Showing papers in "Archives of General Psychiatry in 1978"

Research diagnostic criteria: Rationale and reliability.

Abstract: • A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria.

A Diagnostic Interview: The Schedule for Affective Disorders and Schizophrenia

Abstract: • The Schedule for Affective Disorders and Schizophrenia (SADS) was developed to reduce information variance in both the descriptive and diagnostic evaluation of a subject. The SADS is unique among rating scales in that it provides for (1) a detailed description of the features of the current episode of illness when they were at their most severe; (2) a description of the level of severity of manifestations of major dimensions of psychopathology during the week preceding the evaluation, which can then be used as a measure of change; (3) a progression of questions and criteria, which provides information for making diagnoses; and (4) a detailed description of past psychopathology and functioning relevant to an evaluation of diagnosis, prognosis, and overall severity of disturbance. This article reports on initial scale development and reliability studies of the items and the scale scores.

The de facto US mental health services system: a public health perspective.

Abstract: • The President's Commission on Mental Health has highlighted a heretofore unmet need for the linkage of data on the prevalence of mental disorder with national data on the use of mental health services. This study analyzes available epidemiological data and recent mental health services research findings to estimate the percent of the population with a mental disorder and the proportion utilizing various types of specialty mental health and general medical treatment settings. Provisional estimates indicate that at least 15% of the US population is affected by mental disorders in one year. In 1975, only one fifth of these were served in the specialty mental health sector, with about three fifths identified in the general medical (primary care) sector.

Human Pharmacology and Abuse Potential of the Analgesic Buprenorphine: A Potential Agent for Treating Narcotic Addiction

Abstract: Buprenorphine was evaluated for its abuse potential and utility in treating narcotic addiction. The drug was morphine-like but was 25 to 50 times more potent than morphine and was longer-acting. Little if any physical dependence of clinical significance was produced by buprenorphine. The effects of morphine to 120-mg doses were blocked by buprenorphine, a blockade that persisted for 29 1/2 hours. In man, buprenorphine has less intrinsic activity than morphine, and as such, as a low abuse potential. Moreover, the drug has potential for treating narcotic addiction since it is acceptable to addicts, is long-acting, produces a low level of physical dependence such that patients may be easily detoxified, is less toxic than drugs used for maintenance therapy, and blocks the effects of narcotics.

Affective Disorders in a US Urban Community: The Use of Research Diagnostic Criteria in an Epidemiological Survey

Abstract: • The current point and lifetime prevalence rates of affective disorders, based on the application of Research Diagnostic Criteria to a US urban community sample, are reported. The affective disorders studied included major and minor depression, mania, hypomania, bipolar I and II, primary and secondary depression, schizo-affective disorder, depressive and cyclothymic personality, and grief reactions. Epidemiologic surveys that include treated and untreated persons to obtain rates of specific psychiatric disorders are needed for scientific purposes and health care planning.

Diagnosis in schizophrenia and manic-depressive illness: a reassessment of the specificity of 'schizophrenic' symptoms in the light of current research.

Abstract: • Present clinical and research methods of differential diagnosis of schizophrenia and affective psychoses rely very heavily on presenting symptoms and signs, especially in acute psychosis. We have reviewed studies bearing on this issue, including studies of the phenomenology of psychotic illness, outcome, family history, response to treatment with lithium carbonate, and cross-national and historical diagnostic comparisons. We conclude that most so-called schizophrenic symptoms, taken alone and in cross section, have remarkably little, if any, demonstrated validity in determining diagnosis, prognosis, or treatment response in psychosis. In the United States, particularly, overreliance on such symptoms alone results in overdiagnosis of schizophrenia and underdiagnosis of affective illnesses, particularly mania. This compromises both clinical treatment and research.

