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Abstracted from the Medical Press
DEPRESSION: DlSEASl-:, REACTION, OR POSTURE. Sir Dellis Hill. Amer. ]. Psychiat. 125: 445-457, 1968.
The d"hate which surrounds thp issue of depression as a "disease" and as a "reaction" has heen prominent for til(' past 40 y"ars in the psychiatric literature of most European countril's and North Amerka. For 3,000 yl'ars western medical thought has heen domiuated hy two major contrasting ('OJl('('pts of disease. The first view is that of disease as a separate entity. When a man falls ill, he acquires a disease, which is added uuto him. The second vi,'w prt'sents disease as a deviation from the normal statl'. A healthy man falls ill through the influence of any numher of physicalor psychological factors. As a consequence, the changed man and his suffering is the disease. It is agaimt this background that the problem of depression can be considered. Depression lIS Disease: Depression (previously ealled melancholia) as a clinical entity owes its origin to the 18th century physicians who emulated the hiological scil'ntists in classifying different forms of melancholy. But it was in the latter part of the 19th century that psychiatric clinicopathological entities were described. Kraepelin considered manic-depressive disease to be inherent degenerative process of the hrain and quite distinct as to cause, symptomatology, course and prognosis from schizophrenia. He also desnihed involutional melancholia as a distinct disease and classified reactive (neurotic, psychogenic) depression as another form of degenerative process. Following the Kraepelinian logic, European psychiatrists excluded as a disease all those conditions in which organic changes were not present, or in which such changes could not be postulated with confidenCl'. Depression as a disease has been identified with the words endogenous and psychotic. The word psychotic is vague and can be used to denote both quantitative (as severity) and qualitative (as presence of delusions and hallucinations) aspects of the illness. There is some evidence that true manic-depression may be a distinct genetic entity, but the mode of inheritance remains obscure. As for the majority of depressive illnesses, while the genetic factor is still apparent, there is no evidence to (;()ntradid the mmmonly held view of depression as a continuous spectmm extending from normal sadness to the extreme of psychotic depression. ~(apother opened the controversy of the endogenous-neurotic polarity when he stated that he could find no clinical distinction hetween attacks of neurotic and psychotic depression, and that any attack of deJanuary-February 1969
pression was produced by the same pathological mechanism. From this and the work of Lewis, there arose a classification of affectivl' disorders in thre,' subgroups, in which each had a major and minor form. These were: manic excitement and hypomania, melancholia and mild depression, agitated depression and anxiety state. For each suhgroup, a continuum could be postulated hetween the major and minor varieties. The major forms were associated with intrinsic genetic factors, while the minor forms were associated with extrinsic environmental influences. A seemin~ly powerful argument that endogl'nous ann neurotic depression are separate entities has arisen because of treatment results. It has been pointed out that endogenous depression responds well to Ecr and antidepressant dmgs, while neurotic depression does not. Studies by Kiloh and Garside supported the view that endo~enous and reactive depressions could he dearly differentiated on the basis of constellation!! of symptoms. A later study hy Kendell failed to corroborate this difference, and instead the patients with depression were found to fall on a continuum with no discontinuity. Depression as Reaction: In European psychiatry, Bonhoeffer established that manifestations of mental illnesses were laid down hy previously established characteristics in the patil'nt, and not the consequence of a physical diseasl'. In the United Statl's, ~1eyer had proposed that deprl'ssion was a "reactionset" to one's total life experienee. This waetion was S,'l'n as a regression to early infantile rl'actions and therefore maladaptive for the adult personality. Symptoms were thus viewed as a product of dynamic' psychologic interactions. The author conceives of depression as a reaction in the followin~ way: (I) The psychological stressor which elicits it; (2) the depressive response itself, mmposed to biological and hehavioral elements; and (3) the intrapsychic defensiVl' coping processes. These three processes determine the various psychological defenses by which varieties of deprt'ssive il1nesses can he re('()gnized. Depression as PSljclwbiolofl,ical Posture: A6suming depression as a normal res'P0nse, the morbid degree of the response called a depressive illness differs from it by being no longer dependent upon the circumstances. Just as mourning followin~ bereavement has an autonomy of its own, so has its morbid extension as depression. Its primacy and essential features are not different in quality but only in quantity, from the features of normal sadness. They are postures in the sense that they communicate one's emotional state with both defensive and adaptive functions. Depression as a psychobiological posture is described by the author under the three dimensions of:
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PSYCHOSOMATICS ( 1) sadness or mood, (2) a state of physiological arousal, and (3) a state of inhibition. Within this framework which describes deviation from normal, many of the symptoms may he classified. The disturbance of mood may he overwhelming, with feelings of hopelessness, helplessness, self-depreciation and loss of self-esteem. Arousal may be prominent with anxiety, agitation, restlessness, disturhed sleep, and the inability to concentrate. Induded under inhibition are symptoms such as loss of libido, anorexia, loss of interest in the environment, imlecisiveness, and slowness in thought and movement. The author proposes that research into the pht'nomena of inhibition and arousal would he more promising than pursuing the alleged endogenous-neurotic dichotomy. He states that with the development of physiological. chemical and psychological kchniques for the measurement of such functions as arousal and inhihition, it makes it more necessary to identify and descrihe what is inherently biological in the depressive response and what is the consequence of the patient's acquired anlage and habitual means of coping with crisis. This is an excellent paper whieh reviews historical aspects of depression, giv('s somt' framework to undt'rstand the dinical ('ntity. and provides stimulating ideas for research activities.-\VILLIAl\I \V. K. ZUNG, \1.0.
A PRACTICUM FOR THE USE OF LITHIUM SALTS IN AFFECTIVE PSYCHOSES. Bemard S. Let;y. JAM.A. 206:104.5, 1968. \lore than 19 years of clinical experience have shown that lithium salts are effective therapy for acute manic attacks and more recent evidence suggcsts that it can prevent recurrent psychotic depressive or manic episodes. The author recommends that lithium he tried if there is an t'pisodie illness with a strong affective component. A diet adequate in salt (about 5 ~rm. per day) is essential to prevent side effects and toxic reaction. It should not be used in patients with poor renal fnnction or in pregnant women. Severe and dangerously high levels of lithium can occur in the absence of all symptoms. Therefore, in the first weeks of treatment, while the patient's rondition is being stabilized, serial determinations of the blood level of lithium must be done every three days. Thereafter, monthly determinations are adequate. Lithium is available as the carbonate salt in 300 mgm. capsules. The starting dose in hypomania is 300 mgm. three times a day. The therapeutic blood level is 0.5 to 1 meq./liter. If the serum level is not in this range by the ninth day of treatment, the daily dose should be increased by one capsule and the level followed. Patients have required from 900 to 2100 mgm. of lithium carbonate daily to maintain therapeutie blood levels. For the treatment of mania the dosage requirement may go as high as 3600 mgm. daily. When the mania begins to hreak, it is necessary to decrease the dosage to the maintenance level. Time must be allowed for lithium to cross the blood brain barrier and phenothiazines can be used to control symptoms 58
while this is occurring. When lithium is to be used prophylactically for recurrent depressions, it is necessary to first treat the depression and then institute lithium therapy. Antidepressants, phenothiazines and electroconvulsivf' therapy have been used roncomitantly with lithium. -8. R.SHOCHET,\I.D.
EVALUATION OF NEWER ANTIDEPRESSANT DRUGS. P. H. Ornstein. Amer. Forn. Phys. 7:65, 1964. Depression, particularly masked depression, is the most conunon psychiatric syndrome seen by the general practitioner. The physician must know about the natural course of depression, the different types and their psychodynamics. Normal depressions are short-lived, appropriate reactions to adversity or loss. Usual1y no treatment is required; antidepressant drugs and ECT are contraindicated. Neurotic depressions occur after only slight provocation, because of an inner tendency toward depressive reactions, Moodiness, irritability, sadness. despair, insomnia, fatigue and some diminution of interest in outside activities are usual1y seen but there is ordinarily no agitation, psychomotor retardation or disturbance in autonomic function. The condition may become chronic. Psychotherapy is the preferred treatment but drugs such as amitriptyline or imipramine may be used in severe cases or in the borderland between neurotic and psychotic depression. ECT should not be used. Psychotic depressions are characterized by psychomotor retardation or by agitation. There is a depressed facial expression and the mood is one of despair and hopelessness. Delusional ideas and suicidal thoughts are common, as are sleeplessness (especially early morning awakening), loss of appetite and constipation. Imipramine is the drug of choice for retarded patients and amitriptyline for the agitated. ECT accomplishes its best results in this group. The reported studies on the therapeutic effectiveness of antidepressant drugs exhibit discrepancies due to differences in the type and severity of the depression and variations of the point in the cycle of iI1ness at which the drug is employed. Monoamine oxidase inhibitors may be dismissed as routine antidepressants. Imipramine and amitriptyline and their analogues have stood the test of careful evaluative studies.-LEONARD J. SCHIFF, M.D.
ALOPECIA AREATA. ]. Manrique. Univ. Medica 6:83-90, 1964. Careful review was made of histories of 20 patients in a military hospital, and another ten patients were studied from the psychosomatic viewpoint and fol1owed for approximately two years. The age range was from six months to 32 years (most between 24 and 32) and males predominated in a ratio of 3: 1. All had patchy scalp lesions exclusively but none Volume X
ABSTRACfED FROM THE MEDICAL PRESS suffered from nail changes, vitiligo or any other serious disease. The lesions usually appeared with dramatic onset. Improvement was related to improvement in emotional status, although the patients were unaware of this relationship. Treatment consisted only of simple supportive therapy such as that commonly used by dermatologists. The scalp lesions of alopecia areata are probably caused by emotionally induced vasoconstriction, with resulting ischemia and subsequent loss of hair. Further experimental studies are needed to evaluate the role of emotional stress and to rule out possible simple coincidence. (Original in Spanish )-JAY H. SCHMIDT, M.D. THE CAUSE AND PREVENTION OF POSTOPERATIVE PSYCHOSES IN THE ELDERLY. Davfd D. Stonecypher, Jr., M.D. Amer. J. Ophthol. 55: 605-610, No.3, March 1963.
