วารสารสมาคมจิตแพทย์แห่งประเทศไทย
Journal of the Psychiatrist Association of Thailand
ISSN: 0125-6985
บรรณาธิการ มาโนช หล่อตระกูล
Editor: Manote Lotrakul, M.D.

รัตนา สายพานิชย์, พ.บ.*
มาโนช หล่อตระกูล, พ.บ.*

 Cross-Cultural Aspects of Psychotic Symptoms in Thai Major Depressive Patients.

Ratana Saipanish, M.D.
Manote Lotrakul, M.D.*

 บทคัดย่อ

รายงานนี้เป็นการศึกษาจากเวชระเบียนของแผนกผู้ป่วยนอกของภาควิชาจิตเวชศาสตร์ โรงพยาบาลรามาธิบดีตั้งแต่ปีพ.ศ.2530-2539 พบว่ามีผู้ป่วยจำนวน 71 คนที่มีอาการเข้าได้กับโรค major depressive disorder with psychotic features ตามเกณฑ์การวินิจฉัย DSM-IV ในผู้ป่วยจำนวนนี้ร้อยละ 77.5 มีอาการประสาทหลอน ร้อยละ 49.3 มีอาการหลงผิด และมีทั้งสองอาการร้อยละ 29.6 อาการประสาทหลอนที่พบบ่อยคืออาการหูแว่ว อาการหลงผิดที่พบบ่อยคืออาการหวาดระแวง อาการหลงผิดส่วนใหญ่มีเนื้อหาไม่สัมพันธ์กับภาวะซึมเศร้า โดยพบเพียงร้อยละ 15 เท่านั้นที่มีเนื้อหาสัมพันธ์กับภาวะซึมเศร้า ลักษณะที่ต่างจากทางตะวันตกอีกประการหนึ่งได้แก่อาการหลงผิดชนิดเชื่อว่าตนเองผิดบาปนั้นพบน้อยมาก สาเหตุสำคัญของความแตกต่างเหล่านี้อาจเป็นจากความแตกต่างในเชิงวัฒนธรรมของแนวคิดเกี่ยวกับตัวตน (self)

วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2542; 44(1): 19-29.

คำสำคัญ โรคซึมเศร้า อาการโรคจิต อาการรู้สึกผิด

 *ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล ถนนพระราม 6 กรุงเทพ 10400

 Abstract

A retrospective study of 71 patients with major depression with psychotic features by DSM-IV criteria was conducted based on medical records between 1987 and 1996 at the out-patient psychiatric unit of Ramathibodi Hospital. Data analysis revealed that 77.5% of patients had hallucinations, 49.3% had delusions, and 29.6% presented with both symptoms. The most common types of hallucinations and delusions were auditory hallucinations and persecutory delusions respectively. Nearly all delusions were categorized as mood-incongruent whereas only 15% showed mood-congruent delusions. In contrast to the typical finding in Western societies, very few patients had delusions of guilt. Cultural differences in the concept of the self are discussed as the main contributing factor.

J Psychiatr Assoc Thailand 1999; 44(1): 19-29.

Key words: major depressive disorder, psychosis, guilt

 * Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok 10400, Thailand

 Psychotic depression is a term used to characterize depressive patients who have psychotic symptoms. The salient features separating patients with psychotic depression from those without are the presence of delusions and/or hallucinations. Recent evidence from hospital-based and community studies has suggested that psychotic depression is a distinct clinical entity rather than simply the severe ending of a depressive spectrum^1-4.

For most forms of psychotic disorder it is generally held that the contents of the disorders are, to a certain extent, shaped or influenced by cultural or social factors^5-9. For example, the American psychotic patient may complain that the FBI are "after him" whereas a paranoid patient in an African village is likely to identify his or her persecutors as being sorcerers⁸. Likewise, a common delusion in Thailand such as delusion of being possessed by tep (a guardian spirit) is infrequently found in Western countries. This notion suggests that in identifying delusions cultural factors should be taken into account especially if one attempts to compare delusions involving patients from different cultures.

