Showing papers in "British Journal of Psychiatry in 1985"

Resilience in the face of adversity. Protective factors and resistance to psychiatric disorder.

Abstract: Almost since the beginnings of psychiatric practice, there has been a recognition that negative life experiences and stressful happenings may serve to precipitate mental disorders (Garmezy & Rutter, 1985). Nearly 200 years ago, Pinel wrote about the psychiatric risks associated with unexpected reverses or adverse circumstances, and it is reported that his initial question to newly admitted psychiatric patients was: “Have you suffered vexation, grief or reverse of fortune?” Nevertheless, although an appreciation that a variety of stressors may play a role in the genesis of psychiatric disorder has a long history, the systematic study of such effects is much more recent.

A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up.

Abstract: The two-year follow-up results are reported of a trial of social intervention in families of schizophrenic patients in high social contact with high-expressed emotion (EE) relatives. For those patients who remained on antipsychotic medication throughout the two years, the social intervention significantly reduced the relapse rate. In those experimental families where relatives' EE and/or face-to-face contact was lowered, the relapse rate was 14% compared with 78% for control patients on regular medication (P = 0.02).

Motives for offending among violent and psychotic men

Abstract: Two hundred and three male remanded prisoners were interviewed with respect to their current offence, mental state, and social and psychiatric histories. All but nine of the sub-group of 121 psychotic men showed active symptoms at the time of committing a criminal offence; 20% of the actively ill psychotics were directly driven to offend by their psychotic symptoms, and a further 26% probably so. If some of the indirect consequences of the psychosis were taken into account, 82% of their offences were probably attributable to the illness. Among the normal and neurotic men, none claimed psychotic motives for offending, but motives suggesting high emotional arousal such as panic or retaliation triggered the greatest violence. Within the psychotic group, those driven to offend by their delusions were most likely to have been seriously violent, and psychotic symptoms probably accounted directly for most of the very violent behaviour.

Chronicity and the General Health Questionnaire

Abstract: We propose a new scoring for Goldberg's (1972) General Health Questionnaire. We argue that the response 'no more than usual', to an item describing pathology, should be treated as an indicator of chronic illness rather than of good health, and we score these responses accordingly. We give evidence that this set of responses is associated with other measures of neurotic illness, and that the revised scoring provides a better prediction of caseness than the conventional scoring. The revised scoring is more strongly associated with trait neuroticism, and is more stable in repeated measurement. It is recommended in preference to the conventional scoring for most research and epidemiological purposes.

Organic delusions: phenomenology, anatomical correlations, and review.

Abstract: Organic delusions are common, but have received little systematic study. Review of the literature reveals that they occur most commonly in toxic-metabolic processes and in disorders affecting the limbic system and basal ganglia. A prospective study of 20 consecutive patients with organic delusions revealed four general types of false beliefs: simple persecutory delusions, complex persecutory delusions, grandiose delusions, and those associated with specific neurological defects (anosognosia, reduplicative paramnesia). Simple delusions responded best to treatment, and complex delusions were more resistent. Acting on delusional beliefs was not unusual, and treatment of the delusions was an important aspect of management of the patient.

Anorexia Nervosa, Parental ‘Expressed Emotion’ and Dropping Out of Treatment

Abstract: The number of dropouts from a long-term treatment study of patients with anorexia nervosa (AN) and bulimia nervosa (BN) was substantial. A variety of social, clinical, parental, and treatment factors were examined for their association with early termination of treatment by the patient or the family. Parents' expressed emotion' (EE) (particularly critical comments), BN, and the type of therapy offered (family or individual) were found to interact in some manner to result in dropping out. Some other aspects of parents' EE were also examined, including a comparison of scores in parental pairs; EE was found to be influenced by social class, and there were significant associations with the patient's symptomatology and social adjustment. There was a strong relationship between mothers' and fathers' scores in parental pairs.

Family management in the prevention of morbidity of schizophrenia: the adjustment of the family unit.

Abstract: Changes in the functioning of family members were assessed during a randomly controlled study of community management of schizophrenia. Eighteen families who completed two years community management based upon behavioural family therapy were compared with 18 families who received patient oriented management with family support. Families receiving family management reported less disruption of activities, reductions in physical and mental health problems, and less subjective burden than those receiving the patient oriented approach. It is concluded that the benefits of family management extend beyond the reduction in clinical and social morbidity of the index patient to beneficial effects for the family as a whole.

Irritability: definition, assessment and associated factors.

