The phenomenology of auditory verbal hallucinations in emotionally unstable personality disorder and post-traumatic stress disorder.

OBJECTIVE: To explore the phenomenology of auditory verbal hallucinations (AVHs) in a clinical sample of young people who have a 'non-psychotic' diagnosis. METHODS: Ten participants aged 17-31 years with presentation of emotionally unstable personality disorder or post-traumatic stress disorder and frequent AVHs were recruited and participated in a qualitative study exploring their subjective experience of hearing voices. Photo-elicitation and ethnographic diaries were used to stimulate discussion in an otherwise unstructured walking interview. RESULTS: 'Non-psychotic' voices comprised auditory qualities such as volume and clarity. Participants commonly personified their voices, viewing them as distinct characters with which they could interact and form relationships. There appeared to be an intimate and unstable relationship between participant and voice, whereby voices changed according to the participants' mood, insecurities, distress and circumstance. Equally, participants reacted to provocation by the voice, leading to changes in mood and circumstance through emotional and physical disturbances. In contrast to our previous qualitative work in psychosis, voice hearing was not experienced with a sense of imposition or control. CONCLUSIONS: This phenomenological research yielded in-depth and novel accounts of 'non-psychotic' voices which were intimately linked to emotional experience. In contrast to standard reports of voices in disorders such as schizophrenia, participants described a complex and bi-directional relationship with their voices. Many other features were in common with voice hearing in psychosis. Knowledge of the phenomenology of hallucinations in non-psychotic disorders has the potential to inform future more successful management strategies. This report gives preliminary evidence for future research.

Depression and the dermatologist: a critical analysis of contemporary isotretinoin prescribing practices.

Management of patients with current or previous depression who require isotretinoin treatment for acne is a challenging area. Current opinion favours the view that isotretinoin-induced mood disturbance is a rare, idiosyncratic reaction, not reliably related to the presence of pre-existing depression. Nonetheless, in the absence of a definitive high-quality study, there remains a degree of legitimate uncertainty. With input from a psychiatrist, we created and administered a detailed survey featuring a range of low-, medium- and higher-risk clinical scenarios, designed to capture a snapshot of current dermatological practice. Respondents indicated a wide variability in their approach, with a substantial proportion referring on to Psychiatry where this was not deemed necessary. Few dermatologists appreciated the importance of behaviours suggesting impaired impulse control. We hope this study helps to refine guidance for isotretinoin prescribing, both to maximize safety and to ensure that deserving patients with acne are not excluded from appropriate treatment.

A comparison of stress levels, coping styles and psychological morbidity between graduate-entry and traditional undergraduate medical students during the first 2 years at a UK medical school.

BACKGROUND: Stress levels and psychological morbidity are high among undergraduate medical students (UGs), but there is a lack of research into the psychological health of UK graduate-entry medical students (GEs). GEs are likely to experience different (perhaps more severe) stressors and to cope with stress differently. We compared stress levels, psychological morbidity and coping styles in GE versus UG medical students studying at the same UK medical school in the same academic year. A cross-sectional self-rated questionnaire study of all first- and second-year GE and UG medical students was conducted. Perceived stress, psychological morbidity, recent adverse life events, stress-related personality traits and coping styles were assessed using standard questionnaires. RESULTS: 75% GEs and 46% UGs responded to the questionnaire. Both groups reported equally high levels, and similar profiles of, perceived stress and psychological morbidity. Levels of recent adverse life events and stress-related personality traits were similar in both groups. Compared to UGs, GEs were more likely to use active coping (p = 0.02) and positive reframing (p = 0.03), but were also more likely to use substances (alcohol and other drugs; p < 0.001) to help them cope. Unlike UGs, second-year GEs showed less perceived stress (p = 0.007) and psychological morbidity (p = 0.006) than first-year GEs although levels of both were still high. CONCLUSION: Our results show that both GE students and their younger UG counterparts on a traditional medical course have similar profiles of stress symptoms. They do, however, cope with stress differently. GEs are more likely to use active problem-focused coping strategies, and they are also more likely to cope by using substances (alcohol or other drugs). GE students need interventions to prevent maladaptive coping styles and encourage adaptive coping that are tailored to their needs. Such interventions should be targeted at first-year students. It is vital that these students develop positive coping skills to benefit them during training and in a future career that is inherently stressful.

Understanding auditory verbal hallucinations: a systematic review of current evidence.

