Recent history of European psychiatry--ideas, developments, and personalities: the annual Eliot Slater Lecture.

Erik Strömgren had planned to revise and expand his Slater lecture to a more systematic and comprehensive paper for publication. Shortly before his death, he asked for the editorial opinion of one of us (IIG), but unfortunately he did not get the opportunity to complete his lecture manuscript. We find, however, that although kaleidoscopic and impressionistic, the manuscript, as it is, contains historic and autobiographical information of high value, which deserves a posthumous publication, for availability to a broader audience. His wife, Dr. Lizzie Sand Strömgren, has kindly released the manuscript, which here appears essentially as delivered at the Slater lecture in 1986, except for a few minor textual adaptions and the addition of a list of references (by A.B.).

Validation of Danish case register diagnosis for schizophrenia.

The ABC schizophrenia study aims at investigating sex differences in age of onset, symptoms and course of schizophrenic and paranoid disorders. For this purpose, we used case register data from Denmark and Mannheim and a directly examined sample of first admissions (ABC sample). The Danish case register sample included less clinical diagnoses of schizophrenia and more schizophrenia-related disorders (acute paranoid reaction, paranoid states and borderline schizophrenia) than the Mannheim data (case register and ABC sample). The problem therefore was whether the two datasets are comparable and the results are valid. For this reason a randomized, stratified sample of 116 patients was drawn from the Danish case register sample. The case notes of these 116 patients were requested from the hospitals where the patients had been treated and analyzed by means of a scoring sheet based on the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). The use of operationalized diagnoses of the CATEGO program, based on PSE items, which are integrated in IRAOS, demonstrated that the samples of the Danish and the Mannheim case registers and the directly investigated ABC sample have comparable diagnostic distributions. Possible explanations for the differences between the clinical and the CATEGO diagnoses in the Danish case register may be the frequent use of diagnoses of borderline schizophrenia and reactive psychoses (previously called psychogenic psychoses), and above all a more narrow concept of schizophrenia; in Denmark, schizophrenia is diagnosed relatively late, i.e., after the presence of enduring negative symptoms, and thus mostly after the appearance of residual state.(ABSTRACT TRUNCATED AT 250 WORDS)

Fini Schulsinger's contribution to psychiatric research in genetic epidemiology.

During the last 3 decades, intensive cooperation between researchers in Denmark and the United States has provided important new insights into the genetic and environmental causes of mental disorders. This co-operative work has been centred around the Psykologisk Institut at Kommunehospitalet, Copenhagen, founded and directed by Fini Schulsinger, who has been the mediator of the very different kinds of research projects and who himself has also made important contributions to the understanding of nature-nurture problems within psychiatry.

The concept of schizophrenia: the conflict between nosological and symptomatological aspects.

A brief overview is given of the history of psychiatric nosology during the last 150 years. The varying role of genetics for theories of nosology is described. Classifications of mental disorders, more or less based on nosological concepts, are mentioned, as well as the recent emphasis on operational tools for classification. Conflicts between nosology and modern classifications are mentioned. The place of the schizophrenic syndrome in relation to nosological theories is described, including the questions of schizophrenia being a disease entity, or several entities, or even a part of a continuum, or just a symptomatically characterized reaction form.

Trends in psychiatric hospitalization in Denmark: a 10-year register-based investigation.

Information about all admissions to psychiatric hospitals and departments in Denmark in 1977, 1982 and 1987 and about all resident patients on census days in the same years were extracted from the central psychiatric register. The number of available beds decreased by 43% from 1977 to 1987. The admission rates decreased for all diagnostic groups but schizophrenia, which increased. The group of younger schizophrenic men declined in size, which is alarming if mentally ill homeless people are considered. The census study shows a decrease in all diagnostic groups, most pronounced in the elderly age groups. Patients with neuroses disappear from the available beds in the mental hospitals and departments. The changes in the psychiatric service system from mostly hospitalization to outpatient treatment and community psychiatric treatment require a comprehensive personal registration of treatment regardless of the administrative affiliations of these services.

[Sex differences in schizophrenic diseases]. / Geschlechtsunterschiede bei schizophrenen Erkrankungen.

