Parental divorce as a factor in childhoold psychiatric illness

Although hundreds of papers have been written concerning the effects of separation from parents and bereavement in childhood, the problem of divorce as a factor in psychiatric disturbance in children has been relatively ignored. This neglect is undeserved: in the 15 years following 1950, the number of children affected yearly by divorce in this country doubled, until by 1965 it stood at somewhat more than 600,000 per year¹⁴.Much of the recent literature on the subject^8,13,15 has focused on the effects of the divorce per se in the production of childhood symptoms. Relatively little attention has been paid to antecedents of the divorce or to the possibility that parental divorce and childhood psychiatric illness may both be related secondarily to a common background factor. Because other authors^3,18 have noted the association of certain psychiatric disorders with divorce, it is important to examine the parents and other relatives of psychiatrically ill children for mental illness and to attempt to correlate such illness with marital status.     

Severity of illness and illness behaviour: a comparative study of coronary care patients.

Patients entering a coronary care unit (CCU) usually fall into one of two groups; those with an unequivocal diagnosis of myocardial infarction (MI) who remain to be monitored in CCU for some days before discharge to a general medical ward, and those who fail to attract a diagnosis of MI or other serious illness and are rapidly discharged to a general ward. It was hypothesized that the former group would perceive the severity of their illness as being greater than that of the latter group, and would exhibit patterns of illness behaviour in accord with this perception. In particular, it was expected that patients with MI would exhibit a greater recognition of the presence of serious illness, a greater acceptance of the sick role and a more intense affective response to illness than patients without MI.These expectations were examined by comparing illness behaviour profiles of 120 survivors of MI, with identically obtained profiles of 40 persons admitted to a CCU with chest pain but rapidly discharged with neither a diagnosis of MI or other serious illness. Only the first, relating to the recognition of the presence of serious illness, was confirmed. In all other respects, patterns of illness behaviour among survivors of MI was no different from that among patients without MI.It would seem then that patterns of illness behaviour were more influenced by the element of experience common to the two groups, admission to a CCU, than by differences either in the actual severity of the illness or the degree to which this was recognized. This suggests in turn that patients discharged from a CCU without a diagnosis of MI, are none the less concerned about the integrity of their cardiovascular systems, and if psychological intervention has been shown to benefit patients with MI, it may also be indicated for those patients with the less serious illness.     

A review of the EEG literature on Ganser's syndrome

Ganser's syndrome has been classified as a histrionic disorder, a psychotic illness, a dissociative disorder, a factitious disorder, and an organic illness. The possibility of an underlying organic component to Ganser's syndrome is often implicated. A case which includes CT scan and EEG tests is presented and the EEG data in patients with Ganser's syndrome are reviewed. The majority of EEG data was not suggestive of any specific organic illness.     

Reye syndrome and reye-like syndrome

Reye syndrome is an acute metabolic encephalopathy, largely affecting children and adolescents. In Reye-like syndrome, because of inborn errors of metabolism, hypoglycemia, hypoketonemia, elevated ammonia, and organic aciduria are often evident. It is well-known that fatty-acid oxidation defects can present as Reye-like syndrome. The most commonly diagnosed metabolic disorder in association with Reye syndrome has been medium-chain acyl coenzyme A dehydrogenase deficiency. The present consensus seems to be that Reye syndrome is very rare, and that any child suspected of manifesting this disorder should undergo investigations for inborn errors of metabolism. We recently treated a child with "Reye-like illness" who possibly manifested a long-chain acyl dehydrogenase deficiency, and who had also ingested aspirin. We discuss the possible pathogenesis of the disorder in this child. The end results of mitochondrial dysfunction in Reye syndrome and Reye-like illness may be similar.     

