Long-term follow-up of patients with a diagnosis of paranoid state and hospitalized, 1913 to 1940.

From a sample of 239 patients diagnosed paranoid state and hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied a group of 60 patients without previous hospitalizations, consisting of 57 patients with follow-ups of 5 or more years, and 3 patients who killed themselves (the ultimate follow-up) less than 1 year after discharge. These 60 patients had been retrospectively diagnosed with delusional disorders by DSM-IV criteria. On follow-up, 27% were rated recovered, whereas 52% were rated unimproved. Long-term follow-up was correlated with discharge status. Poor follow-up was significantly correlated with seclusive personality, poor premorbid history, onset 6 months or more before admission, gradual onset, lack of insight, single marital status, and lack of precipitating events. A prognostic scale constructed from the first four of these variables was predictive of long-term outcome. More recent, better treatment results have been contrasted with these findings from an earlier non-drug-treatment era.

Interactions between gastric volume and duodenal nutrients in the control of liquid gastric emptying.

We examined the relationships between gastric volume and duodenal glucose load in the regulation of gastric emptying in adult male rhesus monkeys. Intragastric glucose loads (0.125 g/ml) of volumes ranging from 150 to 375 ml empty from the stomach at the same rate from 20 to 120 min. However, to achieve these equivalent emptying rates, progressively larger volumes were emptied in the initial 20 min with increasing gastric volume. Duodenal glucose infusions dose dependently inhibited the 10-min emptying of various volumes of intragastric saline. Although increasing gastric volume resulted in increased emptying, duodenal glucose right-shifted the relationship between initial gastric volume and volume emptied. These data demonstrate that liquid nutrient gastric emptying represents an interaction between gastric volume and nutrient-induced duodenal feedback. For controlled duodenal caloric delivery rates to be established, sufficient nutrient emptying must occur to increase the magnitude of duodenal feedback to withhold a given gastric volume.

Suicide in patients hospitalized for schizophrenia: 1913-1940.

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Long-term follow-up of patients hospitalized for schizophrenia, 1913 to 1940.

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied 484 patients with follow-ups of 5 or more years. Of the sample of 1357 patients, 28 (10%) committed suicide. None of the suicides were included in the sample of 484, which also eliminated all patients with any previous psychiatric admissions or episodes of mental illness, even without hospitalization. On follow-up, only 13% of the 484 were rated recovered, whereas 58% were rated unimproved. Long-term global follow-up was highly correlated with discharge status. Subgroups retrospectively diagnosed by DSM-IV criteria were significantly related to long-term follow-up in the sample of 484 patients, there being a continuum of poor outcome ranging from the diagnoses schizophrenia through schizophreniform to schizoaffective. Poor follow-up was significantly correlated with poor premorbid history, gradual onset, lack of depressive symptoms and heredity, seclusive personality, lack of precipitating events, lack of confusion, single status, onset before age 21, delusions of control, onset 6 months or more before admission, and emotional blunting. These variables were used to construct a validated prognostic scale. More recent treatment results have been contrasted with these findings from an earlier non-drug treatment era.

Trial of d-alpha-tocopherol in Huntington's disease.

OBJECTIVE: Evidence suggests that the neuropathology of Huntington's disease, a neuropsychiatric disorder due to a mutation on chromosome 4, results from excessive activation of glutamate-gated ion channels, which kills neurons by oxidative stress. Therefore, the authors hypothesized that alpha-tocopherol, which reduces oxyradical damage to cell membranes, might slow the course of Huntington's disease. METHOD: A prospective, double-blind; placebo-controlled study of high-dose d-alpha-tocopherol treatment was carried out with a cohort of 73 patients with Huntington's disease who were randomly assigned to either d-alpha-tocopherol or placebo. Patients were monitored for changes in neurologic and neuropsychologic symptoms. RESULTS: Treatment with d-alpha-tocopherol had no effect on neurologic and neuropsychiatric symptoms in the treatment group overall. However, post hoc analysis revealed a significant selective therapeutic effect on neurologic symptoms for patients early in the course of the disorder. CONCLUSIONS: Antioxidant therapy may slow the rate of motor decline early in the course of Huntington's disease.

Witches, multiple personalities, and other psychiatric artifacts.

