Psychiatric problems in the aged: a reconsideration

The numerically important mental disorders found in the senescent population are reviewed from the point of view of their relationship to the process of ageing. Only two direct relationships are seen: the acute confusional states due to the age-linked decline in stress resistance; and the neurotic reactions due to the diminished capacity for rapid and adequate adjustment to the more subtle but chronic sociopsychological changes the aged individual is so frequently exposed to in our society. The chronic dementing processes of the senium, senile and arteriosclerotic dementia, are more likely to occur at an advanced age, but apparently are not the final outcome of cerebral and/or cerebrovascular ageing, although the ageing process seems to favour their phenotypical manifestation. The functional psychoses may occur at an advanced age but are not directly related to the process of ageing.     

DYNAMICS AND MANAGEMENT OF SELF-INDUCED ERUPTIONS

Self-induced eruptions are always expressions of an emotionally disturbed person. They cover a wide variety of injuries and include aggravation of preexisting dermatoses, neurotic excoriations, mucocutaneous changes from compulsive movements, factitial dermatitis and trichotillomania. The emotional disturbances in such patients range from mild psychoneuroses to severe psychoses. Attention should be focused primarily on the emotional disturbance. The management of psychotic patients is the domain of the psychiatrist. But those unsuitable for psychiatric care and persons with mild psychoneuroses—who fortunately constitute the majority among patients with self-inflicted eruptions—should remain with their dermatologist or general physician and get from him effective supportive psychotherapy in addition to such treatment for the self-induced damage to the skin as may be indicated.     

Childhood antecedents of schizophrenia and affective illness: social adjustment at ages 7 and 11.

OBJECTIVE--To investigate the social adjustment in childhood of people who as adults have psychiatric disorders. DESIGN--Subjects in a prospectively followed up cohort (the national child development study) who had been admitted as adults to psychiatric hospitals were compared with the rest of the cohort on ratings of social behaviour made by teachers at the ages of 7 and 11 years. SUBJECTS--40 adult patients with schizophrenic illnesses, 35 with affective psychoses, and 79 with neurotic illness who had been admitted for psychiatric reasons by the age of 28. 1914 randomly selected members of the cohort who had never been admitted for psychiatric treatment. MAIN OUTCOME MEASURES--Overall scores and scores for overreaction (externalising behaviour) and underreaction (internalising behaviour) with the Bristol social adjustment guide at ages 7 and 11. RESULTS--At the age of 7 children who developed schizophrenia were rated by their teachers as manifesting more social maladjustment than controls (overall score 4.3 (SD 2.4) v 3.1 (2.0); P < 0.01). This was more apparent in the boys (5 (2.6)) than the girls (3.4 (1.8)) and related to overreactive rather than underreactive behaviour. At both ages prepsychotic (affective) children differed little from normal controls. By the age of 11 preneurotic children, particularly the girls, had an increased rating of maladjustment (including overreactions and underreactions). CONCLUSION--Abnormalities of social adjustment are detectable in childhood in some people who develop psychotic illness. Sex and the rate of development of different components of the capacity for social interaction are important determinants of the risk of psychosis and other psychiatric disorders in adulthood.     

PSYCHOLOGICAL PROBLEMS OF AGING

The increasing number of older persons in the United States is having far-reaching economic, social, political and psychological effects. Patients over 60 make up more than a fourth of current admissions to California''s state mental hospitals. Biological, personal, cultural and economic problems are present in each elderly person and must be considered in the treatment of such individuals. Neurotic reactions are much more frequent that the psychoses, and these may be treated by the same therapeutic tools utilized with younger persons.Not all the psychoses in the aged group are such as to necessitate mental hospital care. Many of the patients could be cared for in suitable nursing homes. An adequate mental hygiene program, maintenance of physical health, opportunities for work, and the development of hobby and recreation centers may help ward off many of the difficult problems that the aged now present.     

