Does persisting fear sustain catatonia?

OBJECTIVE: To examine the psychological substrate of catatonia. METHOD: Reviewing the historical descriptions and explanations of catatonic behaviours by clinicians from its delineation in the 19th century to the present. RESULTS: Patients with catatonia are often haunted by fears and terrors; this has not been widely appreciated, and certainly was lost from view in the days when catatonia was considered a subtype of schizophrenia. The report contributes to resolving a major question in catatonia: is the mind in stupor inactive, as the blank state that we picture in anesthetized patients, or is the mind active, so preoccupied as to exclude all other influences. THE MAIN FINDING: Persistent fear occupies the mind of catatonic patients. CONCLUSION: The signs of catatonia are adaptations to persistent fear, akin to tonic immobilization. The relief afforded by sedation supports this interpretation.

Childhood catatonia, autism and psychosis past and present: is there an 'iron triangle'?

OBJECTIVE: To explore the possibility that autism, catatonia and psychoses in children are different manifestations of a single underlying form of brain pathology - a kind of 'Iron Triangle' of symptomatology - rather than three separate illnesses. METHOD: Systematic evaluation of historical case literature on autism to determine if catatonic and psychotic symptoms accompanied the diagnosis, as is found in some challenging present-day cases. RESULTS: It is clear from the historical literature that by the 1920s all three diagnoses in the Iron Triangle - catatonia, autism and childhood schizophrenia - were being routinely applied to children and adolescents. Furthermore, it is apparent that children diagnosed with one of these conditions often qualified for the other two as well. Although conventional thinking today regards these diagnoses as separate entities, the presence of catatonia in a variety of conditions is being increasingly recognized, and there is also growing evidence of connections between childhood-onset psychoses and autism. CONCLUSION: Recognition of a mixed form of catatonia, autism and psychosis has important implications for both diagnosis and treatment. None of the separate diagnoses provides an accurate picture in these complex cases, and when given single diagnoses such as 'schizophrenia', the standard treatment options may prove markedly ineffective.

The doctrine of the two depressions in historical perspective.

OBJECTIVE: To determine if the concept of two separate depressions - melancholia and non-melancholia - has existed in writings of the main previous thinkers about mood disorders. METHOD: Representative contributions to writing on mood disorders over the past hundred years have been systematically evaluated. RESULTS: The concept of two separate depressions does indeed emerge in the psychiatric literature from the very beginning of modern writing about the concept of 'melancholia'. For the principal nosologists of psychiatry, melancholic depression has always meant something quite different from non-melancholic depression. Exceptions to this include Aubrey Lewis and Karl Leonhard. Yet the balance of opinion among the chief theorists overwhelmingly favors the existence of two quite different illnesses. CONCLUSION: The concept of 'major depression' popularized in DSM-III in 1980 is a historical anomaly. It mixes together psychopathologic entities that previous generations of experienced clinicians and thoughtful nosologists had been at pains to keep separate. Recently, there has been a tendency to return to the concept of two depressions: melancholic and non-melancholic illness. 'Major depression' is coming into increasing disfavor. In the next edition of DSM (DSM-V), major depression should be abolished; melancholic mood disorder (MMD) and non-melancholic mood disorder (NMMD) should become two of the principle entities in the mood disorder section.

Somatization and chronic pain in historic perspective.

Practitioners today are confronted with an avalanche of difficult to treat patients with chronic pain for 2 reasons: (1) The culture increasingly encourages patients to conceive vague and nonspecific symptoms as evidence of real disease and to seek specialist help for them; and (2) the rising ascendancy of the media and the breakdown of the family encourage patients to acquire the fixed belief that they have a given illness, often a trendy nondisease such as repetition strain injury or chronic fatigue syndrome. In historic terms, many of these complaints, especially sensory ones featuring chronic pain and chronic fatigue, are relatively new. Patients tend to adopt them on the basis of what the culture considers to be legitimate illness, whereby different patterns exist for men and women.

Multiple chemical sensitivity: pseudodisease in historical perspective.

