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It is common knowledge that the French school of psychiatry began with Pinel (1745–1826) at the end of the 18th century. Pinel is credited with having delivered the insane from their chains in the two hospitals of Paris where they were detained, Bicêtre and la Salpêtrière: his near contemporaries in the humanization of the treatment of the insane were Tuke in England, Chiarugi in Tuscany and Daquin in Savoy. Pinel's essential achievement was the creation of the 19th-century French tradition in psychiatry, encompassing the medical, clinical, descriptive and nosological fields. Pinel's breadth of outlook was shared by his pupil Esquirol (1772–1840), who dominated the so-called ‘classical’ school of the ‘Alienists of the Salpêtrière’ via his numerous disciples and his treatise, published in 1838, Des Maladies Mentales Considérées sous le Rapports Médical, Hygiénique et Médicol-légal.
The suicide rate in England and Wales has increased annually in the period 1975 to 1980. The increase has occurred in both sexes, but has been greater for males. There has been a decrease in suicide by poisoning with solid or liquid substances (including overdoses) and a marked increase in poisoning by vehicle exhaust gas. The rate of hanging, strangulation and suffocation has also increased substantially: taken together (ICD E953) these now form the most common method of suicide in males. Statistics for ‘undetermined’ and ‘accidental’ death have been examined, and indicate that the increase in the official suicide rate represents a real increase in suicides during this period.
Previous work on the inter-relationships among depression, hopelessness and suicidal intent in parasuicide is reviewed. Our own study of 120 hospital-referred parasuicides confirms previous findings that, while both depression and hopelessness correlate with the degree of suicidal intent as measured on a Suicide Intent Scale, the relationship between depression and suicidal intent is dependent on that between hopelessness and suicidal intent. Some practical and theoretical implications are discussed.
Suicide is rare under 14 years but thereafter increases with increasing age, with males predominating. The suicide rate for 15–19 year olds in England and Wales has increased since the nineteen fifties for both males and females, with a recent substantial rise in males. There has also been an increase in the small number of female suicides aged 10–14 years between 1941–50 and 1971–80. In younger age groups there is a higher proportion of undetermined deaths compared with officially recorded suicides, and this category has recently increased disproportionately in the young. The number of deaths by poisoning with solids or liquids recorded as suicide, accidental poisoning or undetermined poisoning has increased markedly in young people, and the relationship between the three groups might repay investigation.
We predicted that the closer the resemblance of attempted suicide to completed suicide, the greater the risk of patients later killing themselves after an unsuccessful attempt. Using two risk scales, one of 6 and the other of 18 socio-demographic and clinical items, weighted according to their value in discriminating between suicides and attempted suicides, and a rating of intent to die during the index suicide attempt, we followed up 1263 attempted suicides for two years. Ten of the twelve suicidal deaths in the first year occurred in patients scoring in the top quartile on the 6-item scale; and among high-risk scorers there was an excess of those defined as ‘failed suicides' at the index attempt. The 18-item scale was superior to the shorter one, but both scales were improved by taking into account the rating of intent-to-die. The potential value of these findings is discussed in the light of some inherent problems of predicting suicide in the clinical setting.
One hundred and ninety three raters drawn from six countries and representing different professional groups considered 16 case histories. Raters were asked to indicate what degree of ‘dangerousness' they attributed to each individual and what they considered to be the optimal management.
The level of agreement between raters concerning the assessment of dangerousness was generally low, the level of 60 per cent being reached for only 4 cases out of 16. Psychiatrists did not reach a higher level of agreement on the ratings of dangerousness than non-psychiatrists. Psychiatrists had a tendency to rate individuals as more dangerous than did non-psychiatrists.
The results of this exercise do not support the use of ‘dangerousness' as a scientifically or operationally valid concept.
One hundred boys and girls who were placed in two group homes by court order were studied. The girls were admitted mostly for status offences while the boys were admitted for offences to property and persons. Over half of the sample had an immediate family member who had committed a serious crime. This group differed in several ways from the group with no family history of crime. When the outcome of the entire sample was investigated, it was found that there are some indicators that could be used as predictors for the outcome in a delinquent population. This could have a definite clinical application.
An investigation carried out on 97 patients with affective disorders and on 100 healthy control subjects, revealed that acute and chronic stress factors occurred more in the group of patients with affective disorders than among healthy control over a similar time period. The frequency of stressful life situations was the same before the first affective episode in patients with unipolar and bipolar illness. The possible participation of such factors in triggering the first phase of illness is discussed. Similar factors appeared in both types of affective disorders. Significantly more frequent among patients than in the control group were: marital and family conflicts, health problems, emotional and ambitional failures, lack of success and work overload.