Attitudes to Psychiatry in the General Hospital

A survey of consultant attitudes to psychiatry in six general hospitals is presented and compared with reported findings in general practitioners and medical students.Psychological factors were accepted as important in a variety of medical conditions. Different specialties differed little in their attitudes to neurotic patients and to psychiatrists, younger consultants tending to be more critical. Consultants had a lower level of neuroticism than the general population and medical students, and physicians were less extraverted than surgeons; these personality factors were not related to expressed attitudes.The results suggest that other specialties accept the role of psychiatry, and its integration into the general hospital is not likely to meet with antagonism.     

Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study

Objective To study the change in risk of suicide among patients with schizophrenia and related disorders.Design Nested case-control design with linked data.Setting 4 longitudinal Danish registers.Participants 18 744 people aged up to 75 years who committed suicide in 1981-97 individually matched with 20 controls.Results Over the time studied the reduction in suicide rate among patients with schizophrenia and schizophrenia spectrum disorder was similar to that seen in the general population (incidence rate ratio 1.00, 95% confidence interval 0.98 to 1.03). The reduction among patients with other psychosis in the schizophrenia spectrum was faster than the reduction seen in the general population. Among people admitted to hospital with schizophrenia the risk of suicide was highest in the first year after first admission, and the excess risk was largest in the younger age groups—that is, the risk decreased per year for every additional year of age.Conclusion The suicide rate among patients with a diagnosis of schizophrenia and related disorders has fallen. This may be due to better psychiatric treatment, reduced access to means of suicide, or improvements in treatment after suicide attempts.     

Drug users in contact with general practice.

A group of heroin users who are in contact with a general practice in north west Edinburgh are described. The study group was younger and included more women than previous studies. These people used a large variety of drugs and mainly purchased them locally. Frequent and often prolonged abstinent periods occurred with no prescribed opiate treatment. The group had experienced a high rate of drug related medical disorders. All these points raise the possibility that opiate users who are known to general practitioners may be a distinctly different population from those who attend drug dependency clinics. The frequency of remission and the prevalence of polydrug use have profound implications for planning and evaluating an effective medical response.     

Genetic disorders presenting as “schizophrenia”. Karl bonhoeffer's early view of the psychoses in the light of medical genetics

There is overwhelming empirical evidence for the influence of genetic factors in the etiology of schizophrenic psychoses. An appreciable and still increasing number of exogenous factors have been known for decades that are capable of inducing psychoses that present as "schizophrenia" or are more or less similar to it. In this article, genetic disorders--chromosomal abnormalities and Mendelian diseases--are summarized that may be associated with such psychoses. These disorders frequently but not necessarily exhibit additional physical symptoms. Although the majority of schizophrenic psychoses can so far not be explained by exogenous factors or well-defined genetic disorders, the proportion of these etiologies among all cases may be higher than presumed so far, because they evade detection. Data from the literature are discussed in the light of Karl Bonhoeffer's early concept of exogenous reaction types and modern medical genetics.     

Release phenomena and iterative activities in psychiatric geriatric patients

This survey was undertaken to assess the frequency of some of the so-called release phenomena and iterative activities in an aged psychiatric population. Three groups of geriatric psychiatric patients with diagnoses of (I) organic brain syndrome, including senile dementia (56), (II) functional psychoses, predominantly schizophrenia (51) and (III) chronic schizophrenia never treated by neuroleptics or other biologic agents (16), were compared with (IV) a control group of 32 elderly people in good physical and mental health.In general, for the manifestations studied, the geriatric psychiatric patients suffering from an organic brain syndrome and treated with neuroleptics differed notably from the control group. This latter group, although older, had few neurological signs of senescence and the spontaneous oral movements usually associated with the use of neuroleptics were absent. Release phenomena such as the grasp and pouting reflexes, as well as the stereotyped activities, were encountered significantly more frequently in patients with an organic brain syndrome than in the two other groups of patients. Our survey has yielded limited results with regard to the possible influence of type of illness and neuroleptic treatment on the incidence of release phenomena and iterative activities.     

The Influence of Various Depressive States on the Emotional Evaluation of Short Musical Fragments in Humans

Emotional evaluation of short musical fragments was compared for healthy people, patients with endogenous or neurotic depression, and opium addicts with affective disorders. Substantial differences in emotional preferences were observed between the healthy people and the patients. Moreover, emotional evaluations differed in the three groups of patients with different affective disorders. The cause of the difference in emotional evaluation was discussed, and the possibility of using the observed differences as a criterion of differential diagnostics was considered.     