Since the emergence of the third edition of the Diagnostic and Statistical Manual of Mental Disorders¹⁰, psychotic symptoms in major depression have been further classified into either mood-congruent or mood-incongruent subtype. Mood-congruent psychotic features are psychotic symptoms that are consistent with the patient's depressive mood, for example, delusions of guilt, delusions of poverty, and nihilistic delusions. Mood-incongruent psychotic features are psychotic symptoms which not involve typical depressive themes, for example, persecutory delusions, delusions of reference, and thought insertion. This emphasis on subtyping also has clinical implications; mood-incongruent delusions are said to be infrequent and imply poor treatment response and prognosis¹¹.

Several problems arise from this approach, for example, do contents of delusions in psychotic depression differ cross-culturally? Is it essential to take culture into account in defining whether the contents of delusions relate to depressed mood or not? Does each subtype differ prognostically across cultures?

Another interesting cultural aspect of psychotic depression is suicidal risk. The greater severity and poorer prognosis in psychotic depressive patients suggest that they may be at higher risk of suicide than other depressive patients. This premise is supported by a study of Roose et al¹², which showed a significant association between the presence of delusions and suicide in hospital among major depressive patients. Miller and Chabrier¹³ focused their study on the relationship between the contents of depressive delusions and suicide attempts. They found that patients with concurrent delusions of guilt and persecution had a significantly higher rate of suicide attempts than those with other delusional contents. Kuhs¹⁴ also found that patients with delusions of guilt had a significantly greater history of suicide attempts. From our previous study of common symptoms in depressive disorders¹⁵, suicidal ideation occurred less frequently among Thai depressive patients than in many other Western samples. It is interesting to identify whether suicidal risk among Thai patients with psychotic depression also occurs less frequently.

Given the recent view that the depressive delusion is a distinct entity rather than a manifestation of the severe ending of a depressive spectrum as mentioned earlier, it is important not only to identify how psychotic symptoms in Thai depressive patients may differ from Western depressive subjects, but also how their prognostic significance may differ. The purposes of this study are to examine in detail the phenomenology of delusions and hallucinations in Thai major depressive patients as compared with that reported in other samples. Age of onset of depressive symptoms and age of first psychotic symptoms are also reviewed.

 MATERIAL AND METHOD

Ramathibodi Hospital is a general hospital with total number of 800 beds. The psychiatric service of the hospital had been exclusively an outpatient service until the opening of a psychiatric ward recently in 1995. The number of new psychiatric cases each year is 10,000-14,000. There were 6-12 psychiatrists in the department during the study period.

The medical records of all patients at the outpatient psychiatric unit from January 1987 to December 1996 were reviewed retrospectively. Patients who had not been seen for 5 years were excluded from the study since a patient's record was destroyed, according to record keeping policy of the hospital, if he or she had not visited the hospital for more than 5 years. Unfortunately, we could not determine how many records had been destroyed.

The records were reviewed for the presence of major depression with psychotic features using DSM-IV criteria¹¹. Patients with diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder, mental retardation, and depression secondary to medical illness or substances were excluded. Eventually, 71 patients were identified following the criteria for the study.

For the purpose of the study, we collected data on 1) demographic and social variables; 2) past psychiatric history, i.e., age of onset of depression, age of onset of psychotic symptoms, and age of first treatment; and 3) symptoms, i.e., types of delusions and hallucinations, suicidal ideation and attempt.

Fisher’s exact test for group differences was used for statistical analysis of the relationship between delusions and hallucinations.

 RESULTS

The samples’ characteristics are shown in Table 1. There were twice as many females as males in our sample. Half of the patients were married and almost all of them were Buddhist.

 Insert Table 1

 The mean age onset of the first depressive illness was 37.0 years (SD=13.6). The mean age at the time of the first psychotic episode was 38.9 years (SD=12.9) and mean age at first visit to the clinic was 37.62 (SD=13.2).

Table 2 shows percentages of patients with delusions and hallucinations. Hallucinations occurred more often than delusions. Nearly half of patients had only hallucinations, 19.7% had only delusions, and 29.6% had both delusions and hallucinations.

 Insert Table 2

 The most common delusion was of persecutory type, which accounted for 67.6% of all delusions whereas delusions of guilt occurred only 5.9% (Table 3). None of our patients had delusions related to karma or bad deeds in previous lives. Most patients had only one delusional theme; only 5.9% had more than one theme. Examples of contents of persecutory delusions are "the neighbors want me to be crazy", "there must be someone in my family trying to poison me".

 Insert T