OBJECTIVE: Auditory verbal hallucinations (AVHs) are core features of psychotic illness and remain significant in predicting poor outcome and risk. There has been a wide range of approaches to understanding these experiences. METHOD: A systematic literature review summarizing different methods of investigation and their results; phenomenology, descriptive psychopathology, psychological, cognitive neurobiology, and neuroimaging. RESULTS: A number of 764 papers and texts were screened and 113 reviewed. Phenomenological studies are comparably few in number, and psychopathology remains based on concepts defined in the early 20th century. Psychological models focus on voice content and emotional reaction, and suggest a continuum of AVHs from normal experience. Neuropsychological models include AVHs as misattribution of inner speech, whilst functional neuroimaging studies focus on the spontaneous activity and connectivity of auditory networks. CONCLUSION: There has been a large growth in research on AVHs in recent decades dominated by neurobiological and neuroimaging studies. Future research should include focus on phenomenological aspects and AVHs change over the course of developing illness. Integration between branches of enquiry is needed, and the risk is that without this, models are proposed and investigated that bear scant relevance to the symptom itself.

The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse.

AIMS: The perinatal period is a time of high risk of relapse for women with a history of bipolar affective disorder (BPAD). We describe the pregnancy management of women with BPAD and identify risk factors for postpartum relapse. METHODS: The case records of 78 women with BPAD referred to perinatal mental health services before conception, during pregnancy or the postpartum period, between 1998 and 2009 in Birmingham U.K., were screened. In women who were managed during pregnancy, those who relapsed in the postpartum were compared with those who remained well. RESULTS: Forty-seven percent of women with BPAD referred in pregnancy suffered postpartum relapse. Women who were unwell at referral, younger, with unplanned pregnancy, previous perinatal episodes or a family history of BPAD were more likely to suffer postpartum illness. CONCLUSION: Identifying risk factors for postpartum relapse enables us to individualise the estimation of a woman's risk and modify care plans accordingly. Duration of wellness prior to pregnancy is not associated with a lower risk of postpartum illness and so it is imperative that all women with BPAD receive referral in pregnancy.

Measuring hypomania in the postpartum: a comparison of the Highs Scale and the Altman Mania Rating Scale.

We examine the prevalence of hypomania on day 3 postpartum using two self-report mania scales: The Highs Scale and Altman Mania Rating Scale (AMRS). 279 women were recruited from postnatal wards and completed the questionnaires on day 3 postpartum. The scales show good correlation, however, 11% of women meet the suggested threshold for caseness on the Highs Scale and 44% on the AMRS. Hypomanic symptoms are commonly experienced in the early postpartum. Although there is some evidence that the Highs Scale might be conservative, the AMRS likely overestimates hypomania in the postpartum. The definition of what constitutes 'a case' of postnatal hypomania requires further validation against clinical interview and ability to predict variables of clinical importance. Mania scales developed in bipolar disorder populations must be specifically validated for postpartum use.

Structural neuroimaging in psychosis: a systematic review and economic evaluation.

OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of structural neuroimaging [structural magnetic resonance imaging (MRI) or computed tomography (CT) scanning] for all patients with psychosis, particularly a first episode of psychosis, relative to the current UK practice of selective screening only where it is clinically indicated. DATA SOURCES: Major electronic databases were searched from inception to November 2006. REVIEW METHODS: A systematic review of studies reporting the additional diagnostic benefit of structural MRI, CT or combinations of these in patients with psychosis was conducted. The economic assessment consisted of a systematic review of economic evaluations and the development of a threshold analysis to predict the gain in quality-adjusted life-years (QALYs) required to make neuroimaging cost-effective at commonly accepted threshold levels (20,000 pounds and 30,000 pounds per QALY). Sensitivity analyses of several parameters including prevalence of psychosis were performed. RESULTS: The systematic review included 24 studies of a diagnostic before-after type of design evaluating the clinical benefit of CT, structural MRI or combinations in treatment-naive, first-episode or unspecified psychotic patients, including one in schizophrenia patients resistant to treatment. Also included was a review of published case reports of misidentification syndromes. Almost all evidence was in patients aged less than 65 years. In most studies, structural neuroimaging identified very little that would influence patient management that was not suspected based on a medical history and/or physical examination and there were more incidental findings. In the four MRI studies, approximately 5% of patients had findings that would influence clinical management, whereas in the CT studies, approximately 0.5% of patients had these findings. The review of misidentification syndromes found that 25% of CT scans affected clinical management, but this may have been a selected and therefore unrepresentative sample. A threshold analysis with a 1-year time horizon was undertaken. This combined the incremental cost of routine scanning with a threshold cost per QALY value of 20,000 pounds and 30,000 pounds to predict the QoL gain required to meet these threshold values. Routine scanning versus selective scanning appears to produce different results for MRI and CT. With MRI scanning the incremental cost is positive, ranging from 37 pounds to 150 pounds; however, when scanning routinely using CT, the result is cost saving, ranging from 7 pounds to 108 pounds with the assumption of a 1% prevalence rate of tumours/cysts or other organic causes amenable to treatment. This means that for the intervention to be viewed as cost-effective, the QALY gain necessary for MRI scanning is 0.002-0.007 and with CT scanning the QALY loss that can be tolerated is between 0.0003 and 0.0054 using a 20,000 pounds threshold value. These estimates were subjected to sensitivity analysis. With a 3-month time delay, MRI remains cost-incurring with a small gain in QoL required for the intervention to be cost-effective; routine scanning with CT remains cost-saving. When the sensitivity of CT is varied to 50%, routine scanning is both cost-incurring or cost-saving depending on the scenario. Finally, the results have been shown to be sensitive to the assumed prevalence rate of brain tumours in a psychotic population. CONCLUSIONS: The evidence to date suggests that if screening with structural neuroimaging was implemented in all patients presenting with psychotic symptoms, little would be found to affect clinical management in addition to that suspected by a full clinical history and neurological examination. From an economic perspective, the outcome is not clear. The strategy of neuroimaging for all is either cost-incurring or cost-saving (dependent upon whether MRI or CT is used) if the prevalence of organic causes is around 1%. However, these values are nested within a number of assumptions, and so have to be interpreted with caution. The main research priorities are to monitor the current use of structural neuroimaging in psychosis in the NHS to identify clinical triggers to its current use and subsequent outcomes; to undertake well-conducted diagnostic before-and-after studies on representative populations to determine the clinical utility of structural neuroimaging in this patient group, and to determine whether the most appropriate structural imaging modality in psychosis should be CT or MRI.

