Showing papers in "British Journal of Psychiatry in 1994"
TL;DR: It is shown that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices, and how these core beliefs about voices may become a new target for treatment.
Abstract: We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
TL;DR: C cognitive therapy was superior to both applied relaxation and imipramine on most measures and self-exposure homework assignments taken at the end of treatment were significant predictors of outcome at follow-up.
Abstract: Recent studies have shown that cognitive therapy is an effective treatment for panic disorder. However, little is known about how cognitive therapy compares with other psychological and pharmacological treatments. To investigate this question 64 panic disorder patients were initially assigned to cognitive therapy, applied relaxation, imipramine (mean 233 mg/day), or a 3-month wait followed by allocation to treatment. During treatment patients had up to 12 sessions in the first 3 months and up to three booster sessions in the next 3 months. Imipramine was gradually withdrawn after 6 months. Each treatment included self-exposure homework assignments. Cognitive therapy and applied relaxation sessions lasted one hour. Imipramine sessions lasted 25 minutes. Assessments were before treatment/wait and at 3, 6, and 15 months. Comparisons with waiting-list showed all three treatments were effective. Comparisons between treatments showed that at 3 months cognitive therapy was superior to both applied relaxation and imipramine on most measures. At 6 months cognitive therapy did not differ from imipramine and both were superior to applied relaxation on several measures. Between 6 and 15 months a number of imipramine patients relapsed. At 15 months cognitive therapy was again superior to both applied relaxation and imipramine but on fewer measures than at 3 months. Cognitive measures taken at the end of treatment were significant predictors of outcome at follow-up.
TL;DR: It is postulated that the depressive state evolved in relation to social competition, as an unconscious, involuntary losing strategy, enabling the individual to accept defeat in ritual agonistic encounters and to accommodate to what would otherwise be unacceptably low social rank.
Abstract: Depressive personality and depressive illness are examined from an evolutionary adaptationist standpoint. It is postulated that the depressive state evolved in relation to social competition, as an unconscious, involuntary losing strategy, enabling the individual to accept defeat in ritual agonistic encounters and to accommodate to what would otherwise be unacceptably low social rank.
TL;DR: It is hypothesised that the increases in rCBF in the orbitofrontal cortex, neostriatum, global pallidus and thalamus were related to urges to perform compulsive movements, while those in the hippocampus and posterior cingulate cortex corresponded to the anxiety that accompanied them.
Abstract: Regional cerebral blood flow was measured with H2 15O positron emission tomography in four patients with obsessive-compulsive disorder. Patients were scanned on 12 occasions in the same session, with each scan paired with brief exposure to one of a hierarchy of contaminants that elicited increasingly intense urges to ritualise. The relationship between symptom intensity and regional cerebral blood flow (rCBF; an index of neural activity) was subsequently examined in the group and in individual patients. The group showed significant positive correlations between symptom intensity and blood flow in the right inferior frontal gyrus, caudate nucleus, putamen, globus pallidus and thalamus, and the left hippocampus and posterior cingulate gyrus. Negative correlations were evident in the right superior prefrontal cortex, and the temporoparietal junction, particularly on the right side. The pattern in single subjects was broadly similar, although individual differences in neural response were also observed. A graded relationship between symptom intensity and regional brain activity can thus be identified in obsessive-compulsive disorder. It is hypothesised that the increases in rCBF in the orbitofrontal cortex, neostriatum, global pallidus and thalamus were related to urges to perform compulsive movements, while those in the hippocampus and posterior cingulate cortex corresponded to the anxiety that accompanied them.
TL;DR: The rate of treatment-emergent switch into mania has been calculated from all available clinical trial data on the selective serotonin re-uptake inhibitors (SSRIs) fluoxetine, fluvoxamine, paroxetines, and sertraline, relative to comparative groups treated with tricyclic antidepressants (TCAs) or placebo.
