Showing papers in "British Journal of Psychiatry in 1977"

The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. An expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976.

Abstract: An account is given of attachment theory as a way of conceptualizing the propensity of human beings to make strong affectional bonds to particular others and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression and emotional detachment, to which unwilling separation and loss give rise. Though it incorporates much psychoanalytic thinking, many of its principles derive from ethology, cognitive psychology and control theory. It conforms to the ordinary criteria of a scientific discipline. Certain common patterns of personality development, both healthy and pathological, are described in these terms, and also some of the common patterns of parenting that contribute to them.

A Danish twin study of manic-depressive disorders.

Abstract: The existence of a nation-wide twin register and central psychiatric register has made possible a catamnestic investigation of an unselected and representative sample of twins with manic-depressive disorders. From a total population of 11,288 same-sexed twin pairs born 1870-1920 in Denmark 126 probands from 110 pairs were ascertained. Among the co-twins of 69 monozygotic probands there were found 46 with manic-depressive disorders, and a further 14 had presented other psychoses or marked affective personality disorders or had committed suicide, yielding a proband rate of strict concordance, C1 = 0-67 and of broad, partial concordance, C2 = 0-87. The corresponding direct pairwise concordance rates were 32/55 = 0-58 and 46/55 = 0-84 respectively. For the dizygotic twins the proband concordance rate of C1 was 11/54 = 0-20 and of C2 20/54 = 0-37, and the direct pairwise rates were 9/52 = 0-17 and 18/52 = 0-35 respectively. The differences between the pairwise rates for the monozygotic and dizgotic twins are significant (P less than 0-001 at X2 analysis). This finding is in accordance with previous twin studies of manic-depressive disorders and confirms the evidence of a strong genetic factor. The concordance with respect to unipolar and bipolar forms was not in contradiction to recent evidence of a genetic difference between the bipolar and unipolar form, the latter probably related to the female sex.

Depression and loss.

Abstract: Recent losses occurring in the two years before onset of depression in women are distinguished from past losses occurring at any time before this. Of past losses only loss of mother before II is associated with greater risk of depression--both among women treated by psychiatrists and among women found to be suffering from depression in a random sample of 458 women living in London. Past loss of a father or sibling before 17 (or a mother between II and 17), or a child or husband, is not associated with a greater chance of developing depression. However, among patients all types of past loss by death are associated with psychotic-like depressive symptoms (and their severity) and other types of past loss with neurotic-type depressive symptoms (and their severity). It is argued that these associations probably reflect direct causal links, and a sociopsychological theory to explain them is discussed.

Psychiatrists and a computer as interrogators of patients with alcohol-related illnesses: a comparison.

Abstract: A computer-administered 'interview' was developed for eliciting evidence relating to alcohol problems. Thirty-six volunteer male patients on their first visits to a specialist alcohol clinic were interviewed three times, by two psychiatrists and by the computer; information was sought about 72 pre-defined indicants concerning alcohol consumption, drinking behaviour, and symptoms. Each patient was asked to complete an attitude questionnaire anonymously. The extent of agreement between the evidence elicited by the computer and by the psychiatrists was quite high, and their estimated error rates were very similar, all between 10 per cent and 12 per cent in total. With respects to amounts of alcohol consumed, patients reported significantly greater amounts to the computer than they reported to the psychiatrists. The median amounts of pure ethanol consumed ranged from 1-19 kg per week calculated from reports made to one of the psychiatrists, up to 1-58 kg per week calculated from reports made to the computer. The results from the attitude questionnaire indicated a high level of acceptability to patients of computer interrogation.

The social network, support and neurosis. The function of attachment in adult life.

Abstract: The psychological function of the social network is considered in terms of attachment theory. Social bonds are proposed as essential for obtaining a commodity commonly but unsatisfactorily referred to as support. Requirements for this complex commodity can be discerned in a wide range of contexts. Examples considered are the evolutionary origin of the social network itself, the concept of psychosocial supplies, the distribution of neurosis in Western and non-Western populations, the use of medical consultations, psychotherapy and habitual responses to adversity or disaster. In these and other contexts, it is apparent that individuals have, quite simply, a requirement for affectively positive interaction with others. Under stressful conditions this interaction is called 'support'. When support is lacking there is evidence that psychiatric and perhaps medical morbidity rates increase. For reaseach, the objective must now be to determine whether depleted primary group interaction is causally related to morbidity, or whether it is only an associated or a secondary factor in aetiology, or indeed wholly unrelated. Elucidating more precisely why people need people constitutes an important new task for social psychiatry.

