levels of emotional exhaustion compared to their male counterparts. This disparity could be attributed to the additional social responsibilities that females often shoulder in relation to household and family obligations, alongside their professional duties. The challenges associated with striking a harmonious equilibrium between managing job-related demands and fulfilling child-rearing responsibilities could significantly contribute to heightened stress levels among female nurses (Brulin et al., 2023 ; Harizanova & Stoyanova, 2020 ). In contrast, males exhibited stronger psychological resilience compared to females (Yada et al., 2014 ). Therefore, it was essential to provide female nurses with enhanced care and support to help them cope with the stress of healthcare crisis.

Compared with Class 1 and Class 2, nursing staff who had participated in public emergency health event rescue were more likely to be grouped into Class 3, namely those who had experience in crisis management during such events exhibited lower levels of emotional exhaustion in the context of healthcare crisis. Participating in rescue work has enabled clinical nurses to accumulate experience in dealing with stress and difficulties, learn to better manage emotions and cope with challenges, be able to detect signs of emotional fatigue earlier, and take appropriate adjustment measures (Liu et al., 2022 ; Wesemann et al., 2020 ).This insight suggested that nursing staff should actively engage in the summarization and sharing of their experiences in responding to public health emergencies, as it could prove valuable for their future work.

Compared to Class 3, nursing staff with poor sleep quality were more likely to be categorized into the high-level emotional exhaustion group. The study demonstrated a strong positive correlation between emotional exhaustion and sleep condition (Tomaszewska et al., 2022 ). During the COVID-19 pandemic, the risk of psychological distress among healthcare professionals had been increased (González-Gil et al., 2021 ) and particularly frontline nurses had been shown to face enormous mental health challenges (Chen et al., 2020 ). Intense psychological pressure may lead to poor sleep quality, further exacerbating the condition of emotional exhaustion.

Therefore, managers should pay active attention to female nursing staff and those without rescue experience, providing them with support and encouragement to help them better cope with the impact of medical crises.

Limitations

Firstly, this study utilized convenience sampling and only focused on a sample of tertiary hospitals in Xi’an city. The pandemic situation in Xi’an may not represent the overall pandemic situation in China, which could introduce potential biases in the results. Secondly, due to the intense medical pressure and busy clinical work after the relaxation of pandemic control policies, it was challenging to collect a large sample size for this study. Additionally, there were limited time points for data collection and follow-up. Thirdly, the causal relationship between poor sleep quality and high emotional exhaustion required further examination and verification. Fourthly, our study was conducted in the form of a self-report questionnaire and the results tended to be subjective.

Our study proved the heterogeneity of emotional exhaustion in clinical nurses in the context of healthcare crisis. By examining the influence of demographic factors and psychological capital, we have identified a subgroup at higher risk of developing a high emotional exhaustion pattern, characterized by being female, having no previous experience in public emergency health event rescue, and reporting poor sleep quality. Future studies should focus on developing timely interventions targeted at these specific subpopulations.

Data availability

The raw data supporting the conclusions of this article is available from the corresponding author ([email protected]).

Abusamra, A., Rayan, A. H., Obeidat, R. F., Hamaideh, S. H., Baqeas, M. H., & M, ALBashtawy (2022). The relationship between nursing care delivery models, emotional exhaustion, and quality of nursing care among Jordanian registered nurses. SAGE Open Nursing, 8 , 23779608221124292. https://doi.org/10.1177/23779608221124292

Alonso, F., Esteban, C., Gonzalez-Marin, A., Alfaro, E., & Useche, S. A. (2020). Job stress and emotional exhaustion at work in Spanish workers: Does unhealthy work affect the decision to drive? PLoS ONE, 15 (1), e0227328. https://doi.org/10.1371/journal.pone.0227328

Article   PubMed   PubMed Central   Google Scholar  

Brulin, E., Lidwall, U., Seing, I., Nyberg, A., Landstad, B., Sjöström, M., ... Nilsen, P. (2023). Healthcare in distress: A survey of mental health problems and the role of gender among nurses and physicians in Sweden. Journal of Affective Disorders , 339 , 104–110. https://doi.org/10.1016/j.jad.2023.07.042

Chen, J., Li, J., Cao, B., Wang, F., Luo, L., & Xu, J. (2020). Mediating effects of self-efficacy, coping, burnout, and social support between job stress and mental health among young Chinese nurses. Journal of Advanced Nursing, 76 (1), 163–173. https://doi.org/10.1111/jan.14208

Article   PubMed   Google Scholar  

Cheng, X., Tang, L., Zhou, M., & Wang, G. (2021). Coevolution of COVID-19 research and China’s policies. Health Res Policy Syst, 19 (1), 121. https://doi.org/10.1186/s12961-021-00770-6

Chiang, Y. C., Gao, D. R., Lee, C. Y., Li, X., Sun, X. Y., & Chen, C. T. (2023). Influence of promoting an “age-friendly cities” strategy on psychological capital and social engagement based on the scenario method. Journal of Aging & Social Policy, 35 (4), 463–485. https://doi.org/10.1080/08959420.2022.2110805

Article   Google Scholar  

Clari, M., Gonella, S., Gatti, P., Garzaro, G., Paleologo, M., Cortese, C. G., & Dimonte, V. (2022). Multi-level analysis of individual and work environment factors associated with nurses’ perceived emotional exhaustion. Applied Nursing Research, 63 , 151514. https://doi.org/10.1016/j.apnr.2021.151514

Coelho, J., Taillard, J., Bernard, A., Lopez, R., Fond, G., Boyer, L., ... Micoulaud-Franchi, J. A. (2023). Emotional exhaustion, a proxy for burnout, is associated with sleep health in French healthcare workers without anxiety or depressive symptoms: A cross-sectional study. J Clin Med , 12 (5). https://doi.org/10.3390/jcm12051895

Costantini, A., Mazzotti, E., Cappitella, C., De Biase, L., Stella, F., & Anibaldi, P. (2022). Prevalence and characteristics of distress in a sample of large hospital’s workers in Rome in a period between two peaks of the covid-19 pandemic. Rivista Di Psichiatria, 57 (5), 212–223. https://doi.org/10.1708/3893.38744

Crippa, J. A. S., Zuardi, A. W., Guimarães, F. S., Campos, A. C., de Lima Osório, F., Loureiro, S. R., ... Hallak, J. E. C. (2021). Efficacy and safety of cannabidiol plus standard care vs standard care alone for the treatment of emotional exhaustion and burnout among frontline health care workers during the COVID-19 pandemic: A randomized clinical trial. JAMA Network Open , 4 (8), e2120603. https://doi.org/10.1001/jamanetworkopen.2021.20603

Ding, J., & Wu, Y. (2023). The mediating effect of job satisfaction and emotional exhaustion on the relationship between psychological empowerment and turnover intention among Chinese nurses during the COVID-19 pandemic: A cross-sectional study. BMC Nursing, 22 (1), 221. https://doi.org/10.1186/s12912-023-01357-y

Dubin, J. M., Bennett, N. E., & Halpern, J. A. (2022). The adverse impact of COVID-19 on men’s health. Current Opinion in Urology, 32 (2), 146–151. https://doi.org/10.1097/mou.0000000000000966

Flinkman, M., Coco, K., Rudman, A., & Leino-Kilpi, H. (2023). Registered nurses’ psychological capital: A scoping review. International Journal of Nursing Practice , e13183. https://doi.org/10.1111/ijn.13183

Galanis, P., Vraka, I., Fragkou, D., Bilali, A., & Kaitelidou, D. (2021). Nurses’ burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of Advanced Nursing, 77 (8), 3286–3302. https://doi.org/10.1111/jan.14839

