Etiology of Mental Disorders

Dr. Issam Bannoura MD JB Psychiatry Clinical tutor, Bethlehem Mental Hospital Psychiatrists are concerned with etiology in two ways: First, in everyday clinical work they try to discover the causes of the mental disorders. Second, for seeking a wider understanding of psychiatry. They are interested in etiological evidence obtained from clinical studies, community surveys, or laboratory investigations. In psychiatry the study of causation is complicated by two problems, the first is that causes are often remote in time from the effects that they produced the second is that a single cause may lead to several effects, conversely a single effect arise from several causes.

The classification of causes

1-predisposin factors: These are factor, many of them operating from early life that determines a persons vulnerability to causes, acting close to the time of the illness. They include genetic, environmental factors in utero, physical, psychological and social factors, in infancy and early childhood. For the etiology of individual case the personality is always an essential element. 2-precipitating factors: These are evens that occur shortly before the onset of a disorder, and appear to have induced it. They may be physical, psychological, and social factors, such as loss of job, moving home ----etc. 3-perpetuating factors: These factors prolong the causes of a disorder after it has been provoked, they may be social and personal factors, such as uncompliance with treatment, high emotional expression, and withdrawal from social activities.

The contribution of scientific disciplines to psychiatric etiology 1-Psychology:

Psychoanalysis arose from clinical experience, and not from work in the basic sciences. Freud originated the psychoanalysis, a central feature of his work, was the concept of the unconscious mind, and all mental processes originated their. According to Freud the unconscious mind had three characteristics that were important for the genesis of neuroses: A-it is divorced from reality: it tended to telescope situations and fantasies that were separated in time, these features were will illustrated, by dream analysis. The translation was affected by a series of mechanisms, such as condensation, displacement, and secondary elaboration.

B-the unconscious mind is dynamic: and contains impulses, these impulses were regarded as sexual, and aggression. Persons have to pass smoothly through psychosexual stage of development, oral anal and genital. If the libido became fixated at any stage, the person regress to such pattern under stress and this may determine the nature of neuroses that will develop later in life. C-there is struggle between unconscious and conscious mind: this conflict was regarded as giving rise to anxiety, and that could generate neurotic symptoms. one of the Freuds lasting contribution was his idea that anxiety, could be reduced by a variety of defense mechanisms. Mechanisms of defense: -Repression: is the exclusion from unconsciousness impulses, emotions, or memories that cause distress. -Denial: is inferred when a person behaves as if unaware of something that he may expected to know. -Displacement: is the transfer of emotions from a person, object, or situation with which it is associated, to a less patent source of distress. -Projection: is the attribution to another person of thoughts on feelings similar to ones own. -Regression: is the adoption of behavior appropriate to earlier stage of development. -Reaction formation: is the adoption of behavior opposite to behavior that would reflect true feelings and intentions. -Rationalization: is the unconscious provision of a false but acceptable explanation of behavior that has a less acceptable origin. -Sublimation: is the unconscious diversion of unacceptable impulses into more acceptable. -Identification: is the adoption of the characteristics or activities of another person, to reduce pain of separation or loss. A characteristic feature in the psychology is the idea of continuity between the normal and abnormal, and the interaction between the person and his environment. For the determining of normal behavior many psychodynamic theories were done: a. learning theory: this theory propose mechanisms by which experiences in childhood and later life give rise to neuroses. b. Behavior theory: Mowrer 1950 tried to resolve this neurotic paradox by proposing a two stage theory, first neutral stimuli become sources of anxiety through classical conditioning, and the second avoidance responses reduce the anxiety. c. Cognitive theory: Beck 1967 has proposed that depressed patients have pessimistic thoughts which consist of negative evaluation of self, world

and future and these develop automatic thoughts that may lead to depression . Automatics thoughts are: -arbitrary inference: drawing a conclusion -abstraction: focusing in detail -overgeneralization: drawing a general conclusion -personalization: relating to oneself

2-Etiological causes in the environment:

Many environmental factors may predispose persons to mental disorder, either directly or through their effect on family life, these conditions are: -poor living conditions -noise -working conditions -unemployment -prison -migration

3-Phisique and personality factors:

Kretchmer 1936 attempted to define psychological types, and link them to recognizable types of body build, pycknin (stocky and rounded), athletic (with strong development of muscles and bones), and asthenic (lean and narrow). He suggested that the pycknic body build was linked to the cyclothymic personality type, while the asthenic to schizotypal personality disorder, and he suggested an association between personality disorder and mental illness. There could be some less specific genetic connection between mental disorder, for example schizoid personality is considered to be partial expression of schizophrenia, and cycloid personality for manic depressive psychoses.

4-The study of early development and life events:

Many early environmental factors may play a major roll in the geneses of some mental disorders. Some of these factors are: pregnancy, health of mother during pregnancy, malnutrition of mother, prematurely, low birth weight, obstetric complication, cyanosis of the enfant, low abgar score, kernicteros, and any other postnatal difficulties. There are association between illness and certain kinds of events in persons life, the studies suggested that the risk of illness was greeted at periods of life change; e.g. residence, finance, departure of a person, loss, imprisonment, immigration. ------etc.

5-Causes within family:

It has been suggested that some mental disorders are an expression of emotional disorder within a whole family; as a result family problems are common among neurotic patients.