The making and breaking of affectional bonds. II. Some principles of psychotherapy. The fiftieth Maudsley Lecture.

Abstract: An account is given of how a clinician guided by attachment theory approaches the clinical conditions to which the theory is held to apply, which include states of anxiety, depression and emotional detachment. Assessment of a patient is in terms of the patterns of attachment and caregiving behaviour which he commonly shows and of the events and situations, both recent and past, which may have precipitated or exacerbated his symptoms. The problems posed by relevant information being suppressed or falsified are noted. Viewed in this perspective a psychotherapist is seen to have a number of inter-related tasks: (a) to provide the patient with a secure base from which he, the patient, can explore himself and his relationships; (b) and (c) to examine with the patient the ways in which he tends to construe current interpersonal relationships, including that with the therapist, and the resulting predictions he makes and actions he takes, and the extent to which some may be inappropriate; (d) to help him consider whether his tendencies to misconstrue, and as a result to act misguidedly, can be understood by reference to the experiences he had with attachment figures during his childhood and adolescence, and perhaps may still be having.

Coefficients of agreement between observers and their interpretation.

Abstract: The measurement of agreement between ratings of patient symptomatology by two or more psychiatrists is discussed. It is noted that coefficients which allow for possible chance agreement are to be preferred, but they involve assumptions about the way in which chance factors may operate. Assumptions which involve prior probabilities of the incidence of a symptom appear to be too stringent, and a new coefficient, called the RE coefficient, is recommended in which is assumed to operate in a purely random way. Binary scales are discussed in detail, but methods of dealing with scales of wider range are also referred to.

What have cognitive deficits to do with schizophrenic symptoms

Abstract: This paper considers possible relationships between cognitive deficits and symptomatology in schizophrenia. It is argued that a combination of defective filtering and slowness in response selection results in a state of information overload in acute schizophrenia. The methods by which normal subjects adapt to experimenter-induced overload may therefore be relevant to aspects of schizophrenic behaviour. The considerable intra- and inter-subject variability in symptomatology of schizophrenic patients may represent differeing adaptations to similar cognitive disturbance, such secondary abnormalities being prominent in chronic patients. Sections of the literature on acute-chronic differences are consistent with such a formulation, although one cannot infer intra-individual change from cross-sectional studies; there is a clear need for longitudinal investigations in this area. The preferred method of adaptation will be dependent on the severity of overload, the environment, and personality factors independent of the psychosis. The implications for the modification of schizophrenics' behavioural abnormalities by operant procedures are discussed.

Suicidal intent in self-injury.

Abstract: The difficulties in measuring suicidal intent in cases of self-injury are discussed, and a scale is described to measure this intent. This scale has been used in 500 cases of self-injury. It is practical and reliable. Results show that the scores derived from it are closely related to the similar Beck Scale; they are also related to age, sex, social isolation method of self-injury, previous history of self-injury or of psychiatric treatment, physical health at the time of self-injury and alcohol abuse. These results are discussed with particular reference to suicide prediction and the future validation of the scale by long-term follow-up.

Cultural and temporal variations in schizophrenia: a speculation on the importance of industrialization.

Abstract: A speculative hypothesis is presented which links the late development of modern concepts of schizophrenia with social and familial effects of industrialization. It is suggested that the social and family structures found historically in pre-industrial societies and currently in developing countries exert a comparatively benign effect upon patients with schizophrenia, and that these effects are lost during and after industrialization. Thus the severe and chronic forms of the illness became prominent and therefore recognized in the segregated institutions of Europe in the latter part of the nineteenth century. Possible mechanisms are examined by which industrialization could influence the structure of communities and families and the development of individuals to produce the postulated changes in the individual's response to the schizophrenic illness. It is suggested that three major areas of interest for the identification of these mechanisms are (i) the rapid increase in size of towns and communities, (ii) changes in perinatal and infant mortality and morbidity, and (iii) changes in family structure. Some ways of testing the hypothesis and its implications are outlined.