Abstract: The rate of treatment-emergent switch into mania has been calculated from all available clinical trial data on the selective serotonin re-uptake inhibitors (SSRIs) fluoxetine, fluvoxamine, paroxetine, and sertraline, relative to comparative groups treated with tricyclic antidepressants (TCAs) or placebo. In predominantly unipolar depressives, the rate of manic switch is less than 1% and differences between drugs and placebo are statistically but not clinically significant. In bipolar depressives, manic switch occurs substantially more often with TCAs (11.2%) than with SSRIs (3.7%) or placebo (4.2%).
TL;DR: This simple mental state recognition task appears to relate to theory of mind, in that both the orbito-frontal cortex and the frontal-polar region are impaired in autism.
Abstract: BACKGROUND The mind's ability to think about the mind has attracted substantial research interest in cognitive science in recent decades, as 'theory of mind' No research has attempted to identify the brain basis of this ability, probably because it involves several separate processes As a first step, we investigated one component process-the ability to recognise mental state terms METHOD In Experiment 1, we tested a group of children with autism (known to have theory of mind deficits) and a control group of children with mental handicap, for their ability to recognise mental state terms in a word list This was to test if the mental state recognition task was related to traditional theory of mind tests In Experiment 2, we investigated if in the normal brain, recognition of mental state terms might be localised The procedure employed single photon emission computerised tomography (SPECT) in normal adult volunteers We tested the prediction (based on available neurological and animal lesion studies) that there would be increased activation in the orbito-frontal cortex during this task, relative to a control condition, and relative to an adjacent frontal area (frontal-polar cortex) RESULTS In Experiment 1, the group with autism performed significantly worse than the group without autism In Experiment 2, there was increased cerebral blood flow during the mental state recognition task in the right orbito-frontal cortex relative to the left frontal-polar region CONCLUSIONS This simple mental state recognition task appears to relate to theory of mind, in that both are impaired in autism The SPECT results implicate the orbito-frontal cortex as the basis of this ability
TL;DR: Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.
Abstract: Background This investigation sought to determine the prevalences of various psychopathologies in outstandingly creative individuals, and to test a hypothesis that the high prevalence of mental abnormalities reported in prominent living creative persons would not be found in those who had achieved and retained world status. Method The family background, physical health, personality, psychosexuality and mental health of 291 famous men in science, thought, politics, and art were investigated. The membership of the six series of scientists and inventors, thinkers and scholars, statesmen and national leaders, painters and sculptors, composers, and of novelists and playwrights was determined by the availability of sufficiently adequate biographies. Extracted data were transformed into diagnoses in accordance with DSM–III–R criteria, when appropriate. Results All excelled not only by virtue of their abilities and originality, but also of their drive, perseverance, industry, and meticulousness. With a few exceptions, these men were emotionally warm, with a gift for friendship and sociability. Most had unusual personality characteristics and, in addition, minor ‘neurotic’ abnormalities were probably more common than in the general population. Severe personality deviations were unduly frequent only in the case of visual artists and writers. Functional psychoses were probably less frequent than psychiatric epidemiology would suggest, and they were entirely restricted to the affective varieties. Among other functional disorders, only depressive conditions, alcoholism, and, less reliably, psychosexual problems were more prevalent than expected in some professional categories, but strikingly so in writers. Conclusions Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.
TL;DR: The theory presented here suggests that chronic stress which activates the HPA will in certain susceptible people produce changes in central monoamines, and the high level of glucocorticoid receptors on such central neurons is postulated as mediating the alterations.
Abstract: Abnormalities in the hypothalamic-pituitary-adrenal axis (HPA) have been the most consistently demonstrated biological markers in depressive illness. Numerous other neuroendocrine disturbances have also been described, including blunted clonidine-induced growth hormone release and blunted fenfluramine-induced prolactin release. These disturbances are generally interpreted in terms of monoaminergic receptor dysfunction. The theory presented here suggests that chronic stress which activates the HPA will in certain susceptible people produce changes in central monoamines. The high level of glucocorticoid receptors on such central neurons is postulated as mediating the alterations. Thus monoamine abnormalities, rather than being a core aetiological feature of depression, are seen as secondary to HPA overdrive.
