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Interpersonal Problems in Narcolepsy
Interpersonal Problems in Narcolepsy CARL SALZMAN,
Narcolepsy, a disorder of the sleep mechanisms, is typically characterized by episodic attacks of REM sleep in situations where sleep is unexpected. Passouant1 has theorized that narcoleptic patients do not have the normal adult REM sleep schedule at night and, pre~umably, must compensate during the day. Kales and Kales have reviewed recent evidence that shows REM latency to be abnormally short in patients with narcolepsy.:! Wyatt, et ai, have demonstrated clinical improvement REM suppression with phenelzine. 3 Patients with narcolepsy often have serious psychological problems. While earlier psychiatric theorists assumed narcolepsy to be a result of psychologic disorder, Dement and Rechstchaffen,4 and Zarcone5 propose that psychological problems arise from dissociated REM sleep stages. Sours, 6 after reviewing the psychiatric literature on narcolepsy, concluded that the "emotional and psychologic facets of the disorder cannot be ignored," although psychogenetic factors pose a heuristic question. Typically, the narcoleptic's sudden and episodic failing asleep (with or without associated cataplexy) has been viewed as a neurotic defensive system against unacceptable feelings of anger, resentment, aggression or guilt. The sleep has also been considered a retreat from confrontation, dependency or other "insoluble life conflicts". Psychotherapy has been helpful in reducing th~se conflicts, although it cannot alter the neurophysiological basis of the sleep disorder. Dependency, expressions of anger, and the loss of self-esteem engendered by the illness itself have been mitigated by psychotherapeutic intervention. 7 While research to date has enriched our understanding of the intrapsychic life of the narcoleptic patient, the effect of the uncontrolled sleep and related symptoms upon interpersonal functioning has as yet commanded little psychiatric attention. Because of the seemingly inexorable nature of the episodic sleep symptom, there can be a direct threat to the family, marital, and work relationships of the narcoleptic patient. For example, Kales and Kales 2 have commented, "Narcoleptic patients, as well as their relatives, friends, and employers, freqently misconstrue the symptomatology of the disorder as indicative of laziness, irresponsibility or emotional instability. Smith and Hamilton 8 stated From the Department of Psychiatry, Harvard Medical School at the Massachusetts Mental Health Center, Boston, Massachusetts 02115. Dr. Carl Salzman is an Assistant Professor of Psychiatry. lan.lFeb.lMarch. 1976
M.D.
that the illness is "frightening, embarrassing and humiliating", and is rarely understood by the patient or others. This report will illustrate the overt consequences of narcolepsy in one marriage, and the indirect use of the symptom by both partners to obscure !>hared marital and sexual dysfunction. CASE REPORT
Mr. J., a 40-year-old professional with diagnosed narcolepsy, was referred for psychiatric treatment of his depression. His initial complaints included a sense of listlessness, inability to complete a task at work or at home, a continual sense of "falling behind," and an "inability to cope" with his job and family. Aside from his narcolepsy, he was in general good health with no other physical or emotional symptoms. Mr. 1. devloped narcolepsy at age 19. His most prominent symptoms were one-half-to two-hour periods of involuntary sleep during the day, which interrupted his work, and during the evening, which kept him from his family and social life. The latter problem caused his wife to complain that he had become withdrawn, dull and sleepy (sometimes he actually fell asleep) at social gatherings. In particular, she was bothered by his inability to stay awake at the movies or in the theatre. She was convinced that he had control over his symptoms and was manifesting them to annoy her. Mr. 1., embarrassed by his frequent falling asleep, tried to work harder, began to avoid a public social life, and developed elaborate excuses for his symptoms, which only increased his marital discord and social isolation. The symptoms of narcolepsy were moderately controlled by daily doses of psychomotor simulants, although the patient found it necessary to gradually increase the drug dosage. After attaining a daily dosage of approximately 60 mg of amphetamine, for example, he would switch to a low dose of methylphenidate and begin again to ascend the dosage ladder. Additional pm doses before social events or movies did not eliminate his falling asleep. A previous trial of imipramine (150 mg/day) offered only temporary relief and was voluntarily discontinued. During the early phases of psychotherapy, Mr. 1. focused upon his inabilities to satisfy both his own expectations for work performance and his wife's expectation for companionship. After the unsuccessful imipramine treatment plan, the patient became even more firmly entrenched in his feelings of ineffectiveness. When it became apparent that his marriage was in danger due to his diminished functioning, Mrs. J. was invited to join the therapy. At first, she considered herself a reality tester of her husband's distortions about herself, but gradually she became involved in the therapy and began to talk of her own problems in the marriage. Mr. and Mrs. J. accepted partnership in a couple's therapy relationship with a new focus on the realistic problems of living with each other and with narcolepsy. The first phase of the couple's therapy was the acceptance of narcolepsy as a chronic, somewhat disabling illness. Both came to understand that Mr. 1's functioning was indeed partially limited. Because of his need to nap, he could not be ex49