The Syndrome of Capgras

Abstract: In eleven patients with the syndrome of Capgras, the clinical data and the results of electroencephalographic, echoencephalographic, air-encephalographic, psychological and brain-scanning investigations are presented and discussed. All patients were psychotic: six were schizophrenic, four were depressive and one suffered from an organic psychosis. A paranoid element was marked in all cases. The present evidence supports the view that organic factors are important in the pathogenesis of Capgras' syndrome.

The impact of an abnormal child upon the parents.

Abstract: Thirty families with a newborn mongol baby were matched with thirty families with a normal baby. Both groups were followed for eighteen months to two years and interviewed six times. Few differences could be found in the mental or physical health of the two groups of parents, but marital breakdown or severe marital disharmony was found in nine of the mongol families and in none of the controls.

Mortality in patients with schizophrenia, mania, depression and surgical conditions. A comparison with general population mortality.

Abstract: Mortality data are presented from a four-decade follow-up study of 200 schizophrenic, 100 manic, 225 depressive patients, and 160 surgical controls (80 appendicectomy; 80 herniorrhaphy). Data for this analysis were available on 648 (95 per cent) members of the study population. Using sex-age standardized mortality ratios (SMR), the mortality experience of the study population was compared with that of the state of Iowa, the geographical area served by the admitting medical facility for the study group. Results are presented for a four-decade period beginning 1935-44, and ending 1965-74. All three psychiatric groups had a significant increase in mortality risk. This was most pronounced in the first decade following admission, although schizophrenic patients, especially females, continued to show a significant excess of deaths throughout the entire four decades of the follow-up period. During no decade of the follow-up period did the mortality of the surgical controls differ significantly from that of the Iowa population.

Validity of the Hamilton Rating Scale for depression.

Abstract: In 26 depressed patients, a high correlation (0-89) was found between the Hamilton score and a psychiatrist's global rating and between the change (0-68) in these ratings during treatment. The Hamilton scale was able to differentiate at the o-01 level four degrees of severity based on the global rating. Limiting the range of severity measured was found to lower significantly the correlation between the ratings. A prospective examination of a six-item sub-scale of the Hamilton scale developed by Beck and associates failed to confirm its claimed improvement in sensitivity or validity.

Assessing dangerousness in criminals.

Abstract: This article formulates a definition of the term dangerousness, indicates why the commission of dangerous offences cannot be reliably predicted, and then reviews the several factors which have been or might be used by those who have to make decisions about dangerousness in criminals. Its suggests that these factors are useful insofar as they help to illuminate the individual's capacity to feel sympathy and to learn by experience. Since the accuracy of prediction varies inversely with time, the maintenance of personal relationships and good communication seems the inescapable requirement in the management of potentially dangerous criminals.

Behaviour problems in pre-school children: family and social factors.

Abstract: In a group of 99 three-year-old children with behaviour problems identified in an epidemiological survey, family and social factors were compared with those in a group of controls. Behaviour problems were significantly associated with a strained marital relationship between parents, with social stresses and with type of housing. There was a high rate of maternal depression in both problem and control groups. The interaction between a behaviour problem in a young child, maternal mental health and social factors is discussed.

Psychiatric morbidity and the menopause: survey of a gynaecological out-patient clinic.

Abstract: Two hundred and seventeen women between the ages of 40 and 55 years referred to a gynaecological out-patient clinic were screened for psychiatric illness by means of the General Health Questionnaire (GHQ) and a brief special questionnaire. Of the 114 women identified as possible psychiatric 'cases' 104 were interviewed. A standardized psychiatric interview schedule was used. Compared with a general population sample from the same geographical area and in the same age range, women presenting at the gynaecological out-patient clinic were predominantly pre-menopausal and from the lower end of the 15-year age range, and were more likely to be separated or divorced, less likely to be single, and more likely to have had previous or to have subsequent contact with the local psychiatric services. A higher proportion of women were identified as psychiatric 'cases' in the clinic population than in the general population, and their psychiatric disorder appeared to be severe and more depressive in nature. The findings for this age group support the view that among women presenting for hysterectomy there is already an excess of psychiatric illness before the operation. The association of gynaecological complaints and psychiatric morbidity in the pre-menopausal years is discussed.

