Why people with probable minor psychiatric morbidity consult a doctor.

This epidemiological investigation examines factors determining medical consultation in people with probable minor psychiatric morbidity. About 54% of people with probable minor psychiatric morbidity and about 23% of the (numerically much greater) remainder with lower probability of psychiatric morbidity consulted a doctor, usually a primary care physician, in the two weeks prior to a research interview. Medical consultation rates were higher in females than in males. The dominant finding was that in people with probable minor psychiatric morbidity physical illness was strongly associated with medical consultation. Almost 89% of males and 97% of females with probable minor psychiatric morbidity and physical illness consulted a doctor in the two weeks prior to interview. Logistic regression modelling was used to investigate the joint effects on medical consultation of physical illness and six socio-demographic variables, and physical illness emerged as the major single determinant of medical consultation in women and, in men, it exerted its effect through an interaction with lower educational level.     

Histories of depression, allopregnanolone responses to stress, and premenstrual symptoms in women

Twenty-six women meeting DSM criteria for premenstrual dysphoric disorder (PMDD) and 39 non-PMDD controls were tested for allopregnanolone (ALLO) responses to mental stress. Approximately half of each group had a history of depression (DEP) (14 PMDD, 17 non-PMDD), though all were free of current psychiatric illness. ALLO was sampled in response to venipuncture stress, after an extended baseline, and again 30 and 60 min following the onset of mental stressors. All women with prior DEP, regardless of PMDD status, showed a blunted ALLO stress response at 30 and 60 min (p < 0.05), and also failed to show the expected decrease from venipuncture to baseline rest (p = 0.08) compared to women with no prior DEP. Women with prior DEP did not show the expected correlation between progesterone and ALLO (r = 0.16) that was seen in those with no prior DEP (r = 0.37, p < 0.05). ALLO levels at extended baseline and blunted ALLO reactivity predicted more severe premenstrual symptoms, but only in PMDD women with prior DEP (p values <0.05). These results suggest that a history of DEP is associated with a failure of ALLO to be appropriately responsive to challenge, with alterations in the conversion of progesterone to ALLO, and confirm prior reports linking ALLO to symptoms in PMDD, but only in PMDD women with histories of DEP.     

Alexithymia: relationship to severity of medical illness and depression

The relationship of depression and the severity of medical illness to alexithymia was investigated in 75 medically ill patients seen in psychiatric consultation. Both depression and living alone predicted alexithymia but severity of medical illness was not related to an individual's alexithymic characteristics measured by the revised Schalling-Sifneos Scale. The implications of the findings are discussed in relationship to previous data regarding alexithymia in a psychiatric consultation population.     

Post-traumatic stress disorder in the community: an epidemiological study

Post-traumatic stress disorder (PTSD) was studied in the Piedmont region of North Carolina. Among 2985 subjects, the lifetime and six month prevalence figures for PTSD were 1.30 and 0.44% respectively. In comparison to non-PTSD subjects, those with PTSD had significantly greater job instability, family history of psychiatric illness, parental poverty, child abuse, and separation or divorce of parents prior to age 10. PTSD was associated with greater psychiatric comorbidity and attempted suicide, increased frequency of bronchial asthma, hypertension, peptic ulcer and with impaired social support. Differences were noted between chronic and acute PTSD on a number of measures, with chronic PTSD being accompanied by more frequent social phobia, reduced social support and greater avoidance symptoms.     

How do you feel? Self-esteem predicts affect, stress, social interaction, and symptom severity during daily life in patients with chronic illness

Self-esteem has been demonstrated to predict health and well-being in a number of samples and domains using retrospective reports, but little is known about the effect of self-esteem in daily life. A community sample with asthma (n = 97) or rheumatoid arthritis (n = 31) completed a self-esteem measure and collected Ecological Momentary Assessment (EMA) data 5x/day for one week using a palmtop computer. Low self-esteem predicted more negative affect, less positive affect, greater stress severity, and greater symptom severity in daily life. Naturalistic exploration of mechanisms relating self-esteem to physiological and/or psychological components in illness may clarify causal relationships and inform theoretical models of self-care, well-being, and disease management.     