This paper refutes the theory that psychoses following cataract extraction are caused by sensory deprivation. Most post-cataract patients have only one eye patched-an eye which had lost so much vision it needed surgery. The other eye, the ears, the other sensory modalities are all working as before surgery. The bandaging simply does not create any signi6cant sensory deprivation. The author associates the fact that most psychotic episodes occur at night with the fact that night is associated with the uneasy feeling of danger, ghosts, death and criminal activity. The author states that in a patient over 60 if his history shows two or more of the following elements, he is subject to post-operative psychosis: 1. A history of marginal social adjustment. 2. Apparent frailty. 3. Long-standing disease. 4. An immigrant. 5. A manual laborer. 6. Retirement. 7. A history of previous psychotic episodes. When a surgeon is concerned he should order a light in the room, paraldehyde for the disoriented period, encourage the patient to bring cherished possessions to the hospital, encourage a radio which gets the patient's mind on world affairs rather than his own person, to bring his own pillow and impress on him that the doctor is eager to serve him.-T. F. SCHLAEGEL, Jr., M.D. DRUG THERAPY WITH OR WITHOUT GROUP DISCUSSION: EFFECTS OF VARIOUS REGIMENS ON THE BEHAVIOR OF GERIATRIC PA· TIENTS IN A MENTAL HOSPITAL. J. R. Williams, Leopold Csalany, Gabriel Misevic. J. Amer. Geriatrics Soc. 15/1, Jan. 1967.
Results were reported on the effects of eight different treatments (each of the drugs, Metrazol, Deladumone and Taractan, with and without W'oup discussion, and two controls) on the behavioral condition of 64 geriatric patients. Randomization of both patients and treatments to the eight groups occurred. One c.c. of Deladumone was given intramuscularly every three weeks. Metrazol was administered in tabJanuary-February 1969
let form, 100 mg three times a day. Taractan was given in variable dosage, 50-100 mg two or three times a day, except in acutely disturbed cases where one c.c. was given intramuscularly every six hours. The discussion groups in each case met once a week for approximately 45 minutes. The "leaders" of the groups were interchanged every three weeks to assure equal exposure over the experimental period. Pre- and post-evaluation of the subjects were C:lTried out by ten trained observers, using a revised, experimental form of a behavior rating scale developed speci6cally for use with geriatric patients. Use of the scale was designed to give an approximate measure of "degree of behavioral normality." The results, while in no case reaching the 5 per cent level of statistical signi6cance, were consistent. Without exception, those groups experiencing group discussion of problems changed more favorably in behavior than did the other groups. Also, in every case, groups receiving both medication and group discussion of problems changed more favorably in behavior than did the groups having discussion of problems alone. Finally, in two out of three cases, those groups receiving more favorable change in behavior than did the "no treatment" group. The results were discussed by comparing them to the Bndings and conclusions of several related studies and writings. The opinion that any single treatment for this individually varied group held limited value was felt to be substantiated.-AuTHoRs' AIISTRACT
DRUG-INDUCED EXT RAPl:' RAM I DAL SYMPTOMS: THEIR INCIDENCE AND TREATMENT. Charles Sheppard, M.A., and Sidney Merlis, M.D. Arner. ]. Psychiat. 123:886, No.7, Jan. 1967.
The question of side effects concurrent with treatment for psychological symptomatology has received added attention in the past decade. The search for chemical structures which provide therapeutic change while producing limited side effects continues, as does the investigation of the incidence of untoward effects with current psychoactive medications. The authors survey the incidence of extrapyramidal symptoms at a large (census 11,182) psychiatric hospital. In previous studies a high percentage of symptom remission has been adequately demonstrated. Therefore, it is unlikely that the data reported on extrapyramidal symptoms was related to inadequate dosage. Five per cent (378) of a total of 7,110 patients receiving psychotropic therapy received antiparkinson medication. The empirical evidence reported indicated a sex difference ( 3: 1 ) females. Different "clusters" of extrapyramidal symptoms were elicited by different drugs. It was suggested that these differences may cut across chemical structure. The in· cidence in side effects seem to be related more to dosage and chemical structure than to a possible psychodynamic interpretation of the patients adjustment to psychophysiological changes induced by the treatment regimen. Nonetheless, in a total treatment program these symptoms should not be ignored.
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PSYCHOSOMATICS They have meaning to the patient, to the therapistpatient relationship, to the ward staff and to the total ward milieu. Effective treatment was achieved by adding anyone of four antiparkinson medications to the therapy regimen. Ninety-seven per cent of the patients treated improved (38 per cent completely, 35 per cent moderately, 24 per cent some and three per cent showed no improvement). Two tables were included. One summarized the antipsychotic drugs, their dosage regimen, incidence and type of most frequent extrapyramidal effect by sex. The second gave the antiparkinson agents used, their median daily dose and dosage range.-AUTHoRs' AIlSTRACT
HYPNOANALYSIS: THEORY AND TWO CASE EXCERPTS. Erika Fromm. Psychotherapy Il:123, Oct. 1965. The author contrasts the authoritarian with the newer, permissive role of the hypnotist. She dispells as a "myth" Freud's concept that "hypnosis circumvents the ego." Perception, sensation, thought, fantasy, memory, learning, and other ego functions manifest themselves in hypnosis, some of them to a heightened degree (e.g., hypermnesis, creativity). Hypnosis is an alteration rather than elimination of ego function. DefenSive ego functions are also present in trance. Even in a light sta~e the therapist can understand and analyze the patient's characteristic defense system more readily than in the process of psychoanalysis. This is because in analysis the patient must learn to separate the observing from the experiencing ego, whereas in hypnosis this separation occurs spontaneously. Indeed the observing ego can be so totally separated from the experiencing ego that pain is observed but not felt, as vividly illustrated in the case material presented. The author urges that we continue to search for new methods of shortening psychotherapy without sacrificing depth or insight, and further that permissive hypnosis be interspersed with psychoanalytically oriented hours with the patient awake for most effective treatment.-ELIzIlETH THOMA, Ph.D.
SU1CIDE IN ADOLESCENCE. A. P. Perlstein, M.D. New York ]. Med. 66:3017, No. 23, Dec. 1966. Two per cent of annual reported suicides and 12 per cent of reported suicide attempts occur in the fifteen- to nineteen-year age range. Some statistical and dinical observations bearing on this problem are reviewed in this paper. Adolescence makes special developmental demands which may overwhelm the ill-prepared adolescent especially when he fails to receive adequate understanding or support from his family. Attention to a syndrome of adaptive decompensation would help to detect oncoming suicide attempts in at least 70 per cent of cases. This syndrome includes decreased or increased eating (also excessive smoking and drinking); decreased or increased sleeping; somatic complaints; and excessively withdrawn or rebellious, impulsive behavior. It is often when this distress is not ade-
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quately attended to that a suicide attempt talce place. Previous suicide attempts or threats preced, three out of four completed suicides. The preseno of a history of a previous suicide attempt or threat, or the syndrome of decompensation described above should lead to psychiatric consultation for the adolescent patient and his family.-AUTHoR's ABSTRACT
DYNAMIC ASPECTS OF SUICIDE. M. H. Hand, M.D., and A. M. Meisel, M.D. New York ]. Med. 66/23, Dec. 1966. About 25,000 persons commit suicide in the United States each year. Men commit suicide more ofteJl than women and old persons more often than yOUDI. The reverse is true of attempted suicide. Physicians are frequently consulted as a last resort, but oftea fail to respond. Suicides view their act as a rebirth, as a gesture of de6ance which preserves their self-worth, and as a means of extricating themselves from an intolerable life situation. A suicidal gesture may be a plea for help and acceptance, which if answered, enables the person to proceed with renewed strength. In order to deal with experiences one must regard one's self as indestructible and central. Any threat to this position is depressing and provokes anxiety. ReafBrmat ion of self worth, by acceptance as a member of a W'oup or sharing difficulties, relieves depression and anxiety. Phantasy, conscious and unconscious, also relieves anxiety and depression. Deprived of phantasy, persons tum to action. A person who cannot love or be loved, who cannot be worthy, important, potent or rich, or who cannot have phantasies of these, cannot survive. The suicide, li1ce others, well or ill, strives to maintain this centrality and his 6nal gesture reRects this need.-AuTHoRs' ABSTRACT
PARADOXICAL INFLUENCE OF A THERAPEUTIC SIDE-EFFECT INTERPRETATION. R. S. Lipman, M.D. Arch. Gen. Psychiat. 15/5, Noo. 1966. Clinicians frequently differ in the way they prepare patients for possible medication side-effects. In order to assess the therapeutic and methodological implications of this nonpharmacological source of variance, atropine was employed to produce dry mouth and doctors were carefully trained to convey systematicaIly either a "positive-therapeutic" or a "ca!Qal-neutral" interpretat¥>n of dry mouth to their patients. In this one-week double-blind study, 204 anxious neurotic outpatients were randomly assigned to both side-effect treatments, and within treatment conditions to the following four medication groups: chlordiazepoxide hydrochloride (10 mg, t.Ld.), chlordiazepoxide plus atropine (0.5 mg, t.i.d.), atropine and placebo. Prior to criterion analysis, it was determined that a) patients on atropine medications experienced more dry mouth than non-atropine patients, and b) that almost all patients correctly recalled their doctors' side-effect preparation. Results indicate a general therapeutic superiority Volume X
ABSTRACTED FRm.i THE MEDICAL PRESS for the chlordiazepoxide medications and an entirely unexpected improvement interaction between sideeffect preparation and atropine vs. non-atropine medications. In the "therapeutic" condition (the likelihood of dry mouth was mentioned two or three times, and always in the context of its being a "good sign" showing the medication was working effectively), patients receiving atropine medications improved less than patients not receiving atropine and medications. In the "neutral" condition (patients were casually prepared for dry mouth and told the dry mouth was "nothing to worry about"), atropine and non-atropine groups showed roughly equal but more improvement than the atropine group under the "therapeutic condition.-AUTHol\'s ABSTI\ACT
HYPOCHONDRIASIS: A CLINICAL STUDY. F. E. Kenyon. Brit. I. Psychiat. 110:478-488, 1964. This study of a group of 512 patients suffering from primary or secondary hypochondriasis indicates that it had a relatively equal sex distribution; depression and anxiety are the most commonly associated diagnoses. Of the somatic complaints in this condition, there was a significantly high incidence of pain in the head, neck and abdomen, particularly on the left side of the body. Primary hypochondriasis seemed to have poorer short term prognosis than the secondary group, but at followup it was observed that 21 per cent of the primary group had been given a changed diagnosis. No specific premorbid personality type could be demonstrated in this hypochondriacal series. It is concluded that hypochondriasis is not a nosological entity but always part of another syndrome which was most commonly affective.-JAY H. SCHMIDT, M.D.