Psychosis in Mental Handicap. The tenth Blake Marsh lecture delivered before the Royal College of Psychiatrists, February 2, 1976.

Abstract: The literature on the purely psychiatric aspects of mental handicap is remarkably limited. In the third edition of Mayer-Gross, Slater and Roth's Clinical Psychiatry, apart from one or two brief incidental mentions elsewhere in the text, the main references consist of just one paragraph on psychoses and two short paragraphs on neuroses included in the section on ‘The Association of Mental Subnormality with Other Syndromes’! Similarly the only reference to mental illness in mental handicap in the eighth edition of Henderson and Gillespie's Text-Book of Psychiatry was a mere four lines on psychosis; by the ninth edition, this had grown to seven lines covering both neuroses and psychoses, but with two of those lines devoted to an admission by the authors of their own lack of knowledge.

Delusional depressions: natural history and response to treatment.

Abstract: A review of the abundant literature concerning the distinction between delusional and non-delusional depressions, especially of the work of Aubrey Lewis, reveals that before the introduction of specific therapies most in-patients with major depressive illness eventually recovered; the small percentage who did not almost all came from the delusional group. The dichotomy lost its clinical significance after the introduction of ECT, as both groups were equally responsive. However, accumulating evidence indicates that unipolar delusional depressives are significantly less responsive to tricyclic anti-depressant therapy than non-delusional depressives. The presence or absence of delusional thinking should be considered as a significant criterion in the classification of depressive disorders, and the presence or absence of delusional thinking should influence the choice of treatment for severely depressed patients.

A clinical trial of phenelzine in anxiety depressive and phobic neuroses.

Abstract: A double-blind clinical trial of phenelzine and diazepam against placebo and diazepam in neurotic patients over a four-week period showed phenelzine to be superior to placebo on three rating scales in some groups of patients who completed the trial. The findings suggest that phenelzine may exert a beneficial effect on some as yet undefined features of anxiety and depression which were not revealed by a multiple regression analysis of clinical symptomatology or premorbid personality.

Cyclone Tracy and Darwin evacuees: on the restoration of the species

Abstract: A validated objective measure of the state of psychological function was used to determine the incidence and course of psychological dysfunction in a group of evacuees from Darwin following disaster caused by a cyclone (Cyclone Tracy). While psychological dysfunction was increased initially (58 per cent) and at ten weeks (41 per cent), it had returned to an Australian general population control level (22 per cent) at 14 months. Factors influencing psychological dysfunction were examined, and it is suggested that the sample faced two different stressors at differing times. Initial psychiatric morbidity was most clearly associated with the experience of thinking that one might die or be seriously injured and therefore conceptualized as a 'mortality stressor'. Psychiatric morbidity at ten weeks appeared to be most closely associated with what has been conceptualized as a 'relocation stressor'. Reasons why psychiatric morbidity decreased to a general population control level are discussed.

The repetitiveness of self-poisoning and self-injury.

Abstract: A year's cohort of 690 suicide 'attempters' was followed for two years in order to monitor further attempts leading to referral to the general hospital. Eighteen per cent were involved in one or more repeat episodes, 16 per cent within the first year. More repeats occurred within the first three months than in the rest of the 21 months, and a large majority of repeats occurred within the first year. Study of a smaller cohort of 141 persons gave information about the frequency and timing of previous attempts. Forty-five per cent had made previous recognized attempts and 10 per cent previous unrecognized attempts. Sixty persons reported 166 previous attempts. Of previous attempters 32 per cent made two or more attempts within a three-month period. Three types of repeaters are suggested: (a) the chronic, habitual repeater; (b) the individual who repeats several times within a short period, and (c) the 'one-off' very occasional repeater.

Parasuicide in Edinburgh--a seven-year review 1968-74.