Multiple chemical sensitivity as a "disease" has emerged as a descendant of food allergy, which, in the 1920s and 1930s, was considered to be responsible for much human suffering and symptoms of disease. After the onmarch of the clinical ecological movement in the 1950s, interest has been focused on the environment, and concern about food allergies and chemical sensitivity has reached epidemic proportions. "Active hazardous waste sites" and "workers exposed to toxic chemicals" are at the top of the list of public worries. The public believes manufactured chemicals to be more dangerous than natural ones, although toxicologists regard the risks as equal. Originally, symptoms of patients were explained as "allergies", but since the 1960s the concept of "chemical sensitivities" has become a big-time diagnosis. The ideas of the clinical ecologists diffused rapidly into the community aided by public media. Today organizations like "Chemical Victims" and "National Foundation for the Chemically Hypersensitive" have thousands of members. Although the diagnosis of the disease is very vague, suffering patients believe that the clinical ecologists can offer them something that traditional medicine cannot: sympathy, recognition of pain and suffering, a physical explanation for their suffering, and active participation in medical care. Ecologic medicine thus soared in the patients' esteem, not just because of the content of the objective diagnoses that ecologic practitioners were able to supply, but because of the subjective nature of the doctor-patient relationship they were able to offer.

The borderland between neurology and history. Conversion reactions.

The epidemic of conversion reactions taking place at the end of the twentieth century is a result of long-term changes in the presentation of functional illness. These changes often are a response to deeper issues in the culture about what constitutes legitimate organic disease. This epidemic also is a response to short-term changes in the attributions to which patients ascribe their illnesses. Such attributions are heavily influenced by the media, and clinicians must be on guard against both long- and short-term changes as they affect the presentation and attribution of illness.

[The growing need for health care of the middle classes in Central Europe 1880-1930]. / Il crescente bisogno di assistenza sanitaria da parte delle classi medie dell'Europa centrale 1880-1930.

After 1850 medicine took on a new character, switching from a remedy for desperation to an everyday lifestyle habit. By examining the increase in recourse to medical care and the data on the availability of beds in private nursing homes, it is possible to assess the economic and social changes which took place as well as the conditions of family life and relations to disease. In this context, the role of women and their influence on the other members of the family is fundamental.

Chronic fatigue in historical perspective.

Chronic fatigue as a presenting complaint, in the absence of other evident organic illness, was seldom reported historically before the second half of the 19th century. Its first eruption was the so-called 'bed cases' or 'sofa cases' among middle-class females in the period from 1860 to about 1910. 'Neurasthenia' does not necessarily represent an early forerunner of chronic fatigue. Many patients receiving that diagnosis did not complain of fatigue. Others with functional fatigue did not receive the diagnosis 'neurasthenia'. Both medical-anecdotal and quantitative sources make it clear that by the time of the First World War, chronic fatigue was a common complaint in Europe and North America. Medical concepts of chronic fatigue since the 1930s have run along four separate lines: (1) 'postinfectious neuromyasthenia', going back to an atypical 'poliomyelitis' epidemic in 1934; (2) 'chronic Epstein-Barr virus' infection, an illness attribution that increased in frequency after the discovery in 1968 that this virus caused mononucleosis; (3) 'myalgic encephalomyelitis', dating from an epidemic at the Royal Free Hospital in London in 1955; and (4) 'fibrositis', or 'fibromyalgia', used as a rheumatological description since the turn of the century. Recently, these four separate paths have tended to converge into the diagnosis of 'chronic fatigue syndrome'.

Inpatient treatment of persistent somatization.

Patients with disabling, persistent somatization pose significant challenges in clinical management. This study describes 92 patients treated on an inpatient psychosomatic medicine unit for persistent somatization. The most important factor in defining clinically significant subgroups of these patients was mood. Compared with depressed somatizing patients, nondepressed somatizing patients had chronic illnesses of early onset, had symptoms that were not correlated with current life stressors, and were generally unresponsive to treatment. There were few clinical predictors of treatment outcome apart from the duration of symptoms, the presence of mood disturbance, and a history of stable interpersonal relationships.

Changes in Family Life and Challenges in Primary Care: The advent of the postmodern family.

Fragmentation of the postmodern family affects several aspects of primary care. In prevention, the physician-patient relationship is most important in forestalling abuse. In morbidity and diagnosis, single or socially isolated patients are more vulnerable to diseases, such as total allergy syndrome. In acute care, fragmentation increases the number of elderly patients in hospital. And in rehabilitation, the two-career family is no longer able to supplement hospital nursing care as it once did.