Facial palsy in Kawasaki syndrome

Facial nerve palsy, a very rare complication of Kawasaki syndrome, has been reported in only 25 patients. We treated a 12-week-old boy with bilateral coronary artery aneurysms due to Kawasaki syndrome who developed marked unilateral peripheral facial nerve palsy on day 36 of illness. None of the 25 previously reported patients with this complication were treated with immunoglobulin; they required 7 to 90 days to recover. In our patient, treatment with this agent was associated with complete resolution of facial nerve palsy within 36 hours. Review of prior cases demonstrates that children with Kawasaki-associated facial nerve palsy have more than twice the risk for coronary artery aneurysm (52% vs <25%) as that of children who do not develop this neurological complication. Unexplained facial nerve paralysis in young children with a prolonged febrile illness should provoke consideration of Kawasaki syndrome and of echocardiography to exclude coronary artery aneurysms. Although facial palsy appears likely to resolve in all patients that survive the acute phase of Kawasaki syndrome, treatment with intravenous immunoglobulin appears to considerably shorten the time to full recovery and provides an important clue to the mechanisms of neurological injury in this illness.     

Reye syndrome

Reye syndrome has emerged as the quintessential example of an acute metabolic encephalopathy. The clinical presentation is quite stereotyped in most instances permitting rapid, accurate diagnosis and early therapeutic intervention. Intoxications and certain inborn metabolic errors may mimic Reye syndrome. All patients with a recurrent episode should be investigated thoroughly for evidence of a metabolic disorder associated with an enzyme deficiency. Notable in this regard are inborn errors affecting organic acid, ammonia, and carbohydrate metabolism. The mitochondrial disturbance in Reye syndrome is well documented but the pathophysiologic sequence linking the antecedent viral illness to the mitochondrial injury remains obscure. Recent identification of a spontaneous Reye-like illness in mice that is associated with a coronavirus infection may provide an opportunity to investigate this initial phase of the pathophysiologic sequence. The primary cerebral insult presumably derives from insufficient substrate availability and results in massive cytotoxic cerebral edema. Treatment revolves around the continuous infusion of hypertonic glucose and intermittent infusion of hypertonic mannitol. Management is designed to attenuate or avoid the various compounding metabolic insults during this critical period when the child is metabolically crippled. In 1963, the disorder was considered to be rare and almost irreversibly fatal. Today, the disorder is recognized to be more common, and the outcome is very satisfactory in 85 to 90 per cent of the cases. The role of aspirin remains very controversial. A number of studies suggest an association between this potential mitochondrial toxin and Reye syndrome, but a causal relationship has not been established. Until better understood, it seems advisable to avoid use of aspirin in children exhibiting symptoms suggestive of Reye syndrome.     

The effect of illness behaviour on the apparent relationship between physical and mental disorders

Evidence for associations between organic disease and psychopathology is reviewed and it is concluded that some of this is determined by complaint and consultation behaviours. The concept of illness behaviour is described. The Self Care Assessment Schedule (SCAS) is a new measure of illness behaviour and has been used to provide an independent assessment of psychiatric day patients, gynaecology and surgical outpatients. Only weak positive correlations were found between SCAS scores and mental illness, measured using the General Health Questionnaire (GHQ). Subjects with organic pathology differed little from those without organic pathology, with regard to SCAS and GHQ scores. However SCAS and GHQ scores were more highly correlated in those without organic pathology. It is concluded that claimed associations between physical disease and psychopathology should be based on objective evidence rather than subjective complaints and that this should be found across the entire spectrum of illness behaviour.     

