Attitudes towards psychiatric hospitalisation: a comparison of involuntary and voluntary patients.

OBJECTIVE: To determine the attitudes towards hospitalisation of both voluntary and involuntary patients admitted to a state psychiatric hospital. METHOD: Interviews of 100 patients admitted consecutively between September 1983 and June 1984. RESULTS: Although patients who were involuntarily admitted initially reported unfavourable attitudes, subsequent to admission they had similar opinions regarding their hospitalisation to those of voluntary patients. This "consumer survey" lends some confidence to the view that compulsory detention and admission is not irrevocably perceived as punitive by patients. These results provide further data which counter the sometimes extreme advocates of the view that compulsory admission and treatment of patients with psychiatric illness is never acceptable.

A comparison of patients in private and public psychiatric facilities.

OBJECTIVE: To compare hospitalised patients in private and public facilities. METHOD: Retrospective medical record review of 100 patients admitted consecutively to both a private psychiatric hospital and a public facility in South Australia in January, 1985. RESULTS: There is a paucity of data about privately treated patients with psychiatric illness. Although several studies have suggested that patients treated in private are similar to those seen at public facilities, thus challenging some of the myths about private practice, a recent Australian study emphasised the differences between private and publicly treated hospitalised patients. The present comparison of hospitalised patients in private and public hospitals, whilst demonstrating some differences, was more marked by the similarities in clinical features. The relevance of the different results, the manner in which they may be interpreted, and the implications for administrative decisions which may affect patients with psychiatric illness are discussed.

The safe use of high dose neuroleptics in a psychiatric intensive care unit.

A review of the use of high dose neuroleptics in the management of acute psychoses in a psychiatric intensive care unit confirms the previously reported safety of such regimes. The risk of extreme unwanted effects, such as cardiac arrest and sudden death, was considerably less than the risk of suicide as an inpatient. Although high doses of neuroleptics appear to be relatively safe, there is no advantage, in terms of the length of admission required in the intensive care unit, in using a dose of neuroleptic above the equivalent of 60-80 mg of haloperidol in any one 24-hour period.

Compulsory admission of the mentally ill: adequacy of documentation.

The issues that are involved in the compulsory detention and treatment of persons with mental illness are complex. There has been an improvement in the adequacy of documentation of such persons in the first five years of operation of the new South Australian Mental Health Act, 1976-1977. However, an appreciable proportion of documents still do not appear to comply adequately with the statutory requirements. This may be related not only to shortcomings in the medical documentation, but also to ambiguities and possible overlapping in the criteria for compulsory detention and treatment.

Safety of the combination of lithium and neuroleptic drugs.

A retrospective study of 60 manic patients treated with neuroleptic medications alone and 69 manic patients treated with a combination of neuroleptic drugs and lithium revealed no difference between groups in side effects and complications of treatment. Similarly, when comparisons were made between patients treated with haloperidol only and those treated with haloperidol and lithium, there were no differences in side effects and complications. The results counter sporadic clinical reports suggesting a toxic interaction between lithium and neuroleptic drugs.

Mental health in marriage: the roles of need for affiliation, sensitivity to rejection, and other factors.

This study reports on the associations between a number of personality factors and spouse mental health, happiness, and communication (N = 78). Lower Affiliative Drive and higher Sensitivity to Rejection emerge in this sample as being associated in wives (but not husbands) with increased psychological morbidity. Wives had higher levels of both Need for Affiliation and Sensitivity to Rejection than husbands, which possibly may lead to higher internal conflict for them. Although causality cannot necessarily be assumed, these results are consistent with the hypothesis that wives' mental health is more "relationship related" than that of husbands.

Suicide in association with psychiatric hospitalisation.

A review of 46 subjects who suicided after having contact with a psychiatric hospital is presented. There were 33 men and 11 women, both with a mean age of 37 years. In comparison with a control group, those who suicided had a greater number of hospital admissions, a greater length of hospitalisation, were more often unemployed, had a history of more previous suicide attempts, more often received the diagnosis of schizophrenia or manic depressive illness (depressed phase), were more often overly depressed at their last contact, and were more often prescribed neuroleptic medications. Although these differences emerged, suicide is an infrequent event, and these factors lack specificity in prediction. The important association of psychiatric illness with subsequent suicide is noted.