TL;DR: This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system.
Abstract: BACKGROUND We developed and evaluated a comprehensive, ongoing intervention for families of schizophrenic patients appropriate for China's complex family relationships and unique social environment. METHOD Sixty-three DSM-III-R schizophrenic patients living with family members were enrolled when admitted to hospital and randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counselling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention. RESULTS At 6, 12, and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalised was lower, the duration of rehospitalisation was shorter, and the duration of employment was longer in the experimental group than in the control group; these differences were statistically significant at the 12 and 18-month follow-ups and were not explained by differences in drug compliance. Family intervention was associated with significantly lower levels of family burden. CONCLUSIONS This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system.
TL;DR: Those reporting CSA are more likely to suffer social, interpersonal and sexual difficulties in adult life and the disruption of intimate relationships by difficulties with trust as well as a propensity to perceive their partners as uncaring and overcontrolling.
Abstract: Background The association was examined between reporting child sexual abuse (CSA) and a range of social, interpersonal and sexual difficulties in adult life. Method A random sample of 2250 women were posted a questionnaire exploring a range of abuse experiences. All 248 reporting CSA were invited for interview, together with an equal number of controls. At interview a detailed inquiry was made into the CSA and into current interpersonal, social and sexual function. Results Significant associations emerged between reporting CSA and a decline in socioeconomic status, increased sexual problems, and the disruption of intimate relationships by difficulties with trust as well as a propensity to perceive their partners as uncaring and overcontrolling. CSA was more common in those from disturbed and disrupted families and in those who also reported physical and emotional abuse. This explained part, but not all, of the apparent association between CSA and negative outcomes. Conclusions Those reporting CSA are more likely to suffer social, interpersonal and sexual difficulties in adult life.
TL;DR: While there is circumstantial evidence to support the hypothesis that schizophrenics who abuse drugs or alcohol are at an increased risk of behaving violently, longitudinal studies are required to facilitate a better understanding of the mediating mechanisms.
Abstract: BACKGROUND Recent research from North America has demonstrated higher than expected rates of drug and alcohol abuse among the seriously mentally ill. Schizophrenics appear to be particularly susceptible to the negative effects of substance abuse. These include psychiatric and social complications, with antisocial behaviour, particularly violence emerging as one of the most worrying features. This review examines the strength of the association and explores the possible explanations for the apparent link between schizophrenia, substance abuse and violence. METHOD The literature was searched using Medline, supplemented with a manual literature search. RESULTS Very few articles specifically approached the problem of violence among substance abusing schizophrenics, but over 80 papers were identified which were helpful in exploring the link between dangerous behaviour and substance abuse by schizophrenics. CONCLUSIONS While there is circumstantial evidence to support the hypothesis that schizophrenics who abuse drugs or alcohol are at an increased risk of behaving violently, longitudinal studies are required to facilitate a better understanding of the mediating mechanisms.
TL;DR: The hypothesis that different aetiological factors would be important in brief and persistent disorders in mothers was upheld and mothers had a significantly higher prevalence of psychiatric ‘caseness’ at both six weeks and six months postpartum than fathers.
Abstract: In the first study to systematically examine postnatal depression in fathers, we examined depression in 200 postnatal couples, using a two-stage design. The prevalence of depression ascertained by the 13-item Edinburgh Postnatal Depression Scale (EPDS), using a cut-off score for 'caseness' of 13 or more in an unselected postnatal sample, was 27.5% in mothers at six weeks postpartum, 25.7% in mothers at six months postpartum, 9.0% in fathers at six weeks postpartum, and 5.4% in fathers at six months postpartum. The prevalence did not differ significantly in either mothers or fathers from a control group of parents with children between three and five years of age. As expected, mothers had a significantly higher prevalence of psychiatric 'caseness' at both six weeks and six months postpartum than fathers. Fathers were significantly more likely to be cases if their partners were also cases. The hypothesis that different aetiological factors would be important in brief and persistent disorders in mothers was upheld.
