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HEARING LOSS IN PARANOID AND AFFECTIVE PSYCHOSES OF THE ELDERLY
Saturday
HEARING LOSS IN PARANOID AND AFFECTIVE PSYCHOSES OF THE ELDERLY A. F. COOPER
A. R. CURRY
D. W. K. KAY
R. F. GARSIDE
M. ROTH
Departments of Psychological Medicine and Otalaryngology, University of Newcastle upon Tyne and Royal Victoria Infirmary, Newcastle upon Tyne Summary
reported association between acquired deafness and paranoid illness The
in the elderly was re-examined. Social deafness and its probable duration was assessed by clinical interviews with patients and relatives and by information from hospital records in sixty-five patients with paranoid psychosis and sixty-seven patients with primary affective disorder. A hundred and eleven of these hundred and thirty-two patients were also tested audiometrically after recovery from the acute phase of the illness, and all those with abnormal audiograms or with evidence of social deafness were examined aurally and an otological diagnosis made. After taking into consideration age and possible selective factors, it was concluded that patients with paranoid psychosis have a more severe degree of hearing loss and are more often socially deaf than patients with affective illness, who probably resemble the general population. The differences seem to be due to a significantly higher proportion of paranoid patients having longstanding, usually severe, bilateral deafness, which is most commonly caused by chronic middle-ear disease. The long interval between the onset of deafness and the onset of psychosis seems to offer opportunities for prevention.
Introduction IT has long been believed that those with hearing loss may undergo changes in personality, and may even have delusions of persecution 12 An association between deafness and paranoid psychosis was reported among elderly patients,3-5 but has not always been confirmed.6 However, in all these studies, hearing was only one factor among many examined, its duration was not always determined, age and type of admission were not carefully controlled, actual hearing loss was not measured, and no otological diagnoses were made. This prompted us to examine the reported association between hearing defects and the paranoid Dsvchoses of later life. 7885
12
October 1974
Patients and Methods All the hundred and thirty-two subjects were or had lately been patients in a psychiatric hospital. None had been mentally ill before the age of 50. Two groups of
diagnosis
were
compared: (1) paranoid psychoses
not
believed to be secondary to any other condition; and (2) affective psychoses. The diagnoses were those made by the hospital consultants. Consecutive admissions.-Sixty-four of the patients were consecutive admissions to the hospital during 1970-71 while the investigation was being carried out, and fortyeight patients had been admitted consecutively to the care of one consultant (Dr H. A. McClelland) during 1966-70. This method of sampling produced a hundred and twelve patients, of whom fifty-three had paranoid psychoses and fifty-nine had affective psychoses.-57% and 46% were first admissions, respectively. Resident patients.-Twenty additional patients who had been in the hospital for more than one year before 1970 The basic were located as a result of a ward survey. sample therefore consisted of a hundred and thirty-two patients-sixty-five with paranoid (nineteen men and fortysix women) and sixty-seven with affective psychoses (twenty-four men and forty-three women).
Group1 A hundred and eleven patients were interviewed (by A. F. C.) and investigated otologically (by A. R. C.). The minimum criterion of deafness was taken to be " difficulty in hearing speech in any part of church/theatre or in group conversation but able to hear speech at close range without aid 11.7 A relative or close friend of the patient was seen in all but five cases. Other sources of information were the psychiatric hospital records and in some the casereports of ear, nose, and throat (E.N.T.) departments. Pure-tone audiometry was performed,8 usually shortly before or after discharge, when the patient had recovered from the effects of electroconvulsive therapy and was able to cooperate fully with the procedure. Testing was done in the audiology unit of the E.N.T. department of the Royal Victoria Infirmary by a senior audiology technician who was unaware of the psychiatric diagnosis. The audiograms were interpreted by A. R. C., who was also unaware of the psychiatric diagnosis. He carried out aural examinations and made an otological diagnosis in every patient who was clinically deaf or had an abnormal audiogram. The remaining patients were regarded as otologically
normal. Normal hearing was defined the limit of social adequacy (<30
as
hearing loss within dB) over the speech
frequency
range (512-2048 Hz) and not greater than 40 dB at the higher frequencies. Sensorineural deafness was divided into three types: (1) presbyacusis, with typical symmetrical sloping curves, and hearing losses of at least p
852 45 dB
8192
at
Hz; (2) acoustic trauma, showing the typical
"
acoustic dip " at 4096 Hz; and (3) other sensorineural defects, with abnormal flat curves, the difference in hearing loss between any two frequencies in one ear not exceeding 25 dB. Conductive deafness was defined as hearing loss of over 30 dB at several frequencies, with a significant air-bone gap (chronic infective middle-ear disease and otosclerosis). In mixed deafness there was evidence of both sensorineural and conductive defects.
