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This report concerns a 27-year-old man in whom psychotic behavior emerged in association with a cerebellar tumor. This presentation supports previous clinical observations which postulate an intimate relationship between cerebellar pathology and the development of schizophrenia.
This study investigated the influence of gestational age, birthweight, caregiving, and maternal personality characteristics on the development of 51 six-month-old infants born to and being reared by cocaine-abusing mothers. Two self-report measures were administered to the pregnant women at intake: the ASI (quantifying drug use) and the MCMI (describing DSM-III Axis II personality characteristics and Axis I clinical syndromes). Infants' biologic vulnerability was assessed by gestational age and birthweight. Caregiving was assessed 6 months later in the home, using the HOME Inventory and maternal caregiving behavior rating scales. Infant development was assessed in the laboratory at 6 months using the Bayley Scales of Infant Development. Higher Bayley scores were associated with heavier birthweight and increased maternal sensitivity. Furthermore, mothers of infants with shorter gestations were found to be more sensitive caregivers, whereas mothers who reported more histrionic-gregarious, narcissistic, borderline-cycloid, and/or paranoid personality characteristics during pregnancy were less sensitive caregivers. Surprisingly, mothers who reported more depressive symptoms during pregnancy provided more sensitive care.
A 29-year-old woman with no history of paranoia or homicidal behavior developed paranoia, homicidal behavior, and seizures after abusing a preparation containing phenylpropanolamine. The paranoia and seizures were replicated in a controlled inpatient setting following phenylpropanolamine challenge.
BACKGROUND: The increasing health problem of hepatitis C virus (HCV) infection has only recently attracted the attention of psychosocial research, especially among subjects at higher risk (e.g. intravenous drug users; IDUs). The aim of the present study was to compare emotional stress symptoms, psychosocial variables (i.e. social support, external locus of control and emotional repression) and coping strategies in HCV-seropositive, human immunodeficiency virus (HIV)-seropositive and HCV/HIV-noninfected IDUs. METHODS: IDUs followed by the Infectious Diseases Outpatient clinic were enrolled in the study over a period of 1 year. HCV-positive (n = 62) and HIV-positive (n = 76) IDUs and HCV/HIV-seronegative IDUs (n = 152) completed the Brief Symptom Inventory, the Social Provision Scale, the Locus of Control scale and the affective inhibition scale of the Illness Behavior Questionnaire. Coping with illness among HCV-positive and HIV-positive subjects was assessed through a modified version of the Mental Adjustment to Cancer Scale. RESULTS: No significant differences were found between the samples with respect to individual and interpersonal variables. HCV-positive subjects showed higher scores on several psychological stress dimensions (i.e. obsessive-compulsive, phobic anxiety, paranoid ideation, psychoticism) and lower scores on fighting spirit, hopelessness and anxious preoccupation towards illness than HIV-positive patients. HCV-positive and HCV/HIV-seronegative IDUs reported comparable scores on most of the psychological measures. CONCLUSIONS: The findings indicate that routine assessment of psychosocial variables and coping mechanisms should be integrated into all HCV and HIV services, especially those dedicated to treatment of patients with substance abuse, as a vulnerable segment of the population at risk for life-threatening physical illness such as HCV and HIV infections.
The present study examined the association between belief in life after death and six measures of psychiatric symptomology in a national sample of 1403 adult Americans. A statistically significant inverse relationship was found between belief in life after death and symptom severity on all six symptom clusters that were examined (i.e., anxiety, depression, obsession-compulsion, paranoia, phobia, and somatization) after controlling for demographic and other variables (e.g., stress and social support) that are known to influence mental health. No significant association was found between the frequency of attending religious services and any of the mental health measures. The results are discussed in terms of the potentially salubrious effects of religious belief systems on mental health. These findings suggest that it may be more valuable to focus on religious beliefs than on religious practices and behaviors in research on religion and mental health.
Anorexia with its associated decreased food intake and weight loss is a common and profoundly important symptom in cancer, and one which has at times a psychological as well as physical component. When it is physical in origin it may be caused directly or indirectly by the disease process or treatment. Most poorly understood is the anorexia-cachexia syndrome of advanced disease. Psychological causes often reflect anxiety about cancer, its possible progression, depression, anticipatory phenomena, and learned food adversions. Pre-existing psychiatric disorders, especially anorexia nervosa or paranoid states, can substantially complicate cancer treatment. Learned food aversions, which can further restrict limited intake, have been demonstrated in children receiving chemotherapy and may also contribute to aversions of specific foods seen among adult patients after chemotherapy or radiation. Regardless of etiology, psychological management of the anorexia is often helpful. Optimal management often involves use of a combination of modalities: psychotherapeutic, behavioral and/or pharmacologic supplemented by education, counseling and support. Behavioral techniques such as relaxation exercises are useful tools to alter this response as well as to relieve the anxiety precipitated by the patient's concerns about anorexia and weight loss. Environmental interventions and nutritional advice can also be of considerable value in reversing the negative effects of this distressing symptom in cancer.
