A degree of resentment against the problem of TB is necessary for the intensification of efforts on the part of the Government and the involvement of the whole community in these efforts. This can only be brought about when a state of awareness is created once again, as it was, following the last National Sample Survey. This is only possible by plotting the date of incidence and prevalence of the disease and, repeating this procedure over points in time to establish a trend. Placing a representative of the community as a multi-purpose worker at each Primary Health Care center, widening the scope of the DTP so as to involve as many practitioners as possible, improving the diagnostic and treatment facilities at the peripheral center in remote areas and, conducting periodic surveys to create awareness, are some suggested measures to solve the problem of TB.

In recent years, we have been pleading, unsuccessfully so far, for the development of sociological tools so that we can measure the extent of the disease both epidemiologically as well as sociologically. And, also for using the sociological parameters for assessing the impact of NTP. It stands to reason that long before the epidemiological parameters show an impact, a reduction in suffering as well as altered pattern of action-taking may show a change in the disease as it goes down and away in a country.

The basic economic difficulties and some of the major problems of patients in the United States, created and intensified by TB, are discussed in this paper. Two major economic problems are listed. Provision for economic care ranges from little assistance in some communities to a minimum relief standard in others, with many intermediate variations. Concerning, emotional problems, those connected to the acceptance of diagnosis are of great significance. Several representative cases are described to illustrate the varying emotions patients experience. There is a growing interest to extend social services to address the above social problems and the social worker plays an important role in studying, evaluating and treating the social and economic problems of TB patients.

Common psychological trends in TB patients are described. Psychological complex of 17 TB patients treated in their homes are investigated, and it is concluded that there are no specific patterns of behaviour in persons suffering from TB. The physician`s role in treating TB cases is discussed.

Those attitudes and emotional reactions of patients which interfere with medical treatment, for instance, patients who suddenly leave the hospital against medical advice, obstinate patients who refuse to accept the diagnosis of TB and refuse medication, could be lessened considerably if the patients' attitudes are recognized and dealt with early in hospitalization. To this end, an attitude form which could be incorporated readily in routine hospital procedures was developed at the Veterans Administration Hospital in Madison, Wisconsin, USA and administered to more than 200 TB patients.

The form aided in evaluating the attitudes and emotional reactions of TB patients in nine significant areas of adjustment. Patients expressed their attitudes and feelings to: (1) Bed rest, (2) Hospitalization, (3) TB, (4) Ward life, (5) The medical staff, (6) Irregular discharge, (7) Family and friends, (8) Medical treatment, (9) Attitudes of a general nature, by completing a series of 80 incomplete sentences.

A preliminary survey of the results indicated that the form promised to be a highly effective means of obtaining the patients' attitudes and thus, assist in dealing with the patients' adjustment to his/ her disease and hospitalization.

The study concerned an investigation of the relationship between selected personality dimensions and several measures of overt behaviour among hospitalized TB patients. A structured Q-sort was constructed to measure the selected dimensions of personality. It was administered to all patients who were 45 years of age and less and who were admitted to the Madison Veterans Administration Hospital, Wisconsin, USA. Data were obtained at an early point in each patient's hospitalization. Assessment of patient behaviour was accomplished by use of the Ward Behavior Rating Scale. The head nurse of each ward rated each subject of her ward, using this scale, approximately three months after the patient's admission to the hospital. It appears that the manifest behaviour of hospitalized tuberculous patients, both in its voluntary aspects (such as ward behaviour) and in its involuntary aspects (such as physiologic response to medical treatment), is to a significant extent a function of personality factors. Some of these personality variables, assessed early in hospitalization, are related predictably to subsequent behaviour patterns. The general implication of the findings supports the view that comprehensive management of TB must take the total person and not only his physical disease as the object of treatment.

The study tested the hypothesis that a life-organizational stress of significant proportions typically appears shortly before the onset of TB. The sample comprised of all persons employed at Firland Sanatorium from its establishment at the present location in Seattle, Washington, USA. One group of sanatorium employees who became ill with TB was compared with an individually matched group of employees who remained well. The matching included age, sex, marital status, education, time of employment, job classification, income, skin test reading, appearance of chest roentgenograms, and previous record of certain chronic conditions. Those who became ill had experienced a concentration of disturbances such as domestic strife, residential and occupational changes and, personal crises during the two years preceding the change in a series of quarterly chest films, leading to the determination of pulmonary TB. This concentration of disturbances or situational crises was significant in comparison with the experience of the group of subjects who were well. The TB group also evidenced a significant degree of psychoneurotic pathology and did not recognize or could not admit their personality deficit on questions in which this recognition was obvious. The conclusion appears reasonable that many of the employees who became ill did so in a situation of stress which would be conducive to lowered resistance. Within the acknowledged limitations of the test, the postulation of psychosocial crisis as one of the precipitant causes is tenable.

