Psychiatric assessment of patients with “20th-century disease” (“total allergy syndrome”)

“Twentieth-century disease”, or “total allergy syndrome”, is a condition attributed to hypersensitivity to the environment that may sometimes be seen as so serious that the patient is incapable of living in the modern world. Although the popular media frequently carry stories about it, there is little scientific literature. It is diagnosed by clinical ecologists, who maintain, among other theories, that susceptible individuals experience an overload in assaults by artificial materials in the environment. The patients usually have multiple ill defined symptoms for which no organic cause can be found, but they vigorously resist psychiatric referral, as they attribute their symptoms to allergy. A group of 18 patients who were purportedly suffering from 20th-century disease were referred to a university psychiatric consultation liaison service. They virtually all had a long history of visits to physicians, and their symptoms were characteristic of several well known psychiatric disorders. The case histories and management of three of them are presented. Although this group of patients may have been atypical in that they had more severe psychologic symptoms, the experience indicates that a psychiatric diagnosis ought to be considered. The symptoms of 20th-century disease have much in common with other conditions known to physicians for centuries.     

A New Look at Bimedial Prefrontal Leukotomy

Forty-four selected patients with “hard core” functional psychiatric illness were treated by bimedial prefrontal leukotomy, in which only the medial half of the prefrontal white matter of both frontal lobes was divided. This operation differs from the conventional or “standard” leukotomy which divides the entire prefrontal white matter. There were six patients with personality disorders, 25 psychoneurotics, 12 schizophrenics, and one with involutional melancholia. Forty-two of the 44 patients had thorough psychiatric follow-up, ranging from one to seven years postoperatively. They were assessed clinically and also on a point-rating scale of assessment.Seventy-six per cent of these patients had excellent or satisfactory outcomes. The most striking benefit was decrease in anxiety and tension.Modified leukotomy is a safe and effective method of reducing the symptoms of excessive tension, anxiety, fear or depression in patients with a variety of illnesses, including anxiety neurosis, phobic psychoneurosis, obsessional neurosis, neurotic or psychotic depressive reactions and schizophrenia. The operation should be considered in such neurotic, personality and psychotic illnesses when medical treatment has failed.     

Psychiatry in the Soviet Union

The services for chronically handicapped people with psychiatric disorders in the Soviet Union are described. The system is based upon a network of community units, each of which includes a day centre, a follow-up clinic, and a sheltered workshop. British services could profitably learn from the experience of these units. The diagnostic system used by many Soviet psychiatrists is different from that incorporated in the International Classification of Diseases. In particular, the term “schizophrenia” is used to describe conditions which British psychiatrists would label in other ways.This clinical difference partly explains the different concept of “criminal responsibility,” but another large component of the difference is political rather than medical. There are also variations from British practice in certain juridical procedures. These differences together make Soviet psychiatric practice in the case of political dissenters unacceptable to most British psychiatrists. It is too soon to say that frank discussions of these matters could not lead to improvement. British and Soviet psychiatrists still have something to learn from each other.     

The Great Plague of 1665 as a Study in Human Reactions to Disaster

Daniel Defoe''s “A Journal of The Plague Year” is reviewed in the light of disaster studies some three centuries later. Familiar disaster phenomena are described, as well as events that were different or perhaps unique. Leadership by civic authorities is noted. The conclusion is one that is familiar in this nuclear age, viz. survivors “should stand stock-still... and not shift”.     

Preventive Psychiatry: The Psychiatric Team as Consultant to the Public Health Nurse

Various forms of collaboration between the disciplines of public health and psychiatry are briefly reviewed and the 25-year-old mental health program of the Vancouver Health Department is described. The public health nurse has prime responsibility in all children with emotional disorders. She is supported by a psychiatric team which provides active treatment and educational and consultative help for the nurse and the school. During the year 1963, six social workers had 2357 contacts with nurses and school personnel but only 1049 treatment interviews. Of 401 children referred to the psychiatric team, 138 received active clinic treatment, 141 remained under supervision by the public health nurse, and 122 were referred elsewhere. In addition, 1330 children were identified as “mental hygiene cases” in the caseload of the 170 public health nurses in the community. By close co-ordination, the public health nurse and the psychiatric team can enhance each other''s contributions to community mental health.     