Gebauer, A. M., Pfaller, M. R., Braeu, F. A., Cyron, C. J., & Wall, W. A. (2023). A homogenized constrained mixture model of cardiac growth and remodeling: Analyzing mechanobiological stability and reversal. Biomechanics and Modeling in Mechanobiology . https://doi.org/10.1007/s10237-023-01747-w

Gedik, Ö., Ülke Şimdi, R., Kıbrıs, Ş, & Sivuk, D. K. (2023). The relationship between workplace violence, emotional exhaustion, job satisfaction and turnover intention among nurses during the COVID-19 pandemic. Journal of Research in Nursing, 28 (6–7), 448–466. https://doi.org/10.1177/17449871231182837

González-Gil, M. T., González-Blázquez, C., Parro-Moreno, A. I., Pedraz-Marcos, A., Palmar-Santos, A., Otero-García, L., ... Oter-Quintana, C. (2021). Nurses’ perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services. Intensive and Critical Care Nursing , 62 , 102966. https://doi.org/10.1016/j.iccn.2020.102966

Harizanova, S., & Stoyanova, R. (2020). Burnout among nurses and correctional officers. Work, 65 (1), 71–77. https://doi.org/10.3233/wor-193059

Hong, Y., Qiu, M., Liu, L., Huang, F., Wang, K., & Lin, R. (2023). Surface acting, emotional exhaustion, career calling and turnover intention among student nurses: A cross-sectional study. Nurse Education in Practice, 69 , 103641. https://doi.org/10.1016/j.nepr.2023.103641

Hui, T., Zakeri, M. A., Soltanmoradi, Y., Rahimi, N., Hossini Rafsanjanipoor, S. M., Nouroozi, M., & Dehghan, M. (2023). Nurses’ clinical competency and its correlates: Before and during the COVID-19 outbreak. BMC Nursing, 22 (1), 156. https://doi.org/10.1186/s12912-023-01330-9

Kang, Y., Mou, J., Lv, B., Liu, P., Fu, Y., Yang, W., ... Deng, F. (2023). How do primary hospitals enact early response to the relaxation of COVID-19 prevention and control measures? The experience from Chengdu, China. The American Journal and Managed Care , 29 (6), e159-e161. https://doi.org/10.37765/ajmc.2023.89373

Karaca, G., Tanova, C., & Gokmenoglu, K. (2023). How do shared values improve eudaimonic workplace well-being: role of perceived justice and emotional exhaustion among nurses. Journal of Health Organization and Management , ahead-of-print (ahead-of-print). https://doi.org/10.1108/jhom-07-2022-0199

Khatin-Zadeh, O., Hu, J., Banaruee, H., & Marmolejo-Ramos, F. (2023). How emotions are metaphorically embodied: Measuring hand and head action strengths of typical emotional states. Cognition and Emotion, 37 (3), 486–498. https://doi.org/10.1080/02699931.2023.2181314

Kumar, N., & Jin, Y. (2022). Impact of nurses’ emotional labour on job stress and emotional exhaustion amid COVID-19: The role of instrumental support and coaching leadership as moderators. Journal of Nursing Management, 30 (7), 2620–2632. https://doi.org/10.1111/jonm.13818

Lee, K., Bae, H., & Jang, S. (2022). Effect of Exercise Combined with Natural Stimulation on Korean college students’ concentration and positive psychological capital: A pilot study. Healthcare (Basel) , 10 (4). https://doi.org/10.3390/healthcare10040673

Lei, H., Yang, L., Yang, M., Tang, J., Yang, J., Tan, M., ... Shu, Y. (2023). Quantifying the rebound of influenza epidemics after the adjustment of zero-COVID policy in China. PNAS Nexus , 2 (5), pgad152. https://doi.org/10.1093/pnasnexus/pgad152

Liu, J., Dong, C., An, S., & Mai, Q. (2022). Dynamic evolution analysis of the emergency collaboration network for compound disasters: A case study involving a public health emergency and an accident disaster during COVID-19. Healthcare (Basel) , 10 (3). https://doi.org/10.3390/healthcare10030500

Liu, Y., Aungsuroch, Y., Gunawan, J., & Zeng, D. (2021). Job stress, psychological capital, perceived social support, and occupational burnout among hospital nurses. Journal of Nursing Scholarship, 53 (4), 511–518. https://doi.org/10.1111/jnu.12642

Lyu, S., Qian, C., McIntyre, A., & Lee, C. H. (2023). One pandemic, two solutions: Comparing the U.S.-China response and health priorities to COVID-19 from the perspective of “Two Types of Control”. Healthcare (Basel) , 11 (13). https://doi.org/10.3390/healthcare11131848

Malik, O. F., Jawad, N., Shahzad, A., & Waheed, A. (2022). Longitudinal relations between abusive supervision, subordinates’ emotional exhaustion, and job neglect among Pakistani Nurses: The moderating role of self-compassion. Current Psychology , 1–21. https://doi.org/10.1007/s12144-022-03817-1

McNeish, D., Peña, A., Vander Wyst, K. B., Ayers, S. L., Olson, M. L., & Shaibi, G. Q. (2023). Facilitating growth mixture model convergence in preventive interventions. Prevention Science, 24 (3), 505–516. https://doi.org/10.1007/s11121-021-01262-3

Olson, D., Calvimontes, D. M., Lamb, M. M., Guzman, G., Barrios, E., Chacon, A., ... Asturias, E. J. (2022). Clinical and economic impact of COVID-19 on agricultural workers, Guatemala(1). Emerging Infectious Diseases , 28 (13), S277-s287. https://doi.org/10.3201/eid2813.212303

Petersen, J., Wendsche, J., & Melzer, M. (2023). Nurses’ emotional exhaustion: Prevalence, psychosocial risk factors and association to sick leave depending on care setting-A quantitative secondary analysis. Journal of Advanced Nursing, 79 (1), 182–193. https://doi.org/10.1111/jan.15471

Pohl, S., Djediat, A., Van der Linden, J., Closon, C., & Galletta, M. (2023). Work engagement, emotional exhaustion, and OCB-civic virtue among nurses: A multilevel analysis of emotional supervisor support. Frontiers in Psychology, 14 , 1249615. https://doi.org/10.3389/fpsyg.2023.1249615

Rink, L. C., Silva, S. G., Adair, K. C., Oyesanya, T. O., Humphreys, J. C., & Sexton, J. B. (2023). Characterizing burnout and resilience among nurses: A latent profile analysis of emotional exhaustion, emotional thriving and emotional recovery. Nursing Open, 10 (11), 7279–7291. https://doi.org/10.1002/nop2.1980

Rotstein, S., Hudaib, A. R., Facey, A., & Kulkarni, J. (2019). Psychiatrist burnout: A meta-analysis of Maslach burnout inventory means. Australasian Psychiatry, 27 (3), 249–254. https://doi.org/10.1177/1039856219833800

Sagherian, K., Steege, L. M., Cobb, S. J., & Cho, H. (2023). Insomnia, fatigue and psychosocial well-being during COVID-19 pandemic: A cross-sectional survey of hospital nursing staff in the United States. Journal of Clinical Nursing, 32 (15–16), 5382–5395. https://doi.org/10.1111/jocn.15566

Seiça, A., Gonçalves, M., Magalhães Leite, J., Pereira Machado, J., Magalhães Rodrigues, J., & Johannes Greten, H. (2023). Qigong for the emotional exhaustion in nurses: Implications of a prospective randomized controlled trial in the COVID-19 pandemic. Alternative Therapies in Health and Medicine, 29 (4), 128–133.