Sex differences in schizophrenic diseases have been known for a long time but have also been subject to long-term neglect by psychiatric epidemiological research, although a study of these sex differences could, in our opinion, yield valuable pointers to pathogenic factors involved in this group of diseases the aetiology of which still awaits clarification. For this reason we initiated large-scale investigations focussed on this topic. The paper presented here discusses a few initial results, basing on data of Mannheim and National Danish Case Records and on our own study on schizophrenia, the latter being a representative record of 392 patients hospitalised for the first time in the Rhine-Neckar region and the eastern part of the Palatinate. First of all, sex differences at the age at which the disease appeared for the first time, were studied while paying close attention to artifacts and other, usually neglected methodical error sources. The difference in the average age of the sexes at first hospitalisation was confirmed, and also--using an instrument specially developed for that purpose--at the onset of the disease. At the time the first signs of the disease are noticed and the first schizophrenic symptoms become apparent, men are about 3 to 4 years younger than women. On the other hand, the cumulative lifetime risk--calculated up to 60 years of age--seems to be the same for both sexes. It appears that there are no sex differences in the pattern of symptoms of the disease at the time of initial hospital admittance, in respect of both the most common and the characteristic signs and symptoms. There were significant although quantitatively not very great differences in respect of patient behaviour which displays socially positive aspects somewhat more often in women and socially negative ones distinctly more often in men. In respect of the course of the disease we could not find any marked sex differences over a period of 10 years after onset of the disease; however, this is presently based only on the Danish case record data and on criteria of the course of the disease, such as number and duration of inpatient treatments.

How does gender influence age at first hospitalization for schizophrenia? A transnational case register study.

Numerous studies have reported a lower mean age at first hospitalization for schizophrenia in males than in females. For this finding not only a gender difference in age at first onset of schizophrenia, but also other factors can be responsible. With the aim of providing a comprehensive analysis of gender differences in onset, symptomatology and course of schizophrenia, we started by testing the hypothesis postulating a gender difference in mean age at first hospitalization. By using the Danish and the Mannheim psychiatric case registers we analysed all hospital admissions for schizophrenia and related diagnoses and all previous admissions for other diagnoses of the Danish population in 1976 and those of the inhabitants of the German city of Mannheim in the period of 1978-80. Artefacts were controlled for systematically. The impact of intervening variables such as selection factors as well as the influence of gender on the ascription of a diagnosis of schizophrenia for the first time were assessed. We found a mean difference of 5 to 6 years in age at first hospitalization between males and females in both countries when a broad definition of the diagnosis was used and of 4 to 5 years when a restrictive definition was applied. The higher mean age at first hospitalization among females is not attributable to artefacts, diagnostic procedures or to any essential extent to gender differences in help-seeking behaviour or occupational status. When a distinction was made between 'single' and 'married', the significant difference in age at first hospitalization between the sexes disappeared in singles. With case register data and without knowing the chronological order of marriage and onset of the disease, it remains an open question whether this finding can be explained by purely correlative associations between sex, marital status and age of onset or by causal effects.

Psychiatric admissions of the elderly.

In 1955 Ole J. Rafaelsen performed an analysis of the admissions of elderly patients to the Aarhus Psychiatric Hospital during the preceding decade. On the basis of nation-wide statistics the changing role since then of the elderly in the Danish psychiatric hospital system is described.

The development of the concept of reactive psychoses.

Although reactive (psychogenic) psychoses have no doubt occurred throughout the history of mankind, it is only during the last century that the corresponding concept has been defined, beginning with Sommer's definition of the term 'psychogenic' and Jaspers' distinctions between 'reaction' and 'process', and between 'neurosis' and 'psychosis', respectively. A change in Kurt Schneider's nosological concepts induced the majority of German-speaking psychiatrists to avoid the concept of psychogenic psychoses. The very varying use of the concept of reactive psychoses in different countries is described and discussed, with special regard to implications for psychiatric epidemiology.

Changes in the incidence of schizophrenia?