Adult Asylum Seekers from the Middle East Including Syria in Central Europe: What Are Their Health Care Problems?

Background

Forced displacement related to persecution and violent conflict has reached a new peak in recent years. The primary aim of this study is to provide an initial overview of the acute and chronic health care problems of asylum seekers from the Middle East, with special emphasis on asylum seekers from Syria.

Methods

Our retrospective data analysis comprised adult patients presenting to our emergency department between 01.11.2011 and 30.06.2014 with the official resident status of an “asylum seeker” or “refugee” from the Middle East.

Results

In total, 880 patients were included in the study. Of these, 625 (71.0%) were male and 255 (29.0%) female. The median age was 34 (range 16–84). 222 (25.2%) of our patients were from Syria. The most common reason for presentation was surgical (381, 43.3%), followed by medical (321, 36.5%) and psychiatric (137, 15.6%). In patients with surgical presentations, trauma-related problems were most common (n = 196, 50.6%). Within the group of patients with medical presentation, acute infectious diseases were most common (n = 141, 43.9%), followed by neurological problems (n = 70, 21.8%) and gastrointestinal problems (n = 47, 14.6%). There were no differences between Syrian and non-Syrian refugees concerning surgical or medical admissions. The most common chronic disorder of unclear significance was chronic gastrointestinal problems (n = 132, 15%), followed by chronic musculoskeletal problems (n = 108, 12.3%) and chronic headaches (n = 78, 8.9%). Patients from Syria were significantly younger and more often suffered from a post-traumatic stress disorder than patients of other nationalities (p<0.0001, and p = 0.05, respectively).

Conclusion

Overall a remarkable number of our very young group of patients suffered from psychiatric disorders and unspecified somatic symptoms. Asylum seekers should be carefully evaluated when presenting to a medical facility and physicians should be aware of the high incidence of unspecified somatic symptoms in this patient population.In general, there is no major difference between asylum seekers from Syria when compared to other nationalities of asylum seekers from the Middle East.     

The Use of Lysergic Acid Diethylamide (LSD) in Psychotherapy

One hundred of 150 patients with non-psychotic functional psychiatric disorders were benefited by the use of LSD psychotherapy. The dosage of LSD employed was 25 to 2000 micrograms intramuscularly per session for from one to 10 sessions. On this regimen four patients became psychotic and required electroconvulsive therapy. None were permanently harmed.Indications for and contraindications to this form of treatment and a procedure involving a doctor and a nurse as co-therapists are discussed. In particular, LSD is considered to permit “perceptualization of the transference”.LSD possibly extends the scope and value of the psychotherapeutic approach in such cases.     

Psychiatry and Psychotherapy: Is a Divorce Imminent?

Despite the long tradition of psychiatrists practicing psychotherapy, many psychiatric and medical leaders are predicting and urging a reorientation of psychiatry toward the medical model. They would leave psychotherapy to psychologists, social workers and the like. Many social, governmental and institutional factors favor such a change. The marriage of psychiatry and psychotherapy has always been an uneasy one, and the push for divorce may be irresistible. The author cautions that a divorce could be detrimental to medicine by substituting, in the name of “science,” a dehumanized, technological psychiatry for the current “moral” treatment. One alternative to divorce is a broader approach to psychiatry, combining biological, neuromedical, socioenvironmental and psychodynamic factors. The divorce, though imminent, should be resisted.     

Do psychiatric diseases follow annual cyclic seasonality?

