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Is paranoid illness associated with sensory defects in the elderly?
Journalof PsychosomoticRereorch, Printed in Great Britain.
IS PARANOID
Vol. 25, No. 2, pp. 69-74,
ILLNESS
DEFECTS
1981,
0022.3999/81/0200694?6 $02.00/0 Pergamon Press Ltd.
ASSOCIATED
WITH SENSORY
IN THE ELDERLY? N. C. MOORE*
(First received 24 April 1980; accepted in revisedform 4 October 1980) Abstract-A study of 340 elderly psychiatric patients did not show the expected association between paranoid illness and sensory defects. Neither the blind nor the deaf had an increased incidence of paranoid illness. Although the blind had more than the expected number of delusions of persecution and organically based psychiatric illnesses, analysis of covariance showed that these findings were due to their increased age and not to the sensory defect. The deaf had fewer delusions of guilt and affective disorders than the hearing. If this last finding is generally true then previous comparisons of paranoid and affective disorders of the deaf may have led to erroneous conclusions. A decreased incidence of affective disorders would have led to an apparent, not real, increase in paranoid disorders.
MOST investigators of sensory defects and psychiatric illness of the elderly have studied paranoid patients and used the affectively ill as controls. Kay and Roth [I] found that, although visual defects were equally prevalent, hearing defects were more common in paranoid patients than in patients with affective and organic disorders. A series of related studies of the same group of elderly paranoid patients [2-51 showed that there was significantly more deafness and blindness than among affectively ill controls. Two studies of elderly schizophrenics used similar controls. One [6] found that physical defects, including deafness and blindness, were equally common while the other [7] found all of them more common in the schizophrenics. The interpretation of these results has always been that there is more deafness than expected among the paranoid. An equally valid interpretation would have been that there is less deafness than expected among the affectively ill. The evidence for the correlation between paranoid illness and deafness is less convincing when considering studies of the deaf compared with hearing controls. Houston and Royse, in an English study [8], found that paranoid schizophrenia was more common among 40 deaf psychotic patients than 40 hearing controls. Most suffered from different forms of schizophrenia (32 deaf and 25 controls) and few had depression (3 deaf and 1 control). The rest were of organic aetiology. Although matched for age, some of the patients had been deaf from birth or infancy. Sjogren, in Scandinavia [9], found no such association between hearing difficulties and paraphrenic illness. More surprising still, he found that the blind had fewer paraphrenic illnesses than the seeing. Both deaf and blind suffered more organic illnesses than those with their senses intact. The most noteworthy finding was that both the deaf and the blind had fewer affective illnesses than expected. The difference in these two studies may have been genetic: the English may be more vulnerable to paranoid illness when deaf than the Scandinavians. A more likely explanation is the difference in age of the populations studied. Hearing disorders of early onset and long duration may cause an increase in psychiatric illness including paranoid disorders, while hearing losses occurring in old age may not. Sjogren’s patients were *From the Royal Air Force Hospital,
Wegberg,
BFPO 40, Germany. 69
70
N. C. MOORE
all over the age of 55 and would have included a larger proportion whose deafness was recent. The aim of the present investigation was to discover: (1) whether affective illnesses were less common than expected in the deaf and blind; (2) whether paranoid illnesses were more common than expected in the deaf and blind; (3) to confirm or deny the validity of the widely held view that there is a correlation between paranoid illness and sensory defects. METHODS A study of all patients over the age of 60 who were admitted to the Bethlem Royal and Maudsley Hospitals during the triennium 1970-1972 was carried out by referring to Item Sheets and case records. Kendell [lo] described the Item Sheet as follows: “It is a record of some 300 items of information covering the same ground as the clinical notes-the patient’s family history, past personal history and premorbid personality and the aetiology, symptomatology, treatment and outcome of the illness. It is completed by the responsible registrar at the time of the patient’s discharge and only those admitted for less