Psychiatry TRANS NO.

1 (2nd Sem) 2019

 ‘‘Distress”: uncomfortable feeling related to the nature of

I L OI L O DO C T O RS ’ C O LL E GE O F ME D I CI N E
Molo, Iloilo City
the stressor and the degree to which the individual feels a
S.Y. 2018-2019 lack of ability to influence or control the stressor.
 Example: Death of a close friend? Failing in a periodic
BATCH 2021
DISCIMUS SAPIENCIA UT VIRTUS exam ?break-up

TOXIC STRESS
PSYCHIATRY  Bad things happen to an individual who has limited
BLOCK 1
support and who may also have brain architecture that
reflects effects of adverse early life events that have
L E CT U RE R: DR. DIOS DA DO V. A MA RGO JR.
impaired the development of good impulse control and
MAIN TOPIC: STRESS AND ADAPTATION judgment and adequate self-esteem.
(JANUARY 9, 2019)  Degree and/or duration of ‘‘distress’’ may be greater.
 Inability to cope is likely to have adverse effects on
Outline behavior and physiology
I. Stress  Acute Stress: Traumatic Incident
II. Four-Fold Symptomatology of Stress  Chronic Stress: low intensity, prolonged time (being a med
III. Hans Selye
student?)
IV. Bruce McEwen
V. Key Role of Excitatory Amino Acids
VI. Life Course and the Epigenetics of Individual Differences RESPONSES
VII. Sex Differences in the Brain  Appraisal of PERCEIVED threat invoke coping responses
(Lazarus & Folkman 1984).
STRESSED OR STRESSED OUT?  CNS produce integrated coping responses rather than
single, isolated response (Hilton 1975).
 Immediate fight-or-flight
What is the difference?
o increased autonomic and hormonal activities that
maximize the possibilities for muscular exertion
STRESS
(Cannon 1929, Hess 1957).
“Stress is a word that is as useful as a Visa card and as
 Aversive situations /vigilance response
satisfying as a Coke. It’s noncommittal and also
o sympathetic nervous system (SNS) arousal with active
noncommitable.”
inhibition of movement and shunting of blood away
from the periphery (Adams et al. 1968).
GOOD STRESS
 Experience of rising to a challenge, taking a risk and feeling
RESPONSE STEREOTYPY
rewarded by an often positive outcome.
 “Situational stereotypy”
 ‘‘Eustress.’’
o different patterns of biologic response to stimuli
 Good self-esteem and good impulse control and decision
(Lacey 1967)
making capability, all functions of a healthy architecture of
 Response Stereotypy
the brain
o Tendency to exhibit a particular pattern of stress
 Adverse outcomes can be ‘‘growth experiences’’: positive,
responses across a variety of stressors (Lacey & Lacey
adaptive characteristics that promote resilience in the face
1958).
of adversity.
 Individuality of stress response
 Example: Set Goals/Objectives, ?Falling in Love
o some with active coping, others with aversive
vigilance (Kasprowicz et al. 1990, Llabre et al. 1998)
TOLERABLE STRESS
 Bad things happen, but individual is able to cope, often
with the support of family, friends and other individuals.
 Adverse outcomes can be ‘‘growth experiences’’

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

FOUR-FOLD SYMPTOMATOLOGY OFSTRESS

COGNITIVE SYMPTOMS
 Memory problems
 Inability to concentrate
 Poor judgment
 Seeing only the negative
 Anxious or racing thoughts
 Constant worrying

EMOTIONAL SYMPTOMS
 Moodiness
 Irritability or short temper
 Agitation, inability to relax
 Feeling overwhelmed ALARM
 Sense of loneliness and isolation  Goal: Restore Homeostasis
 Depression or general unhappiness  fright→ fight or flight response
o the body's resistance to physical damage drops for a
PHYSICAL SYMPTOMS short-time so that organism can rearrange its
 Aches and pains priorities to cope with the stressor
 Diarrhea or constipation o use of available body sources for energy (glycogen),
 Nausea, dizziness redistribution of blood to maintain higher blood
 Chest pain, rapid heartbeat pressure by increase of the peripheral resistance,
 Loss of sex drive increased oxygenation by bronchodilation, increased
muscle, coronary and brain perfusion in order to act
 Frequent colds
 if the stressor no longer exists the body returns to its
BEHAVIORAL SYMPTOMS normal level of resistance
 Eating more or less
 Sleeping too much or too little
 Isolating yourself from others
 Procrastinating or neglecting responsibilities
 Using alcohol, cigarettes, or drugs to relax
 Nervous habits (e.g. nail biting, pacing)

HANS SELYE (GAS)

HANS SELYE
“Stress is anything that seriously threatens homeostasis”

GENERAL ADAPTATION SYNDROME

 Utilized the emergency reaction of :
o sympathetic nervous system
o adrenocortical system
 “Fight or Flight response”

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

STAGE OF RESISTANCE
 Increased energetic demands must be met by metabolism
increasing availability of Glc and FFA
 mainly via regulation of hepatic gluconeogenesis and
adipose tissue lipolysis
 also, optimalisation of the survival following trauma or
infection is achieved by alterations of immune function
o suppression of adaptive immunity
o activation of certain parts of innate immunity, while
suppressing the others
 there are many non-metabolic, non-immune effects of GC
which are desirable in short term prospect but become
adverse in long-term

Tissue/ Organ Physiologic effects Effects of

overproduction
Bone and ↓ osteoblast action and osteoporosis
connective bone formation vs.
tissue ↑osteoclast action and
bone resorption
↓ collagen synthesis and Osteoporosis,
proteolysis poor wound
healing, easy
bruising, thin
skin
GIT ↓calcium absorption Osteoporosis
↑ gastric juice secretion, ↓ Stress- induced
mucus secretion peptic ulcer
Kidney ↑ Na retention Hypertension,
(glucocorticoid-activated hypokalemia
kinase, ↑ Na channel and
angiotensin expression
(liver)
Bone marrow ↑erythrocyte and PMN Polyglobulla,
maturation granulocytosis
Reproductive Supression of production of Oligomerhea,
system estradiol and testosterone infertility
RESISTANCE Behavior Expression of GR in Post-traumatic
 Characteristic: sustained and optimal defense and hippocampus →genomic stress disorder,
adaptation and non-genomic action (↑ “burn-out”
 if the stressor persists (“we can't fight or flee from it or, glutamate, Ca serotonin, depression,
rather, we are unable to apply counteracting psychosocial opiates..), NE from LC anxiety
resources”), level of resistance increases beyond normal, Fetal and Surfactant and fetal lung Fetal lung
relaxed levels → quite energy-consuming state neonatal maturity; fetal hepatic and immaturity
 increased energy demands covered by adipo- and development gastrointestinal enzyme
proteocatabolism, blood pressure maintained by Na systems
retention, …

