REBELS WITH A CAUSE

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disease have greater BHR to methacholine than those with aortic valve disease; the patients with mitral valve disease had higher pulmonary artery wedge pressures.l5 Intravenous infusion of saline increases responsiveness to methacholine in normal subjects.16 Similarly, methoxamine blunts exercise-induced BHR; at least part of the bronchial response to exercise may reflect increased left atrial pressure and mucosal hyperaemia. 17 The vasomotor hypothesis might be tested further by studying the effect of other stimuli that alter left atrial pressure (eg, lower-body negative and positive pressure) on methacholine responsiveness and by conducting methacholine provocation tests in other volume overloaded patients (eg, those with chronic renal failure on dialysis). Can the vasomotor-haemodynamic hypothesis be the sole explanation for the findings of Cabanes et al? Possibly not, for the following reasons. The French workers also showed that methacholine-induced airflow obstruction could be at least partly reversed by inhaled salbutamol, a &bgr;2-adrenoceptor agonist with vasodilator and bronchodilator properties. Moreover, reduction in left atrial pressure should decrease any tendency to methacholine-induced BHR. However, Pison et a113 were unable to show a significant overall increase in PC20 (ie, decrease in BHR) after intensive diuretic therapy that was associated with clinical and radiological improvement. Individual responses were variable and seemed unrelated to change in FEVl. If this last observation is substantiated it also suggests that BHR in cardiac failure cannot be explained on a purely geometric basis-if that were the case, improvement in airway calibre per se should have led to a decrease in hyperresponsiveness.10 Another possibility is that neural control of bronchial smooth muscle might be abnormal in these patients.12 The vagus modulates airways calibre and in dogs raised left atrial pressure increases BHR to histamine through a vagal reflex; a similar reflex might occur in patients with congestive failure.18 The action of methacholine in these patients may reflect an exaggerated vagomimetic response to the drug; this possibility could be addressed by studying the effect of muscarinic antagonists on airways function in cardiac failure.

Testing for BHR with other agents that are unlikely be vasoactive-eg, acidic, hypotonic, and hypertonic solutions-would also be interesting. Other aspects of BHR in congestive failure deserve to to

be addressed. Eicharcker

unable to show airways hyperresponsiveness to methacholine in a group of nine patients with more severe heart failure. 19 This discrepancy needs to be explained; chronicity might lead to loss of BHR. It is noteworthy that patients with CHF get pulmonary oedema at a higher left atrial pressure than those without pre-existing heart failure, and the beneficial response to bronchodilator drugs is lost as heart failure

progresses.44

et

al

were

These observations of airways function in cardiac failure are of potential clinical importance. Persistence of BHR despite adequate reduction in left atrial and bronchial venous pressure may mean that airflow limitation contributes to dyspnoea in CHF-eg, during exercise. If so, bronchodilator drugs might be of therapeutic benefit in this syndrome. Hope J. A treatise on diseases of the heart and great vessels. Philadelphia: Lea and Blanchard, 1842. 2. Osler W. Lectures on angina pectoris and allied states. New York: Appleton and Co, 1987. 3. Robard S. Bronchomotor tone. Am J Med 1953; 15: 356-67. 4. Plotz M. Bronchial spasm in cardiac asthma. Ann Intern Med 1947; 26: 1.

521-25. 5.

Cosby RS, Stowell EC, Hartwig WR, Mayo M. Pulmonary function in left ventricular failure, including cardiac asthma. Circulation 1957; 15: 492-501.

Heyer HE. Abnormalities in the respiratory pattern in patients with cardiac dyspnea. Am Heart J 1946; 32: 457-69. 7. Light RW, George RB. Serial pulmonary function in patients with acute heart failure. Arch Intern Med 1983; 143: 429-33. 8. Peterman W, Barth J, Entzian P. Heart failure and airways obstruction. Int J Cardiol 1987; 17: 207-09. 9. Collins JV, Clark TJH, Brown DJ. Airway function in healthy subjects and patients with left heart disease. Clin Sci Mol Med 1975; 49: 217-28. 10. Moreno RH, Hogg JC, Pare PD. Mechanics of airway narrowing. Am Rev Respir Dis 1986; 133: 1171-80. 11. Wanner A. Circulation of the airway mucosa. J Appl Physiol 1989; 67: 6.

