Physical illness diagnosed as psychiatric: Patients at special risk

Recent research has further confirmed the significant incidence of undiagnosed physical illness in patients presenting psychiatric symptoms. Such research has generally involved psychiatric inpatient or outpatient populations. As a liaison psychiatrist in a general hospital, the author defines two especially high-risk groups for such missed diagnoses and emphasizes the fact that psychiatric symptoms are not illness specific. An approach to the clinical evaluation of such patients is discussed, mentioning the inherent medicolegal implications.     

Relationships between psychological factors and cardiac rhythm and electrical disturbances

The paper explores some relationships between psychological state and cardiac electrical and arrhythmic abnormalities. Prior studies of large clinic populations have disclosed an association between such disorders and hospitalizable mental illness. Conversely, some series of cardiology patients have commonly manifested severe psychological symptoms in the setting of even mild or transient cardiac symptoms. Frequently no cardiac disease was found. Careful studies of individual patients demonstrate that emotional arousal, sometimes related to a specific emotion in a given patient, can trigger episodes of serious arrhythmias.Seven patients with severe, symptomatic, intractable EKG-documented cardiac arrhythmias were interviewed. Recent changes in job status occurred in 5 patients prior to the first onset of arrhythmias. The immediate precipitants of arrhythmic crises included some emotional experiences, such as a patient's son hugging him, and some emotionally trivial experiences, such as awakening in the morning or standing up. Severe and unusual fatigue was present in 3 of the patients prior to their first arrhythmic crisis. It was concluded that important events with relatively long-term consequences in an individual's life may tonically lower the threshold to arrhythmias, and that the short-term effects of a diversity of physiological events (e.g., effort, emotional arousal, relaxation) may interact with the lowered threshold to precipitate and arrhythmic crisis.     

The representation of authority: an adolescent viewpoint

It is argued in this paper that participation of young people in society is to a degree a function of their attitudes towards those in authority. More specifically the research reports results from an investigation designed to assess young people's attitudes (n = 2046) to parents, teachers and police taken together as a multivariate representation of authority. The results, at both scale and item level, provide little support for the position often taken in the literature that adolescents are generally anti-authority. On the contrary the evidence points in the opposite direction with favourable attitudes being displayed to all three authority roles but in particular towards police and parents. Some of the complexities inherent in such research are pointed up with attitude to authority, represented as a tripartite dependent vector variable, being seen to vary with individual attributes such as sex and age and contextual variables such as school attended. In general girls exhibit a more favourable attitude to authority than boys, authority relationships weaken with age and organisation of schools in terms of "caring" principals result in a weakening of adult-authority relationships.     

The significance of object loss in individual response to accidental trauma

This paper deals with the effect of the failure to mourn upon the problem of symptom chronicity resulting from industrial accidents that could not be accounted for on a physical basis. The clinical material presented suggests that the inability to work through important losses prior to such an accident seriously hampers the individual's recovery from such injuries, especially where the question of secondary gain is prominent. Therefore, it is recommended that history taking at the time of the accident include specific inquiry into the matter of pathologic grief and mourning and, if it is positive, that a psychiatric opinion be obtained in an effort to reduce long-term morbidity.     

Presence of a membrane bound pyroglutamyl amino peptidase degrading thyrotropin releasing hormone in rat brain

In the present work we studied the pattern of degradation of [3H-Pro]-TRH by soluble and membrane fractions from rat brain. Demonstration of the membrane bound or soluble nature of the activities was obtained by comparing their distribution to that of lactate dehydrogenase and by looking at the effect of NaCl washes on the membrane fractions. We observed that the pyroglutamyl amino peptidase activity detected in brain homogenates is a result of two different enzymes. One of them is a soluble enzyme previously characterized, that needs DTT and EDTA for its expression, is inhibited by SH-blocking agents such as iodoacetamide and utilizes p-glu-beta-naphtylamide as a substrate. The other one, a membrane enzyme, is inhibited by chelating agents such as EDTA and DTT, is not affected by iodoacetamide and does not degrade p-glu-beta-naphtylamide. The later presents some specificity towards TRH as shown by competition experiments with TRH analogs. We were able to corroborate that the post proline cleaving enzyme acting on TRH is a soluble enzyme. In membranes we demonstrated also the presence of a post-proline dipeptidyl aminopeptidase. The membrane bound pyroglutamidase activity is a potential new source of L-his-L-pro-diketopiperazine in brain. The presence of a TRH degrading enzyme in membrane fractions is of particular importance in searching an inactivation mechanism of this peptide once it is released into the synaptic cleft.     

The recognition and encoding of faces by alcoholic Korsakoff and right hemisphere patients

Alcoholic Korsakoffs, patients with right-hemisphere lesions, long-term alcoholics and normal control subjects were examined on three tests of facial memory and encoding. The Korsakoffs and patients with right-hemisphere lesions were impaired in their memory and simultaneous matching of unfamiliar faces. Their performance on a facial processing task indicated that they matched faces on the basis of superficial features such as paraphernalia and expression rather than the deeper configurational characteristics of faces. It is suggested that such superficial encoding may be partially responsible for these patients' visuoperceptual and memory problems.     