Group 2 The above
procedures could not be performed in twentybecause they were dead, refused, were unable to cooperate, or could not be traced after discharge from hospital. Fourteen of these patients were interviewed by A. F. C. but relatives were not, and the psychiatric and social records of the hospital provided the main source of information on the duration of deafness. This group is important, however, because it helps to correct any bias due to selection of patients for audiometry. one
patients
Results
Group Age
and sex.-The sex ratios were similar in the two groups, and there were no significant differences between men and women in hearing loss or social deafness. The data for both sexes have therefore been combined. The mean ages of the diagnostic groups did not differ significantly (paranoid cases 67-3 years [S.D. ± 9.2] and affective cases 69 years [S.D. ± 8.5]), but there was a difference of 4 years in the age of patients who were first admissions (paranoid 63-6 years and affective 67.6 years).
hearing losses for pureeach of the six frequencies
mean
air conduction at tested are shown in table tone
The results in the better-
I.
the worse-hearing ears, but the t test was significant for only 512 Hz. The hearing losses among patients who were first admissions were examined separately (table n). Hearing losses tended to be greater in the paranoid patients, although the differences between the groups were not significant at any of the frequencies. However, when the age difference between the affective and paranoid groups was taken into account, using analyses of covariance, the differences became significant in the better ears for four of the six frequencies tested and for both the means of the hearing losses over the speech frequency range and over the whole range of frequencies. In none of these eight analyses of covariance was the assumption regarding homogeneity of regression vitiated. The results of analyses of covariance were inconclusive in the worse-hearing ears.
1
Audiometry.—The
and affective groups were significant for four of the six frequencies tested and for the means of the three speech frequencies (512, 1024, and 2048 Hz) and of all the frequencies. There was a similar trend in
hearing ears only are shown because, with asymmetrical hearing loss, the hearing in the better ear rather than that in the worse ear may be presumed largely to determine the degree of social handicap in everyday life. In our study the better ear is defined as that with the lower mean hearing loss of all six frequencies. At each frequency the loss was greater in the paranoid than in the affective group. The t test showed that the differences between the better ears in the paranoid
Social deafness.-As in the case of hearing loss, the difference in social deafness between the groups was highly significant (p<:0-01), with twenty-five patients with paranoid psychoses affected but only twelve with affective disorders. The same trend was found among both first admissions and other admissions, although the difference was significant table 11). only between first admissions (<0’05, reflects the correlation This, presumably, imperfect between hearing loss and social deafness.
Comparison with general population.-Strict comparisons with studies of hearing loss in the general population are difficult to make for various reasonse.g., different conditions of testing. The data provided by Wilkins,,’ whose definitions of social deafness we have tried to follow, may, however, be used to calculate the expected numbers of social deafness by applying his rates (sexes combined) to the number of patients in each age-group by diagnosis. Expected numbers may also be calculated for first and other admissions separately (table ill). The results suggest that the frequency of deafness among first admissions does not differ from that in the general population in
TABLE I—COMPARISON OF THE MEAN HEARING LOSSES IN THE PARANOID AND AFFECTIVE GROUPS II
I
I
*
P
(BETTER EARS) I
t P < 0.01.
