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The growth in the USA of ‘recovered memory therapy’ for past sexual abuse has caused great public and professional concern. It became apparent that the polarisation of views and fierce controversy within the American psychiatric community was in danger of bringing psychotherapy into disrepute and it seemed important to examine objectively the scientific evidence before such polarisation developed in the UK.
A small working group reviewed their own experience, visited meetings and centres with expertise in this field, interviewed ‘retractors' and accused parents, and then began a comprehensive review of the literature.
There is a vast literature but little acceptable research. Opinions are expressed with great conviction but often unsupported by evidence.
The issue of false or recovered memories should not be allowed to confuse the recognition and treatment of sexually abused children. We concluded that when memories are ‘recovered’ after long periods of amnesia, particularly when extraordinary means were used to secure the recovery of memory, there is a high probability that the memories are false, i.e. of incidents that had not occurred. Some guidelines which should enable practitioners to avoid the pitfalls of memory recovery are offered.
Schizoid personality and poor social adjustment have been thought of as common antecedents of schizophrenia but the existing literature is inconclusive. We have carried out a large cohort study with improved methodology.
The premorbid personality and adjustment of 50 054 Swedish men were assessed on entry into the army at the age of 18. Individuals who developed schizophrenia or another psychosis after 15-year follow-up were identified. Odds ratios for variables independently associated with the later development of schizophrenia were calculated, adjusting for potential confounders.
Four variables reflecting early problems with interpersonal relationships were strongly associated with later schizophrenia and, to a lesser extent, non-schizophrenic psychoses, but also occurred commonly in the cohort as a whole. These associations with schizophrenia persisted after early-onset cases were excluded, though their predictive value was low (3.0%, 95% CI 1.5–4.5).
Some aspects of premorbid personality and adjustment may act as risk factors for schizophrenia. The results appear to be most consistent with a multi-factorial aetiology for schizophrenia and offer tentative support for a psychological disturbance mediating genetic and environmental effects on the causal pathway to the illness.
Invited commentaries on: Premorbid adjustment and personality in people with schizophrenia
Hypo-activation of the left dorsolateral prefrontal cortex is inconsistently found in neuroimaging studies of schizophrenia. As the left dorsolateral prefrontal cortex is involved in the generation of action, disordered function in this region may be implicated in schizophrenic symptomatology.
We used H215O positron emission tomography to study dorsolateral prefrontal cortical function in men with schizophrenia (n=13) and male control subjects (n=6) performing joystick movements on two occasions, 4–6 weeks apart. The patients were initially in relapse. To clarify dorsolateral prefrontal cortical function we also scanned another group of control subjects (n=5) performing mouth movements.
The control subjects performing hand or mouth movements activated the left dorsolateral prefrontal cortex to a maximum when the movements were self-selected. The men with relapsed schizophrenia exhibited left dorsolateral prefrontal cortical hypo-activation, which remitted with symptomatic improvement.
Hypofrontality in these patients is a dynamic phenomenon across time, possibly related to current symptomatology. The most appropriate question about the presence of hypofrontality in schizophrenia may be when, rather than whether, it will occur.
It has been suggested that prenatal exposure to maternal stress increases the risk of subsequently developing schizophrenia.
The five-day invasion and defeat of The Netherlands by the German army in May 1940 constituted a severe, well-circumscribed national stressful event. Individuals exposed and non-exposed to this stressor in the first, second and third trimester of pregnancy were followed up for lifetime schizophrenia outcome through the National Psychiatric Case Register.
Cumulative incidence of schizophrenia was higher in the exposed cohort (risk ratio (RR): 1.15, 95% CI: 1.03–1.28), especially in those exposed in the first trimester (RR: 1.28, 95% CI: 1.07–1.53). Significant interaction with gender was apparent in second trimester exposed cohorts (RR men: 1.35, 95% CI: 1.05–1.74; RR women: 0.83, 95% CI: 0.61–1.12).
Maternal stress during pregnancy may contribute to the development of vulnerability to schizophrenia. The apparent longer window of exposure in male foetuses may be related to the slower pace of male early cerebral development.
People with schizophrenia are at high risk of psychotic relapse. The purpose of this study was to evaluate the predictive validity and temporal link of early signs to this.
