Feelings of anxiety and associated variables in a very elderly population

Objective. Anxiety disorders have been reported to decrease with age, while anxiety feelings have been reported to be as common as in younger age groups. In order to further explore this relationship and variables associated with anxiety, a population of very elderly persons was examined. Methods. 966 persons, aged 78 years and over, underwent an examination by a physician including a structured psychiatric interview. Results. Anxiety feelings are strongly associated with psychiatric disturbances (anxiety disorders and depressive disorders). Moreover, the feelings were associated with dementia, a history of psychiatric disorders (most often depression), being female and being dissatisfied with social network. Few of those with a psychiatric disorder were adequately treated, in spite of the fact that most of them had seen a physician during the past month. Conclusions. After excluding an anxiety disorder, one of the most important things to consider in a very old person with anxiety is whether depression is present or not. Generally, there is a need for more education of physicians concerning the common mental disorders in the elderly in order to improve their management. © 1998 John Wiley & Sons, Ltd.     

AGE AND PSYCHOSIS IN DEGENERATIVE DEMENTIA

Among psychiatric inpatients with primary degenerative dementia, those with psychotic symptoms (N=20) were older than those without (N=20) (t=3.48; p<0.001). Persecutory delusions were the most frequent psychotic phenomena. Duration of dementia overlapped, but scores on the Global Deterioration Scale and the Cornell Scale for Depression in Dementia were lower in the psychotic group after correcting for age. The limited literature concerning demographic and clinical correlates of psychosis in dementia is reviewed; the age difference noted is consistent with two other reports. © 1997 by John Wiley & Sons, Ltd.     

Treatment of non-cognitive symptoms in dementia

Non-cognitive symptoms are common in dementia. Emotional disturbances such as depression, anxiety and irritability-aggressiveness dominate. Depression is seen in about one third of demented persons. There are findings indicating that degenerative changes in the brain can cause depressive changes. Depression in elderly and in dementia differs from that in younger ages but no diagnostic criteria have yet been evaluated. Anxiety is a common symptom in depression suggesting a depressive-anxiety disorder. Specific serotonin re-uptake inhibitors (SSRI) are efficient in the treatment of both depression and anxiety while tricyclic antidepressants have side effects including cognitive reduction. Irritability and aggressiveness respond to the treatment with SSRI drugs. Such drugs as benzodiazepines and antipsychotics, especially those with anticholinergic effects, can reduce cognitive function in elderly and demented persons but the knowledge, this side effect is insufficient. Antipsychotics without anticholinergic effects should be used for the treatment of psychotic symptoms in demented persons.     

Incidence of major depression in a very elderly population.

BACKGROUND: Depression is considered to be a major health problem in the elderly. Due to methodological problems, there are few studies on the incidence of depression in old age. The present study examines the prevalence of depression in a 3-year follow-up study of a non-depressed very elderly population, thus estimating the incidence. METHODS: 875 non-depressed persons with a mean age of 85 years were extensively examined by physicians twice with a 3-year interval. Depression diagnosis was made according to DSM-IV. All persons with a history of depression or a current depression were excluded in order to estimate the first incidence. RESULTS: 4.1% of the population was diagnosed as having a depression at the follow-up examination. The estimated first incidence was 1.4% per person year (0.8% in males and 1.5% in females). Characteristics at baseline correlated with the onset of depression were: having a dementia, insufficient social network and having more than two depressive symptoms. CONCLUSIONS: The incidence of depression was slightly lower in this very elderly population than for younger age groups, but followed the same female to male ratio.     