TABLE II-SOCIAL DEAFNESS AMONG FIRST ADMISSIONS AND OTHER ADMISSIONS IN PARANOID AND AFFECTIVE GROUPS
I
853 TABLE III-OBSERVED AND EXPECTED NUMBERS OF DEAF PATIENTS AMONG CONSECUTIVE FIRST ADMISSIONS AND OTHER ADMISSIONS
. p
t
with affective disorder, whereas deafness is about three times as common as would be expected in patients with paranoid psychoses. Among other admissions, the frequency of deafness appears to be increased in both diagnostic groups, although more so in patients with paranoid psychoses.
patients
Otological diagnosis.-Table iv shows logical diagnosis in the better ears, based on
the otothe aural examinations and audiometric tests. Sensorineural hearing loss was more common in the affective group, and conductive and mixed forms of deafness were more common in the paranoid group (p
after the psychiatric illness, leaving twenty-one paranoid and eight affective patients in whom psychosis This was reported to have antedated the illness. difference is highly significant (r<001). However, to attempt to determine retrospectively the time relation between two events, both of which may begin insidiously and be difficult to date precisely, may be an unreliable exercise. For this reason attention was focused on deafness of early onset-i.e., beginning before the age of 50-which was the earliest age at which any of the patients became psychotic. Whereas there was hardly any difference between the groups after the age of 50, there was a highly significant difference in the frequency of deafness beginning before this age. Fifteen paranoid and only three affective patients had been, so afflicted, several of them since childhood or early adult life. Conductive or mixed deafness was the usual otological diagnosis in these patients, which is of course entirely consistent with a history indicating deafness of many years’ duration. When the groups were separated into first and other admissions, it was found that, although all three affective patients with early-onset deafness were " other admissions ", five of the fifteen paranoid patients were first admissions.
Group 2 To complete the picture the twenty-one patients who, for various reasons, were not fully investigated may be briefly described. According to the information in the hospital records, seven of the eleven paranoid patients had been deaf since before the onset of the psychosis. The cause and exact duration of the deafness were not known, but four of them were very deaf and two wore hearing-aids. The one affective patient who was deaf had been hard-of-hearing since the age of 10. If it had been possible to test these patients audiometrically, the difference in hearing loss between the groups would, presumably, have been even more pronounced than it was.
TABLE IV-OTOLOGICAL DIAGNOSIS IN BETTER EARS
Discussion These
findings confirm previous reports that, in hospital samples at least, patients with paranoid psychoses are more often deaf than those with affective disorders, and they also suggest that the frequency of deafness in affective disorders is similar to that The history and the difference examination have shown that otological between the groups is almost entirely due to severe longstanding hearing loss in the paranoid group, associated with otological disease which is predominantly conductive in type; and this finding has been confirmed in a larger study of psychotic patients with hearing loss, which will be reported elsewhere. The association between established otological disease and paranoid illness seems to render superfluous any detailed consideration of other possible explanations for these findings, such as the effect of E.C.T. or drugs. By far the most important question is whether hospital patients are representative; the deaf might, for example, be preferentially admitted for social or medical reasons. One would expect any selective factors of this kind to apply equally to affective and
found in the general population.
p < 0-05
(with df=2).
Onset of deafness.-The results, so far, relate only the hearing status of the patients at the time of investigation. What we really need to know, however, are the proportions with hearing defects which were already present at the onset of the psychosis, or, if there had been more than one episode, at the time of the first attack. In eight patients, four in each group, the deafness was thought to have originated to
854
paranoid disorders, but fortunately we have some direct evidence on this point. A representative sample consisting of four hundred and sixty-six people aged 65 or over, living at home in Newcastle,-had already been studiedand their psychiatric and physical status assessed. In the whole sample 24 % had hearing loss to some extent, but only 1-7% were severely deaf. None of the three individuals with endogenous depression were deaf; but of seven with paranoid psychosis two were severely and two partially deaf; and of the two who had been hospital inpatients, only one was deaf. The numbers are small, but the findings do not suggest that the association between deafness and paranoid illness is confined to hospital samples, or that the deaf are markedly more likely than the non-deaf to be admitted to hospital. Our results do, however, suggest that, once admitted, the deaf of both diagnostic groups are more likely than the nondeaf to remain in hospital or to be readmitted later. The true frequency of deafness in paranoid illness is, therefore, probably somewhat lower than that found in hospital samples which are not restricted to first admissions. The evidence as a whole does not suggest, however, that the association between deafness and paranoid illness can be explained away by a process of selection. We may conclude with reasonable confidence that there is an excess of patients with paranoid psychoses who are hard of hearing and who have been so since early or middle age. Although the part deafness may play in the xtiology of these illnesses is not understood, the long interval which often elapses before the psychosis becomes manifest seems to indicate that there are opportunities for intervention. Further research into the social and psychological problems of the chronically hard-of-hearing is urgently needed. Hospital, Gosstudy patients admitted under their care; Mr Munro Black, Royal Victoria Infirmary, for access to the audiology unit; Mr F. Hebson for carrying out the audioWe thank the consultant staff of St. Nicholas’
forth, for permission
to
grams ; Miss E. M. Foster and Mr 1. Leitch for technical assistance with data processing; and Mrs E. Taylor and Mrs B. Manley for secretarial help. was carried out while A. F. C. Medical Research Council project grant.