A study sample of 60 out-patients with schizophrenia was examined every second week over a period of six months. The study design included self-reporting (Early Signs Scale) and objective assessment (General Psychopathology of Positive and Negative Symptom Scale) of behavioural and phenomenological changes (early signs). Criterion cut-off points were based on a comparison to the subjects' individual baseline scores.
Twenty-seven subjects (45%) experienced a relapse. Composite increased score ($ 10 points) of self-reported/objectively assessed early signs predicted the relapse with a sensitivity of 81% and a specificity of 79%. Thus the predictive validity of early signs of relapse was considerable, particularly self-reporting of early signs of relapse: sensitivity 74% and specificity 79%. The inclusion of objective assessment added only marginally to the prediction. Early signs were detected most often (70%) within the four weeks immediately before the individuals' relapse.
Psychotic relapse is most often preceded by early signs. Clinical practice should integrate this knowledge by an ongoing monitoring including self-reporting.
The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.
A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both inpatient and community-based services.
Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.
The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.
African–Caribbean men are over-represented in psychiatric and forensic services and in the prison population. A failure of community services to engage mentally ill African–Caribbean men and their presentation through the criminal justice system culminates in a repeated pattern of forensic service and criminal justice system contact.
We carried out a cross-sectional survey during a one-year period of a sample of potentially mentally ill men remanded to HMP Brixton in south London. Men were interviewed to establish their place of birth, first language, socio-demographic profile, ethnicity, psychiatric diagnosis, levels of alcohol and substance misuse, criminality, violence involved in their index offence, past psychiatric and forensic contacts and outcome of court appearance.
Two hundred and seventy-seven men were interviewed. In comparison with White men, African–Caribbean men were more often diagnosed as having schizophrenia and were more often sent to hospital under a mental health act order. African–Caribbean men were remanded in custody despite more stable housing conditions and more favourable indices of lifetime criminality, substance misuse and violence.
Community services, including diversion schemes, should be especially sensitive to African–Caribbean men with schizophrenia who ‘fall out of care’, who are not diverted back into care and are therefore unnecessarily remanded.
The aim of this study was to investigate whether ‘dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending.
Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and key workers asked to rate substance misuse and aggression.
The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P=0.001), or recent hostile behaviour (P=0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P=0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables.
Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.
Increased central serotonin (5-HT) function has been hypothesised to be a vulnerability trait in anorexia nervosa.
Eighteen women with a history of DSM–III–R anorexia nervosa and 18 female controls were examined. The subjects had recovered weight and menstrual function. A placebo-controlled d-fenfluramine test was used. Subjects ingested d-fenfluramine or placebo and after three hours were offered a ‘free’ meal. The amounts eaten were recorded and plasma Cortisol and prolactin levels were measured. Questionnaires related to eating attitudes and behaviour, to personality, and to mood were administered.
Unlike the control subjects, those recovered from anorexia nervosa did not show the expected appetite-suppressing responses to d-fenfluramine; their eating attitudes and behaviour were more restrained, ‘negative’ perfectionism was more pronounced, and post-meal plasma Cortisol levels did not rise as expected.
Our results do not suggest that increased central 5-HT function is a trait marker in anorexia nervosa, but dysregulation in part of the central 5-HT system may be a vulnerability factor. The flattened post-meal response to Cortisol in the subjects who had recovered from anorexia nervosa suggests that their hypothalamic–pituitary–adrenal axis may be altered and deserves further investigation.
ODIN aims (a) to provide data on the prevalence, risk factors and outcome of depressive disorders in rural and urban settings within the European Union (EU) based on an epidemiological sampling frame; and (b) to assess the impact of two psychological interventions on the outcome of depression and on service utilisation and costs.
Five centres across the EU are participating in ODIN. The centres are linked electronically and members meet regularly for training and strategic reviews. Urban and rural areas have been identified in each centre. The sampling frame is of adults aged 18–64, identified via primary care databases or electoral registers. Potential cases of depressive disorders are identified using the Beck Depression Inventory. SCAN II and other validated measures are used to assign caseness against DSM–IV and ICD–10 criteria; assess comorbidity, disability, genetic/familial susceptibility, psychosocial stressors, personality traits and cognitive factors; and utilisation of local health care services. A randomised controlled trial of individual problem-solving treatment and a group educational programme is undertaken for respondents identified as cases of depressive disorder. Individuals are followed-up at six and 12 months.
Results and Conclusions
ODIN has already stimulated the development of an effective international research partnership.