Drug and Family Therapy in the Aftercare of Acute Schizophrenics

Abstract: After a brief inpatient hospitalization, 104 acute, young schizophrenics, stratified by premorbid adjustment, were randomly assigned to one of four aftercare conditions for a six-week controlled trial. Conditions involved one of two dose levels of fluphenazine enanthate (1 ml or 0.25 ml) and presence or absence of crisis-oriented family therapy. Relapses during the six-week period and at six-month follow-up were least in patients who received both high-dose and family therapy (0%) and greatest (48%) in the low-dose-no therapy group. Brief Psychiatric Rating Scale symptom ratings disclosed a significant family therapy effect at six weeks that was sustained at six months only for therapy patients originally receiving the high drug dose. Numerous interactions were found between premorbid adjustment status and response to the two treatment conditions.

Secondary Mania: Manic Syndromes Associated With Antecedent Physical Illness or Drugs

Abstract: • While mania usually occurs as a phase of manic-depressive disease, it can occur in association with organic dysfunction— medical and pharmacological—in patients with no history of affective disorder. In reviewing the literature, we have found that mania occurs secondary to drugs, infection, neoplasm, epilepsy, and metabolic disturbances. These cases are best considered secondary manias. They suggest that mania—like, for example, hypertension—is a syndrome with multiple causes and that with further research many manic syndromes currently considered primary will be shifted into the secondary category. Furthermore, the concept of secondary mania casts doubt on any unitary or single-agent hypothesis of the etiology of mania and supports the notion of a continuum of psychopathologic syndromes. Clinicians are alerted to the existence of this syndrome and are urged to screen for it when conditions warrant.

"akinetic depression" in schizophrenia

Abstract: • It is possible that some "postpsychotic depressions" may be a toxic effect of antipsychotic drugs. Out of a total of 94 schizophrenic patients, 28 developed a mild akinesia and 32 never developed extrapyramidal symptoms. Those who developed akinesia became less psychotic, but they also experienced a significant, although modest, increase in depression ratings. Successful treatment of the akinesia resulted in significant improvements in depression, somatic concern, anxiety, emotional withdrawal, blunted affect, and motor retardation on both physicians' and nurses' ratings. A high association between akinesia and both objectively rated and subjectively experienced sedative effect indicates that an "akinetic depression" is not likely if the patient does not look or feel drowsy. The 32 nonakinetic patients also became less psychotic, but not more depressed.

Implications of Sex Differences in the Prevalences of Antisocial Personality, Alcoholism, and Criminality for Familial Transmission

Abstract: • We describe three multifactorial models of disease transmission in which the prevalences of a disease differ in men and women. These models demonstrate explicitly how such sex differences may be caused by genetic factors, home environment, sociocultural, or other nonfamilial factors. Independent sets of family data about antisocial personality and alcoholism in the United States and criminality in Danish twins are analyzed according to these quantitative models. Relevant clinical and adoption data about these disorders are reviewed. The sex differences observed in the development of antisocial personality and of crime appear to be due to familial factors whereas the differences between male and female alcoholics are due to nonfamilial factors. The models and results are discussed in terms of their general implications for testing hypotheses about gender-related differences.

Prenatal loss of father and psychiatric disorders.

Abstract: • To test the role of maternal stress during pregnancy in psychiatric and behavior disorders, a retrospective epidemiological study was conducted, using the Finnish population register for persons born between 1925 and 1957. One hundred sixtyseven persons were detected whose fathers had died before their children's births; a control group comprised 168 persons whose fathers died during the first year of their children's lives. The number of diagnosed schizophrenics treated in psychiatric hospitals and the number of persons committing crimes were significantly higher in the index than in the control group. The incidence of alcoholism and personality disorders was relatively high in both groups. The index psychiatric cases had a low frequency of birth complications, whereas those of the control group were high. The results suggest that especially during months 3 to 5 and 9 to 10 of pregnancy, maternal stress may increase the risk of the child for psychiatric disorders, perhaps mediated through the inborn temperament of the child.

Some genetic aspects of alcoholism and criminality. A population of adoptees.