Individuals with severe, function-impairing personality disorders comprise a large proportion of the difficult-to-manage inmates. Personality disorders are reliably diagnosable using standardized criteria (DSM-IV), and treatment options are now available. Through careful assessment, differential diagnosis, and differential therapeutic selection, clinicians have the opportunity to help these individuals gain more control over unstable affect, impulsive/ irritable aggression, and paranoid perceptual distortions. Appropriate intervention holds the possibility, if not the promise, of reduced morbidity and recidivism, and may reasonably contribute to the public safety mission of corrections and to the primary mission of clinicians, which is improved health.
This study identified the unique and primary contributions of several concurrent risk factors for poor adherence to treatment recommendations in a clinic population of individuals with chronic psychotic disorders, i.e. 48% had DSM-IV diagnoses of schizoaffective disorder, 38% had schizophrenia, paranoid type, 12% had schizophrenia, undifferentiated type, and 2% had affective disorder with psychotic features. The target cohort consisted of 87 consecutive admissions to a continuing day treatment program. As part of a services-oriented quality assurance program, clinical staff completed rating scales for all patients. These included the BASIS-32 rating scale, which consisted of the following five subscales: psychosis; depression/anxiety; impulsive/addictive behavior; relation to self and others; and daily living and role functioning, and the Working Alliance Inventory-short form (therapist version), which consisted of the following three subscales: goal; task; and bond. These data were used to identify risk factors that weaken a patient's adherence to medication and non-medication treatment during the first 2 weeks of treatment in the clinic. Medication treatment consisted of both typical and atypical neuroleptic medications, with most patients being on multiple medications. Correlational analyses suggested that many of the risk factor variables were significantly associated with poor treatment adherence. Regression analyses suggested that the degree of psychoticism was most strongly associated with poor adherence to medication treatment and that difficulties relating to self and others were the strongest predictor of poor adherence to non-medication treatment. A large-sample services research design such as this can begin to determine patterns of associations between previous identified risk factors and poor treatment adherence in individuals with chronic psychotic disorders.
We examined the clinical and research records of 29 acutely ill hospitalized patients with affective disorder who received only lithium carbonate during their first week of treatment. Nineteen patients (Group I) could be continued on lithium ion alone, while 10 patients (Group 2) needed additional somatic treatment. Compared with Group 1, Group 2 patients were significantly younger at illness onset, more severely ill on admission, clinically more "colorful" in dress and behavior, stayed more than twice as long in the hospital, and (although not statistically significant) had more than twice the morbidity risk for affective disorder in first-degree relatives. At discharge, both groups were equally improved, and 70% of Group 2 patients were receiving lithium alone. We did not confirm previous reports that nonresponders to lithium alone (Group 2) were more overactive or paranoid--destructive or less euphoric--grandiose than responders to lithium alone (Group 1). Our Group 2 patients had a more severe or penetrant form of illness than our Group 1 patients, requiring neuroleptic drugs or ECT in addition to lithium therapy. Eventually, however, they had a satisfactory outcome, suggesting therapeutic optimism and tenacity even in those patients who initially fail lithium alone and require polytreatment.
Personality factors related to the outcome of supervised self-care treatment program were studied in 56 patients with intermittent claudication. Psychological methods used were: structured interviews, the Rorschach Test, the Thematic Apperception Test, Beck's Depression Inventory, the Beth Israel Hospital Inventory of alexithymic behavior and Sauri's Creativity Inventory of psychic flexibility and adaptability. The patients who had no apparent signs of psychic disorders and were also capable of coping with disease-related psychic problems showed the best recovery. Alexithymic patients with a low level of psychic adaptability were likely to find the supportive relationship rewarding, but optimal recovery was not achieved. The results indicated that paranoid tendencies may be obstacles to a satisfying doctor-patient relationship and should be controlled.
The finding of marked disorganization of the hippocampal pyramidal cell layer in the brains of schizophrenic patients has recently been reported. The present study was undertaken to determine whether similar abnormalities could be found in the brains of a population of schizophrenic patients, most of whom were never exposed to neuroleptics. Though statistical analysis of 2808 pyramidal cells failed to reveal significantly greater disorganization in a group of seven alleged schizophrenic brains than in brains of age-matched, nonpsychotic controls, the data suggest a relationship between the degree of pyramidal cell disarray and the severity of behavioral impairment due to psychosis. The implications and pitfalls in interpreting these findings are discussed.
Thirty patients with Huntington's disease, a genetically transmitted neuropsychiatric disorder that can be diagnosed reliably, were evaluated systematically for psychopathology, followed for extended periods, and treated with psychopharmacological medications when necessary. DSM-III criteria were used for establishing syndromic diagnoses. Twenty-four individuals demonstrated substantial behavioral abnormalities, including affective and schizophrenic syndromes, changes of personality, and disorders that could not be classified adequately. Pharmacotherapy was modestly beneficial in some cases. Consideration of the array of behavioral disturbances encountered in this pathogenetically unified disorder suggests that a dimensional approach to symptom classification might prove more useful heuristically than present typological methods.