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

METABOLIC EFFECTS OF GC Pancreas ↓insulin secretion Impaired glucose

 Increased turnover of free and stored substrates (beta (suppression of GLUT2 torabce/ diabetes
cell) and K channel, mellitus
Tissue/ Physiologic effects Effects of apoptosis)
Organ overproduction
Liver ↑Hepatic Impaired glucose
gluconeogenesis tolerabce/ diabetes GC AND IMMUNE SYSTEM
(↑Glc) mellitus  Glucocorticoid effect on primary and secondary
(stimulation of key immune cells
enzymes- pyruvate
carboxylase, PEPCK, Monocytes/ ↓ Number of circulating cells (↓
G6Pase) macrophages myelopoiesis, ↓ release)
Hepatic lipogenesis Steatosis/steatohepatitis ↓expression of MHC class II molecules
(↑FA and VLDL) and Fc receptor
(stimulation of key ↓ sysntheis of pro-inflammatory cytokines
enzymes acetyl-CoA- (eg. IL-1, -2, -6, TNFa) and prostaglandin
Carboxylase and FA T cells ↓ Number of circulating cells
synthase (redistribution effect)
↓production and action of IL-2(most
Adipose ↑lipolysis in Insulin resistance in the important)
tissue subcutaneous fat(↑) muscle (competition of Granulocytes ↑Number of circulating Neutrophils
(activation of HSL and FFA with Glc for ↓Number of eosinophils and basophils
inhibition of LPL) oxidation) granulocytes
Endothelial cells ↓ vessel permeability
↓Glc uptake Insulin resistance by ↓ expression of adhesion molecule
(down-regulation of interference with insulin ↓production of IL-1 and prostaglandin
IRS, inhibition of PI3K, post- receptor signaling Fibroblast ↓ proliferation
Glut4 translocation)
↓ production of Fibronectin and
↑adipocyte Truncal (abdominal0
prostaglandin
differentiation in obesity, metabolic
visceral fat syndrome
(expression of GR and
EXHAUSTION
11ßHSd1 different I
 Characteristic: Adaptive response ceases
adipose and visceral
 body resistance collapses due to the inability to meet
fat
energy demands and due to side effects of extreme or
exaggerated stress reactions → diseases of adaptation
Skeletal ↓Glc uptake Insulin resistance by
 extreme catabolism, immunodeficiency, cardiovascular
muscle (down-regulation of interference with insulin
 consequences of metabolic derangements Consequence:
IRS, inhibition of PI3K, post- receptor signaling
Illness and Death
Glut4 translocation)
↑proteolysis, ↓ Muscle atrophy,
proteosyntheis (↑AA) weakness, steroid
(counteracting effect myopathy BRUCE MCEWEN
of IGFs, activation of
ubiquitin-mediated BRUCE MCEWEN
degradation,  American neuroendocrinologist
induction of myostatin  Harold and Margaret Milliken Hatch Laboratory of
and glutamine Neuroendocrinology at Rockefeller University.
synthesis)

