Psychopsychiatry: Can psychosocial factors cause psychiatric disorders?

It is a widely accepted view today that psychosocial factors can cause psychiatric disorders. However, this view has, as yet, no firm foundation of verifiable facts. This paper outlines some research strategies that can provide data in favor of or against this theory: (1) systematic analysis of life events preceding psychiatric disorders, covering both stable events and interactional events; (2) vulnerability research on three levels (biologic, psychological, and sociological), aimed at factors that could explain the increased vulnerability of some individuals to the detrimental effects of life events; (3) pathogenesis research, aimed at analyzing how psychosocial stress disrupts cerebral systems, and discovering which of these disruptions is responsible for disturbed behavior, and (4) research into the efficacy of combined biologic (mainly pharmacotherapeutic) and psycho(socio)therapeutic methods. Some results obtained in these areas of research are discussed.The central idea of this study is that psychosocial and biologic factors do not operate independently but in close interaction. This seems a cliché, but is not, as clearly indicated by the scantiness of relevant research so far carried out. This gap is to be filled if psychiatry is to maintain and reinforce its status as a medical discipline.     

Cranial computerized tomography in clinical psychiatry: 100 Consecutive cases

Many psychiatric patients require neurological investigation and some are referred for computerized tomography. The results in a consecutive series from clinical practice in the English National Health Service are reported here, with discussion of some of the problems of selecting cases for this necessarily restricted facility.     

Neuropathology,pathogenesis, and neuropsychiatric sequelae of Reye syndrome

A clinico-pathologic correlation can be established for those survivors of Reye syndrome in the higher clinical stages who have sustained irreversible and often major neuropsychiatric deficits. The neuropathologic substrate for the clinical manifestations of mental retardation, recurrent seizures, movement disorders, sensori-motor deficits, psychobiologic maladjustment, and mediocre performance in school and on formal psychometric tests consists of multifocal infarction and astrocytosis in cerebral cortex, diencephalon, basal ganglia, and brainstem. While the mortality rate of Reye syndrome in acute stages is still significantly high (25% in our 20 cases, 52% in the tabulated cases in the higher clinical grades), the occurrence of permanent psychomotor deficits is an equally tragic socioeconomic and medical problem. Of our 15 survivors, 3 have suffered major and 1 has sustained minor brain damage. From a review of the literature, over one-third of survivors are consigned to cerebral malfunction, hence their potential for full enjoyment of life and their intellectual, emotional, and economic contributions to their families and society are sadly curtailed.     

A behavioral approach to the treatment of depression

Depression is viewed largely as a disorder in which attempts to control one's interpersonal environment have failed. Twenty depressed outpatients were randomly assigned to one of two treatment groups. Treatment for the experimental group consisted of: (1) training in social learning principles; (2) immediate feedback as to the perception of verbal interactions between patient and spouse; and (3) training in the construction and use of reciprocal behavioral contracts. Treatment for the comparison group varied as a function of the treatment agency (i.e. psychiatrist, general practitioner, social work agency etc.), but usually involved either medication, group therapy, individual psychotherapy, or some combination of these.

Results showed a significant change in problematic behaviors, in Depression Adjective Checklist scores and in the verbal communication style of the experimental group, but not in the comparison group.     

Sex differences and lateral specialization of hemispheric functioning

The study was designed to explore whether male-female differences in the EEG ratio of the left hemisphere to the right hemisphere could be found with general tasks which more closely approximate normal activities. Six males and six females performed tasks chosen to utilize one hemisphere of the brain more than the other. In all, there were four right hemispheric tasks and four left hemispheric tasks. The ratios of EEG power measured from the temporal lobes were statistically significant for the males between these tasks but not for the females. The results suggest that males and females process the same environmental event with different patterns of brain activity as reflected by EEG.     

The use of problem solving to reduce examination and interpersonal anxiety

A 32-yr old woman was treated for examination and interpersonal anxiety by the use of systematic problem solving. Her anxiety occured because domestic difficulties prevented her from preparing for and taking examinations. This procedure was used after cognitive desensitization was unsuccessful in reducing her anxiety. The problem solving procedures provided her with skills in identifying and engaging in appropriate behaviors to reduce domestic pressures. Following treatment her anxiety attacks decreased from approximately five a day to one per week. In addition, the client was able to apply the problem solving skills to other, non-treated areas of her life.     

Effects of atropine, reserpine, 6-hydroxydopamine, and handling on seizure development in the rat

Repeated electrical stimulation in the limbic system causes permanent changes in the susceptibility to epileptiform afterdischarge and motor seizure; the present study examined the involvement of cholinergic and catecholaminergic neural circuits in the mechanism underlying these changes. The cholinergic blocking agent atropine retarded the rate of seizure development without altering the local afterdischarge threshold. Atropine appeared to suppress propagation of epileptiform afterdischarge to other structures within the limbic system. By contrast, attenuation of catecholaminergic activity by intraperitoneal injections of reserpine or intraventricular applications of 6-hydroxydopamine facilitated seizure development, while stress, which elevates catecholaminergic activity, retarded seizure development. These studies suggest that cholinergic circuits in the limbic system play an important role in propagating epileptiform discharge within the limbic system, and raise the possibility that noradrenergic or dopaminergic circuits act in antagonism to these cholinergic “seizure circuits”.     

