Consultation psychiatry in a Japanese general hospital: patients referred to psychiatric consultation

A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

Consultation Psychiatry in a Japanese General Hospital: Patients Referred to Psychiatric Consultation*

Abstract: A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

Running amok

This study examines twenty-four cases of amok, believed the largest number of cases ever collected. They were observed in Sarawak, East Malaysia. They occurred in all indigenous groups in Sarawak, excluding the Chinese, such as Malay, Sea Dayak, Land Dayak, Kayan, Punan and Melanau at frequencies more or less following the proportion of these groups in the total population. No differences were found according to religion, the Malay being Muslim and the other groups either predominantly Christian like the Iban or animistic. Only slight diminution in the frequency was observed from 1954 to 1968. The education level of the amok runners was much lower than that of the average population. The weapons used were those immediately at hand be it parang (short sword), ax, sticks, knives, guns, bare hands or a lorry. The classical four stages were largely present: (a) brooding and withdrawal, (b) homicidal paroxysm, (c) continuation of homicidal behaviour until killed, restrained or falling into stupor of exhaustion, (d) complete or partial amnesia. While in 14 no motive could be ascertained, insult, jealousy and paranoid ideation was present in the others. Both family history of mental illness and personal psychiatric history were predominant. All cases fell into accepted diagnostic categories from organic and endogenous psychosis to neurosis and behaviour disorder.     

The effect of the menstruation cycle on manifestations of pychiatric diseases

In the present study we investigated whether a correlation exists between menstrual cycle phase on the day of an acute psychiatric admission and diagnostic entities. Therefore we assessed the menstrual cycle phase in 155 women at the time of acute admission for any non-organic psychiatric disorder. A specific diagnosis according to ICD-10-criteria and to Leonhard's nosology was established without knowledge of the menstrual cycle phase. Independent of diagnosis and classification, the majority of patients (57%) was admitted during the pre-menstrual/menstrual period. Comparing the frequencies of admission before (increasing blood-estrogen-level) and after ovulation (decreasing blood-estrogen-level) we found using ICD-10 criteria there were no significant differences between affective psychoses (F3), acute polymorphous psychotic disorder (F23), schizophrenia/schizoaffective psychoses (F20 and F25) and patients suffering from neuroses or personality disorders (F4-F6). Applying Leonhard's criteria we found no significant differences between endogeneous psychoses and personality disorders and no significant differences between cycloid psychoses and affective psychoses or affective psychoses and schizophrenias as well. However, patients with cycloid psychoses were significantly more frequently admitted to hospital during the luteal-/menstrual phase than patients with schizophrenia (chi 2-Test, p = 0.02). These findings do not confirm a specificity of a pre-menstrual exacerbation of psychotic symptoms for schizophrenia. Rather we found cycloid psychoses to be significantly more frequently associated with premenstrual exacerbation of symptoms.     

Psychiatric symptoms after therapy with new antiepileptic drugs: psychopathological and seizure related variables.

The purpose of this paper is to understand the association between antiepileptic drugs (AEDs), patient characteristics, changes in seizure pattern and emergent psychiatric disorder, i.e. psychosis or affective disorder. To this end we carried out a retrospective casenote study on 89 patients who developed psychiatric symptoms during treatment with topiramate, vigabatrin or tiagabine. The psychiatric problem was either an affective or a psychotic disorder (not including affective psychoses). It was discovered that 99% of the patients suffered from complex partial seizures with or without secondary generalization. More than half were on polytherapy with two or more other AEDs. Nearly two-thirds had a previous psychiatric history. There was a strong association between the type of previous psychiatric illness and the type of emerging psychiatric problem, both for psychoses and for affective disorders. Patients on vigabatrin had an earlier onset of epilepsy and more neurological abnormalities than those on topiramate. Those patients on lower doses had a shorter interval between the start of the AED therapy and the onset of the psychiatric problem. A seizure-free period was observed in more than half of the patients before they developed the psychiatric symptoms, and of these more were likely to develop a psychosis rather than an affective disorder. There seemed to be an association of suppression of right-sided seizures and the onset of the psychiatric problem. The conclusions drawn were that patients with a previous history of psychosis or affective disorder tended to develop the same psychiatric problem with new AEDs. Those with a seizure-free period before the onset of the psychiatric problem were more likely to develop a psychosis than an affective disorder.     

