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Somatic illness in manic-depressive and schizophrenic patients
Journal of Psychosomohc Research, Vol. 29, No. 3, pp. 281-286, 1985. Printed in Great Britain.
0022-3999/85 $3.00 + .OO C 1985 Pergamon Press Ltd.
SOMATIC ILLNESS IN MANIC-DEPRESSIVE SCHIZOPHRENIC
AND
PATIENTS
A. M. GHADIRIAN* and F. ENGELSMANN* (Received 20 July 1984; accepted in revisedform
8 November
1984)
Abstract-The
study compared the presence of somatic illnesses in manic-depressive (n= 100) and schizophrenic patients (n= 156) in the out-patient psychiatric clinics of three general hospitals. The average age of manic-depressive and schizophrenic patients was 40.7 yr and 39.8 yr respectively and did not differ significantly. The sample consisted of both sexes. Among the manic-depressive patients there were 46 males and 54 females. The schizophrenic sample consisted of 84 (54%) males and 72 (46%) females. The result showed that there was a greater rate of the occurrence of physical illnesses in manic-depressive patients as compared to the schizophrenic patients in respect to all the surveyed systemic disorders except for the gastrointestinal diseases. The cardiovascular, neurological and endocrinological diseases were more frequent in the manic-depressives than in the schizophrenic patients. INTRODUCTION
THE PREVALENCE of somatic
disorders in psychiatric populations has been a subject of special interest to many researchers in recent years. The research findings were reviewed by Baldwin [ 11, Korany 121, and Krakowsky et al. [3]. Korany [2] examined the psychiatric literature on the subject in a span of 40 years and noted that about half of the total of 4000 psychiatric patients reviewed suffered from major medical illnesses. Accordingly, physical conditions directly related to psychiatric symptoms were present in 9-42% of the cases. However, he did not list the specific physical illnesses in his review. Ramsay et al. [4] studied schizophrenic patients of six hospitals in three countries. They found a difference between the occurrence of somatic disorders in schizophrenic patients of chronic hospitals as compared to that at general hospitals. The former was lower than the latter. However, the overall findings of the prevalence of somatic disorders, more specifically bronchial asthma and rheumatoid arthritis, were lower in schizophrenic patients than in the general population. Ross [5], in his study of 1608 patients of a chronic mental hospital in the pre-neuroleptic era, found no association between certain somatic disorders and schizophrenia as well as other psychoses. Pedder [6] reported a lower incidence of schizophrenia among patients suffering from peptic ulcer, bronchial asthma, colitis and eczema. A number of researchers have reported a low incidence of rheumatoid arthritis in schizophrenic patients [7, 81. Likewise, Baldwin [l] found a significant reduction in the relative risk of rheumatoid arthritis in schizophrenics. More recently, Mohamed et al. [9] found, in their study *Department of Psychiatry, McGill University, Montreal, Canada. Dr. Ghadirian is Associate Professor and Dr. Engelsmann is Professor, McGill University and on staff at the Royal Victoria Hospital in Montreal. Dr. Ghadirian is also Director of Medical Education, Douglas Hospital Centre. Address reprints to: Dr. A. M. Ghadirian, Douglas Hospital Centre, 6875 Lasalle Blvd., Verdun, Quebec, Canada H4H 1R3. This paper was presented at the 15th European Conference on Psychosomatic Research, London, England, September 1984. 281
