The technique of forearm plethysmography for assessing anxiety

Studies on the psychosomatic functioning of ill-health according to Eastern and Western medicine 5. Psychosomatic characteristics of anxiety and anxiety-affinitive constitution

In successive studies of the psychosomatic functioning of ill-health according to Oriental and Western medicine in medical students, we established the existence of the psychosomatic characteristics we have provisionally termed the anxiety-affinitve constitution at the core of ill-health. Therefore, we conducted this research because our previous investigation showed this constitution included a high complexity of respiratory movement and eye movement with a significant correlation to the State Trait Anxiety Inventory (STAI). We examined the correlation between the STAI and somatic function of 88 medical students to identify the psychosomatic characteristics of anxiety and the anxiety-affinitive constitution. These tests included STAI, fractal (EEG, EOG, plethysmogram, respiratory curves, and EMG) and non-fractal (accelerated plethysmogram) dimension analyses, and malocclusion (based on Angle's classification). In particular, EOG, plethysmogram, and respiratory curves are known to have close association with trait anxiety. We were able to discover the correlation between (1) trait anxiety and thoracic and abdominal respiratory movements, and malocclusion (Class III), and (2) the correlation of state anxiety with thoracic respiratory movement, horizontal eye movement, a plethysmogram and an EEG-Pz (in males only). In subsequent study the relation between thoracic dominance and state-trait anxiety and between abdominal dominance and state-trait anxiety should be assessed to develop this research regarding the psychosomatic characteristics of anxiety and the anxiety-affinitive constitution. Further, it is essential to create an anxiety-affinitve constitution index based on multi-regression analysis.

Studies on the psychosomatic functioning of ill-health according to eastern and Western medicine. 3. Two treatment methods using kampo medication for stress-related and lifestyle disease

In this study, we examine the modality of improvement in psychosomatic function to verify the suitability of two treatment methods previously described. The subjects were nine medical students with no history of blood stasis-related illness (average age, 24.8; SD, 1.4 years) and 21 patients of our outpatient clinic (average age, 54.3; SD, 10.4 years). For purposes of our research, Kampo medication was selected based on the diagnosis and treatment of unbalanced qi, blood, and body fluid developed by the authors in their previous report. As a result, the therapeutic features of the preventive treatment group of nine medical students and the final treatment group of 21 patients of the outpatient clinic were essentially identical. There were two such features: 1. At the psychological level, this consisted an improvement in stress-related emotional reaction, centered on anxiety and depression, and at the physiological level, this consisted of an improvement in peripheral blood circulation (an increase of the fractal dimension of the plethysmogram, p = 0.0357). 2. The improvement of the foregoing psychosomatic function is related to the improvement of blood stasis (strictly speaking, vital energy stagnation and blood stasis) in Oriental medicine, and the improvement of blood rheological abnormalities in Western medicine. Therefore, this research confirmed the significance of two treatment methods proposed by the authors for stress-related illness and lifestyle disease in individuals with an anxiety-affinitive constitution.

Stereotactic limbic leucotomy--a follow-up at 16 months

Sixty-six patients were assessed clinically, psychologically and physiologically before operation, at six weeks and at a mean of 16 months following stereotactic limbic leucotomy. Seventy-three per cent were clinically improved at six weeks and 76 per cent at 16 months. In obsessional neurosis, 89 per cent of patients showed definite clinical improvement at 16 months; in chronic anxiety, 66 per cent were improved; in depression, 78 per cent; and in the small number of schizophrenics treated the improvement rate was over 80 per cent. Self-assessment and observer-assessment questionaires and scales measuring Depression, Anxiety, Neuroticism, Hysterical symptoms and Obsessional symptoms and traits all showed highly significant reductions of mean scores at 16 months. There was no fall-off in intelligence, and adverse effects were minimal. Limbic leucotomy, with its enhanced accuracy and safety, compares very favourably with similarly assessed, more extensive 'free-hand' procedures, and in obsessional neurosis and chronic anxiety the results are superior.