PubMed   Google Scholar  

Sexton, J. B., Adair, K. C., Proulx, J., Profit, J., Cui, X., Bae, J., & Frankel, A. (2022). Emotional exhaustion among US health care workers before and during the COVID-19 pandemic, 2019–2021. JAMA Network Open, 5 (9), e2232748. https://doi.org/10.1001/jamanetworkopen.2022.32748

Sharma, A., Ahmad Farouk, I., & Lal, S. K. (2021). COVID-19: A review on the novel coronavirus disease evolution, transmission, detection, control and prevention. Viruses , 13 (2). https://doi.org/10.3390/v13020202

Solms, L., van Vianen, A. E. M., Koen, J., Kan, K. J., de Hoog, M., & de Pagter, A. P. J. (2023). Physician exhaustion and work engagement during the COVID-19 pandemic: A longitudinal survey into the role of resources and support interventions. PLoS ONE, 18 (2), e0277489. https://doi.org/10.1371/journal.pone.0277489

Tang, Y., Wang, Y., Zhou, H., Wang, J., Zhang, R., & Lu, Q. (2023). The relationship between psychiatric nurses’ perceived organizational support and job burnout: Mediating role of psychological capital. Frontiers in Psychology, 14 , 1099687. https://doi.org/10.3389/fpsyg.2023.1099687

Tomaszewska, K., Majchrowicz, B., Snarska, K., & Telega, D. (2022). Stress and occupational burnout of nurses working with COVID-19 patients. International Journal of Environmental Research and Public Health , 19 (19). https://doi.org/10.3390/ijerph191912688

Wang, S., Li, H., Chen, X., Yan, N., & Wen, D. (2023). The mediating role of psychological capital in the association between life satisfaction and depressive and anxiety symptoms among Chinese medical students during the COVID-19 pandemic: A cross-sectional study. BMC Psychiatry, 23 (1), 398. https://doi.org/10.1186/s12888-023-04894-7

Wesemann, U., Mahnke, M., Polk, S., Bühler, A., & Willmund, G. (2020). Impact of Crisis Intervention on the mental health status of emergency responders following the Berlin terrorist attack in 2016. Disaster Medicine and Public Health Preparedness, 14 (2), 168–172. https://doi.org/10.1017/dmp.2019.60

Wu, C., Yan, J. R., He, C. Y., Wu, J., Zhang, Y. J., Du, J., ... Lang, H. J. (2022). Latent profile analysis of security among patients with COVID-19 infection in mobile cabin hospitals and its relationship with psychological capital. Frontiers in Public Health , 10 , 993831. https://doi.org/10.3389/fpubh.2022.993831

Xu, S., Ouyang, X., Shi, X., Li, Y., Chen, D., Lai, Y., & Fan, F. (2020). Emotional exhaustion and sleep-related worry as serial mediators between sleep disturbance and depressive symptoms in student nurses: A longitudinal analysis. Journal of Psychosomatic Research, 129 , 109870. https://doi.org/10.1016/j.jpsychores.2019.109870

Xue, B., Wang, S., Chen, D., Hu, Z., Feng, Y., & Luo, H. (2023a). Moral distress, psychological capital, and burnout in registered nurses. Nursing Ethics , 9697330231202233. https://doi.org/10.1177/09697330231202233

Xue, D., Sun, B., Li, W., Zhou, H., Ding, F., & Xiao, W. (2023b). The symptom network structure of teachers’ burnout and its connection to psychological capital. Psychology Research and Behavior Management, 16 , 3503–3518. https://doi.org/10.2147/prbm.S421932

Yada, H., Abe, H., Omori, H., Matsuo, H., Masaki, O., Ishida, Y., & Katoh, T. (2014). Differences in job stress experienced by female and male Japanese psychiatric nurses. International Journal of Mental Health Nursing, 23 (5), 468–476. https://doi.org/10.1111/inm.12080

Yan, D., Wen, F., Li, X., & Zhang, Y. (2020). The relationship between psychological capital and innovation behaviour in Chinese nurses. Journal of Nursing Management, 28 (3), 471–479. https://doi.org/10.1111/jonm.12926

Yuan, Z., Zhang, X., Wang, F., Jin, M., Teng, M., He, H., & Wang, J. (2023). Levels of psychological capital among nurses: A systematic review and meta-analysis. International Nursing Review, 70 (1), 89–96. https://doi.org/10.1111/inr.12803

Yuguero, O., Rius, N., Soler-González, J., & Esquerda, M. (2022). Increase of burnout among emergency department professionals due to emotional exhaustion during the SARS-Cov2 pandemic: Evolution from 2016 to 2021. Medicine (baltimore), 101 (47), e31887. https://doi.org/10.1097/md.0000000000031887

Zhang, H. L., Wu, C., Yan, J. R., Liu, J. H., Wang, P., Hu, M. Y., ... Lang, H. J. (2023). The relationship between role ambiguity, emotional exhaustion and work alienation among chinese nurses two years after COVID-19 pandemic: A cross-sectional study. BMC Psychiatry , 23 (1), 516. https://doi.org/10.1186/s12888-023-04923-5

Download references

Acknowledgements

We would like to express our gratitude to the nursing staff who participated in our series of surveys under immense clinical nursing pressure. We sincerely acknowledge the financial support provided by the research project “Research on the Development Mechanism of Emotional Exhaustion among Nursing Staff and the Construction of Adaptive Strategies in the Post-Pandemic Era” (Grant 2023KXKT018).

This study was supported with grants from the research project “Research on the Development Mechanism of Emotional Exhaustion among Nursing Staff and the Construction of Adaptive Strategies in the Post-Pandemic Era” (Grant 2023KXKT018).

Author information

Chao Wu, Chunyan He, and Hongli Zhang contributed equally to this work.

Authors and Affiliations

Department of Nursing, Fourth Military Medical University, No. 169 Changle West Road, Xi’an, Shaanxi, 710032, China

Chao Wu, Hongli Zhang & Hongjuan Lang

Department of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Hubei, China

Department of Nursing, Shaanxi University of Chinese Medicine, Xianyang, China

Hongli Zhang

956, Hospital of the Chinese People’s Liberation Army, Nyingchi, Tibet, China

Department of Anesthesia Intensive Care Unit, The Second Affiliated Hospital, Fourth Military Medical University, Shaanxi, China

Department of Laboratory, The Affiliated Hospital of Yan’an University, Shaanxi, China

Foreign Training Group, Naval University of Engineering, Wuhan, China

Feixia Cheng

Department of Epidemiology, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Shaanxi, China

You can also search for this author in PubMed   Google Scholar

Contributions

Chao Wu, Chunyan He, Hongli Zhang and Hongjuan Lang performed most of the work on the manuscript. Yawei Lin, Lu Li, Jing He helped select participants and performed the experimental work. Zhaohua Ji was responsible for the statistical analysis of the data. Feixia Cheng was responsible for writing the article and proofreading the language.

Corresponding author

Correspondence to Hongjuan Lang .

Ethics declarations

This study has been reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University (KY20224143-1).

Conflict of interest

No conflict of interest.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 36.8 kb)

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Wu, C., He, C., Zhang, H. et al. Trajectories and predictors of emotional exhaustion in clinical nurses in the context of healthcare crisis: a case study in Xi’an, China. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06156-5

Download citation

Accepted : 14 May 2024

Published : 28 May 2024

DOI : https://doi.org/10.1007/s12144-024-06156-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Emotional exhaustion
• Clinical nurses
• Medical overcrowding
• Growth mixed model
• Find a journal
• Publish with us
• Track your research

• Open access
• Published: 22 May 2024

A family perspective for the mechanism of parent-child conflict on maternal anxiety in Chinese children with autism

• Xue Du 1 , 2 ,
• Le Sun 1 , 2 &
• Qi Dong 1 , 2  

BMC Psychology volume  12 , Article number:  286 ( 2024 ) Cite this article

174 Accesses

Metrics details

Mothers of children with autism reported higher levels of anxiety than mothers of typical children. This study revealed the relationship between parent-child conflict, children’s problem behavior, parenting stress, and maternal anxiety from the perspective of the relationship within the family.