The perception of body shape was studied in 15 female patients with anorexia nervosa and 15 age matched controls. A lens was used which could be manipulated to cause a horizontal distortion of an image projected onto a video monitor. The patients showed a greater tendency to over- and under-estimate their present body shape than did the controls. Further, the patients' desired body shape was significantly thinner than that of controls, as was their estimation of what constitutes a normal body shape. These findings are discussed in relation to the literature and it is suggested that they may have important implications for treatment.
Twenty-three chronic schizophrenic patients and 23 controls, all males between 20 and 40 years of age, were evaluated by CT scan. The lateral, third and fourth ventricles, the Sylvian fissures, and the largest sulcus from each of the frontal, parietal, and occipital lobes, were measured in order to determine whether the previously reported ventriculomegaly in schizophrenics was perhaps due to a disturbance of CSF flow or to atrophy, two common causes of ventricular enlargement. We found that in the schizophrenic group the third and fourth ventricles and both Sylvian fissures were significantly enlarged, but not the lateral ventricles or cerebral sulci. Our data suggest that these ventricular changes are not due to a disturbance of CSF flow or to cerebral atrophy. Other possible explanations are discussed.
Cerebrospinal fluid was collected from 28 psychiatric (mostly schizophrenic) inpatients from Bombay, India. These included eight patients with tardive dyskinesia, five with spontaneous dyskinesia and 15 without dyskinesia. The samples were flown to the National Institute of Mental Health, Washington, D.C., where they were analyzed “blind” for concentrations of noradrenaline and several monoamine metabolites. Patients with tardive dyskinesia had significantly higher noradrenaline concentrations in the CSF as compared with the other two groups. Spontaneous dyskinesia group had significantly lower concentrations of homovanillic acid in the CSF. Our results support the hypothesis of noradrenergic hyperactivity, rather than postsynaptic dopamine receptor supersensitivity, in tardive dyskinesia.
Fifty-nine depressed inpatients who satisfied Feighner's criteria for depression were separated into two groups by the response of their plasma Cortisol (1600 hours) to a dose of 1 mg of dexamethasone given at 2100 hours. No statistically significant differences were found between suppressors and non-suppressors as regards severity of anxiety or depressive symptoms in the Leeds and the MADRS rating scales. No single item either in the Leeds or the MADRS scale was associated with a positive DST. The reason for this negative finding is discussed.
Twenty-five patients with obsessive-compulsive neurosis and matched controls had their life event scores (Paykel's Life Event Schedule) rated for the year prior to the onset of illness and the date of interview, respectively. The Standard Assessment of Personality Schedule, whose high inter-temporal and inter-informant reliability was confirmed, was used to rate the patients' premorbid personality.
The obsessive-compulsive patients' mean life event score was significantly higher than the control subjects; and this excess spanned the six months prior to the onset of illness. Patients with abnormal personality traits (obsessional, anxious and self-conscious) experienced significantly fewer life events than those without such traits.
Four cases of obsessive-compulsive neurosis following head injury are described, three of which are from a consecutive series and the fourth from a discordant monozygotic twin pair. The aetiological significance of head injury in this disorder is discussed in the context of the clinical findings and of previous series of brain injured patients.
From a population of long-stay patients with a diagnosis of schizophrenia according to the St Louis criteria, a group of 21 patients with ‘age disorientation’ was selected, and compared on a series of tests of intellect and learning capacity with a matched control group of 21 schizophrenic patients without this feature. The age-disorientated patients demonstrated substantial impairments on tests of orientation and general knowledge, associational learning, the ‘famous personality’ test, tests of vocabulary and aphasia, Raven's matrices, the digit–symbol substitution test and the mental test score. We conclude that profound ‘organic-type’ psychological deficits (global impairment of intellectual function associated with temporal disorientation) undoubtedly occur in chronic schizophrenia. The findings on the ‘famous personality’ test and the Peabody vocabulary test did not exclude the possibility that such impairment arises early in life, at a time preceding the onset of the illness which leads to hospital admission.
The current maximum recommended dose of disulfiram, 200 mg daily, is often inadequate. Of 63 patients taking disulfiram under supervision who either risked drinking alcohol or who had a medically supervised challenge with alcohol, only half produced a significant response on a dose of 200–300 mg daily. Some patients need as much as 1.5 g daily but even at high dosage significant side effects are uncommon, reversible and rarely serious.
A modification to the recommended technique for a medically supervised alcohol challenge is described, which minimises distress.
Summary A group of 24 opiate addicts admitted to an in-patient drug dependence unit received either electrostimulation or graduated oral methadone withdrawal. Addicts treated with electrostimulation showed high levels of withdrawal symptoms during the first week of treatment: these reached a peak on Day 3. In this respect electrostimulation was markedly inferior to methadone withdrawal treatment. However, although progressive methadone withdrawal quickly reduced symptoms to a moderate or low level, there was no reduction in symptomatology as late as one month after admission (i.e. after ten days without methadone). The implications of these findings are discussed.