282
A. M.
GHADIRIAN
and F. ENGELSMANN
of 111 schizophrenic patients, a negative association between schizophrenia and rheumatoid arthritis. However, studies on the prevalence of physical illness among patients suffering from major affective disorders are quite scarce. Krauthammer and Klerman [lo] reported that manic-depressive illness can occur secondary to drugs, infection, neoplasma, epilepsy and metabolic disorders. Mania, like physical diseases such as hypertension, is viewed as a syndrome with multiple causes. Secondary mania is thus believed to be the consequence of organic dysfunction. The report by Jamison and Wells [l l] is a case in point. A 45 year old man who suffered from metastatic tumors in the right cerebral hemisphere developed a manic episode for the first time. He had no previous history of psychiatric disorders, nor any family history of manic-depressive illness. The manic episode responded favorably to lithium treatment even though the metastatic lesions could not be eliminated. In a study by Lindegard [12], the entire middle-aged male urban population of a Swedish city was evaluated for psychiatric hospitalization for a three-year period. Lindegard found that severe depression correlated positively with infections, myocardial infarctions, asthma and alcohol intoxication. Diabetes mellitus has been found to be associated with affective disorders independent of the use of lithium for treatment [ 131. Lithium, in certain patients, may impair glucose tolerance and cause diabetes. In screening 386 new psychiatric admissions, undiagnosed hypothyroidism was reported to be present in 4 manic-depressive patients admitted to the hospital [14]. Tsuang et al. [15] analyzed the causes of death in a cohort of 200 schizophrenic, 100 manic and 225 depressive patients who were admitted between 1934 and 1944 and were studied 30-40 yr later. The authors reported a significant excess of death due to circulatory system failure in female manics. In the schizophrenic group, both males and females showed a substantial excess of death due to infectious diseases. Rabkin et al. [16] reported 452 psychiatric outpatients diagnosed according to the DSM III criteria [17], that major depressions were three times as common among patients with hypertension as those without hypertension. However, there is a conspicuous rarity of well controlled comparative studies of somatic disorders between the schizophrenic and the manic-depressive patients. OBJECTIVES
Our study explored the prevalence of physical illness among schizophrenics as compared to manic-depressive patients. Differences in the prevalence of the surveyed systemic medical diseases may have implications in the development of psychopathology in these two groups of psychiatric patients. METHOD
Subjects The present study is based on two independent surveys which were carried out on schizophrenic [ 1S] and manic-depressive populations [19]. The former study [18] included patients from psychiatric departments of two general hospitals in Montreal (n = 54) and in Plattsburg (n = 102). The latter study (191 was carried out at the Affective Disorders Clinic of the psychiatric department of the Royal Victoria Hospital. The sample of schizophrenic patients included a total of 156 cases: 84 males and 72 females. Their average age was 39.8 yr, ranging from 20 to 70. In the affective disorders sample there were 100 patients of both sexes (46 males and 54 females). Their average age was 40.7 yr, ranging from 21 to 67.yr. The average age difference between the samples was not significant. Both of the samples consisted of psychiatric outpatients with a wide range of duration of illness who did not show gross organic brain
Somatic
illness in manic-depressive
syndrome. The patients were consecutively to cooperate and if they met the diagnostic
and schizophrenic
patients
included in the study based on their capacity criteria as indicated below in Procedure.
283 and willingness
Procedure In each one of these two surveys a uniform structured questionnaire was completed based on the clinical interview and review of the patient’s file. The questionnaire contained personal, demographic, diagnostic and other clinical data including the presence of a number of physical disorders in the patients and their close relatives. Selection of patients for the study was based on the International Classification of Diseases (ICD-8 and ICD-9) [201 for diagnosis of schizophrenia and manic-depressive illnesses. In addition, the Research Diagnostic Criteria [21] were also used. The present and past somatic illness was ascertained from the patients’ report, medical file and laboratory data.
RESULTS
The results showed a greater rate of occurrence of physical illnesses in manicdepressives as compared to the schizophrenics in respect to all of the surveyed systemic disorders except for gastrointestinal diseases. The cardiovascular, neurological and endocrinological diseases were more frequent in the manic-depressives than in the schizophrenics. Fifty-seven percent of the schizophrenic patients had no systemic physical illnesses as compared to fifty percent of the manic-depressive patients (Table I).
TABLE I.-PHYSICAL
Illness 1. 2. 3. 4. 5. 6. 7. 8. 9.
None Cardiovascular Gastrointestinal Respiratory Neurological Endocrine Gynecological Musculoskeletal Other Missing Information Total
ILLNESS
Schizophrenic n=l56 n % 89 6 10 4 2 9 2 3 19 12 156
57.1 3.8 6.4 2.6 1.3 5.8 1.3 1.9 12.1 7.7 100
Manic-depressive n=lOO n, % 50 9 4 4 4 8 4 3 12 2 100
The analysis of the prevalence of somatic illness in the two groups of patients showed that more manic-depressive males suffered from gastrointestinal disorders as compared with the females. However, the prevalence of this disorder was evenly distributed between the male and female schizophrenic patients. The prevalence of the endocrine and metabolic disorders was higher among the schizophrenic females. Musculoskeletal diseases were more prevalent in manic-depressive females and about the same schizophrenic males and females. The male-female differences in somatic illnesses shown in Table II are based on a smaller sample of schizophrenic patients (n = 102) representing the total population from one study center (in Plattsburg, U.S.A.).