Prevalencia de los trastornos de ansiedad en las personas mayores de 65 años: una revisión sistemática

Anxiety is an emotional problem that causes discomfort and suffering to those that suffer from it. Anxiety disorders can affect the functioning in different facets of a person's life. Studies on the prevalence of anxiety disorders in people over 65 years show variable results, ranging between 0.1% and 17.2%. Most of these studies include samples of the general population, in which the population of people over 65 years is under-represented. These studies evaluate older people with the same diagnostic tools used to assess anxiety disorders in people under 65 years, and collect data from people between 65 and 75 years old, leaving out people aged 75 and over. A systematic review of the prevalence studies of anxiety disorders in elderly people is presented. It is concluded that when representative samples of people over 65 years are used and evaluated with suitable tools, the prevalence rate of these disorders in the elderly is much higher than previously thought, reaching an annual prevalence rate of 20.8%.     

Psychiatric hospitalization in Ontario: the revolving door in perspective.

Ontario government statistics have indicated that during the 1960s the proportion of readmissions to psychiatric hospitals doubled to form two thirds of all admissions. Since this pertained to events rather than to individuals, a cohort of patients first admitted in 1969 was followed for 4 years to trace the pattern of readmission and the characteristics of patients at risk of readmission. Routinely returned data were linked and a sample from the greater metropolitan Toronto area was randomly selected. Of the cohort, 31% were readmitted, 8% three or more times. Age and diagnosis distinguished those readmitted. Most with multiple readmissions were under 25 years of age. Although diagnoses were equally distributed on first admission among psychotic, neurotic and other nonpsychotic disorders, with no significant change on readmission or multiple readmission, there was a predictably greater proportion of functional psychoses among the high-risk group and also an equal representation of personality, addictive and the remaining nonpsychotic conditions. The vulnerable few are identifiable early in their intermittent hospital career. It can be concluded that statistics suggesting that two thirds of admissions are readmissions are misleading.     

Neurotic disorders in monkeys during increased stress on analytic-synthetic processes

It has been shown in experiments on three rhesus monkeys that an enhanced stress of analytical-synthetic processes consisting in learning to differentiate a sequence of tones, leads to neurotic disorders of monkeys higher nervous activity. They are manifested individually and consist in disturbances of general behaviour, in forced movements, breakdowns of differentiations, the missing of positive responses in the previously elaborated conditioned stereotype and in typical dynamics of the formation of positive and negative conditioned reflexes to a chain of tones (2000 + + 4000 c/s; 2000 + 2000 c/s; 4000 + 2000 c/s; 4000 + 4000 c/s).     

Studies of higher nervous activity in functional phychoses.

Psychiatric illnesses can be conceived of as experiments of nature, providing a variety of pathopsychological mechanisms which may elucidate normal psychological processes. Clinically the reactive psychoses are predominantly psychogenic reaction types. They present disturbances of higher nervous activity, similar to those of the neuroses. The unconditional reflex activity is practically as in normal controls, and the most outstanding finding was the large effect of psychodynamic complex structures. This is a physiological parallel to the clinical manifestations with great concern over experienced mental trauma. In the manic-depressive psychoses the most characteristic feature is a marked disturbance of unconditional reflex activity. This factor may be an important physiological mechanism underlying the more biological than psychodynamic reaction type and partly explain the changes of mood and associated interferences with sleep, body weight, sexual activity, aggression and other instinctual and vegetative functions. Schizophrenic psychoses also present changes of unconditional reflex activity, predominantly in the direction of inhibition of response. In addition there are severe dissociations within and between the three levels of unconditional reflexes and the two signaling systems. It is suggested that schizophrenia represents a functional maladaptation, which can be explained from the principles of autokinesis and schizokinesis established by Gantt in animal experiments. Prognostic models based on experimentally established impairment of performances were shown to predict long-term risks of schizophrenic defects just as well as models based on constellations of clinical symptoms. I would predict that psychophysiology and experimental psychology will become increasingly more important for establishing diagnosis and prognosis in the functional psychoses. The data of this article point toward a basis for a prophylactic psychiatry.     

