A comparison of ‘specialized’ and ‘non-specialized’ psychiatric services for old people in the united kingdom

Using data derived from a recent survey of psychiatric services for old people in the UK, services provided by ‘specialized’ consultants (committing 5/11 or more of their working week to old people) were compared with those provided by ‘non-specialized’ consultants (working less than 5/11 with old people). The measures used included total referrals, provision of personnel, provision and location of facilities, teaching activities and research interests. Because of the way in which they were selected, non-specialized respondents were a relatively small and probably enthusiastic proportion of all non-specialized general psychiatrists providing services for old people. Despite this, clear differences emerged in favour of the specialized services on most measures. Future routine statistics in psychiatry should identify ‘specialized’ consultants if they are to be meaningful.     

‘Thank-you for Saying “No”…’

This case study describes an approach to one individual's non-compliant behaviour, which focuses upon reduction of excessive refusal through change of the caregiver interactional style and acknowledgement of the inherent ‘message value’ of escape and avoidance responses. Positive outcomes include not only increased participation, but also greater personal competence, choice and access to ordinary community facilities, with these gains being maintained at three-month follow up. Implications of the approach are discussed.     

Assessment of progression and prognosis in ‘possible’ and ‘probable’ Alzheimer's disease

Objective. The objective of this study was to assess the rate of progression and clinical predictors of decline in subjects with ‘possible’ and ‘probable’ Alzheimer's disease (AD). Design/setting. The annual rate of change (ARC) for cognitive/functional scales was calculated for 95 subjects with AD attending a memory clinic. Two consecutive ARCs were calculated for a subgroup of 39 subjects. Results. The ARCs were relatively normally distributed; however, there was a large degree of variability. Neither age nor duration of symptoms at presentations were predictive of the rate of decline. However, the data suggested an effect of gender, with males having a greater rate of decline in cognition (p=0·02). Finally, the rate of progression over the first year did not predict the subsequent ARC (p=0·25). Conclusions. The high variability in ARCs observed in this study and poor correlation between consecutive ARCs suggest that neither mean ARC values nor the previous rate of decline can be used to aid clinicians in the assessment of response to acetylcholinesterase inhibitors or other specific treatments for AD. © 1998 John Wiley & Sons, Ltd.     

‘Born to …’— Genetics and Behaviour

In its ascendancy, the study of human genetics is shifting from the inheritance of physical structure to that of behaviour and personality; seeking the secret machinery which joins the inherited code to the quirk of character. At the start of the century human behaviour was thought to be largely learned and to stem from upbringing, the blank slate of personality being moulded by parents and events. What had been learned could be unlearned and this accorded with the idea of free will expressed in Cassius' claim that ‘the fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings’. Now, at the century's close, the influence of breeding is back in fashion, bringing the implacable effects of genetic determinism and bad blood. The implications for the successes and failings of the ‘normal’ population are far-reaching. In learning disability, many of these ideas are contained in the concept of the ‘behavioural phenotype’.     

Sensitive delusion of reference, ‘sensitiver Beziehungswahn’

Ten patients discharged with the diagnosis of ‘sensitiver Beziehungswahn’ were followed up 22–28 years after their discharge. In one case, the course of the illness indicates that the patient suffered from a manic-depressive psychosis, and in two cases, this diagnosis was likely. In two cases the disorder seemed definitely to be schizophrenia. One case was presumably a transient paranoid reaction. One patient was likely to have suffered from hysteria or epilepsy, three cases remained uncertain. The study did not prove suitable in the evaluation of the validity of ‘sensitiver Beziehungswahn’ as a nosological entity, since at the time of diagnosis the patients only incompletely fulfilled the criteria set up by Kretschmer, but it throws light on the diagnostic practice and the tendency to a change between the classification into many independent disease entities and the subsequent inclusion into larger and fewer forms.     

Deep brain stimulation in the central nucleus of the amygdala decreases ‘wanting’ and ‘liking’ of food rewards

We investigated the potential of deep brain stimulation (DBS) in the central nucleus of the amygdala (CeA) in rats to modulate functional reward mechanisms. The CeA is the major output of the amygdala with direct connections to the hypothalamus and gustatory brainstem, and indirect connections with the nucleus accumbens. Further, the CeA has been shown to be involved in learning, emotional integration, reward processing, and regulation of feeding. We hypothesized that DBS, which is used to treat movement disorders and other brain dysfunctions, might block reward motivation. In rats performing a lever‐pressing task to obtain sugar pellet rewards, we stimulated the CeA and control structures, and compared stimulation parameters. During CeA stimulation, animals stopped working for rewards and rejected freely available rewards. Taste reactivity testing during DBS exposed aversive reactions to normally liked sucrose tastes and even more aversive taste reactions to normally disliked quinine tastes. Interestingly, given the opportunity, animals implanted in the CeA would self‐stimulate with 500 ms trains of stimulation at the same frequency and current parameters as continuous stimulation that would stop reward acquisition. Neural recordings during DBS showed that CeA neurons were still active and uncovered inhibitory‐excitatory patterns after each stimulus pulse indicating possible entrainment of the neural firing with DBS. In summary, DBS modulation of CeA may effectively usurp normal neural activity patterns to create an ‘information lesion’ that not only decreased motivational ‘wanting’ of food rewards, but also blocked ‘liking’ of rewards.     

Psychosurgery — the ‘don''t knows’ have it

Ashley Robin considers the evidence that has been put forward for the effectiveness of psychosurgery in the treatment of psychiatric disorders. Although the advances from ‘free-hand’ general leucotomy towards stereotaxic surgery of selected pathways are to be welcomed, we still await definitive evidence that psychosurgery, and not other factors such as chance, are providing the claimed recovery.     

Effects of transcranial direct current stimulation on risky decision making are mediated by ‘hot’ and ‘cold’ decisions,personality, and hemisphere

Previous results point towards a lateralization of dorsolateral prefrontal cortex (DLPFC) function in risky decision making. While the right hemisphere seems involved in inhibitory cognitive control of affective impulses, the left DLPFC is crucial in the deliberative processing of information relevant for the decision. However, a lack of empirical evidence precludes definitive conclusions. The aim of our study was to determine whether anodal transcranial direct current stimulation (tDCS) over the right DLPFC with cathodal tDCS over the lDLPFC (anodal right/cathodal left) or vice versa (anodal left/cathodal right) differentially modulates risk‐taking in a task [the Columbia Card Task (CCT)] specifically engaging affect‐charged (Hot CCT) vs. deliberative (Cold CCT) decision making. The facilitating effect of the anodal stimulation on neuronal activity was emphasized by the use of a small anode and a big cathode. To investigate the role of individual differences in risk‐taking, participants were either smokers or non‐smokers. Anodal left/cathodal right stimulation decreased risk‐taking in the ‘cold’ cognition version of the task, in both groups, probably by modulating deliberative processing. In the ‘hot’ version, anodal right/cathodal left stimulation led to opposite effects in smokers and non‐smokers, which might be explained by the engagement of the same inhibitory control mechanism: in smokers, improved controllability of risk‐seeking impulsivity led to more conservative decisions, while inhibition of risk‐aversion in non‐smokers resulted in riskier choices. These results provide evidence for a hemispheric asymmetry and personality‐dependent tDCS effects in risky decision making, and may be important for clinical research on addiction and depression.