Factors predicting the presence of impaired clinical insight in liaison psychiatric patients assessed in the Emergency Room

Objectives: There are limited studies on the factors that can predict the presence of impaired clinical insight specifically in an Emergency Room (ER) psychiatric patient population. The objective of this study is to examine the factors that can predict the likelihood that a patient presenting to the ER will have impaired clinical insight. Methods: Nineteen independent demographic and clinical factors contained on data assessment tools for 337 patients assessed by the crisis team in the ER over 6 months were compiled and analysed using SPSS Version 20 with univariate analyses and logistic regression. Results: Patients who were unemployed or had a history of self-harm or had psychotic symptoms on mental state examination were about two, three and six times, respectively, more likely to have impaired clinical insight compared with those who were employed, had no history of self-harm or had no psychotic symptoms on mental state examination, controlling for other factors in the logistic regression model. Conclusion: Patients who are unemployed, have a history of self-harm or have psychotic symptoms following as psychiatric assessment in the ER may benefit from an insight-oriented psychotherapy.     

Psychotic symptoms in the elderly: a prospective study in a population sample

Background. Most of what is known about psychotic symptoms in older persons is based on hospital series of severe disorders. Method. In the course of a longitudinal community-based survey of older persons, the presence of psychotic symptoms was assessed on two occasions 3–4 years apart. Results. The point prevalence was 5·7%. Risk factors were cognitive impairment, living alone, being male, having had limited education, social isolation, poor health and depressive symptoms. Of the 65 persons who were symptomatic at the start, only six of those still alive had one or more psychotic symptoms after 3–4 years. The incidence was 6·0% over a period of 3·6 years. Conclusions. Risk factors for psychotic symptoms in later life lie in age-related cognitive impairment in interaction with a range of environmental and psychosocial variables. © 1998 John Wiley & Sons, Ltd.     

Diagnosing social anxiety disorder in the presence of obesity: implications for a proposed change in DSM-5

Background: The proposed draft of the DSM‐5 from the Anxiety Disorder Workgroup recommends allowing the diagnosis of social anxiety disorder (SAD) in individuals with medical conditions, if the anxiety is considered to be excessive. Although prior research has examined diagnosing SAD in individuals with stuttering, such research has not yet been conducted in obese individuals. Methods: This study compared demographic and clinical characteristics of obese individuals diagnosed with DSM‐IV SAD (n = 135), modified SAD (clinically significant social anxiety related to weight only; n = 40), and a group of obese individuals with no history of psychiatric disorders (n = 616). All participants were seeking psychiatric clearance for bariatric surgery and completed a comprehensive diagnostic interview. Results: The two social anxiety groups differed from the no disorder group on adolescent and past 5 years social functioning, and overall current functioning. Individuals with modified SAD had a later onset of their social anxiety, yet reported greater impairment in social life and distress about their social anxiety compared to the DSM‐IV SAD group. Conclusions: Although both of the social anxiety groups differed from the no disorder group on social and overall functioning, there were few differences between those with DSM‐IV SAD and modified SAD. This suggests that obese individuals with social anxiety related to weight only may experience comparable severity of anxiety to those with DSM‐IV SAD, and supports adoption of the DSM‐5 Workgroup's recommendation to change criterion H. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds.

OBJECTIVE: To examine the 1-year prevalence of psychotic symptoms and schizophrenia in nondemented 95-year-olds, and to examine the relation between psychotic symptoms and other psychiatric symptoms, sensory impairments, and cognitive functioning. PARTICIPANTS: The representative sample was 95-year-olds living in G?teborg, Sweden (N = 338). Individuals with dementia were excluded (N = 175), leaving 163 subjects for this study. DESIGN: This was a cross-sectional population study, including psychiatric and physical examinations, cognitive tests, and interviews with close informants. MEASUREMENTS: Diagnosis of schizophrenia, psychotic symptoms, paranoid ideation and dementia according to Diagnostic and Statistical Manual of Mental Disorders, Third Revision (DSM-III) were measured. Cognitive function was tested with the Mini-Mental State Exam. Other psychiatric symptoms were measured by the Comprehensive Psychopathological Rating Scale. RESULTS: The one-year prevalence of any psychotic symptom was 7.4% (95% confidence interval [CI] 3.8-12.5); including hallucinations 6.7% (95% CI 3.4-11.8) and delusions 0.6% (95% CI 0.0-3.4). Four (2.4%) individuals fulfilled DSM-III-R criteria for schizophrenia. Individuals with psychotic symptoms or paranoid ideation did not differ regarding cognitive functioning compared with individuals without these symptoms. Individuals with hallucinations and paranoid ideation had an increased frequency of previous paranoid personality traits compared with individuals without psychotic symptoms and paranoid ideation. No individuals with psychotic symptoms had a formal thought disorder, incoherence of speech, or flat affect. CONCLUSION: The authors found a high prevalence of psychotic symptoms, paranoid ideation, and schizophrenia in the very old. Most of the symptoms were elucidated by information from key informants, illustrating the importance of including relatives in the evaluation of elderly persons.     