Abstract: The heading of 'Irritable Mood' was introduced into the Index Medicus in 1985 and it is noted that this term is frequently used but seldom defined. It is therefore important that a consensus is reached concerning its definition in the context of psychopathology and a definition is offered. It seems important to distinguish irritable mood and its outward manifestations from violently assaultive behaviour although there may be a continuum of disturbance from mildly to severely disordered behaviour. Irritability has so far not attracted much attention from clinicians and yet it is a common mood associated with many psychiatric and non-psychiatric conditions. Severe irritability may cause considerable distress both to the patient, his associates and sometimes also those attempting to treat or otherwise help him. It may overshadow other symptoms and the correct diagnosis and management may be missed. The validity and reliability of a convenient self-assessment scale is re-examined in the light of further data. Data from previous studies in the context of mood disorders suggests that irritability is a mood state which is independent of the other major moods of depression and anxiety; the severity of irritability probably has an inverse correlation with age. The most important associated factors are listed in order to inform researchers of the possible methodological pitfalls.

Schizophrenia with good and poor outcome. I: Early clinical features, response to neuroleptics and signs of organic dysfunction.

Abstract: Seventy-seven patients with diagnosis of schizophrenia (62) or schizoaffective disorder (15) were studied 2-20 years since onset of illness, when in a stable condition. The investigation included clinical assessment, measurement of plasma concentrations of neuroleptics and prolactin, computed tomography brain scan, neuropsychological and neurological examination. Outcome of illness was classified according to the presence of chronic psychiatric symptoms and social impairment, and response to neuroleptics according to the effect of treatment in the most recent psychotic episode. Neither outcome nor response to neuroleptics was related to duration of illness. The groups with good and poor outcome differed in premorbid adjustment, age at onset and symptoms of the initial episode, but not in drug bio-availability or prolactin response. Large cerebral ventricles and cognitive impairment, but not neurological 'soft' signs, were associated with unfavourable outcome. The three measures of organicity were not inter-related. No clinical differences were found between chronic patients with and without signs of organic dysfunction. The findings suggest that schizophrenia with good and unfavourable outcome may be separate sub-types. However, the role of organic factors in the latter group remains unclear.

Schizophrenia with good and poor outcome. II: Cerebral ventricular size and its clinical significance.

Abstract: Computer tomography brain scans were carried out on 40 patients with schizophrenia or schizo-affective disorder of 2-20 years duration. Ventricular-brain ratio (VBR) was significantly greater than that of the control group. In six patients the VBR exceeded the control mean + 2 s.d. Among the 13 whose VBR was more than 1 s.d. above the control mean, none had schizo-affective disorder, all but one had chronic illness, and patients with negative symptoms and those with premorbid schizoid traits were over-represented. VBR was unrelated to medical history, age, duration of illness, or neuroleptic treatment. It was not associated with neurological 'soft' signs or cognitive deficit. Among chronic patients, clinical features showed no association with ventricular size. The findings suggest that large ventricles may be related to a sub-type of chronic schizophrenia rather than to its particular clinical features.

Schizophrenia with good and poor outcome. III: Neurological 'soft' signs, cognitive impairment and their clinical significance.

Abstract: Fifty-six patients with RDC schizophrenia (42) or schizoaffective disorder (14), of two to 20 years' duration, were assessed for neurological 'soft' signs and cognitive impairment when in a stable condition--the 'outcome'. Neurological dysfunction (46% of 50 examined patients) was associated with a history of developmental abnormalities, but was unrelated to outcome, psychiatric symptoms, or treatment. Deficits in particular cognitive fields were related to two independent factors: overall severity of residual psychiatric disorder (outcome) and neurological dysfunction. There was no relationship between the size of the lateral brain ventricles on CT scan and either 'soft' signs or cognitive impairment. The findings do not provide evidence for an association between the presence of organic brain disorder (as indicated by the joint occurrence of neurological dysfunction and cognitive impairment) and either poor outcome or particular symptoms of schizophrenia.

Epileptic psychosis: an evaluation of PSE profiles.

Abstract: Data are presented on 24 patients with epilepsy and psychosis whose clinical presentation was rated using the Present State Examination (PSE). Seventeen had complex partial seizures and a diagnosis of temporal lobe epilepsy, seven had generalised epilepsy. An association between a CATEGO category of nuclear schizophrenia (NS) and a lesion of the left side was noted. No clear link between depressive symptoms and a right-sided focus was discovered. Affective disorders were noted in both groups of epileptic patients, although paranoid psychoses were commoner in the temporal lobe group. There was also a tendency for the latter to have more delusions of persecution, ideas of reference, and special features of depression. The group rated as NS appear less likely to show evidence of intellectual deterioration than the other psychotic patients; in addition, the interval between the onset of their epilepsy and the onset of their psychosis is shorter. Radiological assessment by CAT reveals few differences between groups, but the psychotic samples do show higher than expected values on a number of variables, in particular the bilateral septum-caudate distance and the size of the third and fourth ventricle.

