Blood Lipids and Behavior in Mental-Hospital Patients

Transcription

1 Blood Lipids and Behavior in Mental-Hospital Patients IVAN W. SLETTEN, M.D., JOHN A. NILSEN, M.D.,t RHODES C. YOUNG, Ph.D.,t and JOSEPH T. ANDERSON, Ph.D. Two groups of male patients were identified by screening the population of Hastings State Hospital; the 2 with the highest and the 2 with the lowest blood cholesterols were selected for study. Each group was evaluated twice with the Brief Psychiatric Rating Scale, Nurses Evaluation Sheet, and Psychotic Reaction Profile. Differences significant at the. and levels were noted. Lowcholesterol subjects were more regressed and withdrawn, with less evidence of initiative and positive mental health. BLOOD LIPID STUDIES in the 2-year period between 925 and 95 were concerned primarily with relating cholesterol levels to diagnosis and prognosis in mental disease. The consistent findings here seem to have been that () acutely disturbed and "excited" schizophrenics have higher cholesterol values From the Department of Physiologic Hygiene, University of Minnesota, Minneapolis, Minn., and the Hastings State Hospital, Hastings, Minn. The authors wish to express their appreciation to Drs. Gordon Heistad and B. C. Schiele of the Department of Psychiatry, University of Minnesota Hospitals, for permitting their research nurses to do the behavioral ratings referred to in the paper. Present address: Missouri Institute of Psychiatry, St. Louis 39, Mo. fpresent address: Mayo Clinic, Rochester, Minn. JPresent address: Department of Medical Psychology, University of Oregon Medical School, Portland, Ore. Present address: School of Public Health, University of Minnesota, Minneapolis, Minn. Received for publication Dec. 23, 963. than chronic, anergic schizophrenics; ' 2 (2) during exacerbations of manic-depressive disease, cholesterol levels are higher than during periods of comparative mental health; 59-5 and (3) high cholesterol values during acute psychi-^ atric illnesses are associated with a good chance for recovery. More recent work has been with people taken from the general population in an attempt to relate behavioral traits to cholesterol level and cardiovascular findings. Fairly regular findings are that () medical-school examinations, end-of-month reports, and other forms of psychological stress raise blood cholesterol levels; " 7 " 9 and (2) personality traits characterized by competitiveness, strong drive, high energy output, and concern with "meeting deadlines" are associated with sustained elevations in blood cholesterol The purpose of our study was to confirm previous work, using recently developed behavioral rating devices and 26

2 262 BLOOD LIPIDS AND BEHAVIOR chemical determination methods, and perhaps to define new behavioral-physiologic relationships. Method In January 962, we completed serum cholesterol determinations on the male patients of Hastings State Hospital between the ages of 35 and 65 years. Of 8 patients sampled, the 2 with the highest cholesterol values were put in one (high) group, and the 2 with the lowest values in another (low). Subsequent determinations were done on all patients in February or July 962, and again in August 962. Thus two values were determined for each patient after the initial screening. Determinations were made with the same chemical method, at the same time of day, and after a 2-hr, fast. The last two determinations had such good test-retest reliability that only 2 patients shifted from one group to the other if each determination was considered independently. On both occasions, blood levels of phospholipids and triglycerides were also determined. These three lipid levels correlated in each patient well enough so that all but 5 patients stayed in the same group (high or low), no matter which of the three lipid substances one used. The values in Table are based on the average of these last two determinations. Nine patients from each group were placed on similar controlled diets for 3 weeks in February 962. They were supervised by trained personnel, and adjustments made for food not eaten. Sixteen of the 8 stayed in the same range of cholesterol values (high or low). Two from the low group (who had high values for the low group to start with) moved into the high group. Blood samples were taken in August 962 within week of the behavior ratings described below. Two former psychiatric-nurse supervisors rated all patients after several weeks of ward contact. On two occasions (separated by a 2-week period), they rated each patient using the Brief Psychiatric Rating Scale (Overall and Gorham), Nurses Evaluation Scale (Veterans Administration), and the Psychotic Reaction Profile (Lorr). The raters were unaware of blood-lipid levels. Pertinent observations noted in Table 2 were made from the patients' hospital charts. Patients with pancreas, thyroid, or liver, or other disease processes known to affect cholesterol levels were excluded. Results The Brief Psychiatric Rating Scale reveals more motor retardation, emotional withdrawal, mannerisms, posturing, blunted affect, and less grandiosity among patients in the low-cholestercl group. The Nurses Evaluation Scale reveals more untidiness, retardation in motor behavior, lack of initiative, and less positive mental health in the low- TABLE. BLOOD LIPID LEVELS IN TWO GKOUPS OF MENTAL-HOSPITAL PATIENTS Lirw-cholesterol group High-eholesterol group Range, of Range of Av. (mg. A ) av. values Av. (mg. r / f) av. values Cholesterol Phospholipids Triglycerides " l5-255f 7-8* 7-256f ' 227-3f 8-28" -28f Five patients eliminated so that these corrected ranges for high and low groups would not overlap. funeorrected ranges. PSYCHOSOMATIC MEDICINE