than 72 hours are exempt. Regardless of individual nosological preferences every patient is allocated to one of the diagnostic categories of the International Classification of Diseases [l 11. These data are transferred routinely to punched cards, which thus constitute an almost unique source of information, both comprehensive and readily accessible.” Kendell expressed some reservations about the Item Sheets: “Item Sheets are filled in as a routine task by a changing population of junior medical staff, with no personal interest in the uses to which they may be subsequently be put. This situation is conducive to carelessness. . . The same situation, however, serves to minimise the danger of the data being biased by the convictions of the raters. . In essence systematic error is reduced at the expense of an increase in random error”. However, the mean positive agreement, a measure of inter-observer reliability (between Kendell and a registrar where at least one of them rated the item present), was 43% which although poor is no worse than that found in studies of experienced psychiatrists. An estimate of testretest reliability by comparing registrars’ ratings of patients on admission with Item Sheets completed on discharge showed a mean positive agreement of 52%, which was thought acceptable especially since some symptomatology would have changed anyway. Agreement on diagnosis was much higher: 76% for both kinds of reliability. The present investigator was privileged to have access to all Item Sheet information. The data being provided at the time of the illness were not retrospective. However, the design of the Item Sheet had to be accepted as it stood. For example, there was a single entry “deaf or blind (complete or partial)” for recording both defects. The deafness and blindness was a clinical assessment by the registrar in charge of the case. All other symptoms were graded as severe or moderate. There were 340 patients admitted during the triennium. Eleven of these had to be excluded because it was not possible to confirm from their medical records which of the two sensory defects they had. Twenty-two patients (17 women, 5 men) had a hearing defect, 12 (9 women, 3 men) a visual one, 14 (10 women, 4 men) had both and 281 (187 women, 94 men) neither. The deaf were compared with the hearing, and the blind with the seeing, for each symptom in Table 1 and for each diagnosis in Table 2. In each comparison the control group was the remainder of the 329 patients in the study. In all comparisons the males and females were combined as there were no significant differences in the proportions of men to women in the deaf, blind and the rest. The mean age of the deaf was 73.8 years (standard deviation 7.9). of the blind 74.5 years (S.D. 8.9), and of the rest 68.1 years (S.D. 6.8). Student’s t-test showed that the deaf and the blind were significantly (P< 0.01) older than those with intact senses. Socio-economic class did not differ significantly in the sensorily impaired and non-impaired. The mean for the deaf was 4.3 (S.D. 1.7). for the blind 4.1 (S.D. I .5), and for the rest 4.0 (S.D. 1.9). Tests of significance for delusions of guilt and impaired memory were made by the chi-squared test using the three degrees of severity of symptoms: none, moderate and severe. For the remaining symptoms in Table 1, because the numbers were smaller, the moderate and severe groups were combined and Fisher’s exact test done. All the statistical analyses of Table 2 were made by Fisher’s exact test. RESULTS The deaf had fewer than expected (P< 0.01) delusions of guilt (Table 1). The blind had more (P < 0.05) delusions of persecution than their controls but analysis of covariance showed that this was due to their increased age and not to the sensory defect. The deaf had fewer than expected (P < 0.05) affective psychoses (Table 2). The blind had more (P < 0.05) organically based psychiatric illnesses than their controls but again analysis of covariance
Is paranoid
illness associated
with sensory defects in the elderly?
71
TABLE I.-COMPARISONSOFSYMPTOMSOFDEAFANDBLINDPATIENTS
22 Deaf
12 Blind
14 Both
281 No defects
Symptom
M*
S*
M
S
M
S
M
S
Ideas of reference Delusions of guilt Obsessional fears Delusions of bodily change Delusions of passivity Delusions of persecution Sexual delusions or morbid Other delusions Impaired memory Disorientation Auditory hallucinations Other hallucinations Organic lesions of C.N.S.
1 I 1 1 0 2 1 4 4 2 0
3 1 1 1 2 5 0 0 6 4 4 2
1 0 0 0 0 2 0
2 3 1 0 1 4
1 2 1
0 1 0
I
0
0 1
0 4
1
0
0
1
2 4 3 3
0 5 0 0
1 5 4 0
25 67 25 15 IO 25 4 14 55 36 15
1
1
0
8
20 58 12 13 7 31 12 25 68 46 20 13
*M, moderately
jealousy
1
2
1 1 1
9
severe symptom;
4
6
91
S, severe symptom.