Abstract: • The state criminal records and official registers of alcoholics were used in a study of 2,000 adoptees and their biological and adoptive parents. The frequency of registration for the adoptees were approximately the same as for the population in general, but for the biological parents it was two to three times greater. Very few adoptive parents appeared in the records. It is conceivable that to a large extent adoption neutralized the "social heritage" from the biological parents. There was, however, a significant correlation in the records between alcoholism in biological parents and in their adopted-out sons. On the other hand, the criminal records showed no such correlation between biological parents and their children. These results support the hypothesis that there is a genetic explanation for the development of alcoholism, but not for the manifestation of criminality.

Physical Illness Presenting as Psychiatric Disease

Abstract: • A study of 658 consecutive psychiatric outpatients receiving careful medical and biochemical evaluation, defined an incidence of medical disorders productive of psychiatric symptoms in 9.1% of cases. The most frequent presentations were of depression, confusion, anxiety, and speech or memory disorders. The presence of visual hallucinations was believed to indicate medical etiology until proved otherwise. Major illnesses presenting with psychiatric symptoms in order of frequency were infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic and CNS diseases. Forty-six percent of these patients suffered from medical illnesses previously unknown to either them or their physician. A plea is made for careful medical evaluation of psychiatric patients.

The nosological status of neurotic depression: a prospective three- to four-year follow-up examination in light of the primary-secondary and unipolar-bipolar dichotomies.

Abstract: • One hundred patients with "mild" depressive states, variously referred to as "situational," "reactive," or "neurotic," were studied. During a three- to four-year prospective follow-up, 4% had developed bipolar I, 14% bipolar II, and 22% unipolar disorders with predominantly favorable social outcome. Most of the remainder were suffering from nonaffective disorders; in this group, intermittent depressive symptomatology followed a protacted course (paralleling the underlying disorder) with generally unfavorable outcome. Irrespective of diagnostic subtype, a "characterological" component occurring in 24% of the total sample appeared to predict unfavorable prognosis, including three suicides. The diagnostic usage of the concept of neurotic depression may no longer be clinically meaningful, since it lacks sufficient phenomenological characterization and refers to a heterogeneous group of disorders. The data suggest the merits of a biaxial approach to the nosology of depressive disorders whereby phenomenologically based affective diagnoses are qualified as to the presence or absence of character disorder.

Behavior therapy, supportive psychotherapy, imipramine, and phobias.

Abstract: • In a controlled outcome study of phobias, 111 adult patients (69% women, 31% men) received a course of 26 weekly treatment sessions consisting of (1) behavior therapy and imipramine hydrochloride (2) behavior therapy and placebo, or (3) supportive psychotherapy and imipramine. Patients were classified as agoraphobic, mixed phobic, or simple phobic. The great majority of patients in all groups showed moderate to marked global improvement (70% to 86%, depending on rater). In agoraphobics and mixed phobics (both groups experiencing spontaneous panic attacks), imipramine was significantly superior to placebo. There was no difference between behavior therapy and supportive therapy, both resulting in high improvement rates (76% to 100%, depending on rater). In simple phobic patients, there was a high rate of improvement with all treatment regimens (72% to 93%, depending on rater), with no significant difference between imipramine and placebo or between behavior therapy and supportive therapy. Of 88 moderately to markedly improved patients followed up for one year after completing treatment, 83% maintained their gains and 17% relapsed. No patients showed symptom substitution. Eighteen percent of the patients receiving imipramine hydrochloride showed marked stimulant side effects on from 5 to 75 mg/day.

Suicide in schizophrenics, manics, depressives, and surgical controls. A comparison with general population suicide mortality.

Abstract: • This article reports suicide risk among 200 schizophrenic, 100 manic, and 225 depressive patients, and 160 surgical controls. The suicide experience of the study subjects was compared to that of the population of the state of Iowa, the geographical area and population from which the subjects were selected. The suicide experience of the surgical controls was not significantly different from that of the general population. On the other hand, increased risk of suicide was found in all psychiatric groups except female schizophrenics. Suicide appeared pronounced particularly in male patients with affective disorders during the first decade of the follow-up period.

