Merskey H

Psychiatry and chronic pain

Pain and chronic pain have been defined by the International Association for the Study of Pain. Psychological mechanisms are recognized in the production of pain, but their importance has probably been overstated. Selection factors have not been attended to sufficiently, and traditional methods which have been relied upon for the diagnosis of hysterical pain have been misleading. Much emotional change seen with pain is a consequence of the physical disorder. Types of illness, seen by psychiatrists working with patients in pain, are described, and brief comments offered on their management.

Clinical data from a psychiatric service to a group of native people.

Clinical data are reported from a psychiatric service to Native Canadian patients, mainly Cree Indians. Eighteen out of 41 had a clinical diagnosis of depression, three of mania and only one of schizophrenia. Thirty-seven percent used alcohol to excess but alcoholism was rarely the primary diagnosis. Reasons are given for the belief that schizophrenia has been over-diagnosed in Native populations in the past. Seventy-eight percent spoke Cree/Inuit as their primary language. The patients usually held their parents in high regard despite often reporting that they were alcoholic. In reply to tentative enquiries into feelings about their Native identity, only 5% of the patients indicated a preference for another identity, but this figure is only considered to give a minimum estimate of the possible dissatisfaction with being Native in Canada today.

An investigation of the possible inverse relationships between the occurrence of rheumatoid arthritis, osteoarthritis and schizophrenia.

One hundred and eleven inpatients with schizophrenia and 51 with other psychiatric conditions were compared for the frequency of rheumatoid arthritis, other connective tissue disorders and other physical illness. Evidence both of rheumatoid arthritis and osteoarthritis was significantly less in the schizophrenia group. Latex Agglutination Tests were positive to the same extent in both groups. One possible explanation of the findings is that they are due to the reduced frequency of trauma or stress to the joints in schizophrenic inpatients, many of whom lived in hospital, compared with the control group. Other explanations are also considered.

Some calculations on the prevalence of dementia in Canada

The epidemiology of dementia in Canada is not known. However, we report figures on the frequency of dementia in institutions in Ontario based upon the use of a multidimensional observation scale for the assessment of the elderly. These findings on institutionalized patients can be extrapolated to the whole elderly population, but the procedure is clearly too conservative by comparison with findings in other countries and in the light of the known occurrence of numbers of demented patients outside institutions. Ratios in different sutidies for the numbers of patients with dementia outside institutions and within institutions range from 1:1 to 6:1. Using a ratio of 2:1 and applying it to age specific population figures, a prevalence of dementia in Canada of 222,324 for those over 65 is obtained with a rate of 9.4% in that age group. When the figures projected in this way are compared with five epidemiological studies for the rate of dementia elsewhere, the Canadian figure which we have obtained ranks fourth out of six. This estimate provides potential figures on which to base the planning of services, provided that the inferential nature of the estimates is fully recognized.

On the recording of mental illness for civil commitment.

The survey of 102 consecutive certificates for involuntary admission and a review of the case material demonstrated that in 78 cases the form was completed adequately. In 13 cases full description of evidence of mental disorder was lacking on the certificate but after reviewing the cases it, would appear that clear evidence of mental disorder was probably present at the time of certification. In this survey, suicidal or homicidal risk alone was not considered evidence of mental disorder. In the final 11 cases the grounds for diagnosing mental disorder rested upon the presence of phenomena like anger, alcoholism, or mild mental retardation or the presence of a personality disorder, all of these being associated with risk to the patient or another person. Compelling evidence for the necessity of psychiatric commitment in these complex situations cannot be described briefly; thus it does not appear that an altered certification form would solve the problem.

Prediction of discharge from a psychogeriatric unit (development and evaluation of the LPRS Prognosis Index).