Abstract: Parasuicide admissions to the Regional Poisoning Treatment Centre in Edinburgh are reviewed over the seven year period 1968-74. Special emphasis is given to trends in parasuicide rates for Edinburgh City, but social and clinical data are also described. Though the mean annual increase for admissions is 10-6 per cent, recent years have shown a fall in the rates for men and a levelling off for women. There have been increases in the rates for the young, for men in social classes 4 and 5 and for divorced women, and in poisonings with psychotropic drugs and alcohol consumption among women. At the same time it is important to note variables which have not changed: the relative risks by age and sex, repetition rates, the diagnostic picture, poisoning with non-prescribed drugs, and the rank order of municipal ward rates: and variables which have diminished: the rates for divorced men, overcrowding, domestic gas and barbiturate poisoning, and drug misuse. A comprehensive explanation of parasuicide in the contemporary scene would have to explain both the consistencies and the changing trends. The answer to the central question of why parasuicide is changing remains elusive.

A ten-year follow-up study of Chinese schizophrenics in Hong Kong.

Abstract: One hundred and thirty-three Chinese schizophrenic patients first seen in 1965 were traced for a follow-up assessment in 1975. Eighty-two patients attended and were fully evaluated, 47 failed to attend and 4 were known to have died. The course and outcome were graded into four categories, and it was found that 65 per cent of the fully evaluated group had full and lasting remission or showed no or mild deterioration only, despite some relapses. Intra-group comparison showed that being female, a shorter duration of illness, an acute onset, symptom-groups other than disturbances of emotion and volition, and the presence of a supportive relative are factors which affect the prognosis favourably.

Smooth pursuit eye movements of schizophrenics and normal people under stress.

Abstract: Eye movements while watching an oscillating pendulum were recorded in 24 chronic schizophrenies and 24 matched normal controls. As others have reported previously, abnormal tracking movements were significantly commoner in the schizophrenics. However, in a series of experiments with normal subjects it was found that conditions designed to distract attention, or to produce declining arousal and attention, produced abnormal tracking movements indistinguishable from those observed in schizophrenics. As chronic schizophrenics are known to perform badly on a variety of psychomotor tasks and there is evidence that this is due to impaired attention or heightened distractibility, it seems likely that these same factors are responsible for their poor eye-tracking performance.

Capgras' syndrome and cerebral dysfunction.

Abstract: Two cases of Capgras' syndrome in association with coarse brain disease are presented. The authors suggest that prosopagnosia (face nonrecognition) may be the primary expression of a specific cerebral dysfunction which forms the basis for a delusional elaboration resulting in Capgras' syndrome.

Seasonality of Mania: a Reappraisal

Abstract: Some recently published data on the seasonal incidence of mania are re-examined. The reanalysis confirms a strong, seasonal trend in females, but also demonstrates a similar trend in males; the latter results is at variance with an earlier finding which showed no seasonal pattern in males. A simple harmonic curve would describe the data extremely well in both sexes, and the parameters of these curves (the amplitude of variation and the time of maximum incidence) are very close for males and females.

Psychiatric morbidity among university students in Egypt.

Abstract: During a nine-month period (1974-75), 1,050 students (846 male, 204 female) at Ain Shams University, Cairo, attended the Student Health Centre. Fifty-two per cent were referred there by their general practitioners, 5 per cent by their families and 3 per cent through their faculties; the remainder (41 per cent) were self-referred. Male patients represented 2-8 per cent of the male students, but female patients only 0-9 per cent of the female students. In faculties dealing with practical subjects the male-female ratio was higher than in those dealing with more theoretical subjects. The diagnoses included anxiety neurosis (36 per cent of the cases), schizophrenia (18 per cent), depression (15 per cent) and neurotic depression (12 per cent).

Social skills training of out-patient groups. A controlled study of rehearsal and homework.

Abstract: Fifty-one out-patients with social skills deficits (two-thirds men) completed ten weekly sessions of 75-minute group treatment; 44 were followed up for a mean of 16 months. Random assignment was to one of three conditions: (I) Cohesive group discussion; (2) Modelling and role-rehearsal; or (3) Modelling and role-rehearsal + daily social homework. All three treatment conditions produced significant but incomplete improvement at the end of treatment and follow-up. The two role-rehearsal conditions were significantly superior to group discussion on several measures. Patients who completed daily social homework assignments did significantly better than patients who completed control homework. Alcohol and drug abuse patients usually dropped out. Schizophrenic patients in remission had lost their improvement at follow-up. Patients with other diagnoses retained their gains to 16-month follow-up.