TABLE 2.-CohiPAatsoNs
OFDIAGNOSESINDEAFANDBLINDPATIENTS
Diagnosis
22 Deaf
12 Blind
14 Both
4 0 2 2 1
7 0 0 4
1
2 0 0 0
Psychiatric disorders of organic aetiology Non-paranoid schizophrenia (category 295 except 295.3) Paranoid disorders (category 295.3; 297.1; 298.3; 301 .O) Affective psychoses (category 296) Reactive psychoses (category 298 except 298.3) Depressive neuroses (category 300.4) All other neuroses (category 300 except 300.4) Personality disorders (category 301 except 301 .O) No psychiatric illness (category 3 17.0)
0 1 1
1
281 No defects 59 6 20 121 13 50 10
1 1
showed that this was due to their increased age and not to the sensory defect. There were no significant correlations between sensory defects and paranoid disorders before or after correction for age, even though paranoid disorders were themselves associated with age.
DISCUSSION
AND CONCLUSIONS
Some of the findings are unexpected. One explanation could be that the sample of patients studied is atypical. Previously published figures show that, at least in the incidence of sensory defects, this is not so. The 20% paranoid who were deaf in this study compared with 15 11, 91 and 30 [12] in previous studies. The 6% of affectives who were deaf compared with 7 [l]. 12 [9] and 2 [13]. The results for the blind were also fairly typical. The 7% paranoid who were blind compared with 7 [l] and 15 [9). The 5% affectives who were blind compared with 6 [ 131 and 9 [9]. It was very striking in this investigation that both delusions of guilt and affective disorders in the deaf were significantly less common than in the hearing. The same was true of affective disorders in Sjogren’s study [9], which is one of the few that compared those with and without sensory defects within psychiatric diagnoses, as in the present investigation. The widely held view that paranoid disorders are more frequent in the deaf may be only partly correct. In any comparison of paranoid
72
N. C. MOORE
with affective disorders a low incidence of the latter would result in an apparent increase of the former. There is no agreement about whether the incidence of paranoid illness is increased in the blind. Two studies of paranoid disorders 14, 71 found an increased proportion of blindness while two others [ 1, 61 found that the proportions were the same as in affective disorders. In the present study, although the incidence of delusions of persecution was greater in the blind, this was due to their increased age. Delusions of persecution in the blind were associated with sexual delusions and impaired memory (Table 3). The incidence of paranoid disorders did not differ significantly from normal whereas Sjogren [9] found fewer than expected paraphrenic illnesses in the blind. At first sight it is not surprising that organically based illnesses are more common in the blind. The same organic process might cause both the blindness and the psychiatric illness. Sjogren [9] and Kay er al. [14] found an association between organically based psychiatric illness and both deafness and blindness. In this investigation those with sensory defects were matched for age with the controls, in as much as they were all over the age of 60. However, the deaf and blind were on average about 5 years older than the control group. After correction for age, the increased incidence of organically based psychiatric illness in the blind disappeared, showing that it was an artefact due to their greater age. Age did not contribute to the finding of fewer than expected affective disorders in the deaf. Within this sample of patients the difference between age distributions of the deaf and non-deaf did not reach significance. Why did the deaf have fewer delusions of guilt and affective psychoses? Maybe a sense of guilt was less likely to develop in the deaf than the hearing because they had an obvious reason for feeling depressed, making it unnecessary to blame themselves for the illness. When the deaf did infrequently develop delusions of guilt they were associated with delusions of passivity, ideas of reference and obsessional fears (Table 3), suggesting that in them it was more part of a paranoid or schizophrenic illness than an affective one. This study has shown how the variable of age obscures the issues when trying to understand the relationship between sensory defects and psychiatric illness. Even matching for over the age of 60 was insufficient. A difference of only 5 years caused an increase in delusions of persecution and organic illness in the blind. Deafness and blindness increase with age and so do certain psychiatric symptoms and illnesses, including delusions of persecution, paranoid disorders and organic psychoses. In the elderly many cases of deafness and blindness are recent and not so deleterious to mental health as prolonged sensory impairment. Apart from the duration of such handicaps the timing of onset would also be vital; being deaf and blind before the development of communication and before the character or personality have formed would probably be more harmful than being sensorily impaired after maturity. The crucial difference between this study and most others is that the comparisons are not of affective with paranoid patients. This has shown up the possibility that there is a decreased incidence of affective psychoses and delusion of guilt in the deaf. If these findings are replicated by others, it will suggest that previous interpretations of the difference in the incidence of paranoid and affective disorders in those with sensory impairment was, at least partly, erroneous.
