- Email: [email protected]
FEAR OF ALIEN ABDUCTION
LETTERS TO THE EDITOR
of the patient's childhood history. When a preschool child has experienced "repeated hospitalization for medical and surgical procedures," we need to wonder whether hospital personnel, often speaking strange languages, often with decided accents, and dressed in scrub suits, masks, and other medical designer clothes, might have been experienced by the young child as "aliens." The fear of abduction may have well been related to the fact that the child was indeed "abducted" by the hospital in the sense that he could not return home as he undoubtedly might have wished. Particularly so if these procedures were "traumatic and disruptive to his emotional, cognitive, and social progress" (p. 974). In addition, the authors perhaps make too light of what they call "an unrelated near-drowning incident." While the authors understandably focus on the sexual abuse, the 15year-old adolescent presented with "fears of drowning, water. ..." A near-drowning experience by a young child is certainly experienced as traumatic, particularly since it had strong physical manifestations. Since the authors state that "treatment was effective," I think it would have been helpful had the authors indicated how the therapy was directed at dealing with these highly individualistic traumatic experiences. While the duration of treatment was unstated, the only time frame given was a 2-week period of hospitalization. In these days of managed care, I would not want the impression created that 2 weeks of hospitalization was adequate, unless it actually was. My own work in this area (Shopper, 1995) indicates that early medical and surgical traumatic experiences, particularly when they occur in the preverbal period, tend to be telescoped and interdigitate with succeeding traumata-in this case, drowning, sexual abuse, and a traumatic separation between parents. I agree with the authors that this case "illustrates the importance of listening to patients," and I would emphasize that it also illustrates the importance of taking a thorough, accurate, and complete history of early life events. When there are serious bodily illnesses, bodily intrusions, and/or medical and surgical procedures, no matter how beneficial and well-meaning they may be (as viewed by the adults), they may be viewed by the young child from an entirely different perspective, i.e., hostility, abduction, powerful aliens causing fear and pain, etc. Listening to the child and/ or empathizing with the child's experience helps us to better understand the symptomatology and thus better inform our therapeutic efforts. I am pleased that the editor has created this section in our Journal, and I hope it expands in a productive way. Moisy Shopper, M.D. St. Louis
556
Shopper M (1995), Medical procedures as a source of trauma. Bull Menninger Clin 59:191-204 Takhar ], Fisman S (1995), Alien abduction in PTSD (letter). jAm Acad Child Ado/esc Psychiatry 34:974-975
Drs. Fisman and Takhar reply: We appreciate the comments made by Dr. Shopper and agree with them. Unfortunately, within the space confines of a letter, elaboration of childhood history is, of necessity, limited. The details of this young man's history confirm the relationship of the traumatic experiences of medical/surgical procedures to his ideas of alien abduction. He described the aliens as odd-looking creatures with oval-shaped faces wearing surgical masks, invading his body with instruments, while he was placed on a table inside the spaceship. He also recalled being covered with a slimy cocoon. These particular descriptions coincided with two bouts of pyrexia of unknown origin and bouts of meningitis and bladder infections during which time he had extensive, intrusive investigations occurring between age 2 and 4 years. The above trauma, the experience of nearly drowning (explaining his phobic avoidance of water as an adolescent), and the exposure to sexual traumatization and family violence all contributed to the delayed onset of posttraumatic stress disorder in adolescence (Terr 1991). This patient's longitudinal history is extremely complex, beginning with medical threats to his physical integrity at a very young age (bronchoscopy at 6 months) and repeated hospitalizations because of respiratory infections. The initial insults occurred at a time of progressive stepwise myelination of the brain (Koranyi, 1993). One must consider the vulnerability of the developing nervous system to increased sympathetic nervous system activity. Repeated traumatic events followed these early insults, continuing until 8 years of age. The chronic state of overarousal generated by external events may lead to endogenous neurochemical restructuring (Kaplan and Sadock, 1991). Thus, a complex interplay of experiential and biological factors come together to generate the individual experience of posttraumatic stress symptomatology. Finally, we would not want to leave readers with the impression that a 2-week hospitalization served as the entire solution for this patient's distress and dysfunction. The hospitalization enabled us to accurately assess his symptomatology, ruling out a psychotic disorder, and to provide a period of stabilization and initial treatment. School reintegration and a period of intensive individual outpatient work followed the hospitalization. It has been our experience with traumatized children and adolescents that an open-door policy to reenter treatment as needed is essential to a better
