Social breakdown in the elderly, I. Case studies and management.

This report focuses on the syndrome of social breakdown of the elderly (SBE), which, although common, has attracted surprisingly little attention in clinical geropsychiatry. Profound social isolation, extreme neglect of self-care, and stubborn refusal of help are the main characteristics of SBE. In most cases, the syndrome of SBE is part of a well-defined major psychiatric illness (secondary SBE). In other cases, stressful life events cause lifelong personality abnormalities to deteriorate into full-blown syndrome of SBE (pure SBE). Two detailed case histories highlight the clinical features of pure SBE and its management.     

Social factors and psychopathology in epilepsy

One hundred and six epilepsy patients were assessed over a period of 6 months for psychiatric morbidity, social support, stressful life events in previous year and disability. 45 patients (42.45%) had a psychiatric diagnosis. Organic depressive disorder headed the list (16.98%) followed by mild cognitive disorder (11.32%) and tobacco dependence (8.49%). There was no significant difference in the mean age, sex, mean education, age at onset of epilepsy, duration of epilepsy, psychiatric diagnosis, mean scores on social support scale, presumptive stressful life event scale and disability assessment schedule between different types of epilepsy. The difference in mean scores of presumptive stressful life events scale and disability assessment schedule between epileptics with and without psychiatric diagnosis was not statistically significant.     

Sociodemographic change and the elderly population of England and Wales

Sociodemographic characteristics in later life are associated with differentials in both health status and the need for health and other services. An understanding of how sociodemographic changes affect both ageing individuals and the elderly population is therefore important for health care planning. Three aspects of this issue are considered. Changes in the demographic composition of the elderly population, including projected increases in the number of very old people and in the ratio of men to women, are discussed in the first section. The second section based on longitudinal data, concerns sociodemographic differentials in age-related household changes, and shows that, for example, both housing tenure and density of the local elderly population seem to be associated with differentials in the probability of moving into an institution. In the third section possible influences on the supply of informal support are considered. At the moment there is no evidence that working women or the divorced are less likely than others to live with an elderly parent (including an elderly parent they care for), but further work in this area is needed.     

Delusions and the psychopathology of the elderly with dementia

Thirty-seven, out of a sample of 100 elderly subjects, all suffering from dementia, were found to have delusions. The delusions were more common in women, in patients with a history of psychiatric illness, and amongst those with higher information subscores (Blessed Scale); and were less common in patients suffering from apraxia or severe psychosocial incompetence. Amongst the deluded patients the simultaneous presence of disorientation, hallucinations and hyperactivity often signified the diagnosis of delirium, but on follow up it was not correlated with death within 18 months. The same symptoms in the non-deluded patients were correlated with severe social incompetence and death within 18 months. It is concluded that the presence of delusions in subjects over 75 years old suffering from dementia is related, to certain extent, to previous or concomitant psychiatric illness, and that it reflects a relative preservation of mental function amongst those without such history.     

Cognitive deficits and psychopathology in institutionalized versus community-dwelling elderly schizophrenia patients.

We evaluated psychiatric symptoms and neurocognitive functioning among 25 institutionalized and 25 outpatient DSM-IV-diagnosed schizophrenia patients, as well as 25 middle-aged and elderly normal comparison subjects. All subjects were assessed with the Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression, modified Simpson-Angus Extrapyramidal Symptom Scale, the Abnormal Involuntary Movement Scale, and the Mattis Dementia Rating Scale (DRS). The two patient groups had similar levels of depressive symptoms, but the institutionalized patients had more severe positive and negative symptoms and were on higher doses of neuroleptic medication. The institutionalized patients had significantly more cognitive impairment on the DRS than outpatients and normal comparison subjects, particularly on the subscales of initiation/perseveration, conceptualization, and memory. Results are discussed in terms of the possible neuropathology associated with cognitive impairment in chronic schizophrenia.     

Music psychopathology. II. Assessment of musical expression

A short polarity profile which was well suited for the assessment of the musical expression of performances recorded from mentally ill patients and controls is described. 9 out of 12 polarities showed sufficient differentiating qualities, ranging from professional to poor amateur performances. Only 3 polarities had to be reformulated. The assessments of the 3 experts had a high interrater reliability and retest stability. The very significant correlation between the results of the experts and 50 independent subjects indicates the validity of the experiment.     

Social networks and psychopathology among substance abusers

The authors studied the social networks and psychopathology of 168 patients with diagnoses of substance abuse. Small network size was correlated with higher scores on the Modified Michigan Alcohol-Drug Screening Test, higher symptom reports on the SCL-90 and the Beck Depression Inventory, and more observed psychopathology according to the Brief Psychiatric Rating Scale. Larger network size was correlated with better functioning according to the Global Assessment Scale and DSM-III axis V. The authors conclude that such symptom complexes as paranoia and phobia may undermine the social networks of substance abusers more than such symptom complexes as anxiety and depression.     