Contemporary psychiatric misdirections derived primarily from standard medical errors of oversimplification, misplaced emphasis, and invention are reviewed. These particular errors, however, were in part prompted and sustained by the sociocultural fads and fashions of the day. The results have been disastrous for everyone--patients, families, the public and psychiatry itself.

A "letter of experience" about faculty promotion in medical schools.

The author discusses major issues of faculty promotion in medical schools by describing the decision-making processes of the Professorial Promotion Committee (PPC) at The Johns Hopkins School of Medicine, a committee he chaired for several years. Perhaps the major dilemma of medical school promotion committees is how to define standards that encompass the several different excellences and highly diverse talents of their faculty. This dilemma prompts a search for a natural set of "families" of rank, admission to which can be defined clearly and operationally. The author discusses methods of doing this (via various faculty track systems) and the pros and cons of each; analyzes the processes by which the PPC assesses evidence of nominees' achievements and attributes of scholarship; defines the three major career pathways at his school and explains the criteria used to evaluate nominees in each; outlines how the PPC evaluates individuals nominated for their excellence in teaching; and describes characteristics of nominees that may lead to their rejection. He makes clear that the decision-making processes of effective promotion committees are neither simple nor mechanistic and are sometimes difficult and problematic, and stresses the importance (in any promotional process, whether the setting be a medical school or a pencil factory) of institutional memory and of the committee's knowledge of leaders elsewhere whose generative contributions can be compared with those of nominees. The author concludes that the promotional process is not a simple "survival of the fittest" exercise but is a struggle to realize and foster an ideal of faculty quality to continue the high level of the institution's excellence and collegiality.

Age-dependent effects of CCK and devazepide in male and female rats.

Peripheral administration of the brain/gut peptide cholecystokinin (CCK) has been demonstrated to inhibit food intake in a variety of species, and administration of the specific type A CCK receptor antagonist devazepide increases food intake in a variety of experimental paradigms. The potency of CCK to inhibit intake depends upon a variety of factors, but CCK is generally less potent under conditions of elevated food intake. At different developmental stages, rats' intake requirements differ as growth rates change. To determine whether CCK plays a variable role in the control of intake in rats of different ages, we examined the feeding-inhibitory effect of various doses of CCK and the feeding-enhancing potential of various doses of devazepide on glucose consumption (0.5 kcal/ml) in male and female rats at 45-70 and 110-130 days of age. CCK was more potent in older male and female rats than in younger rats, and inhibited intake in a dose-related fashion. In younger rats, the efficacy of CCK was attenuated and the inhibition was not dose related. Administration of devazepide had no effect on intake in younger rats of either sex, but significantly increased glucose consumption in the older rats. These data suggest that during a period of rapid growth and high levels of food intake relative to body weight, adolescent rats are relatively insensitive to exogenous CCK and endogenous CCK does not appear to play a significant role in controlling their intake.

Personality disorder in later life: a community study.

BACKGROUND: This exploratory study compares the prevalence of personality disorders and traits in people over and under 55 years of age. The comorbidity between personality and other psychiatric disorders is also examined. METHOD: Psychiatrists examined 810 subjects in a two-stage community survey. The semi-structured Standardized Psychiatric Examination was used to diagnose all DSM-III personality disorders and other psychiatric disorders. RESULTS: The older subjects were significantly less likely than the younger subjects to have any personality disorder (6.6% v. 10.5%; relative odds = 0.42, 95% confidence interval = 0.25-0.70, P < 0.001). Antisocial and histrionic personality disorders were much less prevalent in the older than younger subjects (P < 0.05). The older subjects also had significantly fewer maladaptive personality traits (chi 2 = 88.9, d.f. = 3, P < 0.001). The patterns of comorbidity between personality disorders and other psychiatric disorders were different in the two age groups. CONCLUSIONS: It is important to evaluate personality in patients of all ages. While some older patients no longer meet criteria for personality disorder, maladaptive traits may become evident during times of stress.

Pharmacological dissociation of responses to CCK and gastric loads in rat mechanosensitive vagal afferents.