General hospitals and the severely mentally ill: changing patterns of diagnosis

OBJECTIVE:The author's goal is to determine whether there has been a recent change in the number and proportion of severely ill psychiatric patients treated in general hospitals. METHOD: He analyzed the discharge data from the National Hospital Discharge Survey for the years between 1970 and 1987, focusing particularly on the discharges of patients with psychiatric versus nonpsychiatric diagnoses. The number and proportion of discharges of patients with psychiatric diagnoses in four major diagnostic groups (depression, bipolar spectrum disorders, schizophrenia, and other psychoses) were determined. RESULTS: Between 1970 and 1987, discharges of patients with psychiatric diagnoses from general hospitals increased by a factor of 0.8. The percentage of discharges of patients with the diagnoses of depression (18.0%-22.7%), schizophrenia (9.4%-13.6%), and paranoid or other nonorganic psychoses (3.1%-4.0%) remained relatively constant. The percentage of discharges of patients with the diagnosis of nondepressed bipolar disorder increased from 0.6% in 1970 to 3.2% in 1987. CONCLUSIONS: Although there has been a recent absolute increase in the number of general hospital patients with severe psychiatric diagnoses, the increase has been tempered by a concomitant increase in the number of patients with nonsevere diagnoses. Changes in classification systems (DSM-II or ICDA-8 to DSM-III or ICD-9-CM) and questions regarding the rigor with which the nosologic changes have been incorporated into practice complicate the interpretation of these findings.     

Nonschizophrenic psychotic disorders: the case of cycloid psychoses

BACKGROUND: Cycloid psychosis is a psychiatric disorder known for about 100 years. This disorder is at present partly and simplified represented in the ICD-10. SAMPLING AND METHODS: Over a period of 15 months, 139 consecutively acutely admitted psychotic patients were assessed, by means of different diagnostic instruments, in order to investigate the prevalence and the symptom profile of cycloid psychoses. In addition, the concordance between the diagnoses cycloid psychosis, brief psychotic disorder, and acute polymorphic psychotic disorder with or without symptoms of schizophrenia was calculated. RESULTS: Cycloid psychoses were present in 13% of the patients. There was a significant but small overlap with the DSM brief psychotic disorder and the ICD acute polymorphic psychotic disorder. CONCLUSIONS: This study demonstrates that cycloid psychoses can be identified with the proper diagnostic instruments in a proportion that is also found in other studies. Since this type of psychosis entails a distinct prognosis and may require a specific treatment, its identification is of clinical importance. Limitations are the nature of the psychiatric facility with an inherent bias in the selection of patients and the lack of a long-term evaluation.     

The psychiatric comorbidity of epilepsy

Several studies have assessed the prevalence of psychiatric disorders in epilepsy. They are characterized by considerable heterogeneity, because of differences in the population setting and type of study. A non-systematic review of the literature allows us to draw some useful, although not definite, conclusions. Six per cent of people with epilepsy in the general population appear to suffer from a psychiatric disorder, while this rises to 10-20% in populations with temporal lobe and/or refractory epilepsy. Mood disorders are the most common culprit (24-74%), particularly depression (30%), followed by anxiety disorders (10-25%), psychoses (2-7%) and personality disorders (1-2%). This comorbidity appears to be related to endogenous and exogenous (including iatrogenic) factors and to the severity and chronicity of epilepsy. Conditions such as schizophrenia-like psychosis of epilepsy and interictal dysphoric disorder are represented only in epilepsy. Adequate recognition and treatment of psychiatric conditions in epilepsy is essential for patient management because of their considerable burden in morbidity and quality of life.     