FOLLOW-UP STUDY OF HYSTERlCAL AMBLYOPIA. Herbert Friesen, M.D. and William A. Mann, M.D. Amer.}. Ophthal. 62:1106-1115, No.6, Dec. 1966. The authors were able to follow 11 cases with a <.'Onfirmed diagnosis of hysterical amblyopia for a period ranging from four to 31 years. Five demonstrated a cure or marked improvement, whereas three had become worse, and three were about the same. The authors also suggested tubular fields may be much more common in psychiatric patients than is generally realized.-T. F. SCHLAEGEL, JII., M.D.
PSYCHIATRIC SYMPTOMS IN ADOLESCENTS. P. G. S. Beckett. I.A.M.A. 198:359-363, 1966. Adolescents pose several major challenges to the psychiatrist of today. For instance, given the large and increasing number of adolescents in our population and the fact that psychiatric referrals are now quite fashionable, how can we cope with the volume? Or, a more critical question, how many of those referred should actually be considered psychiatric patients? A few have clearcut syndromes but most show only disturbances in behavior. Is any nonJanuary-February 1969
utopian behavior to be considered a psychiatric problem? Or any non-utopian psychodynamic problems? Or should we consider abnormal only behavior which departs from the statistical average? Such nonaverage behavior can be described in terms of deviations from the mean but the question arises as to whether it is the "average" of the block, the neighborhood, or the nation in which we refer. Average in one community is not average someplace else. In practice one uses a combination of clinical diagnosis, psychodynamic diagnosis, accessibility or personal awareness of conflict. and estimates of behavioral bizarreness and of therapcutic potential to determine which one is to be a psychiatric patient. Since it i.~ difficult to separate between forces within the family which influence the adolescent and forces in the peer group and neighborhood which influence him, both of these must be taken into account in therapy. Treatment of the adolescent therefore involves more than individual psychotherapy, although this is a central technique. It is also necessary to have the adolescent experience directly that the adults in his environment are consistent, realistic, and not vindictive. Since verbal methods are usually ineffective in doing this, in many cases it is necessary to set up a controlled living situation, where a set of clearcut rules exist and where these rules arc enforced by a system of rewards for compliance, and restrictions for non-compliance. Detailed planning is discussed. As internal controls within the adolescent take over from these external <.'Ontrols imposed by the adult world, it is then very helpful to accelerate identification with appropriate adults. This can probably be accomplished by emotional arousal, as animal studies suggest that arousal of any emotion promotes identification. Some practical possibilities are mentioned. Finally in all adolescents the influence of the peers must not be neglected. Various techniques for promoting a therapeutically healthy peer group in the hospital environment are discussed; these include the use of patient government and a patient disciplinary committee.-AuTIlol\'s ABSTI\ACT
THE DANGER OF AMPHETAMINE DEPENDENCY. Frederkk Lemere, M.D. Allier. I. Psychiat. 123:569, No.5, Nov. 1966. The full extent of the danger of amphetamine dependency is not generally recognized. There is an increasing number of young people experimenting with this and other dangerous drugs out of curiosity and for "kicks." The large number of patients talting amphetamines for fatigue, depression, and weight reduction adds to the pool of potential addicts. Amphetamine dependency is often a precursor to "hard" narcotic addiction. The experience of the Japanese with over 200,000 amphetamine addicts after World War II has demonstrated that this drug can also produce permanent organic brain damage. CJioi0111, pathological, and experimental evidence confirms the Japanese experience. Excessive consumption of amphetamines can produce serious psychiat. ric complications, from severe J}{'rsonality disorders to chronic psychoses. Because of the organic compo-
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PSYCHOSOMATICS nent, treatment of these disorders is even more dUBcult than that of spontaneous psychiatric illnesses. New government controls will help to curb this problem, but the aid of physicians will also be required. Because of their potential danger, amphetamines should be prescribed with caution, reluctance, and only under the strictest supervision.-AUTHOR'S ABSTRACT
H. Enke, et al. Moo. Welt (Stuttg.) 1O:5I4-S2Q, 1964.
THE BASIC PSYCHOSOMATIC PROBLEM.
This study deals with the onset and course of various physical symptoms in patients attending the psychotherapeutic psychosomatic clinic. It is intended as a contribution to the basic psychosomatic problem, to demonstrate the unity of mind and matter by exploring the existence of isolated conditions. After an outline of hypothesis, a clinical and psychological comparison is made of the course of the symptoms in patients with chronic, and chronic recurrent complaints and patients who are symptomprone. The main finding here is that affective reactivity is higher in the chronic recurrent than in the chronic patients. The chronic patients seem to show much more signs of affective restriction and loss of contact. Those who are prone to complaints occupy a special position. A definitive psychological classification still is impossible, however, on the basis of the criteria examined. A eomparison was made between a small group of patients who were ahsolutely free from symptoms in the intervals and the relatively small group of patients with chronic symptoms. Patients in the former category were more intelligent, had better control and offered greater possibilities for treatment. The chronic group ( with permanent symptoms) showed excessive restriction and rigidity in mental affective processes. (Or,ginol in German)JAY H. SCHMIDT, M.D.
FAMILY RESEARCH ON THE PROBLEM OF ULCERATIVE COLITIS. Don D. Jackson, M.D. and Irvin Yalom, M.D. Arch. Gen. Psychiat. 15:410, No. 4,1966. From a study of eight families in which the identified patient had ulcerative colitis, from observation of several other such families, and from discussions with family therapists who had treated such families, the authors were struck by the similarity of behavior among these families when interacting in conjoint family therapy. All the families appeared to be severely socially restricted and actively restricted each other in the range of permissihle behavior. Data collected on individual family members as to their "outside the family" behavior corroborated the impression that they existed in a narrow band of social participation when compared to the group of "ordinary" families under study at the Mental Research Institute. The limitation in the range of interaction, the careful dealing with each other, the handling of a variety of situations in a similar fashion, suggest at one and the same time a feeling of des82
pair and yet a feeling of family sameness that almost approached solidarity. Wynne's term "pseudomutual. ity" best describes the apparently false solidarity 01 these families. The study sample was composed of white, middleclass families, and no data was collected to control for the effect of a chronically ill child on family interaction. It is obvious that the study needed to be broadened, both in the size and range of the sample, and a control instituted for the effect of chronic illness on family interaction, by utilizing disorders with no known emotional etiology, such as cystic fibrosis and muscular dystrophy. The authors are presently conducting such a study, and will be comparing the ulcerative colitis families on a variety of measurements with a normal sample, as well as the above-mentioned chronically ill child sample. Three terms: "restrictiveness," "restricted family," and "recursive arborization" are introduced as possible conceptual aids in the study of family interactional pattems.-AUTHoRs' ABSTRACT ANALYTICAL GROUP TREATMENT OF THE POST-HOSPITAL SCHIZOPHRENIC. Louis C.
Alikakos. Intemat. J. Group Psychother. XIV:492, Oct. 1965.
Post-hospital treatment of schizophrenia has been unsatisfactory because many patients lack insight and motivation and are reluctant to expose themselves to an intense relationship, and also because psychiatrists hesitate to use insight therapy fearing it will precipitate recurrences, or at best will be ineffective with these patients. The author presents his experience with analytic group therapy as the method of choice, primarily because the intense and mercurial transference reactions are diluted in the group. Moreover, group dynamics tend to reduce anxiety and guilt feelings, to provide support, limit regression, enhance self-esteem, and provide graded socializing experiences. Over a period of several years a number of schizophrenic patients were able to work on their personality problems; the five and one-half year treatment of one such patient is presented in detail. In view of the paucity of studies in this area, it would be useful to see other work on the effectiveness of long-term group analytic treatment of the post-hospital schizophrenic.-EuzABETH THOMA, Ph.D. TREATMENT OF BARBITURATE COMA. Zelman L. Bernstein, M.D. New York ]. Med. September, 1966.