Caregiver burden and psychotic patients' perception of social support in a Nigerian setting

  Background: In Nigeria, there are no national social welfare and community rehabilitation programmes for the mentally ill. Families have to bear the major burden of care. The present study aimed to assess the severity of indices of burden among relatives of 75 schizophrenics and 20 major affective disorder cases, to identify the factors associated with burden, to assess the relationship between caregiver burden and patients' perception of social support, and to compare these with equivalent data for cancer patients' relatives. Method: Caregivers were assessed, using a burden questionnaire and Goldberg's General Health Questionnaire (GHQ-12). Patients were assessed for perception of social support from the extended family. Results: Clinical severity and burden indices were similar for the psychiatric illness groups. However, relatives of patients with psychotic symptoms, unco-operative behaviour, marital instability and unemployment had significantly higher GHQ scores; while patients from such families perceived a wider social support network. Financial burden was greater than effect on family routines. Disruption of family routines, GHQ scores and (inversely) size of family network patient expected support from, predicted global rating of burden. Although clinical severity and disruption of family routines for cancer patients were higher; relatives of psychiatric patients had higher GHQ scores, more family disharmony and greater social stigma. Conclusions: Disturbed behaviour is a greater determinant of severity of burden than psychiatric diagnosis; hence adequacy of treatment is a first step in reducing caregiver burden. The tolerance shown by this group of relatives implies that they have strong potentials for playing useful roles in community care. Research and policy should consider measures to strengthen extended family network ties in developing countries. Accepted: 13 November 2000     

Determinants of psychiatric inpatient admission to general hospital psychiatric wards: an epidemiological study in a region of central Italy

Objective: To determine which factors contribute to the decision to admit individuals to psychiatric wards in general hospitals. Method: Data on 1,379 individuals undergoing psychiatric evaluation in eight emergency rooms in a region of central Italy were collected. A logistic regression analysis was used to evaluate the likelihood of psychiatric admission considering the independent effects of demographic, social, and clinical factors and of the history of psychiatric treatment. Results: The adjusted odds ratio for psychiatric admission significantly increased with the following variables: severity of symptoms; presence of paranoid states and schizophrenic psychoses, affective psychoses and acute psychotic conditions (with neurotic disorders used as reference); a history of outpatient treatment; the presence of a staff member of a community mental health facility upon presentation at the emergency room; and the availability of beds in the psychiatric ward. Conclusion: The independent effect played by the presence of a staff member of a community mental health facility is of particular interest, suggesting the existence of a collaborative relationship between inpatient and outpatient services. Accepted: 11 December 1998     

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

Background: A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts. Methods: Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes. Results: Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset. Conclusions: The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic

