Biomedical subjects
Publications and source records attributed to P Tyrer.
A rating scale suitable for recording anxious symptoms is described. It is a subdivision of the Comprehensive Psychopathological Rating Scale and comprises 10 items, all of which are rated on a 7 point scale. It is suitable for the rating of pathological anxiety alone or for anxiety occurring in the setting of other psychological or medical disorder.
Current psychiatric classifications of anxiety are examined critically. In the European literature a specific cluster of symptoms is diagnostic of anxiety neurosis and their subsidiary classification is based on precipitating factors and duration of symptoms. In the American literature, exemplified by DSM-III, greater emphasis is placed on symptomatic classification and panic is given separate diagnostic status, both alone and in conjunction with agoraphobia. In both classifications generalized anxiety is at the bottom of a diagnostic hierarchy so that all other symptoms take precedence. It is argued that neither classification properly identifies a discrete syndrome of pathological anxiety that is recognizable in clinical practice.
The impact of devolving out-patient care to general practice (GP) psychiatric clinics over a two-year period is examined by comparing the frequency of contact with different psychiatric services in practices with and without psychiatric clinics. The clinics led to an increase in the number of outpatients seen, but to a fall in the number of new referrals. There was also a relative increase in the number of domiciliary visits and increase in acute day hospital referrals. The most important result was a 20 per cent fall in the number of admissions to the psychiatric hospital, which took place at a time when the national trend of falling admission rates was reversed. The findings suggest that psychiatric resources for in-patients can be deployed successfully in primary care without any increase in staffing.
The patients seen at five psychiatric clinics in general practice (GP) serving an urban population of 78,200 are described, and their attitudes to the clinic compared with those for conventional out-patient clinics. The GP psychiatric clinics were strongly preferred, mainly because of their ease of access and absence of stigma; 19 per cent of the patients seen would not have attended a hospital clinic. The patients seen encompassed the entire range of psychiatric disorder, but most were treated in the clinic or by other members of the primary care team. It is concluded that GP psychiatric clinics offer a way of achieving better community psychiatry without any need for increased resources.
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41 outpatients who were long-term consumers of diazepam in therapeutic dosage were gradually withdrawn from the drug over 3 months by stepwise reduction. In a double-blind procedure half the patients began withdrawal immediately and half after 8 weeks. Of 36 patients who completed treatment, 16 (44.4%) experienced true withdrawal phenomena on reducing their drugs, but 8 other patients had pseudo-withdrawal reactions at a time when their drug treatment was unchanged. The pseudo-withdrawal reactions consisted of an increase in anxiety symptoms only, whereas true withdrawal symptoms also included perceptual changes and psychotic symptoms. Examination of pharmacological and clinical predictors of withdrawal phenomena and later relapse showed that personality factors were the most important, patients with passive-dependent traits having a significantly greater prevalence of withdrawal reactions.
There is good evidence that many types of tranquilliser are effective in treating anxiety disorders that result from stress, but this evidence is not sufficient to recommend their use for acute stress disorders. Although there is little doubt that they will relieve the mood disturbance of severe mental and physical trauma, they may aid the process of denial. There is also a danger that short-term use of tranquillisers may progress to long-term dependence despite the initial intention of the prescriber. It is recommended that tranquillisers should be only used if the stress is severe enough to lead to marked changes in behaviour, is unpredicted and is likely to have a clear beginning and end. Benzodiazepines are usually the tranquillisers of choice but other drugs are available in patients prone to dependence.
The Personality Assessment Schedule, an interview schedule specifically designed for assessing personality disorder, was administered twice to 28 psychiatric patients, with a mean interval of 2.9 years between each assessment. The first assessment was made by a psychiatrist and the second by a medical student who had no prior knowledge of the patients. The reliability of the 2 assessments was measured using 4 different techniques. Although the reliability of individual personality traits was inconsistent over time, the categorical diagnosis of personality disorder was good (Kw = 0.64), giving some support to the validity of the schedule. Reasons for discordance in the assessments were examined and appeared to be due mainly to confusion between clinical symptoms and personality traits, retrospective errors in recording past personality in chronic patients, and special difficulties in determining the primary abnormality in severe personality disorder.