Is paranoid
illness associated
with sensory defects in the elderly?
I--
AJOUEU paJ!odwI
I
AIlpoq ,o s”ols”,aO
s,tJa,
,ouolssasqO
I
I
I
I
I
73
74
N. C. MOORE
Acknowledgement-1 thank Dr. R. Levy, Consultant Psychiatrist, Bethlem Royal and Maudsley Hospital, ior suggesting the subject for study, for his advice in carrying it out and for his valuable criticism of the manuscript. REFERENCES and hereditary factors in the schizophrenias of old age 1. KAY D. W. K. and ROTH M. Environmental (“Late paraphrenia”) and their bearing on the general problem of causation in schizophrenia. J. Ment. SC;. 107,649-686 (1961). 2. COOPER A. F., CURRY A. R., KAY D. W. K., GARSIDE R. F. and ROTH M. Hearing loss in paranoid and affective psychosis of the elderly. Lancer 2,851-854 (1974). 3. COOPER A. F. and CURRY A. R. The pathology of deafness in the paranoid and affective psychoses of later life. Psychosom. Res. 20,97-105 (1976). in the paranoid and affective 4. COOPER A. F. and PORTER R. Visual acuity and ocular pathology psychosis of later life. J. Psychosom. Res. 20, 107-I 14 (1976). of paranoid from 5. KAY D. W. K., COOPER A. F., GARSIDE R. F. and ROTH M. The differentiation affective psychoses by patients’ premorbid characteristics. Er. J. Psychiut. 129, 207-215 (1976). on a case 6. MCCLELLAND H. A., ROTH M., NEUBAUER H. and GARSIDE R. F. Some observations material based on patients with common schizophrenic symptoms. Proceedings of the Fourth World Congress on Psychiatry, Vol. 4, pp. 2955-2957. Excerpta Medica Foundation, London (1968). zabolevaniya 7. ROTH M. and MCCLELLAND H. A. Sensory defekty, fizichesky urodstva i somatichesky pri schizophrenli (Sensory defects, physical deformity and somatic illness in schizophrenics). Vest. Acad. nauk. SSSR Med. 5,77-79 (1971). between deafness and psychotic illness. J. Ment. Sci. 100, 8. HOUSTON F. and ROYSE A. B. Relationship 990-993 (1954). melancholic and psychoneurotic states in the pre-senile/senile period of life. 9. SJ~GREN H. Paraphrenic, Actapsychiat. stand. 40, Suppl. 176 (1964). 10. KENDELL R. E. The Classification of Depressive Illnesses. Maudsley Monograph No. 18. Oxford University Press, London (1968). II. REGISTRAR GENERAL. Studies on Medical and Population Subjects, No, 22. H.M.S.O., London (1968). 12. POST F. Persistent Persecutory States of the Elderly. Pergamon Press, Oxford (1966). 13. POST F. The Significance of Affective Symptoms in Old Age. Maudsley Monograph No. 10. Oxford University Press, London (1962). 14. KAY D. W. K., BEAMISH P. and ROTH M. Old age mental disorders in Newcastle-upon-Tyne. Br. J. Psychiat. 110,668%682 (1964).
IS PARANOID
Vol. 25, No. 2, pp. 69-74,
ILLNESS
DEFECTS
1981,
0022.3999/81/0200694?6 $02.00/0 Pergamon Press Ltd.