The motor disorders of severe psychiatric illness: a conflict of paradigms.

Abstract: The motor disorder of 100 patients with severe psychiatric illness is described and the contribution of previous treatment, hospitalization and possible neurological disorder is considered. The conflict of paradigms between the concept that this motor disorder has two distinct aetiologies, psychiatric and neurological, and the concept that both motor and mental disorder are an expression of underlying cerebral disorder is discussed. An attempt is made to resolve this conflict by description of motor disorder without reference to neurological or psychiatric diagnosis.

Repetition of self-poisoning and subsequent death in adolescents who take overdoses.

Abstract: Hospital Activity Analysis data and record linkage were used to investigate repetition of self-poisoning, and deaths, among 2,492 people, aged 12 to 20 years, who took overdoses between 1974 and 1978. Repetition occurred most frequently during the first few months after an initial admission; 9.5% of patients repeated within the study period (mean follow-up of 2.8 years). Ten of the 2,492 subjects died during the study period, and the average annual death rate in the cohort was approximately four times higher than the national average annual death rate in this age-group as a whole. Six of the deaths were probably suicides. Repetition and suicide rates were highest among males aged 16 to 20 years.

Postnatal depression and child development. A three-year follow-up study.

Abstract: This study investigates whether three-year-old children whose mothers had been depressed after their birth showed more behaviour disturbance than children of mothers who were not depressed at that time. Ninety-one of 103 mothers who took part in an earlier prospective study of postnatal depression were reinterviewed three years later to determine their present mental state, and to assess their child's behaviour, using Richman's Behavioural Screening Questionnaire. No relationship was found between a prolonged postnatal depression and behaviour disturbance in the child, but children whose mothers had brief postnatal depressive episodes showed more behaviour disturbance than those whose mothers had not been depressed since childbirth.

Recent undesirable life events and psychiatric disorder in childhood and adolescence.

Abstract: A sample of children and adolescents (n = 157) attending a child psychiatry outpatient clinic with conduct or emotional disturbance were compared with community controls (n = 76) for the number and type of recent life events. A Life Events Schedule for children and adolescents was developed and used as a semi-structured interview. Four clinical groups were identified according to their predominant presenting symptoms (conduct, mild mood, severe mood, or somatic). An excess of events carrying a severe degree of negative impact was found for all four groups, compared with matched controls. Eleven classes of events were examined: there is a suggestion that two classes (martial/family, accident/illness) may be more important for conduct and mild mood disorders, and that a further class (permanent separations, termed exits) may be more important for somatic and severe mood disorders.

Violence and Asperger's syndrome: a case study.

Abstract: A recent review of the clinical features of 'autistic personality disorder' (Wing, 1981), originally described by Asperger (1944), emphasised the diagnostic primacy of the impairment of two-way social interaction shown by such patients, who reveal a profound lack of empathy for others. They appear unable to perceive the meaning or implications of the expressions and gestures of others, and such non-verbal behaviour in other people is often misinterpreted or ignored. There is usually a corresponding poverty, or other abnormality of nonverbal expression by the patient. Speech may be delayed, but the understanding of the spoken word is not, and a good command of language is usual in adults. However, the speech is often pedantic, repetitive (especially on subjects dear to the patient), and circumstantial; a monotonous lack of intonation is common, rendering the voice inexpressive and idiosyncratic. Those with the syndrome are usually inflexible in other ways: they frequently favour repetitive, familiar activities and become closely attached to certain possessions or places. Play in childhood is similarly restricted and 'pretend games', especially those which involve taking on another identity, are strange to the affected child, and rarely played. Similarly, they often develop an intense interest in a chosen field, such as astronomy or chemistry, on which they are prepared to expound at great lengths, being insensitive to the reaction of the listener. Gait and posture are frequently clumsy, manneristic, and iII-coordinated. Clumsiness, like the other features, dates back to infancy. A history of abnormalities of the baby's response to the mother may often be elicited, but the problem usually becomes conspicuous when the child is three or four years old. Individuals with the syndrome have particular difficulties in peer relationships, and in childhood, the closest relationships are usually made with adults. The present report concerns one patient who demonstrates all these clinical features but has developed, in addition, interests and behaviour which pose considerable potential hazards for others and which led to his continued detention in a Special Hospital. Dangerous behaviour in assocIatIOn with the syndrome has not been described in any detail previously, although in her review, Wing (1981) wrote that \"a small minority have a history of rather bizarre anti-social acts, perhaps because of their lack of empathy. This was true of four of the present sesries, one of whom injured another boy in the course of his experiments on the properties of chemicals\". Details of the incident are not further elaborated, but are of relevance here, since an interest in chemicals and their potential as the means for homicide are important features of our patient's presentation. Wolff & Chick (1980) summarise the main features of the patients described by Asperger (1944): in one case, the emotional disturbances were illustrated by \"cool threats to stab the mother\", while more generally, \"extreme personal sensitivity and egocentrism associated with callousness towards others\" were observed. Their own series of 20 boys described as suffering from \"schizoid personality in childhood\" probably includes patients with Asperger's syndrome, although they did not use his criteria in diagnosis. One of the 20, ten years after diagnosis, was in the Scottish State Hospital at Carstairs, after an assault on a patient in a conventional psychiatric hospital.