The State-Trait Anxiety Inventory (STAI) and Caregiver Strain Questionnaire (CGSQ) were used to measure maternal anxiety and parenting stress respectively from 102 mothers of children with autism. We also collected information on parent-child relationships and children’s problem behaviors by using the Child-Parent Relationship Scale (CPRS) and Conners Parent Symptom Questionnaire (PSQ).

Parent-child conflict positively predicted state and trait anxiety in mothers of children with autism. The severity of children’s psychosomatic disorders fully mediated the positive association between parent-child conflict and state-trait anxiety in mothers of children with autism. Parenting stress significantly moderated the impact of parent-child conflict on maternal state anxiety and trait anxiety.

In the case of children with autism spectrum disorders, parent-child conflict can directly affect maternal anxiety levels, especially when mothers have low levels of parenting stress. Parent-child conflict can also affect children’s problem behaviors and thus indirectly affect maternal anxiety. Therefore, this study is of great significance for the alleviation of anxiety of mothers of autistic children and the family intervention for the early rehabilitation of autistic children.

Peer Review reports

Introduction

Autism spectrum disorder (ASD) is a neurological disorder characterized by difficulties in social interactions, patterns of communication, and repetitive behaviors and/or interests, which can lead to difficulties with extensive social interaction, communication, and participation in daily activities [ 1 ]. Recently, the incidence of autism in the United States was reported as high as 1 in 36 children [ 2 ]. The development and adaptation of children with ASD are difficult to understand and unpredictable, which can easily lead to uncertainty in mothers [ 3 ]. Therefore, parenting a child with ASD presents unique challenges to parents that can negatively impact caregivers’ mental health [ 4 ]. As the child’s primary caregiver, mothers of children with ASD were at increased risk for anxiety compared with fathers [ 5 ], healthy children, or children with other developmental disabilities [ 6 , 7 , 8 , 9 ].

Anxiety is an unpleasant state of fear and anxiety, accompanied by physical activation. It often involves efforts and expectations to avoid danger and threat, but inefficient in dealing with that danger or threat [ 10 ]. Anxiety is divided into two types: State-anxiety and Trait-anxiety [ 11 ]. State anxiety refers to a person’s temporary, passive state. This state exists immediately and has a certain intensity level. Excessive state anxiety levels will damage an individual’s mental health. Trait anxiety refers to stable individual differences in a person’s relatively enduring personality characteristics [ 12 ].

Ecosystem theory believes that the family microsystem is an important component of the ecosystem that affects the development of family members [ 13 ]. As two important family micro factors, parent-child relationship, and parenting pressure have a profound impact on individual physical and mental development [ 13 , 14 , 15 ]. For example, a good parent-child interaction can reduce the mother’s depression and anxiety [ 16 ], while a poor parent-child relationship can lead to the individual suffering from mental illness [ 17 , 18 ], such as depression and anxiety [ 19 ]. Parent-child conflict, as a manifestation of a negative parent-child relationship [ 20 , 21 ], can increase the mother’s parenting difficulty leading to more anxiety in the typical development populations. However, the relationship between the parent-child relationship and anxiety in Chinese mothers of children with ASD is unclear.

Similarly, according to the transactional models [ 22 ], parental characteristics can not only affect children’s development outcomes, but children’s development outcomes can also affect parents’ emotional health levels and behaviors [ 23 , 24 ], there is a continuous interaction between children and their mothers [ 25 , 26 , 27 ]. Previous results have confirmed that compared with children with low behavioral problems, parents of children with high behavioral problems have higher anxiety levels [ 28 ] and parents’ trait anxiety can positively predict preschool children’s emotional problems [ 29 ]. That is to say, children’s problem behaviors caused by diseases are an important source of stress and depressive symptoms for parents of children with ASD [ 30 , 31 , 32 ], which harms the mother’s health [ 33 ].

To sum up, according to the family systems theory, children’s problem behavior, parenting stress, and parent-child conflict may work together on anxiety, but few studies have focused on mothers of children with ASD. Therefore, this study will start from the main dimension of maternal anxiety of ASD children to explore the relationship between the parent-child relationship and ASD maternal anxiety, as well as the possible mechanisms of children’s problem behaviors and parenting stress. This can help us better understand the role of family factors in the onset of autism, improve the quality of life of families of children with autism, and promote early intervention of children with autism.

Participants

In this study, a questionnaire survey was used to collect hypothesis test data. The formal investigation was conducted from February to June 2023 at designated disabled Persons federations and special education institutions in Chongqing. We used G-Power3.1 to measure the sample size we needed, with 108 participants needed to achieve 80% statistical test power at a moderate effect size (F = 0.25) and a significance level of 0. 05. The survey was conducted online and offline at the same time, a total of 118 data were received, and 102 were finally received, with a recovery rate of 86%. Factors such as incomplete paper, online recycling, and short or long regular response time were excluded. Inclusion criteria for children with autism: (1) Meet the diagnostic criteria of the American Diagnostic and Statistical Manual of Psychiatry, Fifth Edition (DSM-5); (2) The family members of the children signed a written informed consent form. Inclusion criteria for mothers of children with ASD: (1) Mothers of children with ASD who have been diagnosed; (2) Clear consciousness, no intellectual disability, and able to complete the scale assessment; (3) Voluntarily participate in the survey. The study obtained the informed consent of all participating mothers, and mothers were informed of the ethical principles of voluntary participation. This study was in line with the Declaration of Helsinki and approved by the Ethics Committee of the College of Educational Sciences, Chongqing Normal University.

Research tools

Demographic information.

A self-made questionnaire was used to collect the demographic information of the research subjects, including the mother’s age, marital status, education, occupations, family income, number of children, children’s age and gender, cost of treatment (see Table  1 ).

State-trait anxiety inventory (STAI)

The State-Trait Anxiety Inventory developed by Spielberger was used to measure the anxiety level of the participants [ 34 ]. The Chinese revised version of the measurement tool used in this study contains two subscales (40 items in total). Questions 1 to 20 are the State Anxiety Inventory. Questions 21 to 40 were the Trait Anxiety Inventory [ 35 ]. Both the state anxiety and trait anxiety subscales were scored on a scale of 1 to 4. The higher the cumulative total score, the higher the individual’s state anxiety level or the more obvious the trait anxiety [ 36 ]. In this study, the Cronbach’s α coefficient of this scale was 0.905.

Child-parent relationship scale (CPRS)

The Child-Parent Relationship Scale was compiled by Pianta to investigate the parent-child relationship in families with young children [ 37 , 38 ]. Two dimensions including parent-child intimacy and parent-child conflict with a total of 22 questions in this scale. Participants were asked to answer on a 5-point Likert scale ranging from “completely inconsistent to completely consistent.” Two dimensions are scored separately, the higher the score, the higher the conflict or intimacy between parents and children. In this study, a parent-child conflict subscale was selected to measure the negative conflict between mother and child. The final score was calculated by averaging all the questions, and the higher the score, the higher the conflict between parents and children. The Cronbach’s α coefficient for this dimension was 0.879.