Seasonal affective disorder (SAD) famously follows annual cycles, with incidence elevation in the fall and spring. Should some version of cyclic annual pattern be expected from other psychiatric disorders? Would annual cycles be similar for distinct psychiatric conditions? This study probes these questions using 2 very large datasets describing the health histories of 150 million unique U.S. citizens and the entire Swedish population. We performed 2 types of analysis, using “uncorrected” and “corrected” observations. The former analysis focused on counts of daily patient visits associated with each disease. The latter analysis instead looked at the proportion of disease-specific visits within the total volume of visits for a time interval. In the uncorrected analysis, we found that psychiatric disorders’ annual patterns were remarkably similar across the studied diseases in both countries, with the magnitude of annual variation significantly higher in Sweden than in the United States for psychiatric, but not infectious diseases. In the corrected analysis, only 1 group of patients—11 to 20 years old—reproduced all regularities we observed for psychiatric disorders in the uncorrected analysis; the annual healthcare-seeking visit patterns associated with other age-groups changed drastically. Analogous analyses over infectious diseases were less divergent over these 2 types of computation. Comparing these 2 sets of results in the context of published psychiatric disorder seasonality studies, we tend to believe that our uncorrected results are more likely to capture the real trends, while the corrected results perhaps reflect mostly artifacts determined by dominantly fluctuating, health-seeking visits across a given year. However, the divergent results are ultimately inconclusive; thus, we present both sets of results unredacted, and, in the spirit of full disclosure, leave the verdict to the reader.

Should we expect psychiatric disorders to show a cyclic annual pattern? This study reveals that psychiatric diseases’ annual patterns were remarkably similar across the studied diseases in both the US and Sweden, with the magnitude of annual variation significantly higher in Sweden than in the US for psychiatric, but not infectious, diseases.     

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Design: Follow up study. Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders. Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist. Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.

Key messages

• Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare
• The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder
• Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up
• Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists

     

Diagnosis and Treatment of Delirium

Delirium is not a clinical entity but a symptom-complex of manifold etiology. Its presence signifies acute cerebral insufficiency and often represents a medical and/or psychiatric emergency.Though some forms of delirium have distinctive features, the fundamental phenomena are common to all, with clouding of consciousness the sine qua non. The condition has two major components: (1) the basic “acute brain syndrome” and (2) associated release phenomena.Clinicians must first make the vital differentiation between delirium and “functional” mental disorder, then proceed with the elucidation of the underlying diagnosis and the concurrent organization of symptomatic and etiologic treatment.Proper treatment combines management of the acute brain syndrome with general and specific procedures for control of the underlying condition. Dealing with the symptom-complex itself involves the principles and practice of sedation, hydration, and nutrition, nursing care and supportive measures. Provided the basic organic condition is treatable, the prognosis today is usually good.     

Against All Odds: Genocidal Trauma Is Associated with Longer Life-Expectancy of the Survivors

Does surviving genocidal experiences, like the Holocaust, lead to shorter life-expectancy? Such an effect is conceivable given that most survivors not only suffered psychosocial trauma but also malnutrition, restriction in hygienic and sanitary facilities, and lack of preventive medical and health services, with potentially damaging effects for later health and life-expectancy. We explored whether genocidal survivors have a higher risk to die younger than comparisons without such background. This is the first population-based retrospective cohort study of the Holocaust, based on the entire population of immigrants from Poland to Israel (N = 55,220), 4–20 years old when the World War II started (1939), immigrating to Israel either between 1945 and 1950 (Holocaust group) or before 1939 (comparison group; not exposed to the Holocaust). Hazard of death – a long-term outcome of surviving genocidal trauma – was derived from the population-wide official data base of the National Insurance Institute of Israel. Cox regression yielded a significant hazard ratio (HR = 0.935, CI (95%) = 0.910–0.960), suggesting that the risk of death was reduced by 6.5 months for Holocaust survivors compared to non-Holocaust comparisons. The lower hazard was most substantial in males who were aged 10–15 (HR = 0.900, CI (95%) = 0.842–0.962, i.e., reduced by 10 months) or 16–20 years at the onset of the Holocaust (HR = 0.820, CI (95%) = 0.782–0.859, i.e., reduced by18 months). We found that against all odds genocidal survivors were likely to live longer. We suggest two explanations: Differential mortality during the Holocaust and “Posttraumatic Growth” associated with protective factors in Holocaust survivors or in their environment after World War II.     