3 i i SLETTEN ET AL. 263 TABLE 2. DATA FROM HOSPITAL RECORDS ON LOW- AND HIGH-CHOLESTEROL GROUPS Average age (yr.) Average weight (lb.) Length of hospitalization (yr.) Marital status Single Married Divorced Diagnostic categories Paranoid schizophrenia Catatonic schizophrenia Hebephrenic schizophrenia Chronic undifferentiated schizophrenia Simple schizophrenia Depressive reaction Chronic brain syndrome (CBS) secondary to lues CBS secondary to alcoholism CBS secondary to intracranial infection CBS (undetermined etiology) History of physical disease Phenothiazine medication (total gm.) in past 6 months (Stelazine,* Thorazine,* Compazine') Somatic therapies Lobotomy Electroconvulsive therapy Insulin coma Metrazol shock Time on provisional discharge (yr.) 5 Low-chol group No difference noted High-chol. group 5 8 lb. heavier than low group (not statistically significant, p > ) No difference noted Smith Kline & French Laboratories, Philadelphia, Pa. cholesterol group. The Psychotic Reaction Profile indicates more disorganization in thinking, withdrawal, and agitated depression in the low group. The findings on the three scales are compatible and point in the same direction; the low group was more emotionally withdrawn and regressed, with less evidence of initiative and positive mental health (Table 3). The following items in the rating scales were not found to be significantly related to the lipid sub- stances measured: somatic concern, anxiety, conceptual disorganization, guilt feelings, tension, depression, hostility, suspiciousness, hallucinatory behavior, uncooperativeness, and unusual thought content (Brief Psychiatric Rating Scale); paranoid belligerence (Psychotic Reaction Profile); and items relating to combativeness, agitation, withdrawal from other patients, thought disturbance, depression, and bodily concern (Nurses Evaluation Scale). VOL. XXVI, NO. 3, 96