284
A. M. GHADIRIAN and F. ENGELSMANN
TABLE II.-SEX
RELATED
DIFFERENCESOFTHE PREVALENCEOFSOMATK SCHIZOPHRENIC PATIENTS
Illness 1. None 2. Cardiovascular
3. 4. 5. 6. 7. 8. 9.
Gastrointestinal Respiratory Neurological Endocrine and Metabolic Gynecological Musculoskeletal Other Missing Information Total
Schizophrenics Male n % 35 3 4 0 0 2 0 2 5
1 52
67.3 5.8 7.7 0 0 3.8 0 3.8 9.7 1.9 100
(n = 102) Female n % 31 2 4 1 0 4 3 0 5 0 50
62 4 8 2 0 8 6 0 10 0 100
ILLNESSIN MANIC-DEPRESSIVE AND
Manic-depressives (n = 100) Male Female % n % n 24 3 4 1 3 4 0 0 7 0 46
52.2 6.5 8.7 2.2 6.5 8.7 0 0 15.2 0 100
26 6 0 3 1 4 4 3 5 2 54
48.1 11.1 0 5.6 1.9 7.4 1.4 5.6 9.2 3.7 100
DISCUSSION
We found that the absence of somatic illness was greater in the schizophrenic population (57.1 Vo) than in the manic-depressive group (50%). This absence of physical illness was even more conspicuous (78.5%) in a Polish sample of 3 11 schizophrenic patients [4] who were comparable to our sample of schizophrenic patients from general hospitals. Our finding of high prevalence of cardiovascular disease in manic-depressive patients is consistent with the findings of Rabkin er a/. [16] who reported high prevalence of depression in the hypertensive patients. However, this high prevalence of depression may partly be due to the pharmacological treatment of hypertension. The high prevalence of hypertension in depression can be explained on the basis of the theory of sodium-potassium balance in depression. This theory suggests retention of sodium during depression and diuresis of this substance during mania [22]. The low prevalence of musculoskeletal disorders, particularly rheumatoid arthritis, in schizophrenic patients, was evidenced in previous studies as reviewed by Ramsay et al. [4], and most recently Mohamed et al. [9]. In spite of the general trends in the prevalence of the systemic physical illnesses, there can be a considerable sex related difference in specific disorders within a particular system. For example, peptic ulcer was found more prevalent in manic-depressive males than females. Likewise, rheumatoid arthritis was found more common in schizophrenic females than males [4, 181. Male manic-depressive patients were found to have much higher frequency of neurological and gastrointestinal disorders than the females. In contrast, female manic-depressives had twice as much cardiovascular and respiratory diseases as compared with the males. Neuroleptics and lithium may be associated with certain types of neurological, musculoskeletal, endocrinological and other physical symptoms, but causal links are complex and need further exploration. It should be kept in mind that differences in psychopathology, psychopharmacology, genetic dispositions and environmental conditions, including nutrition of these patients, might have affected Manic-depressive outpatients may be less the expression of somatic illnesses. regressed, cognitively impaired, and disorganized, and able to recall and express their
Somatic illness in manic-depressive
and schizophrenic
285
patients
physical symptoms more easily than the schizophrenics. In schizophrenic patients, for example, there is a general assumption that the defense mechanism of repression is minimal. Therefore, emotional conflicts are not expressed through physiological symptoms. Such assumptions, based on psychosomatic theories, remain however speculative and tentative requiring more empirical validation [23]. Epidemiological differences of somatic illness reported in these two groups of patients should be interpreted with caution because of the size of the samples and the method of information obtained. There is a need for comparison of these findings with epidemiologic data of physical disorders in other groups of psychiatric patients. Furthermore, the prevalence of mental disorders such as schizophrenia and manicdepressive illness should be explored in samples of patients suffering from specific physical disorders such as diabetes, hypertension, and rheumatoid arthritis. Acknowledgement-The Lenihan.