TL;DR: Home-based care for serious mental illness in inner London is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.
Abstract: BACKGROUND A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London. METHOD Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction. RESULTS Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.) CONCLUSIONS It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.
TL;DR: The childhood risk factors were particularly important (judged by a path analysis), and a challenge for future research will be to establish the intervening processes involved with this distal link.
Abstract: BACKGROUND We consider how far it is possible to predict a chronic course of a depressive disorder from psychosocial and clinical material available at the point of onset. METHOD A population survey found 404 working-class mothers living in an inner-city area of London. The majority were interviewed three times over a 3-year period. RESULTS Chronicity (more than 12 months' duration) was strongly related to both childhood adversity (parental indifference, family violence or any sexual abuse) and current adult interpersonal difficulties. The lack of positive events during the course of the episode was also independently related to chronicity, but to a lesser degree. Clinical characteristics were relatively unimportant compared with psychosocial factors. CONCLUSIONS The childhood risk factors were particularly important (judged by a path analysis), and a challenge for future research will be to establish the intervening processes involved with this distal link.
TL;DR: The HADS is valid for use as a screening instrument in non-psychiatric units and although initially developed for use in hospital settings, it could be usefully employed in community settings of developing countries to screen for mental morbidity.
Abstract: BACKGROUND The utility of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for anxiety and depressive disorders in non-psychiatric units (medical & surgical wards; gynaecology & antenatal clinics of a teaching hospital) and a community sample in Nigeria was investigated. METHOD A two-stage screening procedure was employed. This involved the use of GHQ-12/GHQ-30 and HADS against the criteria of a standardised (PSE schedule) psychiatric interview, with psychiatric diagnosis assigned in accordance with ICD-9 criteria. RESULTS Sensitivity for the anxiety sub-scale ranged from 85.0% in the medical and surgical wards to 92.9% in the ante-natal clinic, while sensitivity for the depression sub-scale ranged from 89.5% in the community sample to 92.1% in the gynaecology clinic. Specificity for the anxiety sub-scale ranged from 86.5% in the gynaecology clinic to 90.6% in the community sample, while specificity for the depression sub-scale ranged from 86.6% in the medical and surgical wards to 91.1% in the ante-natal clinic and community sample. Misclassification rates ranged from 9.9% in the community sample to 13.2% in the medical and surgical wards. Relative Operating Characteristic (ROC) analyses showed the HADS and the GHQ-12 to be quite similar in ability to discriminate between cases (anxiety and depression) and non-cases. CONCLUSIONS The HADS is valid for use as a screening instrument in non-psychiatric units and although initially developed for use in hospital settings, it could be usefully employed in community settings of developing countries to screen for mental morbidity.
TL;DR: The model reveals that medication that appears expensive in terms of cost per day may not be so when patient compliance and the total costs of treatment are taken into account.
Abstract: The purpose of this study was twofold: to measure the overall direct costs of depression for 1990 in the UK, and to develop a model to illustrate issues in the evaluation of the relative cost-effectiveness of the pharmacological treatment of depression. We compared a tricyclic antidepressant, imipramine, with paroxetine, a newer antidepressant. For assessing the cost of illness, we used a top-down approach. We calculated direct but not indirect costs. Cost-effectiveness was evaluated by developing a simulation model based on the theory of clinical decision analysis to compare the costs and outcome of each treatment. From this we estimated the expected cost per patient and the cost per successfully treated patient. The total cost to the nation of depressive illness was estimated to be 222 pounds million. The expected costs per patient were found to be similar for paroxetine and imipramine (430 pounds v. 424 pounds). The costs per successfully treated patient were found to be lower for paroxetine (824 pounds) than for imipramine (1024 pounds). The results were stable when a sensitivity analysis was applied to the variables employed in the model. The most sensitive variable was the cost of treatment failure. Our model thus reveals that medication that appears expensive in terms of cost per day may not be so when patient compliance and the total costs of treatment are taken into account.