Caregiver strain questionnaire (CGSQ)

The Caregiver Strain Questionnaire was compiled by Brannan and introduced to China by the Institute of Mental Health of Peking University in 2001, it had good test-retest reliability and structural validity [ 39 , 40 ]. The Caregiver Stress Questionnaire assessed the caregiver’s parenting stress, with a total of 21 items, including 3 dimensions, namely objective pressure, subjective internal pressure, and subjective external pressure. It adopted a five-level score of 1 to 5 points. The higher the score, the higher the caregiver’s stress [ 41 ]. Another study found that it had good reliability and validity in assessing the stress issues of caregivers of autistic children [ 42 ]. In this study, the Cronbach’s α coefficient of this scale was 0.945.

Conners parent Symptom Questionnaire (PSQ)

The Conners Parent Symptom Questionnaire was compiled by Conners in 1969, this scale was widely used abroad and had good reliability and validity [ 43 ]. It was also suitable for assessing behavioral problems of Chinese children aged 3 to 17 years old [ 44 ]. The scale consists of 48 questions, including five dimensions: conduct problems, learning problems, psychosomatic disorders, impulsive-hyperactive and anxiety. There were 4 levels of scoring, with options ranging from 0 to 3, representing “none” to “a lot” respectively. The questionnaire was filled out by the child’s father or mother, with higher scores indicating more severe behavioral problems. In this study, the Cronbach’s α coefficient of this scale was 0.962.

Analytical procedure

The main analysis procedures of this study were as follows:

Firstly, descriptive statistics were used to analyze the information of 102 mothers of children with ASD.

Secondly, according to Hayes’s suggestion [ 45 ], the SPSS plug-in PROCESS was used to test the mediating role of the five sub-dimensions of children’s behavioral problems (conduct behavior, learning problems, psychosomatic disorders, impulsivity-hyperactivity, and anxiety) in the relationship between parent-child conflict and maternal anxiety. The BOOTSTRAP was used for parameter estimation. The sample size was 5000. The 95% confidence interval didn’t include 0, which meant that the parameter was significant.

Finally, according to Edwards and Lambert [ 46 ], parenting stress was divided into high and low stress levels. The moderating effects of high and low stress levels on parent-child conflict, child problem behavior, and maternal anxiety were estimated. In the grouping of maternal parenting stress levels, the high-level group was one standard deviation (SD) above the mean (M + 1SD), and the low-level group was one standard deviation (SD) below the mean (M-1SD).

Common method bias test

Since the data in this study, all come from the mother’s evaluation, during the data collection process, anonymous participation, reverse question scoring, and balanced scale order were used for control [ 47 ]. Harman’s single factor test was used to conduct unrotated factor analysis for possible common method deviations, and the total number of factors with characteristic roots greater than 1 was found to be 29. The explanation rate of the first common factor was 22.23%, which was less than the critical value of 40%. Therefore, it was believed that the data in this study didn’t have serious common method bias problems.

Table  1 presents demographic information on mothers of autistic children. The average age of the mothers was 36.13 ± 0.67 years old; a very small number of mothers were divorced or unmarried; more than half of the mothers had a bachelor’s degree or college education; nearly a quarter of the mothers were unemployed; 60.8% of the families had only one child; the gender of the children was 79 boys and 23 girls and the age of the children was mainly 3–6 years old.

Descriptive statistics and correlations

Table  2 shows the descriptive, correlation, and reliability results regarding the variables of interest. The results showed that the mother’s age was somewhat related to the main study variables. Therefore, it was included as a control variable in the subsequent analyses. Mother’s state anxiety was significantly positively correlated with the dimensions of parent-child conflict, parenting stress, conduct problems in children’s behavioral problems, psychosomatic disorders, and anxiety. Mother’s trait anxiety was significantly positively correlated with the dimensions of parent-child conflict, conduct problems in children’s behavioral problems, psychosomatic disorders, and anxiety. Therefore, in the next test of the mediating effect, the dimensions of conduct problems, psychosomatic disorders, and anxiety in children’s behavioral problems were tested as mediating variables.

Mediation effect test

Table  3 shows that parent-child conflict positively affected mothers’ state-trait anxiety (B = 0.136, P  < 0.05; B = 0.166, P  < 0.01). The results also showed that parent-child conflict was significantly related to psychosomatic disorders in children with ASD (B = 0.418, P  < 0.001), and psychosomatic disorders in children with ASD were significantly related to mother’s state-trait anxiety (B = 0.217, P  < 0.01; B = 0.158, P  < 0.05). Under this condition, the indirect effect of parent-child conflict on state-trait anxiety in mothers of ASD children was significant (B = 0.091, 95% confidence interval [CI]: [0.028, 0.175]; B = 0.066, 95% confidence interval [CI]: [0.004, 0.157]), the mediating effect plot was shown in Fig.  1 . and Fig.  2 . Children’s conduct problems and anxiety didn’t mediate the impact of parent-child conflict on maternal anxiety. In summary, the severity of children’s psychosomatic disorders fully mediated the relationship between parent-child conflict and state-trait anxiety in mothers.

Diagram of the mediating effect of psychosomatic disorders on the impact of parent-child conflict on state anxiety

Diagram of the mediating effect of psychosomatic disorders on the impact of parent-child conflict on trait anxiety

Moderating effect test

The moderating effect of a mother’s parenting stress is shown in Table  4 . The interaction term between parent-child conflict and maternal parenting stress significantly predicted maternal state anxiety (B=-0.005, t=-0.814, p  < 0.001) and trait anxiety (B=-0.001, t=-0.095, p  < 0.001). In summary, parenting stress significantly mediated the impact of parent-child conflict on maternal state anxiety and trait anxiety.

To reveal the essence of the interaction, a simple slope analysis was carried out, and the moderating variable parenting stress was added or subtracted by one standard deviation as the high-stress group and the low-stress group respectively.

Firstly, parenting stress had a moderating effect on the relationship between parent-child conflict and maternal state anxiety (Fig.  3 ). The results found that when the level of parenting stress was high, parent-child conflict had a significant negative predictive effect on state anxiety (simple slope=-0.27, t=-2.91, p  < 0.01); when the level of parenting stress was low, parent-child conflict had a significant positive predictive effect on state anxiety (simple slope = 0.32, t = 4.22, p  < 0.001), and the predictive effect is large (the value of simple slope changes from − 0.27 to 0.32). The specific performance was as follows: for mothers with high parenting pressure, as parent-child conflict increases, the mother’s state anxiety will decrease; for mothers with low parenting stress, as parent-child conflict increases, their state anxiety will increase significantly.

Secondly, parenting stress had a moderating effect on the relationship between parent-child conflict and maternal trait anxiety ((Fig.  4 ). The results found that when the level of parenting stress was high, the predictive effect of parent-child conflict on maternal trait anxiety was not significant ( p  = 0.093); when the level of parenting stress was low, parent-child conflict had a significant positive predictive effect on state anxiety (simple slope = 0.34, t = 4.80, p  < 0.001). The performance was as follows: for mothers with high parenting stress, their trait anxiety levels were higher regardless of parent-child conflict; for mothers with low parenting stress, a significant increase in trait anxiety occurred as parent-child conflict increased.

Parenting stress as a moderator between parent-child conflict and STATE anxiety (PS = Parenting Stress, the same as Fig.  4 .)

Parenting stress as a moderator between parent-child conflict and TRAIT anxiety

From the perspective of the family, this study revealed the mechanism of children’s behavioral problems and parenting stress on the relationship between parent-child conflict and maternal anxiety. It showed that alleviating parenting stress and reducing the probability of parent-child conflict had a positive significance for improving the anxiety state of mothers of children with ASD and promoting their mental health development.

