Reliability of a procedure for measuring and classifying "present psychiatric state"

Reliability of psychiatric assessment in older patients

A number of the causes of psychiatric diagnostic disagreement are discussed in this paper. The use of the Geriatric Mental Status interview to achieve diagnostic reliability is examined in three studies in which U.S.--U.K. Cross-National Project psychiatrists rated and diagnosed thirty-two British and twenty-one American patients. There were no systematic differences between U.S. and U.K. team members in their diagnoses; and agreement on six principal diagnostic categories was achieved in about three-quarters of the cases. The reliability fo the ratings of psychopathology that formed the basis for the diagnoses was satisfactory and is reported in detail.

A factor-analytical study of depression across cultures (African and European)

In a factor-analytical study of depression across two cultures, African and European, certain similarities and important differences were found. Depression in African cultures presented principally as depressed mood, somatic symptoms and motor retardation. In European cultures depression presented with depressed mood, guilt, suicidal ideas, motor retardation or anxiety. Both groups lost interest in work and the environment. Guilt and suicidal ideas and acts are uncommon in African sample, and appear to be culturally determined.

Use of a standardized psychiatric interview in mentally handicapped patients

This study attempted to assess the applicability of the Clinical Interview Schedule (Goldberg et al., 1970) to mentally handicapped patients in a hospital. Twenty-seven patients were rated simultaneously by three raters. Of the 31 items assessed for reliability, 11 were completely satisfactory, 8 were satisfactory, 6 unsatisfactory and 6 'not proven'. Ratings made by all raters for overall severity of psychiatric illness correlated significantly with similar ratings made by the consultants responsible for the patients.

Psychiatric symptom profiles of patients with epilepsy: a controlled investigation

A comparison was made of the mental state of patients with chronic epilepsy and matched controls with locomotor disorders, using a reliable psychiatric interview technique. The symptom profiles of the two groups were similar. The profiles of temporal lobe and other epileptics were also similar. Epileptic patients with a high current psychiatric morbidity were characterized by a raised incidence of previous neurotic illness and raised neuroticism scores on the Eysenck Personality Inventory.

EEG features of depressive and schizophrenic states

A 25-year-old female patient with a psychotic illness lasting three months in which schizophrenia and depressive episodes occurred was studied by serial EEGs. These were coded, masked and rated in a set way without knowledge of the clinical state. It was found that the schizophrenic state was characterized by a decrease in the amount and poor organization of alpha activity, as well as the occurrence of paroxysmal phenomena in particular a typical spike and wave. In the depressive episode, alpha activity was prominentand only scanty paroxysmal features were seen. Using these criteria a series of EEGsfrom psychiatric patients were assessed 'blind' with a view to separating them into either a schizophrenic or a depressive category. This proved possible in 17 cases (9 depressive and 8 schizophrenic). In only two was the categorization completely misjudged. These results suggest that further detailed study of the EEG, possibly with computer analysis, combined with assessment of the behavioural state might not only yield useful diagnostic information but also lead to a better understanding of the underlying neurophysiological basis of certain mental disorders.

Concepts and methods in student mental health

Considering their potential contribution to the community, the growth of clinical services in relation to the specialized mental health problems of students in higher education has been haphazard. Although most universities have developed or are on the way to developing comprehensive health services on the lines recommended in the report of the Royal College of Physicians (1966), services in the non-university sector are often less than adequate. This report accepted as established that about 5 per cent of students have psychological disorders which cause serious distress, and a further 10 to 20 per cent have less severe though handicapping disorders. It was accepted that special provision would need to be made for these mental health problems, as part of the range of preventive and treatment activities relevant to a College community.

High first admission rates for schizophrenia in the west of Ireland

Standardized clinical instruments were used to examine a consecutive series of 89 mental hospital admissions in the west of Ireland and 174 admissions representative of mental hospital admissions in London. The diagnoses given to these patients by the U.S./U.K. Project psychiatrists were compared with diagnoses given the same patients by the hospital psychiatrists in the two countries. Similar levels of agreement were obtained between hospital and Project psychiatrists in the two countries and, where the alcoholic patients were removed, the proportion diagnosed as schizophrenic by the Project in the two samples was identical.

