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Etiology of mental disorder

Paul Thisayakorn, MD.

Etiology of mental disorder


How different between psychiatric disorder and other medical disorders? The Stress-diathesis model The Bio-Psycho-Social model The 4Ps model The integrative model for case formulation

How different between psychiatric disorder and other medical disorders?


Thai female, 22 y/o Complaint of Lt.side weakness ,numbness and progressive headache for 1 mo. Looked cachexia, febrile, cervical LN positive, oral thrush positive ,motor gr.III, decrease pinprick sensation,rt. Blood profile and CT show the abnormality Thai female , 22 y/o Her mother complaint of behavioral change (talk with herself, withdrawn, preoccupy about religion) for 1 mo. Poor hygiene, poor eye contact ,guarded, and said that she can contact to the ghost and god. She also thought that her friends poisoned her. PE: normal Blood profile and CT: normal

General approach
Problem list (sign& symptom) Psychiatric problems or not? What is the psychiatric syndrome? What is the DSM-IV diagnostic system? What are the causes of the syndrome? How to manage this syndrome?

Problem list (sign& symptom)


Consciousness Perception Mood & affect , anxiety Memory & cognition Thought (form & content) intelligence Motor behavior

Problem list (sign& symptom)


Disorder or not? Use your feeling Use your rationale Use criteria

Psychiatric S&S

Organic
CNS disease -encephalitis, meningitis, intracranial hemorrhage, trauma systemic disease - electrolyte imbalance, uremia, metabolic, endocrine , infection, hypertension, hypoglycemia drug / substance - Abuse , Dependence - Intoxication , Withdrawal - alcohol, amphetamine

functional
Psychotic disorder Mood disorder Anxiety disorder Somatoform disorder Dissociative disorder Personality disorder Adjustment disorder

What is the psychiatric syndrome?


Organic mental disorder Substance use disorder Psychotic disorder Mood disorder Anxiety disorder Somatoform disorder Dissociative disorder Personality disorder Adjustment disorder

hierarchy

What is the DSM-IV diagnostic system?


Syndromal approach Diagnostic criteria Axis I Axis V

Etiology of mental disorder :The history


Superstitious, supernatural Black bile melancholia Unknown neurological symptom hysterical conversion Freud intrapsychic problem The emerging of neurotrophic drug and other modern knowledge But we still can not completely explain the etiology of the mental disorder!!!

The Stress-diathesis model


A person may have a specific vulnerability (diathesis) When acted on by a stressful influence develop a psychiatric symptom The difference between individual, character of

stress loss of balance

The Bio-Psycho-Social model


The diathesis or the stress can be
biological, psychosocial, environmental or both

Combination of these 3 factors disorder The difference between the severity of Bio-Psycho-Social factors in each person

The Bio-Psycho-Social model


Genetic factor ; heterogeneous genetic basis for some mental problems

ex. Alzheimers dementia, Substance use disorder, Schizophrenia, Mood disorders, even homosexuality!!!

The Bio-Psycho-Social model


Neuropathology - neuroanatomy and neuroimaging :
frontal lobe, temporal lobe, limbic system (ex.amygdala,hippocampus), fronto-subcortical circuit etc.

- developmental-degenerative process :
childhood mental disorder, Schizophrenia as the dementia precox, psychotic symptoms in dementia pt.

Neuropathology

The Bio-Psycho-Social model


Neuropathology -neurophysiology ; electrophysiology (psychiatric
symptoms in epilepsy, limbic kindling in Bipolar disorder), abnormal sleep-wake cycle in mood disorder

-neurochemistry (neurotransmitter : DA, NE, 5HT, Ach, GABA) ; Dopamine hypothesis in


Schizophrenia, Catecholamine abnormality in MDD, decrease of Ach in AD, etc., the efficacy of psychotropic drugs, the effect of substance use

The Bio-Psycho-Social model


Neuropathology
-neuroendocrinology ; cortisol level in chronic
stress person, Hypo-hyperthyroid cause the mental change, Sex hormone related to premenstrualpostpartum symptoms

-neuroimmunology ; stress and immune response


(eg. academic stress during final exam among medical students low NK cell activity), psychiatric manifestation in SLE, MS

The Bio-Psycho-Social model


Psychological cause -psychoanalytic theory : topographic theory
(unconscious-preconcious-concious), structural theory (Id-Ego-Superego), Eriksons 8 stages of life cycles

-cognitive-behavioral theory :
stimuli sensation perception thinking emotion behavior ex. Cognitive triad in depression

The Bio-Psycho-Social model


Psychological cause -Existential-humanistic theory ; ex.
loss of meaning of life suicide , end of life situation depression, Satirs model

-Personality theory ; ex.


:Schizotypal PD (A) vs. schizophrenia :Antisocial PD (B) vs. alcohol use :Borderline PD (B) vs. mood disorder :Histrionic PD (B) vs. somatization disorder :Avoidant PD (C) vs. anxiety disorder

Behavior Feeling
Thought & perception

Expectation Yearning self

The Bio-Psycho-Social model


Social cause -Socioeconomic and cultural factors
; a disproportionate number of schizophrenia pts. are in the low socioeconomic groups (contrastively to Bipolar disorder). ; Social stressors in urban settings affect the development of schizophrenia in persons at risk. ; The stress of immigration delusional disorder ; single status as a risk of suicide

The Bio-Psycho-Social model


Family dynamic ; high expressed emotion in family
high relapse rate, the impact of family problem to the child (eg. Divorce , loss of parent) , the formation of gender identity and role etc.

Learning theory (classical conditioning,


operant conditioning, social learning theory) ex.
Phobia & PTSD, learned helplessness vs. depression, aggressive social behavior vs. aggression in children

The 4Ps model


There are many factors along ones lifetime that may contribute to the mental disorder.

Predisposing factors Precipitating factors Perpetuating factors Protective factors

The 4Ps model

Precipitating Protective

Purpetuating Predisposing

The case formulation


4Ps X Bio-Psycho-Social case formulation
Predisposing Precipitating Perpetuating Protective

Bio Psycho Social

The case formulation


Predisposing Precipitating Perpetuating Protective

Bio

Psycho

Social

Conclusion
There are many factors that cause the mental disorder One specific factor can not completely explain these illnesses. Stress-diathesis model + Bio-Psycho-Social model + 4Ps model help us understand the etiologies of the psychiatric disorders.