J.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996
LETTERS TO THE EDITOR
outcome. This allows for brief interventions at times of symptom exacerbation which is often linked to both environmental stressors and developmental changes. Sandra Fisman, M.B. Children's Hospital of Western Ontario Jatinder Takhar, M.D. University of Western Ontario London, Ontario Kaplan HI, Sadock B (1991), Synopsis of Psychiatry: Behavioral Sciences/ Clinical Psychiatry, 6th cd. Baltimore: Williams & Wilkins Koranyi ER (1993), Review of Neurophysiology from the Perspective of Clinical Psychiarry. Review Course of Psychiatry, Revised. Onawa Terr LC (1991), Childhood rraumas: an outline and overview. Am J Psychiatry 148: 10-20
THE NEED FOR OUTCOME STUDIES
To the Editor: As second-year psychiatry residents rotating through an inpatient child psychiatry service, we found the unit in a state of transition. The average length of stay had decreased from 4 months to 3 weeks in the last 2 years, and a further reduction to 2 weeks was imminent. The staff was noticeably disturbed and concerned over the recent and upcoming changes. The question, "How can we expect to help these children in only 2 weeks?" was frequently raised. This prompted the rather naive question characteristic of someone new to the field, "Is there any evidence that a longer length of stay is more beneficial?" We were surprised by the silence and the simple answer, "No, it is not clear." This motivated us to conduct a review of the literature assessing the relationship between length of hospital stay and treatment outcome. Surprisingly, this resulted in a disappointingly small yield. There were no controlled prospective studies examining this question, and there were only a few studies which evaluated the efficacy of long-term residential psychiatric treatment of children in general. The most comprehensive study was a meta-analysis performed by Pfeiffer and Strzeleck (1990). In their review, the authors found only seven studies, from 1975 to 1990, which addressed length of stay as a variable in treatment outcome. The results were equivocal, with three studies
of child patients, and not the cost, should be the ultimate priority, unless equal treatment efficacy can be achieved at a lower price. Furthermore, treatment decisions should be made by those individuals qualified to do so by training and not by those who do not appreciate the need for various treatment modalities; some cases require a longer length of stay or more comprehensive evaluation and treatment course secondary to a more severe psychiatric history and illness. At the present time, however, our lack of understanding of which treatment modalities are most effective limits our credibility when justifYing the decisions we make regarding length of stay and the need for inpatient hospitalization. This should serve as a mandate for the psychiatric community to aggressively pursue further outcome studies since costeffective treatment is of increasing concern in the age of managed medical care. We agree with Dr. Schowalter's proposition for a "Project Now" (Schowalter, 1995). This Project calls for a steering committee and a set of task forces to join both researchers and clinicians in studying treatment outcomes "NOW." Perhaps Dr. Schowalter said it best: "The most important outcome we discover may be our own." Robert Chang, M.D. Gerard Sanacora, M.D., Ph.D. Ramiro Sanchez, Jr., M.D. Yale University School of Medicine New Haven, CT Grizenko N, Papineau 0 (1992), A comparison of the cost-effectiveness of day treatment and residential rreatment for children wirh severe behavior problems. Can J Psychiatry 37:393-400 Pfeiffer SI, Srrzeleck SC (1990), Inpatient psychiatric treatment of children and adolescents: a review of outcome studies. JAm Acad Child Adolesc
Psychiatry 29:847-853 Schowalter JE (1995), Managed care: income to outcome. JAm Acad Child Adolesc Psychiatry 34: 1123
GOING BEYOND DSM-IV
To the Editor: Weinberger and Gomes (1995) do well in presenting their work, a long-awaited study to support, as they note, decades-long clinical appreciation that for children with conduct disorders "the technique of aggressive behaviors is one way of avoiding feelings of depression" (Burks and
showing a correlation between a longer length of stay and
Harrison, 1962). While they may be correct in their assertion
improved outcome and four others finding no significant relationship. More recent studies have suggested that day treatment programs may be at least equally effective as inpatient hospitalization in the treatment of children with severe behavioral problems (Grizenko and Papineau, 1992). In addition, day hospitalization treatment can be provided at a fraction of the inpatient cost. However, the well-being
that diagnostic criteria (DSM-IV) for oppositional defiant or conduct disorders may not necessarily require revision, it is also true that clinicians need to go beyond DSM-IV thinking to assess the phenomenon of this study and to deal effectively with these patients. Foremost is the fact that reliance on structured interviews and checklists does not help identifY this phenomenon.
