Low self-esteem and psychiatric patients: Part I – The relationship between low self-esteem and psychiatric diagnosis

Background

The objective of the current study was to determine the prevalence and the degree of lowered self-esteem across the spectrum of psychiatric disorders.

Method

The present study was carried out on a consecutive sample of 1,190 individuals attending an open-access psychiatric outpatient clinic. There were 957 psychiatric patients, 182 cases with conditions not attributable to a mental disorder, and 51 control subjects. Patients were diagnosed according to DSM III-R diagnostic criteria following detailed assessments. At screening, individuals completed two questionnaires to measure self-esteem, the Rosenberg self-esteem scale and the Janis and Field Social Adequacy scale. Statistical analyses were performed on the scores of the two self-esteem scales.

Results

The results of the present study demonstrate that all psychiatric patients suffer some degree of lowered self-esteem. Furthermore, the degree to which self-esteem was lowered differed among various diagnostic groups. Self-esteem was lowest in patients with major depressive disorder, eating disorders, and substance abuse. Also, there is evidence of cumulative effects of psychiatric disorders on self-esteem. Patients who had comorbid diagnoses, particularly when one of the diagnoses was depressive disorders, tended to show lower self-esteem.

Conclusions

Based on both the previous literature, and the results from the current study, we propose that there is a vicious cycle between low self-esteem and onset of psychiatric disorders. Thus, low self-esteem increases the susceptibility for development of psychiatric disorders, and the presence of a psychiatric disorder, in turn, lowers self-esteem. Our findings suggest that this effect is more pronounced with certain psychiatric disorders, such as major depression and eating disorders.

     

Low self-esteem and psychiatric patients: Part II – The relationship between self-esteem and demographic factors and psychosocial stressors in psychiatric patients

Background  

The objective of the present study was to identify the effects and relative importance of demographic factors and psychosocial stressors on self-esteem of psychiatric patients.     

Cannabis use and psychiatric and cogitive disorders: the chicken or the egg?

PURPOSE OF REVIEW: Cannabis is the world's most commonly used illicit drug. In this review, we consider the recent literature on the effects of cannabis on mental health and on cognition. RECENT FINDINGS: Cannabis use in adolescence increases the risk of later schizophrenia-like psychoses, especially in genetically vulnerable individuals. Not surprisingly, patients already suffering from psychosis who use cannabis have a worse outcome than those who do not. These effects of cannabis may be consequent on its impact on the dopamine system. There is less evidence of cannabis playing an aetiological role in other mental disorders including depression, but there have been far fewer studies. Heavy cannabis use has also been shown to affect memory and learning performance, both in healthy individuals and in patients suffering from psychosis. Combined cognitive-behavioural therapy and motivational interviewing seems a promising psychological intervention to achieve a cessation of cannabis use in patients suffering from schizophrenia. SUMMARY: Further research is needed to understand the biological mechanisms underlying the effects of cannabis on mental health, but intervention strategies to help patients abstain should currently be implemented in psychiatric services, and public education campaigns should be directed at increasing awareness of the health risks of cannabis.     

State-level women’s status and psychiatric disorders among US women

Purpose  

Although greater gender equality at the state-level is associated with fewer depressive symptoms in women after controlling for individual-level confounders, the extent to which state-level women’s status is related to psychiatric disorders in women and gender differences in psychopathology has never been examined. We examined these associations in the current report.     

Involuntary psychiatric admission: The referring general practitioners’ assessment of patients’ dangerousness and need for psychiatric hospital treatment

Abstract

Background: In Norway, GPs may decide to refer patients to involuntary psychiatric treatment. Internationally, there has been a discussion regarding criteria for involuntary admission. In Norway and in other countries where the treatment criterion is still used, some have suggested its removal. Aims: To examine which legal criteria GPs used to refer patients to involuntary admission, whether they had thought about using a different criterion, and on which information they based their decision. Methods: A total of 74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews. Results: In total, 38% (28) had applied the danger criterion only and 23% (17) had applied the treatment criterion only; 32% (24) had applied both criteria, while 7% (5) did not answer this question; 74% (55) said that they could not have chosen a different criterion; 45% (33) had based their decision on events/behaviour prior to and during the consultation, 43% (32) on events prior to the consultation only, and 8% (6) on information obtained during the consultation only; 4% (3) did not answer this question. None had used tools to aid in the assessment of danger. Clinical implications: The danger criterion was frequently used by the referring GPs. It is unclear how a removal of the treatment criterion from Norwegian legislation might impact clinical practice. Conclusions: While the danger criterion was applied by a majority, the treatment criterion was also chosen by many and was of importance to the doctors’ reasoning regarding referrals to involuntary admission. Most thought they could not have chosen a different criterion.     