A commingling analysis of platelet monoamine oxidase activity

The distribution of platelet monoamine oxidase (MAO) activity is examined in a large cohort of 18-year-olds from a college setting. A mixture of three distributions is needed to describe the data, even when a power transformation is used to remove skewness in the distribution. This is compatible with MAO activity being controlled by a single major locus with a gene frequency of 0.02 for high-MAO activity. Accordingly, it is unlikely that such a locus could serve as a genetic marker for a disorder which is associated with low activity. However, this finding does not rule out the possibility that MAO activity is an associated risk factor in disease.     

A reassessment of catatonia

We consider catatonia as a disease entity having a cyclic, alternating course with periods of depression and mania. The prodromal symptoms observed often have a strong affective component. Diagnosis of catatonic schizophrenia should not be made on the basis of catatonic features or symptoms alone. It should only be made after schizophrenia has first been diagnosed by recognized diagnostic criteria.Research is needed to validate these observations. Epidemiologic studies, family genetic studies, and laboratory methods (such as the dexamethesone suppression test and other procedures) may offer avenues for pursuing catatonia as described by Kahlbaum as mainly an affective disorder.The presence of catatonic features demands a careful differential diagnosis. To merely label a patient with catatonic features as schizophrenic without further examination and investigation may deprive such a patient of proper treatment, which in cases such as malignant neuroleptic syndrome may mean the difference between life and death.     

The psychiatric liaison nurse in the general hospital: three models of practice.

The creation and implementation of the role of the psychiatric liaison nurse in three general hospitals are described. The historical evolution and theoretical bases of the role are reviewed, as well as the specific reasons for creation of such a role in each of the three hospitals. Three typical patient consultations by liaison nurses illustrate the need for provision of such services within the general hospital. Similarities in the implementation of the role of liaison nurse in the three hospitals are discussed.     

Pure motor hemiplegia with occlusion of the extracranial carotid artery

Two patients with the syndrome of pure motor hemiplegia are presented in whom occlusion of the carotid artery in the neck was demonstrated angiographically. A relationship between extracranial vascular disease and pure motor hemiplegia is suggested and potential implications in the management and treatment of such patients are discussed.     

Some methodological issues in consultation-liaison psychiatry research

This is a research methodologic design model that may be useful to consultation-liaison psychiatrists. It is intended to facilitate such researchers in setting up and executing carefully controlled studies of the effectiveness (in psychiatric, medical, surgical, functional, cost, or other areas) of consultation-liaison interventions. The specific variables discussed are areas of particular interest to the authors, but many other variables may be readily substituted into this basic model. The design may be expanded or contracted relatively easily as would be appropriate for particular projects. The overall purpose of this paper is, hopefully, to serve as a catalyst for consultation-liaison psychiatrists to consider such research in their academic settings and to foster increased discussion and critical thinking regarding such research. The authors consider such research efforts important for the future regarding the scientific basis, proven effectiveness, and funding of consultation-liaison and general hospital psychiatry.     

Psychobiological profiles in infertile men

To investigate the psychosomatic impact in male infertility, we analysed relationships among psychological (life events, personality attitudes) and biological (gonadotrophins, sex steroids, seminal parameters) variables in 101 husbands of barren couples. In patients with subnormal fertility parameters, personality attitudes were not different from those of a reference group of the questionnaire (FAPK) used in this study. However, patients with high scores on test scales such as regression, hypochondria, or emotional vacuity showed better fertility characteristics. These results agree with previously reported data, suggesting that social assertiveness and extraversion but not introversion and depression are associated with male infertility.     

Prognosis in the treatment of female sexual inhibition

Prognostic variables in the treatment of female sexual inhibition were reviewed. Symptom variables (such as duration and severity), psychological variables (including nonsexual psychopathology, general anxiety, phobias, obsessions and compulsions, neuroticism, extraversion, and hostility), patient variables (such as the marital relationship, motivation, sexual dysfunction in the male partner), and treatment variables (such as theoretical orientation and treatment techniques, individual versus unit treatment, single therapist versus dual sex therapy team), as well as other prognostic variables are considered. Although only a few controlled studies exist, based on a rapidly growing number of reports tentative conclusions were drawn and ranked according to the weight of the supporting evidence.     

Central monoamine metabolism in depressions. I. Serotonin and related compounds

This article reviews research into the possible significance of disorders of the central 5-HT metabolism in the pathogenesis of recurrent depressions. The available data would seem to warrant the tentative conclusion that such metabolic disorders are indeed involved in a certain subcategory of vital depressions and play a (possible predisposing) role in the pathogenesis of these depressions.The use of 5-HT precursors in depressions is regarded as a potential asset, although the conclusion that real substitution therapy can thus be given would be premature.     