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REDEFINING GAS
 GAS is no longer interpreted to mean that all types of
stress evoke the same stereotyped response of the stress
mediators
 The hypothalamic–pituitary–adrenal (HPA) axis and the
noradrenergic and adrenergic nerves have different
patterns of response that are related to the type of
stressor.
 Then “fight or flight” response does not apply equally to
both sexes
o Female response to non-life threatening stress has
been characterized as “tend-and-befriend,” not “fight
or flight.”
o Not only differing perceptions of and behavioral
responses to stressors, but also physiologic
differences in the regulation of mediators
REDEFINING GAS
 Third stage needs reinterpretation
o Stress mediators can have both protective
and damaging effects, depending on the time
course of their secretion.
o Rather than problems being caused by an
exhaustion of defence mechanisms, it is the
stress mediators themselves that can turn on
the body and cause problems.
DEFINING ALLOSTASIS
 Homeostasis, the stability of the physiologic systems
that maintain life.
o limited number of physiologic variables (end
points)
o pH, body temperature, glucose levels and
oxygen tension
o truly essential for life and that are therefore
maintained within a narrow range of their
respective set-points.
 These set-points and other boundaries of control may
themselves change with environmental conditions;
however, these changes cannot be explained solely by
the notion of homeostasis.
 Allostasis : superordinate system by which stability is
achieved through change.
 Primary mediators
o hormones of the HPA axis, catecholamines
and cytokines.
 Systems that are essential for life (homeostasis)
 Those that maintain these systems in balance
(allostasis)
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ALLOSTATIC STATE
 Results in an imbalance of the primary mediators,
reflecting excessive production of some and
inadequate production of others.
 Some examples of allostatic states
o chronic hypertension
o a flattened cortisol rhythm in major
depression or after chronic sleep
deprivation
o chronic elevation of inflammatory
cytokines accompanied by low cortisol in
chronic fatigue syndrome
o Lower cortisol, higher corticotropin-
releasing factor and elevated cytokines
associated with increased risk for
autoimmune and inflammatory disorders
 Allostatic state: altered and sustained activity
levels of the primary mediators (e.g.,
glucocorticosteroids) that integrate energetic
and associated behaviours in response to
changing environments and challenges such as
social interactions, weather, disease, predators
and pollution.
LOAD/OVERLOAD
 Allostatic states can produce wear and tear on the
regulatory systems in the brain and body.
 “allostatic load” / “allostatic overload” : cumulative
results of an allostatic state
 Allostatic overload serves no useful purpose and
predisposes the individual to disease.
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SELYE REINTERPRETED
 Alarm response : process leading to adaptation, or
allostasis
o glucocorticoids and epinephrine, as well as
other mediators
 Resistance : protective effects of the adaptation to the
stressor.
 Exhaustion: allostatic overload
o glucocorticoids and catecholamines is
repeatedly elevated
o inevitable wear and tear produced by
repeated exposure to mediators
 Selye’s diseases of adaptation are the result of the
allostatic state leading to allostatic overload and
resulting in the exacerbation of pathophysiologic
change.
“PROTECTION VS DAMAGE”
 Individual Responses on challenges of daily life:
o Adaptation and protection via allostasis
o wear-and-tear on the body and brain via
allostatic load/overload
 ‘‘protection vs. damage’’
o E.g. Immune system
 acute stressor activates an acquired
immune response via mediation by
catecholamines and glucocorticoids
and locally produced immune
mediators
 chronic exposure to the same
stressor over several weeks has the
opposite effect and results in
immune suppression.
HEALTH-PROMOTING AND HEALTH DAMAGING BEHAVIORS
 Sense of control and mindset determines whether or
not the response to experiences can have a successful
outcome or may lead to allostatic overload
 Common stressor may cause us to behave in certain
ways
 Being ‘‘stressed out’’
o may cause us to be anxious and or
depressed, to lose sleep at night, to eat
comfort foods and take in more calories than
our bodies need, and to smoke or drink
alcohol excessively.
o may also cause us to neglect seeing friends,
or to take time off from our work, or reduce
our engagement in regular physical activity as
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Psychiatry TRANS NO. 1 (2nd Sem) 2019
we, for example, sit at a computer and try to
get out from under the burden of too much
to do.
o Tempted to take medications
CENTRAL ROLE OF THE BRAIN
 CNS
o Interprets “stress”
o Changes in architecture, molecular profile
and neurochemistry : directs many systems
of the body—metabolic, cardiovascular and
immune
 Healthy Brain
o Neural circuits in are remodeled by
experiences
o Circuitry adapts to a new situation along with
underlying changes in gene expression
 Unhealthy brain
o May not be so plastic, or it may have
maladaptive circuitry or plasticity and, as a
result, is less able to adapt appropriately or
likely to ‘‘get stuck.’’
o Excessive activation of excitatory amino
acids, potentiated by glucocorticoids,
irreversible damage occurs
ADRENAL STEROID RECEPTORS IN HIPPOCAMPUS
 Discovery of glucocorticoid and mineralocorticoid
receptors in the hippocampal formation : gateway to
understanding how systemic hormones affect higher
brain functions.
 Hippocampal formation : episodic and spatial memory
and mood regulation
 Neurogenesis in dentate gyrus: functional role of
neuronal replacement in the adult brain
BRAIN CHANGES WITH STRESS
 Hippocampus : dendritic shrinkage and loss of spines.
 Amygdala
o Acute stress :increased spine density on
basolateral amygdale (BlA) neurons
o Chronic stress :expansion of BlA dendrites;
loss of spines and shrinkage of dendrites of
medial amygdala.
 Implicated in increased anxiety and in posttraumatic
stress disorder (PTSD)-like behaviors, as well as social
avoidance as in social defeat
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 Prefrontal Cortex
o Chronic stress : debranching and shrinkage of
dendrites in medial PFC (mPFC) neurons
 Orbitofrontal cortical neurons:
o Expanded dendrites : increased vigilance
o Dendritic shrinkage : cognitive rigidity
 Clues to age related loss of resilience; impaired
memory ; effects of circadian disruption and
extinction of fear memory.
GLUCOCORTICOID EFFECTS IN BRAIN
 Genomic and non-genomic
o Biphasic effects
o Directly stimulate release of excitatory amino
acids via membrane-associated receptors
o indirectly regulate both glutamate and GABA
release via their ability to induce local
synthesis of endocannabinoids
o translocate GR to mitochondria where they
promote Ca++ sequestration and regulate
mitochondrial gene expression
o high glucocorticoid levels cause a failure of
this mechanism and lead to increase free-
radical formation
 Genetically induced overexpression of GR in forebrain:
o increased ability of mood related behaviors
o confers greater responsiveness to
antidepressant drugs
 Underexpression of GR : opposite effect.
 Increased CpG methylation within the GR promotor :
sluggish HPA stress response : associated with early
life abuse in human suicide victims.
 Timing is important:
o protective role for adequate glucocorticoid
levels at time of trauma on PTSD
o repeated high dose glucocorticoids
treatment mimics chronic stress and induces
dendritic lengthening in BlA.
GLUCOCORTICOIDS EFFECT
 Glucocorticoids program cellular circadian clocks in
brain and in liver leading
o dissonance between brain regions
o obesity and metabolic syndrome
STRESS, BDNF AND BRAIN ATROPHY
 Brain-derived neurotrophic factor (BDNF)
o sustains the viability of brain neurons
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o under stress, the gene for BDNF may be
repressed
 Stress can lower 5HT levels and can acutely increase,
then chronically deplete, bothNE and DA.
 Monoamine changes with deficient amounts of BDNF
may lead to atrophy and possible apoptosis in the
hippocampus and other brain areas such as prefrontal
cortex
APOPTOSIS
 If the genes for BDNF are turned off (left), the
resultant decrease in BDNF could compromise the
brain’s ability to create and maintain neurons and
their connections.
 This could lead to loss of synapses or even whole
neurons by apoptosis.
KEY ROLE OF EXCITATO RY AMINO ACIDS
GLUTAMATE
 Major excitatory transmitter: excess causes damage
and inflammation
 Chronic stress:
o shrinkage of apical dendrites of hippocampal
CA3 neurons
o Dentate gyrus neurons of hippocampus
o Medial amygdala and mPFC
 excess glutamatergic activity, without adequate
reuptake in the aftermath of trauma from seizures,
ischemia and head trauma, leads to the permanent
neuronal loss by a process that is exacerbated by
glucocorticoids
 Unregulated overflow of glutamate: depressive-like
behaviour; aging and dementia
INSULIN RESISTANCE IN THE BRAIN AND EXCITATORY AMINO
ACIDS
 Insulin resistance
o disrupted memory and executive function
o Corresponding metabolic decline in the
mPFC,
o Reductions in hippocampal volumes
o Aberrant intrinsic connectivity between the
hippocampus and mPFC
 Antisense inactivation of insulin receptor in
hippocampus
o cognitive impairment without systemic
consequences
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 Antisense inactivation of insulin receptor in
hypothalamus
o systemic insulin resistance and dyslipidemia
o Insulin resistance the hippocampus
o Depressive-like behaviour and cognitive
impairment
 Changes induced in hypothalamus are reversed by
dietary restriction (brain can be resilient)
LIFE COURSE AND THE EPIGENETICS OF INDIV IDUAL
DIFFERENCES
EPIGENETICS
 Gene-environment interactions: key to how the brain
develops and changes with experience
 Epigenetics
o Important role of the social and physical
environment in shaping the brain and body
over the life course.
o Mechanistically it refers to events “above
genome” that regulate expression of genetic
information without altering the DNA
sequence.
 CpG methylation
 Histone modifications that repress
or activate chromatin unfolding
 Actions of non-coding RNA’s
 Transposons and retrotransposons
 RNA editing
LIFE COURSE AND THE EPIGENETICS
 Individual traits: buily upon experiences in the life
course, particularly those early in life
 Results in healthy/unhealthy brain architecture and
epigenetic regulation that promotes or fails to
promote gene expression responses to new
challenges
 genetically identical individual differ: length of
dendrites in the prefrontal cortex to differences in MR
levels in hippocampus; locomotor activity and
neurogenesis rates; and the influences that lead to
those differences begin early in life
 For example, identical twins diverge over the life
course in patterns of CpG methylation of their DNA
reflecting the influence of “non-shared” experiences
 Early life events related to parental care: powerful
role in later mental and physical health
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Psychiatry TRANS NO. 1 (2nd Sem) 2019
 Adverse childhood experiences (ACE) studies,
o “neonatal handling” (Levine and Denenberg)
o Methylation of CpG residues in DNA
(Meaney, Syzf and colleagues)
o Epigenetic trans generational effects
transmitted by maternal care: anxiety-like
phenotype detected in adolescence predicts
not only a consistent anxiety phenotype but
also shorter lifespan
 Consistency of care over time and exposure to novelty
 Prenatal stress and adolescent stress: impairs
hippocampal development
 Insufficient maternal care (Rice et al) and the
surprising attachment shown by infant rats to their
less attentive mothers: involve an immature amygdale
o Activation of which by glucocorticoids causes
an aversive conditioning reponse
 Maternal anxiety leads to chronic anxiety of the
offspring, as well as signs of metabolic syndrome
 Genetic factors also play an important role
 Different alleles of commonly occurring genes