Follow-up and family study of postpartum psychoses Part I: Overview

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2–35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower-morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.     

Nonorganic and Organic Psychiatric Disorders in Patients after Epilepsy Surgery

This study aimed at describing preoperative psychiatric morbidity in a consecutive series of 70 epilepsy patients who were surgically treated and to analyze postoperative psychiatric morbidity and predisposing factors. Nonorganic (DSM-III-R) and organic (Lindqvist-Malmgren diagnostic system) psychiatric morbidity was prospectively assessed preoperatively and during the first two postoperative years. At presurgical evaluation 44.3% of the patients had a psychiatric diagnosis (nonorganic in 14.3%, organic in 38.6%). The most common nonorganic diagnosis was major depression; the most common organic diagnosis was Astheno-Emotional disorder (AE disorder). During the first two postoperative years 68.1% of the patients received some psychiatric diagnosis. The most common nonorganic diagnoses were anxiety and depressive disorders (AD disorders) in 36.2%; the most common organic diagnosis was AE disorder in 52.2%. Patients with a preoperative history of AD disorders or AE disorder had a significantly higher risk of postoperative AD disorders (P < 0.01 and P < 0.001 respectively). Laterality, type of resection, histopathological diagnosis, or outcome were not significantly related to postoperative psychiatric morbidity. The importance of psychiatric assessment, including organic psychiatric disorders, is emphasized.     

Survey of psychiatric morbidity in a semi-urban population in Sri Lanka

This paper reports a survey of psychiatric morbidity in a semiurban community (population 7,653) in Sri Lanka. The entire population was first screened by social workers using a standardized interview. Probable cases were then examined by psychiatrists. Each psychiatric disorder identified was rated on four different parameters of severity, and only those rating moderate or severe were labelled as cases. The socio-demographic characteristics of the cases and the population at risk, and the frequency and nature of psychiatric disorders are presented in Tables. The 6-month period prevalence for all psychiatric disorders was 45.5 per 1,000, with psychoses amounting to 6.9 (males 5.5; females 8.4) per 1,000, and neuroses to 25.2 (males 9.9; females 40.6) per 1,000. The large majority of disorders were chronic and had not received psychiatric treatment. The relevance of these surveys in the provision of psychiatric services in developing countries is discussed.     

Clinical characteristics, 4-year course, and DSM-IV classification of patients with nonaffective acute remitting psychosis

OBJECTIVE: The authors examined the clinical characteristics and 48-month illness course of cases of nonaffective acute remitting psychosis and described the classification of these cases in the DSM-IV system. METHOD: The data were derived from the Suffolk County (N.Y.) Mental Health Project, a study of first-admission patients with psychotic disorders admitted to psychiatric facilities between September 1989 and December 1995. The authors compared the demographic and clinical characteristics, 48-month course, and longitudinal research diagnoses of 16 patients with nonaffective acute remitting psychosis, defined by onset in 2 weeks or less and duration of less than 6 months, to those of 26 patients with other nonaffective remitting psychoses. RESULTS: Nonaffective acute remitting psychosis had a distinctly benign course-46% of the patients remained in full remission throughout the 48-month follow-up, compared with 14% of patients with other remitting psychoses. Nonaffective acute remitting psychosis was also associated with fewer negative symptoms than other remitting psychoses. By 24-month follow-up, only 6% of the patients with nonaffective acute remitting psychosis, compared with 77% of the patients with other remitting psychoses, received a research diagnosis of schizophrenia or schizoaffective disorder, whereas 44% of patients with nonaffective acute remitting psychosis, compared with 12% of patients with other remitting psychoses, were given the residual diagnosis of psychotic disorder not otherwise specified. CONCLUSIONS: Nonaffective acute remitting psychosis is a highly distinctive yet not adequately classified condition. Better delineation of nonaffective acute remitting psychosis in current diagnostic systems could lead to better understanding of this condition and improve the applicability of diagnostic systems in developing countries, where these conditions are more common than in industrialized countries.     