TL;DR: It is argued that a hypothesis combining genetic diathesis with environmental stress cannot be disproved, and it is also possible that 'non-genetic' factors consist entirely of stochastic events affecting gene expression or structure.
Abstract: The evidence for a genetic contribution to schizophrenia is compelling. However, the pattern of inheritance is complex and it is usually assumed that environmental factors also have a role that will eventually be identified. We argue that this is not necessarily the case. While a hypothesis combining genetic diathesis with environmental stress cannot be disproved, it is also possible that 'non-genetic' factors consist entirely of stochastic events affecting gene expression or structure.
TL;DR: Preliminary findings suggest that the types of compulsions present may help to discriminate between two putative subgroups of OCD, i.e. those with and without tics.
Abstract: The phenomenological features of 35 obsessive-compulsive disorder (OCD) patients with a lifetime history of tics were compared to 35 age- and sex-matched OCD patients without tics. Seven categories of obsessions and nine categories of compulsions were determined using the symptom checklist of the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Discriminant function analysis revealed that, compared to their counterparts without tics, OCD patients with tics had more touching, tapping, rubbing, blinking and staring rituals, and fewer cleaning rituals, but did not differ on obsessions. These preliminary findings suggest that the types of compulsions present may help to discriminate between two putative subgroups of OCD, i.e. those with and without tics.
TL;DR: Depressed and normal subjects showed similar causal inferences for both attributional measures, but deluded subjects showed a marked shift in internality, attributing negative outcomes to external causes on the transparent Attributional Style Questionnaire but, on the more opaque Pragmatic Inference Task, showing a cognitive style resembling that of the depressed group.
Abstract: Abnormalities of 'social' reasoning were investigated in patients suffering from persecutory delusions and in matched depressed and normal controls using transparent (obvious) and opaque (unobvious) tests of attributional style. Whereas depressed and normal subjects yielded similar causal inferences for both attributional measures, the deluded subjects showed a marked shift in internality, attributing negative outcomes to external causes on the transparent Attributional Style Questionnaire but, on the more opaque Pragmatic Inference Task, attributing negative outcomes to internal causes and thus showing a cognitive style resembling that of the depressed group. This finding, interpreted in terms of explicit versus implicit judgements, supports the hypothesis that delusions function as a defence against underlying feelings of low self-esteem.
TL;DR: The prevalence of AS in Broadmoor Hospital is greater than that reported for the general population, and the addition of equivocal cases increased the prevalence to 2.3%.
Abstract: BACKGROUND The hypothesis that Asperger's syndrome (AS) may go unrecognised in forensic populations was examined by ascertaining the prevalence in Broadmoor Special Hospital. METHOD The entire male patient population was screened by examination of case notes. Identified cases were subject to the next stage of the study, which involved observation and interviewing of patients, and a semi-structured interview of key staff. RESULTS A prevalence of 1.5% (0.6% to 3.3%, 95% CI) was found. The addition of equivocal cases increased the prevalence to 2.3%. CONCLUSION The prevalence of AS in Broadmoor Hospital is greater than that reported for the general population.
TL;DR: The findings indicate that the medial prefrontal cortex is a common area of neural dysfunction in the manifestation of both primary depression and depression in PD.