Characteristics of Attempted Suicide by Patients with Schizophrenia Compared with Those with Mood Disorders: A Case-Controlled Study in Northern Japan

Recent reports suggest a lifetime suicide risk for schizophrenia patients of approximately 5%. This figure is significantly higher than the general population suicide risk consequently, detection of those at risk is clinically important. This study was undertaken to define the characteristics of suicide attempts by schizophrenia patients compared with attempts by patients with mood disorders. All patients were diagnosed using the ICD-10 criteria. The study population comprised 65 patients with F2 disorders (schizophrenia, schizotypal and delusional disorders), i.e., “the F2 group”, and 94 patients with F3 disorders (mood disorders), i.e., “the F3 group”, who presented in the clinical setting of consultation-liaison psychiatry. The F2 group had a significantly younger mean age and significantly higher ratios of ‘past/present psychiatric treatment’ and ‘more than 3 months interruption of psychiatric treatment’. In contrast, the ratios of ‘physical disorder comorbidity’, ‘alcohol intake at suicide attempt’ and ‘suicide note left behind’ were significantly higher in the F3 group. The F2 group attempted suicide by significantly more serious methods. Furthermore, ‘hallucination-delusion’ was the most prevalent motive in the F2 group and was the only factor that showed a significant association with the seriousness of the method of suicide attempt (OR = 3.36, 95% CI: 1.05–11.33).     

The Risks of Sleeping “Too Much”. Survey of a National Representative Sample of 24671 Adults (INPES Health Barometer)

Background

A significant U-shaped association between sleep duration and several morbidity (obesity, diabetes or cardiovascular disease) and mortality risks has been regularly reported. However, although the physiological pathways and risks associated with “too short sleep” (<5 hours/day) have been well demonstrated, little is known about “too much sleeping”.

Purpose

To explore socio-demographic characteristics and comorbidities of “long sleepers” (over 10 hours/day) from a nationally representative sample of adults.

Methods

A cross-sectional nationally representative sample of 24,671 subjects from 15 to 85-year-old. An estimated total sleep time (TST) on non-leisure days was calculated based on a specifically designed sleep log which allows to distinguish “long sleepers” from “short sleepers” (<5 hours/day). Insomnia was assessed according to the International classification of sleep disorders (ICSD-2).

Results

The average TST was 7 hours and 13 minutes (+/− 17 minutes). Six hundred and twelve subjects were “long sleepers” (2.7%) and 1969 “short sleepers” (7.5%). Compared to the whole group, “long sleepers” were more often female, younger (15–25 year-old) or older (above 65 year-old), with no academic degree, mostly clerks and blue collar workers. “Long sleepers” were significantly more likely to have psychiatric diseases and a greater body mass index (BMI). However, long sleep was not significantly associated with the presence of any other chronic medical disease assessed. Conversely, short sleep duration was significantly associated with almost all the other chronic diseases assessed.

Conclusions

In the general population, sleeping too much was associated with psychiatric diseases and higher BMI, but not with other chronic medical diseases.     

Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey

Data on the prevalence of psychiatric disorders in late life are lacking. The present study addresses this gap in the literature by examining the prevalence of the broadest range of psychiatric disorders in late life to date; comparing prevalences across older adult age groups using the largest sample of adults aged 85+; and exploring gender differences in the prevalence of psychiatric disorders in late life. Using data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, we examined the prevalence of past-year mood, anxiety, and substance use disorders, and lifetime personality disorders in a nationally representative sample of 12,312 U.S. older adults. We stratified our analyses by gender and by older age groups: young-old (ages 55-64), middle-old (ages 65-74), old-old (ages 75-84), and oldest-old (ages 85+). The proportion of older adults who experienced any past-year anxiety disorder was 11.4%, while the prevalence of any past-year mood disorder was 6.8%. A total of 3.8% of older adults met criteria for any past-year substance use disorder, and 14.5% of older adults had one or more personality disorder. We observed a general pattern of decreasing rates of psychiatric disorders with increasing age. Women experienced higher rates of mood and anxiety disorders, while men had higher rates of substance use disorders and any personality disorder. Gender differences in rates of most psychiatric disorders decreased with increasing age. These data indicate that psychiatric disorders are prevalent among U.S. older adults, and support the importance of prevention, diagnosis, and treatment of psychiatric disorders in this population.     