316 psychiatric patients--predominantly out-patients--with a clinical diagnosis of neurosis (International Classification of Disease), were given an interview schedule for assessing personality disorders. Nearly two fifths were rated as having personality disorder, the anankastic type being the most common and sociopathic personality disorder the least. Patients with anxiety, phobic and obsessional neurosis were all significantly more likely to show personality disorder than those with depressive neurosis. Broadly, passive-dependent personalities were linked to anxiety neurosis, anankastic personality disorder to obsessional neurosis, and both anankastic and passive-dependent personalities to phobic neurosis. In a clinical trial of the efficacy of two dosage regimes of phenelzine in 60 patients the presence of personality disorder significantly impaired clinical outcome. The results suggest strongly that the assessment of personality in neurotic disorders is necessary to make an adequate diagnosis and predict the outcome of treatment.
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Thirty-two agoraphobic patients were randomly allocated to four groups and treated by repeated exposure to cine-films at twice weekly intervals for three weeks. Three of the groups saw the same cine-film, comprising a range of agoraphobic scenes, and a control group saw a potter working on his wheel. The three groups seeing the phobic cine-film included one who viewed it at an illumination level below the visual threshold (subliminal group), one seeing it under normal conditions (supraliminal group) and one which underwent graduated exposure from subliminal to supraliminal viewing levels as the study proceeded (faded group). The faded group showed significantly greater improvement than the control and supraliminal groups and this improvement was maintained over twelve weeks.
Classical pharmacological dependence accompanied by euphoria, clinical evidence of tolerance and escalation of dosage are very rare with the benzodiazepines. However, there is now abundant evidence that prolonged administration of doses within the therapeutic range leads to true dependence in a significant minority of patients. This dependence is characterised by withdrawal symptoms on stopping treatment; these include perceptual disturbances, epileptic seizures, weight loss, insomnia and autonomic symptoms. As some of the symptoms are qualitatively different from those of anxiety neurosis, and as the withdrawal syndrome commonly lasts between 5 and 15 days, the possibility that the symptoms represent a return of pre-existing anxiety can be discounted. The withdrawal syndrome is more likely if: (a) the benzodiazepine has been taken in regular dosage for more than 4 months; (b) higher dosages have been used; (c) the drug is stopped suddenly; and (d) a short acting benzodiazepine has been taken. The withdrawal syndrome is most likely to occur when there is a rapid fall in blood benzodiazepine concentrations; this may be associated with altered sensitivity of benzodiazepine receptors. The syndrome can best be avoided by gradual reduction of dosage. The temporary prescription of other drugs, particularly beta-adrenoceptor blocking drugs, may attenuate withdrawal symptoms, but antipsychotic drugs in low dosage are of no benefit.
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40 patients seen in general practice and psychiatric outpatient clinics who had taken lorazepam or diazepam alone in regular dosage for a mean period of 3.6 years had their benzodiazepine replaced by propranolol (60--120 mg/day) or placebo for two weeks under double-blind conditions. Depending on the criteria for the definition of an abstinence syndrome, 27--45% of the patients had withdrawal symptoms during the study. Propranolol did not affect the drop-out rate or the incidence of withdrawal symptoms but significantly reduced their severity in patients completing the study. The percentage fall in serum levels of desmethyldiazepam in patients who experienced withdrawal symptoms after stopping diazepam was significantly greater in patients with no withdrawal symptoms.
Six groups of volunteer students were shown a series of four 90-second pictures: and anxiety inducing, one neutral, and two control sequences with no information content, under both subliminal and supraliminal conditions. Self-report and physiological responses to each picture were recorded. Each group was shown the same set of eight motion pictures, in counterbalanced order, but the level of subliminal presentation was varied from completely subliminal in group 1 to a level at which all the subjects could recognize the material in group 6. The results showed that although the anxiety-provoking motion pictures produced significantly greater anxiety responses under supraliminal conditions, there were no significant differences between responses to the pictures at any level of subliminal exposure.
Twenty-three patients taking lithium carbonate alone in therapeutic dosage for a mean period of 43 months (range 6--108 months) and 23 control subjects matched for age and sex had the frequency and amplitude of postural tremor measured and extrapyramidal symptoms assessed by standard techniques. Patients on lithium had a significantly lower peak frequency of tremor than control subjects (P less than 0.05) and significantly greater extrapyramidal symptoms (P less than 0.01), indicating that tremor appearing after chronic lithium therapy is likely to be an extrapyramidal symptom. Such symptoms are common long-term adverse effects of lithium carbonate.
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