authors
gratefully
acknowledge
the
secretarial
assistance
of
Mrs
Valerie
REFERENCES and physical disease. PsycholMed 1979; 9: 61 I-618. 1. BALDWIN JA. Schizophrenia 1980; 21: 887-891. 2. KORANYEK. Somatic illness in psychiatric patients. Psychosomatics patients. Presented at the XIV 3. KRAKOWSKI AJ, ENGELSMANN F. Somatic illness in schizophrenic European Conference on Psychosomatic Research, The Netherlands, 19-25 September 1982 (in press). RA, KRAKOWSKIAJ, RYDZYNSKY S, JAROSZM, ENGELSMANNF, ANANTH J. International 4. RAMSAY comparison of the prevalence of psychosomatic disorders in schizophrenic patients. Psychother Psychosom 1982; 38: 206-220. with various psychoses. Psychosom 5. Ross WD. The assessment of certain vegetative disturbances Med 1950; 12: 171-177. diseases and psychoses. JPsychosom Res 1969; 13: 339-346. 6. PEDDER JR. Psychosomatic arthritis and schizophrenia. J Nerv Ment Dis 1956; 7. PILKINGTON TL. The coincidence of rheumatoid 124: 604. arthritis in schizo8. MELLSOP GW, KOADLOW L, SYRNE J, WHIT~INGHAM S. Absence of rheumatoid phrenia. S Australia NZ JMed 1974; 4: 247-252. of the possible inverse 9. MOHAMED SN, MERSKEY H, KAZARIAN S, DISNEY RF. An investigation relationships between the occurrence of rheumatoid arthritis, osteoarthritis and schizophrenia. Can JPsychiut 1982; 27: 381-383. mania: manic syndromes associated with antecedent 10. KRAUTHAMMER C, KLERMAN GL. Secondary physical illness or drugs. Arch Gen Psych& 1978; 35: 1333-1339. 11. JAMIESONRC, WELLS CE. Manic psychosis in a patient with multiple metastatic brain tumors. J Clin Psych& 1979; 40: 280-283. Sweden. 12. LINDEGARDB. Physical illness in severe depressives and psychiatric alcoholics in Gothenburg, JAffDis 1982; 4: 383-393. 13. RUSSELLJD, JOHNSON GF. Affective disorders, diabetes mellitus and lithium. Austrulia NZ J Psychiat 1981; 15: 349-353. 14. MORLEY JE, SHAFER RB. Thyroid function screening in new psychiatric admissions. Arch Intern Med 1982; 142: 591-593. 15. TSUANG MT, WOOLSON F, FLEMING JA. Causes of death in schizophrenia and manic-depression. Br JPsychiut 1980; 136: 239-242. E, KASS F. Hypertension and DSM III Depression in Psychiatric Outpatients. 16. RABKIN JG, CHARLES Am JPsychiut 1983; 140: 1072-1074. 17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Third Edition) (DSM III). American Psychiatric Association, Washington, D.C., 1980. 18. RAMSAY RA, ANANTH J, ENGELSMANN F, KRAKOWSKI AJ, WITTKOWER ED, GHADIRIAN AM. Schizophrenia and psychosomatic illness. JPsychosom Res 1982; 26: 33-42. 19. GHADIRIAN AM, LALINEC-MICHAUD M, ENGELSMANNF. Early and Late onset of Affective Disorders: Clinical and Family Characteristics (in press).
286
A. M. GHADIRIAN and F. ENCELSMANN
20. Manual for the Classification of Psychiatric Diagnoses, Statistics Canada, Health and Welfare Division. Information Canada (ICD-8) 1969, and (ICD-9) 1978. 21. SPITZER RL, ENDICOTT J, ROBINS E. Research diagnostic criteria. Arch Gen Psychiut 1978; 36: 773-782. 22. BAER L, PLATMANSR, FIEVERR. The role of electrolytes in affective disorders-sodium, potassium and lithium ions. Arch Gen Psychiof 1970; 22: IO&l 13. 23. ENCELSMANNF, ANANTH J, GHALXRIANAM, RAMSAY RA, KRAKOWSKI AJ. Schizophrenia and psychosomatic disorders: a review. In Psychosomatic Medicine (Edited by KRAKOWSKI AJ, KIMBALLCP), pp. 56-67. New York: Plenum, 1983.