BACKGROUND: The syndrome of manic-depressive insanity (MDI), as conceptualized by Emil Kraepelin a century ago, with later refinements, continues to dominate research and clinical practice with mood disorder patients. Current understanding of Kraepelin's views by Anglophones is heavily influenced by the late, highly developed, MDI concept represented in the 1921 partial English translation of the last complete edition of his textbook, the product of gradual development over several decades. METHOD: We reviewed all nine editions and revisions of Kraepelin's Textbook (1883-1926) and other writings by him to document the evolution of his views of MDI, and characterized salient developments within biographical and historical contexts. RESULTS: We found support for the traditional impression that Kraepelin's clinical perception of similarities of various forms of periodic psychiatric disorders marked by fundamental dysregulation of excitation and inhibition of thought and behavior, as well as of mood--as distinct from chronic psychotic illnesses--encouraged his broad, mature concept of MDI. However, our findings indicate a complex evolution of Kraepelin's MDI concept in the 1880s and 1890s, his use of more creative and less empirical clinical methods than traditionally believed, and his considerable personal uncertainty about making clear distinctions among MDI, dementia praecox, intermediate conditions, and paranoid disorders--an uncertainty that persisted to the end of his career in the 1920s. CONCLUSIONS: Kraepelin responded to a compelling international need for diagnostic order in nineteenth-century psychiatry, and effectively promoted his diagnostic proposals with a widely used and influential textbook. Though his methods were less empirical than is usually realized, his legacy includes analysis of large clinical samples to describe psychopathology and illness-course, along with efforts to define psychobiologically coherent and clinically differentiable entities, as steps toward defining psychiatric syndromes. Modern international "neo-Kraepelinian" enthusiasm for descriptive, criterion-based diagnosis should be tempered by Kraepelin's own appreciation of the tentative and uncertain nature of psychiatric nosology, particularly in classifying illnesses with both affective and psychotic features.
OBJECTIVE: To evaluate the ictal and psychiatric aspects underlying the high risk of suicide among epileptic patients. METHOD: We surveyed the records of 1611 epileptic patients seen in a neurology clinic during an eight-year period, found four who died by suicide, and characterized their ictal and psychiatric features. RESULTS: All four epileptic patients had partial complex seizures and temporal lobe foci. Two had an associated paranoid schizophrenia with suicidal ideation, and good or improving seizure control at the time of their deaths. Another patient killed himself during a brief psychotic episode associated with increasing epileptiform discharges. The fourth patient had ictal depression and committed suicide during a flurry of partial complex seizures. CONCLUSIONS: These findings suggest that the high suicide rate among epileptic patients has a greater association with psychotic behaviors and psychic auras than with major depression or the psychosocial burden of being epileptic. We further review other reported risk factors for suicide in epilepsy.
The clinical basis for the long established contraindication of electroconvulsive therapy (ECT) in the presence of brain tumor is reviewed, as is the recent literature that has questioned the absolute nature of that contraindication. A need for a specific estimate of risk is noted. Seven retrospective case reports are added to the 28 cases reported in the literature. The clinical case report data are then pooled and evaluated by outcome. Results indicate a 74 per cent overall morbidity, including a 28 per cent 1-month mortality rate for patients with brain tumors who receive ECT. Twenty-one per cent of the patients had a positive behavioral response to ECT without complication.
Patient aggression is a common problem on psychiatric units. Recent research has focused on the relationship between aggressive behavior and various patient characteristics, including psychopathology. The purpose of this study was to examine the relationship between diagnostic groups and particular types of patient aggression in a state psychiatric hospital. A secondary analysis was performed on existing data. There was no significant difference noted among DSM III diagnoses in total patient aggression. However, there was a significant difference between individuals with organic disorders and individuals with paranoid schizophrenia in the category of physical aggression against other people. Improved ability to identify a particular diagnostic group with the potential for aggression will strengthen efforts to decrease the risk of patient aggression in psychiatric facilities.
BACKGROUND: Both integration and sealing over have been identified as global, clinically distinct coping styles with the psychotic illness and integration was found to be associated with a better outcome. We studied a series of potential correlates of these coping styles. SAMPLING AND METHODS: A total of 75 psychiatric patients in a recovery phase after a psychotic episode were studied. All patients filled out the Frankfurt Self-Concept Inventory and the Parental Bonding Instrument; the Integration/Sealing over Scale and the Positive and Negative Syndrome Scale were completed by an investigator for all patients during a semistructured interview. Besides, some sociodemographic and clinical data were collected. RESULTS: A relationship was found between the integrative coping style and absence of negative symptoms, housing with partner or alone indicating more social competence and a diagnosis of psychotic illness other than (paranoid) schizophrenia. CONCLUSIONS: As only 25% of the variance were explained, other--still unknown--factors are also of importance.
The psychoanalytic treatment of the seriously disturbed patient depends on working through the countertransference. If the analyst regresses without debilitating anxiety to early levels of psychic development, as does the analysand while reliving his or her early traumatic psychic development, both analyst and analysand may be able to enter states of reverie simultaneously and to communicate with one another in a type of verbal squiggle game. In this variant of Winnicott's written squiggle game, each may easily communicate with the other with quick shifts from the autistic-contiguous, paranoid-schizoid, and depressive positions. During such unusual periods of exquisite understanding, very early pathological experiences can be relived, understood, and repaired.