Relationship between mood and digit-symbol performance in hospitalized patients with functional psychiatric disorders

This paper reports the relationship between mood, as measured by the Visual Analogue Mood Scale, and digit-symbol performance within individual hospitalized patients in a consecutive series of admissions with functional psychiatric disorders. It confirms the earlier finding of Folstein and Luria that a significant mood-digit-symbol relationship distinguishes clear cases of affective psychoses from clear non-affective disorders. Furthermore, it shows that, among patients who do not present with classical affective syndromes, those who manifest a significant mood-digit-symbol relationship tend to receive specific treatments for mood disturbances, have a positive family history of depression or mania, and improve significantly at discharge.

A re-analysis of the reliability of psychiatric diagnosis

Classification systems such as diagnosis have two primary properties, reliability and validity. Reliability refers to the consistency with which subjects are classified; validity, to the utility of the system for its various purposes. In the case of psychiatric diagnosis, the purposes of the classification system are communication about clinical features, aetiology, course of illness and treatment. A necessary constraint on the validity of a system is its reliability. There is no guarantee that a reliable system is valid, but assuredly an unreliable system must be invalid.

Structured interview for the assessment of work-related attitudes in psychiatric patients: preliminary findings

A structured interview was developed to assess the drive, realism, self-confidence, and self-rated disablement of psychiatric patients in relation to work. The clinical and research value of the interview was demonstrated by (1) studies of rater consistency, temporal stability, and parallel form reliability, and (2) by an investigation of its predictive validity.

A standardized assessment of the work behaviour of psychiatric patients

This paper describes the development of a standardized report intended for the assessment of the work behaviour of psychiatric patients in hospital workshops and clerical units. The report form was developed in the Rehabilitation Unit of the Maudsley Hospital, and primarily within the workshops and clerical section which are integral parts of the coordinated unit.

Codification and automation of psychiatric data: the CAPRICE system

In the United States of America, many centres are now running automated data programmes in the psychiatric field (Kline and Laska, 1968; Ulett and Sletten, 1971). In Britain, such developments have been much more restricted; prominent examples however are the North-East Scotland psychiatric register, and the Maudsley Hospital—Institute of Psychiatry check-list, together with the Camberwell register. As a clinical itemization, the ‘Present Psychiatric State’ (Wing et al., 1967) presents a comprehensive listing of over 400 symptoms, the evaluation being confined to the previous four weeks of the patient's experience. This is a valuable research tool, but for routine clinical history requirements it would be both too detailed and, by definition, too limited in scope.

Culture and the differentiation of emotional states

The experience of another person is never directly available to us, just as our own experiences cannot be directly experienced by other people. ‘We're all of us sentenced to solitary confinement inside our own skins' (Tennessee Williams). We can use empathy to get closer to another person's experience; in other words we imagine ourselves in the same situation as he is in and credit him with the feelings we would then experience. However, it is invariably our own experience that we use as the yardstick. We judge another person's experience from his behaviour, of which speech is one of the most informative parts. If another person says, ‘I see a man’, and there is indeed a man in our shared visual field, then both of us assume we are sharing a common perceptual experience. When there is no external referent, as in the statement ‘I feel sad’, the assumption of a common experience rests on more tenuous grounds. We can sometimes look to an external situation, like the loss of a close relative, to confirm that we understand the statement in the same way. But on many occasions there is no readily understandable link between a person's mood and the situation in which he finds himself. In judging a person's mood we also depend a great deal on non-verbal accompaniments of emotional states, but these are known to vary from culture to culture and from individual to individual. The movements used to express emotion, particularly those of the face, are so complex that very few attempts have been made to describe and categorize them accurately. There is a paucity of studies of this kind between Charles Darwin's pioneering work of 1872, which attempted to show the similarity of emotional expression throughout the races of mankind, and the recent work of Ekman and Friesen (1968) and Grant (1970). The few systematic studies in the intervening century do not support an invariable pattern of expression accompanying specific emotions. However, Ekman et al. (1969) found that subjects from literate cultures accurately identified emotions from photographs of the face, although subjects from pre-literate cultures showed much less agreement.

