Ruth Taylor

Attachment style in patients with unexplained physical complaints

BACKGROUND Patients who present with physical symptoms that lack an organic explanation are common, difficult to help and poorly understood. Their medical help-seeking is a form of care-eliciting behaviour and, as such, may be understandable in terms of attachment style. Adult attachment style influences functioning in relationships, and may affect help-seeking behaviour from professional carers such as the family doctor. METHOD A consecutive sample of 2,042 primary-care attenders completed questionnaires on: the reason for consultation, attribution of symptoms, psychiatric distress (GHQ), somatic distress (BSI), and self-reported adult attachment style (ASQ). Their doctors rated presentations into explained physical, unexplained physical, or psychological. RESULTS There is a powerful relationship between type of presentation and adult attachment style. Both abnormal attachment and level of psychiatric distress increased significantly from the explained physical group, through the unexplained physical group to the group who presented psychologically. Logistic regression models determined three explanatory variables that made significant independent contributions to presentation type: psychiatric distress, attachment style and symptom attribution. CONCLUSION Presentation to the doctor with unexplained physical symptoms is associated with both higher levels of psychiatric symptoms and abnormal attachment style when compared to presentations with organic physical symptoms. Patients who present overt psychological symptoms suffer more psychiatric distress and have more abnormal attachment than those presenting physical symptoms (either organically explained or unexplained). Models to explain these findings are discussed.

The association between needs and quality of life in an epidemiologically representative sample of people with psychosis

Slade M, Leese M, Taylor R, Thornicroft G. The association between needs and quality of life in an epidemiologically representative sample of people with psychosis.

Links between social networks and quality of life : an epidemiologically representative study of psychotic patients in South London

Abstract Quality of life has been found to be associated with social networks in patients with psychiatric disorders. We aimed to determine whether quality of life was related to social network size in a group of severely mentally ill subjects living in the community. In a population-based, prospective controlled study of two sector mental health teams in South London, a random sample of representative 1-year prevalent cases of non-organic psychosis was identified. Patients were interviewed at baseline, and associations between quality of life and social network size were analysed cross-sectionally. For average quality of life there was an increase up to a certain level of social network size (about 20 social contacts). For the quality of life subscore on social relations there appeared to be an optimal middle level of network size (10–12), with lower subscores for smaller and larger networks. Multivariate analysis confirmed the associations between quality of life and social network size. In analyses of network subgroups the importance of confiding contacts was underlined.

Delusional parasitosis presenting as folie à trois: successful treatment with risperidone