4 26 BLOOD LIPIDS AND BEHAVIOR TABLE 3. BEHAVIOR RATING SCALES SIGNIFICANTLY DIFFERENTIATING THE GROUPS DIVIDED ON THE BASIS OF SERUM CHOLESTEROL CONCENTRATION Scale Mean Lota chol. S.D. BPRS 3 (Emotional withdrawal) 5.7' (Mannerisms and posturing) 3 (Motor retardation) 8 (Grandiosity) 6 (Blunted affect) (Untidiness) (Positive mental health) (Motor behavior) (Lack of initiative) (Withdrawal) (Thinking disorganization) (Agitated depression) High ch Mean NES PRP 'Composite score of ratings (two raters rating twice). Items significant on one scale are significant on the others, with these exceptions: Withdrawal is significant on the Brief Psychiatric Rating Scale and nonsignificant on the Nurses Evaluation Scale; thinking disorganization is significant on the Psychotic Reaction Profile; conceptual disorganization is nonsignificant on the Brief Psychiatric Rating Scale; agitated depression is significant on the Psychotic Reaction Profile; and depression is nonsignificant on the Brief Psychiatric Rating Scale. The items in the three scales relating to similar aspects of behavior are worded differently, and the items noted in the Psychotic Reaction Profile represent a summation of several questions relating to a general area of behavior. Still, % of the behavior-rating-scale items administered were found to differentiate significantly the high- from the lowcholesterol groups S.D Significance T-values Level As shown in Table 2, the high and low groups were quite similar in average age, weight, length of hospitalization, marital history, diagnostic classification, history of physical disease, and amount of phenothiazine medication received in the 6 months prior to January 962. They differed significantly in amount of somatic therapy received and in the amount of time spent on provisional discharge. Discussion Our results have much in common with those of others:. Schizophrenic patients with comparatively little motor activity have low serum cholesterol, while "excited" schizophrenics, who manifest more motor activity, have higher values. 2. Patients with high cholesterol have a better prognosis. Since our high group PSYCHOSOMATIC MEDICINE

5 SLETTEN T AL. 265 was more likely to go on provisional discharge and since they were less regressed, with more evidence of positive mental health, it can be concluded that they had a better prognosis than the low group. 3. People with high cholesterol levels have a higher energy output, more drive, and are more concerned with "deadlines." Our high-cholesterol patients showed more initiative, motor activity, and grandiosity. These personality traits identify them with people in the community who have energy and drive. Our patients who manifested intense emotional reactions probably induced physicians to use more intense forms of therapy. Since our high-cholesterol patients received more somatic therapies, perhaps they correspond with the people in the community who are intensely concerned with "meeting deadlines." We made no attempt to control exercise, although it is believed to lower serum cholesterol level. ' 2 Inasmuch as the high-cholesterol group showed the most motor activity on the rating scales, it is unlikely that our findings would be changed if we had attempted to have both groups exercise equally. On the contrary, the differences would have been perhaps more extreme, since the low group would be exercising more and thus their cholesterol values would have gone down even lower. Since it appears true that high cholesterol and certain behavioral traits are correlated, it is important to define their relationship as carefully as possible, if for no other reason than the likelihood of high cholesterol levels predisposing to coronary arterial disease. 2 The evidence raises the question whether these behaviors may, in fact, raise blood cholesterol. If this causal chain exists, successful modification of this behavior could lead to the desired modifications in blood cholesterol. VOL. XXVI, NO. 3, 96 Summary Two groups of male patients were selected for study by screening the population of Hastings State Hospital for the 2 with the highest and 2 with the lowest blood cholesterol levels. Serum cholesterol determinations were repeated twice in the subsequent 6 months, and all patients remained in their respective groups (high or low). Nine patients from both groups were placed on control diets, and all but 2 remained in their own group during this time. Each group was evaluated twice with the Brief Psychiatric Rating Scale, Nurses Evaluation Scale, and Psychotic Reaction Profile. Differences significant at the. and levels were noted. Low-cholesterol subjects were more regressed and withdrawn, with less evidence of initiative and positive mental health. High-cholesterol subjects were found to have behavioral characteristics similar to persons with high serum cholesterol levels living in the community; they had energy, drive, and intense emotional reactions. The possibility that cholesterol levels can be lowered through modification of behavior should be further explored. Since high cholesterol levels are believed to contribute to cardiovascular disease, the findings might be applicable to the problem of cardiovascular disease prevention. Missouri Institute of Psychiatry 5 Arsenal St. St. Louis 39, Mo. References. BRICE, A. T., JR. The blood fats in schizophrenia. /. New. is- Ment, Dis. 8I.-63, FRIEDMAN, M., and ROSENMAN, R. H. Association of specific overt behavior pattern with blood and cardiovascular findings. /. A. M. A , FRIEDMAN, M., ROSENMAN, R. H., and

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