The attribution of affect in pain clinic patients: a psychophysiological study of the conversion process.

In a study to examine the relationship between the conversion process and physiological correlates of emotional arousal, three key elements of conversion were assessed separately in patients experiencing chronic pain for which no adequate somatic cause could be demonstrated. Thirty-seven patients referred to a pain clinic were categorized as members of either high, intermediate, or low conversion groups on the basis of their scores on the Disease Conviction, Affective Disturbance and Denial scales of the Illness Behaviour Questionnaire (IBQ). All patients scored in the high range on Disease Conviction. High conversion patients acknowledge little dysphoric affect and denied life problems apart from physical illness. Intermediate conversion patients also denied life problems other than somatic, but acknowledged high levels of dysphoria. Low conversion patients reported dysphoria and acknowledged life problems which they did not attribute to physical illness. The prediction that the high conversion group would show lower levels of resting skin conductance than the low conversion group was confirmed. Patients in the intermediate conversion group resembled those in the high conversion group in that their resting skin conductance was significantly lower than that observed in members of the low conversion group. These findings are consistent with those of previous studies of conversion disorders. They point to the importance in these conditions of the interaction between dysphoria and the cause to which it is attributed by the patient.

Factorial structure of the aftermath of suicide instrument.

Initial factor-analytic studies of the Aftermath of Suicide Instrument suggested that there may be four broad areas of social reaction to suicide. In a replication study, this 25-item questionnaire was administered to a community sample of 54 persons aged between 21 and 77 years. Factor analysis of their responses identified five factors, but only one of these was similar to any of the original factors. This marked variation is probably due to differences in the population sampled, with the present group of respondents more heterogeneous. While the content of the Aftermath of Suicide Instrument remains valid, it appears that its factorial structure requires further clarification. This is consistent with the emotional and clinical complexities of the subject of suicide.

Relaxation training for chronic pain patients using EMG feedback: an analysis of process and outcome effects.

The purpose of the present study was to clarify the role of EMG-based relaxation training for a diverse group of chronic pain patients by examining in detail both process and outcome changes. Eighteen pain clinic patients were each given 10 sessions of relaxation training using frontalis feedback. The results of the study do not support the use of relaxation training as a standard procedure for chronic pain patients. Psychophysiological assessment carried out before and after training indicated some reduction in EMG levels, with less change in GSR and HR activity. No significant alteration occurred in mean pain and medication measures after training, although there was a trend for sedative/hypnotic usage to be smaller. Most important, individual differences in outcome were not consistently related to process variables monitored during training. This lack of association supports the view that physiological change is not necessary for clinical benefit after relaxation training.

Temporo-mandibular joint dysfunction: pain and illness behaviour.

This study investigated prospectively the illness behaviour of 100 patients with temporo-mandibular (TMJ) dysfunction and 100 asymptomatic patients. It has previously been shown that a simple illness behaviour questionnaire (IBQ) can discriminate between patients with intractable facial pain and minor odontogenic pain [28]. The purpose of this study was to determine whether it was possible to prospectively identify those patients who may be resistant to conservative therapy. The results showed that the TMJ dysfunction patients had significantly increased levels of disease conviction (P less than 0.001), anxiety or depression (P less than 0.005), and were less likely to deny the existence of problems in their life (P less than 0.05) compared to control patients. However, the TMJ population was much closer to the control population than to a pain clinic population. In the small percentage (13%) of patients who failed to respond to conservative therapy, over half showed abnormal illness behaviour. Seventy-five percent of all the TMJ patients could be excluded from further assessment of abnormal illness behaviour at little risk of incorrect classification. Thus the illness behaviour questionnaire can be used as a screening device to identify those patients who require psychologic treatment rather than more aggressive surgical treatment.

Intractable facial pain and illness behaviour.