Correlates of illness worry in chronic fatigue syndrome

BACKGROUND: Anxiety about illness leading to restriction of activity and physical deconditioning has been hypothesized to contribute to the chronicity of fatigue. Pathological symptom attributions, personality traits, and depression have all been hypothesized to contribute to illness worry. METHODS: We compared 45 chronic fatigue syndrome (CFS) and 40 multiple sclerosis (MS) outpatients using a battery of psychometric instruments comprising the 12-item Illness Worry scale, the Symptom Interpretation Questionnaire (SIQ), the NEO Five-Factor Inventory (NEO-FFI), and a modified version of the SCL-90R Depression scale. RESULTS: There was no difference between the two diagnostic groups on neuroticism, depressive symptoms, as well as the three scales of the SIQ. On the illness worry index, the CFS group had significantly higher scores than the MS group. This difference was due to items tapping vulnerability to illness and the perception that others are not taking their illness seriously. Somatic attributional style, neuroticism, depressive symptoms, and age were all significant predictors of illness worry in both CFS and MS patients. CONCLUSIONS: Somatic attributions, neuroticism, and depression all contribute to illness worry in chronic illness. However, these factors do not account for the higher levels of illness worry in CFS as opposed to MS, which may be due to other specific cognitive and social interactional processes.     

Organic brain syndrome in three cases of acquired immune deficiency syndrome

A triad of psychiatric symptoms involving mood disturbance, thought disorder with grandiose delusions, and severe memory deficits is described for three male homosexual patients suffering from acquired immume deficiency syndrome. The evidence suggests that the last two of these symptoms are inexplicable on the basis of previous psychiatric history or as a reaction to medical illness. Rather, an organic brain syndrome may be part of the natural history of AIDS for some patients.     

The associations between epilepsy and depressive illness in secondary care

BACKGROUND: The association between epilepsy and depressive illness has long been established. However, though various explanations-psychosocial and anatomical-have been proposed findings from studies are inconsistent and often contradictory.AIMS: This study aimed to compare the features of those people with epilepsy seen in a secondary care setting who developed a depressive illness with those that did not.METHOD: Information regarding the patient's epilepsy, history and presence of depressive illness and perceived social functioning was gathered from case notes, questionnaire and patient interview.RESULTS: The experience of a depressive episode was associated with the presence of a right sided lesion, attacks occurring more than once each month, diagnosis made in adulthood and a perceived marked effect of the epilepsy on mobility and social activity.CONCLUSION: These findings are not all consistent with work already carried out in this field. However, they do point to a multifactorial aetiology of depressive illness in this group as is the case in the general population. Possible explanations for frequently contradictory findings are discussed.     

Increased risk for metabolic syndrome in persons seeking care for mental disorders.

BACKGROUND: An increased risk for metabolic syndrome has been described for persons with psychotic and mood disorders. Our objectives were to determine whether the odds for metabolic syndrome (MetSyn) were increased among insured adults with and without mental illness, and to determine whether this risk extends beyond psychotic and affective disorders. METHOD: This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa claims data. Three definitions of MetSyn were examined: 1) presence of any 3 or more components of MetSyn (obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus), 2) criteria #1 and/or claim for glucose intolerance/diabetes mellitus, and 3) criteria #1, criteria #2, and/or claim for obesity. ICD-9 codes were used to define obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus. Multivariate logistic regression was used to investigate the association between mental illness and MetSyn. RESULTS: Prevalence of MetSyn for subjects with any mental illness as compared to those without was 4.9% vs. 2.0% (criteria #1), 8.1% vs. 4.2% (criteria #2), and 13.2% vs. 6.2% (criteria #3). MetSyn was more common (OR = 1.3-1.5) for subjects with any mental illness as compared to those without, regardless of which definition of MetSyn was used. Subjects with sexual disorders (OR = 1.7-1.8), sleep disorders (OR = 1.2-1.7), and mood disorders (OR = 1.3-1.6) had significantly higher odds of MetSyn compared to those without claims for mental disorders, regardless of which definition of MetSyn was used. CONCLUSIONS: These results suggest that MetSyn is not only problematic among persons with psychosis and affective disorders, but that it also affects patients with other forms of mental illness. Clinicians should have a heightened awareness of metabolic risk factors, particularly when mental illness is present.     

Recurrent coma and Lesch-Nyhan syndrome.