This work
by
a
Requests for reprints should be addressed Department of Psychological Medicine, Infirmary, Newcastle upon Tyne.
was
to
supported
D. W. K. K., Victoria
Royal
REFERENCES
Kraepelin, E. in Psychiatrie; vol. IV, p. 1441. Leipzig, 1915. Houston, F., Royse, A. B. J. ment. Sci. 1954, 100, 990. Kay, D. W. K., Roth, M. ibid. 1961, 107, 649. 4. Post, F. Persistent Persecutory States of the Elderly. London, 1966. 5. McClelland, H. A., Roth, M., Neubauer, H., Garside, R. F. Proc. fourth Wld Congr. Psychiat. 1968, 4, 2955. 6. Sjögren, H. Acta psychiat. scand. 1964, 40, suppl. 176. 7. Wilkins, L. T. The Prevalence of Deafness in the Population of England, Scotland and Wales. Central Office of Information, London, 1948. 8. Pickard, B. in Scott Brown’s Diseases of the Ear, Nose and Throat (edited by J. Ballantyne and J. Groves); vol. 2, chap. 1. London, 1. 2. 3.
1971. 9.
Kay, D. W. K., Bergmann, K., Foster, E. M., McKechnie, A. A., Roth, M. Comp. Psychiat. 1970, 2, 26.
FAMILIAL HODGKIN’S DISEASE: AN ENVIRONMENTAL AND GENETIC DISORDER N. J. VIANNA A. K. POLAN
J. N. P. DAVIES P. WOLFGANG
Cancer Control Bureau, New York State Department of Health, and Department of Pathology, Albany Medical
College, New York, U.S.A. Evaluation of cases of familial Hodgkin’s disease among first-degree bloodrelations suggests that the time-intervals between diagnoses are shorter than the age differences between family members. This and the observation that the time-intervals between diagnoses for relatives living in the same household were shorter than for those living apart are consistent with an environmental aetiology. However, since many familial pairs had the same Rye subtypes at diagnosis, regardless of their relationship or proximity, host reactivity may possibly be related to genetic factors.
Summary
Introduction THERE is growing evidence that environmental factors are important in Hodgkin’s disease 1-4 and that horizontal transmission may occur under certain circumstan.ces 56 The precise role of genetic factors in either predisposing the individual to the development of the disease or its expression remains to be elucidated. Some such role is suggested by the increased susceptibility to Hodgkin’S’ .disease of people with HL-A antigens belonging to the 4C system.’ The relative importance of environmental or genetic factors has been studied in instances of familial Hodgkin’s disease. If Hodgkin’s disease is a genetic disorder with a definite age association, affected siblings might be expected to develop the disease at similar ages.8 In contrast, if an environmental factor, particularly an infectious agent, produces familial clustering of Hodgkin’s disease, then the time-interval between diagnoses of two related cases should be shorter than the age difference. While several cases have been reported in the same family,9-U unfortunately they were based on individual hospital surveys and cases with similar dates of onset were probably more completely ascertained. Putting aside this possible bias, evaluation of sib-sib and parent-child familial cases of Hodgkin’s disease derived from the two largest surveys 9-10 in the above manner suggested that environmental factors were more important than genetic factors. If this is true, an individual in whom Hodgkin’s disease develops, while living in the same household with a relative already diagnosed as having Hodgkin’s disease, is likely to be exposed to common environmental factors. Thus, it would be reasonable to postulate that the time-interval between diagnoses in these patients might be shorter than that for similarly related patients who are not living together. To be compatible with an environmental aetiology, however, the interval between diagnoses should be shorter than the age difference between groups. These hypotheses are evaluated in the present study of familial Hodgkin’s disease.