Background: Psychotic major depression (PMD) is a severe mental disorder characterized by high levels of illness severity, chronicity, impairment, and treatment resistance. However, most past research on PMD has been conducted in inpatient hospital samples, and relatively little is known about PMD patients presenting for treatment in the community specifically. Methods: In this study, we examined the prevalence and clinical characteristics of PMD in a large sample (n=2,500) of treatment‐seeking outpatients who were administered structured clinical interviews by trained diagnosticians. Results: Of the patients diagnosed with major depression, 5.3% had psychotic features. PMD patients were more likely to be members of a racial/ethnic minority and to have lower educational attainment compared to those with nonpsychotic major depression. In addition, PMD patients were found to have greater current depression severity, suicidal ideation, and social and work impairment. These patients also were more likely to have histories of suicide attempts and psychiatric hospitalizations, to report an earlier age of illness onset, and to meet criteria for chronic depression. In terms of psychiatric comorbidity, PMD patients had higher rates of certain anxiety disorders as well as more somatoform and cluster A personality disorders. Conclusions: Results indicated that PMD was present in a relatively small percentage of treatment‐seeking outpatients but was associated with disproportionately high levels of severity and impairment. Similarities and differences between the current findings and those from past research are discussed, including clinical implications for the identification and treatment of PMD in routine practice settings. Depression and Anxiety, 2009. © 2008 Wiley‐Liss, Inc.     

Arrest among psychotic inpatients: assessing the relationship to diagnosis, gender, number of admissions, and social class

The present study of psychotic patients investigates the relationship of specific psychotic diagnoses (i.e., psychoactive-substance-induced psychosis, schizophrenia, bipolar disorder, other DSM-III Axis I psychotic disorders), social class, gender, and number of admissions to the rate of arrest in the community. All admissions with psychotic symptoms to hospitals providing inpatient psychiatric services in the Baltimore area were surveyed during a 6-year period. Study participants were assessed using a modified version of the Diagnostic Interview Schedule. During the course of the interview, patients were asked whether they had ever been arrested as a juvenile or as an adult. After adjusting for age, gender, number of admissions, and social class, we found that patients admitted for psychoactive-substance-induced psychosis were more likely to report having been arrested than patients with other psychotic diagnoses. Patients with schizophrenia were not more likely to have an history of arrest than patients with other psychotic disorders. Number of admissions and social class were independent predictors of history of arrest. The relationship between psychotic diagnosis and history of arrest was modified by gender. Psychotic patients with substance-induced diagnosis who were male were more likely to report a prior arrest in the community than their female counterparts. Our results suggest that type of psychotic diagnosis and social class, in addition to gender and number of admissions, are important predictors of differences in arrest-rate histories among psychotic patients. Gender appears to be an effect modifier of the relationship between psychotic diagnosis and history of arrest. Accepted: 12 December 1997     

DEMENTIA PROGRAMME EFFECTIVENESS IN LONG-TERM CARE

Objective. To examine the effectiveness of dementia programmes and report factors related to programme outcomes. To describe the characteristics which placed hostel residents at risk for nursing home placement and to measure changes in dependencies and impairments over 2 years. Design. Longitudinal, quasi-experimental using in situ resident groups matched on resident and facility characteristics. Setting. Australian hostels for the elderly. Subjects. 587 residents (programme group N=184, comparison group N=162, frail groups N}=241). Measures. Mini-Mental State Examination, Geriatric Depression Scale and staff-rated indices of functioning, including activities of daily living, problem behaviours, psychiatric symptomology and health status, were used to monitor changes in resident characteristics. Time to nursing home placement was another outcome measure. Results. Residents in hostel dementia programmes remained significantly longer than those in the comparison group (2.5 months over 2 years) before exit to a nursing home. Quality of life for residents in dementia programmes was enhanced through higher levels of social contact with relatives and lower reported levels of depressive symptoms. Conclusions. Dementia programmes worked, but the reasons why were more difficult to establish. The programmes did not appear to modify the capacities of residents by slowing rates of decline. Dementia programmes provided specialist (non-personal care) staff focusing on the social and emotional needs of residents. These staff provided appropriate, targeted activities for residents with dementia, had a clearly defined role directed exclusively to these residents and felt directly responsible for them. Dementia programmes produced a system effect. They increased the capacity of hostels to care for residents with dementia for longer periods, before admission to a nursing home. © 1997 John Wiley & Sons, Ltd.     