Abstract: BACKGROUND This study investigated biological correlates of depression in patients with idiopathic Parkinson's disease (PD). We tested the hypothesis that in patients with PD and depression, there was regional dysfunction involving brain areas previously implicated in functional imaging studies of patients with primary depression. METHOD Using positron emission tomographic measurements of regional cerebral blood flow (rCBF), patterns of resting rCBF were measured in ten patients with PD and major depression, and ten patients with PD alone. The results were compared with findings from ten patients with primary depression and ten normal controls, scanned using identical methods as part of an earlier study. Groups were matched for age, sex and symptom severity. RESULTS Bilateral decreases in rCBF were observed in anteromedial regions of the medial frontal cortex and the cingulate cortex (Brodmann's areas (BA) 9 and 32) in the depressed PD group, compared with those with PD alone and compared with normal controls. This regional disturbance overlapped that observed in patients with primary depression. CONCLUSIONS The findings indicate that the medial prefrontal cortex is a common area of neural dysfunction in the manifestation of both primary depression and depression in PD.
TL;DR: Segal as mentioned in this paper is the daughter-in-law of a distinguished Kleinian analyst and is well placed to gain insight into the ideas and controversies associated with Melanie Klein's work.
Abstract: Being the daughter-in-law of a distinguished Kleinian analyst, Julia Segal is wellplaced to gain insight into the ideas and controversies associated with Melanie Klein's work. Being untrained in psychoanalysis herself, she writes for the non-cognoscenti. There has been a slow but inexorable development over the years â€”¿ what Hinshelwood described as a body of knowledge care fully kept by a group of people with an â€œ¿ aloof sense of insecurity and a worry about what others who came to possess the knowledge might do with itâ€•,is now becoming widely disseminated by the â€ ̃¿ third generation'. Klein's contribution is essential to an understanding of object-relations psychology and underpins much of the modern psychoanalytic work coming out of the USA, where once it was close to an â€ ̃¿ un-American activity'. Segal writes well and provides a satisfying confron tation with crucial issues in her chapter â€ ̃¿ Criticisms and Rebuttals'. Curiously, reference to the internationally renowned work of Dr Donald Meltzer in expounding and developing Kleinian ideas is conspicuous by its absence!
TL;DR: The results suggest that although depressive symptoms appear to be largely heritable, the influence of genetic and environmental factors may vary with age.
Abstract: BACKGROUND: Although depression in childhood appears to be familial, transmission of symptoms could be genetic or environmental. Twin studies enable us to separate these effects. Our aim was to assess the importance of genetic and environmental factors on depressive symptoms during childhood and adolescence in an epidemiological sample of twins. METHOD: Questionnaires (including the Mood and Feelings questionnaire) were mailed to a systematically ascertained sample (411 twin pairs) aged between 8 and 16 years. The overall response rate was 77%. RESULTS: Data for the whole sample were best explained by an additive genetic model, with heritability of depressive symptom scores estimated at 79%. However, on splitting the sample, symptoms in children (aged 8 to 11) could be explained by shared environmental factors only, while symptoms in adolescents (aged 11 to 16) remained highly heritable. CONCLUSIONS: The results suggest that although depressive symptoms appear to be largely heritable, the influence of genetic and environmental factors may vary with age.
TL;DR: Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients, and significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management.
Abstract: BACKGROUND We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8-10 sessions of therapy is as effective as 16-20 sessions, and (c) brief therapist training is as effective as intensive training. METHOD Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM-III-R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up. RESULTS Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change. CONCLUSIONS Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16-20 sessions of treatment is more effective, on average, than 8-10 sessions.
TL;DR: Use of MDMA may be associated with a broader spectrum of psychiatric morbidity than heretofore suspected, and cases with psychosis may be clinically similar to psychotic patients with no history of substance use.