Psychiatric disorder in the middle-aged and elderly mentally handicapped.

Abstract: In a study of 357 long-stay hospital residents aged 40 years and over, 30% had significant psychiatric disorder, while a retrospective survey of 215 new admissions over a seven-year period to a psychiatric unit for the mentally handicapped revealed that 20% of patients were aged 40 years and over. Both similarities and differences were found in the overall pattern of disorders between the two groups and a non-handicapped population in a comparable age-range.

The importance of dosage in prescribing antidepressants.

Abstract: The treatment of depressive disorders was significantly altered by the introduction of the tricyclic antidepressants and the monoamine oxidase inhibitors. One salient factor in determining efficacy is the dose prescribed. The few good dose response studies which are available indicate that patients should receive 300 mg of imipramine or equivalent, and a separate trial of 90 mg of phenelzine or equivalent, before concluding they are treatment refractory. Data are reviewed which suggest many patients receive inadequate doses.

Plasma amino acids in relation to cerebrospinal fluid monoamine metabolites in schizophrenic patients and healthy controls.

Abstract: Compared to healthy controls, unmedicated schizophrenic patients had significantly higher plasma concentrations of taurine, methionine, valine, isoleucine, leucine, phenylalanine, and lysine. Except for taurine, these amino acids share the L-transport system for neutral amino acids. In the patients, homovanillic (HVA) acid levels in CSF were decreased and the plasma levels of the amino acids competing with tyrosine and tryptophan for transport into the brain, were all negatively correlated to the CSF concentrations of HVA and 5-HIAA. These findings could be explained by a change in the affinity of the L-system or by a decrease in its overall capacity in schizophrenia. Raised plasma levels of the competing amino acids may limit the brain uptake of tyrosine, leading to a diminished dopamine turnover, and resulting in a compensatory development of supersensitive dopamine receptors.

Depression: distress or disease? Some epidemiological considerations.

Abstract: Surveys using clinical-type interviews have documented a high rate of depression among working-class women, and this is discussed in the light of a recent survey in an inner-city area. While women with caseness of depression contacting a psychiatrist did not differ in number of core depressive symptoms from those who did, they did in certain characteristics that would make them worrying for a general practitioner to deal with. It is concluded that there is a considerable overlap in the severity of depressive conditions between those seen by psychiatrists and those defined as cases in population surveys; any differences that do exist may relate more to the way symptoms are expressed than to the severity of the depressive disorder as such.

The present status of monoamine oxidase inhibitors.

Abstract: The present status of monoamine oxidase inhibitors in the treatment of depression is reviewed. With adequate doses they are effective antidepressants, but dosages have in the past been too low. Provided proper dietary precautions are taken, the incidence of fatality from dietary interactions is very small and should not deter doctors from using these drugs, especially in those depressed patients who do not respond to tricyclic-type antidepressants. The present status of combining monoamine oxidase inhibitors with tricyclics is discussed, as are the newer specific inhibitors particularly clorgyline and deprenyl.

The Nottingham ECT Study. A double-blind comparison of bilateral, unilateral and simulated ECT in depressive illness.

Abstract: Sixty nine patients took part in a double-blind study to investigate the efficacy of bilateral, unilateral, and simulated ECT in the treatment of depressive illness. The findings suggest that both bilateral and unilateral ECT are highly effective treatments for depression and are significantly superior to simulated ECT. There was also evidence that patients receiving bilateral ECT recovered more rapidly than those receiving unilateral ECT and required significantly fewer treatments. The relevance of these findings to clinical practice is discussed.

Biological antagonism and epileptic psychosis.