On the supposition that a predisposition towards TB in individuals is characterized by a need for affection and a life situation which frustrates or aggravates this need, it is postulated that large-scale threats to the interpersonal relationships in a nation or group will tend to increase the communal prevalence of TB. Threatened or broken love-links with an associated significantly increased incidence of pulmonary TB occur in war, in primitive cultures after the advent of the white man, involuntary or economically determined migrations, and in mental hospitals where the schizophrenic is particularly vulnerable to TB because of the nature of his mental disease which leads to the destruction or loss of natural affection.

The results of this exploratory study suggest that TB patients who show a more rapid rate of recovery during the early stages of hospital treatment can be distinguished from the slower recoverers on the basis of age, acuteness of illness, stage of treatment, and body type. Slow recoverers are more depressed, hypochondriacal, self-preoccupied, and socially withdrawn. Spread of recovery was generally not related in a significant way with psychiatric diagnosis although schizoid individuals were prone to be slow recoverers, whereas aggressive personalities improved more rapidly.

The purpose of this paper was to emphasize that the emotional factors preceding the onset of pulmonary TB were of greater importance than the mere presence of the bacilli. A historical review of this topic reveals that as early as 1,500 B.C., Hindus mentioned grief as one factor in the development of TB. The discovery that micro-organisms caused diseases pushed this and similar observations into the background with the result that psychological factors, which gained credence in the 19th century, were paid scant attention. Wittkower (1949, 1952, 1955) was one of the earliest contributors to the study of emotional factors in the causation of TB. While the value of his research findings was greatly reduced because of a lack of control series, the finding that the predominant personality trait in TB patients was an "Inordinate need for affection" was echoed in several studies (Friddmann, Kastelin & Kooperstein (1946), Westermann (1951) using the psychosomatic approach. A rigorously designed series of studies by Kissen (1955 - 1957) found emotional factors preceding the onset of TB in a significantly higher proportion as compared with controls. The predominant emotional factor was a break in a love-link. Psychosocial situations corroborating Kissen's finding are presented and the implication for the choice of home or hospital treatment is discussed.

To get a clear and meaningful picture of a TB patient's illness and, to manage it better, one has to visualize the illness against the background of the personality characteristics of the person and his life situations. Viewing the patient in this way is termed the psychosomatic approach. Using this approach has contributed to our understanding of the varying reactions of the TB patient to his/ her illness, specifically, reactions before seeking help, reactions to diagnosis, reactions to illness and pre-morbid personality. TB patients also vary in their reactions to the different types of available treatment (domiciliary, surgical, living in a sanatorium) and, to the rehabilitation process. Therefore, psychological and social problems should be given due consideration in planning the management of these cases. Most of the psychological and social problems may be handled by the physician in charge of the case, but a small number of cases may require expert help, and the physician should be alert to spot these cases.

To study the psycho-social variations of hospitalized TB patients, fifty percent of the population of the TB Sanatorium named Hermitage, of Sangrur District in Punjab, was selected. The subjects responded to the Structured Interview Schedule, a Physician's Rating Scale and objective-type psychological tests. The findings revealed that the peak age of the patients was in the range of 25-45 years; that most of the population of that Sanatorium was illiterate, and their socio-economic status was poor. Eighty-two percent of the patients came from the countryside; 77.5 were married and 84% among them had 1-7 children. Sixty-five percent of the patients had been ill for less than two years. About 56% of the male patients had a habit of drinking. Only 13% of the patients had disturbed family relations. No correlation was found between the patients' attitude towards their illness and the physician's rating about the severity of their illness. The Psychological Tests indicated that TB patients did not have different neurotic scores when compared with patients with other chest diseases.

The study aimed to determine some of the psychosocial variables of hospitalized male and female TB patients and how they responded on the Rorschach Ink Blot and Thematic Apperception Tests (TAT). Evidence suggesting social rejection, apprehensions about life and unhealthy family relationships were looked for among the responses to the tests. Two consecutive series of 25 male and 25 female TB patients admitted to the TB Ward of K.G's Medical College and, Gandhi Memorial and Associated Hospitals, Lucknow, from May-November 1968, were studied. They responded to a structured interview. Information on the history of parental attitudes, any parental deprivation and broken home situations was elicited and, the Rorschach test and TAT were administered. The mean ages of the males and females were 33.2 and 22.4 years respectively.