0022-3999/85 $3.00 + .OO C 1985 Pergamon Press Ltd.
SOMATIC ILLNESS IN MANIC-DEPRESSIVE SCHIZOPHRENIC
AND
PATIENTS
A. M. GHADIRIAN* and F. ENGELSMANN* (Received 20 July 1984; accepted in revisedform
8 November
1984)
Abstract-The
study compared the presence of somatic illnesses in manic-depressive (n= 100) and schizophrenic patients (n= 156) in the out-patient psychiatric clinics of three general hospitals. The average age of manic-depressive and schizophrenic patients was 40.7 yr and 39.8 yr respectively and did not differ significantly. The sample consisted of both sexes. Among the manic-depressive patients there were 46 males and 54 females. The schizophrenic sample consisted of 84 (54%) males and 72 (46%) females. The result showed that there was a greater rate of the occurrence of physical illnesses in manic-depressive patients as compared to the schizophrenic patients in respect to all the surveyed systemic disorders except for the gastrointestinal diseases. The cardiovascular, neurological and endocrinological diseases were more frequent in the manic-depressives than in the schizophrenic patients. INTRODUCTION
THE PREVALENCE of somatic
disorders in psychiatric populations has been a subject of special interest to many researchers in recent years. The research findings were reviewed by Baldwin [ 11, Korany 121, and Krakowsky et al. [3]. Korany [2] examined the psychiatric literature on the subject in a span of 40 years and noted that about half of the total of 4000 psychiatric patients reviewed suffered from major medical illnesses. Accordingly, physical conditions directly related to psychiatric symptoms were present in 9-42% of the cases. However, he did not list the specific physical illnesses in his review. Ramsay et al. [4] studied schizophrenic patients of six hospitals in three countries. They found a difference between the occurrence of somatic disorders in schizophrenic patients of chronic hospitals as compared to that at general hospitals. The former was lower than the latter. However, the overall findings of the prevalence of somatic disorders, more specifically bronchial asthma and rheumatoid arthritis, were lower in schizophrenic patients than in the general population. Ross [5], in his study of 1608 patients of a chronic mental hospital in the pre-neuroleptic era, found no association between certain somatic disorders and schizophrenia as well as other psychoses. Pedder [6] reported a lower incidence of schizophrenia among patients suffering from peptic ulcer, bronchial asthma, colitis and eczema. A number of researchers have reported a low incidence of rheumatoid arthritis in schizophrenic patients [7, 81. Likewise, Baldwin [l] found a significant reduction in the relative risk of rheumatoid arthritis in schizophrenics. More recently, Mohamed et al. [9] found, in their study *Department of Psychiatry, McGill University, Montreal, Canada. Dr. Ghadirian is Associate Professor and Dr. Engelsmann is Professor, McGill University and on staff at the Royal Victoria Hospital in Montreal. Dr. Ghadirian is also Director of Medical Education, Douglas Hospital Centre. Address reprints to: Dr. A. M. Ghadirian, Douglas Hospital Centre, 6875 Lasalle Blvd., Verdun, Quebec, Canada H4H 1R3. This paper was presented at the 15th European Conference on Psychosomatic Research, London, England, September 1984. 281