The relationship between parent-child conflict and anxiety in mothers of children with ASD

This study found that parent-child conflict can significantly and positively predict anxiety in mothers of children with ASD, which was similar to previous research results. In a study of children with autism, more than half of the mothers experienced significant psychological distress, and parent-child conflict was one of the predictors [ 48 ]. In families of children with ASD, both mother-child and father-child relationships were affected by parents’ mental health [ 33 ]. Stress, anxiety, and stress and depressive symptoms in mothers of children with autism predict poorer parent-child relationships [ 49 ]. Another study pointed out that compared with families of non-autistic children, parents of autistic children were more likely to experience stress and depression, and these emotions were also related to parent-child conflict [ 50 ]. In caring for a child with autism, a mother may find that her own needs and the needs of other family members were ignored or placed on the back burner. Therefore, early interventions that support mothers may help reduce their stress and anxiety to improve families’ overall quality of life [ 51 ]. Previous studies generally focused on the relationship between the parent-child relationship and mental health problems of mothers of ASD children. This study further refined the dimension of mental health problems and paid attention to the impact of parent-child conflict on the anxiety of mothers of ASD children.

The mediating role of children’s behavioral problems

This study found that psychosomatic disorders in children’s behavioral problems play a mediating role between parent-child conflict and anxiety in mothers of children with ASD.

On the one hand, conflictual parent-child relationships can easily lead to serious psychosomatic disorders in children. Parent-child conflicts can affect the quality of parent-child relationships, undermine the stability of family relationships, make children feel insecure, and trigger children’s behavioral questions [ 17 ]. Some studies have also shown that the parenting stress caused by children with ASD usually affects the entire family, and the symptoms of children with ASD can have an impact on family relationships (parent-child relationship) [ 52 ].

On the other hand, the severity of children’s behavioral problems will have an impact on the anxiety of mothers of children with ASD, which is consistent with existing research results. Behavioral problems in children with autism have a positive predictive effect on parental anxiety [ 36 ], children’s behavioral problems trigger sources of stress and anxiety in mothers [ 53 ], and the state and trait anxiety of mothers are positively related to the total score of children’s difficulties and emotional symptoms [ 54 ]. Therefore, children’s behavioral problems become an important factor in alleviating mothers’ anxiety levels, which also provides evidence for the importance of early intervention for children with autism.

The moderating role of parenting stress

This study found that parenting stress mediates the relationship between parent-child conflict and maternal anxiety in children with ASD. At low parenting stress levels, parent-child conflict has a greater predictive effect on maternal state and trait anxiety. At high parenting stress levels, the parent-child conflict has a greater predictive effect on maternal state and trait anxiety. The predictive effect of parent-child conflict on maternal trait anxiety was not significant, this is similar to previous research results. Compared with mothers of ordinary children, ASD caregivers face greater parenting stress [ 55 ]. High levels of parenting stress and depressive symptoms are associated with maladaptive parenting behaviors and/or related to low-quality parent-child relationships. High parenting pressure can also cause negative parenting behaviors in mothers [ 56 ], forming a bad parent-child relationship [ 57 ], leading to a decrease in the frequency of parent-child conflicts, resulting in more severe negative emotions [ 58 , 59 ].

Under low parenting stress levels, parent-child conflict will lead to increased state-trait anxiety in mothers of children with ASD. State anxiety mainly reflects a short-term anxious emotional state, which is directly triggered by environmental stimuli and is closely related to life events and stress [ 54 ]; Trait anxiety can be understood as a relatively stable emotional pattern reflected by individuals in the face of dangerous situations in the outside world, with significant individual differences [ 60 ]. Therefore, under the condition of low parenting stress levels, mothers of children with ASD will pay more attention to external events (conflict-type interactions between parents and children), thereby increasing their state anxiety level. The daily stress of children with ASD caused by impaired social functions caregiving, rehabilitation support, and financial burdens can put mothers in a chronic state of stress for a long time, leading to an increased risk of trait anxiety [ 61 ]. Under high levels of parenting stress, maternal trait anxiety will be at a higher level regardless of parenting stress. Parenting stress will make mothers of children with ASD feel long-term anxiety. At this time, external events (conflict-type interactions between parents and children) have no significant predictive effect on the trait anxiety of mothers of children with ASD. Therefore, we should try to reduce the parenting stress of mothers of children with ASD, so that mothers can better face conflicts with their children, thereby improving their anxiety state and improving their mental health.

Limitations and future directions

Even though this is the first study to reveal the mechanism of parent-child conflict on maternal anxiety in Chinese children with autism from a family perspective, it also has certain limitations. Firstly, as a cross-sectional study, it cannot explore the causal relationship between variables. In the future, it is necessary to further explore the causal relationship between variables through longitudinal research or experimental research. Secondly, the sample size of girls and the overall sample size are small; in addition, this study focuses only included mothers, and data collection on fathers and comparison of anxiety between parents were not considered. Finally, the data used in this study are mothers’ self-assessments, it only examines the relationship between parent-child conflict, child behavioral problems, parenting stress, and maternal anxiety from the mother’s perspective. Future research can use a variety of assessment methods, such as professional evaluation from a different perspective to obtain more comprehensive and objective research conclusions.

Conclusions

This study elucidated the mechanism of parent-child conflict on maternal anxiety of autistic children and the intricate interactions therein from the perspective of families. The findings provide strong evidence to support the relationship between these key variables. Specifically, parent-child conflict became an important predictor of maternal anxiety in children with autism. In addition, the mediating role of children’s behavior problems in parent-child conflict and maternal anxiety in autistic children emphasizes the importance of early intervention in autistic children. In addition, this study highlights the relationship between parenting stress and parent-child conflict becoming maternal anxiety in children with autism. In a word, this study has important implications for the clinical practice of early family intervention for children with autism.

Data availability

The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 ™ . 5th ed. Arlington, VA, US: American Psychiatric Publishing, Inc.; 2013.

Book   Google Scholar  

Maenner MJ. Prevalence and characteristics of Autism Spectrum Disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. MMWR Surveill Summ. 2023;72(SS–2):1–14.

Article   PubMed   PubMed Central   Google Scholar  

Firth I, Dryer R. The predictors of distress in parents of children with autism spectrum disorder. J Intellect Dev Disabil. 2013;38:163–71.

Article   PubMed   Google Scholar  

Da Paz NS, Wallander JL. Interventions that target improvements in mental health for parents of children with autism spectrum disorders: a narrative review. 2017. https://doi.org/10.1016/j.cpr.2016.10.006 .

Bitsika V, Sharpley CF, Bell R. The buffering effect of resilience upon stress, anxiety and depression in parents of a child with an Autism Spectrum Disorder. J Dev Phys Disabil. 2013;25:533–43.

Article   Google Scholar  

Ingersoll B, Meyer K, Becker MW. Increased rates of depressed mood in mothers of children with ASD associated with the presence of the broader autism phenotype. Autism Res off J Int Soc Autism Res. 2011;4:143–8.

Hayes SA, Watson SL. The impact of parenting stress: a meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. J Autism Dev Disord. 2013;43:629–42.

Hodges H, Fealko C, Soares N. Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation. Transl Pediatr. 2020;9(Suppl 1):S55–65.

Zhou H, Xu X, Yan W, Zou X, Wu L, Luo X, et al. Prevalence of Autism Spectrum Disorder in China: a Nationwide Multi-center Population-based study among children aged 6 to 12 years. Neurosci Bull. 2020;36:961–71.

Huang X. Psychology of personality. Hangzhou: Zhejiang Education; 2003.

Google Scholar  

Shek DT. The factorial structure of the Chinese version of the state-trait anxiety inventory: a confirmatory factor analysis. Educ Psychol Meas. 1991;51:985–97.

Spielberger CD. Anxiety, cognition and affect: a state-trait perspective. Hillsdale, NJ, US: Lawrence Erlbaum Associates, Inc; 1985.