ASSOCIATED
WITH SENSORY
IN THE ELDERLY? N. C. MOORE*
(First received 24 April 1980; accepted in revisedform 4 October 1980) Abstract-A study of 340 elderly psychiatric patients did not show the expected association between paranoid illness and sensory defects. Neither the blind nor the deaf had an increased incidence of paranoid illness. Although the blind had more than the expected number of delusions of persecution and organically based psychiatric illnesses, analysis of covariance showed that these findings were due to their increased age and not to the sensory defect. The deaf had fewer delusions of guilt and affective disorders than the hearing. If this last finding is generally true then previous comparisons of paranoid and affective disorders of the deaf may have led to erroneous conclusions. A decreased incidence of affective disorders would have led to an apparent, not real, increase in paranoid disorders.
MOST investigators of sensory defects and psychiatric illness of the elderly have studied paranoid patients and used the affectively ill as controls. Kay and Roth [I] found that, although visual defects were equally prevalent, hearing defects were more common in paranoid patients than in patients with affective and organic disorders. A series of related studies of the same group of elderly paranoid patients [2-51 showed that there was significantly more deafness and blindness than among affectively ill controls. Two studies of elderly schizophrenics used similar controls. One [6] found that physical defects, including deafness and blindness, were equally common while the other [7] found all of them more common in the schizophrenics. The interpretation of these results has always been that there is more deafness than expected among the paranoid. An equally valid interpretation would have been that there is less deafness than expected among the affectively ill. The evidence for the correlation between paranoid illness and deafness is less convincing when considering studies of the deaf compared with hearing controls. Houston and Royse, in an English study [8], found that paranoid schizophrenia was more common among 40 deaf psychotic patients than 40 hearing controls. Most suffered from different forms of schizophrenia (32 deaf and 25 controls) and few had depression (3 deaf and 1 control). The rest were of organic aetiology. Although matched for age, some of the patients had been deaf from birth or infancy. Sjogren, in Scandinavia [9], found no such association between hearing difficulties and paraphrenic illness. More surprising still, he found that the blind had fewer paraphrenic illnesses than the seeing. Both deaf and blind suffered more organic illnesses than those with their senses intact. The most noteworthy finding was that both the deaf and the blind had fewer affective illnesses than expected. The difference in these two studies may have been genetic: the English may be more vulnerable to paranoid illness when deaf than the Scandinavians. A more likely explanation is the difference in age of the populations studied. Hearing disorders of early onset and long duration may cause an increase in psychiatric illness including paranoid disorders, while hearing losses occurring in old age may not. Sjogren’s patients were *From the Royal Air Force Hospital,
Wegberg,
BFPO 40, Germany. 69
70
N. C. MOORE
all over the age of 55 and would have included a larger proportion whose deafness was recent. The aim of the present investigation was to discover: (1) whether affective illnesses were less common than expected in the deaf and blind; (2) whether paranoid illnesses were more common than expected in the deaf and blind; (3) to confirm or deny the validity of the widely held view that there is a correlation between paranoid illness and sensory defects. METHODS A study of all patients over the age of 60 who were admitted to the Bethlem Royal and Maudsley Hospitals during the triennium 1970-1972 was carried out by referring to Item Sheets and case records. Kendell [lo] described the Item Sheet as follows: “It is a record of some 300 items of information covering the same ground as the clinical notes-the patient’s family history, past personal history and premorbid personality and the aetiology, symptomatology, treatment and outcome of the illness. It is completed by the responsible registrar at the time of the patient’s discharge and only those admitted for less than 72 hours are exempt. Regardless of individual nosological preferences every patient is allocated to one of the diagnostic categories of the International Classification of Diseases [l 11. These data are transferred routinely to punched cards, which thus constitute an almost unique source of information, both comprehensive and readily accessible.” Kendell expressed some reservations about the Item Sheets: “Item Sheets are filled in as a routine task by a changing population of junior medical staff, with no personal interest in the uses to which they may be