282
A. M.
GHADIRIAN
and F. ENGELSMANN
of 111 schizophrenic patients, a negative association between schizophrenia and rheumatoid arthritis. However, studies on the prevalence of physical illness among patients suffering from major affective disorders are quite scarce. Krauthammer and Klerman [lo] reported that manic-depressive illness can occur secondary to drugs, infection, neoplasma, epilepsy and metabolic disorders. Mania, like physical diseases such as hypertension, is viewed as a syndrome with multiple causes. Secondary mania is thus believed to be the consequence of organic dysfunction. The report by Jamison and Wells [l l] is a case in point. A 45 year old man who suffered from metastatic tumors in the right cerebral hemisphere developed a manic episode for the first time. He had no previous history of psychiatric disorders, nor any family history of manic-depressive illness. The manic episode responded favorably to lithium treatment even though the metastatic lesions could not be eliminated. In a study by Lindegard [12], the entire middle-aged male urban population of a Swedish city was evaluated for psychiatric hospitalization for a three-year period. Lindegard found that severe depression correlated positively with infections, myocardial infarctions, asthma and alcohol intoxication. Diabetes mellitus has been found to be associated with affective disorders independent of the use of lithium for treatment [ 131. Lithium, in certain patients, may impair glucose tolerance and cause diabetes. In screening 386 new psychiatric admissions, undiagnosed hypothyroidism was reported to be present in 4 manic-depressive patients admitted to the hospital [14]. Tsuang et al. [15] analyzed the causes of death in a cohort of 200 schizophrenic, 100 manic and 225 depressive patients who were admitted between 1934 and 1944 and were studied 30-40 yr later. The authors reported a significant excess of death due to circulatory system failure in female manics. In the schizophrenic group, both males and females showed a substantial excess of death due to infectious diseases. Rabkin et al. [16] reported 452 psychiatric outpatients diagnosed according to the DSM III criteria [17], that major depressions were three times as common among patients with hypertension as those without hypertension. However, there is a conspicuous rarity of well controlled comparative studies of somatic disorders between the schizophrenic and the manic-depressive patients. OBJECTIVES
Our study explored the prevalence of physical illness among schizophrenics as compared to manic-depressive patients. Differences in the prevalence of the surveyed systemic medical diseases may have implications in the development of psychopathology in these two groups of psychiatric patients. METHOD
Subjects The present study is based on two independent surveys which were carried out on schizophrenic [ 1S] and manic-depressive populations [19]. The former study [18] included patients from psychiatric departments of two general hospitals in Montreal (n = 54) and in Plattsburg (n = 102). The latter study (191 was carried out at the Affective Disorders Clinic of the psychiatric department of the Royal Victoria Hospital. The sample of schizophrenic patients included a total of 156 cases: 84 males and 72 females. Their average age was 39.8 yr, ranging from 20 to 70. In the affective disorders sample there were 100 patients of both sexes (46 males and 54 females). Their average age was 40.7 yr, ranging from 21 to 67.yr. The average age difference between the samples was not significant. Both of the samples consisted of psychiatric outpatients with a wide range of duration of illness who did not show gross organic brain
Somatic
illness in manic-depressive
syndrome. The patients were consecutively to cooperate and if they met the diagnostic
and schizophrenic
patients
included in the study based on their capacity criteria as indicated below in Procedure.
283 and willingness
Procedure In each one of these two surveys a uniform structured questionnaire was completed based on the clinical interview and review of the patient’s file. The questionnaire contained personal, demographic, diagnostic and other clinical data including the presence of a number of physical disorders in the patients and their close relatives. Selection of patients for the study was based on the International Classification of Diseases (ICD-8 and ICD-9) [201 for diagnosis of schizophrenia and manic-depressive illnesses. In addition, the Research Diagnostic Criteria [21] were also used. The present and past somatic illness was ascertained from the patients’ report, medical file and laboratory data.
RESULTS
The results showed a greater rate of occurrence of physical illnesses in manicdepressives as compared to the schizophrenics in respect to all of the surveyed systemic disorders except for gastrointestinal diseases. The cardiovascular, neurological and endocrinological diseases were more frequent in the manic-depressives than in the schizophrenics. Fifty-seven percent of the schizophrenic patients had no systemic physical illnesses as compared to fifty percent of the manic-depressive patients (Table I).
TABLE I.-PHYSICAL
Illness 1. 2. 3. 4. 5. 6. 7. 8. 9.
None Cardiovascular Gastrointestinal Respiratory Neurological Endocrine Gynecological Musculoskeletal Other Missing Information Total
ILLNESS
Schizophrenic n=l56 n % 89 6 10 4 2 9 2 3 19 12 156
57.1 3.8 6.4 2.6 1.3 5.8 1.3 1.9 12.1 7.7 100
Manic-depressive n=lOO n, % 50 9 4 4 4 8 4 3 12 2 100
The analysis of the prevalence of somatic illness in the two groups of patients showed that more manic-depressive males suffered from gastrointestinal disorders as compared with the females. However, the prevalence of this disorder was evenly distributed between the male and female schizophrenic patients. The prevalence of the endocrine and metabolic disorders was higher among the schizophrenic females. Musculoskeletal diseases were more prevalent in manic-depressive females and about the same schizophrenic males and females. The male-female differences in somatic illnesses shown in Table II are based on a smaller sample of schizophrenic patients (n = 102) representing the total population from one study center (in Plattsburg, U.S.A.).
