General aetiology and the

its therapeutic implications

September 2019
Learning outcome
At the end of this posting, students should be able to perform:

• Evaluation of the etiological factors involve in the development of psychiatric

illness including predisposing, precipitating & perpetuating factors
(bio-psycho-social model).

• Therapeutic principles from aetiological perspectives

References
1. Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen Tom
Burns and Mina Fazel, 7th ed (2018) Oxford University Press
2. Synopsis of Clinical Psychiatry by Benjamin J. Sadock & Virginia Alcott
Sadock,10th edition, (2015) Wolters Kluwer
Introduction
1. Important to know causes of psychiatric disorders
a. Scientific knowledge
b. Empathic understanding
c. Forming coherent account of patients, illnesses, predicaments
i. Etiological formulation
2. First reason - everyday clinical work - evaluate possible causes
3. Second reason - adds to general understanding of psychiatric disorders -
contribute to advances in diagnosis, treatment or prognosis
Case study 1
1. A 38-year old married man
2. Increasingly depressed for 4 weeks, wake-up early, gave up his usual
activities and spoke of suicide at times
3. Symptoms started after wife left him for another man
4. Other information
a. His mother had psychiatric treatments for severe depressive disorders and mania
b. No environmental causes
c. At 14-year old, mother lived with another man, children lived with father
d. Several years later - felt rejected and unhappy but settled down
e. Married and had 2 children; aged 13 and 10
5. Wife came back after 2 weeks and regretted, admitted her real love for him
6. Despite that - symptoms continues
Aetiology of individual patient
1. First draw knowledge of scientific studies of depressive disorders
2. Genetic studies -depression is probably genetically transmitted
3. Is separation from mother significant for this episode? Previous studies on
separation from parents
4. Extrapolation and clinical experience suggest importance
5. Separation from wife recapitulates the similar distressing experiences
6. Wife returning should improve the condition but it did not. This lack of
improvement can be explained by evidence that distressing events can
induce depressive disorder
The case illustrates issues on aetiology
1. Interaction of different causes in a single case
2. Different kind of cause
3. Concept of stress and psychological reaction to it
4. Role of scientific evidences
5. Empathy and common sense
Remote causes and multiple causes
1. Certain events in childhood associated with psychiatric disorders in adult
a. Eg Schizophrenia - more likely than controls to have been exposed to complications in
pregnancy and labour
2. One cause can lead to several effects
a. Eg Lack of parental affection in childhood reported to predispose to suicide, antisocial
behaviours and depressive disorders
3. Conversely, single effect can be caused by several causes, which act singly
or in combination
a. Eg Learning disability can be caused by several reasons, depressive disorders can be caused
by combination of genetic and recent stressful events
Classification of causes
Predisposing factors
1. When presence of multiple
causes
Constitution
a. Predisposing - determine
vulnerability to other causes, many
early in life, social and
psychological factors Precipitating ILLNESS
b. Precipitating - events occur shortly factors
before the onset and appear to
induce it - physical, psychological or Perpetuating
social - head injury - physical factors
changes, psychological effects etc
c. Perpetuating - prolong disorder after
it has begun, some features self
perpetuating eg thinking errors, RECOVERY/ CHRONICITY
overprotective attitudes
Etiological formulation - Case 1
Biological / Physical Psychological Social

Predisposing

Precipitating

Perpetuating
Brain function and interaction

Baker and Volkow; 2006; Hypothesis on brain function and addiction

COMPREHENSIVE?