subsequently be put. This situation is conducive to carelessness. . . The same situation, however, serves to minimise the danger of the data being biased by the convictions of the raters. . In essence systematic error is reduced at the expense of an increase in random error”. However, the mean positive agreement, a measure of inter-observer reliability (between Kendell and a registrar where at least one of them rated the item present), was 43% which although poor is no worse than that found in studies of experienced psychiatrists. An estimate of testretest reliability by comparing registrars’ ratings of patients on admission with Item Sheets completed on discharge showed a mean positive agreement of 52%, which was thought acceptable especially since some symptomatology would have changed anyway. Agreement on diagnosis was much higher: 76% for both kinds of reliability. The present investigator was privileged to have access to all Item Sheet information. The data being provided at the time of the illness were not retrospective. However, the design of the Item Sheet had to be accepted as it stood. For example, there was a single entry “deaf or blind (complete or partial)” for recording both defects. The deafness and blindness was a clinical assessment by the registrar in charge of the case. All other symptoms were graded as severe or moderate. There were 340 patients admitted during the triennium. Eleven of these had to be excluded because it was not possible to confirm from their medical records which of the two sensory defects they had. Twenty-two patients (17 women, 5 men) had a hearing defect, 12 (9 women, 3 men) a visual one, 14 (10 women, 4 men) had both and 281 (187 women, 94 men) neither. The deaf were compared with the hearing, and the blind with the seeing, for each symptom in Table 1 and for each diagnosis in Table 2. In each comparison the control group was the remainder of the 329 patients in the study. In all comparisons the males and females were combined as there were no significant differences in the proportions of men to women in the deaf, blind and the rest. The mean age of the deaf was 73.8 years (standard deviation 7.9). of the blind 74.5 years (S.D. 8.9), and of the rest 68.1 years (S.D. 6.8). Student’s t-test showed that the deaf and the blind were significantly (P< 0.01) older than those with intact senses. Socio-economic class did not differ significantly in the sensorily impaired and non-impaired. The mean for the deaf was 4.3 (S.D. 1.7). for the blind 4.1 (S.D. I .5), and for the rest 4.0 (S.D. 1.9). Tests of significance for delusions of guilt and impaired memory were made by the chi-squared test using the three degrees of severity of symptoms: none, moderate and severe. For the remaining symptoms in Table 1, because the numbers were smaller, the moderate and severe groups were combined and Fisher’s exact test done. All the statistical analyses of Table 2 were made by Fisher’s exact test. RESULTS The deaf had fewer than expected (P< 0.01) delusions of guilt (Table 1). The blind had more (P < 0.05) delusions of persecution than their controls but analysis of covariance showed that this was due to their increased age and not to the sensory defect. The deaf had fewer than expected (P < 0.05) affective psychoses (Table 2). The blind had more (P < 0.05) organically based psychiatric illnesses than their controls but again analysis of covariance
Is paranoid
illness associated
with sensory defects in the elderly?
71
TABLE I.-COMPARISONSOFSYMPTOMSOFDEAFANDBLINDPATIENTS
22 Deaf
12 Blind
14 Both
281 No defects
Symptom
M*
S*
M
S
M
S
M
S
Ideas of reference Delusions of guilt Obsessional fears Delusions of bodily change Delusions of passivity Delusions of persecution Sexual delusions or morbid Other delusions Impaired memory Disorientation Auditory hallucinations Other hallucinations Organic lesions of C.N.S.
1 I 1 1 0 2 1 4 4 2 0
3 1 1 1 2 5 0 0 6 4 4 2
1 0 0 0 0 2 0
2 3 1 0 1 4
1 2 1
0 1 0
I
0
0 1
0 4
1
0
0
1
2 4 3 3
0 5 0 0
1 5 4 0
25 67 25 15 IO 25 4 14 55 36 15
1
1
0
8
20 58 12 13 7 31 12 25 68 46 20 13
*M, moderately
jealousy
1
2
1 1 1
9
severe symptom;
4
6
91
S, severe symptom.
TABLE 2.-CohiPAatsoNs
OFDIAGNOSESINDEAFANDBLINDPATIENTS
Diagnosis
22 Deaf
12 Blind
14 Both
4 0 2 2 1
7 0 0 4
1
2 0 0 0
Psychiatric disorders of organic aetiology Non-paranoid schizophrenia (category 295 except 295.3) Paranoid disorders (category 295.3; 297.1; 298.3; 301 .O) Affective psychoses (category 296) Reactive psychoses (category 298 except 298.3) Depressive neuroses (category 300.4) All other neuroses (category 300 except 300.4) Personality disorders (category 301 except 301 .O) No psychiatric illness (category 3 17.0)
0 1 1
1
281 No defects 59 6 20 121 13 50 10
1 1
showed that this was due to their increased age and not to the sensory defect. There were no significant correlations between sensory defects and paranoid disorders before or after correction for age, even though paranoid disorders were themselves associated with age.