284
A. M. GHADIRIAN and F. ENGELSMANN
TABLE II.-SEX
RELATED
DIFFERENCESOFTHE PREVALENCEOFSOMATK SCHIZOPHRENIC PATIENTS
Illness 1. None 2. Cardiovascular
3. 4. 5. 6. 7. 8. 9.
Gastrointestinal Respiratory Neurological Endocrine and Metabolic Gynecological Musculoskeletal Other Missing Information Total
Schizophrenics Male n % 35 3 4 0 0 2 0 2 5
1 52
67.3 5.8 7.7 0 0 3.8 0 3.8 9.7 1.9 100
(n = 102) Female n % 31 2 4 1 0 4 3 0 5 0 50
62 4 8 2 0 8 6 0 10 0 100
ILLNESSIN MANIC-DEPRESSIVE AND
Manic-depressives (n = 100) Male Female % n % n 24 3 4 1 3 4 0 0 7 0 46
52.2 6.5 8.7 2.2 6.5 8.7 0 0 15.2 0 100
26 6 0 3 1 4 4 3 5 2 54
48.1 11.1 0 5.6 1.9 7.4 1.4 5.6 9.2 3.7 100
DISCUSSION
We found that the absence of somatic illness was greater in the schizophrenic population (57.1 Vo) than in the manic-depressive group (50%). This absence of physical illness was even more conspicuous (78.5%) in a Polish sample of 3 11 schizophrenic patients [4] who were comparable to our sample of schizophrenic patients from general hospitals. Our finding of high prevalence of cardiovascular disease in manic-depressive patients is consistent with the findings of Rabkin er a/. [16] who reported high prevalence of depression in the hypertensive patients. However, this high prevalence of depression may partly be due to the pharmacological treatment of hypertension. The high prevalence of hypertension in depression can be explained on the basis of the theory of sodium-potassium balance in depression. This theory suggests retention of sodium during depression and diuresis of this substance during mania [22]. The low prevalence of musculoskeletal disorders, particularly rheumatoid arthritis, in schizophrenic patients, was evidenced in previous studies as reviewed by Ramsay et al. [4], and most recently Mohamed et al. [9]. In spite of the general trends in the prevalence of the systemic physical illnesses, there can be a considerable sex related difference in specific disorders within a particular system. For example, peptic ulcer was found more prevalent in manic-depressive males than females. Likewise, rheumatoid arthritis was found more common in schizophrenic females than males [4, 181. Male manic-depressive patients were found to have much higher frequency of neurological and gastrointestinal disorders than the females. In contrast, female manic-depressives had twice as much cardiovascular and respiratory diseases as compared with the males. Neuroleptics and lithium may be associated with certain types of neurological, musculoskeletal, endocrinological and other physical symptoms, but causal links are complex and need further exploration. It should be kept in mind that differences in psychopathology, psychopharmacology, genetic dispositions and environmental conditions, including nutrition of these patients, might have affected Manic-depressive outpatients may be less the expression of somatic illnesses. regressed, cognitively impaired, and disorganized, and able to recall and express their
Somatic illness in manic-depressive
and schizophrenic
285
patients
physical symptoms more easily than the schizophrenics. In schizophrenic patients, for example, there is a general assumption that the defense mechanism of repression is minimal. Therefore, emotional conflicts are not expressed through physiological symptoms. Such assumptions, based on psychosomatic theories, remain however speculative and tentative requiring more empirical validation [23]. Epidemiological differences of somatic illness reported in these two groups of patients should be interpreted with caution because of the size of the samples and the method of information obtained. There is a need for comparison of these findings with epidemiologic data of physical disorders in other groups of psychiatric patients. Furthermore, the prevalence of mental disorders such as schizophrenia and manicdepressive illness should be explored in samples of patients suffering from specific physical disorders such as diabetes, hypertension, and rheumatoid arthritis. Acknowledgement-The Lenihan.