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.     

Bipolar manic-depressive psychoses: Results of a genetic investigation

Summary Ninety-five patients with bipolar manicdepressive disorders were followed from 1959 to 1975, and their first-degree relatives (N=617) were studied. In the search for heterogeneity of bipolar illness the patients were subclassified according to various criteria: sex, age at onset, number of episodes, and longitudinal syndrome subtypes (Dm, MD, Md), and the genetic findings were used as an external criterion.The first-degree relatives of female probands showed a higher morbidity risk for psychiatric disorders than the relatives of male probands, and the highest morbidity risk was found in the female relatives of female probands. Early onset and late-onset patients did not differ from a genetic point of view. Patients with ten episodes or more showed slightly higher family morbidity than those with less than ten episodes.The three subtypes of bipolar disorders preponderantly depressed (Dm), nuclear type (MD), and preponderantly manic (Md), showed significant genetic differences. The families of type Dm had the highest morbidity, and families of type Md, the lowest! The type MD took an intermediate position. The results are surprising and not compatible with current hypotheses of multifactorial heredity assuming a continuum from depression to mania with distinct thresholds for the manifestation of unipolar depression, bipolar psychosis, and pure mania. The findings also do not suggest the existence of a drug-induced hypomania.Father-son transmission was frequent, and this fact excludes a substantial amount of X-chromosomal inheritance.Parents, siblings, and children exhibited roughly the same morbidity risk. If a proband had an affected parent, the morbidity risk for his siblings and children was nearly twice as high as without such a parent (38% vs 21%). The analysis of the intrafamilial distribution of diagnoses supported the assumption that neurotic depression belongs to the true spectrum of affective psychoses.     

Clustering of physical health multimorbidity in people with severe mental illness: An accumulated prevalence analysis of United Kingdom primary care data

BackgroundPeople with severe mental illness (SMI) have higher rates of a range of physical health conditions, yet little is known regarding the clustering of physical health conditions in this population. We aimed to investigate the prevalence and clustering of chronic physical health conditions in people with SMI, compared to people without SMI.Methods and findingsWe performed a cohort-nested accumulated prevalence study, using primary care data from the Clinical Practice Research Datalink (CPRD), which holds details of 39 million patients in the United Kingdom. We identified 68,783 adults with a primary care diagnosis of SMI (schizophrenia, bipolar disorder, or other psychoses) from 2000 to 2018, matched up to 1:4 to 274,684 patients without an SMI diagnosis, on age, sex, primary care practice, and year of registration at the practice. Patients had a median of 28.85 (IQR: 19.10 to 41.37) years of primary care observations. Patients with SMI had higher prevalence of smoking (27.65% versus 46.08%), obesity (24.91% versus 38.09%), alcohol misuse (3.66% versus 13.47%), and drug misuse (2.08% versus 12.84%) than comparators. We defined 24 physical health conditions derived from the Elixhauser and Charlson comorbidity indices and used logistic regression to investigate individual conditions and multimorbidity. We controlled for age, sex, region, and ethnicity and then additionally for health risk factors: smoking status, alcohol misuse, drug misuse, and body mass index (BMI). We defined multimorbidity clusters using multiple correspondence analysis (MCA) and K-means cluster analysis and described them based on the observed/expected ratio. Patients with SMI had higher odds of 19 of 24 conditions and a higher prevalence of multimorbidity (odds ratio (OR): 1.84; 95% confidence interval [CI]: 1.80 to 1.88, p < 0.001) compared to those without SMI, particularly in younger age groups (males aged 30 to 39: OR: 2.49; 95% CI: 2.27 to 2.73; p < 0.001; females aged 18 to 30: OR: 2.69; 95% CI: 2.36 to 3.07; p < 0.001). Adjusting for health risk factors reduced the OR of all conditions. We identified 7 multimorbidity clusters in those with SMI and 7 in those without SMI. A total of 4 clusters were common to those with and without SMI; while 1, heart disease, appeared as one cluster in those with SMI and 3 distinct clusters in comparators; and 2 small clusters were unique to the SMI cohort. Limitations to this study include missing data, which may have led to residual confounding, and an inability to investigate the temporal associations between SMI and physical health conditions.ConclusionsIn this study, we observed that physical health conditions cluster similarly in people with and without SMI, although patients with SMI had higher burden of multimorbidity, particularly in younger age groups. While interventions aimed at the general population may also be appropriate for those with SMI, there is a need for interventions aimed at better management of younger-age multimorbidity, and preventative measures focusing on diseases of younger age, and reduction of health risk factors.