Toward a biochemical classification of depressive disorders. I. Differences in urinary excretion of MHPG and other catecholamine metabolites in clinically defined subtypes of depressions.

Abstract: • The urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) and other catecholamine metabolites was measured in a series of 63 patients with various clinically defined subtypes of depressive disorders. MHPG excretion was significantly lower in patients with bipolar manic-depressive depressions and schizoaffective depressions than in patients with unipolar nonendogenous depressions. Patients with schizophrenia-related depressions also excreted reduced levels of MHPG when compared with patients with unipolar nonendogenous depressions. Moreover, levels of urinary epinephrine and metanephrine were significantly lower in patients with schizophrenia-related depressions. These data, coupled with our recent finding that patients with schizophrenia-related depressions had significantly higher levels of platelet monoamine oxidase activity than control subjects or patients with unipolar endogenous depressions, suggest that we can discriminate three biochemically discrete subgroups of depressive disorders corresponding to the following clinically defined subtypes: (1) the bipolar manic-depressive depressions plus the schizo-affective depressions; (2) the unipolar nonendogenous depressions; and (3) the schizophreniarelated depressions.

Subjective Response as a Predictor of Outcome in Pharmacotherapy: The Consumer Has a Point

Abstract: • Forty-two newly admitted patients with a schizophrenic illness were given a test dose of chlorpromazine, and their subjective response was graded on a euphoric-dysphoric continuum. Subjective response at 4, 24, and 48 hours after the test dose was significantly correlated with the subsequent outcome of a therapeutic course of treatment with chlorpromazine, as measured by the Brief Psychiatric Rating Scale, the Global Assessment Scale, and a write-in symptom scale. An early dysphoric response to chlorpromazine seemed to augur a poor prognosis for further treatment with the drug. These findings suggest that the subjective response to a test dose of chlorpromazine may be a useful predictor of short-term symptomatic outcome.

Huntington's Dementia: Clinical and Neuropsychological Features

Abstract: • The neuropsychiatric syndrome of Huntington's disease is outlined in this report with an emphasis on the cognitive deficits that lend themselves to future neurobehavioral research. Eighteen patients without disabling cognitive or psychiatric symptoms were evaluated for a period of 3 to 15 weeks, with assessment of their cognitive disorder, psychiatric, and neurological symptoms. Neuropsychological examination included repeated mental status examination, the Wechsler Adult Intelligence Scale (WAIS), and, for some, parietal lobe testing. In addition to suffering from a loss of finely detailed memories, patients demonstrated impaired organizing, sequencing, planning, and recalling of information on request. On the WAIS, mean verbal and performance scores were not significantly different. Neuropsychological findings suggested that the Huntington's disease pattern of cognitive impairment is not initially diffuse and homogeneous, but characterized by a relative sparing of several higher cortical functions. Many patients had increased irritability and labile affect. The similarity of Huntington's disease to frontal lobe syndromes is also discussed.

Psychopathology in Adopted-Away Offspring of Biologic Parents With Antisocial Behavior

Abstract: • A study of 246 adoptees aged 10 to 37 years separated at birth from biologic parents is used to study genetic heritability of antisocial behavior and to delineate the extent and quality of "antisocial spectrum" conditions. Evidence is presented for a genetic factor in adoptee antisocial behavior and for the following as "spectrum" conditions: (1) hysteria in adult females (Briquet's syndrome) or multiple somatic complaints without medical explanation in younger female subjects and (2) mood swings possibly associated with the symptom of audible thoughts.

Age at Onset of Bipolar Affective Illness

Abstract: • The age at onset of bipolar affective illness was determined for 100 males and 100 females who met the newly proposed DSM-III criteria for mania. Three different indices of onset were employed: first hospitalization, first treatment, and first apparent symptoms. A table was constructed indicating the cumulative percentage of those who became ill by the time they passed through each age quinquennium. One third were hospitalized before their 25th birthday, and at least 20% had already shown evidence of illness as adolescents. The early 20s was the peak period of onset. No manic episodes were confirmed prior to age 13, and onset after age 60 was rare. Sex, ethnicity, and socioeconomic status did not significantly affect age at onset. Affective illness should be given serious consideration in the differential diagnosis of mental disorders in young people.