SIR, Delusional parasitosis (DP) is a condition that dermatologists find difficult to treat, predominantly as it is not a disease of the skin per se, but is a true psychotic delusion: a fixed false belief of infestation by organisms. It carries a high level of psychosocial morbidity and may even result in the patient’s suicide. Another individual may share the delusion—a phenomenon known as ‘folie à deux’. In very rare instances folie à trois may occur. Treatment in a joint dermatology/psychiatry environment has been advocated, and in the past, pimozide has been used successfully in the treatment of the condition. The side-effect profile of pimozide has necessitated the search for other, less dangerous treatments. Risperidone, an atypical antipsychotic that acts on serotonergic 5-HT2 and dopaminergic D2 receptors, has a much better safety profile than pimozide. We report its successful use in the treatment of a patient with DP and the subsequent resolution of symptoms of her husband and son who shared her delusions as folie à trois. A 35-year-old woman presented to her general practitioner (GP) on multiple occasions, originally to have her 6-year-old son treated for head lice. The boy was treated and referred to a paediatric dermatologist who found him to be clear of lice, and he was discharged. The woman continued to attend the GP and complained of itching. The GP treated her and the family for scabies and eczema on multiple occasions and eventually referred her to the dermatology clinic. After initially being treated for nodular prurigo, the patient was referred on to the joint liaison psychiatry/dermatology clinic at Barts and the Royal London Hospital. During this assessment she described a continuous sensation of itching and a conviction that there were small insects infesting her skin. She produced a specimen of nonspecific skin debris, which she insisted was examined microscopically. Her husband and son, who accompanied her, also complained of itching and shared the patient’s conviction that not only was she infested, but they were infested too. None of the family had any other health issues or was on any medication, and there was no family history of psychosis. Examination of the patient revealed widespread, symmetrical excoriated nodules with the appearance of nodular prurigo. There was no evidence of mite or louse infestation. Psychiatrically, she had mild signs of clinical depression and had reported the use of cocaine and amphetamines many years previously, but denied any current drug abuse—an aspect of the history which we could find no reason to doubt. The husband and son had no clinical signs. The patient was treated with risperidone 1Æ5 mg daily and within a month there had been a dramatic improvement in her symptoms and signs. She reported that she was no longer troubled by parasites and clinically, the excoriated nodules were improving. Remarkably, the husband and son also became asymptomatic during this period despite receiving no treatment. On subsequent visits, the patient was noncompliant with the medication, but gave no reason for her noncompliance. She reported a recurrence of the parasites but confirmed that her husband and son remained symptom free. When restarted on risperidone, there was another dramatic improvement, again within 4–6 weeks. It is not apparent why the patient insisted on stopping her medication, but it may be due to the fact that she ‘felt better’. To date, the patient is off medication and has not continued risperidone for any period greater than 3 months. She still complains of a sensation of itching from time to time but denies any further troubles with insect infestation. Thibierge initially described delusions of parasitosis in 1894, as ‘acarophobia’. The condition was later renamed ‘parasitophobia’ until Ekbom described a group of seven women with the condition in 1938 and it became known as Ekbom’s disease (not to be confused with Ekbom’s restless leg syndrome). In 1946, Wilson and Miller proposed the term ‘delusions of parasitosis’, which is a more appropriate name as the condition is a true delusion, a fixed, false belief, rather than a phobia, an abnormal fear response to a stimulus. DP occurs at a mean age of 59 years but the reported range is wide. In the over-50s, women are more commonly affected than men, with a ratio of 2 : 1, but this predilection is not seen in younger age groups. The prevalence of DP remains unknown, but in a survey by Reilly and Batchelor, 144 of 215 dermatologists who replied to a postal survey reported having seen at least one case in the last 5 years. DP has a high burden of psychosocial morbidity and sufferers may take extreme measures to rid themselves of parasites including self-harming behaviour and suicide. One man set fire to his house and later flooded it in an attempt to rid himself of the parasites. The clinical presentation is variable, ranging from a lack of cutaneous findings to multiple excoriations resembling nodular prurigo. There have been some case reports of patients

Relation between psychiatric disorder and abnormal illness behaviour in patients undergoing operations for cervical discectomy

OBJECTIVE To test the hypothesis that depression in patients being considered for cervical disc surgery is associated with severe organic pathology. Secondly, to test whether depression and abnormal illness attitudes recorded preoperatively would predict poorer recovery. METHODS Seventy four patients with pain and disability from cervical arthrosis were examined during investigations before potential cervical surgery. The prevalence of psychiatric disorder was assessed using the SCAN, and attitude to illness using the illness attitude scale. RESULTS There was a rate of depressive disorder in the sample of 37%. The depressed patients did not have more severe organic pathology, more neurological symptoms or signs, or more disablement. They reported more pain and displayed more abnormal illness behaviour. Fifty patients went on to cervical surgery. Outcome four to eight months postoperatively was not related to the presence of psychiatric disorder or illness attitude recorded preoperatively. CONCLUSION Depressive disorder is not secondary to severe pathology; the outcome of surgery is predominantly determined by physical factors.

Uses and Limits of Randomised Controlled Trials in Mental Health Service Research

This chapter begins by outlining the theoretical requirements which must be fulfilled in an adequate evaluation of any medical intervention. The Randomised Control Trial (RCT) fulfils these requirements. The power of this experimental design in overcoming methodological difficulties, and its consequent value in assessing alternative clinical interventions are summarized. There are, however, important differences between the paradigms in medicine, where the RCT has been most extensively used and developed, and its use in evaluating psychiatric care. These differences are due to the nature of that which is being evaluated, and they produce both conceptual and technical problems in using the RCT design.