Bronfenbrenner U. Contexts of child rearing: problems and prospects. Am Psychol. 1979;34:844–50.

Wang Y, Luan J, Li Y. The relationship between maternal parenting stress and children’s anxiety: the mediating role of parent-child conflict and the moderating role of maternal mindfulness. Psychol Dev Educ. 2023;39:702–9.

Hutchinson EA, Rosen D, Allen K, Price RB, Amole M, Silk JS. Adolescent Gaze-Directed attention during parent-child conflict: the effects of depressive symptoms and parent-child relationship quality. Child Psychiatry Hum Dev. 2019;50:483–93.

Agazzi H, Tan SY, Ogg J, Armstrong K, Kirby RS. Does parent-child Interaction Therapy reduce maternal stress, anxiety, and Depression among mothers of children with Autism Spectrum Disorder? Child Fam Behav Ther. 2017;39:283–303.

Bradford AB, Burningham KL, Sandberg JG, Johnson LN. The Association between the parent-child relationship and symptoms of anxiety and depression: the roles of attachment and perceived spouse attachment behaviors. J Marital Fam Ther. 2017;43:291–307.

Hu Y, He Z, Zeng Z, Zhan L, Shen Z. The effect of parent-child relationship on adolescent depression: the role of cognitive flexibility and friendship quality. Chin J Clin Psychol. 2023;:682–7.

Nakić Radoš S. Parental sensitivity and responsiveness as Mediators between Postpartum Mental Health and Bonding in mothers and fathers. Front Psychiatry. 2021;12:723418.

Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411–27.

Bögels SM, Siqueland L. Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2006;45:134–41.

Sameroff A. Transactional models in early social relations. Hum Dev. 1975;18:65–79.

Xing X, Wang M. Sex differences in the reciprocal relationships between mild and severe corporal punishment and children’s internalizing problem behavior in a Chinese sample. J Appl Dev Psychol. 2013;34:9–16.

Wang M, Liu L. Reciprocal relations between Harsh Discipline and Children’s Externalizing Behavior in China: a 5-Year longitudinal study. Child Dev. 2018;89:174–87.

Ambert A-M. The effect of children on parents. New York, NY, England: Haworth Press, Inc; 1992.

Pettit GS, Arsiwalla DD. Commentary on special section on bidirectional parent-child relationships: the continuing evolution of dynamic, transactional models of parenting and youth behavior problems. J Abnorm Child Psychol. 2008;36:711–8.

Lanjekar PD, Joshi SH, Lanjekar PD, Wagh V. The effect of parenting and the parent-child relationship on a child’s Cognitive Development: A literature review. Cureus. 2022;14:e30574.

PubMed   PubMed Central   Google Scholar  

Wang Y, Zhang J, Yi C. The relationship between children’s behavioural problems and parental shame, anxiety and family environment. Chin J Mental Health. 2008;:692–3.

Zhou T, Yi C. Relationship between behavioral inhibition, parental trait anxiety and behavioral problems in preschool children. Chin J Clin Psychol. 2016;24:828–32.

Orsmond GI, Seltzer MM, Greenberg JS, Krauss MW. Mother-child relationship quality among adolescents and adults with autism. Am J Ment Retard AJMR. 2006;111:121–37.

Rodriguez G, Hartley SL, Bolt D. Transactional relations between parenting stress and child autism symptoms and behavior problems. J Autism Dev Disord. 2019;49:1887–98.

Civick PD. Maternal and paternal differences in parental stress levels and marital satisfaction levels in parents of children diagnosed with autism spectrum disorders. Diss Theses - Gradworks; 2008.

Hickey EJ, Hartley SL, Papp L. Psychological well-being and parent-child relationship quality in relation to child autism: an actor-Partner modeling Approach. Fam Process. 2020;59:636–50.

Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G. Manual for the State-Trait Anxiety Inventory (Form Y1 – Y2). 1983.

Cheng C, He J, Yu Y, Zhong X, Li C, Zhang X, et al. Measurement equivalence of the Chinese version of the state-trait anxiety scale. Chin J Clin Psychol. 2021;29:68–73.

Li X, Wu J, Yao X, Liu Y, Ren J, Chen S. The relationship between behavioral problems and parental anxiety in children with autism and intellectual disability: the mediating role of parenting stress and the moderating role of perceived social support. Psychol Dev Educ. 2023;39:77–84.

Pianta RC, Nimetz SL, Bennett E. Mother–child relationships, teacher–child relationships, and school outcomes in preschool and kindergarten. Early Child Res Q. 1997;12:263–80.

Zhang X, Chen H, Zhang G, Zhou B, Wu W. A longitudinal study of parent-child relationships and Problem behaviors in early childhood: transactional models. Acta Psychol Sin. 2008;40:571.

Brannan A, Heflinger C, Bickman L. The caregiver strain questionnaire: measuring the impact on the family of living with a child with serious emotional disturbance. J Emot Behav Disord - J Emot BEHAV DISORD. 1997;5:212–22.

Kang Chuanyuan. A follow-up study of adolescent in boys with attention deficit hyperactivity disorder. Master. Peking university; 2005.

Du M, Kang C, Li X, Wan S, Cao Y, Ding K, et al. Effects of abnormal behaviors in children with pervasive developmental disorders on caregiver’s mental health. Chin J Neuropsychiatric Dis. 2015;41:199–202.

Chung ST, Lok EYC, Chan QKN, Cheng K-M, Lam S-M, Lui SSY. Psychometric properties of the Caregiver strain questionnaire in a Chinese sample of caregivers of children with Autism Spectrum Disorder. J Autism Dev Disord. 2023. https://doi.org/10.1007/s10803-023-06028-0 .

Wender EH. Hyperactive children: a handbook for diagnosis and treatment. Arch Pediatr Adolesc Med. 1982;136:655.

Su L, Li X, Huang C, Luo X, Zhang J. Conners parent Symptom Questionnaire in Chinese City norms. Chin J Clin Psychol. 2001;:241–3.

Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: The Guilford; 2013.

Edwards JR, Lambert LS. Methods for integrating moderation and mediation: a general analytical framework using moderated path analysis. Psychol Methods. 2007;12:1–22.

Hao Z, Lirong L. Statistical remedies for common method biases. Adv Psychol Sci. 2004;12:942.

Duarte CS, Bordin IA, Yazigi L, Mooney J. Factors associated with stress in mothers of children with autism. Autism Int J Res Pract. 2005;9:416–27.

Kulasinghe K, Whittingham K, Mitchell AE. Emotional availability in the mother-child relationship for families of young children with autism spectrum disorder in Australia: a cross-sectional survey. Res Dev Disabil. 2022;131:104365.

Estes A, Olson E, Sullivan K, Greenson J, Winter J, Dawson G, et al. Parenting-related stress and psychological distress in mothers of toddlers with autism spectrum disorders. Brain Dev. 2013;35:133–8.

Davis NO, Carter AS. Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: associations with child characteristics. J Autism Dev Disord. 2008;38:1278–91.

Wang Z, Liu Q, Luo B, Chen J. The impact of autism in children on family relationships. Contemp Educational Theory Pract. 2016;8:129–31.

Rezendes DL, Scarpa A. Associations between parental Anxiety/Depression and child behavior problems related to Autism Spectrum disorders: the roles of parenting stress and parenting self-efficacy. Autism Res Treat. 2011;2011:395190.

Liu S, Lin L, Wang X, Dai M, Chen Q, Chen J, et al. Association between emotional and behavioral problems and maternal anxiety in children with autism spectrum disorder. Chin J Child Health Care. 2022;30:361–5.