determine how individuals will respond to
experiences
 Short form of the serotonin transporter: alcoholism
and vulnerable to respond to stressful experiences by
developing depressive illness
 Individual with monoamine oxidase A alleles:
vulnerable to abuse in childhood and more likely
themselves to become abusers and to show antisocial
behaviors
 Same alleles in positive, nurturing environment may
lead to successful outcomes (Suomi and by Tom Boyce
and colleagues): called them “reactive or context-
sensitive alleles” rather than “bad genes’’
SEX DIFFERENCES IN THE BRAIN
MALES VS FEMALES
 Rodent studies:
o Females do not show the same pattern of
neural remodelling after chronic stress
o hippocampus: remodelinf of CA3 dendrites
did not occur in females after chronic
restraint stress (CRS)
o Cognitive consequences of repeated stress:
males showing impairment of hippocampal
dependent memory
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o Acute tail shock stress during classical eye
blink conditioning improves performance in
males: mechanisms influenced by gonadal
hormones
SEX DIFFERENCES
 Gonadal hormone:
o ovariectomy prevented CRS effects on
dendritic length and branching
o estradiol treatment of ovariectomized (OVX)
females increased spine density in mPFC
neurons, irrespective of where they were
projecting
 Sex: differences: mediate how males and females
interpret stressful stimuli and that a sense of control
is paramount to coping with those stimuli
WHEN THINGS GO WRONG OVER THE LIFE COURSE
ADVERSE CHILDHOOD EXPERIENCES
 ACE
o powerful effect on lifelong trajectories of
health and disease
o Poverty creates circumstances for ACE
 Increased inflammatory tone, not only in children but
also in young adults related to early life abuse
o includes chronic harsh language, as well as
physical and sexual abuse
LOW SES
 increase the likelihood of stressors in the home and
neighbourhood, including also exposure to toxic
chemical agents such as lead and air pollution, chaos
in the home is associated with development of poor
self-regulatory behaviors, as well as obesity.
 Deficient in language, skills, as well as self-regulatory
behaviors, and also in certain types of memory that
are likely to be reflections of impaired development of
parasylvian gyrus language centers, prefrontal cortical
systems and temporal lobe memory systems
 Correlate with smaller hippocampal volumes;
reduction in prefrontal cortical systems and temporal
lobe memory systems
 Correlate with smaller hippocampal volumes;
reduction in prefrontal cortical gray matter; greater
amygdala reactivity to angry and sad faces
(predisposing factor for early cardiovascular disease)
 Depression high in low SES, and children of depressed
mothers have increased amygdala volume while
hippocampal volume was not affected
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REACTIVE ALLELES
 Nurturing environments facilitate beneficial outcomes
 Allostatic processes are adjusted via epigenetic
influences
 “Trade –offs” (Jackson et al)
o increase the likelihood of passing on one’s
genes by improving coping with adversity and
enhancing mental health and overall
reproductive success,
o Or may impair later health, e.g., by eating of
“comfort foods”
CENTRAL ROLE OF THE BRAIN
SO WHAT CAN BE DONE ABOUT BEING “STRESSED
OUT?”
REDIRECTION
 The social and physical environments ‘‘get under the
skin’’ and shape the brain and body.
 There is no such thing as ‘‘reversibility’’ (i.e., ‘‘rolling
the clock back’’)
 But rather a change in trajectory in keeping with the
original definition of epigenetics as the emergence of
characteristics not previously evident or even
predictable from an earlier developmental stage.
 ‘‘redirection’’ instead of ‘’reversibility’’
 Health Policies
 Incentives at home and work
 Community services that encourage individuals to
learn tools that help them develop beneficial
individual lifestyle practices.
 Education is essential as is providing some sense of
economic security via a social safety net.
 Individual stand point
o Imptove sleep quality and quantity
o Improve social support and promote a
positive outlook on life
o maintain a healthy diet
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o avoid smoking and have regular moderate
physical activity.
CHANGING TRAJECTORIES
 To change trajectories of mental and physical health
o Behavioral therapies
o Treatments, including pharmaceutical agents,
that ‘‘open up windows of plasticity’’ in the
Brain
 Major challenge throughout the life
o Find ways of redirecting future behavior and
physiology in more positive and healthy
directions
o Easier said than done
o Represents an important challenge for the
future to increase ‘‘healthspan’’ and promote
full enjoyment of life and also to reduce the
financial burden of disease and disability on
the individual and on society
STRESS MANAGEMENT TECHNIQUES
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THE FIVE PRECEPTS
I undertake to observe the rule:
1. to abstain from taking life
2. to abstain from taking what is not given
3. to abstain from sensuous misconduct
4. to abstain from false speech
5. to abstain from intoxicants as tending to cloud the
mind
THE TEN COMMANDMENTS
1. I am the LORD thy God, No other gods before me
2. No graven images or likenesses
3. Not take the LORD's name in vain
4. Remember the sabbath day
5. Honour thy father and thy mother
6. Thou shalt not kill
7. Thou shalt not commit adultery
8. Thou shalt not steal
9. Thou shalt not bear false witness
10. Thou shalt not covet
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I L OI L O DO C T O RS ’ C O LL E GE O F ME D I CI N E
Molo, Iloilo City
S.Y. 2018-2019
BATCH 2021
DISCIMUS SAPIENCIA UT VIRTUS
PSYCHIATRY
BLOCK 1
L E CT U RE R: DR. VAL E RIA A NDO RA - QU IL AT ON
MAIN TOPIC: PSYCHODYNAMIC THEORIES
KANDEL AND APLYSIA
“Synaptic connections can be permanently altered and
strengthened through the regulation of gene
expression when learning takes place.”
PSYCHOTHERAPY IS A TREATMENT!
 Equal in efficacy with psychiatric medications
 Subgroup most effective includes those with
 History of childhood trauma (physical or sexual)
 Neglect
 Loss of parents at an early age
PSYCHODYNAMIC PSYCHOTHERAPY
 Term referring to a range of therapeutic strategies
 Underpinned by various theoretical models
 Designed to treat psychological disorders
PSYCHODYNAMIC THEORIES
 Common factors:
 Mental processes interaction generate problems in
experience and behavior.
 Aims to strengthen patient’s ability to understand
motivations for and meaning of their and other’s
experience, behavior, and relationships.
DIFFERENT PSYCHODYNAMIC THEORIES:
I. EGO PSYCHOLOGY
 Developed by Freud
 Erik Erikson’s contribution
developmental scheme
Assumptions:
1. The existence of the Unconscious
2. The Intrapsychic world is always in conflict
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Psychiatry TRANS NO. 1 (2nd Sem) 2019
3. Defense mechanisms are activated to lower anxiety
produced by conflict
4. Development is epigenetic linked with oral, anal,
phallic libidinal zones
STRUCTURAL MODEL OF THE MIND
COMPROMISE FORMATION
 Contains the original wish and defense mechanism
against the wish
 Makes up the patient’s character and his traits
 Treatment using ego psychology focuses on:
 Analysis of defenses
 Dealing with resistances
HIERARCHY OF DEFENSE MECHANISMS
1. PRIMITIVE DEFENSES
 Splitting
 In splitting, persons toward whom patients’
feelings are, or have been, ambivalent are divided
into good and bad.
 Projection
 In projection, patients attribute their own
unacknowledged feelings to others.
 Projective Identification
 Mainly in borderline personality
 Disorder and consists of three steps.
 First, an aspect of the self is projected onto
someone else.
 The projector then tries to coerce the other
person into identifying with what has been
projected.
 Finally, the recipient of the projection and the
projector feel a sense of oneness or union.
 Denial
on epigenetic
 Existence of unpleasant realities is disavowed;
 Refers to keeping out of conscious awareness any
aspects of external reality that, if acknowledged,
would produce anxiety.
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 Distortion
 A gross reshaping of external reality to meet
internal needs.
 Dissociation
 Replacement of unpleasant affects with pleasant
ones.
 Idealization
 Involves creating an ideal impression of a person,
place or object by emphasizing their positive
qualities and neglecting those that are negative.
 People often idealize their recollections of being
on holiday or memories from childhood, seeing
them as ‘happier times’, but fail to recollect
arguments or stresses during those periods.
 We often idealize the image we hold of people we
admire - relatives, partners or celebrities, making
excuses for their failures and emphasizing their
more admirable qualities.
 Acting out
 Patients directly express unconscious wishes or
conflicts through action to avoid being conscious
of either the accompanying idea or the affect.
 Tantrums, apparently motiveless assaults, child
abuse, and pleasureless promiscuity are common
examples.
 Somatization
 Occurs when the internal conflicts between the
drives of the id, ego and super ego take on
physical characteristics.
 Regression
 Unconscious defense mechanism in which a
person undergoes a partial or total return to
earlier patterns of adaptation.
2. NEUROTIC/HIGHER LEVEL DEFENSES
 Introjection
 A defense mechanism invoked to deal with the
distress connected with the object’s loss
 Because the lost object is regarded with a mixture
of love and hate, feelings of anger are directed
inward at the self.
 Identification
 According to Freud’s concept of the Oedipus
Complex, a child may experience feelings of
resentment towards their father as they compete
for the affection of their mother
 In order to pacify a person whom we perceive to
be a threat, we may emulate aspects of their
behavior.
 By adopting their mannerisms, repeating phrases
or language patterns that they tend to use and
mirroring their character traits, a person may
attempt to appease a person.
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 Displacement
 Unconscious defense mechanism by which the
emotional component of an unacceptable idea or
object is transferred to a more acceptable one.
 Seen in phobias.
 Externalization
 An unconscious defense mechanism by which an
individual "projects" his or her own internal
characteristics onto the outside world, particularly
onto other people.
 For example, a patient who is overly
argumentative might instead perceive others as
argumentative and himself as blameless.
 Intellectualization
 When a person is attached emotionally to an
issue, they may be tempted to consider it in
intellectual terms.
 This often involves standing back from the
situation and attempting to take a cold, neutral
view of it.
 For instance, a person who has been made
redundant after twenty years of service to a
company may intellectualize it, acknowledging the
management’s view that redundancies needed to
be made for the company to survive.
 Isolation of Affect
 Isolation is characteristic of controlled, orderly
persons who are often labeled obsessive-
compulsive personalities.
 Persons with obsessive-compulsive personality
remember the truth in fine detail but without
affect.
 In a crisis, patients may show intensified self-
restraint, overly formal social behavior, and
obstinacy.
 Rationalization
 When a person attempts to explain or create
excuses for an event or action in rational terms.
 In doing so, they are able to avoid accepting the
true cause or reason resulting in the present
situation.
 Sexualization
 Endowing an object or function with sexual
significance that it didn’t previously possess.
 Can also refer to warding off anxieties associated
with prohibited impulses or derivatives.
 Reaction Formation
 When the insatiable desires of the id conflict with
the ego and super ego, a person may formulate a
reaction to those impulses.
 Often, this action is the direct opposite to the
demands of the original desire, and helps to
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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