Self-attention, life stress, and illness: a prospective study

Using a prospective design, this study examined the hypothesis that a predisposition to focus on internal aspects of the self serves as a stress resistance resource. One hundred and twenty subjects filled out the Private Self-Consciousness inventory, a schedule of recent life events and a symptom checklist. Two months later they were asked again to report life events and symptoms that had occurred in the interval. Data were analyzed by means of hierarchical panel analysis. The results showed, consistent with the hypothesis, that incidence of stressful life events predicted subsequent illness among persons low in private self-consciousness but not in persons high in private self-consciousness. It is proposed that the tendency on the part of persons low in private self-consciousness to disattend to their psychologic and somatic reactions to stressful life events and to fail to take corrective actions may lead to lowered body resistance over time and hence increase their susceptibility to physical illness. The results are interpreted as consistent with Schwartz's concept of disregulation and control systems analysis of health behavior and Leventhal's work on the role of internal monitoring for coping with stress.     

Contribution of psychological and social factors to psychotic and non-psychotic relapse after childbirth in women with previous histories of affective disorder.

Twenty-six women with a history of bipolar or schizoaffective disorder, 17 women with histories of major depressive disorder and 45 control women without any previous psychiatric history were assessed in the 9th month of pregnancy on selected psychosocial measures. No subject was a 'case' as defined by the Research Diagnostic Criteria (RDC) from this time until the delivery. Within 6 months postpartum, 22 (51%) of the women with histories of mental illness were categorised as having relapsed (RDC case). Twelve women developed a psychosis (mania, hypomania or schizomania) and these illnesses occurred only in women with histories of affective or schizoaffective psychosis whereas 10 other women who became depressed after delivery came equally from the women with histories of psychosis (N = 5) as from those with histories of major depression (N = 5). Three (7%) control women also developed postpartum non-psychotic depressive disorders. Multivariate analyses suggest that different psychosocial factors contribute to the recurrence of affective and schizoaffective psychosis after delivery as opposed to non-psychotic postpartum affective disorders. A non-psychotic illness was predicted by antenatal neuroticism and a severe life event before illness onset. A recurrence of psychosis postpartum was predicted by a history of mania, hypomania or schizomania, a more recent psychiatric admission and reported marital difficulties. In this sample of women, life stress led to postpartum depression irrespective of the subject's past history and the high rates of recurrence of affective or schizoaffective psychosis (47%) probably mainly reflected a pre-existing physiological or psychological vulnerability which may have been exacerbated by, or contributed to, marital difficulties.     

The relationship between prior psychiatric disorder and chronic fatigue: evidence from a national birth cohort study

BACKGROUND: Increased rates of psychiatric disorder have previously been reported in those diagnosed with chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), although the direction of causation in this relationship has not been established. We aimed to test the hypothesis that individuals with self-reported CFS/ME have increased levels of psychiatric disorder prior to the onset of their fatigue symptoms. METHOD: A total of 5,362 participants were prospectively followed with various measures of personality, psychiatric disorder and fatigue levels collected over the first 43 years of their life. CFS/ME was identified through self-report during a semi-structured interview at age 53 years. RESULTS: Thirty-four (1.1%) of the 3,035 subjects assessed at age 53 years reported a diagnosis of CFS/ME. CFS/ME was more common among females, but there was no association between CFS/ME and either social class, social mobility or educational level. Those with psychiatric illness between the ages of 15 and 36 years were more likely to report CFS/ME later in life with an odds ratio (OR, adjusted for sex) of 2.65 [95% confidence interval (CI) 1.26-5.57, p=0.01]. Increased levels of psychiatric illness, in particular depression and anxiety, were present prior to the occurrence of fatigue symptoms. There was a dose-response relationship between the severity of psychiatric symptoms and the likelihood of later CFS/ME. Personality factors were not associated with a self-reported diagnosis of CFS/ME. CONCLUSIONS: This temporal, dose-response relationship suggests that psychiatric disorders, or shared risk factors for psychiatric disorders, are likely to have an aetiological role in some cases of CFS/ME.     

Factors associated with being granted a pension among psychiatric outpatients with major depression

BACKGROUND: Little is known about factors associated with early retirement due to major depression in naturalistic settings. We examined to what extent major depression leads to disability pension and whether there are any associated factors with being granted a pension. METHODS: In our retrospective document-based cohort study of 213 adult psychiatric outpatients with first-time documented DSM-III-R major depression, several sociodemographic, clinical and treatment characteristics were detected during the follow-up time of 3 months of medical care in Finland. This information was related to official registers of granted pensions with a follow-up time of 30 months. RESULTS: Forty-six (21.6%) patients were granted a pension during the follow-up period. Greater age, comorbidity and lowered self-esteem were strongly associated with being granted a pension. DISCUSSION: Some risk factors associated with subsequent retirement could be identified at the early phase of the illness.     