Neurotransmitters and prefrontal cortex–limbic system interactions: implications for plasticity and psychiatric disorders

The prefrontal cortex (PFC) efferent projections to limbic areas facilitate a top-down control on the execution of goal-directed behaviours. The PFC sends glutamatergic outputs to limbic areas such as the hippocampus and amygdala which in turn modulate the activity of the nucleus accumbens (NAc). Dopamine and acetylcholine neurons in the brainstem and basal forebrain/septal areas, which send outputs to NAc, hippocampus and amygdala, are also regulated by PFC glutamatergic projections, and seem to be of special relevance in modulating motor, emotional and mnemonic functions. Both the physiological and pathological changes in the PFC influence the activity of these limbic areas and the corresponding final-guided behaviours. We revise our most recent studies on PFC–NAc interactions focussed on the role of dopamine and glutamate receptors in the PFC. Specifically, by performing microinjections/microdialysis studies we found that the activation of D2 dopamine receptors and the blockade of glutamate NMDA receptors in the PFC change the release of dopamine and acetylcholine in the NAc. We suggest the possibility that dopamine and glutamate receptors in the PFC could change the activity of dopamine and acetylcholine function in the hippocampus and amygdala. Finally, it is speculated that changes in the function of the PFC, associated with psychiatric disorders or due to environmental-dependent plasticity, can change PFC–limbic system interactions.     

Can the MMPI-2 discriminate between mild-moderate TBI and other neurologic and psychiatric populations?

MMPI-2 maintains an extensive empirical base with psychiatric populations, although more recently, neurologically compromised patients have documented unique elevation patterns. This study examined mild-moderate TBI patients, Alzheimer's Dementia patients, and Psychiatric controls on MMPI-2 scales. Participants included 160 outpatients (TBI n = 26, AD n = 74, Psychiatric n = 60). Controlling for family-wise-error, five ANCOVAs were conducted on five MMPI-2 scales, correcting for age and education. TBI and Psychiatric group means were significantly higher than AD group means for scales Hypochondriasis, Depression, and Hysteria at an alpha of .01. Results support previous research with mild TBI patients, and further document a unique pattern of elevations in this population.     

What do psychiatric patients expect of inpatient psychiatric hospital treatment?

Patients are mostly passive utilizer of the health-care-system. They are confronted with a supply of medical service and they are allowed to show their satisfaction with it retrospectively. Our medical system has in future to develop itself from an effective perspective to an utilizer orientated medicine. Orientation to the utilizers means to ask for the expectations of the patients for supply (at customer's option). Aim of our investigation was to check the subjective expectations of the patients before the beginning of in-patient treatment: 1. What is their opinion about the label of the disorder, they are suffering. 2. Of what therapeutic measures do they expect help for theirselves. 3. Do they want to play a part in planning of therapeutic measures. 209 of 344 (61%) of the patients were at admission ready for answering a self designed questionnaire. Only 4% of the patients said, that their disorder is called insanity. They preferred labels like mental illness (45%), somatic illness (43%) and mental health problem (42%). A pharmacological therapy expected in totally 61% of the patients. Mostly were expected drugs against depressive disorders (32%), drugs against addiction (31%) and tranquilizers (29%). Only 10% of the patients expected to get antipsychotic drugs. A verbal therapeutic intervention expected 76% of the patients. To have a speak with the doctor is with 69% a first rank desire, followed by speaking with the psychologist (60%), the nurses (58%) and the patients comrades (56%). Psychotherapy in a narrower sense expect only 40% of the patients. Furthermore there are privacy and recreation through promenades in front of the expectations (69%), followed by relaxation (59%), occupational therapy (55%) and sports or active exercise therapy (54%). 75% of the patients want to be informed about the therapy. 69% want to cooperate with planning of the therapy. Only 21% commit the therapy to the doctor. About one third of the patients expect a consultation with their relatives, the custodians and their family doctor.     