Management of intractable facial pain (IFP) patients is time consuming and potentially frustrating. Earlier identification of IFP patients may be helped by considering such cases in terms of their illness behaviour rather than a large rang of other diagnostic labels. A group of 24 IFP patients, with diagnoses including temporomandibular joint dysfunction pain, atypical facial pain and facial neuralgia, completed a questionnaire designed to measure illness behaviour. Compared to a control group of patients with minor odontogenic pain, IFP patients were more somatically preoccupied, could not accept reassurance from a doctor as easily, and were less likely to acknowledge psychological aspects of illness. These attitudes, similar to those reported by other intractable pain patients, are unlikely to be related to degree of organic pathology or chronicity of pain. Use of a discriminant function resulted in three-quarters of the total sample being correctly separated into the two clinical groups on the basis of their IBQ scores.

Intractable facial pain.

Case histories of 225 patients with intractable pain attending the Pain Clinic of a large metropolitan teaching hospital were retrospectively analysed. The 29 cases of intractable facial pain were investigated to determine if there were any clinical or historical factors which might indicate intractability and thus speed diagnosis of such cases in future. Significant factors were age, duration of pain, number of surgical interventions and psychiatric factors. Patients with intractable facial pain are more likely to be over 40 years of age, to have pain of long duration, to have had one or more operations, and to require psychiatric assistance than patients with non-intractable facial pain. Temporomandibular joint dysfunction pain and atypical facial pain merged in the intractable state and differ from intractable neuralgias with respect to sex ratio and psychiatric assistance. The incidence of intractable facial pain in South Australia was eight cases per million population per year. Compared to those with intractable pain at other body sites, patients with intractable facial pain have unilateral pain, do not suffer major impairment to their daily lives and are not concerned with monetary compensation. Patients with intractable pain are more likely to show a pattern of organic preoccupation, non-acceptance of reassurance and disease conviction. These findings, together with some current psychiatric aspects of intractable pain, including the concept of illness behaviour, are discussed. It is suggested that early psychiatric assessment will improve management but it is realised that although it is not possible to apply some of the factors studied to each patient, the findings may alert the clinician to potential intractability.

Ethnicity and illness behaviour.

The 52-item Illness Behaviour Questionnaire (IBQ) was administered to 134 general practice patients of Greek, Anglo-Greek, and Anglo-Saxon origin. Responses were scored on 7 dimensions of illness behaviour labelled general hypochondriasis, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial and irritability. Results of a three-way analysis of variance (ethnicity, age and sex) indicated that Greek patients were significantly more likely to differ from Their Anglo-Saxon counterparts on the initial 3 IBQ scales. Compared with the Anglo-Saxon group, the Greek sample showed greater hypochrondriacal concern, were more likely to manifest conviction as to the presence of serious physical disease, and took a more somatic view of illness. Anglo-Greek patients varied from one scale to another in the degree to which their responses resembled the pattern of illness behaviour reported by Greek patients. They were most similar to the latter in their hypochondriacal attitude, and least similar in their psychological perception of illness. Although the IBQ responses to the Greek sample were consistent with patterns described in other studies of Mediterranean cultural groups, it was found that relationships observed between ethnicity and illness behaviour were to some extent dependent upon age and sex.

Is illness behavior related to chronicity in patients with intractable pain?

One hundred patients, referred for the management of intractable pain, completed a 52-item Illness Behaviour Questionnaire (IBQ). Responses were scored on 7 scales: general hypochondriasis, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial and irritability. IBQ scale profiles were used to study the relationship between chronicity of pain and pattern of illness behaviour reported. Except in the case of one scale, no significant correlation emerged. This overall lack of association between chronicity and illness behaviour remained even when the patient sample was restricted to those 20 patients having substantial organic pathology associated with their pain. These findings suggest that degree of chronicity is unlikely to play a major role in determining the illness behaviour manifested by patients with intractable pain.

Illness behaviour syndromes associated with intractable pain.

One hundred patients, referred for the management of intractable pain, completed a 52-item Illness Behaviour Questionnaire (IBQ). Responses were scored on 7 scales: general hypochondriasis, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial, and irritability. IBQ scale profiles were subjected to numerical analysis and 6 taxonomic clusters were identified. Patients in groups 1-3 were characterized by a relatively non-neurotic, reality-oriented attitude to illness, as indicated by low scores on the first three scales. Patients in groups 4-6 manifested greater evidence of 'abnormal illness behaviour', and presented syndromes resembling 'hysteria', 'conversion reaction', and 'hypothchondriasis' respectively.