Differenzierte Diagnostik, Verlauf und Ausgang postpartaler Psychosen Eine katamnestische Untersuchung

In a polydiagnostic study, a systematically recruited collective of 34 women with a first-episode postpartum psychosis was reexamined after a period of 6-26 years (averaging 12.6 years) in order to establish lifetime-diagnoses according to ICD-10 and Leonhard's classification, and to determine course and outcome. According to ICD-10, unipolar depressive disorders (32%) and acute polymorphous psychotic disorders (28%) represented the most frequent diagnoses. Applying Leonhard's classification revealed a marked predominance of cycloid psychoses (62%) with the subform of motility psychosis being the most frequent diagnosis (38%). Schizophrenias occurred rarely according to both classifications. Investigating the long-term course, we found in 59% multiphasic disorders. The mean number of episodes per patient was 2.5 (range 2-6) with a mean duration of 9.8 weeks (SD = 5.2). 6 patients (18%) had undergone a monophasic course, in 4 cases (12%) the course was not determinable. 17 women (50%) had 19 further deliveries during the follow-up period. The frequency of relapses in connection with a further delivery was 47%. Administering the Strauss-Carpenter-Outcome-Scale revealed a favourable outcome with a mean value of 14.1 (SD = 2.83) for our total sample. Only 4 patients (12%) had never recovered fully since the onset of the illness. Our findings suggest that cycloid psychoses, in particular motility psychoses, account for the majority of postpartum psychoses, and do not support the hypothesis of a nosological independence of postpartum psychoses. They provide further evidence of a favourable prognosis of severe postpartum psychiatric disorder despite a relatively high rate of non-puerperal and especially puerperal relapses.     

Psychiatric in-patients in Anambra State, Nigeria. A psychosocial study

In a 1-day survey, the sociodemographic and diagnostic characteristics of 128 patients in a psychiatric hospital in Nigeria were studied. There were more males (67%) than females (33%). The three main diagnostic groups found were schizophrenia (58%), affective psychoses (17%) and organic psychoses (12%). A total of 28% of the patients were illiterate and a further 47% had received primary school education terminating at various stages. The majority (66%) were either unskilled or unemployed. There was a predominance of young persons under the age of 40 years. Rural patients consulted traditional healers and prayer houses more often than did their urban counterparts. Electroconvulsive therapy was extensively used. The number of in-patient psychiatric beds in the State was found insufficient for its population size, and suggestions are made for future improvement. The possible sociocultural and medical implications of the findings are discussed.     

A family hereditary study of post-partum “psychoses”

Summary A group of 80 women suffering from a severe psychiatric post-partum disorder and hospitalized for the first time in their lives was followed up between 4 and 35 years later. Besides the further evolution of psychic health of the patients, the occurrence of endogenous (i.e., functional) psychoses in first degree relatives was investigated. A global morbidity risk for endogenous psychoses of 10.9% was found, affective psychosis accounting for two-thirds of secondary cases. Subdivision of the sample according to the criterion of absence or presence of further psychotic episodes unrelated to childbirth revealed that first degree relatives of patients with exclusively puerperal decompensations had a low morbidity risk of 2.0%, but relatives of patients with later nonpuerperal episodes of illness one of 15.2%, the difference being statistically significant (P < 0.002). This suggests that severe psychiatric disorders occurring exclusively in the post-partum period are nosologically distinct from those followed by nonpuerperal psychotic episodes of illness. Only the latter seem to be related to the traditionally recognized subgroups of endogenous psychoses.     