6-Social factors:
There have been studies that correlated between social class and certain mental disorders, thus schizophrenia is 11 times more frequent in social Class V than social class I, depression is more frequent in social class V and mania in social class I. The social class classified as the following: -social class I high professionals (doctors, politicians .etc.) -social class II low professionals (teachers, nurses .etc.) -social class III skilled workers. -social class IV semiskilled workers. -social class V unskilled workers

7-Genetic factors:
Genetic investigations are concerned with three issues; the contribution of genetic and environmental factors to etiology, the mode of inheritance, and the mechanism of inheritance. There are three studies that explain the roll of inheritance in mental disorders. -family studies: investigate the risk of psychiatric condition among the relatives of affected persons, and compares it with the expected risk in the general population. -twin studies: this investigation seeks to separate genetic and environmental influences, by comparing the concordance rate in MZ and DZ twins. If concordance for psychiatric disorder is substantially higher in MZ twins than in DZ twins, a major genetic component is presumed. -adoption studies: provide another useful method of separation genetic and environmental influences, and compared the frequency of the disorder between two groups of adopted people, the rate of illness is higher in persons if the biological parents are ill. The mode of inheritance may be monogenic or heterogenic, recessive, dominant, sex linked or mixed model. The studies have been successful in Alzheimer disease, and Huntington chorea. Attempts to study other psychiatric disorders in this way, have led to equivocal results, particularly schizophrenia and affective disorders.

8-Biochemical studies:
These studies can be directed either to the cause of the disease, or to the mechanism by which the disease produces its effects. Methods of biochemical investigations are too numerous, such as : levels of metabolite of neurotransmitter in CSF fluid, blood, and urine. Post-mortem studies, which identify the density of specific receptors, for example the density of dopamine receptors has been found to be increased in nucleus accumbens and caudate nucleus in schizophrenic patients. Studies of receptor bindings in different groups of patients, by using positron imaging, these methods include; magnetic resonance imaging MRI, positron emission tomography PET, single photon emission computerized tomography SPECT. These three methods may measure the regional blood flow, structure, energy and metabolism of the brain. There are three major types of neurotransmitters in the brain: -The biogenic amines -The amino acids -The peptides I The biogenic amines: The six biogenic amine neurotransmitters are ;dopamine D, adrenalin A, noradrenalin NA, serotonin S, acetylcholine Ach, and histamine H. -Dopamine: Dopamine, noradrenalin, and adrenalin are all synthesized from same amino acid precursor, Tyrosine. Serotonin is synthesized from precursor, Tryptophan Tyrosine + T.hidroxilase L. Dopa + LD decaboxilaze Dopamine. Dopamine (metabolism) +MAO or COMT HVA (homovanilic acid) The most important dopamine tracts are the nigrostriatal, the mezolimbic, and the tuberoinfundbular tract. It is metabolized to homovanilic acid, and its receptors are concentrated in the nucleus accumbens, and frontal cortex. It was suggested that dopamine secretion is high in schizophrenia. Dopamine may also involved in mood disorders, may be low in depression and high in mania. -Noradrenalin and adrenalin: they are synthesized from the same precursor Tyrosine Dopamine + dopamine B carboxylase Noradrenalin (NA) Noradrenalin (metabolism) +MAO 3M4HPG (3methoxy4hydroxy phenyl glycol) Adrenalin + PNMT(phenylN. Methyl transferase Adrenalin

The major concentration of NA and Adrenalin cell bodies in the brain, is in locus ceruleus in the bons. NA is involved in mood disorders and its secretion is low in depression and may be involved in other mental disorders. -Serotonin : Serotonin is synthesized from precursor tryptophan. Tryptophan (T) + T.hydroxilase 5HT (5hydroxytryptamin) 5HT (metabolism) + MAO 5HIAA (5 hydroxyindoloacetic acid ) The major site of serotonin cell bodies is in the median and dorsal raphe nuclei in the upper pons and the midbrain. Serotonin levels become low in depressive disorders, and may be involved in other psychiatric conditions such as anxiety and panic disorder. II Amino acids: Amino acid neurotransmitters are the most abundant in the brain, the major excitatory is Glutamate, and the inhibitory are GABA and Glicine. Glutamate has an excitatory effect in schizophrenia, and there is an association between benzodiazepines and GABA-ergic system and its potential role in pathogeneses of anxiety disorder. III Peptides: They may be 300 peptides in human brain; they are made in neuronal cell body. Selected peptide neurotransmitters are: endogenous opoids, substance P, cholesystokinin, somatostatin, vasopressin, and oxytocin.

9- Physiology:
Physiological methods can be used to investigate the cerebral and peripheral disturbance associated with disease state. Several methods have been used:-studies of cerebral blood flow in chronic organic syndromes. -EEG. -psychological methods. -pulse rate. -blood pressure and blood flow. -skin conductance. -evoke potentials.

10-Neuropathology:

Neuropathological studies attempt to answer the question, whether a structural change in the brain, localized or diffuse, accompanies a particular kind of mental illness? Such studies have an obvious application in the etiology of dementia, and some other mental disorders. It was showed and demonstrated the enlargement of the lateral ventricles in schizophrenia. The major brain areas implicated in mental disorders are the limbic structure, bazal ganglia, frontal lobe, thalamus, and the brain steam.

11-Endocrinilogy:
Changes in the concentration of the circulating hormones can have profound effects on mood and behavior. Hormones may alter brain function and have implication for pathophisiology of mental disorders, for example; the adrenal axis, thyroid axis, growth hormone, prolactin, and melatonin. Further reading:-Oxford textbook of psychiatry -Comrehensive textbook of psychiatry.