To identify the transduction mechanisms underlying gastric vagal afferent responses to gastric loads and cholecystokinin (CCK), we investigated the ability of specific CCK antagonists, acute pylorectomy, and cholinergic blockade to effect these vagal afferent responses. The CCK-B antagonist L-365,260 (10 pmol-1 nmol) failed to block the gastric vagal afferent response to gastric loads or 100 pmol CCK, while the CCK-A antagonist devazepide (100 pmol-100 nmol) competitively and dose dependently attenuated the response to CCK but not to gastric loads. Application of 100 nmol of the low-affinity CCK receptor antagonist CCK-JMV-180 also completely blocked the gastric vagal afferent response to 100 pmol CCK. Acute pylorectomy failed to block the gastric vagal afferent response to 100 pmol CCK or 2-ml gastric loads. Atropine sulfate administration (15 mg/rat) failed to block the gastric vagal afferent response to 100 pmol CCK or 2-ml gastric loads. These data suggest that 1) the vagal afferent response to CCK is mediated through CCK's interactions with vagal, rather than pyloric, CCK-A receptors, and 2) the vagal afferent responses to CCK and to gastric loads are mediated by dissociable, possibly independent, transduction mechanisms.

DSM-III personality disorders in the community.

OBJECTIVE: The aims of this study were to estimate the prevalence and investigate the comorbidity and potential consequences of DSM-III personality disorders in the community. METHOD: A total of 810 adults were examined in the second stage of the Eastern Baltimore Mental Health Survey in 1981, part of the National Institute of Mental Health Epidemiologic Catchment Area program. The subjects were directly examined by psychiatrists using a semi-structured method that allowed diagnosis of all DSM-III personality disorders as well as other DSM-III psychiatric disorders. RESULTS: The prevalence of personality disorders in these adults was 5.9% (9.3% when provisional cases were included). Men had higher rates than women, and subjects who were separated or divorced had the highest rates. There was little comorbidity among specific personality disorders. Subjects with personality disorders were significantly more likely to have a history of sexual dysfunctions, alcohol use disorders, and drug use disorders as well as suicidal thoughts and attempts. In addition, they reported significantly more life events in the past year. Among subjects with any axis I disorder, those with personality disorders were judged by the psychiatrists to be more in need of treatment; however, only 21% were receiving treatment. CONCLUSIONS: Personality disorders are relatively common in the community. They are associated with axis I disorders and life events. Only one-fifth of the individuals who qualify for diagnoses of personality disorders in the community are receiving treatment.

Obsessions and compulsions in the community.

A total of 810 adults were examined by psychiatrists in the second stage of the Eastern Baltimore Mental Health Survey. A semistructured examination, the Standard Psychiatric Examination, was used. The relationships between obsessions and compulsions and personal characteristics, childhood behaviors, family history, and other psychopathology were evaluated. The estimated prevalence of obsessions and compulsions in this population was 1.5%. Cases were significantly more likely to report having had childhood fears, learning disabilities and a family history of alcoholism and suicidal behavior. There were significant positive relationships between scores on compulsive, borderline and histrionic personality disorder scales and the probability of obsessions and compulsions. These exploratory analyses in an epidemiologic sample may identify factors of etiologic importance in this condition.

Screening for psychiatric morbidity in a medical outpatient clinic for HIV infection: the need for a psychiatric presence.

OBJECTIVE: To ascertain the prevalence and type of psychiatric morbidity present in HIV infected patients presenting for the first time to a specialty HIV medical clinic. Also, to develop a way of screening for psychiatric cases in this setting using established self-report questionnaires. METHOD: Fifty patients who presented consecutively for medical care at the Johns Hopkins Hospital General HIV Clinic participated in this study. These patients were first screened using the General Health Questionnaire and the Beck Depression Inventory and subsequently underwent a comprehensive neuropsychiatric evaluation. RESULTS: Fifty-four percent were found to suffer from a psychiatric disorder with an additional 22 percent from an active substance use disorder. These rates are one-and-one-half to two times higher than those reported from other medical clinics. The GHQ and BDI used together as screens could identify psychiatric "cases" with a sensitivity of 81 percent and a specificity of 61 percent, an efficacy similar to that found in other clinics. CONCLUSIONS: Given the high prevalence of psychiatric disorders in HIV infected patients presenting for medical care, screening, evaluating, and treating for these disorders is crucial and should be pursued systematically. This is best done through the presence of a psychiatric team within HIV medical clinics rather than in affiliation with such clinics.