Stereotactic limbic leucotomy--a follow-up study of thirty patients

This prospective study reports the results of stereotactic limbic leucotomy at a mean of 17 months following surgery. Clinical improvement had occurred in twenty-four (80%) of the patients, fifteen (50%) of them being symptom free or much improved. Fourteen of sixteen patients suffering from obsessional neurosis were improved, as were five of seven with chronic anxiety and the degree of improvement at 17 months was superior to that at 6 weeks. Psychometric scores of anxiety, obsessions and neuroticism were all significantly reduced at 17 months. The mean depression scores were also significantly reduced and this result was superior to that reported in a previous study of ‘free-hand’ operations.

Adverse effects were not a problem following limbic leucotomy. Emotional blunting, disinhibition, post-operative epilepsy and excessive weight gain were not encountered, and intelligence was unaffected by the operation. Limbic leucotomy is a much more limited and precise procedure than older ‘free-hand’ operations which we have studied, but its therapeutic effects are comparable and in obsessional neurosis, superior.

Stereotactic limbic leucotomy: a preliminary report on forty patients

The neurophysiological aspects and operative technique of stereotactic limbic leucotomy have been described in a previous paper (Kelly, Richardson and Mitchell-Heggs, 1973). The present investigation is a prospective study designed to assess the results of such surgery in a group of 40 severely ill psychiatric patients, who had failed to respond satisfactorily to every other type of treatment. The results have been assessed clinically, psychologically and physiologically, in a very detailed way, at six weeks; a similar follow-up at one year is in progress. A comparison is made between the results of the present series and those of a previous: study (Kelly et al., 1972), in which more extensive leucotomy operations were carried out, and similar means of assessment were employed.

A psychological and physiological evaluation of the effects of intravenous diazepam

Intravenous diazepam is widely used both in general medicine and in psychiatry. It is used to produce sedation in psychiatric emergencies and to enhance systematic desensitization; it is also employed in the treatment of drug-induced dystonic reactions, status epilepticus and tetanus, and as an anaesthetic agent. Its property of relieving severe muscle spasm has been utilized to treat patients suffering from ‘stiff-man syndrome‘.

Modified leucotomy assessed clinically, physiologically and psychologically at six weeks and eighteen months

After more than thirty years the operation of leucotomy still remains a controversial treatment, and its value is questioned by many. This scepticism, and the advent of new surgical techniques, have emphasized the need for careful appraisal of the results of psychosurgery. In a previous prospective study 40 patients were assessed six weeks after modified leucotomy, and 75 per cent of these patients were found to be clinically improved (Kelly, Walter and Sargant, 1966). They were less neurotic on the M.P.I., had lower Taylor Manifest Anxiety scores and rated themselves as less anxious; a good clinical outcome was associated with diminution of physiological arousal as measured by forearm blood flow and heart rate. This group has now been followed-up and reassessed 18 months after operation, and a further group of 38 patients has been examined before, and again six weeks after, leucotomy. The data from the two groups have been combined to determine the immediate outcome for various diagnostic categories, and a multiple regression has been performed to elicit which of the pre-operative factors predict a favourable post-operative result.

Depressive illness, pulse rate and forearm blood flow

In depression alteration in mood is accompanied by pronounced physical and behavioural changes. Characteristically there is a decline in appetite, weight and libido, insomnia and a disturbance of diurnal rhythm. A slowing of thought and movement to the point of severe retardation or even stupor may occur. Anxiety is often present and in agitated depression is accompanied by restless psychomotor activity. As lesions in the hypothalamus may produce disturbances in appetite, weight, libido and sleep, it has been suggested that hypothalamic dysfunction may play a part in the aetiology of those depressions in which physical symptoms predominate (Pollitt, 1965).