Barbiturate poisoning, regardless of the dose ingested, should no longer be considered a fatal disease when treated properly. If a patient is admitted to a hospital in uncomplicated coma but still alive, he should survive. Three cases of deep coma with high blood levels are presented. The usual coma level for short-acting barbiturates is one to three mg per 100 cc in the blood. This is very variable. Death has been reported with less than 1 mg per 100 cc of shortacting barbiturates. In the three cases described the blood barbiturate levels were 10.2, 6.85 and 5.8 mg Volume X
ABSTRACTED FROM THE MEDICAL PRESS per 100 cc, respectively. In addition each case had circumstances which are known to enhance the depth of coma, i.e. anemia, anoxia and other drugs. Each patient went from deep coma to full consciousness within 48 hours. Treatment consisted of tracheotomy and peritoneal dialysis. Analysis of dialysatic samples showed appreciable amounts of barbiturates removed. This method of treatment is compared with the classic Scandinavian method. Since peritoneal dialysis is a simple procedure which can be performed in any hospital, some alteration in the standard treatment is recommended for consideration; other methods of treatments used are discussed. These include gastric lavage, analeptic drugs, mannitol, forced diuresis, alkalinization of urine and steroids. If an airway and respiratory tract hygiene are instituted promptly along with peritoneal dialysis, the above methods arl' not necessary.-AuTHoR's ABSTRACT
IMPROVEMENT OF VISUAL ACUITY BY AMOBARBITAL COMBINED WITH PLEOPTICS. ]un Tsutsui, M.D. Amer.]. Ophthal. 2:1171-1176, No.6, Dec. 1966. Pleoptics is a relatively new form of training to improve vision in amblyopia. The author found visual acuity to be improved during narcoanalysis. It was his opinion that amobarbital in pleoptics can produce more marked visual improvement than ordinary pleoptics, and he speculates that the effects are due to a removal of an inhibiting mechanism from the higher centers. This study suggests that amblyopia with a definite and immediate response to amobarbital is of a suppre$sion type whereas that amblyopia with no immediate response is due to an undeveloped function or some undetected organic change. Thus amobarbital may be of value in differ('ntiating various types.-T. F. SCHLAEGEL, JII., M.D.
THE WIVES OF DRUG ADDICTS. S. D. Taylor, R.N., M. Wilbur, A.A.P.S.W. and R. Omos, M.D. Amer. ]. Psychillt. 123:585, No.5, Nov. 1966. An interview schedule was administered to six wives of drug addicts in treatment at the Greenwich House Counseling Center, to determine why they married and remained married to addicts. The husbands were not atypical from the rest of the clinic's male population. The characteristics of each husband and wife were similar in age and ethnic and religious background. The women met their husbands in conventional ways and marriage was not precipitous. The wives were attracted to the men by characteristics associated with passive personalities, such as "gentle, clean, and sweet." Only two men began using drugs after the marriage. The wives had difficulty recalling the chronology of crises, separations and attempts at abstinence which were typical of the marriages. One-half of the wives experimented with drugs themselves. Their attitude towards addiction evolved from one of naivete (or denial) to a more realistic appraisal. In their ranuary-February 1969
relationships with their own families the wives appeared to have many unresolved conHicts. The predominant pattern was a strong identification with their mothers and a view of their fathers as weak men. The authors' impression is that the personality make-up of the wives obligates them to remain involved with weak men whom they usually can dominate and who make only minimal adult heterosexual demands on them.-AuTHoRS' ABSTRACT
GROUP PSYCHOTHERAPY WITH DEPRESSED WOMEN. P. R. Miller, M.D. and L. Ferone, M.S.W. Amer. ]. Psychiat. 123:701, No.6, Dec. 1966. The Mental Health Clinic of De Paul University has been treating depressed women with outpatient group psychotherapy for three years. This experience revealed that depressed women have remarkably similar symptoms and character structures, and that group therapy works with severely disturbed depressed women. Presenting complaints were inability to manage the household, poor relationships with family, feelings of inadequacy and depression, and realistic stresses representing an object loss. Our patients could be described as demanding and provocative, hypochondriacal, cognitivel}' disturbed, agitated, confused in their thinking, troubled with psychosomatic symptoms and clinging in their appeals for love. They were also envious, lonely, and gratified by their illness. They used roles of martyrdom and attempted to control others by provoking guilt in them. The character structun' and psychodynamics of these patients appear vividly in the role relations of group therapy. They placed one another in the roles of rejecting mother, preferred sibling, distant father, etc. They were alternately supportive and harshly realistic with one another, much in the manner of Alcoholics Anonymous and Synanon. Group therapy with depressed women works as well as, and sometimes better than, individual therapy. Five patients had to be hospitalized for psychiatric reasons prior to joining the group, none subsequently. Those who had been in individual therapy previously did not sustain symptom relief, but they did maintain their improvement in group therapy.-AuTHoRS' ABSTRACT
TREATMENT OF TIC DOULOUREUX WITH G32883 (CARBAMAZEPINE). E. Lutz, M.D. Diy. Nerv. Syst. 27:600, 1966. A review of a new anticonvulsant, G-32883 (Carbamazepine) is presented with its specific effectiveness for symptomatic relief from tic douloureux (trigeminal neuralgia) which in the past had unsatisfactorily responded to medical treatment measures. The numerical agreement of approximately 85 per cent or more positive results in the treatment series of most investigators indicates the remarkable efficacy and specmcity of this symptomatic drug. The incidence (approximately 15 per cent) of thera-
63
PSYCHOSOMATICS peutic failures can be further decreased by the combined treatment with carbamazepine and diphenylhydantoin and by the addition of neuroleptics. The average daily requirement is 600 to 800 mg carbamazepine but may vary from 200 to 1600 mg. Interruption of polysynaptic reflex activity appears to be the mode of therapeutic action of carbamazepine, an iminostilbene derivative, related to imipramine. This new drug represents a major therapeutic break-through and an attractive alternative to in· effective medical management and often mutilating and unsatisfactory neurosurgical treatment.-AuTIfoR's ABSTRACT
laboratory values showed no changes that were clin. ically significant. The patients were chronically ill and had been resistant to other medications, thus they constituted a severe challenge to the activity of any drug. The drugs seemed to be almost equally effective in attaclting the target symptoms. Haloperidol, a non-phenothiazine derivative, may offer another choice in the class of therapeutic drugs in some chronic schizophrenics.-AuTIfORS' ABSTRACT
HALOPERIDOL AND THIORIDAZINE IN TREATMENT OF CHRONIC SCHIZOPHRENICS. L. Prasad, M.D. and M. C. Townley, M.D. Dis. Nero. Syst. 27:722, No. II, Nov. 1966.
1965. Urinary 17-hydroxycorticosteroids (17-OHCS), an index of anterior pituitary adrenocortical activity, were found to alternate regularly every other day. On days that the patient was manic, the 17-0HCS levels were low; during days of depression, they were elevated. Later during the course of the ill· ness, stable periods were associated with stability of these levels. A marked denial of illness characterized the manic periods; during depression there was no denial, but expressions of severe suffering.
A 12-week, double-blind study on 37 female and three male patients was undertaken to assess the antipsychotic merits of haloperidol (butyrophene) relative to those of thioridazine, an effective phenothiazine derivative. All of the forty patients included in this study had hi.~tories of long illness and had been resistant to treatment with other psychotherapeutic agents. The average duration of illness was more than ten years. Sixteen patients were diagnosed as paranoid, nine hebephrenic, four catatonic, one schizo-affective and ten undifferentiated. Clinical laboratory tests, including hemoglobin, CBC, SCOT, alkaline phosphatase and urinalysis, were performed on all patients initially and after two, four, eight and 13 weeks. A modified Lorr Scale was used by the psychiatrist to record changes in patients' symptoms, initially and bi-weekly. Weekly records of ward behavior were made by the nurses. At the end of the study, each patient's status was evaluated on the basis of behavior and symptoms. The dosage ranged from 2 mgs to 24 mgs daily in the patients treated with Haloperidol, and 60 mgs to 720 mgs daily in the patients treated with thioridazine. Tables based on statistical analysis showed an almost equal amount of improvement in patients treated with either drug (mean change 39 per cent). Eleven patients in the thioridazine group and nine in the haloperidol group showed no essential change in their psychotic profiles. Of twenty patients treated with thioridazine, 13 lost weight and seven gained weight. In patients treated with haloperidol, 16 lost weight, two gained, and two experienced no change in weight. Four patients treated with thioridazine, and all but one patient treated with haloperidol, experienced side effects at some time during the study. More neurological side effects were noted with haloperidol. Transient corneal haziness was discovered in two patients receiving haloperidol, but it was not established that this was a drug-related change. Final
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A PSYCHOENDOCRINE STUDY OF A PATIENT WITH 48·HOUR MANIC-DEPRESSIVE CY. CLES. W. E. Bunney, Ir., E. L. Harlmonn orad I. W. MtuOn, Arch. Gen. PSl/chiat. 12:619 (June)
ACUTE ERGOTISM. P. Hudgson and I. A. L. Harl. Moo. I. Australia, 51(2), 15: 589-591, 1965. The authors cite a case of acute ergotism which was caused by overdosage of Cafergot. They review the literature, with particular emphasis on the neurological and cardiovascular manifestations of ergot poisoning. They stress the importance of gastric analysis in patients where overdosage is suspected.
SEXUAL IMPOTENCE IN MEN HAVING LOWBACK SYNDROME. Myron M. Laban. M.D. Arch. Phys. Med. 47:715-723, 1966. Forty-three men with back injuries from industrial accidents were studied while in a rehabilitation unit. Twenty-seven of these men were sexually impotent. Although the impotent men had more hospitalizations and surgical procedures than the others. both groups were similar in other respects, including intelligence, education, skill and physical toleranCf'. As a group, the impotent men came from relatively unstable homes where parental loss due to death or separation was common and hence several children often competed for one parent's limited attention. Half of this group were first or only children. The impotent men made relatively few and halfhearted attempl~ to return to work and then finally gave up. Many then cared for the house and children while the wives worked. On the whole, these men showed less concern about their sexual inadequacy than do most men facing diminished potency. W.O.
