Stigmatisation of people with mental illnesses.

BACKGROUND: Recognition of the additional social handicaps and distress that people with mental illnesses experience as a result of prejudice. AIMS: To determine opinions of the British adult population concerning those with mental illnesses as baseline data for a campaign to combat stigmatization. METHOD: Survey of adults (n = 1737 interviewed; 65% response) regarding seven types of common mental disorders. Responses evaluated concerned eight specified perceptions. RESULTS: Respondents commonly perceived people with schizophrenia, alcoholism and drug addiction as unpredictable and dangerous. The two latter conditions were also viewed as self-inflicted. People with any of the seven disorders were perceived as hard to talk with. Opinions about effects of treatment and prognosis suggested reasonable knowledge. About half the respondents reported knowing someone with a mental illness. CONCLUSIONS: Negative opinions indiscriminately overemphasize social handicaps that can accompany mental disorders. They contribute to social isolation, distress and difficulties in employment faced by sufferers. A campaign against stigma should take account of the differences in opinions about the seven disorders studied.

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia.

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.

Combined pharmacotherapy and cognitive behavior therapy in the treatment of panic disorder.

Cognitive behavior therapy (CBT) has been combined with pharmacotherapy in the treatment of panic disorder in three ways: (1) to treat agoraphobic symptoms in the condition of panic with agoraphobia; (2) to reduce withdrawal effects during drug taper; and (3) to treat panic attacks. Exposure treatment and pharmacotherapy have a modest additive effect, although more patients drop out of exposure therapy combined with imipramine treatment compared with exposure therapy alone. CBT reduces symptoms of withdrawal from alprazolam and other benzodiazepines and improves the outcome of drug treatment. At present, sufficient data are not available to determine whether the effects of CBT combined with drug therapy are additive in treating panic disorder. The results of a large trial are awaited. Current CBT consists of 12 sessions and is not widely offered to patients because of cost considerations. Efforts are being made to decrease the number of sessions necessary by improving cognitive techniques. One of these models is the subject of an ongoing trial. Finally, efforts to educate and counsel patients in the clinical setting regarding the psychopathology of panic attacks may improve the outcome of pharmacotherapy.

Biological psychiatry in perspective.

Biological psychiatry is a technical term that denotes physiological and biochemical approaches to psychiatric aetiology and, despite the usual wider meaning of the word biological, excludes psychosocial approaches. 'Biological' causes of severe psychiatric disorder have been suspected from the earliest times, and in some periods an excessive focus upon them has led to neglect of psychological and social approaches to treatment, to the detriment of patients. It is important that current research into biological psychiatry should be carried forward in conjunction with the important advances that have been made in psychological and social research. The causes of psychiatric illness are complex and it is unlikely that any single approach, biological or psychosocial, will be sufficient on its own. The great potential of biological psychiatry will be realized only if it is viewed within these wider historical and scientific perspectives.

Cognition-behaviour links in the persistence of panic.

The cognitive theory of panic disorder proposes that panic attacks occur as a result of an enduring tendency to misinterpret bodily sensations as a sign of imminent catastrophe such as a heart attack. The persistence of such catastrophic cognitions is in part due to the tendency of patients to avoid and/or escape situations where panic occurs. It is proposed that within-situation safety seeking behaviours also have the effect of maintaining catastrophic cognitions in the face of repeated panics during which the feared catastrophe does not occur. The association between catastrophic cognitions and within-situation safety behaviours matched the pattern predicted from the cognitive theory in 147 panic disorder patients. The implications of these findings for the way in which therapy is conducted are discussed.

Cognitive treatment for panic disorder.

Several kinds of evidence indicate that there are important psychological causes of panic disorder as well as the biological causes that have been demonstrated by others. These psychological causes are fears that physical symptoms of anxiety will be followed by an immediate medical emergency: for example, that palpitations will be followed by a heart attack. Evidence is presented to show (a) that such fears are more frequent among panic disorder patients than other anxious patients; (b) that activating the fears can produce panic; and (c) that reducing the fears can attenuate the effects of procedures that produce panic. For panic disorder, cognitive therapy, which reduces these specific fears, gives results comparable to those of imipramine and alprazolam. If further research confirms that these therapeutic effects of cognitive therapy are sustained well beyond the end of treatment, cognitive therapy could be the treatment of choice for panic disorder.

New ways of treating panic disorder.

The research evidence strongly suggests that the most effective form of treatment for panic disorder is cognitive therapy. It is more practical, however, to initiate treatment with alprazolam or with imipramine. Either drug will suppress symptoms and even a half of the patients will stay well.