Schizophreniform psychosis among epileptics in a mental hospital

Several years have passed since the last study of the psychiatric abnormalities shown by epileptic patients in an English mental hospital (2), during which time detailed information has become available about the development of schizophreniform states in some chronic epileptics (3). This study was undertaken to examine the mental state of patients with epilepsy resident in Bexley Hospital, using a semi-structured psychiatric interview technique (6). The criteria used for the definition of epilepsy were those of Gunn and Fenton (1)—a history of at least three epileptic attacks in a two-year-period, and continuation of anti-convulsant therapy if the period did not immediately precede the time of examination.

The relevance of the neurophysiological concepts of excitation and inhibition to clinical psychiatry

The discovery of the excitatory function of the brainstem reticular formation helped in the formulation of a number of psychological theories relating to arousal. The demonstration of sensory inhibition, and the discovery of inhibitory centres in the cortex, hippocampus and mid-pons provided a physiological explanation for the phenomenon of habitutation. The measurement of indices of arousal and habituation, together with careful clinical assessment, proved useful in a number of diagnostic studies.

In normal subjects arousal was subjectively perceived as wakefulness and was associated with predictable changes in physiological measures. The excitation-inhibition balance, measured by the amplitude of the orienteering reflex, its rate of habituation, and habituation point, was correlated with the Neuroticism Score on the Eysenck Personality Inventory.

Thought disorder schizophrenics failed in habituate, and paranoid schizophrenics had difficulty dishabituating, indicating abnormal inhibitory function. Some neurotic groups with symptoms of chronic anxiety, had an abnormally high state of arousal.

Impaired habituation in cases of Korsakoff's psychosis implicates the hippocampus in the mediation of inhibition. The catecholamines have an important role in regulating excitation, as shown by the increase in arousal associated with L-Dopa administration, and the decreased arousal shown after alpha methyl dopa.

Role of fluphenazine decanoate in lessening the burden of chronic schizophrenics on the community

This paper reports the social results of a double-blind placebo controlled trial of fluphenazine decanoate. Among patients on placebo there was a deterioration in family relationships, which was due to an increase in aggression, noisiness, talking about delusions, and socially embarrassing behaviour after withdrawal of active drug.

Measures of depressive mood at monthly intervals

Various inevitably indirect attempts to quantify mood states have recently been reviewed by Aitken and Zealley (1970). In the present study, the results of administering two depression rating scales to the same group of patients were compared and their usefulness appraised.

Phenelzine in phobic anxiety: a controlled trial

A double-blind trial of phenelzine versus placebo in psychiatric outpatients with long-standing phobic anxiety is described. Forty patients with agoraphobia or social phobias entered the trial and 32 of these completed treatment with either phenelzine or placebo (with appropriate dietary restrictions) in flexible dosage for two months. Fourteen pairs of patients were prospectively matched, and analysis of the score differences between these pairs showed a significant improvement for patients on phenelzine compared with placebo on overall assessment (P<0·01) and secondary phobias (P<0·05). These differences were not shown at assessment after one month's treatment, but became marked after two months. The improvement on phenelzine, which was maintained at follow-up, was not related to initial depressive symptoms in the patients. It is suggested that phenelzine is an effective agent in the treatment of phobic anxiety but that treatment needs to be continued for at least two months before full benefit is achieved.

Life-events and psychiatric disorders. 1. Some methodological issues

The paper focuses on recent criticisms of the study of the role of life-events in the onset of psychiatric conditions and suggests that measurement error and bias can be reasonably well controlled by various methodological procedures. Failure to comply with these may be expected, however, to increase rather than decrease the chances of establishing a ‘positive’ resuit. Three further factors to do with the design of studies and the analysis of data are discussed which are likely to mask real differences between patient and comparison group, and which therefore might explain the ‘negative’ results reported in the literature. They concern: (1) the choice of an appropriate comparison group; (2) specification of the length of the period between event and onset; and (3) specification of the event in terms of some measure of severity. Results from two London studies of schizophrenic and depressive patients are presented to illustrate the argument. The studies suggest that life-events do play an important causal role in bringing about both disorders.

Changes in rating behaviour during the learning of a standardized psychiatric interview

The rating behaviour of eight psychiatrists was studied while they learned to use a standardized psychiatric clinical interview schedule. Their progress was followed during live interviews, and also by their ratings of videotape interviews. Significant and consistent changes towards the standards of the teachers were demonstrated, as was a universal tendency to pass through a phase of rating at a higher level of abnormality than the standards they were trying to approach.