Neuropsychological, neuroimage and psychiatric aspects of primary Sjögren's syndrome

We report a case of a 49-year-old woman diagnosed with primary Sj?grens Syndrome (pSS) who was submitted to extensive neuropsychobiological assessment. Examination revealed a Wechsler Adult Intelligence Scale-Revised (WAIS-R) Full Scale IQ of 97 with no Verbal/Performance IQ discrepancy and performance below estimated premorbid levels on arithmetic skills, visual tracking, naming and delayed paired associate learning/memory. CT scans of the brain were normal. However, there were subcortical hyperintensities on MRI and left parieto-temporal hypoperfusion on SPECT. Neuropsychological impairment is consistent with the pattern of neuroimage findings. We hypothesize that the pathophysiological mechanisms of pSS involve direct immune attack on neurons in addition to indirect effects through small-vessel angiopathy and thereby induce natural fracture lines in behavior according to location in the central nervous system.     

PTSD and the law of psychiatric injury in England and Wales: finally coming closer?

With the increase in terrorism in several parts of the world, more people are exposed to traumatic events that could cause psychiatric injury either to them or to members of their families. In Britain, terrorist attacks or other catastrophes are not unknown; indeed, the case law relating to psychiatric injury is vast. However, the intersection between medicine and the law is minimal. The result is a law that lags behind the scientific evidence and, on occasion, may seem unfair.     

Mechanical and pharmacological restraints in acute psychiatric wards—Why and how are they used?

Restraint use has been reported to be common in acute psychiatry, but empirical research is scarce concerning why and how restraints are used. This study analysed data from patients' first episodes of restraint in three acute psychiatric wards during a 2-year study period. Logistic regression analyses were used to identify predictors for type and duration of restraint. The distribution of restraint categories for the 371 restrained patients was as follows: mechanical restraint, 47.2%; mechanical and pharmacological restraint together, 35.3%; and pharmacological restraint, 17.5%. The most commonly reported reason for restraint was assault (occurred or imminent). It increased the likelihood of resulting in concomitant pharmacological restraint. Female patients had shorter duration of mechanical restraint than men. Age above 49 and female gender increased the likelihood of pharmacological versus mechanical restraint, whereas being restrained due to assault weakened this association. Episodes with mechanical restraint and coinciding pharmacological restraint lasted longer than mechanical restraint used separately, and were less common among patients with a personality disorder. Diagnoses, age and reason for restraint independently increased the likelihood for being subjected to specific types of restraint. Female gender predicted type of restraint and duration of episodes.     

Traumatic injuries of children and adolescents--are they associated with psychiatric contacts?

Our aim was to investigate whether a large number of hospital visits by children and adolescents because of injuries are associated with psychiatric treatments and subsequent suicides. We examined the case records of 250 randomly chosen patients, 156 (62%) boys and 94 (38%) girls, out of 2306 outpatients who were 0-16 years old and had been treated because of traumatic injuries in Oulu University Hospital in 1984 and were alive in 1997. Boys with seven or more accidents had had psychiatric treatments more commonly than did boys with fewer accidents (39% vs. 8%). In addition, the case records of the patients who had died before the end of 1997 out of the 2306 patients were examined. Twenty-one (0.9%) patients (20 males and one female) had died, and seven (0.3%) of them had committed suicide. The traumatically injured male patients had a twofold suicide rate compared to the national average. The researchers also re-coded the causes of death from the death certificates. There seems to be a tendency to interpret adolescent suicides as accidental, as one of the seven registered suicides (14%), but six of the seven re-coded suicides (86%) had occurred before the age of 20.     