A patient with Lesch-Nyhan syndrome has had 3 recurrent episodes of coma, each associated with an acute illness. Extensive investigation for known causes of coma has failed to yield a diagnosis. Although coma is not generally recognized as a feature of Lesch-Nyhan syndrome, similar patients have been reported previously. This and other episodic phenomena observed in Lesch-Nyhan syndrome may be explained by the disruption of cellular energy metabolism due to purine depletion, consequent to lack of the purine salvage pathway normally provided by the hypoxanthine-guanine-phosphoribosyl-transferase enzyme.     

Illness perception and symptom components in chronic fatigue syndrome.

Two-hundred and eight patients with chronic fatigue syndrome (post-viral fatigue syndrome) completed a questionnaire which dealt both with their illness in general and with the extent to which they experienced specific symptoms. A factor analysis of the symptom data yielded four components: emotional distress; fatigue; somatic symptoms; and cognitive difficulty. Emotional disturbance is a common feature of the disorder and its role has been widely debated. When the symptom components were considered independently, fatigue, somatic symptoms and cognitive difficulty were associated with questionnaire items relating to general illness severity, but emotional distress was not. Thus negative emotions did not contribute directly to patients' perception of illness severity. They were, however, correlated with the other symptom components. It is argued that this correlation reflects a reciprocal influence, with negative emotions exacerbating fatigue and other key symptoms and the debilitating nature of these symptoms enhancing emotional vulnerability.     

An investigation of the sundowning syndrome

Geriatric clinicians have observed that some demented individuals show increased agitation, restlessness and confusion in late afternoon, evening or night. This has popularly been named ‘sundowning’, or the ‘sundowning syndrome’. References to ‘sundowning’ in clinical writings disagree on virtually every aspect of the syndrome, and little research has been conducted to investigate this phenomenon. In this study, agitation was measured in terms of motor activity, using an electronic monitor with a movement sensor. A total of 12 demented Alzheimer's patients were continuously monitored for four days each. Analyses indicated that some subjects showed increased afternoon activity, but these individuals did not correspond to nursing-assigned groups of ‘sundowners’ and ‘non-sundowners’. Movement correlates of ‘sundowning’ were seen in Alzheimer's patients presumably in the mid-stages of the dementia, and less so in patients with more years of illness.     

Cognitive behaviour therapy in chronic fatigue syndrome.

Fifty patients fulfilling operational criteria for the chronic fatigue syndrome (CFS), and who had been ill for a mean of five years, were offered cognitive behaviour therapy in an open trial. Those fulfilling operational criteria for depressive illness were also offered tricyclic antidepressants. The rationale was that a distinction be drawn between factors that precipitate the illness and those that perpetuate it. Among the latter are cognitive factors such as the belief that physical symptoms always imply tissue damage, and behavioural factors such as persistent avoidance of activities associated with an increase in symptoms. Therapy led to substantial improvements in overall disability, fatigue, somatic and psychiatric symptoms. The principal problems encountered were a high refusal rate and difficulties in treating affective disorders. Outcome depended more on the strength of the initial attribution of symptoms to exclusively physical causes, and was not influenced by length of illness. These results suggest that current views on both treatment and prognosis in CFS are unnecessarily pessimistic. It is also suggested that advice currently offered to chronic patients, to avoid physical and mental activity, is counterproductive.     

Three forms of factitious illness in children: when is it Munchausen syndrome by proxy?

Examples of fabrication of illness in children are described. Primarily uncomplicated cries for help are differentiated from two major subtypes (the Active Inducer and the Doctor Addict) which define the spectrum of Munchausen syndrome by proxy. Primary differences involve the form of deception, age of the victim, and maternal affect. Five histories are presented and it is suggested that doctor addiction is more common than has thus far been recognized.     