Volume X
The d"hate which surrounds thp issue of depression as a "disease" and as a "reaction" has heen prominent for til(' past 40 y"ars in the psychiatric literature of most European countril's and North Amerka. For 3,000 yl'ars western medical thought has heen domiuated hy two major contrasting ('OJl('('pts of disease. The first view is that of disease as a separate entity. When a man falls ill, he acquires a disease, which is added uuto him. The second vi,'w prt'sents disease as a deviation from the normal statl'. A healthy man falls ill through the influence of any numher of physicalor psychological factors. As a consequence, the changed man and his suffering is the disease. It is agaimt this background that the problem of depression can be considered. Depression lIS Disease: Depression (previously ealled melancholia) as a clinical entity owes its origin to the 18th century physicians who emulated the hiological scil'ntists in classifying different forms of melancholy. But it was in the latter part of the 19th century that psychiatric clinicopathological entities were described. Kraepelin considered manic-depressive disease to be inherent degenerative process of the hrain and quite distinct as to cause, symptomatology, course and prognosis from schizophrenia. He also desnihed involutional melancholia as a distinct disease and classified reactive (neurotic, psychogenic) depression as another form of degenerative process. Following the Kraepelinian logic, European psychiatrists excluded as a disease all those conditions in which organic changes were not present, or in which such changes could not be postulated with confidenCl'. Depression as a disease has been identified with the words endogenous and psychotic. The word psychotic is vague and can be used to denote both quantitative (as severity) and qualitative (as presence of delusions and hallucinations) aspects of the illness. There is some evidence that true manic-depression may be a distinct genetic entity, but the mode of inheritance remains obscure. As for the majority of depressive illnesses, while the genetic factor is still apparent, there is no evidence to (;()ntradid the mmmonly held view of depression as a continuous spectmm extending from normal sadness to the extreme of psychotic depression. ~(apother opened the controversy of the endogenous-neurotic polarity when he stated that he could find no clinical distinction hetween attacks of neurotic and psychotic depression, and that any attack of deJanuary-February 1969
pression was produced by the same pathological mechanism. From this and the work of Lewis, there arose a classification of affectivl' disorders in thre,' subgroups, in which each had a major and minor form. These were: manic excitement and hypomania, melancholia and mild depression, agitated depression and anxiety state. For each suhgroup, a continuum could be postulated hetween the major and minor varieties. The major forms were associated with intrinsic genetic factors, while the minor forms were associated with extrinsic environmental influences. A seemin~ly powerful argument that endogl'nous ann neurotic depression are separate entities has arisen because of treatment results. It has been pointed out that endogenous depression responds well to Ecr and antidepressant dmgs, while neurotic depression does not. Studies by Kiloh and Garside supported the view that endo~enous and reactive depressions could he dearly differentiated on the basis of constellation!! of symptoms. A later study hy Kendell failed to corroborate this difference, and instead the patients with depression were found to fall on a continuum with no discontinuity. Depression as Reaction: In European psychiatry, Bonhoeffer established that manifestations of mental illnesses were laid down hy previously established characteristics in the patil'nt, and not the consequence of a physical diseasl'. In the United Statl's, ~1eyer had proposed that deprl'ssion was a "reactionset" to one's total life experienee. This waetion was S,'l'n as a regression to early infantile rl'actions and therefore maladaptive for the adult personality. Symptoms were thus viewed as a product of dynamic' psychologic interactions. The author conceives of depression as a reaction in the followin~ way: (I) The psychological stressor which elicits it; (2) the depressive response itself, mmposed to biological and hehavioral elements; and (3) the intrapsychic defensiVl' coping processes. These three processes determine the various psychological defenses by which varieties of deprt'ssive il1nesses can he re('()gnized. Depression as PSljclwbiolofl,ical Posture: A6suming depression as a normal res'P0nse, the morbid degree of the response called a depressive illness differs from it by being no longer dependent upon the circumstances. Just as mourning followin~ bereavement has an autonomy of its own, so has its morbid extension as depression. Its primacy and essential features are not different in quality but only in quantity, from the features of normal sadness. They are postures in the sense that they communicate one's emotional state with both defensive and adaptive functions. Depression as a psychobiological posture is described by the author under the three dimensions of:
57
PSYCHOSOMATICS ( 1) sadness or mood, (2) a state of physiological arousal, and (3) a state of inhibition. Within this framework which describes deviation from normal, many of the symptoms may he classified. The disturbance of mood may he overwhelming, with feelings of hopelessness, helplessness, self-depreciation and loss of self-esteem. Arousal may be prominent with anxiety, agitation, restlessness, disturhed sleep, and the inability to concentrate. Induded under inhibition are symptoms such as loss of libido, anorexia, loss of interest in the environment, imlecisiveness, and slowness in thought and movement. The author proposes that research into the pht'nomena of inhibition and arousal would he more promising than pursuing the alleged endogenous-neurotic dichotomy. He states that with the development of physiological. chemical and psychological kchniques for the measurement of such functions as arousal and inhihition, it makes it more necessary to identify and descrihe what is inherently biological in the depressive response and what is the consequence of the patient's acquired anlage and habitual means of coping with crisis. This is an excellent paper whieh reviews historical aspects of depression, giv('s somt' framework to undt'rstand the dinical ('ntity. and provides stimulating ideas for research activities.-\VILLIAl\I \V. K. ZUNG, \1.0.
A PRACTICUM FOR THE USE OF LITHIUM SALTS IN AFFECTIVE PSYCHOSES. Bemard S. Let;y. JAM.A. 206:104.5, 1968. \lore than 19 years of clinical experience have shown that lithium salts are effective therapy for acute manic attacks and more recent evidence suggcsts that it can prevent recurrent psychotic depressive or manic episodes. The author recommends that lithium he tried if there is an t'pisodie illness with a strong affective component. A diet adequate in salt (about 5 ~rm. per day) is essential to prevent side effects and toxic reaction. It should not be used in patients with poor renal fnnction or in pregnant women. Severe and dangerously high levels of lithium can occur in the absence of all symptoms. Therefore, in the first weeks of treatment, while the patient's rondition is being stabilized, serial determinations of the blood level of lithium must be done every three days. Thereafter, monthly determinations are adequate. Lithium is available as the carbonate salt in 300 mgm. capsules. The starting dose in hypomania is 300 mgm. three times a day. The therapeutic blood level is 0.5 to 1 meq./liter. If the serum level is not in this range by the ninth day of treatment, the daily dose should be increased by one capsule and the level followed. Patients have required from 900 to 2100 mgm. of lithium carbonate daily to maintain therapeutie blood levels. For the treatment of mania the dosage requirement may go as high as 3600 mgm. daily. When the mania begins to hreak, it is necessary to decrease the dosage to the maintenance level. Time must be allowed for lithium to cross the blood brain barrier and phenothiazines can be used to control symptoms 58
while this is occurring. When lithium is to be used prophylactically for recurrent depressions, it is necessary to first treat the depression and then institute lithium therapy. Antidepressants, phenothiazines and electroconvulsivf' therapy have been used roncomitantly with lithium. -8. R.SHOCHET,\I.D.
EVALUATION OF NEWER ANTIDEPRESSANT DRUGS. P. H. Ornstein. Amer. Forn. Phys. 7:65, 1964. Depression, particularly masked depression, is the most conunon psychiatric syndrome seen by the general practitioner. The physician must know about the natural course of depression, the different types and their psychodynamics. Normal depressions are short-lived, appropriate reactions to adversity or loss. Usual1y no treatment is required; antidepressant drugs and ECT are contraindicated. Neurotic depressions occur after only slight provocation, because of an inner tendency toward depressive reactions, Moodiness, irritability, sadness. despair, insomnia, fatigue and some diminution of interest in outside activities are usual1y seen but there is ordinarily no agitation, psychomotor retardation or disturbance in autonomic function. The condition may become chronic. Psychotherapy is the preferred treatment but drugs such as amitriptyline or imipramine may be used in severe cases or in the borderland between neurotic and psychotic depression. ECT should not be used. Psychotic depressions are characterized by psychomotor retardation or by agitation. There is a depressed facial expression and the mood is one of despair and hopelessness. Delusional ideas and suicidal thoughts are common, as are sleeplessness (especially early morning awakening), loss of appetite and constipation. Imipramine is the drug of choice for retarded patients and amitriptyline for the agitated. ECT accomplishes its best results in this group. The reported studies on the therapeutic effectiveness of antidepressant drugs exhibit discrepancies due to differences in the type and severity of the depression and variations of the point in the cycle of iI1ness at which the drug is employed. Monoamine oxidase inhibitors may be dismissed as routine antidepressants. Imipramine and amitriptyline and their analogues have stood the test of careful evaluative studies.-LEONARD J. SCHIFF, M.D.
ALOPECIA AREATA. ]. Manrique. Univ. Medica 6:83-90, 1964. Careful review was made of histories of 20 patients in a military hospital, and another ten patients were studied from the psychosomatic viewpoint and fol1owed for approximately two years. The age range was from six months to 32 years (most between 24 and 32) and males predominated in a ratio of 3: 1. All had patchy scalp lesions exclusively but none Volume X
ABSTRACfED FROM THE MEDICAL PRESS suffered from nail changes, vitiligo or any other serious disease. The lesions usually appeared with dramatic onset. Improvement was related to improvement in emotional status, although the patients were unaware of this relationship. Treatment consisted only of simple supportive therapy such as that commonly used by dermatologists. The scalp lesions of alopecia areata are probably caused by emotionally induced vasoconstriction, with resulting ischemia and subsequent loss of hair. Further experimental studies are needed to evaluate the role of emotional stress and to rule out possible simple coincidence. (Original in Spanish )-JAY H. SCHMIDT, M.D. THE CAUSE AND PREVENTION OF POSTOPERATIVE PSYCHOSES IN THE ELDERLY. Davfd D. Stonecypher, Jr., M.D. Amer. J. Ophthol. 55: 605-610, No.3, March 1963.