Emotions, self-esteem, and paranoid episodes: an experience sampling study

OBJECTIVES.?The evidence to date for a causal role of emotions in the generation of paranoid symptoms is scarce, mainly because of a lack of studies investigating the longitudinal association between emotional processes and paranoia. The primary aim of this study was to investigate whether momentary emotional experiences (anxiety, depression, anger/irritability) and self-esteem predicted the onset and duration of a paranoid episode. We also studied whether levels of emotional experiences and self-esteem were respectively higher and lower during a paranoid episode. DESIGN.?A 1-week, prospective momentary assessment study. METHODS.?Data were collected using the experience sampling method, a structured self-assessment diary technique. The sample consisted of 158 individuals who ranged across the paranoia continuum. Participants with a psychotic disorder were recruited from in-patient and out-patient mental health services. Participants without psychotic disorder were sampled from the general population. RESULTS.?Specific aspects of emotional experience were implicated in the onset and persistence of paranoid episodes. Both an increase in anxiety and a decrease in self-esteem predicted the onset of paranoid episodes. Cross-sectionally, paranoid episodes were associated with high levels of all negative emotions and low level of self-esteem. Initial intensity of paranoia and depression was associated with longer, and anger/irritability with shorter duration of paranoid episodes. CONCLUSIONS.?Paranoid delusionality is driven by negative emotions and reductions in self-esteem, rather than serving an immediate defensive function against these emotions and low self-esteem. Clinicians need to be aware of the central role of emotion-related processes and especially self-esteem in paranoid thinking.     

The relationship between life change and relative autonomic balance.

The frequency of life changes, as measured by questionnaires, is reported to increase prior to illness onset. Each event presumably adds to the accumulating amount of adaptive stress that confronts the individual. Total frequencies, or weighted scores, are considered important etiological factors in the illness. A more direct measure of stress is the A test of relative autonomic balance between sympathetic and parasympathetic systems. To assess the relationship between these two measures 76 undergraduates were given both a life change questionnaire and the A test. Significant negative correlations were expected because both low A and high life change scores supposedly measure adaptive stress. No significant correlations were obtained; female Ss (N = 41) reported significantly more life changes than did male Ss (N = 26). The etiological value of life changes is scrutinized, and it is hypothesized that these questionnaires may be effective to identify stress only in populations that already have existent active or latent disease processes.     

Premorbid functioning in adolescent onset bipolar I disorder: a preliminary report from an ongoing study

BACKGROUND: This study reports on premorbid academic and peer functioning and psychiatric illness in a rigorously diagnosed sample (N = 28) of adolescent onset bipolar I patients. METHODS: Premorbid functioning was assessed by parental report and review of the Ontario School Record (OSR). Premorbid psychiatric diagnoses were assigned on the basis of all information gathered. RESULTS: Overall, findings suggest that this cohort demonstrates good to excellent peer and academic functioning prior to illness onset. Rates of premorbid psychiatric illnesses were similar to that described in epidemiologic samples. CONCLUSIONS: Results are discussed in relation to current understanding of early onset bipolar illness and directions for future research.     

Biopsychosocial determinants of treatment outcome for mood and anxiety disorders up to 8 months postpartum

Little is known about the biopsychosocial determinants that predict postpartum treatment outcome for mood and anxiety disorders. Postpartum mood and anxiety symptoms and psychosocial/biological variables were recorded for 8 months of 22 women treated with antidepressants during pregnancy. Depression scores decreased by 58%, whereas anxiety scores decreased by 35%. Family history of psychiatric illness and prior psychiatric illness unrelated to pregnancy predicted depressive treatment outcome, and sexual abuse history and prior psychiatric illness unrelated to pregnancy predicted anxiety outcome. Biological and psychosocial variables predicted pharmacological treatment outcome in postpartum-depressed and anxious women.     