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996
557
of the patient's childhood history. When a preschool child has experienced "repeated hospitalization for medical and surgical procedures," we need to wonder whether hospital personnel, often speaking strange languages, often with decided accents, and dressed in scrub suits, masks, and other medical designer clothes, might have been experienced by the young child as "aliens." The fear of abduction may have well been related to the fact that the child was indeed "abducted" by the hospital in the sense that he could not return home as he undoubtedly might have wished. Particularly so if these procedures were "traumatic and disruptive to his emotional, cognitive, and social progress" (p. 974). In addition, the authors perhaps make too light of what they call "an unrelated near-drowning incident." While the authors understandably focus on the sexual abuse, the 15year-old adolescent presented with "fears of drowning, water. ..." A near-drowning experience by a young child is certainly experienced as traumatic, particularly since it had strong physical manifestations. Since the authors state that "treatment was effective," I think it would have been helpful had the authors indicated how the therapy was directed at dealing with these highly individualistic traumatic experiences. While the duration of treatment was unstated, the only time frame given was a 2-week period of hospitalization. In these days of managed care, I would not want the impression created that 2 weeks of hospitalization was adequate, unless it actually was. My own work in this area (Shopper, 1995) indicates that early medical and surgical traumatic experiences, particularly when they occur in the preverbal period, tend to be telescoped and interdigitate with succeeding traumata-in this case, drowning, sexual abuse, and a traumatic separation between parents. I agree with the authors that this case "illustrates the importance of listening to patients," and I would emphasize that it also illustrates the importance of taking a thorough, accurate, and complete history of early life events. When there are serious bodily illnesses, bodily intrusions, and/or medical and surgical procedures, no matter how beneficial and well-meaning they may be (as viewed by the adults), they may be viewed by the young child from an entirely different perspective, i.e., hostility, abduction, powerful aliens causing fear and pain, etc. Listening to the child and/ or empathizing with the child's experience helps us to better understand the symptomatology and thus better inform our therapeutic efforts. I am pleased that the editor has created this section in our Journal, and I hope it expands in a productive way. Moisy Shopper, M.D. St. Louis
556
Shopper M (1995), Medical procedures as a source of trauma. Bull Menninger Clin 59:191-204 Takhar ], Fisman S (1995), Alien abduction in PTSD (letter). jAm Acad Child Ado/esc Psychiatry 34:974-975
Drs. Fisman and Takhar reply: We appreciate the comments made by Dr. Shopper and agree with them. Unfortunately, within the space confines of a letter, elaboration of childhood history is, of necessity, limited. The details of this young man's history confirm the relationship of the traumatic experiences of medical/surgical procedures to his ideas of alien abduction. He described the aliens as odd-looking creatures with oval-shaped faces wearing surgical masks, invading his body with instruments, while he was placed on a table inside the spaceship. He also recalled being covered with a slimy cocoon. These particular descriptions coincided with two bouts of pyrexia of unknown origin and bouts of meningitis and bladder infections during which time he had extensive, intrusive investigations occurring between age 2 and 4 years. The above trauma, the experience of nearly drowning (explaining his phobic avoidance of water as an adolescent), and the exposure to sexual traumatization and family violence all contributed to the delayed onset of posttraumatic stress disorder in adolescence (Terr 1991). This patient's longitudinal history is extremely complex, beginning with medical threats to his physical integrity at a very young age (bronchoscopy at 6 months) and repeated hospitalizations because of respiratory infections. The initial insults occurred at a time of progressive stepwise myelination of the brain (Koranyi, 1993). One must consider the vulnerability of the developing nervous system to increased sympathetic nervous system activity. Repeated traumatic events followed these early insults, continuing until 8 years of age. The chronic state of overarousal generated by external events may lead to endogenous neurochemical restructuring (Kaplan and Sadock, 1991). Thus, a complex interplay of experiential and biological factors come together to generate the individual experience of posttraumatic stress symptomatology. Finally, we would not want to leave readers with the impression that a 2-week hospitalization served as the entire solution for this patient's distress and dysfunction. The hospitalization enabled us to accurately assess his symptomatology, ruling out a psychotic disorder, and to provide a period of stabilization and initial treatment. School reintegration and a period of intensive individual outpatient work followed the hospitalization. It has been our experience with traumatized children and adolescents that an open-door policy to reenter treatment as needed is essential to a better