917-25. 12. Barnes PJ. Neural control of human airways in health and disease. Am Rev Respir Dis 1986; 134: 1289-314. 13. Pison C, Malo JL, Rouleau J-L, Chalaoui J, Ghezzo H, Mato J. Bronchial hyperresponsiveness to inhaled methacholine in subjects with chronic left heart failure at a time of exacerbation and after increasing diuretic therapy. Chest 1989; 96: 230-35. 14. Cabanes LR, Weber SN, Matran R, et al. Bronchial hyperresponsiveness to methacholine in patients with left ventricular function. N Engl J Med 1989; 320: 1317-22. 15. Rolla G, Bucca C, Scappaticci E, et al. Bronchial reactivity in heart valve disease. Chest 1987; 92: 955. 16. Rolla G, Scappaticci E, Baldi S, Bucca C. Methacholine inhalation challenge after rapid saline infusion in healthy subjects. Respiration 1986; 50: 18-22. 17. Dinh-Xuan AT, Chaussain M, Regnard J, Lockhart A. Pre-treatment with an inhaled alpha 1-adrenergic agonist, methoxamine, reduces exercise induced asthma. Eur Respir J 1989; 2: 409-14. 18. Kikuchi R, Sekizawa K, Sasaki H, et al. Effects of pulmonary congestion on airway reactivity to histamine aerosol in dogs. J Appl Physiol 1984; 57: 1640-47. 19. Eicharker PQ, Seidelman MJ, Rothstein MS, Lejemtel T. Methacholine bronchial reactivity testing in patients with chronic congestive heart failure. Chest 1988; 93: 336-38.

REBELS WITH A CAUSE

Many human beings are happiest when they are devoted to a cause: when they are members of a group of highly motivated people with a mission to save the country or the world; when a strong leader shows them the true path, and they know that God is on their side; when they feel their whole commitment is demanded in the cause, and all other goals are insignificant compared with the one great objective. Many people felt this way during the 1939-45 war, and found it hard to reconcile such near ecstasy with the horror of warfare. In the UK, the inhabitants of Wing in Buckinghamshire had a similar experience when they joined together to save their patch of countryside from the threat of a third London airport. But what if there is no immediate threat? What if we see that the world is destroying itself with overpopulation and pollution but there is no credible message of salvation? One answer is to make do with the pursuit of mundane goals such as decency, learning, artistic expression, and

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economic advancement. Another solution is to join a cult. No-one reading Cults and New Religious Movements,1 a report of the American Psychiatric Association, can avoid the conclusion that most cults provide some very positive experiences for the members. "Anyone studying these groups is struck by the happiness of the members ... [who]. feel exceptionally well, physically and emotionally. Any symptoms of anxiety, somatic distress, mundane or existential preoccupations, simply melt away." Any adverse effects of cult membership are apparent only to outsiders, especially to their families of origin: "During the period of ultimate commitment to the group, they are often alienated or estranged from their parents. They are suffused with self-righteousness and justification. They feel especially sanctified and enhanced. Not only are their earlier feelings of alienation, demoralisation, and low self-esteem overcome, but they feel ’wonderful’ in all respects. They experience happiness, clarity of thought and high motivation. They feel healthier and want to share their sense of self-improvement; they proselytize, they propound, they bore. Their bliss and happiness are, however, not contagious. Their simplistic reasoning, their overriding commitment, their narrowed focus, their suspension of critical judgement-all of these offend and concern us, but they are hallmarks of fundamental true believers, of any ilk."1 Although there are thought to be some 2500 cults in the USA, this report is concerned only with the few large ones-Eastern-based cults such as the Divine Light Mission and Hare Krishna, and their Western-based counterparts such as the Children of God and the Unification Church (Moonies). The report is based on a few direct studies of the cults by participant observers but mainly on reports of those who have left the cults. There is intense opposition to the cults, some of which is shared by members of the APA’s Committee on Psychiatry and Religion which prepared this report-hence its appearance as an edited volume of independent contributions. Thus one contributor regards the cults as "a public health hazard" and emphasises the harm done by the cults to the members and their families: "There are a good many people already dead or dying, ill or malfunctioning, crippled or developing improperly as a result of their involvement in cults. They are exploited; they are used and misused; their health suffers; they are made to commit improprieties ranging from lying (’heavenly deception’) to murder. Their lives are being gobbled up by days, months, and years. Their families are often devastated."2 Other ..