In general, results of epidemiological studies on schizophrenia performed during the last century have the remarkable feature that no significant differences in expectancies and incidences have been found, neither between different populations nor over time. Recently, however, some studies have tended to show a noteworthy decrease in the incidence, as measured by statistics of first admissions. Possible sources of error are discussed, partly on the basis of recent Danish investigations. Although it is uncertain whether a true change in the incidence of schizophrenia has occurred, one feature is becoming evident: under modern treatment and care of schizophrenics the natural history of the disease is becoming increasingly different between the two sexes. This fact, in combination with one of the hardest facts in schizophrenia research, namely the higher age of onset in females, may be useful starting points for hypotheses on aetiology, or at least necessary components of such hypotheses.

Lack of effect of tryptophan treatment in demented gerontopsychiatric patients. A double-blind, crossover-controlled study.

Twenty-eight elderly patients with dementia and in many cases also depression received daily treatment with either L-tryptophan (3g in the evening) or casein (control substance) for 1 month each, using a crossover design and double-blind procedures. Each patient's mental condition and performance ability were rated, and biological variables (serum tryptophan levels, platelet 5-HT uptake, platelet MAO activity, red blood cell thiamine, pyridoxine and riboflavin levels) were measured. Serum tryptophan levels were elevated by tryptophan treatment, but the treatment failed to have significant effects on the mental condition of the patients as a whole. Dividing the patients into two groups on the basis of the treatment during which they received their best behavioral rating failed to show significant relations to biological variables, except for differences between Vmax values for platelet 5-HT uptake. The findings indicate that long-term administration of tryptophan to gerontopsychiatric patients does not generally have beneficial effects.

Sympathetic outflow to muscles during treatment of hypertension with metoprolol.

Microelectrode recordings of multiunit sympathetic vasoconstrictor activity were made in muscle branches of the peroneal nerve in patients with essential hypertension before and during long-term treatment with the cardioselective beta-adrenergic receptor antagonist metoprolol. Nerve activity was quantified by counting the number of sympathetic bursts in the mean voltage neurogram. Metoprolol treatment lowered blood pressure and heart rate in all subjects. During long-term treatment, nerve activity was reduced both when compared to the level of activity after the first dose of the drug (p less than 0.01) and when compared to the control level before treatment (p less than 0.05). It is suggested that the reduction of sympathetic vasoconstrictor outflow to muscles contributed to the blood pressure reduction.

Short-term effects of felodipine, a new dihydropyridine, in hypertension.

Felodipine, a dihydropyridine, is a new vasodilating calcium antagonist which lowers blood pressure (BP) by selective action on vascular smooth muscle, especially in the resistance vessels. The effects on BP, heart rate (HR) and tolerance of different single oral doses of felodipine were studied in two series of hypertensive patients. When felodipine was given as single drug to 14 previously untreated hypertensives in a single-blind manner, BP was rapidly reduced by about 15% while HR increased by 25%. Felodipine given in a double-blind manner to eight patients on chronic beta-adrenoceptor blockade reduced BP by some 15-20% compared to placebo, while HR did not change. There was a significant correlation between the pre-treatment mean arterial BP (MAP) and the maximal relative change in MAP, i.e. the higher the initial BP the greater the reduction after felodipine. A significant correlation was also found between the plasma concentration of felodipine and the relative change in MAP. Felodipine was generally well tolerated. When given alone felodipine caused the side effects expected from a pure vasodilator, i.e. headache, flushing and palpitations. When given together with a beta-adrenoceptor blocker, the side effects were much less apparent.

Acute effects of metoprolol on muscle sympathetic activity in hypertensive humans.

Recordings of multiunit sympathetic activity were made from muscle branches of the peroneal nerve in eight previously untreated subjects with essential hypertension during intravenous administration of the cardioselective beta-adrenoceptor antagonist, metoprolol. Intraarterial blood pressure and central venous pressure were monitored simultaneously. After metoprolol, heart rate fell and central venous pressure increased in all subjects. Blood pressure increased in some subjects and decreased in others whereas the rate of rise of the systolic pulse wave regularly decreased. Sympathetic activity, discharged in pulse synchronous bursts of action potentials, was quantitated by counting the number of bursts and their amplitudes in the mean voltage neurogram. In all subjects, the average diastole was associated with outflow of more sympathetic impulses after metoprolol than before. Total sympathetic activity (expressed as bursts/min multiplied by mean burst strength) also increased after the drug. The mechanism behind the increase of sympathetic activity may be either a direct central nervous effect or a reflex effect elicited from arterial baroreceptors or cardiac receptors.