In an observational analysis of primary care data from the UK, Naomi Launders and colleagues study the prevalence and clustering of physical health conditions and multimorbidity in individuals with severe mental illnesses.     

Health care rationing: the public's debate.

OBJECTIVE--To elicit the views of a large nationally representative sample of adults on priorities for health services. DESIGN--An interview survey based on a random sample of people aged 16 and over in Great Britain taken by the Office of Population Censuses and Surveys. SUBJECTS--The response rate to the survey was 75%, and the total number of adults interviewed was 2005. MAIN OUTCOME MEASURES--A priority ranking exercise of health services supplemented with attitude questions about priorities, who should set priorities, and budget allocation. RESULTS--The results of the main priority ranking exercise of 12 health services showed that the highest priority (rank 1) was accorded to "treatments for children with life threatening illness," the next highest priority (rank 2) was accorded to "special care and pain relief for people who are dying." The lowest priorities (11 and 12) were given to "treatment for infertility" and "treatment for people aged 75 and over with life threatening illness." Most respondents thought that surveys like this one should be used in the planning of health services. CONCLUSIONS--The public prioritise treatments specifically for younger rather than older people. There is some public support for people with self inflicted conditions (for example, through tobacco smoking) receiving lower priority for care, which raises ethical issues.     

Rheumatoid Arthritis and Personality: A Controlled Study

Evidence in support of claims for the existence of a special relationship between personality and rheumatoid arthritis is conflicting. In this study four groups—one of patients with early rheumatoid arthritis, one of patients with chronic rheumatoid arthritis, one of neurotic patients, and a normal control group—were compared by means of the Maudsley Personality Inventory (M.P.I.) and a neurotic trait in childhood (N.T.C.) score. Both arthritis groups had a lower M.P.I. neuroticism score than the normal control group, with greater significance in the chronic arthritis group. The neurotic group had a significantly higher neuroticism score than the other three groups. Both arthritis groups had a lower extraversion score than normal controls, again with greater significance in the chronic arthritis group. The neurotic group scored significantly less than normal controls on the extraversion scale and intermediately between the early and chronic arthritis groups. There was no significant difference between the arthritis groups and the normal control group in the N.T.C. score, but it was significantly increased in the neurotic group.These findings suggest that people with rheumatoid arthritis differ significantly in personality from normal and from neurotic people, that the differences are accentuated with chronicity in the rheumatoid process, and that the differences develop as a result of the arthritis.     

Aging impairs IFN regulatory factor 7 up-regulation in plasmacytoid dendritic cells during TLR9 activation

Plasmacytoid dendritic cells (pDCs) are innate sensors that produce IFN-alpha in response to viral infections. Determining how aging alters the cellular and molecular function of these cells may provide an explanation of increased susceptibility of older people to viral infections. Hence, we examined whether aging critically impairs pDC function during infection with HSV-2, a viral pathogen that activates TLR9. We found that impaired IFN-alpha production by aged murine pDCs led to impaired viral clearance with aging. Upon TLR9 activation, aged pDCs displayed defective up-regulation of IFN-regulatory factor 7, a key adaptor in the type I IFN pathway, as compared with younger counterparts. Aged pDCs had more oxidative stress, and reducing oxidative stress in aged pDCs partly recovered the age-induced IFN-alpha defect during TLR9 activation. In sum, aging impairs the type I IFN pathway in pDCs, and this alteration may contribute to the increased susceptibility of older people to certain viral infections.