PREDISPOSING AND PRECIPITATING FACTORS TO MENTAL ILLNESS

Hyacinth C. Manood. MD, FPPA

BIOLOGICAL

• Genetics• Psychoneuroendocrinol

ogy• Psychoneuroimmunolog

y• Biological Rhythms

PSYCHOLOGICAL• Freud• Erickson

SOCIAL• Stress• Environment• Life Events• Trauma

BIOLOGICAL

I. GENETICS- many major psychiatric disorders have shown to have strong hereditary predispositions.

Examples: Schizophrenia Bipolar Disorder and Major

Depressive disordersfirst degree relatives – 8 – 18x

monozygotic twins – 33-90% concordance Tourette’s Disorder – autosomal

dominant

BIOLOGICAL

II. PSYCHONEUROENDOCRINOLOGY- refers to the structural and functional relations between hormonal system and CNS and the behaviors that modulate and arise from it.

HYPOTHALAMIC-PITUITARY-ADRENAL1. Cushing’s Syndrome (inc. cortisol)

> 50% mood disturbances> 10% psychosis and suicidal thoughts>cognitive impairments

- Decreasing the cortisol level normalizes mood and mental status

2. Addison’s Disease (Adrenal insufficiency)> apathy, withdrawal, impaired sleep and decreased concentration.> replacement of glucocorticoids resolves the above symptoms.

3. Depression > increased cortisol concentration> failure to suppress cortisol in response to dexamethasone> increased adrenal size and sensitivity to ACTH> blunted ACTH response to CRH> increased concentrations of CRH in the brain

4. Insulin – involved in learning and memory> lower insulin concentration in CSF of patients with Alzheimer’s Disease.>depression is frequent in patients with diabetes> antipsychotic effects dysregulate insulin metabolism

HYPOTHALAMIC-PITUITARY-GONADAL AXIS

5. Testosterone> associated with increased violence and aggression in animals;> testosterone improves mood and decreases irriability in hypogonadal males

> anabolic-androgenic steroids – euphoria, increased energy, sexual arousal; irriability, mood swings, violent feelings, anger and hostility;> DHEA improves well-being and functional status in both depressed and normal individuals.

2. Estrogen and Progesterone> antipsychotic effect changes over menstrual cycles> risk of tardive dyskinesia depends partly on estrogen concentration;> Estrogen administration decreases risks ad severity of Alzheimer’s dementia.> Estrogen has mood-enhancing properties> Premenstrual dysphoric disorder

3. Prolactin> increased PRL – depression, decreased libido, stress intolerance, anxiety, increased irritability;> severity of tardive dyskinesia

HYPOTHALAMIC-PITUITARY-THYROID AXIS

TRH - neuronal excitability, behavior, neurotransmitter regulation.

Hyperthyroidism – fatigue, irritability, insomnia, anxiety, restlessness, weight loss, emotional lability; marked impairment in memory and concentration; delirium and dementia; psychotic feature : paranoia

Chronic hypotyroidism – fatigue, decreased libido, memory impairment, irritability; suicidal ideation common.

GROWTH HORMONE stressful experiences – decreased GHdec. GH – major depressive disorder and dysthymia

ENDOGENOUS OPIOIDS - eating behaviorMELATONIN – circadian phase disorders

(jetlag)- increases speed of falling asleep

OXYTOCIN – sexSUBSTANCE P - memory

III. PSYCHONEUROIMMUNOLOGY

> Stress lowers immune response.> HIV – depression> neurosyphilis – neuropsychiatric manifestations> Schizophrenia> Major Depressive Disorder> Alzheimer’s disease> Chronic fatigue syndrome

IV. BIOLOGICAL RHYTMS* SLEEP> deprivation leads to breakdown in concentration, motor skills, self-care, attention, judgement, communication; hallucinations and illusions.

PSYCHOLOGICAL

I. FREUDSTAGES OF PSYCHOSEXUAL

DEVELOPMENT1. ORAL STAGE ( 0 – 1)

- to establish a trusting dependence on nursing and sustaining objects;- to establish comfortable expression and gratification of oral libidinal needs without excessive conflicts or ambivalence from oral sadistic wishes.