This paper refutes the theory that psychoses following cataract extraction are caused by sensory deprivation. Most post-cataract patients have only one eye patched-an eye which had lost so much vision it needed surgery. The other eye, the ears, the other sensory modalities are all working as before surgery. The bandaging simply does not create any signi6cant sensory deprivation. The author associates the fact that most psychotic episodes occur at night with the fact that night is associated with the uneasy feeling of danger, ghosts, death and criminal activity. The author states that in a patient over 60 if his history shows two or more of the following elements, he is subject to post-operative psychosis: 1. A history of marginal social adjustment. 2. Apparent frailty. 3. Long-standing disease. 4. An immigrant. 5. A manual laborer. 6. Retirement. 7. A history of previous psychotic episodes. When a surgeon is concerned he should order a light in the room, paraldehyde for the disoriented period, encourage the patient to bring cherished possessions to the hospital, encourage a radio which gets the patient's mind on world affairs rather than his own person, to bring his own pillow and impress on him that the doctor is eager to serve him.-T. F. SCHLAEGEL, Jr., M.D. DRUG THERAPY WITH OR WITHOUT GROUP DISCUSSION: EFFECTS OF VARIOUS REGIMENS ON THE BEHAVIOR OF GERIATRIC PA· TIENTS IN A MENTAL HOSPITAL. J. R. Williams, Leopold Csalany, Gabriel Misevic. J. Amer. Geriatrics Soc. 15/1, Jan. 1967.
Results were reported on the effects of eight different treatments (each of the drugs, Metrazol, Deladumone and Taractan, with and without W'oup discussion, and two controls) on the behavioral condition of 64 geriatric patients. Randomization of both patients and treatments to the eight groups occurred. One c.c. of Deladumone was given intramuscularly every three weeks. Metrazol was administered in tabJanuary-February 1969
let form, 100 mg three times a day. Taractan was given in variable dosage, 50-100 mg two or three times a day, except in acutely disturbed cases where one c.c. was given intramuscularly every six hours. The discussion groups in each case met once a week for approximately 45 minutes. The "leaders" of the groups were interchanged every three weeks to assure equal exposure over the experimental period. Pre- and post-evaluation of the subjects were C:lTried out by ten trained observers, using a revised, experimental form of a behavior rating scale developed speci6cally for use with geriatric patients. Use of the scale was designed to give an approximate measure of "degree of behavioral normality." The results, while in no case reaching the 5 per cent level of statistical signi6cance, were consistent. Without exception, those groups experiencing group discussion of problems changed more favorably in behavior than did the other groups. Also, in every case, groups receiving both medication and group discussion of problems changed more favorably in behavior than did the groups having discussion of problems alone. Finally, in two out of three cases, those groups receiving more favorable change in behavior than did the "no treatment" group. The results were discussed by comparing them to the Bndings and conclusions of several related studies and writings. The opinion that any single treatment for this individually varied group held limited value was felt to be substantiated.-AuTHoRs' AIISTRACT
DRUG-INDUCED EXT RAPl:' RAM I DAL SYMPTOMS: THEIR INCIDENCE AND TREATMENT. Charles Sheppard, M.A., and Sidney Merlis, M.D. Arner. ]. Psychiat. 123:886, No.7, Jan. 1967.
The question of side effects concurrent with treatment for psychological symptomatology has received added attention in the past decade. The search for chemical structures which provide therapeutic change while producing limited side effects continues, as does the investigation of the incidence of untoward effects with current psychoactive medications. The authors survey the incidence of extrapyramidal symptoms at a large (census 11,182) psychiatric hospital. In previous studies a high percentage of symptom remission has been adequately demonstrated. Therefore, it is unlikely that the data reported on extrapyramidal symptoms was related to inadequate dosage. Five per cent (378) of a total of 7,110 patients receiving psychotropic therapy received antiparkinson medication. The empirical evidence reported indicated a sex difference ( 3: 1 ) females. Different "clusters" of extrapyramidal symptoms were elicited by different drugs. It was suggested that these differences may cut across chemical structure. The in· cidence in side effects seem to be related more to dosage and chemical structure than to a possible psychodynamic interpretation of the patients adjustment to psychophysiological changes induced by the treatment regimen. Nonetheless, in a total treatment program these symptoms should not be ignored.
59
PSYCHOSOMATICS They have meaning to the patient, to the therapistpatient relationship, to the ward staff and to the total ward milieu. Effective treatment was achieved by adding anyone of four antiparkinson medications to the therapy regimen. Ninety-seven per cent of the patients treated improved (38 per cent completely, 35 per cent moderately, 24 per cent some and three per cent showed no improvement). Two tables were included. One summarized the antipsychotic drugs, their dosage regimen, incidence and type of most frequent extrapyramidal effect by sex. The second gave the antiparkinson agents used, their median daily dose and dosage range.-AUTHoRs' AIlSTRACT
HYPNOANALYSIS: THEORY AND TWO CASE EXCERPTS. Erika Fromm. Psychotherapy Il:123, Oct. 1965. The author contrasts the authoritarian with the newer, permissive role of the hypnotist. She dispells as a "myth" Freud's concept that "hypnosis circumvents the ego." Perception, sensation, thought, fantasy, memory, learning, and other ego functions manifest themselves in hypnosis, some of them to a heightened degree (e.g., hypermnesis, creativity). Hypnosis is an alteration rather than elimination of ego function. DefenSive ego functions are also present in trance. Even in a light sta~e the therapist can understand and analyze the patient's characteristic defense system more readily than in the process of psychoanalysis. This is because in analysis the patient must learn to separate the observing from the experiencing ego, whereas in hypnosis this separation occurs spontaneously. Indeed the observing ego can be so totally separated from the experiencing ego that pain is observed but not felt, as vividly illustrated in the case material presented. The author urges that we continue to search for new methods of shortening psychotherapy without sacrificing depth or insight, and further that permissive hypnosis be interspersed with psychoanalytically oriented hours with the patient awake for most effective treatment.-ELIzIlETH THOMA, Ph.D.
SU1CIDE IN ADOLESCENCE. A. P. Perlstein, M.D. New York ]. Med. 66:3017, No. 23, Dec. 1966. Two per cent of annual reported suicides and 12 per cent of reported suicide attempts occur in the fifteen- to nineteen-year age range. Some statistical and dinical observations bearing on this problem are reviewed in this paper. Adolescence makes special developmental demands which may overwhelm the ill-prepared adolescent especially when he fails to receive adequate understanding or support from his family. Attention to a syndrome of adaptive decompensation would help to detect oncoming suicide attempts in at least 70 per cent of cases. This syndrome includes decreased or increased eating (also excessive smoking and drinking); decreased or increased sleeping; somatic complaints; and excessively withdrawn or rebellious, impulsive behavior. It is often when this distress is not ade-
BO
quately attended to that a suicide attempt talce place. Previous suicide attempts or threats preced, three out of four completed suicides. The preseno of a history of a previous suicide attempt or threat, or the syndrome of decompensation described above should lead to psychiatric consultation for the adolescent patient and his family.-AUTHoR's ABSTRACT
DYNAMIC ASPECTS OF SUICIDE. M. H. Hand, M.D., and A. M. Meisel, M.D. New York ]. Med. 66/23, Dec. 1966. About 25,000 persons commit suicide in the United States each year. Men commit suicide more ofteJl than women and old persons more often than yOUDI. The reverse is true of attempted suicide. Physicians are frequently consulted as a last resort, but oftea fail to respond. Suicides view their act as a rebirth, as a gesture of de6ance which preserves their self-worth, and as a means of extricating themselves from an intolerable life situation. A suicidal gesture may be a plea for help and acceptance, which if answered, enables the person to proceed with renewed strength. In order to deal with experiences one must regard one's self as indestructible and central. Any threat to this position is depressing and provokes anxiety. ReafBrmat ion of self worth, by acceptance as a member of a W'oup or sharing difficulties, relieves depression and anxiety. Phantasy, conscious and unconscious, also relieves anxiety and depression. Deprived of phantasy, persons tum to action. A person who cannot love or be loved, who cannot be worthy, important, potent or rich, or who cannot have phantasies of these, cannot survive. The suicide, li1ce others, well or ill, strives to maintain this centrality and his 6nal gesture reRects this need.-AuTHoRs' ABSTRACT
PARADOXICAL INFLUENCE OF A THERAPEUTIC SIDE-EFFECT INTERPRETATION. R. S. Lipman, M.D. Arch. Gen. Psychiat. 15/5, Noo. 1966. Clinicians frequently differ in the way they prepare patients for possible medication side-effects. In order to assess the therapeutic and methodological implications of this nonpharmacological source of variance, atropine was employed to produce dry mouth and doctors were carefully trained to convey systematicaIly either a "positive-therapeutic" or a "ca!Qal-neutral" interpretat¥>n of dry mouth to their patients. In this one-week double-blind study, 204 anxious neurotic outpatients were randomly assigned to both side-effect treatments, and within treatment conditions to the following four medication groups: chlordiazepoxide hydrochloride (10 mg, t.Ld.), chlordiazepoxide plus atropine (0.5 mg, t.i.d.), atropine and placebo. Prior to criterion analysis, it was determined that a) patients on atropine medications experienced more dry mouth than non-atropine patients, and b) that almost all patients correctly recalled their doctors' side-effect preparation. Results indicate a general therapeutic superiority Volume X
ABSTRACTED FRm.i THE MEDICAL PRESS for the chlordiazepoxide medications and an entirely unexpected improvement interaction between sideeffect preparation and atropine vs. non-atropine medications. In the "therapeutic" condition (the likelihood of dry mouth was mentioned two or three times, and always in the context of its being a "good sign" showing the medication was working effectively), patients receiving atropine medications improved less than patients not receiving atropine and medications. In the "neutral" condition (patients were casually prepared for dry mouth and told the dry mouth was "nothing to worry about"), atropine and non-atropine groups showed roughly equal but more improvement than the atropine group under the "therapeutic condition.-AUTHol\'s ABSTI\ACT
HYPOCHONDRIASIS: A CLINICAL STUDY. F. E. Kenyon. Brit. I. Psychiat. 110:478-488, 1964. This study of a group of 512 patients suffering from primary or secondary hypochondriasis indicates that it had a relatively equal sex distribution; depression and anxiety are the most commonly associated diagnoses. Of the somatic complaints in this condition, there was a significantly high incidence of pain in the head, neck and abdomen, particularly on the left side of the body. Primary hypochondriasis seemed to have poorer short term prognosis than the secondary group, but at followup it was observed that 21 per cent of the primary group had been given a changed diagnosis. No specific premorbid personality type could be demonstrated in this hypochondriacal series. It is concluded that hypochondriasis is not a nosological entity but always part of another syndrome which was most commonly affective.-JAY H. SCHMIDT, M.D.