counteract impulses which may be unacceptable

to act out or fulfill.  Sublimation
 Repression  The sign of a successful sublimation is neither
 Repression is perhaps the most significant of careful cost accounting nor shrewd compromise,
defense mechanisms in that repressed feelings but rather psychic alchemy.
and impulses can lead to the use of many other  By analogy, sublimation permits the oyster to
mechanisms. transform an irritating grain of sand into a pearl.
 Undoing
 When we act on an idea or impulse that we later II. MELANIE KLEIN AND OBJECT RELATIONS
regret, we may adopt a defense mechanism of THEORY
attempting to “undo” that action in order to
protect the ego from feelings of guilt or shame.
Infancy:
3. MATURE DEFENSES
Object Relations → Splitting → Ambivalence →
 Humor
 Humor makes life easier. Depressive Position → Acceptance
 With humor one sees all, feels much, but does not
act. Humor permits the discharge of emotion
without individual discomfort and without 1. OBJECT RELATIONS THEORY
unpleasant effects upon others.
 Mature humor allows individuals to look directly at  Representation of others affects the representation
what is painful of self and vice versa.
 Suppression
 Suppression is a defense that modulates  Personality is a product of early mother-child
emotional conflict or internal/external stressors relationship
through stoicism.  Low focus on biological basis of behavior and drives
 Suppression minimizes and postpones but does  Human contact and relatedness as the prime motive
not ignore gratification. of human behavior
 Ascetism
Assumptions:
 Eliminating the enjoyment of experiences by
assigning moral values to specific pleasures.
 The infant began life with a primal anxiety of
 Gratification is derived from renunciation.
annihilation
 Altruism
 The infant’s drives develop in context of the mother-
 Involves an individual getting pleasure from giving
infant relationship
to others what the individual would have liked to
 The Object Relationships building blocks of life
receive.
involve representation of self, representation of the
 For example, using reaction formation, a former
object and the affect that links the two.
alcohol abuser works to ban the sale of alcohol in
his town and annoys his social drinking friends.  Internal representation is not always the same as
 Anticipation the external figure it is based.
 Capacity to keep affective response to an
unbearable future event in mind in manageable 2. PARANOID SCHIZOID POSITION
doses.  Lead to splitting
 The defense of anticipation reflects the capacity to
Assumptions:
perceive future danger affectively as well as
cognitively and by this means to master conflict in  First 6 months
small steps.
 Overwhelming feelings of GOOD vs. BAD
 Examples are the fact that moderate amounts of
 Fears that the mother will attack him (PSP)
anxiety before surgery promote postsurgical
adaptation and that anticipatory mourning  Inability to resolve issue will lead to splitting
facilitates the adaptation of parents of children (Idealization vs. Hating)
with leukemia.

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

c. Depressive Position Exploring/ Behavior Behavior

Behavior
Attachment Orientation when Stranger when
of
type towards mother anxiety mother
Assumptions: mother leaves returns
mother

 Second 6 months Explore

 Depressive thoughts that anger may cause harm to unfamiliar Comfortable
Greeted
Sensitive
room with an Some with stranger and
mother Secure
orientation discomfort when mother
her
supportiv
positively
 Self-Object Differentiation towards is present e
 Realistic Acceptance of Badness and Goodness mother
No
OBJECT RELATIONS THEORY Avoidant-
orientation to Unconcern
Comfortable Unintere
Rejected/
mother while ed with her ignored
Insecure with stranger sted
exploring absence infant
Part representation of others ← AFFECT → Part room
representation of self Resistant-
Unconcerned
Intense
Uncomfortab
Rejected Inconsist
with le with
insecure distress her ent
exploring stranger

III. SELF-PSYCHOLOGY
 SECURE SELF OBJECTION CONNECTION
 Developed by Heinz Kohut based on his study of
narcissistically disturbed patients
IV. ATTACHMENT THEORY
 Daniel Stem developed the 5 stages of self
 Developed by John Bowlby with emphasis on child’s
Assumptions: early experience and the impact of the external
world
 Vulnerability in self-esteem is due to the lack of
developmentally appropriate empathy from their  Ainsworth emphasized the importance of
primary caretaker, their mother attachment using the STRANGE SITUATION

Self-object Functions: Assumptions:

 Others must perform for a child to be able to  The goal of the child is to achieve a
develop appropriately psychophysiological state in close proximity with the
mother or caretaker
 Absence leads to deficit situations
 Parent’s mental models of attachment predict
 Leading to poor self-esteem
patterns between infant and child
Self-Object Functions or Self Object  The caregivers ability to observe the infant’s internal
Transferences world and intentional state influence the security of
attachment
1. Mirror transference
 An attempt to capture the gleam in the mother’s
eye
 Exhibitionistic behavior displays for the approving
and mirroring responses
 COHERENT SENSE OF SELF

2. Idealizing transference
 Child maintains self-esteem by being a shadow of
their ideal
 Feelings of being whole and worthy is due to the
reflected glory of their ideal
 WHOLE AND WORTHY FEELING

3. Twinship or alter ego transference

 They want to be like their parent
 Imitative behavior prominent

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

ANALYZING PSYCHOPATHOLOGY

The case of Mr. Z

 Mr. Z described his family of origin as very poor. His

father deserted his mother when the patient was 12
years of age and, as the oldest child, he had to take
considerable responsibility for younger siblings, as
well as to work part-time while attending school. He
knew that his maternal grandfather had committed
suicide and that two maternal uncles were
alcoholics. A paternal uncle had died in prison after
a long period of antisocial behaviour.
 Physical, laboratory and neurological studies were
negative.
The Case of Queen C
1. Describe the patient’s symptoms and problems

2. Propose a Hypothesis about the mechanisms

causing the disorder and problems

3. Identify precipitating, perpetuating, and protective

factors the current disorder and problems

4. The origins of the mechanism.

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

I L OI L O DO C T O RS ’ C O LL E GE O F ME D I CI N E
 Can derive from biological, psychosocial and
Molo, Iloilo City sociocultural causal factors
S.Y. 2018-2019
 May be perceived as the distal necessary or
BATCH 2021 contributory cause
DISCIMUS SAPIENCIA UT VIRTUS  A more proximal undesirable event or situation
(the stressor) produces the disorder in someone
with the distal necessary or contributory cause
PSYCHIATRY
BLOCK 1 Diathesis-stress models
 When mental disorders develop when some kind
LECTURER: DR. MARIA CORAZON JARDIOLIN
of stressor operates on a person
MAIN TOPIC: NATURE AND CAUSES OF MENTAL Stress is a response to an adjustment demand.
ILLNESSES
(JANUARY 17, 2019) MODELS OF HOW DIATHE SIS AND STRESS MAY
COMBINE TO PRODUCE A DISORDER
ABNORMAL OR MALADAPTIVE BEHAVIOR
Several models of how diathesis and stress may
ABNORMAL OR MALADAPTIVE BEHAVIOR combine to produce a disorder:
 is the joint product of a person’s vulnerability  Additive model:
(diathesis) to disorder and of certain stressors o diathesis and stress together must reach
that challenge his or her coping resources the a particular level
causes of abnormal behavior o may reach this level with only diathesis
or stress but easier if both are present
Etiology  Interactive model:
 is the causal pattern of abnormal behavior o some amount of diathesis and stress
Necessary cause required
 is a condition that must exist for a disorder o if both are not present, the disorder will
Sufficient cause not develop
 of a disorder is a condition that guarantees the
occurrence of a disorder Protective factors
Contributory  Are influences that modify a person’s response
 causes increase the probability of a disorder to environmental stressors making it less likely
Distal causal factors that the person will experience the adverse
 are causal factors occurring relatively in life that consequences of the stressors
do not show their effects for years
Proximal causal factors: a. Having at least one parent who is warm and
 are causal factors that operate shortly before the supportive
occurrence of the symptoms of a disorder b. Exposure to moderate stressful experiences
Reinforcing contributory cause dealt with successfully
 is a condition that maintains maladaptive c. Girls are less vulnerable than boys
behavior d. Other protective attributes: easygoing
Diathesis or Vulnerability temperament, high self-esteem, high
 Is a predisposition toward a given disorder intelligence and school achievement