authors
gratefully
acknowledge
the
secretarial
assistance
of
Mrs
Valerie
REFERENCES and physical disease. PsycholMed 1979; 9: 61 I-618. 1. BALDWIN JA. Schizophrenia 1980; 21: 887-891. 2. KORANYEK. Somatic illness in psychiatric patients. Psychosomatics patients. Presented at the XIV 3. KRAKOWSKI AJ, ENGELSMANN F. Somatic illness in schizophrenic European Conference on Psychosomatic Research, The Netherlands, 19-25 September 1982 (in press). RA, KRAKOWSKIAJ, RYDZYNSKY S, JAROSZM, ENGELSMANNF, ANANTH J. International 4. RAMSAY comparison of the prevalence of psychosomatic disorders in schizophrenic patients. Psychother Psychosom 1982; 38: 206-220. with various psychoses. Psychosom 5. Ross WD. The assessment of certain vegetative disturbances Med 1950; 12: 171-177. diseases and psychoses. JPsychosom Res 1969; 13: 339-346. 6. PEDDER JR. Psychosomatic arthritis and schizophrenia. J Nerv Ment Dis 1956; 7. PILKINGTON TL. The coincidence of rheumatoid 124: 604. arthritis in schizo8. MELLSOP GW, KOADLOW L, SYRNE J, WHIT~INGHAM S. Absence of rheumatoid phrenia. S Australia NZ JMed 1974; 4: 247-252. of the possible inverse 9. MOHAMED SN, MERSKEY H, KAZARIAN S, DISNEY RF. An investigation relationships between the occurrence of rheumatoid arthritis, osteoarthritis and schizophrenia. Can JPsychiut 1982; 27: 381-383. mania: manic syndromes associated with antecedent 10. KRAUTHAMMER C, KLERMAN GL. Secondary physical illness or drugs. Arch Gen Psych& 1978; 35: 1333-1339. 11. JAMIESONRC, WELLS CE. Manic psychosis in a patient with multiple metastatic brain tumors. J Clin Psych& 1979; 40: 280-283. Sweden. 12. LINDEGARDB. Physical illness in severe depressives and psychiatric alcoholics in Gothenburg, JAffDis 1982; 4: 383-393. 13. RUSSELLJD, JOHNSON GF. Affective disorders, diabetes mellitus and lithium. Austrulia NZ J Psychiat 1981; 15: 349-353. 14. MORLEY JE, SHAFER RB. Thyroid function screening in new psychiatric admissions. Arch Intern Med 1982; 142: 591-593. 15. TSUANG MT, WOOLSON F, FLEMING JA. Causes of death in schizophrenia and manic-depression. Br JPsychiut 1980; 136: 239-242. E, KASS F. Hypertension and DSM III Depression in Psychiatric Outpatients. 16. RABKIN JG, CHARLES Am JPsychiut 1983; 140: 1072-1074. 17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Third Edition) (DSM III). American Psychiatric Association, Washington, D.C., 1980. 18. RAMSAY RA, ANANTH J, ENGELSMANN F, KRAKOWSKI AJ, WITTKOWER ED, GHADIRIAN AM. Schizophrenia and psychosomatic illness. JPsychosom Res 1982; 26: 33-42. 19. GHADIRIAN AM, LALINEC-MICHAUD M, ENGELSMANNF. Early and Late onset of Affective Disorders: Clinical and Family Characteristics (in press).
286
A. M. GHADIRIAN and F. ENCELSMANN
20. Manual for the Classification of Psychiatric Diagnoses, Statistics Canada, Health and Welfare Division. Information Canada (ICD-8) 1969, and (ICD-9) 1978. 21. SPITZER RL, ENDICOTT J, ROBINS E. Research diagnostic criteria. Arch Gen Psychiut 1978; 36: 773-782. 22. BAER L, PLATMANSR, FIEVERR. The role of electrolytes in affective disorders-sodium, potassium and lithium ions. Arch Gen Psychiof 1970; 22: IO&l 13. 23. ENCELSMANNF, ANANTH J, GHALXRIANAM, RAMSAY RA, KRAKOWSKI AJ. Schizophrenia and psychosomatic disorders: a review. In Psychosomatic Medicine (Edited by KRAKOWSKI AJ, KIMBALLCP), pp. 56-67. New York: Plenum, 1983.