Yorke I, White P, Weston A, Rafla M, Charman T, Simonoff E. The Association between emotional and behavioral problems in children with Autism Spectrum Disorder and Psychological Distress in their parents: a systematic review and Meta-analysis. J Autism Dev Disord. 2018;48:3393–415.

Liu L, Wang M. Parenting stress and children’s problem behavior in China: the mediating role of parental psychological aggression. J Fam Psychol JFP J Div Fam Psychol Am Psychol Assoc Div. 2015;43:29:20–8.

Zvara BJ, Mills-Koonce WR, Heilbron N, Clincy A, Cox MJ, Family Life Project Key Contributors. The interdependence of adult relationship quality and parenting behaviours among African American and European couples in Rural, Low-Income communities. Infant Child Dev. 2015;24:343–63.

Baker JK, Seltzer MM, Greenberg JS. Longitudinal effects of adaptability on behavior problems and maternal depression in families of adolescents with autism. J Fam Psychol JFP J Div Fam Psychol Am Psychol Assoc Div. 2011;43:25:601–9.

McStay RL, Dissanayake C, Scheeren A, Koot HM, Begeer S. Parenting stress and autism: the role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism. Autism Int J Res Pract. 2014;18:502–10.

Lau JYF, Eley TC, Stevenson J. Examining the state-trait anxiety relationship: a behavioural genetic approach. J Abnorm Child Psychol. 2006;34:19–27.

Minichil W, Getinet W, Derajew H, Seid S. Depression and associated factors among primary caregivers of children and adolescents with mental illness in Addis Ababa, Ethiopia. BMC Psychiatry. 2019;19:249.

Download references

Acknowledgements

The authors would like to express their appreciation for their involvement in this study.

This research was supported by the Humanities and Social Science Youth Project of the Ministry of Education (19YJC190006), Venture & Innovation Support Program for Chongqing Overseas Returnees(cx2018107), Chongqing Social Science Planning and Cultivation Project (2020PY61), The 72th Batch of General Financial Grant from the China Postdoctoral Science Foundation(2022M720597), Scientific and Technological Research Program of Chongqing Municipal Education Commission(KJQN202000508), General Project of Humanities and Social Sciences Research of Chongqing Municipal Education Commission(22SKGH109), Youth Project of the Chongqing Education Science Planning(K22YY205692), General Project of scientific research on disability prevention and rehabilitation in the disabled people in Chongqing(KFKT202204), Open Research Fund of Key laboratory of cognition and personality, Ministry of Education、Doctoral Fund of Chongqing Normal University(18xwb005).

Author information

Authors and affiliations.

College of Educational Science, Chongqing Normal University, Chongqing, 401331, China

Xue Du, Le Sun & Qi Dong

Key Laboratory of Applied Psychology, Chongqing Normal University, Chongqing, 401331, China

You can also search for this author in PubMed   Google Scholar

Contributions

Xue Du contributed to the conception of the study, secured funding, organized the investigation, and revised the manuscript. Le Sun analyzed the data, wrote the original paper and organized the investigation. Qi Dong helped data collection and analyzed the data. All authors reviewed the manuscript.

Corresponding author

Correspondence to Xue Du .

Ethics declarations

Ethics approval and consent to participate.

This study is in line with the Declaration of Helsinki and approved by the Ethics Committee of the College of Educational Sciences, Chongqing Normal University. Informed consent was obtained from all subjects involved in the study.

Consent for publication

Not Applicable.

Competing interests

I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Du, X., Sun, L. & Dong, Q. A family perspective for the mechanism of parent-child conflict on maternal anxiety in Chinese children with autism. BMC Psychol 12 , 286 (2024). https://doi.org/10.1186/s40359-024-01786-7

Download citation

Received : 24 December 2023

Accepted : 13 May 2024

Published : 22 May 2024

DOI : https://doi.org/10.1186/s40359-024-01786-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Mothers of children with autism
• Child problem behavior
• Parent-child conflict
• Parenting stress

BMC Psychology

ISSN: 2050-7283

• General enquiries: [email protected]

Quality over quantity for screen time -- study

New research reveals what we consume online affects us more than length of exposure.

It is what we are looking at, rather than how much time we are spending our time online that influences our health and wellbeing, according to a major new report.

The study, published in the journal World Psychiatry , is a comprehensive examination of the latest scientific evidence on screen time and mental health, carried out by an international research team.

The authors emphasise the importance of taking an individualised and multi-dimensional approach to how the Internet affects mental health, cognition and social functioning. Content that may be relatively harmless to some users may be damaging to a different demographic, such as the impact photos promoting unrealistic body shapes may have on people vulnerable to eating disorders or low self-esteem.

The report addresses a range of impacts that an increased online presence has on wellbeing, tackling issues such as 'fear of missing out', how behaviours and viewpoints are manipulated through social media, isolation, social comparisons, and the effects on the body such as increased sedentary behaviour.

Co-author Lee Smith, Professor of Public Health at Anglia Ruskin University (ARU), said: "Take two scenarios: In the first, a young person is accruing a total of four hours per day online, through constantly engaging with distracting notifications whenever they appear on screen, and then scrolling endless streams of short-form media which can be algorithmically geared towards their vices or insecurities. This could result in reduced concentration on important tasks, or cause body image issues or low self-esteem.

"In the second scenario, there is an older adult spending the exact same four hours per day online, but instead using this time to foster new social relationships and access educational content, providing benefits for their wellbeing and even brain functioning. Here, we can see very different outcomes arise from the exact same amount of time spent online."

This emerging evidence of how the online world can influence our social functioning and brain health can be used to begin developing more concrete guidelines and strategies for helping people to maximise the benefits, and minimise the risks, of their own individual 'online lives'.

Senior Author, Dr Josh A. Firth from University of Leeds explained: "Right now, lots of the guidelines and recommendations around internet usage have focused on limiting the amount of time we spend online.

"While there is common sense in reducing our digital device usage to ensure time for healthy 'real world' activities, we are now able to describe how the consequences of our digital device usage are determined by things far beyond just time spent online."

Professor Smith added: "Through drawing together the latest evidence from neuroscience, populational health and psychological studies, this report is able to describe how the positive or negative effects of internet usage for an individual can be influenced by simple things like age and sociodemographic status, along with complex factors around the actual nature of individuals' 'online lives'."

• Mental Health
• Child Development
• Relationships
• Privacy Issues
• Public Health
• Social Issues
• World Development
• Public health
• Substance abuse
• Delayed sleep phase syndrome
• Psychologist
• Mental illness
• Environmental impact assessment

Story Source:

Materials provided by Anglia Ruskin University . Note: Content may be edited for style and length.

Journal Reference :

• Joseph Firth, John Torous, José Francisco López‐Gil, Jake Linardon, Alyssa Milton, Jeffrey Lambert, Lee Smith, Ivan Jarić, Hannah Fabian, Davy Vancampfort, Henry Onyeaka, Felipe B. Schuch, Josh A. Firth. From 'online brains' to 'online lives': understanding the individualized impacts of Internet use across psychological, cognitive and social dimensions . World Psychiatry , 2024; 23 (2): 176 DOI: 10.1002/wps.21188

Cite This Page :

Explore More

• The Case of the Missing Black Holes
• Adjusting Sunglasses for Your Windows
• Novel Gene-Editing Tool Created
• How Hummingbirds Hover With Such Accuracy
• Complete X and Y Chromosomes of Great Apes
• Moonlets Stuck Together Orbit 'Dinky' Asteroid
• Orchids Aid Seedlings Through Fungal Networks
• Precise Maps of the Moon's Surface
• Amazing Expertise of Scent Detection Dogs
• Getting to Grips With a Handy Extra Thumb

Trending Topics

Strange & offbeat.