J.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996
LETTERS TO THE EDITOR
outcome. This allows for brief interventions at times of symptom exacerbation which is often linked to both environmental stressors and developmental changes. Sandra Fisman, M.B. Children's Hospital of Western Ontario Jatinder Takhar, M.D. University of Western Ontario London, Ontario Kaplan HI, Sadock B (1991), Synopsis of Psychiatry: Behavioral Sciences/ Clinical Psychiatry, 6th cd. Baltimore: Williams & Wilkins Koranyi ER (1993), Review of Neurophysiology from the Perspective of Clinical Psychiarry. Review Course of Psychiatry, Revised. Onawa Terr LC (1991), Childhood rraumas: an outline and overview. Am J Psychiatry 148: 10-20
THE NEED FOR OUTCOME STUDIES
To the Editor: As second-year psychiatry residents rotating through an inpatient child psychiatry service, we found the unit in a state of transition. The average length of stay had decreased from 4 months to 3 weeks in the last 2 years, and a further reduction to 2 weeks was imminent. The staff was noticeably disturbed and concerned over the recent and upcoming changes. The question, "How can we expect to help these children in only 2 weeks?" was frequently raised. This prompted the rather naive question characteristic of someone new to the field, "Is there any evidence that a longer length of stay is more beneficial?" We were surprised by the silence and the simple answer, "No, it is not clear." This motivated us to conduct a review of the literature assessing the relationship between length of hospital stay and treatment outcome. Surprisingly, this resulted in a disappointingly small yield. There were no controlled prospective studies examining this question, and there were only a few studies which evaluated the efficacy of long-term residential psychiatric treatment of children in general. The most comprehensive study was a meta-analysis performed by Pfeiffer and Strzeleck (1990). In their review, the authors found only seven studies, from 1975 to 1990, which addressed length of stay as a variable in treatment outcome. The results were equivocal, with three studies
of child patients, and not the cost, should be the ultimate priority, unless equal treatment efficacy can be achieved at a lower price. Furthermore, treatment decisions should be made by those individuals qualified to do so by training and not by those who do not appreciate the need for various treatment modalities; some cases require a longer length of stay or more comprehensive evaluation and treatment course secondary to a more severe psychiatric history and illness. At the present time, however, our lack of understanding of which treatment modalities are most effective limits our credibility when justifYing the decisions we make regarding length of stay and the need for inpatient hospitalization. This should serve as a mandate for the psychiatric community to aggressively pursue further outcome studies since costeffective treatment is of increasing concern in the age of managed medical care. We agree with Dr. Schowalter's proposition for a "Project Now" (Schowalter, 1995). This Project calls for a steering committee and a set of task forces to join both researchers and clinicians in studying treatment outcomes "NOW." Perhaps Dr. Schowalter said it best: "The most important outcome we discover may be our own." Robert Chang, M.D. Gerard Sanacora, M.D., Ph.D. Ramiro Sanchez, Jr., M.D. Yale University School of Medicine New Haven, CT Grizenko N, Papineau 0 (1992), A comparison of the cost-effectiveness of day treatment and residential rreatment for children wirh severe behavior problems. Can J Psychiatry 37:393-400 Pfeiffer SI, Srrzeleck SC (1990), Inpatient psychiatric treatment of children and adolescents: a review of outcome studies. JAm Acad Child Adolesc
Psychiatry 29:847-853 Schowalter JE (1995), Managed care: income to outcome. JAm Acad Child Adolesc Psychiatry 34: 1123
GOING BEYOND DSM-IV
To the Editor: Weinberger and Gomes (1995) do well in presenting their work, a long-awaited study to support, as they note, decades-long clinical appreciation that for children with conduct disorders "the technique of aggressive behaviors is one way of avoiding feelings of depression" (Burks and
showing a correlation between a longer length of stay and
Harrison, 1962). While they may be correct in their assertion
improved outcome and four others finding no significant relationship. More recent studies have suggested that day treatment programs may be at least equally effective as inpatient hospitalization in the treatment of children with severe behavioral problems (Grizenko and Papineau, 1992). In addition, day hospitalization treatment can be provided at a fraction of the inpatient cost. However, the well-being
that diagnostic criteria (DSM-IV) for oppositional defiant or conduct disorders may not necessarily require revision, it is also true that clinicians need to go beyond DSM-IV thinking to assess the phenomenon of this study and to deal effectively with these patients. Foremost is the fact that reliance on structured interviews and checklists does not help identifY this phenomenon.
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996
557