contributors take a more sanguine view: "The vast majority of members go through these experiences relatively unscathed, have a tough time after they (almost inevitably) come out (usually in under two years), and gradually reconstitute and reintegrate. For most of the youthful members, the radical departure ends up as an intense life experience which few people would have recommended or prescribed, but which manages to serve a developmental

purposes There is general agreement on the advice that should be given to parents when they discover that a child has joined a cult-do nothing but keep the lines of communication open in a non-judgmental way. Joining a parents’ self-help group be useful.

Attempts to "rescue" the novice from the cult discouraged. The horrifying accounts of kidnapping and deprogranaming emphasise that the attempted remedy may be worse than the disease. Some parents try to gain legal control over their children as being can

should be

of unsound mind, and it is salutary to realise that the Soviet Union was not alone in its tendency to categorise as insane those who hold different religious or political beliefs from oneself. These cases have given rise to a minor industry for lawyers and expert witnesses, and the committee members acknowledge that their cooperation in producing this report was jeopardised by the fact that their more usual meeting place is across the floor of a court room. Parents may be comforted by the knowledge that the average stay in a cult is less than two years. When the members leave the cult they may need help, which if possible should include a self-help group of former members of the same cult. The cults themselves need to be controlled by inspection, along the lines recommended by the European Parliament in 1984. The welfare of children born in the cults needs special scrutiny. Despite, or perhaps because of, their difficulties, the Committee and the editor, Marc Galanter, have produced a report that cannot fail to fascinate anyone interested in human groups, the development of belief, or the relief of depression. How can we give our patients the benefits they get from the cults without the manifest disadvantages? Common to the cults is the espousal of bizarre belief, and it seems that the degree of the relief from depression and alienation is correlated with the degree of bizarreness. If the short road to the relief of depression lies in total surrender of the self to a weird cult, then psychiatrists must continue to urge their patients on the long path. Since it would be unethical to offer them bizarre beliefs (except possibly in the form of psychological theories), they must be helped to develop their self-esteem and identity along more mundane lines. And that, in the long run, may be better for them. 1. Levine SV. Life in the cults. In Galanter M, ed. Cults and new religious movements: a report of the American Psychiatric Association. Washington: American Psychiatric Association, 1989: 95-107. £30. ISBN 0-890422125. 2. West LJ. Persuasive techniques in contemporary cults: a public health approach. In Galanter M, ed. Cults and new religious movements: a report of the American Psychiatric Association. Washington: American Psychiatric Association, 1989: 165-92.

HEAD TO HEAD OVER HARROGATE The policy for managing patients with head injury in many British accident and emergency departments is to admit those who have been unconscious or amnesic and to discharge those who have not Most patients have skull radiographs.3 Consequently there are many admissions and even more skull radiographs are taken-yet undetected intracranial haematoma remains an important cause of avoidable death and disability after head injury 4-9 The Royal College of Radiologists has declared more than once that the number of skull radiographs being done in emergency departments is excessive, expensive, and time consuming, while the yield of skull fractures and early detection of intracranial haematomas is poor-11 Neurosurgeons, on the other hand, say that the presence of a skull fracture greatly increases the risk of intracranial haematoma in both adults and children.I3-15 Moreover, 25% of patients with compound depressed skull fractures have never been unconscious or amnesic yet the dura is torn in half these cases.16 Serial publications have not reversed these polarised views. In 1983 the Department of Health and Social Security (DHSS) convened a meeting of radiologists and