FOLLOW-UP STUDY OF HYSTERlCAL AMBLYOPIA. Herbert Friesen, M.D. and William A. Mann, M.D. Amer.}. Ophthal. 62:1106-1115, No.6, Dec. 1966. The authors were able to follow 11 cases with a <.'Onfirmed diagnosis of hysterical amblyopia for a period ranging from four to 31 years. Five demonstrated a cure or marked improvement, whereas three had become worse, and three were about the same. The authors also suggested tubular fields may be much more common in psychiatric patients than is generally realized.-T. F. SCHLAEGEL, JII., M.D.
PSYCHIATRIC SYMPTOMS IN ADOLESCENTS. P. G. S. Beckett. I.A.M.A. 198:359-363, 1966. Adolescents pose several major challenges to the psychiatrist of today. For instance, given the large and increasing number of adolescents in our population and the fact that psychiatric referrals are now quite fashionable, how can we cope with the volume? Or, a more critical question, how many of those referred should actually be considered psychiatric patients? A few have clearcut syndromes but most show only disturbances in behavior. Is any nonJanuary-February 1969
utopian behavior to be considered a psychiatric problem? Or any non-utopian psychodynamic problems? Or should we consider abnormal only behavior which departs from the statistical average? Such nonaverage behavior can be described in terms of deviations from the mean but the question arises as to whether it is the "average" of the block, the neighborhood, or the nation in which we refer. Average in one community is not average someplace else. In practice one uses a combination of clinical diagnosis, psychodynamic diagnosis, accessibility or personal awareness of conflict. and estimates of behavioral bizarreness and of therapcutic potential to determine which one is to be a psychiatric patient. Since it i.~ difficult to separate between forces within the family which influence the adolescent and forces in the peer group and neighborhood which influence him, both of these must be taken into account in therapy. Treatment of the adolescent therefore involves more than individual psychotherapy, although this is a central technique. It is also necessary to have the adolescent experience directly that the adults in his environment are consistent, realistic, and not vindictive. Since verbal methods are usually ineffective in doing this, in many cases it is necessary to set up a controlled living situation, where a set of clearcut rules exist and where these rules arc enforced by a system of rewards for compliance, and restrictions for non-compliance. Detailed planning is discussed. As internal controls within the adolescent take over from these external <.'Ontrols imposed by the adult world, it is then very helpful to accelerate identification with appropriate adults. This can probably be accomplished by emotional arousal, as animal studies suggest that arousal of any emotion promotes identification. Some practical possibilities are mentioned. Finally in all adolescents the influence of the peers must not be neglected. Various techniques for promoting a therapeutically healthy peer group in the hospital environment are discussed; these include the use of patient government and a patient disciplinary committee.-AuTIlol\'s ABSTI\ACT
THE DANGER OF AMPHETAMINE DEPENDENCY. Frederkk Lemere, M.D. Allier. I. Psychiat. 123:569, No.5, Nov. 1966. The full extent of the danger of amphetamine dependency is not generally recognized. There is an increasing number of young people experimenting with this and other dangerous drugs out of curiosity and for "kicks." The large number of patients talting amphetamines for fatigue, depression, and weight reduction adds to the pool of potential addicts. Amphetamine dependency is often a precursor to "hard" narcotic addiction. The experience of the Japanese with over 200,000 amphetamine addicts after World War II has demonstrated that this drug can also produce permanent organic brain damage. CJioi0111, pathological, and experimental evidence confirms the Japanese experience. Excessive consumption of amphetamines can produce serious psychiat. ric complications, from severe J}{'rsonality disorders to chronic psychoses. Because of the organic compo-
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PSYCHOSOMATICS nent, treatment of these disorders is even more dUBcult than that of spontaneous psychiatric illnesses. New government controls will help to curb this problem, but the aid of physicians will also be required. Because of their potential danger, amphetamines should be prescribed with caution, reluctance, and only under the strictest supervision.-AUTHOR'S ABSTRACT
H. Enke, et al. Moo. Welt (Stuttg.) 1O:5I4-S2Q, 1964.
THE BASIC PSYCHOSOMATIC PROBLEM.
This study deals with the onset and course of various physical symptoms in patients attending the psychotherapeutic psychosomatic clinic. It is intended as a contribution to the basic psychosomatic problem, to demonstrate the unity of mind and matter by exploring the existence of isolated conditions. After an outline of hypothesis, a clinical and psychological comparison is made of the course of the symptoms in patients with chronic, and chronic recurrent complaints and patients who are symptomprone. The main finding here is that affective reactivity is higher in the chronic recurrent than in the chronic patients. The chronic patients seem to show much more signs of affective restriction and loss of contact. Those who are prone to complaints occupy a special position. A definitive psychological classification still is impossible, however, on the basis of the criteria examined. A eomparison was made between a small group of patients who were ahsolutely free from symptoms in the intervals and the relatively small group of patients with chronic symptoms. Patients in the former category were more intelligent, had better control and offered greater possibilities for treatment. The chronic group ( with permanent symptoms) showed excessive restriction and rigidity in mental affective processes. (Or,ginol in German)JAY H. SCHMIDT, M.D.
FAMILY RESEARCH ON THE PROBLEM OF ULCERATIVE COLITIS. Don D. Jackson, M.D. and Irvin Yalom, M.D. Arch. Gen. Psychiat. 15:410, No. 4,1966. From a study of eight families in which the identified patient had ulcerative colitis, from observation of several other such families, and from discussions with family therapists who had treated such families, the authors were struck by the similarity of behavior among these families when interacting in conjoint family therapy. All the families appeared to be severely socially restricted and actively restricted each other in the range of permissihle behavior. Data collected on individual family members as to their "outside the family" behavior corroborated the impression that they existed in a narrow band of social participation when compared to the group of "ordinary" families under study at the Mental Research Institute. The limitation in the range of interaction, the careful dealing with each other, the handling of a variety of situations in a similar fashion, suggest at one and the same time a feeling of des82
pair and yet a feeling of family sameness that almost approached solidarity. Wynne's term "pseudomutual. ity" best describes the apparently false solidarity 01 these families. The study sample was composed of white, middleclass families, and no data was collected to control for the effect of a chronically ill child on family interaction. It is obvious that the study needed to be broadened, both in the size and range of the sample, and a control instituted for the effect of chronic illness on family interaction, by utilizing disorders with no known emotional etiology, such as cystic fibrosis and muscular dystrophy. The authors are presently conducting such a study, and will be comparing the ulcerative colitis families on a variety of measurements with a normal sample, as well as the above-mentioned chronically ill child sample. Three terms: "restrictiveness," "restricted family," and "recursive arborization" are introduced as possible conceptual aids in the study of family interactional pattems.-AUTHoRs' ABSTRACT ANALYTICAL GROUP TREATMENT OF THE POST-HOSPITAL SCHIZOPHRENIC. Louis C.
Alikakos. Intemat. J. Group Psychother. XIV:492, Oct. 1965.
Post-hospital treatment of schizophrenia has been unsatisfactory because many patients lack insight and motivation and are reluctant to expose themselves to an intense relationship, and also because psychiatrists hesitate to use insight therapy fearing it will precipitate recurrences, or at best will be ineffective with these patients. The author presents his experience with analytic group therapy as the method of choice, primarily because the intense and mercurial transference reactions are diluted in the group. Moreover, group dynamics tend to reduce anxiety and guilt feelings, to provide support, limit regression, enhance self-esteem, and provide graded socializing experiences. Over a period of several years a number of schizophrenic patients were able to work on their personality problems; the five and one-half year treatment of one such patient is presented in detail. In view of the paucity of studies in this area, it would be useful to see other work on the effectiveness of long-term group analytic treatment of the post-hospital schizophrenic.-EuzABETH THOMA, Ph.D. TREATMENT OF BARBITURATE COMA. Zelman L. Bernstein, M.D. New York ]. Med. September, 1966.