Mentally disordered offenders in Zimbabwe and in England and Wales: a socio-demographic study.

Our aim was to compare socio-demographic, clinical and criminal characteristics of mentally disordered offender patients in a special institution in a developing and a developed country. Zimbabwe data from 1980-1990 was obtained from a hospital patient survey, in a written semistructured format. The English special (high security) hospital patients' data for the same period was obtained from the case register. The sample size for Zimbabwe was 367 patients (337 males, 30 females) and for England and Wales it was 1,966 patients (1,643 males, 323 females). The average age for Zimbabwean patients was 36 years, with standard deviation of 9.7; for England and Wales the average age was 29.7 with standard deviation of 9.6. There was significant difference in marital status in the two countries. Seventy-eight per cent of patients were single in England and Wales, compared with 49% in Zimbabwe. There were 20% illiterate patients in Zimbabwe, compared with 4% in England and Wales. Thirty-seven per cent of the patients in England and Wales had a diagnosis of personality disorder, compared with 6% in Zimbabwe. There were 53% of homicides in Zimbabwe, compared with 20% in England and Wales. Employment in the two countries was similar: 34% in Zimbabwe and 33% in England and Wales. There were differences in the socio-demographic characteristics in the two countries, except for employment status. Differences were also noticed in the diagnoses of the patients, types of crime and the methods of assault.

History of psychiatry in West Africa.

This paper explores the social context of the development of mental asylums in colonial Nigeria. The characteristics of the medical leadership is described, as is the environmental condition of the asylums. The colonial period produced conceptualizations of the African mind and of the pattern and distribution of mental illness in Africans. These conceptualizations are critically examined.

First compulsory admissions under part II of the Mental Health Act 1983: a retrospective five-year study.

The aim was to explore what happened during a five-year period to a group of patients with no previous psychiatric admissions, who were detained for the first time in a psychiatric hospital under part II of the Mental Health Act 1983. Subjects (n=189) who were detained under Section 2 or 3 in 1996 and 1997 in Queen Elizabeth Psychiatric Hospital, Birmingham were identified from computerised inpatient admission records. The mean age was 40.0 years (range 21-65). Nearly half of the cohort had a diagnosis of psychoses. Asians had the highest proportion of psychoses (64%) compared to African-Caribbean patients (48%) and White patients (41%). Almost half of the sample had a further admission, with Asian and African-Caribbean patients more likely to be readmitted than their white counterparts. Nearly a third of the cohort had a further compulsory detention. On re-admission, African-Caribbean subjects were more likely to be detained compared to Asian and White subjects. Fifty per cent had a further compulsory admission within a year of the index admission. The high number of psychoses in the Asian group may be due to their psychosis being more serious at presentation as a result of denial of illness and an increased co-morbidity with drug use in Asian men.

Recognition memory abnormalities in asymptomatic biological parents of a patient with schizophrenia.

