High-Risk Periods for Psychopathology
Psychiatrists who treat children and adolescents are par-ticularly aware of the precursors and onset of psychiatric illnesses. Two examples of age-specific vulnerabilities will be discussed, but Figure 7.8 gives an overview of the periods of most probable onset for many of the major psychiatric disor- ders. The first example is autism, which is unusual in both its invariant early onset and its striking presentation. The second is suicide, which is particularly interesting because of epi-sodic periods of particularly high risk during the developmen-tal course.
Autism is a disease of early onset that has been shown to have a strong genetic basis. Nevertheless, the role of the environ-ment in affecting the onset of autism is still striking, as demon-strated by the quite dramatic variability in the symptom presen-tations and ultimate adaptations of monozygotic twins. Autistic children appear normal at birth. During their first months of life, they begin to develop severe deficits in their capacity to form re-lationships and communicate with others. Once fully expressed, autism has a devastating impact on the subsequent development of afflicted children. What is perhaps most striking is the inevi-tability of early expression as there are no examples of onset later in childhood or adolescence.
Suicide provides a sharp contrast to autism. Suicide is highly associated with mental disorder in general and affective disorder in particular. It has also been shown to be moderately heritable. Whereas the onset of suicidal thoughts does occur in rare cases in the preschool period, the capacity to commit suicide in-creases with age. After puberty the rate of suicide increases nearly tenfold. The underlying explanation for this dramatic increase is complex and involves consideration of risk factors at the level of the individual, family and community. However, the ultimate life course pattern is striking, as there is a second dramatic increase in suicidality in the later years of life. The explanation for this sec-ond increase usually focuses on the increase in medical problems of the elderly, but the multiple emotional losses of these years also provide a vulnerable context for depression and despair.