HEARING LOSS IN PARANOID AND AFFECTIVE PSYCHOSES OF THE ELDERLY A. F. COOPER
A. R. CURRY
D. W. K. KAY
R. F. GARSIDE
M. ROTH
Departments of Psychological Medicine and Otalaryngology, University of Newcastle upon Tyne and Royal Victoria Infirmary, Newcastle upon Tyne Summary
reported association between acquired deafness and paranoid illness The
in the elderly was re-examined. Social deafness and its probable duration was assessed by clinical interviews with patients and relatives and by information from hospital records in sixty-five patients with paranoid psychosis and sixty-seven patients with primary affective disorder. A hundred and eleven of these hundred and thirty-two patients were also tested audiometrically after recovery from the acute phase of the illness, and all those with abnormal audiograms or with evidence of social deafness were examined aurally and an otological diagnosis made. After taking into consideration age and possible selective factors, it was concluded that patients with paranoid psychosis have a more severe degree of hearing loss and are more often socially deaf than patients with affective illness, who probably resemble the general population. The differences seem to be due to a significantly higher proportion of paranoid patients having longstanding, usually severe, bilateral deafness, which is most commonly caused by chronic middle-ear disease. The long interval between the onset of deafness and the onset of psychosis seems to offer opportunities for prevention.
Introduction IT has long been believed that those with hearing loss may undergo changes in personality, and may even have delusions of persecution 12 An association between deafness and paranoid psychosis was reported among elderly patients,3-5 but has not always been confirmed.6 However, in all these studies, hearing was only one factor among many examined, its duration was not always determined, age and type of admission were not carefully controlled, actual hearing loss was not measured, and no otological diagnoses were made. This prompted us to examine the reported association between hearing defects and the paranoid Dsvchoses of later life. 7885
12
October 1974
Patients and Methods All the hundred and thirty-two subjects were or had lately been patients in a psychiatric hospital. None had been mentally ill before the age of 50. Two groups of
diagnosis
were
compared: (1) paranoid psychoses
not
believed to be secondary to any other condition; and (2) affective psychoses. The diagnoses were those made by the hospital consultants. Consecutive admissions.-Sixty-four of the patients were consecutive admissions to the hospital during 1970-71 while the investigation was being carried out, and fortyeight patients had been admitted consecutively to the care of one consultant (Dr H. A. McClelland) during 1966-70. This method of sampling produced a hundred and twelve patients, of whom fifty-three had paranoid psychoses and fifty-nine had affective psychoses.-57% and 46% were first admissions, respectively. Resident patients.-Twenty additional patients who had been in the hospital for more than one year before 1970 The basic were located as a result of a ward survey. sample therefore consisted of a hundred and thirty-two patients-sixty-five with paranoid (nineteen men and fortysix women) and sixty-seven with affective psychoses (twenty-four men and forty-three women).
Group1 A hundred and eleven patients were interviewed (by A. F. C.) and investigated otologically (by A. R. C.). The minimum criterion of deafness was taken to be " difficulty in hearing speech in any part of church/theatre or in group conversation but able to hear speech at close range without aid 11.7 A relative or close friend of the patient was seen in all but five cases. Other sources of information were the psychiatric hospital records and in some the casereports of ear, nose, and throat (E.N.T.) departments. Pure-tone audiometry was performed,8 usually shortly before or after discharge, when the patient had recovered from the effects of electroconvulsive therapy and was able to cooperate fully with the procedure. Testing was done in the audiology unit of the E.N.T. department of the Royal Victoria Infirmary by a senior audiology technician who was unaware of the psychiatric diagnosis. The audiograms were interpreted by A. R. C., who was also unaware of the psychiatric diagnosis. He carried out aural examinations and made an otological diagnosis in every patient who was clinically deaf or had an abnormal audiogram. The remaining patients were regarded as otologically
normal. Normal hearing was defined the limit of social adequacy (<30
as
hearing loss within dB) over the speech
frequency
range (512-2048 Hz) and not greater than 40 dB at the higher frequencies. Sensorineural deafness was divided into three types: (1) presbyacusis, with typical symmetrical sloping curves, and hearing losses of at least p
852 45 dB
8192
at
Hz; (2) acoustic trauma, showing the typical
"
acoustic dip " at 4096 Hz; and (3) other sensorineural defects, with abnormal flat curves, the difference in hearing loss between any two frequencies in one ear not exceeding 25 dB. Conductive deafness was defined as hearing loss of over 30 dB at several frequencies, with a significant air-bone gap (chronic infective middle-ear disease and otosclerosis). In mixed deafness there was evidence of both sensorineural and conductive defects.