PATHOLOGICAL: extremes of oral gratification can result in libidinal fixations;- excessive optimism, narcissism, pessimism, demandingness;oral traits - envy and jealousy

2. ANAL STAGE (1 – 2)- a period of striving for independence and separation from dependence

PATHOLOGICAL:Fixation – orderliness, obstinacy, stubbornness,

willfulness, frugality, and parsimonyIf less effective – heightened ambivalence,

lack of tidiness, messiness, defiance, rage ad sadomasochistic tendencies.

3. URETHRAL STAGE (2 – 3)- transitional; issues of control and shaming

4. PHALLIC STAGE ( 3 – 6)- castration anxiety; penis envy; - identification from parental figures- foundation for an emerging sense of sexual identity- oedipal conflict resolution- internal source of regulation - superego

5. LATENCY STAGE ( 5-6 TO 11-13)- stage of relative quiescence or inactivity of sexual drive;- homosexual affiliations; sublimation- development of important skills

PATHOLIGAL: lack of control leads to failure to sublimate energies in the interests of learning and development of skills.

6. GENITAL STAGE (11-13 TO young adulthood)- ultimate separation from dependence on and attachment to parents.-establishment of mature, nonincestous object relations;

2. ERIKSON

EPIGENETIC PRINCIPLE – development occurs in sequential, clearly defined stages, and that each stage must be satisfactorily resolved for development to proceed smoothly.

- In relation to Freudian theory, Erikson described a corresponding zone with a specific pattern or mode of behavior.

EIGHT STAGES OF THE LIFE CYCLE:1. TRUST VS. MISTRUST (birth – 18 months)

- incorporation- development of basic trust- impairment leads to basic mistrust

>prolonged separation during infancy

hospitalism or anaclitic depression later life

dysthymia, depression, sense of hopelessness

Social mistrust Projection

Paranoid or delusional disorders, Schizoid PD, Schizophrenia, Substance abuse, thrill-seeking behaviors

2. AUTONOMY VS SHAME AND DOUBT (18M – 3)- terrible two

If too much shame and doubt – obsessive personality

Too rigorous toilet training – stingy, meticulous, selfish

Too much shaming – delinquent behavior; impulsive behavior

3. INITIATIVE VS GUILT ( 3 – 5)- active and intrusive- Oedipus complex

If excessive guilt – GAD and phobiasPunishment or severe prohibitions – sexual

inhibitionsIf oedipal conflict not resolved – conversion

disorder; specific phobia

4. INDUSTRY VS INFERIORITY (5 – 13)- covers pleasure of production- learning new skills and takes pride in things made- teachers and other role models are important

If unprepared – sense of inferiority or inadequacy

Extremes – feelings of inadequacy; compensatory drive for money, power and prestige; work can become the main focus of life

5. IDENTITY VS. ROLE CONFUSION ( 13 – 21)- running away, criminality, overt psychoses

Defenses – joining cults, gangs ; identifying with folk heroes- Conduct disorders, Disruptive Behavior disorder, Gender identity disorders, Schizophreniform disorders

6. INTIMACY VS ISOLATION (21-40) - successful formation of stable marriage and family

7. GENERATIVITY VS STAGNATION (40-60)- establishing and guiding the next generation- depression- inc. substance use

8. INTEGRITY VS DESPAIR- acceptance- Psychosomatic illnesses, Hypochondriasis, Depression- suicide rate is highest over age 65

SOCIAL FACTORS

STRESS- Stress Diathesis Model of Schizophrenia- Social Causation hypothesis

SOCIAL STATUSLIFE EVENTS/ TRAUMATIC EVENTSPHYSICAL TRAUMA/PHYSICAL ILLNESSMALNUTRITIONPOLLUTIONCROWDING

STRESS DIATHESIS MODEL

A person may have a specific vulnerability (diathesis) that, when acted on by a stressful influence, allows the symptoms of schizophrenia to develop.-integrates biological, psychosocial, and environmental factors.

SOCIAL CAUSATION HYPOTHESIS

The stresses experienced by members of low socioeconomic group contribute to the development of schizophrenia.

SOCIAL LEARNING THEORY:

A person can learn by imitating the behavior of another person, but personal factors are involved

.- relies on role models, identification, and human interactions.

THANK YOU & GOOD DAY