Up Close With Dr. E

Causes of psychiatric illness


Psychiatric illness is caused by the interaction of three factors:

1. Genetic vulnerabilities handed down in families for disorders such as depression.

2. Environmental stressors such as medical illness, loss or death of a parent, exposure to violence, abuse, neglect, trauma.

3. The level of cognitive development — how advanced the brain’s thinking was — when struck by stressors. (Don’t be intimidated by the word cognitive, it simply means “to think” or “thinking”.)

Understanding Cognitive Development:

The following statements come from adults who are struggling with common cognitive distortions. None of them have received psychiatric care. Each quote is followed by a label designating the type of developmental disruption.

1. “I’ve never liked myself.” (Personal identity, self-esteem).

2. “When men tell me I’m beautiful, I turn my mind into scissors and cut up each compliment.” (Body image, sense of goodness).

3. “I’m the big wig at work, but secretly, I’m a fake, living in fear that someone will see the real me.” (Personal identity).

4. “I avoid close relationships because of rejections.” (Relationships).

5. “Confidence? What’s that? I never try new things; I live inside a box I’ve built.” (self-direction, motivation).

6. “I’ve never felt smart. It’s as if my college degrees belong to someone else.” (Intellectual).

7. “Why so many zombie movies? It’s because of people like me, the walking dead.” (Observing vs experiencing life).

These quotes are examples of distorted (false) cognitive blueprints. What caused them? Let’s find out.

The staircase of cognitive development:

Picture a stairway with 100 steps. Each ascending stair represents a new and more complex skill. Just like motor skills, where a child crawls before walking, so too must children go from simple to complex thinking.

An example of a simple cognitive skill is Object Permanence (OP). Infants begin with this logic: Out of sight means gone forever. When a mother leaves the infant’s room, the child cries. Why? The child believes her mother has gone forever. By age two or three, the infant masters OP. This new skill allows the child to think – Out of sight, but not out of mind. Mommy leaves their room, but the child doesn’t panic. Why not? The child has advanced to a higher step, allowing them to visualize pictures of mommy which are now on display in the permanent gallery of the child’s memory.

This is why child neglect is so devastating. Lacking a stable caregiver, the neglected child learns a very different life lesson: “When I cry, no one comes.” This child’s cognitive stairway now has missing or broken steps, and in these gaps, fear rushes in.

What happens if a child’s cognitive development is far below that required to understand life’s complexities? The child will make errors in thinking called “cognitive distortions,” or false blueprints. The quotes above are examples. Can these errors be corrected? Yes, and this process is called Cognitive-Behavioral treatment. Here’s a story about what happens when a child is unable to understand the complex logic of cause and effect.

When my daughter was six, I took her butterfly hunting. Unable to catch any, we sat down on a log to rest. After a few minutes, a Monarch butterfly landed on her shoulder. Excited she whispered, “Daddy, the butterfly likes me.” Later that night, as we walked around our neighborhood, she gazed up at the full moon. “Daddy, the moon is following me.”

These stories illustrate her cognitive stage of development, where she is the “Puppet Master.” Her belief that she controlled the universe meant that whenever a bad thing happened, it was her fault.

Tell me how my daughter would explain this: I come home angry and yell at her, “stupid brat!” She runs to her bedroom, crying. Her explanation? “I did something wrong, it’s my fault, I’m bad, I’m stupid. I must try harder, be better, be perfect.”


The seeds of psychiatric illness are sown in the first decade of life. Whether they sprout depends, in part, upon the damage done to the cognitive stairway.

How could your life change if the steps in your own cognitive staircase were rebuilt? Perhaps the quotes listed earlier would change: “I’ve never liked myself, but now I’m learning why. When I receive a compliment, I can now say thank you.”

You can’t change your past. But you can bet your bottom dollar that your past has changed you. If you know how your past has altered your cognitive development, you can act.

In the Disney movie, “The Lion King,” the wise baboon, Rafiki, tells Simba, who has tragically lost his father and home, this: “You can run from your past, or, you can learn from it.” Which are you doing?

The content of this article is for educational purposes only and should not be used as a substitute for treatment by a professional. The characters in this story are not real. Names and details have been changed to protect confidentiality.


1. “The Lion King,” Walt Disney Company, adapted by Don Ferguson, 1994.

2. “Stahl’s Essential Psychopharmacology,” 2013, Cambridge.


Dr. Richard Elghammer contributes his column to the Journal Review each week.


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