Abstract: BACKGROUND 3,4-methylenedioxymethamphetamine (MDMA or 'Ecstasy') has become one of the most widely used illicit substances in the UK. Little is known of the psychiatric morbidity which may be associated with its use. We have examined this association by collecting a series of psychiatric cases in which MDMA use was a prominent feature. METHOD Patients presenting between 1990 and 1992 with psychiatric symptoms which developed in the context of MDMA use (n = 13) were interviewed, and their psychiatric, medical and drug history, sociodemographic background and mental state were examined in detail. The psychopathology of cases with psychosis (n = 8) was assessed with the Present State Examination and compared with that of substance-na√Ove psychotic controls (n = 40). RESULTS Eight patients presented with psychotic syndromes, two experienced visual illusions, hallucinations and palinopsia, one had panic attacks, one suffered from depression, and one described chronic depersonalisation and derealisation. The psychopathology of the patients with psychoses was very similar to that of controls. CONCLUSIONS Use of MDMA may be associated with a broader spectrum of psychiatric morbidity than heretofore suspected. Cases with psychosis may be clinically similar to psychotic patients with no history of substance use.
TL;DR: Findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.
Abstract: Background The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity. Method We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale. Results After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf. Conclusions These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.
TL;DR: The finding of two subgroups of mentally handicapped male sex offenders has important implications for prevention, assessment and treatment.
Abstract: BACKGROUND Sex offences are overrepresented in the mentally handicapped, but information about the characteristics and offence behaviour of this group is limited. METHOD A retrospective case note survey was made of 47 male patients referred for antisocial sexual behaviour. RESULTS Of 191 offences and/or incidents committed, 55.5% were heterosexual, 24% indecent exposure, 12.4% homosexual, 13.6% serious and 3.6% involved physical assault. Average age of the offenders was 23.9 years, with a mean IQ of 59.5, and there was a high prevalence of family psychopathology, psychiatric illness, minor physical disabilities, sexual experience, impaired relationship skills and sexual recidivism. Recidivists showed a low specificity for offence type and age and sex of victim. Categorical analysis differentiated a 'sex offences only' group from a 'sex plus other offences' group in the key areas of psychopathology, offence behaviour and outcome; this was supported by factor analysis. CONCLUSION The finding of two subgroups of mentally handicapped male sex offenders has important implications for prevention, assessment and treatment.
TL;DR: It is hypothesized that psychomotor disturbance is specific to the melancholic subtype of depression and capable of defining melancholia more precisely than symptom-based criteria sets, and the utility of a refined, operationally driven set of clinician-rated signs is examined.
Abstract: We hypothesised that psychomotor disturbance is specific to the melancholic subtype of depression and capable of defining melancholia more precisely than symptom-based criteria sets. We studied 413 depressed patients, and examined the utility of a refined, operationally driven set of clinician-rated signs, principally against a set of historically accepted symptoms of endogeneity. We specified items defining psychomotor disturbance generally as well as those weighted either to agitation or to retardation. We demonstrated the system's capacity to differentiate 'melancholic' and 'non-melancholic' depression (and the comparable success of DSM-III-R and Newcastle criteria systems) by reference to several patient, illness and treatment response variables, to an independent measure of psychomotor disturbance (reaction time) and to a biological marker (the dexamethasone suppression test).
TL;DR: Antipsychotic medication is the mainstay of treatment for the functional psychotic illnesses, which include schizophrenia, mania in the course of a bipolar mood disorder, and, more rarely, depression accompanied by psychotic symptoms.
Abstract: Antipsychotic medication is the mainstay of treatment for the functional psychotic illnesses. Such drugs are also referred to as neuroleptics (meaning a drug with both antipsychotic effects and effects on movement) and major tranquillisers. The psychotic illnesses for which they are prescribed include schizophrenia, mania in the course of a bipolar mood disorder, and, more rarely, depression accompanied by psychotic symptoms. These are not uncommon illnesses. At some time during their lives approximately 1% of the population will suffer at least one episode of schizophrenia and a further 1% will suffer at least one episode of mania. During an episode some patients, but by no means all, suffer extreme changes in their thinking, mood and behaviour which can be very distressing to experience and which can make patients a danger to themselves or other people.