A significantly higher number of females (72%) perceived their childhood as having been difficult compared to 45% of the males. There was no difference in male and female patients with regard to indications of disturbed interpersonal relationships with parental figure as revealed by the Rorschach test. On the TAT, more females projected fear of death and fear of being cast out of the social sphere than males. This result is probably due to the social settings, where most females are found to be economically dependent.

An investigation was carried out to determine whether it was possible to divide TB patients in advance into a positive and a negative group regarding curative results on the basis of psychological tests.

A study was undertaken to know the frequency of depression in hospitalized TB patients, its relation to various socio-cultural factors, duration and severity of the illness. Ninety-six proven male cases of pulmonary TB admitted in S.R.B.B.Y.A. Sadan, Bari, Udaipur from July-September 1975 were selected for the study. A structured psychiatric interview of these cases was done by a psychiatrist and the Hindi version of the Self-rating Depression Scale (S.D.S.) of Zung (1965) was administered. The raw scores obtained were converted into the S.D.S. index by a conversion chart as developed by Zung and his criteria were used for diagnosing the depression. Those patients who had a previous history of any psychiatric illness before developing pulmonary TB and patients developing psychiatric illness other than depression were excluded from the study. The minimum and maximum age limit was 21 and 59 years respectively. Of the 96 cases having pulmonary TB, 52 (54.17%) were found to be suffering from depression. The incidence of depression was higher in illiterates (65.4%) and farmers (84.7%). Depression was positively correlated with the duration and severity of pulmonary TB.

This paper is based on the assumption that a tuberculous patient`s alcoholism is determined by specific characteristic feature of his personality, where an important role is played by his fear of death. The assumptions were corroborated by comparison between tuberculous alcoholics, on the one hand, and tuberculous patients, alcoholics and healthy subjects on the other hand.

Two hundred and seventy two patients with pulmonary TB (with positive sputum) contacting the TB Demonstration and Training Centre cum Chest Institute, Agra and selected through a specified sampling procedure, were subjected to detailed psychiatric screening. Those suspected to be suffering from a psychiatric condition were assessed by a second psychiatrist for diagnostic reliability. Eighty patients were found to be suffering from a psychiatric condition in addition to pulmonary TB giving a psychiatric morbidity rate of 294.12 per thousand, which was much higher than the rates in the general population of comparable age group as found in various studies. When compared to their counterparts, psychiatric break down was more frequent among those patients who had concomitant physical illnesses, special strains and severe anxieties and, those who were housewives.

The study investigated the family background and other socio-economic factors in TB patients as well as the personality pattern and frequency of depression among them. The sample was drawn from the out-patients' clinic of TB and Chest Diseases, S.R.N. Hospital, Allahabad, during February-March 1978 and was restricted only to proven cases of pulmonary TB. A control group of an equal number of cases undergoing treatment for long-term fever of any etiology except TB, was selected from those admitted in the same hospital, after matching age, sex and economic status. First, detailed information concerning the family background and behavior pattern was obtained through a semi-structured interview. Subsequently, the subjects were administered the Hamilton Rating Scale for Depression (1966). Depression was observed in 32 of the experimental subjects in comparison to 7 of controls. Test results also indicated significantly high scores on the Hamilton Rating Scale for depression among experimental subjects.

Severe psycho-social stress and anti-TB drugs, such as Isoniazid, can precipitate acute psychosis. A patient (prisoner) on anti-TB treatment who developed acute delusional psychosis resulting in homicide is reported.

TB like any other chronic infection needs prolonged treatment. It also carries a social stigma and results in adverse psychological reactions. The study details the pattern of psychiatric morbidity among patients sufferings from TB. The study group includes 50 out-patients of pulmonary TB attending Guru Teg Bahadur TB hospital in Delhi with the mean age of 28.3 years (range 11-55 years). Their socio-demongraphic and clinical details were noted on a semi-structured proforma. These patients were then interviewed in detail and specialist’s opinion and relevant investigations were obtained whenever required. Diagnosis of psychiatric disorder was made according to ICD 10 (International Classification of Diseases 10th Edition). The male and female sex ratio was 3:1.

Thirty nine patients (78%) had associated psychiatric disorders; the commonest being mixed anxiety and depressive disorders. The remaining 22% did not have any psychiatric disorders.

The TB patients showed a higher degree of psychiatric disorder like denial, hopelessness about life, fear of being neglected by the spouse, family and society. This could be because of the nature of illness, prolonged treatment, social stigma, misconception about illness, reactions of family members and economical stress.

More studies are warranted with a larger sample size to find out the causation and pattern of psycho-social disturbance among patients sufferings from TB and other chronic physical illness.