Group 2 The above
procedures could not be performed in twentybecause they were dead, refused, were unable to cooperate, or could not be traced after discharge from hospital. Fourteen of these patients were interviewed by A. F. C. but relatives were not, and the psychiatric and social records of the hospital provided the main source of information on the duration of deafness. This group is important, however, because it helps to correct any bias due to selection of patients for audiometry. one
patients
Results
Group Age
and sex.-The sex ratios were similar in the two groups, and there were no significant differences between men and women in hearing loss or social deafness. The data for both sexes have therefore been combined. The mean ages of the diagnostic groups did not differ significantly (paranoid cases 67-3 years [S.D. ± 9.2] and affective cases 69 years [S.D. ± 8.5]), but there was a difference of 4 years in the age of patients who were first admissions (paranoid 63-6 years and affective 67.6 years).
hearing losses for pureeach of the six frequencies
mean
air conduction at tested are shown in table tone
The results in the better-
I.
the worse-hearing ears, but the t test was significant for only 512 Hz. The hearing losses among patients who were first admissions were examined separately (table n). Hearing losses tended to be greater in the paranoid patients, although the differences between the groups were not significant at any of the frequencies. However, when the age difference between the affective and paranoid groups was taken into account, using analyses of covariance, the differences became significant in the better ears for four of the six frequencies tested and for both the means of the hearing losses over the speech frequency range and over the whole range of frequencies. In none of these eight analyses of covariance was the assumption regarding homogeneity of regression vitiated. The results of analyses of covariance were inconclusive in the worse-hearing ears.
1
Audiometry.—The
and affective groups were significant for four of the six frequencies tested and for the means of the three speech frequencies (512, 1024, and 2048 Hz) and of all the frequencies. There was a similar trend in
hearing ears only are shown because, with asymmetrical hearing loss, the hearing in the better ear rather than that in the worse ear may be presumed largely to determine the degree of social handicap in everyday life. In our study the better ear is defined as that with the lower mean hearing loss of all six frequencies. At each frequency the loss was greater in the paranoid than in the affective group. The t test showed that the differences between the better ears in the paranoid
Social deafness.-As in the case of hearing loss, the difference in social deafness between the groups was highly significant (p<:0-01), with twenty-five patients with paranoid psychoses affected but only twelve with affective disorders. The same trend was found among both first admissions and other admissions, although the difference was significant table 11). only between first admissions (<0’05, reflects the correlation This, presumably, imperfect between hearing loss and social deafness.
Comparison with general population.-Strict comparisons with studies of hearing loss in the general population are difficult to make for various reasonse.g., different conditions of testing. The data provided by Wilkins,,’ whose definitions of social deafness we have tried to follow, may, however, be used to calculate the expected numbers of social deafness by applying his rates (sexes combined) to the number of patients in each age-group by diagnosis. Expected numbers may also be calculated for first and other admissions separately (table ill). The results suggest that the frequency of deafness among first admissions does not differ from that in the general population in
TABLE I—COMPARISON OF THE MEAN HEARING LOSSES IN THE PARANOID AND AFFECTIVE GROUPS II
I
I
*
P
(BETTER EARS) I
t P < 0.01.