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e. Protective factors may lead to resilience –
the ability to cope successfully with very
difficult circumstances
VIEWPOINT FOR UNDERSTANDING THE CAUSE OF
MENTAL ILLNESS
Viewpoints for Understanding the Cause of Mental
Illness
 Viewpoints help organize observations, provide a
system of thought in which to place the observed
data, and suggest areas of focus for research and
treatment.
 The understanding and treatment of mental
illness has moved from biological, to unconscious
psychological forces, to sociocultural influences
on behavior.
 The biopsychosocial viewpoint incorporates the
biological, psychological and sociocultural factors
and looks at how nature and nurture interact to
produce mental health issues
a. Synapse - a tiny fluid-filled space
between neurons
b. Dysfunction may occur in how
neurotransmitters are deactivated
c. May be a problem with receptors in the
postsynaptic neuron
d. Norepinephrine, dopamine and
serotonin are monoamines (each
synthesized from a single amino acid)
that have been extensively studied
NATURE AND CAUSES OF MENTAL ILLNESSES
 Events that may have precipitated or contributed
in the development of mental illnesses
o Non-organic causes – may cause
functional mental illness
o Organic causes – determined through
history
 Personal history and family history will give a
clue why, what of his mental illness
 Communication maybe: verbal or non-verbal
 Psychosis :(+) thinking disturbance (content,
progression, product)
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 Mood disorder: affective disturbance
(depression, mania)
CAUSES OF ILLNESSES
 Organic disease process – congenital,
neurological, circulatory, inflammatory, toxic
 Functional – emotional
CAUSES OF MENTAL ILLNESSES
 Predisposing factors – set the stage for the
triggering actions of precipitants
o conditions that come before and pave
way for possible occurrence of the
disorder
o Relatively remote in time from its effects
 Precipitating factors – occurs immediately or
shortly before its effects
Behavior is a result is a of both heredity & environmental
conditions that prove too much for an individual &
triggers the disorder
4 CLASSES OF DETERMI NANTS OF CAUSES OF
MENTAL ILLNESSES
1. Hereditary Factors – genetic defects eg.
Chromosomal aberration in Down’s Syndrome
– Faulty gene due to gene mutation after
exposure to special mutagen like ionizing
radiation, drugs & chemicals
2. Biological Factors
3. Psychosocial Factors – include Psychological & Social
Factors
4. Sociocultural Factors
Genetic Vulnerabilities
1. Abnormalities in the structure or number of
chromosomes
2. Genes- very long molecules of DNA
3. Chromosomes- chain-like structures within a cell
nucleus that contain genes
4. Vulnerabilities to mental disorders are almost
always polygenic, which means multiple genes
influence them.
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5. Genes affect behavior indirectly; expression is not a
simple outcome of the information
6. The relationship of genotypes to phenotypes
7. Polygenic- mental disorders that are influenced by
multiple genes
8. Genotype- a person’s total genetic endowment
9. Phenotype- the interaction of the genotype and the
environment
10. Genotype-environment correlations occur when the
genotype shapes the environmental experiences a
child has
GENOTYPE-ENVIRONMENT INTERACTIONS
 People with different genotypes may be
differentially sensitive or susceptible to their
environment
Temperament
1. Refers to a child’s reactivity and characteristics of I.
self-regulation
2. Approximately five dimensions of temperament
have been identified:
a. Fearfulness
b. Irritability or frustration
c. Positive affect
d. Activity level
e. Attentional persistence
Temperamental characteristics seem to be related to
three important dimensions of adult personality:
a. Neuroticism or negative emotionality
b. Extraversion or positive emotionality
c. Constraint (conscientiousness and agreeableness)
 May set the stage for various forms of
psychopathology later in life
 Behaviorally inhibited—label for children who II.
are fearful or hypervigilant in unfamiliar
situations
Brain Dysfunction and Neural Plasticity
1. Considerable neural plasticity or flexibility of the
brain in making changes un organization and
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function in response to pre- and post-natal
experiences, stress, diet, drugs, maturation, etc.
2. Animal studies clearly document that both positive
and negative events can lead to changes in the
structure and functioning of the brain
3. Recent evidence suggests that unstimulating
deprived environments can cause retarded
development in humans
4. Developmental systems approach acknowledges not
only the genetic activity influences on neural activity
but also how the environment also impacts
psychopathology
5. Recent research emphasizes the importance of a
developmental systems approach—genetic activity
influences neural activity which in turn influences
behaviour which in turn influences the environment
but also that these influences are bidirectional
HEREDITARY FACTORS - Predisposition
 Nature of mental illness will be seen only at
later time if induced through environmental
condition
 Many genetic patterns of inheritance for a
given trait: genes may be sex-linked or
autosomal, single or multiple, dominant or
recessive
 Very crucial because it gives the person the
potentials or predisposition to mental illness
from the parents to their offsprings
 Nature of mental illness will be seen only at a
later time if induced through environmental
conditions
 Environment will ultimately determine whether
the potential will remain as potentials only or if
it will develop into a mental illness
BIOLOGICAL - non hereditary biological
predisposition
 Structure of individual given to a person by
the :
a. Genotype
b. Pre-natal
c. Post-natal and does not include
environment
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 based on this are types of personality
 Biological factors – eg. Constitutional
liabilities, physical deprivations, disruptive
emotional process & brain pathology
 Biological precipitants – may precipitate
functional disorders to which a person is
predisposed or may cause structural changes
in the brain
1. Noxious agents – egs., disease
producing bacteria, toxic chemicals,
physical injury
2. Deprivation of necessary biological
substances
(vitamins,hormone,oxygen)
 Biological predisposing causes:
1. Constitution
o those that you inherit from your
parents & comes out within 24
hours after birth
o Due to traits that we inherit, the
concepts we have of ourselves &
our outlook in life and ability to
communicate is affected
2. Physique/ Body Structure
o physical defects affect way of
communication
o body build component of
constitution is correlated with
temperamental characteristics &
types of
mental disorder
3. Bodily functions
o minor deviation in the chemical
functioning of the body can also
affect predisposition to various
form of disturbed behavior
o Biochemical factors
neurotransmitters
PERMISSIVE HYPOTHESI S (KETY-PRANGE)
“A deficit in central indoleaminergic transmission permits
affective disorder but is (by itself) insufficient for its
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cause; and changes in central catecholaminergic
transmission, when they occur in the context of a deficit
in indoleaminergic transmission, acts as a proximate
cause for affective disorders and determine their quality,
catecholaminergic transmission being elevated in mania
and dimished in depression.”
Equations :
IA = indoleaminergic transmission
(serotonin)
CA = catecholaminergic transmission
(norepinephrine, dopamine)
 IA normal + CA normal = Normal
 IA↓+ CA normal = predisposition to
affective disorder
 IA↓ + CA↓ = depression
 IA↓ + CA increased = Mania
Deprivational States
 lack of basic bodily needs if sufficiently great or
prolonged may lead to serious constitutional
deficits if they occur in the developmental period
1. Sleep
2. Oxygen deprivation
3. Nutrition
4. Sensory deprivation
PSYCHOBIOLOGICAL CON STITUTION & TYPES OF
PERSONALITY ACCORDIN G TO KRETSCHMER
4 types of Physique
1. Pyknic / pyknosomatic
 short stature, short large neck, stocky, round
figure, outgoing, energetic, extrovert
–
 characterized by pronounced peripheral
development – body cavities; tendency to
distribution of fat around the trunk, rounded
figure
 prone to manic-depressive disorder
 associated with cyclothymic personality
2. Leptosomatic/ Asthenic
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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