Patterns of Childhood Social Development in Adult Schizophrenics

Abstract: • Previous analysis of teachers' comments in school records of schizophrenics showed progressive deviance in their childhood social behavior and sharp differences between the sexes. This report presents a replication of the longitudinal study and a reanalysis of the combined samples. The principal findings from the earlier study were confirmed: in the later school years, preschizophrenic girls were primarily introverted and preschizophrenic boys mainly disagreeable. In the new study, the preschizophrenic girls were also emotionally unstable, introverted, and passive from kindergarten through grade 6, suggesting an earlier history of social disengagement than was previously apparent, and the preschizophrenic boys were emotionally unstable in grades 7 through 12, confirming a nonsignificant trend in the original study. The boys were not behaviorally distinguishable from other boys in elementary grades, so the notion of progressive deviance appears more applicable in their case.

Temperature biofeedback in the treatment of migraine headaches: a controlled evaluation.

Abstract: • After an Initial four-week baseline phase, during which daily records of headache frequency and Intensity and dally medication records were kept, 30 patients with frequent (at least one per month) migraine headaches were randomly assigned to three conditions: (1) temperature biofeedback, autogenic training, and regular home practice; (2) progressive relaxation with regular home practice; and (3) a waiting-list control condition. Comparisons of headache data from the four weeks of baseline and last two weeks of treatment showed that both the relaxation and biofeedback groups improved significantly on total headache activity, duration of headaches, and peak headache intensity and reduced consumption of analgesic medication, while the waiting list control group did not. All three groups showed significant decreases in headache frequency. Although the relaxation training was more effective than biofeedback training at the last week of treatment, follow-up data at one, two, and three months showed no differences between the two treated groups on any dependent measure.

Prolactin Responses to Neuroleptics in Normal and Schizophrenic Subjects

Abstract: • The prolactin response to neuroleptics can serve as an index of dopamine blockade in humans. Plasma prolactin increments to single doses of chlorpromazine, and prolactin decrements to single doses of levodopa, were similar in normal and schizophrenic subjects. Antischizophrenic drugs of all chemical classes stimulated prolactin release, while chemically related drugs and other psychotropic agents ineffective in schizophrenia did not. The prolactin response to neuroleptic therapy occurred in all patients, and tolerance did not develop. Within subjects, prolactin responses were graded according to neuroleptic dose, but the upper limit of sensitivity of the response curve was achieved at doses below the therapeutic range. Relative prolactin-stimulating potency in humans of chlorpromazine, thioridazine, trifluoperazine, butaperazine, and haloperidol correlated well with their relative clinical potencies.

The Collaborative Neuropsychological Study of Polydrug Users

Abstract: • A controlled three-month prospective collaborative investigation involving eight National Institute on Drug Abusesupported polydrug units was carried out. Clinical review of test protocols assessed 37% of polydrug users, 26% of psychiatric patients, and 8% of nonpatients as impaired on the Halstead-Reitan Battery. Impairment in test performance was related to increasing age, educational deprivation, and premorbid medical factors in all groups, extensive use of CNS depressants and opiates among polydrug users, and extensive use of antipsychotic drugs in psychiatric patients. Both language-related and perceptuomotor neuropsychological test deficits were found in polydrug users, but only the latter in psychiatric patients. At three-month follow-up 34% of polydrug users, 27% of psychiatric patients, and 4% of nonpatients were impaired in these test performances. Recent drug-taking (polydrug group) and schizophrenia diagnosis (psychiatric patients) were additional correlates of test impairment. Persistence of performance deficit in polydrug users raises the possibility that CNS depressants and opiates may have longer-term, slowly reversible, or even permanent effects on neuropsychological tests. The same possibility exists for antipsychotic drugs. The link of these test deficits to other specific neuropsychological functions, to performance in life situations generally, or to specific brain dysfunction, as well as the basis for a lack of test impairments in the majority of polydrug subjects remain to be determined.