TABLE II-SOCIAL DEAFNESS AMONG FIRST ADMISSIONS AND OTHER ADMISSIONS IN PARANOID AND AFFECTIVE GROUPS
I
853 TABLE III-OBSERVED AND EXPECTED NUMBERS OF DEAF PATIENTS AMONG CONSECUTIVE FIRST ADMISSIONS AND OTHER ADMISSIONS
. p
t
with affective disorder, whereas deafness is about three times as common as would be expected in patients with paranoid psychoses. Among other admissions, the frequency of deafness appears to be increased in both diagnostic groups, although more so in patients with paranoid psychoses.
patients
Otological diagnosis.-Table iv shows logical diagnosis in the better ears, based on
the otothe aural examinations and audiometric tests. Sensorineural hearing loss was more common in the affective group, and conductive and mixed forms of deafness were more common in the paranoid group (p
after the psychiatric illness, leaving twenty-one paranoid and eight affective patients in whom psychosis This was reported to have antedated the illness. difference is highly significant (r<001). However, to attempt to determine retrospectively the time relation between two events, both of which may begin insidiously and be difficult to date precisely, may be an unreliable exercise. For this reason attention was focused on deafness of early onset-i.e., beginning before the age of 50-which was the earliest age at which any of the patients became psychotic. Whereas there was hardly any difference between the groups after the age of 50, there was a highly significant difference in the frequency of deafness beginning before this age. Fifteen paranoid and only three affective patients had been, so afflicted, several of them since childhood or early adult life. Conductive or mixed deafness was the usual otological diagnosis in these patients, which is of course entirely consistent with a history indicating deafness of many years’ duration. When the groups were separated into first and other admissions, it was found that, although all three affective patients with early-onset deafness were " other admissions ", five of the fifteen paranoid patients were first admissions.
Group 2 To complete the picture the twenty-one patients who, for various reasons, were not fully investigated may be briefly described. According to the information in the hospital records, seven of the eleven paranoid patients had been deaf since before the onset of the psychosis. The cause and exact duration of the deafness were not known, but four of them were very deaf and two wore hearing-aids. The one affective patient who was deaf had been hard-of-hearing since the age of 10. If it had been possible to test these patients audiometrically, the difference in hearing loss between the groups would, presumably, have been even more pronounced than it was.
TABLE IV-OTOLOGICAL DIAGNOSIS IN BETTER EARS
Discussion These
findings confirm previous reports that, in hospital samples at least, patients with paranoid psychoses are more often deaf than those with affective disorders, and they also suggest that the frequency of deafness in affective disorders is similar to that The history and the difference examination have shown that otological between the groups is almost entirely due to severe longstanding hearing loss in the paranoid group, associated with otological disease which is predominantly conductive in type; and this finding has been confirmed in a larger study of psychotic patients with hearing loss, which will be reported elsewhere. The association between established otological disease and paranoid illness seems to render superfluous any detailed consideration of other possible explanations for these findings, such as the effect of E.C.T. or drugs. By far the most important question is whether hospital patients are representative; the deaf might, for example, be preferentially admitted for social or medical reasons. One would expect any selective factors of this kind to apply equally to affective and
found in the general population.
p < 0-05
(with df=2).
Onset of deafness.-The results, so far, relate only the hearing status of the patients at the time of investigation. What we really need to know, however, are the proportions with hearing defects which were already present at the onset of the psychosis, or, if there had been more than one episode, at the time of the first attack. In eight patients, four in each group, the deafness was thought to have originated to
854
paranoid disorders, but fortunately we have some direct evidence on this point. A representative sample consisting of four hundred and sixty-six people aged 65 or over, living at home in Newcastle,-had already been studiedand their psychiatric and physical status assessed. In the whole sample 24 % had hearing loss to some extent, but only 1-7% were severely deaf. None of the three individuals with endogenous depression were deaf; but of seven with paranoid psychosis two were severely and two partially deaf; and of the two who had been hospital inpatients, only one was deaf. The numbers are small, but the findings do not suggest that the association between deafness and paranoid illness is confined to hospital samples, or that the deaf are markedly more likely than the non-deaf to be admitted to hospital. Our results do, however, suggest that, once admitted, the deaf of both diagnostic groups are more likely than the nondeaf to remain in hospital or to be readmitted later. The true frequency of deafness in paranoid illness is, therefore, probably somewhat lower than that found in hospital samples which are not restricted to first admissions. The evidence as a whole does not suggest, however, that the association between deafness and paranoid illness can be explained away by a process of selection. We may conclude with reasonable confidence that there is an excess of patients with paranoid psychoses who are hard of hearing and who have been so since early or middle age. Although the part deafness may play in the xtiology of these illnesses is not understood, the long interval which often elapses before the psychosis becomes manifest seems to indicate that there are opportunities for intervention. Further research into the social and psychological problems of the chronically hard-of-hearing is urgently needed. Hospital, Gosstudy patients admitted under their care; Mr Munro Black, Royal Victoria Infirmary, for access to the audiology unit; Mr F. Hebson for carrying out the audioWe thank the consultant staff of St. Nicholas’
forth, for permission
to
grams ; Miss E. M. Foster and Mr 1. Leitch for technical assistance with data processing; and Mrs E. Taylor and Mrs B. Manley for secretarial help. was carried out while A. F. C. Medical Research Council project grant.