Suicidal behavior in bipolar manic-depressive patients and their families

There is a high risk of suicidal behavior in patients with primary affective disorder. An extensive investigation in patients with primary affective disorder reported attempted suicide in 26% of bipolar patients and 21% of unipolar patients, the highest rate occurring in female bipolar patients.¹ Woodruff et al.²⁰ found attempted suicide in 14% of unipolar patients as against 32% of bipolar patients with the highest rate in male bipolar patients. Winokur¹⁸ in a study of bipolar manic depressive patients found that 25% of patients had made at least one suicidal attempt and 70% had made threats of suicide at least some time in their lives. Venkabo Rao¹⁶ reported that suicidal ideas occurred in 75% of patients with recurrent affective disorder.Family studies have also reported a high incidence of suicide in the relatives of patients with affective disorder.⁸Mendlewicz et al.⁷ studying a matched group of bipolar probands with and without a family history of manic depressive illness, found high rates of suicide in first and second degree relatives but there was no significant difference in relation to sex or family history. The diagnosis of the relative that suicided was not stated. A study of relatives of patients with primary affective disorder¹⁰ reported that 79% of the suicides in first degree relatives were associated with a diagnosis of probable affective disorder and 10% by a diagnosis of probable alcoholism in the relative. Fathers in index cases were more likely to have committed suicide than mothers. A family history of suicide is considered a major risk factor in assessment of potentially suicidal patients,¹³ however, the relationship between attempted suicide in patients and suicide or attempted suicide in relatives has received little attention and the nature and predictability of this association is uncertain.The following report concerns an analysis of suicidal behavior in a population of bipolar manic-depressive patients and the relationship of this attempt to suicide or attempted suicide in their first and second degree relatives.     

Treatment of obsessive-compulsive hair pulling (Trichotillomania) by behavioral and cognitive contingency manipulation

A case of trichotillomania of 11 yr duration in a 21-yr-old female was successfully treated using contingency management for both hair pulling behavior and the urge to pull hair. During treatment of approximately two months, the hair pulling behavior was associated with a mild aversive procedure and her awareness of the urge to pull hair was used as a cue to initiate hair grooming. She remains essentially symptom free of hair pulling and has a markedly reduced awareness of urges to pull her hair at 7-months follow-up.     

A rapid multi-component treatment for an obsessive-compulsive disorder

A 67-yr-old woman with a 45-yr history of obsessive-compulsive problems related to fear of contamination was treated rapidly by a multi-component intervention. Questionnaire data following treatment showed the patient to be free of obsessive-compulsive complaints, and these were corroborated by behavioral observations. Follow-up probes conducted 6, 12 and 18 months later revealed continued maintenance of treatment gains. Patient-therapist contact time totalled 6 hr, about one-third of the time employed by Marks for exposure and response prevention, indicating the cost-effectiveness of a multi-component treatment intervention.     

Mouth asymmetry during spontaneous speech

A high proportion of normal subjects have speech expression controlled predominantly by the left hemisphere. Since the left hemisphere also has stronger control of the right side of the lower face, it might be expected that normal subjects would show a right-sided asymmetry in mouth opening during speech. This hypothesis was tested by measuring lip opening in 196 subjects. Of these, 150 (76%) showed greater right-side opening. This tendency was found for males, females, left- and right-handers in four experiments using two different techniques. Mouth asymmetry during speech may provide an indication of which hemisphere is dominant for expressive speech.     

Consultation evaluation: I. Psychotropic drug recommendations.

A follow-up chart review was undertaken of 100 consecutive patients seen in psychiatric consultation for whom psychotropic medication was recommended. Significant differences in implementation (P less than 0.01) by class of drugs (neuroleptics, tricyclics, benzodiazepines) were found. Most often no discernible reason for consultee disagreement could be found or inferred. The importance of such follow-up studies for consultation work is stressed.     

Carbon dioxide as a reciprocal inhibitor in the treatment of neurosis

A patient with long standing ‘panic’ attacks was successfully treated using a variant of systematic desensitization with a carbon dioxide-oxygen mixture as a reciprocal inhibitor.     

Facial screening: Effects on appropriate and inappropriate behaviors

Facial screening involves covering the subject's face for a number of seconds contingent upon the occurrence of the target behavior. This technique was applied to a disruptive behavior (hand clapping) during a language training class, and its effects on appropriate verbal responses were also examined. The subject was a 7-yr-old schizophrenic boy. Facial screening suppressed hand clapping but had no effect on correct verbal responses. Positive reinforcement increased appropriate verbalizations but had no effect on hand clapping. Follow-up data collected at 6 months indicated that the treatment gains had been maintained.     

Etiology and onset of agoraphobia: a critical review

Research on the etiology and onset of agoraphobia is reviewed. Evidence indicates that it is the most prevalent clinical phobic disorder with age of onset in the mid- to late-twenties. It primarily affects women with no particular socioeconomic distinctions. A number of claims have been made linking various family, childhood, and premorbid personality characteristics to onset, however, strong empirical support for these has yet to be demonstrated. Increased attention is being devoted to the role of biological factors in the development of this disorder and some findings have suggested that spontaneous panic attacks may be biologically linked. Studies have shown that the onset of agoraphobia usually occurs following a period of stress or an identifiable precipitant. Interpersonal difficulties have frequently been reported as stressors, but the range of traumata associated with onset is quite extensive. Suggestions for future research are presented.     

Spatial abilities,sex differences and EEG functioning

The relationship of EEG asymmetry to spatial performance was studied for high and low spatial ability males and females. As in previous research for high spatial ability males relatively greater right hemispheric activity was associated with successful spatial performance. For low ability males, a group rarely studied, the opposite relationship was found. Both high and low ability females showed no consistent pattern of relationships.