Effects of a dopamine agonist piribedil in depressed patients: relationship of pretreatment homovanillic acid to antidepressant response.

Abstract: • Piribedil, a compound that stimulates dopamine receptors in a relatively specific fashion, was administered to 11 hospitalized depressed patients. The dopamine agonist significantly decreased rapid eye movement (REM) sleep and percent REM sleep and increased REM latency. Piribedil decreased the probenecid-induced accumulation of the dopamine metabolite homovanillic acid (HVA) in CSF. A range of mild to moderate antidepressant effects was noted; one patient worsened and one developed recurrent manic episodes. The degree of improvement in depression was negatively correlated with pretreatment values of HVA in CSF ( r = —.66, p

Psychic distress, life crisis, and use of psychotherapeutic medications: national household survey data

Abstract: • Findings are reported from a nationwide survey of a crosssection probability sample (N = 2,552) of US adults. Data on psychic distress were obtained from a shortened version of the Hopkins symptom checklist, data on life crises from a shortened version of the Holmes-Rahe social readjustment rating scale. Methods for collecting data on use of psychotherapeutic medications were validated in a separate study. Data are presented on the prevalence of high levels of psychic distress and life crisis among various age, sex, and other demographic subgroups; on the relation between life crisis and psychic distress; and on the relation of life crisis and psychic distress to use of psychotherapeutic medications and alcohol. The findings suggest an illness behavior model for the use of psychotherapeutic medications in outpatient practice, and they lend little support to a "selfindulgent consumer" interpretation.

Excess Mortality in Schizophrenia and Affective Disorders: Do Suicides and Accidental Deaths Solely Account for This Excess?

Abstract: • Excess mortality was found in the first decade of follow-up for schizophrenia and affective disorders. This trend continued for schizophrenia throughout the entire four decades of the follow-up period. Suicides were higher than expected for all psychiatric groups except female schizophrenics and male manics. Accidental deaths were higher in these two groups, which did not show significantly excessive suicide rates. Suicides and accidental deaths were then excluded from the mortality analysis to determine their contribution to excess mortality. We conclude that death due to suicides and accidental deaths is not the sole cause for excess mortality, especially in schizophrenia.

Psychologic Status of Community Residents Along Major Demographic Dimensions

Abstract: • In a 1972 Chicago area survey of 2,299 adult community residents the prevalence of several psychologic measures were outlined along major demographic dimensions. Measures of psychologic status included a psychiatric symptom index, number of psychosomatic disorders, recent use of psychoactive drugs, and indexes of self-esteem and of self-efficacy. Results for psychiatric symptomatology showed it to be decidely higher among women, those in the lowest socioeconomic level, and those who are separated from their spouses. Blacks and whites showed no differences in symptomatology. Using multiple regression analysis, the combined effects of sex, age, marital status, and income accounted for 7% of the total variance of psychiatric symptoms. In a like manner, the prevalence of the other four psychologic characteristics has been viewed in the context of major demographic variables, with each showing a specific pattern of relationships.

Psychiatric Disorder, Hospital Admission, and Season

Abstract: • psychiatric disorder has been considered to have seasonal variation for a long time. The studies to date have suffered frequently from small samples and imprecise terminology, and the results have been inconclusive. This study has attempted to overcome these difficulties by examining hospital admissions to all facilities in the province of Ontario for a six-year period, with each year carefully divided into seasons. Statistically significant seasonal variation, with peaks in the spring and fall, was found overall for neurotic and endogenous depression. Alcoholism also showed a spring peak. No other diagnoses, overall, showed seasonality, although personality disorders, drug addictions, and transient situational disturbances exhibited trends similar to neurotic depression for certain age and sex groups. The findings are discussed in terms of their clinical and research significance.