1. PREDISPOSING AND PRECIPITATING FACTORS TO MENTAL ILLNESS Hyacinth C. Manood. MD, FPPA

3. BIOLOGICAL GENETICS - many major psychiatric disorders have shown to have strong hereditary predispositions. Examples: Schizophrenia Bipolar Disorder and Major Depressive disorders first degree relatives – 8 – 18x monozygotic twins – 33-90% concordance Tourette’s Disorder – autosomal dominant

4. 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-ADRENAL Cushing’s Syndrome (inc. cortisol) > 50% mood disturbances > 10% psychosis and suicidal thoughts >cognitive impairments - Decreasing the cortisol level normalizes mood and mental status

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

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

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

8. 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

9. Chronic hypotyroidism – fatigue, decreased libido, memory impairment, irritability; suicidal ideation common. GROWTH HORMONE stressful experiences – decreased GH dec. GH – major depressive disorder and dysthymia ENDOGENOUS OPIOIDS - eating behavior MELATONIN – circadian phase disorders (jetlag) - increases speed of falling asleep OXYTOCIN – sex SUBSTANCE P - memory

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

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

12. PSYCHOLOGICAL FREUD STAGES OF PSYCHOSEXUAL DEVELOPMENT 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

13. ANAL STAGE (1 – 2) - a period of striving for independence and separation from dependence PATHOLOGICAL: Fixation – orderliness, obstinacy, stubbornness, willfulness, frugality, and parsimony If less effective – heightened ambivalence, lack of tidiness, messiness, defiance, rage ad sadomasochistic tendencies. URETHRAL STAGE (2 – 3) - transitional; issues of control and shaming

14. 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 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.

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

16. 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.

18. 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 INITIATIVE VS GUILT ( 3 – 5) - active and intrusive - Oedipus complex If excessive guilt – GAD and phobias Punishment or severe prohibitions – sexual inhibitions If oedipal conflict not resolved – conversion disorder; specific phobia

19. 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 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

20. INTIMACY VS ISOLATION (21-40) - successful formation of stable marriage and family GENERATIVITY VS STAGNATION (40-60) - establishing and guiding the next generation - depression - inc. substance use INTEGRITY VS DESPAIR - acceptance - Psychosomatic illnesses, Hypochondriasis, Depression - suicide rate is highest over age 65

21. SOCIAL FACTORS STRESS - Stress Diathesis Model of Schizophrenia - Social Causation hypothesis SOCIAL STATUS LIFE EVENTS/ TRAUMATIC EVENTS PHYSICAL TRAUMA/PHYSICAL ILLNESS MALNUTRITION POLLUTION CROWDING

22. 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.

23. SOCIAL CAUSATION HYPOTHESIS The stresses experienced by members of low socioeconomic group contribute to the development of schizophrenia.

24. 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.

25. THANK YOU & GOOD DAY