BACKGROUND: Recognition memory dysfunction has been frequently reported in schizophrenic populations, and has been linked with the development of delusions and thought disorder. A range of neuropsychological abnormalities have also been documented in the biological asymptomatic relatives of patients with schizophrenia; however, recognition memory has not been one of them. AIM: This study was carried out in order to investigate: (i) verbal and facial recognition memory in terms of accuracy and false alarm rates; and (ii) contributions from the episodic and semantic memory systems to recognition memory, in the biological asymptomatic parents of a reported schizophrenic patient and a set of male and female psychotic controls. RESULTS: Gender differences failed to emerge between the psychotic controls on any of the recognition measures (discrimination accuracy, response bias, hit and false alarm rates, 'remember' and 'know' recognition memory decisions). However, there was evidence of recognition dysfunction in the female relative, and to a lesser extent, in the male. Both parent's recognition memory performance profiles were marked by a pathologically elevated false alarm rate, and an increased dependence 'remember' judgements, i.e. input from the episodic memory system, to drive recognition memory decisions. CONCLUSIONS: These findings are discussed in the context of models of episodic and semantic memory impairment in schizophrenia.

The delusions of Capgras and intermetamorphosis in a patient with right-hemisphere white-matter pathology.

Previous neuropsychological studies have demonstrated an association between person misidentification and right-hemisphere dysfunction. In the study reported here, we explore the contribution of facial and visual recognition impairments in a patient with right-hemisphere subcortical white-matter pathology in the frontal and parietal lobes and a diagnosis of vascular cognitive impairment. The patient displayed false recognition of unfamiliar faces and deficient retrieval of key biographic detail for famous faces. These results are discussed in the context of the contribution of deficiencies in the visual system and subcortical white-matter lesions to the development of Capgras delusion.

Formal justifications for compulsory psychiatric detention.

The formal justifications for all detentions under s.2 of the Mental Health Act 1983 within an inner-city mental health trust were examined over a 12-month period. The study explored: the nature of the justifications for detention; the extent to which these were associated with patient characteristics; and the extent to which the two medical practitioners involved in each case agreed on the justifications. The justifications reflected a greater emphasis on the protection of the individual concerned rather than the protection of others. A content analysis of the textual justifications revealed five broad themes: the nature of the risk posed by the patient; the patient's capacity to provide informed consent; their need for hospitalization; their lack of consent to informal admission; and their reliability or likely compliance. There was a significant association between patients' sex, ethnic group, diagnosis and the nature of risk indicated in the documentation, but further research is needed to clarify the nature of this association. The study found that in nearly a quarter of cases, the two professionals did not agree about whether or not the patient presented a danger to others. This lack of agreement was not associated with any patient or professional characteristics, and may reflect the complexity of this area of risk assessment. The authors suggest that the issue of 'risk' needs to be addressed in a more sophisticated manner within the Mental Health Act. Specifically, further guidance is needed as to the nature and levels of risk that constitute grounds for detention. Further guidance is also needed regarding the issues that need to be recorded on the legal documentation for detention.

A review of the phenomenology and cognitive neuropsychological origins of the Capgras syndrome.

In this article the epidemiology, aetiology, neuroanatomy and neuropsychology of the Capgras syndrome (CS) are reviewed in detail. CS is characterized by the delusional belief that one or a few highly familiar people have been replaced by impostors who are physically very similar to the original/s. The patient acknowledges that the double and known person look alike, but maintains the belief that the significant person, in psychological terms, is absent. CS is relatively rare, occurring predominantly in the context of schizophrenia, and was traditionally considered to have its origins in psychodynamic conflict. More recently, however, it has been estimated that between 25 and 40% of cases are associated with organic disorders, which include dementia, head trauma, epilepsy and cerebrovascular disease. Neuroimaging evidence suggests a link between CS and right hemisphere abnormalities, particularly in the frontal and temporal regions. Neuropsychological research has provided empirical support for these findings, by consistently reporting the presence of impairments in facial processing--an established right hemisphere function. It is likely that the study of this symptom will lead to a greater understanding of the neurological basis of psychotic experiences and may provide a paradigm for how the psychoses should be investigated.

Measuring mania and critical appraisal of rating scales.

BACKGROUND: In clinical trials of acute mania, a number of measures have been used to assess the severity of illness and its response to treatment. Rating instruments need to be validated in order for a clinical study to provide reliable and meaningful estimates of treatment effects. OBJECTIVE: To critically assess rating scales used in measuring mania. METHOD: A systematic search of the literature, retrieval of reports of clinical trials of drugs used in mania and the rating scales and a critical and systematic appraisal of their quality. RESULTS: Eight symptom-rating scales were identified. The Mania Rating Scale (MRS) was the most commonly used for assessing treatment response. Two more recently developed scales are the Manchester Nurse Rating Scale for Mania (MNRS-M) and the Clinician-Administered Rating Scale for Mania (CARS-M). The latter appears well validated but its in-use reliability needs to be explored further. The translation of observed changes in instrumental ratings into clinically meaningful change has to be established further. In particular, the relative weighting to be attached to the individual items needs further study. The advantage of the MRS is that there is a relatively extensive database of studies based on it and this will no doubt ensure that it remains a gold standard for the foreseeable future. CONCLUSION: Useful rating scales are available for measuring mania but further cross-validation and validation against clinically meaningful global changes are required.