Barbiturate poisoning, regardless of the dose ingested, should no longer be considered a fatal disease when treated properly. If a patient is admitted to a hospital in uncomplicated coma but still alive, he should survive. Three cases of deep coma with high blood levels are presented. The usual coma level for short-acting barbiturates is one to three mg per 100 cc in the blood. This is very variable. Death has been reported with less than 1 mg per 100 cc of shortacting barbiturates. In the three cases described the blood barbiturate levels were 10.2, 6.85 and 5.8 mg Volume X
ABSTRACTED FROM THE MEDICAL PRESS per 100 cc, respectively. In addition each case had circumstances which are known to enhance the depth of coma, i.e. anemia, anoxia and other drugs. Each patient went from deep coma to full consciousness within 48 hours. Treatment consisted of tracheotomy and peritoneal dialysis. Analysis of dialysatic samples showed appreciable amounts of barbiturates removed. This method of treatment is compared with the classic Scandinavian method. Since peritoneal dialysis is a simple procedure which can be performed in any hospital, some alteration in the standard treatment is recommended for consideration; other methods of treatments used are discussed. These include gastric lavage, analeptic drugs, mannitol, forced diuresis, alkalinization of urine and steroids. If an airway and respiratory tract hygiene are instituted promptly along with peritoneal dialysis, the above methods arl' not necessary.-AuTHoR's ABSTRACT
IMPROVEMENT OF VISUAL ACUITY BY AMOBARBITAL COMBINED WITH PLEOPTICS. ]un Tsutsui, M.D. Amer.]. Ophthal. 2:1171-1176, No.6, Dec. 1966. Pleoptics is a relatively new form of training to improve vision in amblyopia. The author found visual acuity to be improved during narcoanalysis. It was his opinion that amobarbital in pleoptics can produce more marked visual improvement than ordinary pleoptics, and he speculates that the effects are due to a removal of an inhibiting mechanism from the higher centers. This study suggests that amblyopia with a definite and immediate response to amobarbital is of a suppre$sion type whereas that amblyopia with no immediate response is due to an undeveloped function or some undetected organic change. Thus amobarbital may be of value in differ('ntiating various types.-T. F. SCHLAEGEL, JII., M.D.
THE WIVES OF DRUG ADDICTS. S. D. Taylor, R.N., M. Wilbur, A.A.P.S.W. and R. Omos, M.D. Amer. ]. Psychillt. 123:585, No.5, Nov. 1966. An interview schedule was administered to six wives of drug addicts in treatment at the Greenwich House Counseling Center, to determine why they married and remained married to addicts. The husbands were not atypical from the rest of the clinic's male population. The characteristics of each husband and wife were similar in age and ethnic and religious background. The women met their husbands in conventional ways and marriage was not precipitous. The wives were attracted to the men by characteristics associated with passive personalities, such as "gentle, clean, and sweet." Only two men began using drugs after the marriage. The wives had difficulty recalling the chronology of crises, separations and attempts at abstinence which were typical of the marriages. One-half of the wives experimented with drugs themselves. Their attitude towards addiction evolved from one of naivete (or denial) to a more realistic appraisal. In their ranuary-February 1969
relationships with their own families the wives appeared to have many unresolved conHicts. The predominant pattern was a strong identification with their mothers and a view of their fathers as weak men. The authors' impression is that the personality make-up of the wives obligates them to remain involved with weak men whom they usually can dominate and who make only minimal adult heterosexual demands on them.-AuTHoRS' ABSTRACT
GROUP PSYCHOTHERAPY WITH DEPRESSED WOMEN. P. R. Miller, M.D. and L. Ferone, M.S.W. Amer. ]. Psychiat. 123:701, No.6, Dec. 1966. The Mental Health Clinic of De Paul University has been treating depressed women with outpatient group psychotherapy for three years. This experience revealed that depressed women have remarkably similar symptoms and character structures, and that group therapy works with severely disturbed depressed women. Presenting complaints were inability to manage the household, poor relationships with family, feelings of inadequacy and depression, and realistic stresses representing an object loss. Our patients could be described as demanding and provocative, hypochondriacal, cognitivel}' disturbed, agitated, confused in their thinking, troubled with psychosomatic symptoms and clinging in their appeals for love. They were also envious, lonely, and gratified by their illness. They used roles of martyrdom and attempted to control others by provoking guilt in them. The character structun' and psychodynamics of these patients appear vividly in the role relations of group therapy. They placed one another in the roles of rejecting mother, preferred sibling, distant father, etc. They were alternately supportive and harshly realistic with one another, much in the manner of Alcoholics Anonymous and Synanon. Group therapy with depressed women works as well as, and sometimes better than, individual therapy. Five patients had to be hospitalized for psychiatric reasons prior to joining the group, none subsequently. Those who had been in individual therapy previously did not sustain symptom relief, but they did maintain their improvement in group therapy.-AuTHoRS' ABSTRACT
TREATMENT OF TIC DOULOUREUX WITH G32883 (CARBAMAZEPINE). E. Lutz, M.D. Diy. Nerv. Syst. 27:600, 1966. A review of a new anticonvulsant, G-32883 (Carbamazepine) is presented with its specific effectiveness for symptomatic relief from tic douloureux (trigeminal neuralgia) which in the past had unsatisfactorily responded to medical treatment measures. The numerical agreement of approximately 85 per cent or more positive results in the treatment series of most investigators indicates the remarkable efficacy and specmcity of this symptomatic drug. The incidence (approximately 15 per cent) of thera-
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PSYCHOSOMATICS peutic failures can be further decreased by the combined treatment with carbamazepine and diphenylhydantoin and by the addition of neuroleptics. The average daily requirement is 600 to 800 mg carbamazepine but may vary from 200 to 1600 mg. Interruption of polysynaptic reflex activity appears to be the mode of therapeutic action of carbamazepine, an iminostilbene derivative, related to imipramine. This new drug represents a major therapeutic break-through and an attractive alternative to in· effective medical management and often mutilating and unsatisfactory neurosurgical treatment.-AuTIfoR's ABSTRACT
laboratory values showed no changes that were clin. ically significant. The patients were chronically ill and had been resistant to other medications, thus they constituted a severe challenge to the activity of any drug. The drugs seemed to be almost equally effective in attaclting the target symptoms. Haloperidol, a non-phenothiazine derivative, may offer another choice in the class of therapeutic drugs in some chronic schizophrenics.-AuTIfORS' ABSTRACT
HALOPERIDOL AND THIORIDAZINE IN TREATMENT OF CHRONIC SCHIZOPHRENICS. L. Prasad, M.D. and M. C. Townley, M.D. Dis. Nero. Syst. 27:722, No. II, Nov. 1966.
1965. Urinary 17-hydroxycorticosteroids (17-OHCS), an index of anterior pituitary adrenocortical activity, were found to alternate regularly every other day. On days that the patient was manic, the 17-0HCS levels were low; during days of depression, they were elevated. Later during the course of the ill· ness, stable periods were associated with stability of these levels. A marked denial of illness characterized the manic periods; during depression there was no denial, but expressions of severe suffering.
A 12-week, double-blind study on 37 female and three male patients was undertaken to assess the antipsychotic merits of haloperidol (butyrophene) relative to those of thioridazine, an effective phenothiazine derivative. All of the forty patients included in this study had hi.~tories of long illness and had been resistant to treatment with other psychotherapeutic agents. The average duration of illness was more than ten years. Sixteen patients were diagnosed as paranoid, nine hebephrenic, four catatonic, one schizo-affective and ten undifferentiated. Clinical laboratory tests, including hemoglobin, CBC, SCOT, alkaline phosphatase and urinalysis, were performed on all patients initially and after two, four, eight and 13 weeks. A modified Lorr Scale was used by the psychiatrist to record changes in patients' symptoms, initially and bi-weekly. Weekly records of ward behavior were made by the nurses. At the end of the study, each patient's status was evaluated on the basis of behavior and symptoms. The dosage ranged from 2 mgs to 24 mgs daily in the patients treated with Haloperidol, and 60 mgs to 720 mgs daily in the patients treated with thioridazine. Tables based on statistical analysis showed an almost equal amount of improvement in patients treated with either drug (mean change 39 per cent). Eleven patients in the thioridazine group and nine in the haloperidol group showed no essential change in their psychotic profiles. Of twenty patients treated with thioridazine, 13 lost weight and seven gained weight. In patients treated with haloperidol, 16 lost weight, two gained, and two experienced no change in weight. Four patients treated with thioridazine, and all but one patient treated with haloperidol, experienced side effects at some time during the study. More neurological side effects were noted with haloperidol. Transient corneal haziness was discovered in two patients receiving haloperidol, but it was not established that this was a drug-related change. Final
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A PSYCHOENDOCRINE STUDY OF A PATIENT WITH 48·HOUR MANIC-DEPRESSIVE CY. CLES. W. E. Bunney, Ir., E. L. Harlmonn orad I. W. MtuOn, Arch. Gen. PSl/chiat. 12:619 (June)
ACUTE ERGOTISM. P. Hudgson and I. A. L. Harl. Moo. I. Australia, 51(2), 15: 589-591, 1965. The authors cite a case of acute ergotism which was caused by overdosage of Cafergot. They review the literature, with particular emphasis on the neurological and cardiovascular manifestations of ergot poisoning. They stress the importance of gastric analysis in patients where overdosage is suspected.
SEXUAL IMPOTENCE IN MEN HAVING LOWBACK SYNDROME. Myron M. Laban. M.D. Arch. Phys. Med. 47:715-723, 1966. Forty-three men with back injuries from industrial accidents were studied while in a rehabilitation unit. Twenty-seven of these men were sexually impotent. Although the impotent men had more hospitalizations and surgical procedures than the others. both groups were similar in other respects, including intelligence, education, skill and physical toleranCf'. As a group, the impotent men came from relatively unstable homes where parental loss due to death or separation was common and hence several children often competed for one parent's limited attention. Half of this group were first or only children. The impotent men made relatively few and halfhearted attempl~ to return to work and then finally gave up. Many then cared for the house and children while the wives worked. On the whole, these men showed less concern about their sexual inadequacy than do most men facing diminished potency. W.O.
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