Psychosocial and illness related predictors of consultation rates in primary care--a cohort study

BACKGROUND: Despite extensive research, the reasons why patients consult their doctors are unclear. The aim of the current study was to identify the psychosocial and illness related factors that independently predicted primary care consultation over a 5-year period. METHOD: We carried out a prospective, population-based cohort study with three waves of data collection by postal questionnaire in one general practice in Greater Manchester (UK). Consultation data were sought from primary care records on a random subsample of 800 adult patients. The main outcome measure was the number of consultations (including surgery and home visits) over the 5 years of the study as determined by raters blind to questionnaire responses. Questionnaire measures included the 12-item version of the General Health Questionnaire, the Illness Attitude Scales, a somatic symptom scale, a fatigue scale, a functional assessment of disability. RESULTS: Consultation data were obtained on 738 patients (92% of selected subjects), who accounted for 12182 consultations. Negative illness attitudes, the presence of physical and psychiatric disorder, health anxiety, changes in psychological distress, reported physical symptoms and demographic factors such as age and sex were independently associated with consultation over a 5-year period. These variables together accounted for a difference of ten consultations per year between groups. CONCLUSION: Consultation in primary care is a complex behaviour with a complex aetiology. Terms such as 'frequent attenders' may be less helpful than recognizing a number of dimensions that operate across the whole spectrum of consultation frequency. Future research should consider the wider context of consultation.     

Psychologic stress and glycemic control: a comparison of patients with and without proliferative diabetic retinopathy

Using a case/control design, patients with (cases) and without (controls) proliferative diabetic retinopathy were compared using three psychosocial measures: life events, psychiatric symptomatology, and ego development. Cases reported significantly more symptoms. They also demonstrated a modest and significant correlation of negative life events with HgbA1c that was not shown in the controls. When the relationship of life events with glycemic control was explored in cases of varying durations of proliferative retinopathy, we found that the association between negative life events and HgbA1c was accounted for by the cases with a recent onset of retinopathy. Patients in this recent group showed a trend towards more negative life events that decreased with longer duration of proliferative retinopathy. This study suggests that the onset of proliferative retinopathy portends a life crisis during which metabolic control is sensitive to additional life stress and that this association is not found among patients whose illness is more stable.     

The role of life events in depression in primary medical care versus psychiatric settings

BACKGROUND: The relationship between negative life events and depression is inconsistent. The purpose of the current study is to investigate the hypothesis that depression in the community may be related more to major life events than is depression in psychiatric settings. METHODS: This hypothesis was tested using depressed primary medical care (PC; n=70) and psychiatric patients (n=62). Nondistressed (n=109) and distressed/nondepressed PC patients (n=43) served as comparison-control groups. Life events were rated using the contextual method of Brown and Harris (Brown, G.W., Harris, T.O., 1978. Social origins of depression. Tavistock, London). RESULTS: Depressed PC patients, but not depressed psychiatric patients, were significantly more likely to have recent severe events than the comparison-control groups. Self-reported distress in the absence of depression was not associated with severe life events. LIMITATIONS: History of depression was assessed using a simple count of number of previous episodes, and the assessment of depression history may require more sophisticated assessment. The measure of endogenous depression used in this study was created post-hoc and needs replication. CONCLUSIONS: Diathesis-stress models need to accommodate a lack of universality for severe stress prior to the onset of depression. Clinical strategies may need to reflect patient treatment preferences associated with differences across settings with respect to the perceived role of stress in their depression.     

Adherence by medical-surgical inpatients to recommendations for outpatient psychiatric treatment

A records review of medical-surgical inpatients at a university hospital reveals that only 20% of patients seen in psychiatric consultation followed recommendations to seek psychiatric outpatient treatment. The study is unique in that immediate appointments with the consulting psychiatrists were offered prior to patients' discharge. The low rate is similar to the findings by others. Diagnosis of depression was associated with patients' keeping appointments, although social class may have been an indirect factor. Transformation of the medical-surgical inpatient to psychiatric outpatient remains a poorly understood process.     

Is hysteria still prevailing? A retrospective study of sociodemographic and clinical characteristics

A retrospective study was conducted in a psychiatric setup of S.P. Medical College, Bikaner (Raj.) to assess the social demographic and clinical characteristics of hysterical patients. The illness was more common in female patients. Most of the patients were young, married and illiterate. Nearly half of them had faced some stress prior to onset of their illness. Fits of unconsciousness and aphonia were the commonest presentation in female and male patients respectively. Duration of stay was 2-3 days and most of the patient responded well to different treatment modalities.     

Psychoendocrine antecedents of persistent first-episode major depression in adolescents: a community-based longitudinal enquiry

BACKGROUND: This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression. METHOD: Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression. RESULTS: Compared to the never depressed (N = 30) and remitted adolescents (N = 19), persistently depressed cases (N = 11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence. CONCLUSIONS: In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.