Anxiety and the effects of sodium lactate assessed clinically and physiologically

Anxiety neurosis has been the subject of intensive study during the past ten years. Renewed interest in this syndrome has arisen both from the stimulus of new methods of treatment and from attempts to classify anxiety more accurately. Recently Pitts and McClure (1967) reported that anxiety symptoms and anxiety attacks could be produced by a specific biochemical stimulus: sodium lactate. This work was prompted by the finding that 'standard exercise’ tends to produce an excess amount of lactic acid in patients with anxiety neurosis (Cohen and White, 1950; Jones and Mellersh, 1946; Linko, 1950; Holmgren and Strom, 1959). Pitts and McClure found that an intravenous infusion of 10 ml. of half-Molar sodium (DL) lactate per kilogram of body weight, given over a twenty minute period, produced an anxiety attack in patients suffering from anxiety neurosis. The symptoms began a minute or two after the infusion was started and developed rapidly, and some patients reported ‘exacerbations of their characteristic symptom profiles for two to five days after the sodium lactate infusion’. In their double-blind study, many fewer symptoms were produced when calcium ion was added to the lactate infusion, and almost no symptoms were produced by an infusion of glucose in saline of similar osmolarity. Many fewer and less severe symptoms were produced in normal controls than in the patient group, both in response to sodium lactate and to lactate with added calcium, and almost no symptoms during the glucose and saline infusion. Pitts and McClure postulated that anxiety symptoms may have a common determining biochemical end-mechanism, involving the complexing of ionized calcium at the surface of excitable membranes by lactate ion with resulting interference ‘with the normal functioning of calcium in transmitting nerve impulses' (Pitts, 1969). They concluded that ‘there may be something highly specific about lactate ion in producing the naturally occurring hypocalcaemic anxiety symptoms in human beings'.

A controlled physiological, clinical and psychological evaluation of chlordiazepoxide

“Much doubt persists about the different benefits from, and indications for, all the many drugs proposed for the relief of anxiety” (Lancet, 1965). Chlordiazepoxide is one of the most popular minor tranquillizers used by psychiatrists, physicians and general practitioners. Its efficacy has been advocated in the “Today's Drugs” column of the British Medical Journal (1967, 1968a and b). Others, however, have been “impressed by the number of patients who claim great benefit but show little evidence of this” (Jenner, 1965).

A clinical and physiological relationship between anxiety and depression

There has been a great deal of argument during the past 30 years about the symptomatic differences between anxiety and depressive states. Mapother (1926) thought that anxiety states should be regarded merely as one of the numerous sub-divisions of the manic-depressive illnesses, since they merged through a series of patients into agitated depression. Lewis (1966) too saw no sharp division between anxiety states and depression and classified agitated depression and anxiety states together as one sub-division of the affective disorders. Garmany (1956, 1958) and Mayer-Gross, Slater and Roth (1960), however, felt that anxiety states and depression were basically different forms of illness.

Forearm blood flow and phobic anxiety

The measurement of muscle blood flow using occlusive plethysmography has recently been proposed as an objective index of anxiety (Harper et al., 1965; Kelly, 1966, 1967). Although the method has been used by physiologists for many years, and its sensitivity to psychological stress has often been mentioned as an incidental finding in physiological studies, its application in psychiatric or psychological research has been slow to develop, perhaps because rather cumbersome apparatus is required. However, promising results were reported by Kelly (1966), who differentiated patients suffering from anxiety states from mixed neurotic patients and normal controls, and who showed changes after leucotomy in anxious patients.

The relationship between clinical diagnosis and anxiety, assessed by forearm blood flow and other measurements

Anxiety may be present to a greater or lesser degree in almost every psychiatric syndrome. The ability to quantify the degree of anxiety present in an individual patient has important implications for diagnosis, treatment and prognosis. Accurate clinical assessment of anxiety is by no means an easy task, although many psychiatrists believe it to be. If no other methods are used, there is no way of knowing how often an individual clinician is right or wrong. However, if several independent methods of assessing anxiety are used, more data are available, and a better overall judgment on an individual patient can be made.