BIOLOGY PSYCHOLOGY
SP
SOCIAL
SPIRITUAL
Case study 1
1. A 38-year old married man
2. Increasingly depressed for 4 weeks, wake-up early, gave up his usual
activities and spoke of suicide at times
3. Symptoms started after wife left him for another man
4. Other information
a. His mother had psychiatric treatments for severe depressive disorders and mania
b. No environmental causes
c. At 14-year old, mother lived with another man, children lived with father
d. Several years later - felt rejected and unhappy but settled down
e. Married and had 2 children; aged 13 and 10
5. Wife came back after 2 weeks and regretted, admitted her real love for him
6. Despite that - symptoms continues
Models in aetiology
1. Model - mean a way of ordering information
2. Seeks to explain certain phenomena ad to show relationships between them
3. It does so in a broad way and comprehensive that cannot be proved wrong by
carrying out experiment
4. Reductionist model - back to simpler and earlier stages, eg Schizophrenia
because of disordered neurotransmission in certain area of brain
5. Non-reductionist model - wider set of issues, neurosis contribute by
disordered family life
6. Medical model - approach to research eg organic psychiatry, schizophrenia,
severe affective disorders; less useful in neuroses and personality disorders
7. Behavioural model - approach to research - disorders are explained in terms
of factors that determine normal and abnormal behaviour; eg drives,
reinforcements, attitudes and beliefs and cultural influences
Cont - Behavioural model
a. Useful in neuroses and personality disorders
b. Can be reductionist - eg conditioning
c. Can be non-reductionist - eg social influences
Methodological approaches
1. Epidemiology
2. Genetic
3. Biochemical studies
4. Pharmacology
5. Endocrinology
6. Neuropathology
7. Electrophysiology
8. Psychology
9. Ethology
10. Sociology
1. Epidemiology
1. Study of distribution of diseases in space and time within a population
2. Also study of factors that influence this distribution
3. Used to provide information about prevalence (planning services) and
causation
4. Definition - case, rate, prevalence and incidence
5. Study design - case-control, cohort, prevalence (or cross-sectional),
ecological
2. Genetics
1. Concerned with 3 issues
a. Relative contributions of genetic and environmental factors in aetiology
b. Mode of inheritance of disorders that have genetic basis
c. Biochemical mechanism involved in hereditary disease
2. Epidemiological studies
a. Family risk studies - expectancy rates and morbid risks
b. Twin studies - concordance rates - eg twins reared apart - rates in reared apart vs together
c. Adoption studies - biological parent vs adopted parent; bias of SES; eg Schizophrenia,
Affective disorders
d. Mode of inheritance - dominant, recessive, sex-linked
3. Cellular and molecular genetics - information about chromosomal and genetic
abnormalities and mechanism of inheritance
a. Cytogenetic studies - identify abnormalities if structure or number of chromosomes eg
karyotyping
b. Linkage studies - identify chromosomal region likely to be carrying the responsible genes
c. Association studies - case-control studies
3. Biochemical studies
1. Difficult to carry out
a. Living brain is inaccesible to direct study and post-mortem tissue is not often available (most
disorders not lead to death). Indirect approaches - CSF, blood, urine - uncertain relationship
b. Animal study of limited use (useful for study of drug actions on brain)
c. Difficult to prove that biochemical changes are causal and not secondary to diet, activity
induced by mental disorders, or effects of drug
2. So far - post-mortem of brain studies are informative in Alzheimer disease
(transmitter function), schizophrenia (dopamine) and affective disorders
(serotonin)
3. Brain imaging techniques
a. Structural imaging techniques - eg CT (lateral ventricular enlargment in schizophrenia), MRI
(more subtle changes in schizophrenia)
b. Functional imaging techniques - PET (measure regional cerebral blood flow), SPET, fMRI
4. Pharmacology
1. If a drug alleviates disorder, and if a mode of action is known then it might be
able to infer possible biochemical abnormality
2. But not so direct
3. Effective drug do not always act on biochemical abnormality
5. Endocrinology
1. How hormonal activity on psychiatric patients eg cortisol increased in
depressed patients
2. Changes in endocrine function used as indirect measures of other process eg
endocrine abnormalities indicating reduced 5HT function in depressed
patients
6. Neurpathology
1. Post-mortem brain studies - useful in dementia and organic but not yet for
psychoses etc
7. Electrophysiology
1. Not much except for epilepsy
8. Psychology
1. Psychology is study of normal behaviour
2. Therefore important for study of abnormal behaviour
3. Good contribution in understanding anxiety disorders esp factors that
maintain the disorders not at the onset
a. Classical conditioning - learning through association
b. Operant conditioning - reinforcement of behaviour by its consequences
c. Cognitive processes aspects of ways patient select, interpret and act on information from
sense organs and memory stores. Knowledge of these leads to CBT etc
d. Coping mechanisms - ways people deals with stressors - adaptive vs maladaptive (eg
substance related)
i. Has 2 processes eg bereavement
1. Internal - thinking about religious beliefs, change the meaning attached
2. Observable behaviours - joining social clubs etc
9. Ethology
1. Concerned with observation and description of behaviour
2. Behaviour disorders of children
3. Provide quantitative observations that allows comparisons in people and
animals
4. Eg Effects of separating human infants and monkeys from mothers are similar
- both are distressed and active at first, then call less and adopt hunched
posture
5. Helps distinguished between innate and cultural determined aspects
10. Sociology
1. Study of human society
a. Social role - behaviour develops from others expectations, multitasking etc
b. Sick role - behaviour expected and required of ill person
c. Illness behaviour - behaviour of persons in sick role
d. Social class - schizophrenia and low social class
e. Life events - associated with onset and maintenance of illnesses
f. Culture - way of live shared by a group of human beings
g. Social mobility - change of role or status - downward drift - schizophrenia lead to downward
social mobility; upward mobility may lead to stress and adjustment
h. Migration - movement between societies - known to cause stress
i. Social institution - nucleus family, extended family, role of father, mother etc
j. Total institution - inmates spend time in one place, little freedom eg long stay psychiatry etc,
unduly ordered, repetitive and restrictive, lose initiatives, withdraw ito fantasy, rebel or
institutionalised
Evidenced based medicine
1. Textbooks - not up to date - newer revision
2. Guidelines - CPGs etc
3. Journals
4. Consensus
5. Case series
6. Opinions
Conclusion
1. Understanding of etiological formulation in psychiatry leads to proper
assessment and management
2. Evidence-based medicine is a practice
Q&A