Effects of neocortical ablations on eating elicited by hypothalamic stimulation

Unilateral and two-stage bilateral ablations had marked effects on stimulation-bound feeding. These included temporary or permanent failure to feed, increase in current thresholds, and reduction in the persistence of feeding during stimulation. Analysis of the data by a multiple regression technique indicated that the failure to feed was related to the amount of unilateral and bilateral damage to the frontal, but not other cortical regions. Changes in threshold were not related to frontal damage as such; rather, these changes appeared to be a function of an interaction between the sites of stimulation and amount of cortical damage. Persistence changes were related to the degree of frontal damage. Failure to feed appeared to reflect disorganization of food-seeking rather than consummatory responses.     

Allergic potential and emotional precipitants of asthma in children.

The relationship between certain psychological and allergic variables in childhood asthma was studied. The prediction was that across patients of equal illness severity, an inverse relationship would be observed between measures of the involvement of emotional symptom precipitants and of allergic factors. This relationship failed to emerge at a statistically significant level when the index of emotional precipitants included only such things as worry, anger, upset, excitement, etc. and excluded emotionally toned “respiratory behaviors” such as crying or laughing. When crying was included in the index of emotional precipitants, the prediction was clearly supported. These findings were discussed in terms of their bearing on what is meant by the involvement of psychological factors in asthma, and a broader conceptual scheme was suggested. A clinical implication of the findings and certain methodological considerations was also discussed.     

Processing capability of the primary visual cortex and possible physiologic basis for an apparent motion illusion

The primary visual cortex is known to process stimuli in a given part of the visual field such that divisions of the cortical column into orientation and ocular dominance minicolumns are present. Applying a model incorporating both the Hebb learning hypothesis and a Mountcastle-like organizational structure to the visual cortex, we predicted that the processing capabilities of the column involve dynamic interactions among minicolumns and are much greater than presently documented. In particular, processing of rotational stimuli in area 17 was suggested by the model. Motivated by this, a psychophysics experiment was conducted that demonstrated a spatial-temporal filling-in process in apparent motion. We have now presented this "human illusion" to cats and recorded from units in area 17 with results which clearly demonstrate striking phenomena not simply understood. The purpose of this note is to present our experimental paradigm with the preliminary results.     

Mitochondrial myopathy with multisystem abnormalities and normal ocular movements.

A woman aged 27 years is described with mental retardation, short stature, epilepsy, muscle weakness, chorioretinitis, nerve deafness, ataxia, abnormalities of the electroencephalogram and electrocardiogram, elevated cerebrospinal fluid protein and abnormal carbohydrate metabolism. There was no ophthalmoplegia. Histopathological studies on quadricepts muscle biopsy demonstrated a high proportion of Type I fibres with subsarcolemmal collections of granular material (“ragged-red” fibres). There was also an increase in intracellular lipid. On electron microscopy, abnormal mitochondria containing paracystalline inclusions were seen predominantly in subsarcolemmal regions. The patient differs from other cases of mitochondrial myopathy with this syndrome in having normal ocular movements. Muscle disease in such cases appears to be only one manifestation of a more widespread disorder of tissue metabolism.     

Some stereological correction formulae with particular applications in quantitative neurohistology.

The present report furnishes explicit formulations for correcting the observed nucleolar and nuclear volume fractions of neurons sampled on the basis of the presence of nucleolar profiles when sectioned. Such samples, frequently chosen for quantitative studies in neurohistology, can result in the overestimation ov component volume fractions. The correction formulae are derived by considering theoretical spherical models exhibiting "nucleus-nucleolus" concentricity and eccentricity, and are tested by applying them to analogous neuron populations in rat spinal cord. It is concluded that, with certain reservations, the formulae can be usefully applied to data obtained from nucleolar-biased samples, thereby increasing the reliability of quantitative information gleaned from such samples.     

Compliance and the health belief model: a challenge for the liaison psychiatrist

Noncompliance or nonadherence to prescribed medical regiments is a widespread problem. The behavior of noncompliance is complex, requiring an analysis based upon theoretical constructs. We review the Health Belief Model (HBM) as one such construct that may aid in understanding the problem. The four essential ingredients of the model include (1) a perception of susceptibility to disease, (2) a belief that the impact of this disease will affect him/her biologically and/or psychosocially, (3) a belief that the potential benefits of the regime outweigh the risks of the disease and its treatment, and (4) an ability to surmount barriers to treatment. The HBM has been shown to have construct validity and has provided a means of exploring practical and cost effective methods for reducing noncompliance and perhaps morbidity and mortality associated with failures to follow up on recommended medical procedures. Moreover, the general problem of noncompliance provides a unique opportunity for students of human behavior to interact constructively with their medical and surgical colleagues.