Polydipsia, psychosis, and familial psychopathology.

OBJECTIVE: To compare the demographic and clinical factors and familial psychopathology of chronic psychiatric inpatients with, and without, polydipsia. METHOD: We undertook a case-control study of chronic psychiatric inpatients both with, and without, polydipsia. Clinical and demographic data were gathered using a predesigned questionnaire, the Positive and Negative Syndrome Scale (PANSS), the Abnormal Involuntary Movement Scale (AIMS), the Mini-Mental State Examination Scale (MMSE), and the Family History-Research Diagnostic Criteria (FH-RDC). RESULTS: The prevalence rate of polydipsia was 20.2%. The group with polydipsia was significantly younger, both at the time of their first-ever psychiatric and current psychiatric admissions, compared with the group without polydipsia. The 2 groups were similar in terms of their illness characteristics and psychiatric diagnoses. In the group with polydipsia, alcohol abuse predated the psychotic illness by a mean of 10.5 (SD 4.4) years, compared with 4.8 (SD 1.6) years for the same period in the unaffected group. The 2 groups did not differ significantly regarding the antipsychotic medication dosage, the proportion on concomitant anticholinergic medication, the documented previous response to antipsychotic medication, or past treatment with electroconvulsive therapy (ECT). First-degree relatives of patients with polydipsia were found to have significantly higher rates of alcohol dependence. CONCLUSION: This study provides further evidence for the higher rate of polydipsia among chronic psychiatric patient populations and for high rates of alcohol-related problems among their first-degree relatives.     

Social skills in schizophrenia: assessing the relationship between social skills,psychopathology and community functioning

Social skills training (SST) has been widely used in attempts to rehabilitate chronic schizophrenic patients. The key assumption underlying SST is that social skills deficits are important determinants of the social isolation, poor social role functioning, and low quality of life characteristic of schizophrenic patients. To test this assumption, 89 patients meeting DSM-III-R criteria for schizophrenia were assessed on behavioural and self-report measures of social skills. A structured clinical interview, a self-report inventory of distress during social interaction, and self-monitoring of time in social interaction were used to assess social functioning. Positive psychotic symptoms were assessed in a standardised clinical interview. A structural equation modelling analysis showed that observed social skills predicted social functioning, and that this association was statistically independent of severity of psychotic symptoms. This finding is consistent with the hypothesis that social skills are important in the social functioning of patients with schizophrenia.     

Social functioning, psychopathology, and medication side effects in relation to substance use and abuse in schizophrenia

OBJECTIVE: To identify correlates of self-reported substance use and problems associated with that use in people with schizophrenia. METHODS: A sample of 404 patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder and longitudinal assessments of substance use were examined. Three groups were formed according to consistency of substance use over time: No/Low Alcohol, Alcohol Only, and Drug Use (with or without alcohol use). Similar groups were formed regarding problems associated with alcohol use. Groups were compared on demographics, psychiatric history, psychopathology, medication side effects, and social functioning. RESULTS: Substance users were more likely to be young, male, and to have lower levels of education. Substance users generally had fewer negative symptoms, more social contacts, and better social-leisure functioning. However, substance users, especially drug users, also were rated as having more interpersonal and family problems, had an earlier age at first psychiatric hospitalization, and were more likely to have been recently hospitalized. Patients reporting problems with alcohol use reported more frequent alcohol and drug use, greater severity of akathisia, and problems in interpersonal, family, and self-efficacy domains. CONCLUSIONS: Many of the same variables that correlate with substance use disorder also correlated with moderate substance use in this sample of people with schizophrenia. Although moderate users of alcohol and drugs may have better social functioning in some areas, they also are likely to have substantial problems in interpersonal relationships, especially those involving family members.     

Apomorphine and psychopathology.

Forty men, mainly alcoholics, were administered either the dopamine receptor agonist, apomorphine HCl (1 mg), or distilled water subcutaneously three times a day for 14 days in a double blind study. None of the subjects developed an endogenous depression or schizophrenic symptoms. Scores on the Hamilton Rating Scale, Zung Self Rating Scale, and Brief Psychiatric Rating Scale showed improvement with both apomorphine and placebo. There were no significant differences between the two treatments on these rating scales. A significant incidence of spontaneous penile erections occurred after apomorphine treatment compared with placebo. Both treatments eliminated subjective craving for alcohol. Acute administration of apomorphine had no effect on psychomotor retardation or depressed mood in two patients with endogenous depression.     

Music psychopathology. V. Objective features of instrumental performance and psychopathology.

Mental disease systematically impairs musical expression according to nosologic classification. This was demonstrated with a polarity profile of the instrumental performances of 60 inpatients and 14 controls matched for musical aptitude. Objective performance characteristics such as irregularities and playing faults were analyzed too. No meaningful correlation between these features and psychopathology resulted. This indicates that even in severe psychopathologic alterations performance features, which depend mainly on education and actual training, are not altered in a systematic manner, in contrast to expressive qualities.