Stereotactic multi-target limbic leucotomy for treating intractable psychiatric disease in 30 patients☆ Three-year follow-up of memory, intelligence, and psychiatric symptoms

BACKGROUND： The biochemical hypothesis of dopamine hyperfunction in the brain can explain the pathological mechanisms of schizophrenia. Surgery is performed based on limbic system circuit theory correspondence to above-mentioned hypothesis. Stereotactic surgery for the treatment of mental disorders is related to stereotactic surgery that influences the Papez circuit. OBJECTIVE： To observe the effects of stereotactic multi-target limbic leucotomy on the improvements in memory, intelligence and psychiatric symptoms in the treatment of intractable psychiatric disease. DESIGN： Self-control case analysis and follow-up of therapeutic effects. SETTING： Department of Neurosurgery, First Hospital, Hebei Medical University. PARTICIPANTS： Thirty patients with intractable psychiatric disease, who received stereotactic surgery in the Department of Neurosurgery, First Hospital, Hebei Medical University between July 2002 and August 2005, were included in this study. The patients, 21 males and 9 females, all met the diagnostic criteria of intractable psychiatric disease, determined by the national psychosurgery cooperation team in 1998. Informed consents for surgery and clinical follow-up exams were obtained from patients and/or patients＇ relatives （guardians）. METHODS： In 30 patients with intractable psychiatric disease, limbic leucotomy was performed by stereotactic technique. Multi-target radiofrequency hyperthermia was performed in the intracranial amygdaloid nucleus, anterior limb of internal capsule, callosal gyrus, among other regions. The therapeutic effects of patients were evaluated by Brief Psychiatric Rating Scale （BPRS） before surgery, and 6 months, 1, and 3 years after surgery. The Wechsler Adult Intelligence Scale （WAIS） and Clinical Memory Scale （CMS） were used to assess memory and intelligence before and after surgery. MAIN OUTCOME MEASURES： Memory, intelligence, and psychiatric symptoms of patients before and after operation. RESULTS： Thirty patients were included in the final     

What do consumers say they want and need during a psychiatric emergency?

Behavioral emergencies are a common and serious problem for consumers, their families and communities, and the healthcare providers on whom they rely for help. In recent years, serious concerns about the management of behavioral and psychiatric emergencies-in particular, the misapplication and overuse of physical and chemical restraints and seclusion-have become a focus of attention for mental health professionals and policy makers as well as for the lay public, the media, and patient advocacy organizations. Policy leaders and clinicians are searching for ways to balance the rights of consumers with considerations of safety and good care in an area in which it is difficult to conduct research. A survey of mental health professionals who are experts on the treatment of psychiatric and behavioral emergencies identified consumer input and collaboration between patient and clinician whenever possible as being extremely important in achieving the best short-term and particularly the best long-term outcomes for patients. The survey of consumer perspectives described in this article was undertaken in response to the need to better understand consumer experiences and preferences. The authors describe four emergency services forums conducted in 2002, which involved a total of 59 consumers. Each forum involved a written consumer survey as well as a workshop to develop and prioritize recommendations for improving psychiatric emergency care. The authors present the results of the consumer survey and summarize the top recommendations from the workshops. In both the survey and the workshops, the consumers repeatedly stressed the importance of having staff treat them with respect, talk to them, listen to them, and involve them in treatment decisions. There were a number of important areas of agreement between the recommendations of the consumer panel and those of the experts in emergency psychiatry surveyed for the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. These include the desirability of verbal interventions, the use of a collaborative approach, and the use of oral medications guided by the individual consumer's problems, medication experiences, and preferences. The majority of the consumer panel reported adverse experiences with general hospital emergency rooms and, in fact, called for the development of specialized psychiatric emergency services such as those recommended in the Expert Consensus Guidelines. One-fifth of the consumer panel attributed their emergency contact to lack of access to more routine mental health care. The consumers clearly do not reject medications categorically. Almost half indicated that they wanted medications and a similar number indicated benefit from medications, although many complained of forced administration and unwanted side effects. The consumer panel preferred benzodiazepines and ranked haloperidol as a least preferred option. Among their key recommendations for improving psychiatric emergency care, the consumer panel stressed the development of alternatives to traditional emergency room services, the increased use of advance directives, more comfortable physical environments for waiting and treatment, increased use of peer support services, improved training of emergency staff to foster a more humanistic and person-centered approach, increased collaboration between practitioners and patients, and improved discharge planning and post-discharge follow-up. The implications of these findings for improving psychiatric emergency care are considered.