This work
by
a
Requests for reprints should be addressed Department of Psychological Medicine, Infirmary, Newcastle upon Tyne.
was
to
supported
D. W. K. K., Victoria
Royal
REFERENCES
Kraepelin, E. in Psychiatrie; vol. IV, p. 1441. Leipzig, 1915. Houston, F., Royse, A. B. J. ment. Sci. 1954, 100, 990. Kay, D. W. K., Roth, M. ibid. 1961, 107, 649. 4. Post, F. Persistent Persecutory States of the Elderly. London, 1966. 5. McClelland, H. A., Roth, M., Neubauer, H., Garside, R. F. Proc. fourth Wld Congr. Psychiat. 1968, 4, 2955. 6. Sjögren, H. Acta psychiat. scand. 1964, 40, suppl. 176. 7. Wilkins, L. T. The Prevalence of Deafness in the Population of England, Scotland and Wales. Central Office of Information, London, 1948. 8. Pickard, B. in Scott Brown’s Diseases of the Ear, Nose and Throat (edited by J. Ballantyne and J. Groves); vol. 2, chap. 1. London, 1. 2. 3.
1971. 9.
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FAMILIAL HODGKIN’S DISEASE: AN ENVIRONMENTAL AND GENETIC DISORDER N. J. VIANNA A. K. POLAN
J. N. P. DAVIES P. WOLFGANG
Cancer Control Bureau, New York State Department of Health, and Department of Pathology, Albany Medical
College, New York, U.S.A. Evaluation of cases of familial Hodgkin’s disease among first-degree bloodrelations suggests that the time-intervals between diagnoses are shorter than the age differences between family members. This and the observation that the time-intervals between diagnoses for relatives living in the same household were shorter than for those living apart are consistent with an environmental aetiology. However, since many familial pairs had the same Rye subtypes at diagnosis, regardless of their relationship or proximity, host reactivity may possibly be related to genetic factors.
Summary
Introduction THERE is growing evidence that environmental factors are important in Hodgkin’s disease 1-4 and that horizontal transmission may occur under certain circumstan.ces 56 The precise role of genetic factors in either predisposing the individual to the development of the disease or its expression remains to be elucidated. Some such role is suggested by the increased susceptibility to Hodgkin’S’ .disease of people with HL-A antigens belonging to the 4C system.’ The relative importance of environmental or genetic factors has been studied in instances of familial Hodgkin’s disease. If Hodgkin’s disease is a genetic disorder with a definite age association, affected siblings might be expected to develop the disease at similar ages.8 In contrast, if an environmental factor, particularly an infectious agent, produces familial clustering of Hodgkin’s disease, then the time-interval between diagnoses of two related cases should be shorter than the age difference. While several cases have been reported in the same family,9-U unfortunately they were based on individual hospital surveys and cases with similar dates of onset were probably more completely ascertained. Putting aside this possible bias, evaluation of sib-sib and parent-child familial cases of Hodgkin’s disease derived from the two largest surveys 9-10 in the above manner suggested that environmental factors were more important than genetic factors. If this is true, an individual in whom Hodgkin’s disease develops, while living in the same household with a relative already diagnosed as having Hodgkin’s disease, is likely to be exposed to common environmental factors. Thus, it would be reasonable to postulate that the time-interval between diagnoses in these patients might be shorter than that for similarly related patients who are not living together. To be compatible with an environmental aetiology, however, the interval between diagnoses should be shorter than the age difference between groups. These hypotheses are evaluated in the present study of familial Hodgkin’s disease.