Data based on the 36-item London Psychogeriatric Rating Scale was statistically analysed in order to select a small number of questions which would discriminate well between those psychogeriatric inpatients who were likely to be discharged in the following six months and those who were not. A very brief Prognosis Index was developed utilizing the five best discriminating items of the LPRS. The content of these indicated that patients who could communicate coherently, made friends and did not threaten others were those most likely to leave hospital. The predictive accuracy of the index was assessed for the inpatient populations of a 136-bed psychogeriatric unit at three different points in time. The index was found to correctly predict whether or not patients would be discharged within six months in 78–85% of all cases. Correct prediction was generally seen to increase with time. Predictive accuracy reached as high as 96% (25/26) in the sample of acute ward patients examined after eighteen months. Since discharge was seen to be dependent on the availability of appropriate placements, the predictive accuracy of the Prognosis Index might be seen as surprisingly high. The simplicity and predictive accuracy of the items utilized and the fact that administration and scoring of the index can be done in less than five minutes without cooperation on the part of the patient suggest that the Prognosis Index is a useful measure. The results also emphasize the importance of personal relationships in determining discharge from hospital.

Hysteria: The History of an Idea

Hysteria has long been recognized as a condition involving multiple somatic symptoms and resulting from a state of the emotions. By the time of Charcot, it became possible to attribute a hysterical symptom to an idea. It appears that the first detailed statement to this effect was made by Russell Reynolds (1) and it was adopted by Charcot (2), particularly because of his experience that hypnosis could be used to suggest hysterical symptoms. These concepts provided the starting point for Freuds theories.

Symptom patterns of alcoholism in a northern Ontario population.

Alcoholism is noted to be a common problem in Canada and particularly in native populations. We report here a survey of the frequency of evidence of alcoholism over a period of four months in a relatively isolated Northern Ontario population in which more than 80% were either status Indians or of partly Indian origin. Using questionnaire methods, “definite” alcoholism was found to affect 27% of adults seen at a clinic and probable alcoholism affected another 20%. This gives a minimum prevalence of 14.6% of the local adult population over a four month period on the basis merely of examination of less than one third of the adults in the community. Blackouts, tremors, bad temper, chest pain, unsteadiness, loss of appetite, vomiting, sadness and stomach pain occurred significantly more often in the alcoholic patients. Stomach pain, loss of appetite and vomiting were less prominent with alcoholism in this population than in a Southern population. The findings indicate the importance in general practice of looking for alcoholism, the ease with which this may be undertaken with a few very simple short questions and the importance of some characteristic patterns, especially blackouts, shakiness and unsteadiness as one pattern and stomach pain and other gastro-intestinal symptoms as another pattern.

Clinical patterns in a behavior modification unit.

The principles and practice of a Behaviour Modification Unit in a psychiatric hospital are described. A simple but consistent program of rewards related to privileges is employed together with attention to individual counselling and family therapy. A consecutive series of 56 patients is reported. They had a high frequency of personality disorders, behaviour disorders and past psychiatric treatment irrespective of diagnosis. Improvement was measured in terms of success, three months after discharge, in staying out of hospital and maintaining an independent existence in the community. By this criterion 42 out of 56 patients (75%) were improved. Patients who improved had had less past treatment of various types and this relationship was highly significant. The justification for this type of program is briefly discussed.

Family background and physical health of adolescents admitted to an inpatient psychiatric unit, I: Principal caregivers.

A retrospective chart review of 100 consecutive adolescents discharged from a provincial psychiatric hospital adolescent unit was conducted. At the time of admission, eighty-four percent no longer lived with one or both of the biological parents. The children remained with the mother more often than with the father. However, boys who had lost their principal male caregiver more often acquired a new one, compared with girls. The latter tended to remain more in a single-mother home. Thirty jour patients were no longer in the care of either parent at admission. Seventy jour had a conduct disorder. Members of this group were more likely to have lost one or both parents. Recent loss of a parent seemed to be related to a combined diagnosis of depression and conduct disorder. Parental loss was not prominent among one class of the patients with conduct disorder — those with under-socialized aggressive disorders. The latter were often still in their intact biological family of origin, and in four instances they presented serious cases of aggressive actions in the absence of any history of parental deprivation.