DISCUSSION
AND CONCLUSIONS
Some of the findings are unexpected. One explanation could be that the sample of patients studied is atypical. Previously published figures show that, at least in the incidence of sensory defects, this is not so. The 20% paranoid who were deaf in this study compared with 15 11, 91 and 30 [12] in previous studies. The 6% of affectives who were deaf compared with 7 [l]. 12 [9] and 2 [13]. The results for the blind were also fairly typical. The 7% paranoid who were blind compared with 7 [l] and 15 [9). The 5% affectives who were blind compared with 6 [ 131 and 9 [9]. It was very striking in this investigation that both delusions of guilt and affective disorders in the deaf were significantly less common than in the hearing. The same was true of affective disorders in Sjogren’s study [9], which is one of the few that compared those with and without sensory defects within psychiatric diagnoses, as in the present investigation. The widely held view that paranoid disorders are more frequent in the deaf may be only partly correct. In any comparison of paranoid
72
N. C. MOORE
with affective disorders a low incidence of the latter would result in an apparent increase of the former. There is no agreement about whether the incidence of paranoid illness is increased in the blind. Two studies of paranoid disorders 14, 71 found an increased proportion of blindness while two others [ 1, 61 found that the proportions were the same as in affective disorders. In the present study, although the incidence of delusions of persecution was greater in the blind, this was due to their increased age. Delusions of persecution in the blind were associated with sexual delusions and impaired memory (Table 3). The incidence of paranoid disorders did not differ significantly from normal whereas Sjogren [9] found fewer than expected paraphrenic illnesses in the blind. At first sight it is not surprising that organically based illnesses are more common in the blind. The same organic process might cause both the blindness and the psychiatric illness. Sjogren [9] and Kay er al. [14] found an association between organically based psychiatric illness and both deafness and blindness. In this investigation those with sensory defects were matched for age with the controls, in as much as they were all over the age of 60. However, the deaf and blind were on average about 5 years older than the control group. After correction for age, the increased incidence of organically based psychiatric illness in the blind disappeared, showing that it was an artefact due to their greater age. Age did not contribute to the finding of fewer than expected affective disorders in the deaf. Within this sample of patients the difference between age distributions of the deaf and non-deaf did not reach significance. Why did the deaf have fewer delusions of guilt and affective psychoses? Maybe a sense of guilt was less likely to develop in the deaf than the hearing because they had an obvious reason for feeling depressed, making it unnecessary to blame themselves for the illness. When the deaf did infrequently develop delusions of guilt they were associated with delusions of passivity, ideas of reference and obsessional fears (Table 3), suggesting that in them it was more part of a paranoid or schizophrenic illness than an affective one. This study has shown how the variable of age obscures the issues when trying to understand the relationship between sensory defects and psychiatric illness. Even matching for over the age of 60 was insufficient. A difference of only 5 years caused an increase in delusions of persecution and organic illness in the blind. Deafness and blindness increase with age and so do certain psychiatric symptoms and illnesses, including delusions of persecution, paranoid disorders and organic psychoses. In the elderly many cases of deafness and blindness are recent and not so deleterious to mental health as prolonged sensory impairment. Apart from the duration of such handicaps the timing of onset would also be vital; being deaf and blind before the development of communication and before the character or personality have formed would probably be more harmful than being sensorily impaired after maturity. The crucial difference between this study and most others is that the comparisons are not of affective with paranoid patients. This has shown up the possibility that there is a decreased incidence of affective psychoses and delusion of guilt in the deaf. If these findings are replicated by others, it will suggest that previous interpretations of the difference in the incidence of paranoid and affective disorders in those with sensory impairment was, at least partly, erroneous.
Is paranoid
illness associated
with sensory defects in the elderly?
I--
AJOUEU paJ!odwI
I
AIlpoq ,o s”ols”,aO
s,tJa,
,ouolssasqO
I
I
I
I
I
73
74
N. C. MOORE
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