Phasic and process psychoses: a polydiagnostic comparison among the Frankfurt Classification System, DSM III, RDC, Feighner criteria and ICD-9

The classification of endogenous psychoses is a controversial sector of psychiatry. Differences with regard to the evaluation of course and outcome contribute to this controversy. The course and outcome of a psychiatric illness are basic to the Frankfurt Classification System (FC) of endogenous psychoses. The main groups are process and phasic psychoses (typical and atypical). A third group, encompassing cases which could not be definitely classified at the time of examination, is entitled 'nonclassified endogenous psychoses'. This system was outlined according to the AMDP system and SANS using the cases of 100 patients admitted to the hospital (aged 18-86 years; 57 men, 43 women) and compared with four classifications (ICD-9, RDC, DSM III and Feighner). The listed definitions do not state whether or not a defective symptomatology is absolutely irreversible. Most of the atypic-phasic psychoses of the FC (50-78%) were schizoaffective psychoses according to the other classifications (Feighner, RDC, ICD-9) and most of the process psychoses (85-97%) were schizophrenias according to Feighner, ICD-9, RDC and DSM III. The major reason for the great correspondence (97%) between process psychoses (FC) and DSM III schizophrenias appears to be that 85% of the sample consisted of chronic and not subchronic schizophrenic disorders according to DSM III. On the other hand, about 45% of the ICD-9 and RDC schizophrenias (principally acute and subacute) were not diagnosed as process psychoses according to the FC. In the case of the typic-phasic psychoses, there was almost complete agreement with the other diagnostic systems. Most of the cases in which classification into the group 'process' or 'phasic psychosis' was unclear were diagnosed as schizophreniform disorders according to DSM III (70%) or into nearly equivalent groups according to RDC or ICD-9. Nonetheless, complete equivalency among these similar groups was not possible. In the context of some research aims (e.g. definitions of phenomenological or biological parameters), a classification system based on clearly-defined inclusion and exclusion criteria of such concepts as phasic and process psychoses (in shifts or insidious) is methodologically useful. The FC is suggested as a step in this direction.     

产后精神病42例的临床分析及随访

目的 探讨产后精神病的临床特点及产后精神病是否为独立的疾病单元。方法 对42例产后精神病作回顾性研究,根据中国精神疾病分类方案与诊断标准（CCMD－2－R）对42例产后精神病进行重新诊断分类并对其中23例进行随访调查。结果 42例产后精神病中30例在产后二周内起病,39例呈急性起病,28例有躯体或心理因素作为起病诱因。根据CCMD－2－R诊断为精神分裂症19例,器质性精神障碍13例,抑郁症5例,神经症5例;27例临床短期疗效达痊愈;随访到23例患者7例未再出现精神异常,改诊为精神分裂症10例,情感障碍4例,分裂情感性精神病1例,周期性精神病1例。结论 产后精神病以急性起病,临床症状不典型,易变性和混乱为特点;按国内现有诊断标准本组42例产后精神病均可归类,未发现区别于其它精神障碍的特有症状,提示产后精神病并非独立的疾病单元。     

The persistence of developmental markers in childhood and adolescence and risk for schizophrenic psychoses in adult life. A 34-year follow-up of the Northern Finland 1966 birth cohort

Childhood precursors of schizophrenia include multiple abnormalities of development. Continuities between early and subsequent deviance are poorly characterised. We studied associations among premorbid developmental deviance using data at ages 1 year (learning to stand, walk, and speak, attainment of bladder and bowel control) and 16 years (success at school). Generalised linear modelling was used to examine differential linear associations and trends across adult psychiatric diagnoses. In babies who, as adults, suffered schizophrenia or any psychosis, those who learned to stand latest were also more likely to perform poorly at school in both motor and theoretical domains at age 16 when compared with earlier learners. The effect was independent of genetic and perinatal factors. We conclude that the early developmental deviation in the first year of life is associated with lower school performance at age 16. Developmental continuity among children who develop psychoses was stronger than among normal controls and those hospitalized for nonpsychotic psychiatric disorder. These findings are in line with the hypothesis that a neural diathesis is present during postnatal brain development before schizophrenia. This supports the longitudinal dimension and life span models of schizophrenia.