Abstract: The controversial literature about the biological antagonism between schizophrenia and epilepsy involves at least two areas of clinical interest. Firstly, it is frequently stated that convulsive treatment was introduced into psychiatry for the management of psychosis because of this antagonism, and secondly, it has a bearing on the topics of 'alternative psychosis' and 'forced normalisation', as reported in the epilepsy literature. In addition to these, the subject is of theoretical interest in its relationship to other biological antagonisms that may be found in nature, but closer examination of the literature suggests that some of the discussions and controversies surrounding this problem are based on assumptions that may be incorrect. One possible reason for this may be the fact that much of the original work was written in German, and we propose therefore to give a brief account of the origins of the theories, as derived from their original sources.

Puerperal mental illness, clinical features and classification: a study of 142 mother-and-baby admissions.

Abstract: The case notes were studied of 142 mothers admitted to psychiatric hospitals in the south-east Thames region within 12 months of childbirth during the years 1979 and 1980. Only 6% of the sample were categorised as schizophrenics by RDC criteria, whereas affective disorders were found to predominate in 80%. Manic and schizo-affective illnesses almost always began within two weeks of parturition, as did psychotic depressions. A third of the patient sample had suffered relatively minor disorders, and given adequate resources, some might have been better managed in the community. A parallel investigation of diagnostic returns to the Department of Health revealed considerable uncertainty about how to classify puerperal mental illnesses in accordance with ICD-9. There is an urgent need to improve the system for categorising and registering mental illnesses related to childbirth. Until this is achieved, research into aetiology, outcome, and the provision of services will continue to be impeded.

Treatment of seasonal affective disorder with light in the evening.

Abstract: A cross-over comparison study of exposure, in the evenings only, to bright versus dim light was carried out on nine female patients with seasonal affective disorder A significant antidepressant effect of the bright lights was shown No consistent observable effects were produced by the dim lights These results support earlier studies demonstrating the efficacy of bright light given morning and evening The antidepressant effect of light is not mediated by sleep deprivation, and the early morning hours are not crucial for a response

Depression in general practice: case thresholds and diagnosis.

Abstract: Using multiple diagnostic and epidemiological criteria, three samples of general practice (GP) depressives were studied: those prescribed a new course of antidepressants, those given other treatment, and those missed by the GP. The majority of patients qualified as psychiatric cases on the PSE Index of Definition, the Bedford College Criteria, and the Research Diagnostic Criteria. Most satisfied diagnostic criteria for depression, or (fewer) anxiety. The disorders were relatively mild and often borderline on all three systems. Depressives given other treatment most often failed to meet diagnostic criteria. About half the antidepressant treated patients received RDC diagnoses of major depression. Among the other treatment sample, only one-fifth met these criteria, and half had non-depressive diagnoses. Most cases of depression treated by GPs satisfy criteria for psychiatric disorder, but tend to be relatively mild and borderline in quality.

A comparison of elective mutism and emotional disorders in children.

Abstract: The case notes of 24 children diagnosed as elective mutes were compared with those of 24 matched controls with diagnosed emotional disorders. One-third of the elective mutes (but none of the controls) had experienced delayed development of speech or difficulties in articulation. All the elective mutes lived in two-parent families, but marital discord was noted in half the families in both groups. Compared with the controls, the mute children were more often described as 'anxious', 'depressed' and 'manipulative', and their mothers were characterised as 'over-protective', and tending to 'spoil' their children. Three unusual cases, of mutism at home, are described in detail. It is proposed that elective mutism is associated with particular personal and family characteristics and represents a condition different from any recognised emotional disorder.

Psychiatric illness in first-degree relatives of patients with paranoid psychosis, schizophrenia and medical illness.

Abstract: This study examines the respective morbid risk for psychiatric illness determined by the family history method in the first-degree relatives of medical controls and patients with delusional disorder (paranoid psychosis) and schizophrenia. The morbid risk for schizophrenia and schizoid-schizotypal personality disorder was significantly greater in the relatives of the schizophrenic patients than in those of the delusional disorder or medical control patients, but no difference in the risk for affective illness or alcoholism was found in the three groups of relatives. Paranoid personality disorder was significantly more common in the relatives of the delusional disorder patients than in those of the medical controls. These results support the familial independence of delusional disorder and schizophrenia.

A follow-up study of accident neurosis.

Abstract: Thirty five claimants with accident neurosis, in which there were gross perplexing somatic symptoms without demonstrable organic pathology were traced and followed-up in their homes, from one to seven years after compensation was received. Few claimants recovered and such recovery as did take place was unrelated to the time of compensation. Family processes leading to over-protection by relatives were examined and appeared to be vitally important in the prolongation of symptoms. The legal process and the delays involved caused great distress.