Changes in attitudes towards mental disorders and psychiatric treatment 1976–2014 in a Swedish population

Background: Mental illness has always been subject to stigma and discrimination. There are a number of studies on public attitudes towards people with mental illness. Long-term studies, however, examining changes over time are scarce. Aims: The aim of this study was to examine potential changes concerning attitudes between 1976 and 2014 in Vilhelmina, a community in northern Sweden. Methods: A postal questionnaire was sent out to a random sample of 500 adults aged 18–70 years. The same questionnaire has previously been used in 1976 and 2003. Results: The attitudes towards people with mental illness have not generally become more positive over the years. In 2014 almost a quarter of the population still think that “people with mental illness commit violentX acts more than others”. Even more people in 2014 than in 1976 agree to the statement that “mental illness harms the reputation more than a physical disease” (77.2% versus 52.8%). People with low educational level have more negative views than people with higher education. Younger respondents, < 20 years, had a more positive view than the older age groups. Almost 70% of the respondents would advise someone with psychological problems to seek a psychiatrist but only 23% of the respondents would follow their own advice. Psychotherapy has been and is still highly appreciated. As regards medication the perception is more critical, but there has been a significant change, however, to a more positive attitude towards medication since 1976. Conclusion: Attitudes towards mental illness and mentally ill people have not changed substantially over time.     

Stress and psychosomatic illness

Increasing attention has been addressed to the relationship of stress and illness during the past several decades. Despite extensive and intensive research in this area leading to statistically significant correlations, the specificity of the relationship remains vague. Some of the difficulty evolves from the definition of stress and illness. What is stress? How is it defined? Can it be defined independent of an identifiable reaction or change in behavior? How is illness defined? How does stress as a phenomenon relate to its perception and cognition and on what levels? To what extent do the physiological-worded concepts of Selye and Levi relate to the social and psychological ones of Holmes, Rahe and others? What do we mean by psychosomatic illness? How specific is it in terms of discrete entities. If we are in agreement that there is something there—something relating to change in behavior, conceptualized in social, psychological and biological terms with an event occuring external or internal to the individual. what greater precision can we strive for in determining and identifying specificity and the particulate? Is it possible to define a new model of relationships that will assist in identifying, determining and intervening in stress-related illness situations?     

Dhat syndrome: is it a distinct clinical entity?

Dhat syndrome is a culture-bound neurotic disorder seen in the Indian subcontinent. The disorder has recently been included in ICD-10. In the present study, illness behaviour of 50 dhat syndrome patients was studied using a Hindi version of Illness Behaviour Questionnaire (IBQ) and was compared with 50 controls. Sixty-six percent of dhat syndrome patients received unspecified diagnoses on DSM-III-R. Patients with dhat syndrome showed a distinct illness behaviour profile consisting of higher scores on IBQ factors of general hypochondriasis and affective discomfort and lower scores on denial compared with controls, suggesting that the disorder may be a distinct entity.     

Chronic fatigue syndrome: A qualitative investigation of patients'' beliefs about the illness

The chronic fatigue syndrome is a disabling chronic condition of uncertain cause. Previous studies have found that patients seen in hospital clinics with the syndrome often strongly believe that their illness is physical in nature and minimize the role of psychological and social factors. There is also evidence that patients cope by avoiding activity. However, almost all of these studies have assessed illness beliefs only by questionnaire. The aim of this study was to explore the nature and origin of illness beliefs in more detail using in-depth interviews and a qualitative analysis of patient responses. Sixty-six consecutive referrals meeting Oxford criteria for chronic fatigue syndrome were recruited. Analysis of responses indicated that, whereas the most commonly described explanation for the illness was a physical one, more than half the patients also believed “stress” had played a role. Patients believed that they could partially control the symptoms by reducing activity but felt helpless to influence the physical disease process and hence the course of the illness. Patients reported that they had arrived at these beliefs about the illness after prolonged reflection on their own experience combined with the reading of media reports, self-help books, and patient group literature. The views of health professionals played a relatively small role. There is potentially a considerable opportunity to help patients arrive at a wider and more enabling explanation of their illness when they first present to primary care.