 spare, angular, narrowly built, flattened  linear fragile, flatness of the chest,
chest, introvert prone to anxiety Schizophrenia, Peptic
 deficiency in thickness combined with Ulcer Disease
average lessened length
 frail, linear physique PSYCHOLOGICAL VIEWPOINTS
 vulnerable to overt Schizophrenia A. The Psychodynamic Perspectives
 associated with Schizoid PD  Sigmund Freud founded the psychoanalytic
school, which emphasizes the role of
3. Athletic unconscious motives and thoughts
 short, muscular vigourous physique  Fundamentals of Freud’s psychoanalytic
 psychosomatic, antisocial personality D/o theory
4. Dysplastic a. The structure of personality: id, ego,
 characterized by aberrations, myxedema, superego
infantilism, eunuchidism 1) Life instincts and libido
 strikingly deviant aspect to the individual’s 2) Death instincts
built 3) Pleasure principle
 assoc. with pituitary hormone problems 4) Primary process thinking
 Schizophrenic 5) Secondary process thinking
6) Reality principle
PSYCHOBIOLOGICAL CON STITUTION & TYPES OF 7) Intrapsychic conflicts
PERSONALITY ACCDG TO SHELDON 8) Libido- the basic emotional and
psychic energy of life
 Endomorph
9) Pleasure principle- id operates
o assoc. with viscerotonic temperament
on this engaging in selfish and
 relaxation, love for physical comfort;
pleasure oriented behavior
sociability
10) Primary process thinking-
 softness, spherical appearance
realistic actions needed to meet
 pleasure seeking and sentimental
instinctual demands
 Mesomorph
11) Ego- second part of the
o assoc. with somatotonic temperament
personality that mediates
 assertive, high energy level;
between the id and the realities
competitive
of the real world
 strong tough resistant to injury,
12) Secondary process thinking-
muscular, athletic, equipped
ego’s adaptive measures
strenuous physical demands
13) Reality principle- ego operates
 active, energetic, more achievement
on this
 oriented, aggressive
14) Superego- the third part of
 Ectomorph
personality, conscience
o assoc. with cerebrotonic temperament
15) Intrapsychic conflicts- inner
 sensitive, delicate, intelligent, more
mental conflicts that lead to
religious & withdrawing
mental disorders
 restraint in posture & movement; love
b. Psychosexual stages of development
of privacy, sensibility
1) Oral stage
2) Anal stage

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3) Phallic stage
4) Latency period
5) Genital stage
c. The Oedipus Complex and the Electra
Complex
1) Castration anxiety
2) Penis envy
ANXIETY, DEFENSE MECHANISMS, AND THE
UNCONSCIOUS
1) Ego-defense mechanisms – irrational protective
measures to defend a bruised ego
2) Freud believed anxiety played a key causal role in
most forms of psychopathology
3) Neurotic and moral anxiety, because they are
unconscious, cannot be dealt with rationally thus
the ego resorts to irrational protective
mechanisms referred to as ego-defense
mechanisms
NEWER PSYCHODYNAMIC PERSPECTIVES
a. Ego psychology- when the ego does not function
adequately
b. Object-relations theory focuses on individual’s
interactions with real and imagined other people
experience between their internal and external
objects
c. The interpersonal perspective views
psychopathology as rooted in unfortunate
tendencies we have developed while dealing
with our interpersonal environments
d. Attachment theory emphasizes the importance
of early experience, specifically the quality
parental care to the development of secure
attachments
COGNITIVE-BEHAVIORAL PERSPECTIVE
 Bandura stressed that human beings regulate their
behaviour by internal symbolic processes-thought-
or internal reinforcement
 Cognitive behavioural perspective focuses on how
thoughts and information processing can become
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Psychiatry TRANS NO. 1 (2nd Sem) 2019
distorted and lead to maladaptive emotions and
behaviors
 Believed that treatment works by improving self-
efficacy, the belief that one can achieve one’s
desired goal
SCHEMAS AND COGNITIVE DISTORTIONS
a. The cognitive or cognitive-behavioral perspective
focuses on how thoughts and information
processing can become distorted and lead to
maladaptive emotions and behavior.
b. Schema- underlying representation that guides
current processing of information and lead to
distortions
c. Aaron Beck developed the concept of a schema or
underlying representative of knowledge that
guides the current processing of information and
often leads to distortions in attention, memory,
and comprehension.
d. Self-schemas include our views about who we are,
what we might become, and what is important to
us.
III. PSYCHOSOCIAL FACTORS –
predisposing/precipitating
 Maternal Deprivation
 Psychogenic family patterns
 Early Psychic Trauma
 Pathogenic Interpersonal Relationships
 Severe Stress
Maternal Deprivation – “masked deprivation”
 is caused by inadequate & distorted maternal
care
 Faulty development may occur:
o Separation from the mother or
placement in the institution
o Lack of adequate “mothering” at home
PATHOGENIC FAMILY PATTERNS
Faulty Parent-Child Relationship
a. Rejection – neglect, denial of love & affection,
lack of interests in child’s activities &
achievements, harsh & inconsistent
punishments, failure to spend time with child,
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lack of respect for child’s rights & feelings as a
person
b. Overprotection & Restrictiveness
c. Overpermissiveness & Indulgence
d. Perfectionism & Unrealistic Demands
e. Faulty discipline
f. Contradictory Demand & communication
g. Undesirable Parental Models
 learning faulty values, formulation of
unrealistic goals & development of
maladaptive coping patterns
 Maladaptive Family Structure
Inadequate Parenting Styles
 Parent-child relationship are always bidirectional
 Parental psychopathology
o Parents suffering from schizophrenia,
depression, antisocial personality
disorder, or alcoholism tend to have
children at heightened risk for a wide
variety of developmental difficulties.
o Effects do not seem to be due simply to
genetic variables
o Importance of protective factors such as
warm and nurturing relationship with an
adult, having good intellectual skills,
having social and academic competence,
and being appealing to adults.
EXAMPLES OF MALADAPTIVE FAMILY STRUCTURE
 Inadequate family – inability to cope with the
ordinary problems of family living
 Disturbed family – psychologically unstable parents
 Antisocial family – parents covertly engaged in
behavior that violates standards & interests of
society & chronically in difficulty with the law
 Disrupted family – incomplete, whether as a result
of death, divorce or separation
Early Deprivation or Trauma
A. Institutionalization
 Many children institutionalized in infancy
or early childhood show severe
emotional, behavioral, and learning
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problems and are at risk for disturbed
attachment relationships and
psychopathology.
 Adoption can lead to significant
improvement; the earlier the adoption,
the better the children did.
B. Neglect and abuse in the home
 Among infants, gross neglect may be
worse than abuse
 Abused children may be overly
aggressive, suffer difficulties in linguistic
development, and develop significant
problems in behavioral, emotional, and
social functioning, including conduct
disorder, depression, anxiety, and
impaired relationship with peers.
 Atypical patterns of attachment are
common-most often a disorganized and
disoriented style.
 These early experiences may never be
overcome
 There is a 30 percent chance of
intergenerational transmission
 Improvements may be seen when the
caregiving environment changes
C. Separation
Early Psychic Trauma
 traumatic experiences that temporarily shattered
one’s feeling of security, adequacy & worth are
important in influencing later evaluation of
oneself & his environment
 apt to leave psychological wounds that never
heal completely
Pathogenic Interpersonal Relationships
 Marital Instability
TYPES PATHOGENIC INTERPERSONAL
RELATIONSHIPS
A. Fraudulent Interpersonal Contract – terms of the
relationship being violated by one person to
exploit the other
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B. Collusion – relationship is established &
maintained only because the partner simply
agree to follow certain maladaptive rules &
norms of their own choosing, rather than socially
established ones
Marital Discord and Divorce
 Marital Discord
o When marital discord is long-standing,
may lead to frustrating, hurtful, and
generally damaging effects on both
adults and children
o Effects may be buffered if one parent is
warm, prone to praise and approval, and
able to inhibit rejecting behavior toward
child or if child has supportive peers.
 Divorced Families
o Effects of divorce on parents
o Direction of the causal relationship-
overrepresentation among psychiatric
patients
o Effects of divorce in children
 Long lasting modest negative
effects documented
 Effects of divorce are often more
favorable than the effects of
remaining in a home with marital
discord
 Children living with stepparents-
especially very young children-
are at increased risk for physical
abuse
Maladaptive Peer Relationships
 Despite attitudes against bullying, most children
do nothing to discourage bullying
o 20-30 percent of children actually
encourage the bully
 Sources of popularity versus rejection
o Popular children tend to be either
prosocial or antisocial
o Rejected children tend to be too
aggressive or too withdrawn
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Severe Stress
A. Devaluating frustrations – e.g. Failures, losses,
personal limitations, lack of resources, guilt &
loneliness
B. Value Conflict
C. Pressures of modern living – e.g. competition;
educational, occupational & family demands;
complexity & pace of modern living
Psychological Determinants:
 the stimulus that precipitates abnormal behavior
are characterized by conflict, frustration, long
continued vigilance, uncertainty, deprivation or
threat
 both excessive frustration & over gratification,
defensiveness & neurotic behavior
 early psychological experiences are crucial & may
lead to severe damage
 deprivations of maternal care, dependency
behavior, sensory stimulation or social
interaction are likely to precipitate psychological
disturbance, varying from mild difficulties to
severe psychosis
 a stable individual breaks down only under
severe stress; unstable person breaks down with
mild stress
 in childhood, certain phase3s & types of
experience (oral, anal, & phallic) are crucial
determinants of later behavior
 close relationships with parents & peers in
childhood minimize the probability that
emotional disorder will occur
Socio-Cultural determinants:
 Predisposing/Precipitating Factors
 Biological & psychological determinants of
behavior act upon the person within a cultural
environment
o family, neighborhood, community,
occupation, ethnic group, socioeconomic
class & national culture
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 Attitudes of different cultural groups towards
behavior vary enormously
 Depending on the severity of sociocultural stress,
biological & psychological determinants will have
different effects on the individual
 Social disorganization, cultural conflict &
economic deprivation & other undesirable
aspects of membership in the lowest
socioeconomic class are major socio-cultural
variables affecting various mental disorders
including Schizophrenia
 Stressful & critical situations – unemployment,
family disintegration due to divorce or death,
rapid technological change & residential mobility
have negative effects on emotional functioning
a. War & violence
b. Group prejudice & discrimination
c. Economic & employment problems
d. Accelerating technological & social
change
Effects of War on Emotional Disturbance:
1. Direct stress of physical danger
2. May entail economic, family, & geographic
dislocation
3. Biological deprivation
4. Political oppression
5. Increase mental disorder in the area
Sociocultural Casual Factors
 Low Socioeconomic Status and Unemployment
o Correlation between psychopathology
and low socioeconomic status; strength
of correlation varies by disorder
o Stressors are common
o Lower SES families tend to have more
problems
o Unemployment associated with
enhanced vulnerability and elevated
rates of psychopathology
 Prejudice and Discrimination in Race, Gender,
and Ethnicity
o Stereotypes are demoralizing
o Two primary types of discrimination:
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 Access discrimination
 Treatment discrimination
o In addition to discrimination, women
have also suffered from sexual
harassment in the workplace.
Social Change and Uncertainty
 Numerous adjustments demanded by change in
our society
 Helplessness engendered by events such as
September 11, 2011
Urban Stressors: Violence and Homelessness
 Annually 3.5 million people worldwide die from
violence.
 Domestic violence impacts physical health, lost
productivity, and increases rates of anxiety,
PTSD, depression, and suicide.
 One-third of homeless people suffer from mental
illness
The Impact of the Sociocultural Viewpoint
 Broadened view from a focus on the individual to
include a concern with societal, communal,
familial, and other group settings
 Led to design of programs
 Led to community facilties
OTHER DETERMINANTS OF CAUSEATION OF MENTAL
ILLNESSES
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1. Sex which comprises INTERNAL STANDARD &