Psychiatric illness in a cohort of adults with Prader-Willi syndrome

Previous studies have suggested an association between PWS and comorbid psychiatric illness. Data on prevalence rates of psychopathology is still scarce. This paper describes a large-scale, systematic study investigating the prevalence of psychiatric illness in a Dutch adult PWS cohort. One hundred and two individuals were screened for psychiatric illness. Case vignettes were written by the first author on 63 individuals with a positive screening on psychopathology according to the interviews, medical history, medication use and behavioural questionnaires. These case vignettes were rated by two psychiatrists specializing in intellectual disability (ID). Psychopathology was divided into four diagnostic categories: bipolar disorder with psychotic symptoms, psychotic illness, depressive illness with psychotic symptoms and depressive illness without psychotic symptoms. Nine out of 53 persons (17%) with a 15q11-13 deletion and 28 out of 44 (64%) persons with maternal uniparental disomy (mUPD) were diagnosed with a current or previous psychiatric illness. Depressive illness with psychotic symptoms was the cause of psychiatric problems in the majority of persons with PWS due to deletion (56%). In the case of mUPD, almost all individuals with histories of psychopathology suffered from psychotic symptoms (85%) with or without affective component. Psychiatric examination should be part of general management of adults with PWS, especially when caused by mUPD. More attention should be paid to the presence of precursor symptoms, indicating a developing psychiatric episode. Longitudinal studies are needed to gain more insight into the natural history of psychiatric illness in adults with PWS.     

Association between financial strain,social network and five-year recovery from first episode psychosis

Despite much effort to positively affect long-term outcome in psychosis and schizophrenia many patients are still facing a poor outcome with persistent psychotic symptoms and decline in social functioning. The aim of this study was to examine the relationship between financial strain and social network and five-year outcome of first episode psychosis (FEP). FEP patients were divided into recovered (n = 52) and non-recovered (n = 19). Each person was matched according to age and gender with four persons (n = 284) from a longitudinal population-based study. All persons had answered an extensive questionnaire including social network, quantitative and qualitative, financial strain and mental health. Linear regression analysis showed that both financial strain and social network were associated, and had a unique contribution, to outcome. The results indicate that FEP patients might benefit from interventions that reduce financial strain thus facilitating daily life and cultural and social activities.     

Demented and chronic depressed patients attending a day hospital: stress experienced by carers

Objective. The main hypothesis was that carers of elderly patients attending a day hospital with chronic depression experience considerable stress. A subsidiary hypothesis was that this stress is equivalent to that experienced by carers of dementia patients attending the same day hospital. Design. All attenders of the day hospital with a diagnosis of depression or dementia coresident with their principal carers. Setting. An urban psychogeriatric day hospital in the UK. Patients. A consultant diagnosis of dementia or depression with a history of present illness in excess of 12 months in patients over 65. The total sample was 57, 32 dementia and 25 depression (19 major depressive episode). Measures. Dementia patients: Mini-Mental State Examination (MMSE), Clifton Assessment Schedule (CAPE). Depressed patients: MMSE, Montgomery–Asberg Depression Rating Scale (MADRS) and Brief Psychiatric Rating Scale (BPRS). Carers: Semi-structured questionnaire, General Health Questionnaire (GHQ-30) and Relatives Stress Scale (RSS). Results. Dementia patients were older than depressed (75.66 vs 71.84). The two groups were of comparable severity. The dementia carers were significantly more stressed on the GHQ and RSS than depression carers but these carers also exceeded the threshold for psychiatric ‘caseness’. Important negative views about life upset and carer burden were expressed by both groups. Conclusions. The main hypothesis but not the subsidiary one is supported. More sophisticated study of the burden of caring for chronic depressive illness is required. © 1998 John Wiley & Sons, Ltd.     