A national committee for the ethics of research.

A National Committee for the Ethics of Research could consider new questions arising from innovations in research or practice, deal with multi-centre trials, adjudicate when separate local committees give conflicting advice about similar projects, or oversee the work of district committees. The value of each of these functions is assessed and it is concluded that a national committee would be most valuable in providing detailed evaluations of difficult or controversial issues. Though it could offer useful advice about multi-centre trials, local committees would probably wish to continue to consider research involving patients within their health districts even though approval had been given by a central committee. A national committee could usefully oversee the working of a system of quality control throughout the country, but the detailed monitoring of district committees would be done more effectively at regional level.

Effect of amitriptyline on endocrine responses to intravenous L-tryptophan.

The endocrine responses to the 5-hydroxytryptamine (5HT) precursor, L-tryptophan, were assessed in 10 depressed patients before and after at least 4 weeks of treatment with amitriptyline. Overall, amitriptyline did not alter either prolactin or growth hormone responses to L-tryptophan. When three subjects with severe pretreatment weight loss were excluded, however, the remaining seven patients showed a significant increase in the prolactin response to L-tryptophan, consistent with other published studies. The findings suggest that severe recent weight loss may alter the effects of tricyclic antidepressants on 5HT-mediated prolactin release.

Panic attacks: new approaches to an old problem.

Anxiety attacks were included in the first descriptions of the syndrome of anxiety neurosis. Recently it has been suggested that such attacks (now usually called panic attacks) characterize a distinct form of anxiety disorder--panic disorder. It has also been proposed that panic attacks result from a biochemical disorder and require pharmacological treatment. Some of the evidence for these ideas is presented, and two other explanations for panic attacks are reviewed: that they are caused by hyperventilation, and that they result from a cognitive disorder. It is concluded that although it is not possible on the present evidence to choose between the three theories, there is strong indirect support for the cognitive theory and good reason to investigate cognitive factors more thoroughly. Future work on biochemical causes of, and pharmacological treatments for panic attacks should take account of such factors.

Schizophrenia with good and poor outcome. I: Early clinical features, response to neuroleptics and signs of organic dysfunction.

Seventy-seven patients with diagnosis of schizophrenia (62) or schizoaffective disorder (15) were studied 2-20 years since onset of illness, when in a stable condition. The investigation included clinical assessment, measurement of plasma concentrations of neuroleptics and prolactin, computed tomography brain scan, neuropsychological and neurological examination. Outcome of illness was classified according to the presence of chronic psychiatric symptoms and social impairment, and response to neuroleptics according to the effect of treatment in the most recent psychotic episode. Neither outcome nor response to neuroleptics was related to duration of illness. The groups with good and poor outcome differed in premorbid adjustment, age at onset and symptoms of the initial episode, but not in drug bio-availability or prolactin response. Large cerebral ventricles and cognitive impairment, but not neurological 'soft' signs, were associated with unfavourable outcome. The three measures of organicity were not inter-related. No clinical differences were found between chronic patients with and without signs of organic dysfunction. The findings suggest that schizophrenia with good and unfavourable outcome may be separate sub-types. However, the role of organic factors in the latter group remains unclear.

Changes in platelet alpha 2-adrenoceptor binding post partum: possible relation to maternity blues.

Platelet alpha 2-adrenoceptor binding characteristics were investigated in 28 healthy women during the peripartum period. The number of platelet alpha 2-adrenoceptors fell after childbirth, corresponding to a fall in the circulating levels of oestrogen and progesterone. Two-thirds of the women had an episode of maternity blues. At 7-10 days post partum the platelet alpha 2-adrenoceptor capacity in these subjects was significantly higher than in those women who did not show signs of maternity blues and significantly higher than a control group of normally menstruating women. We conclude that platelet alpha 2-adrenoceptors may be affected by the circulating levels of endogenous oestrogen and progesterone and that a delayed or diminished fall in platelet alpha 2-adrenoceptor capacity after childbirth may be associated with the development of maternity blues.

Social phobia: a comparative clinical study.

Eighty-seven people with the symptom of social phobia were compared with 57 people with the symptom of agoraphobia to determine whether these symptoms were part of distinct syndromes. Comparisons were made on demographic, clinical and questionnaire data. Significant differences were found on important variables. The social phobics were younger and more often male, unmarried, and from social classes I and II. The pattern of phobic situations was different in the two groups and so was the pattern of autonomic symptoms experienced in these situations. Symptoms visible to others were more frequent among social phobics. Fainting was more frequent among the agoraphobics.