 Females - predisposed to schizophrenic IDEALS; represents conscience
tendencies
 Males – predisposed to general paresis II. Biological Theory
2. Marriage  based on the assumption that emotion,
 Long Lasting marriage – adjust properly to mood & behavior can be influenced by a
partner pathophysiological dysfunction that
 Mental illness more common among single affects the central nervous system which
than married individuals can be corrected through pharmacologic
manipulation
3. Physical Trauma
4. Culture III. Psychosocial –Familial System Theory
 associated with assigned social roles & is  explains the origin & maintenance of
culturally determined psychopathology from early in life as the
 feminine traits – somatization & nail biting fundamental characteristics of a stable
more common system that functions to resist change
 masculine traits – addiction & antisocial
PD Concepts of Psychopathology
5. Occupation 1) Medical Model
 Compulsive personalities – whose works  role of organic conditions eg. Infections,
make them socially withdrawn but they may drug intoxication & nutritional
deal with people through the products of deficiencies (Constitutional factors as
their works Predisposition)
6. Illness – diseases that affects the brain 2) Psychoanalytic & Humanistic models
7. Mental Conflicts  Threat ------ Anxiety
a) Bereavement  from acutely unpleasant condition
 normal process of grief : Anxiety functions as warning of danger
(physiological) danger & demanding alleviation
 beyond 1 year (stage of pathological 3) Behavioristic model
grief)  Faulty Learning
b) Aggression – death instinct/ reactive instinct
(frustration-rage) Failure to Learn
+ aversive conditioning or faulty learning
PSYCHOPATHOLOGIC THE ORIES + reinforcement
will maintain maladaptive behavior
I. Psychological theory
 conscious thought and behavior are
Maladaptive Behavior is due to:
often discordant:
a. Failure to learn necessary adaptive behavior
a. ID – comprises the basic instincts, drives,
competencies
impulses and wishes which are
b. Learning maladaptive behavior
unconscious
b. EGO- controls the mental functions
4) Humanistic & Existential models
i. mediates between the individual
 blocked or distorted personal growth
& reality
5) Interpersonal model
c. SUPEREGO –embodies the ego-ideal

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

 unsatisfactory interpersonal relationships birth of his child as

6) Sociocultural Model though he himself had
 pathological social conditions given birth to the child
 Fatigue may weaken the controlling
SOURCES OF MENTAL ILLNESSES strength of the ego
 Work - outlet for creative person
1. Interpersonal relationship – mother-child
o outlet for aggression
 autism – lack of tactile & kinesthetic
o strong ego support
sensations from the mother
o important for mental health if it
is satisfying
2. Bereavement
 Avitaminosis, Alcoholism ; Syphilis –
 Normal Process of Grief: 6 moths – 1
produce Psychosis
year
 Bromides, Barbiturate derivatives, Sulfa
 Beyond 1 year – Stage of Pathological
drugs, Lead, Morphine; Cocaine,
Grief
Marijuana – produce mental symptoms
 Pellagra and Wernicke’s Syndrome –
3. Anniversary Reaction
encephalopathy syndrome due to lack of
vitamins
4. Aggression – goal directed self-assertion
2 Theories:
a. Freudian Concept CEREBRAL DYSFUNCTION
 man becomes aggressive 1. Acute Organic syndrome – result of temporary,
because it is part of instinct reversible, diffuse impairment of brain tissue
b. Reactive Theory function
 life is filled with frustration and  characterized by disturbance of
may cause no achievement  consciousness, difficulty of
 Rage –aggression – compromise,  apperception, somnolence, coma.
withdraw, meet  cloudy & delirious stats

5. Mental Conflict 2. Chronic Organic Brain Syndrome – result from

 Genetic Factor plays a significant permanent, usually irreversible, diffuse
predisposing role in Schizophrenic impairment of cerebral tissue function
 Immigrant population – more subject to  Disturbance of memory, judgment,
psychiatric hospitalizations orientation, comprehension and affect
 Urban areas – alcoholism is common, persists permanently
psychosis due to substance use; mood  May be permanent, diffused, or
disorders, non-psychotic psychiatric D/o localized/ circumscribed
 Rural areas – Dementia
 Schizophrenia – equal in both rural &
urban areas
 Low socio-economic class – schizophrenia CAUSES OF GENERAL BRAIN DYSFUNCTION
 Parental Identification with Maternal rol
 Trauma
o Couvade syndrome
 Infection
 father takes to his bed
 Toxic states
during or shortly after

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 Psychiatry TRANS NO. 1 (2nd Sem) 2019

 Metabolic disturbances
 Deprivational states (biological/psychological)

PSYCHIATRIC DIAGNOSI S IN A GIVEN CASE MAY

BE WARRANTED IF THERE IS:
1. Marked accentuation of character traits
2. Non-psychotic psychiatric symptoms
3. Psychotic symptoms
4. Serious difficulty in dealing adequately with
social relationship
5. Limited capacity for work
6. impaired ability to gain satisfaction & enjoyment
in life

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