Influence of family life on the course of schizophrenic disorders: a replication

In spite of the new methods of treatment and care introduced during the past fifteen years, schizophrenic patients are still liable to relapse with a recurrence of florid symptoms such as delusions, hallucinations and disturbed behaviour, and great suffering can be caused to all concerned (Brown et al., 1966). It has been shown that the onset of florid symptoms is often preceded during the previous three weeks by a significant change in the patient's social environment (Brown and Birley, 1968; Birley and Brown, 1970). Other studies have focused on the influence of more persistent environmental factors, such as the emotion expressed towards the patients by relatives with whom they were living. In an exploratory survey of discharged long-stay men it was found that close emotional ties with parents or wives indicated a poor prognosis (Brown, Carstairs and Topping, 1958; Brown, 1959). In a further study, patients were seen in hospital just before discharge, and their relatives were interviewed at home at the same time, and both were seen together at a joint interview shortly after discharge. It was found that those patients who returned home to live with relatives who were highly emotionally involved with them (as judged by ratings of the relatives' behaviour) were more likely to suffer a relapse of florid symptoms, even when the severity of psychiatric disturbance at the time of discharge was taken into account (Brown et al., 1962). Ratings of the patient's own expressed emotion showed much less involvement, and were much less highly associated with subsequent relapse. There was also a suggestion that short-term and long-term influences might have a cumulative effect; for example, that a raised level of tension in the home made relapse more likely in the event of a critical change in the patient's social environment (Brown and Birley, 1968). These facts, together with the contrasting but just as handicapping reaction of schizophrenic patients to an under-stimulating social milieu, were brought together in a more general theory of environmental influences on the course of schizophrenia (Wing and Brown, 1970). This also took account of the high physiological arousal which had been found in the most withdrawn schizophrenic patients (Venables, 1968; Venables and Wing, 1962). It was argued that in a socially intrusive environment acting upon a patient whose thought disorder was in any case liable to become manifest whenever circumstances became too complicated, a patient would tend to attempt to protect himself by social withdrawal; but this process might easily go too far, both in hospital and outside it, leading to complete social isolation and inability to care for himself. The optimum social environment, for those who remained handicapped, was seen as a structured and neutrally stimulating one with little necessity for complex decision making.

Studies in the classification of affective disorders. The relationship between anxiety states and depressive illnesses. I

Disorders in which anxiety or depression is the predominant feature constitute a large part of contemporary psychiatric practice. They are also being increasingly recognized as the underlying causes of many conditions in general medicine and family practice for which, even after prolonged investigation, no physical basis can be discovered.

Dependence of schizophrenic patients on elderly relatives

As part of a survey of the need for rehabilitation services in Camberwell, a representative group of 56 unemployed psychiatric patients were selected from the Camberwell Register during 1968; most of these were chronic schizophrenics, and 29, or just over half of them, were living with their parents or siblings. This paper describes a special analysis made by a medical sociologist into the problems of these 29 patients as perceived by their relatives. Assessment of the patient's handicaps and the burden felt by the family showed a dependence on parents of pensionable age which is an obstacle to rehabilitation. Patients were content, but relatives were dissatisfied and experienced considerable financial burden and symptoms of reactive anxiety and depression. The need for special services is emphasized to help the patient towards a more independent existence when the relative dies.

Medical Research Council Social Psychiatry Unit

The Medical Research Council Social Psychiatry Unit was set up at the Institute of Psychiatry in 1948 by Professor Sir Aubrey Lewis, who remained its honorary director until March 1965. The origins of the unit were described by Dr. Neil O'Connor in an introduction toStudies in Psychiatry(Shepherd and Davies, 1968). This book in honour of Professor Lewis contains six chapters by former unit members summarizing the scientific programme up to that date. A new unit, with the same name, was then set up at the Institute of Psychiatry under the directorship of Professor J. K. Wing, with the aim of investigating social and clinical factors which influence the development of chronic disablement in psychiatric patients and of devising and evaluating techniques of treatment and prevention.