Relationship of Psychiatric Diagnosis and Weight Loss Maintenance in Obese Breast Cancer Survivors

Objective: Obese breast cancer survivors are a unique population for weight loss counseling because both obesity and a diagnosis of breast cancer can increase the risk of depression. In this pilot study, weight loss maintenance was examined in obese breast cancer survivors with relationship to psychiatric diagnosis. Research Methods and Procedures: Forty‐eight subjects were enrolled. The intervention, which used individualized counseling for diet and exercise, lasted 24 months. After a 6‐month period of no contact with study subjects, a follow‐up body weight was obtained at 30 months. Results: The nine subjects who dropped out of the study before 12 months all failed to complete a structured psychiatric interview. Of the remaining 39 subjects, 9 had major depressive disorder, and 10 had a definable psychiatric disorder of lesser severity such as adjustment disorder. Subjects with any type of psychiatric diagnosis displayed significantly less weight loss at the 12‐month time‐point than those with no diagnosis (6.3% vs. 12.6% loss of baseline weight, respectively). At the 30‐month follow‐up visit, subjects with any psychiatric disorder had a mean weight loss of 1.2% of baseline weight compared with 7.8% weight loss in subjects with no diagnosis. Discussion: These results suggest that the presence of psychiatric disorders can interfere with weight loss. Therefore, recognition and treatment of psychiatric disorders may be important in attempts at weight reduction, and this will be especially important in populations such as cancer survivors, who seem to have higher rates of depression and other disorders than the general population.     

Opportunities for rehabilitation of patients with radiation fibrosis syndrome

This review discusses the pathophysiology, evaluation, and treatment of neuromuscular, musculoskeletal, and functional disorders that can result as late effects of radiation treatment.Although radiation therapy is often an effective method of killing cancer cells, it can also damage nearby blood vessels that nourish the skin, ligaments, tendons, muscles, nerves, bones and lungs. This can result in a progressive condition called radiation fibrosis syndrome (RFS). It is generally a late complication of radiotherapy which may manifest clinically years after treatment. Radiation-induced damage can include “myelo-radiculo-plexo-neuro-myopathy,” causing muscle weakness and dysfunction and contributing to neuromuscular injury.RFS is a serious and lifelong disorder which, nevertheless, may often be decremented when identified and rehabilitated early enough. This medical treatment should be a complex procedure consisting of education, physical therapy, occupational therapy, orthotics as well as medications.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Problems Related to the Use of Food Additives in the United States

Major problems encountered by enforcement agencies and by regulated industries, respectively, in implementing and conforming to recent food additive laws are reviewed. Decisions as to which substances fall within the broad terms of the legal definition, and which escape by virtue of “generally recognized as safe” (GRAS) status, are often difficult and complex. Distinctions cannot be made solely on the basis of whether substances are old or new, natural or synthetic. Registration of pesticides on a “no residue” basis and establishment of “zero tolerances” for food additives have created an anomalous situation as a result of improvements in sensitivity of analytical techniques which revealed the presence of minute amounts of substances where none were believed to exist. A solution has been recommended by a specially appointed committee of the National Academy of Sciences-National Research Council (U.S.A.). Enforcement of the new food additive laws warrants revision of present labelling requirements to provide for designating chemical ingredients by functional categories rather than by confusing chemical terminology.