Psychotic experience subtypes, poor mental health status and help-seeking behaviour in a community sample of young adults

Background: Different subtypes of psychotic experiences (PEs) have been identified in clinical and non‐clinical samples. Researchers have considered these PEs to either be variations of personality or expressions of vulnerability to psychotic disorder. This study aimed to determine which particular subtypes of PEs were more likely to be associated with poor mental health status and help‐seeking behaviour in a non‐clinical sample of young adults. Methods: The study was conducted on a community sample of 997 young adults. The prevalence of PEs and distress was measured using the Community Assessment of Psychic Experiences (CAPE), depressive and anxiety symptoms were measured using Beck Depression Inventory‐II and Beck Anxiety Inventory, and general functioning was measured using the General Health Questionnaire‐12. Factorial analysis of the CAPE positive dimension was conducted and correlations between factors and clinical variables were analysed. Results: Four PE subtypes were identified: perceptual abnormalities, persecutory ideas (PI), bizarre experiences, and magical thinking. At least one high frequency PI was endorsed by 60.8% (n = 606) of the sample and proved to be significantly associated both with poor mental health status and help‐seeking behaviour. Conclusion: PEs subtypes are differentially associated with various markers of poor mental health status. PI seem to have stronger psychopathological significance than other subtypes of PEs. Further longitudinal studies are required to extend these findings.     

Health anxiety and fear of fear in panic disorder and agoraphobia vs. social phobia: a prospective longitudinal study

Background: This study is aimed to evaluate the role of two vulnerability factors, health anxiety and fear of fear, in the prediction of the onset of panic disorder/agoraphobia (PDA) relative to a comparison anxiety disorder. Methods: Young women, aged between 18 and 24 years, were investigated at baseline and, 17 months later, using the Anxiety Disorders Interview Schedule‐Lifetime and measures of health anxiety and fear of bodily sensations (subscale disease phobia of the Whiteley Index, and total score of the Body Sensations Questionnaire). First, 22 women with current PDA were compared to 81 women with current social phobia and 1,283 controls. Second, 24 women with an incidence of PDA were compared to 60 women with an incidence of social phobia and 1,036 controls. Results: Multiple logistic regression analyses adjusted for history of physical diseases, somatic symptoms, and other psychological disorders revealed that (a) fear of bodily sensations was elevated for women with PDA vs. controls as well as women with social phobia, and (b) health anxiety (and history of physical diseases) was elevated in women who developed PDA vs. controls and vs. women who developed social phobia. Conclusions: These results suggest that health anxiety, as well as history of physical diseases, may be specific vulnerability factors for the onset of PDA relative to social phobia. Whereas fear of bodily sensations was not found to be a risk factor for the onset of panic disorder/agoraphobia, it was a specific marker of existing PDA relative to social phobia. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls

Background: Several studies have demonstrated that obsessive–compulsive disorder (OCD) is associated with interference in quality of life (QOL) and functional impairment. However, these studies did not compare individuals in remission to individuals who continue to have the disorder, predominantly used comparisons with norms and not with a matched normal sample, and did not always consider the impact of comorbidity. Methods: We administered multiple measures that assess QOL and functional impairment to 66 OCD patients who had previously consented for a clinical trial and to 36 age and sex matched individuals who denied any psychiatric history. Results: Results confirm that OCD was associated with significantly lower QOL and functional impairment compared to healthy controls (HCs) in areas of work, social life, and family life. Individuals with OCD and other comorbid psychiatric diagnoses showed the poorest QOL and functioning, with comorbid depression accounting for much of the variance. The levels of QOL and functioning in individuals in remission tended to lie in between HCs and individuals with current OCD: their QOL or functioning did not differ significantly from HCs nor did they consistently differ significantly from those who had current OCD. Conclusion: These results suggest that individuals who are in remission have improved levels of QOL and functioning, whereas individuals with OCD are significantly impaired, and individuals with OCD and comorbid disorders are the most impaired. Treatment strategies should be focused on achieving remission of all symptoms to have the greatest impact on functioning and QOL. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.