Some contributions to the measurement of psychopathology

This paper presents some of the more important results of a factor analysis of the mental state ratings made as part of the United States–United Kingdom Diagnostic Project's cross-national study. The project was organized in order to help account for the large differences between the two countries in the admission rates for schizophrenia and for the affective disorders (see Kramer, 1969, and Zubin, 1969). The major results of the study have been reported by Cooper, Kendell et al. (1969), Gurland et al. (1969), Cooper (1970), and Cooper, Kendell, Gurland et al. (1972).

Classification and the British Glossary of Mental Disorders: some experience of its use

A Glossary of Mental Disorderswas published in 1968, prepared by the Registrar-General's Advisory Committee on Medical Nomenclature and Statistics. The document used as a basis the Eighth Edition of the World Health Organization's International Classification of Diseases (I.C.D.), Section V, which deals with mental disorders and mental subnormality. For the first time in this country the meaning of the categories listed in the I.D.C. are described, and the new Glossary stands beside the Second Edition of the American Diagnostic and Statistical Manual (D.S.M. II) which was also published in 1968. The psychiatrists working on the United States-United Kingdom Diagnostic Project at the Institute of Psychiatry, Maudsley Hospital, London, and the Psychiatric Institute, New York, made diagnoses according to the new Glossary descriptions on 820 hospital in-patients drawn from both sides of the Atlantic and interviewed using a standardized interview. The comments contained in this article are based on their experience.

Trial of maintenance therapy in schizophrenia

A double-blind, placebo-controlled trial was carried out to determine the value of maintenance therapy with phenothiazines in a population of outpatients who had recently recovered from an acute episode of schizophrenia. The drug was shown to be significantly more effective than the placebo in preventing relapse. The relationship of the trial patients to the population from which they were selected was defined in terms of clinical, historical, and social data. Maintenance therapy seems of little value in patients with a good prognosis and in the severely ill, but it is of value in the indeterminate group between these two extremes.

Differences in usage of diagnostic labels amongst psychiatrists in the British isles

This paper examines the differences in diagnostic practice and rating behaviour between groups of psychiatrists trained in different centres in the British Isles, using their observations on three video-taped psychiatric interviews. The findings are also briefly compared with similar data obtained in the United States.

Screening for psychiatric disorder

The concept of screening, and in particular multiphasic screening, is being introduced into medical practice. The subject is controversial and doubts have been expressed as to ils present applicability. This article is concerned with whether screening is appropriate for psychiatric disorder and is subdivided into a review of screening in general, the distribution of psychiatric disorder, psychiatric screening instruments, an outline of a psychiatric screening survey, and, finally, the evaluation of psychiatric screening.

Parental abnormalities of verbal communication in the transmission of schizophrenia

A carefully controlled comparison of communication defects and deviances in parents of schizophrenics and neurotics was undertaken using the 41-category Rorschach manual of Singer and Wynne. Subjects were tested and scored blindly and scoring was shown to be reliable. Although a statistically significant difference was found between the two groups, the marked overlap of the distribution of scores found in this study is not compatible with theories advanced by other authors concerning communication abnormality in parents of schizophrenics. Evidence is presented which provides a more parsimonious explanation of the difference between groups and leads to a hypothesis which would explain the failure of this study to confirm the striking differences between groups reported by previous workers.

Crises and life changes preceding the onset or relapse of acute schizophrenia: clinical aspects

In a previous publication (Brown and Birley, 1968) we have presented some findings which suggest that life changes and crises frequently precipitate the acute onset, relapse or exacerbation of schizophrenic states. To summarize : consecutively admitted patients diagnosed as suffering from schizophrenia were seen at mental hospitals serving a known catchment area. The first fifty whose onsets occurred within three months of admission and could be accurately dated within a week were included. Both the patient and at least one other informant were interviewed about the occurrence of certain previously defined and datable events occurring to the patient or to close relatives. These included such events as moving house, starting or leaving a job, admission to hospital, birth, marriage or death during the twelve weeks prior to onset. These were classified, according to their apparent independence of the patient's control, as ‘independent’ or ‘possibly independent’. The former were those which could be regarded as outside his control, e.g. discovering a burglary or hearing of a brother's serious illness. ‘Possibly independent’ events were those which were considered to have been within the patient's control but which had not been brought about by any unusual behaviour on the patient's part. They were chiefly changes of job, or of opposite sex friends. (Loss of job would, under certain circumstances, be rated as ‘independent’, e.g. when a whole firm closed down).