PSYCHOSOMATICS pected to he the most productive member of his firm nor the most scintillating guest at a prolonged evening social event. Like all sufferers of a chronic disability, Mr. and Mrs. J. had to mourn the partial loss of his functional capacity and to express anger at the illness: "Why me? Why us?". Through the shared expressions of sadness and rage, the couple became less embarrassed and secretive about Mr. 1's symptoms. Neighbors and friends were accepting and empathic when the disease was explained, and the J's shared fear of social ostracism and ridicule vanished. Mrs. J. began to understand that her husband's social withdrawal or somnolence during theatrical performances were not passive-aggressive communications of hostility directed towards her, but were a common, involuntary symptom of narcolepsy. Knowing that others with narcolepsy also fell asleep in the movies (even during exciting films) helped alIeviate Mr. 1's guilt and quiet Mrs. 1's suspicions. The couple were then ready to discuss their sexual difficulties. Because of the long-standing marital grievances, the depression and anger of each, and the soporific symptoms of narcolep~y, there had been an almost complete cessation of sexual activity. Shame and inhibition had prevented them from openly discussing their sexual difficulties, and Mr. J's narcolepsy, as usual, was blamed for all of the problems. As the couple gradually accepted joint responsibility for their lack of sexual activity, they became willing to work together towards a solution. Mr. 1's depression and the danger of a failing marriage both disappeared as he began to share the burden of sexual problems with his wife. Improvement was rapid and dramatic; sexual frequency and pleasure were restored to the marriage. Shortly thereafter, the couple decided by mutual consent to terminate treatment, feeling that they had achieved their therapeutic goals. It was most interesting to observe the effect of open communication and shared responsibility for sexual problems upon the narcolepsy symptoms. Mr. J. reported a decreased need for amphetamines and reduced his daily dosage by one half. His daytime sleeping was reduced to one one-halfhour nap in the early afternoon. He began to stay awake at evening social events, participate in them, and even, in one case, became "the life of the party". It was clear, therefore, that his depression, resulting from a diminished self-esteem over reduced personal and professional functioning, was expressed through a worsening of narcolepsy and increased sleep. Like other families containing a depressed member, Mr. 1's family was initially sympathetic but soon became angry and frustrated. EventualIy, they shared the patient's sense of helplessness, hopelessness and worthlessness. This, in turn, increased the patient's sense of guilt and further reducd his already marginal self-esteem. Sleep became a means of escape, as well as a clinical symptom of a neurological illness. During the termination interview, Mr. and Mrs. J. mentioned a neighbor who had just learned that he had narcolepsy. He and his wife seemed to be deeply embarrassed by the oddity of his symptoms, as they had withdrawn from all neighborhood social activities. Mr. and Mrs. J. recognized themselves in this couple and concluded that narcolepsy, while a problem per se, often was a distraction from more important personal and interpersonal problems. They commented that psychotherapy might be useful to other narcoleptic persons, or to couples and families with a narcoleptic member. A six-month folIow-up revealed both the patient and his wife to be functioning well at work, play and sex. The symptoms of narcolepsy remained in good control with moderate doses of psychomotor stimulants. 50
COMMENT
The psychologic consequences of Mr. J's narcolepsy can be separated into three distinct phases, each requiring a particular kind of psychiatric intervention. The first was the development of depression. Like many others with narcolepsy, or other chronic physical disabilities, this patient suffered from a loss of selfesteem. Bibring9 has described the development of depression when one's capacity for self-achievement does not meet one's personal goals or when one's fear of being defective seems to come true. In an attempt to overcome a growing sense of worthlessness, the patient worked harder, but achieved less. His attempts at compensation only produced an increase in narcoleptic symptoms and, consequently, less achievement. Guilt, and shame over his self-perceived inadequate functioning fueled a sense of growing despair which in tum led to withdrawal. At this point, therapeutic goal was to help the patient acknowledge his depression and confront a very real compromise in performance due to a chronic illness. The second phase was necessitated when the patient's wife, no longer able to understand her husband's illness, became frustrated in her attempts to help him with his depression and began to share his sense of hopelessness. The marital relationship, which once might have survived either partner's periods of depression, began to disintegrate. Therapy in this phase of the illness focused on helping the patient's wife enter the therapeutic alliance and share her feelings about the illness and its effects on her life. In this phase, both partners were given specific medical information about narcolepsy. Both learned that the unusual symptoms were not under voluntary control, nor were they deliberate attempts by the patient to "escape". Rather, there were practical ways for both of them to cope with narcolepsy, such as daytime naps, sharing the domestic chores normally allotted to the husband, and sharing the automobile driving. It was particularly necessary for this couple to realize that boring situations were likely to induce a sleep attack. A rearrangement of social activities was begun in order to minimize the patient's participation in theatre and film activities. He no longer felt guilty about falling asleep. His wife was able to enjoy these activities more by herself or with friends, than she had with the constant irritation of her husband snoring in the seat beside her. An additional goal of this phase of therapy was to help both partners support each other's expression of anger, frustration and guilt at the symptoms and the inevitable compromise in function that they implied At this stage of successful therapeutic intervention, the third phase of psychotherapy was initiated in the area of serious progressive erosion of marital intimacy. Mutual withdrawal of sexual interest, with a tacit Volume XVII
INTERPERSONAL PROBLEMS IN NARCOLEPSY-SALZMAN
assumption of culpability on the part of the narcolepsy patient, caused the patient to employ the narcolepsy symptoms as protection against further sexual failure and loss of self-esteem. In return, his wife became increasingly angry and decreasingly interested in sex, and assumed that the marriage was irreversibly failing. The patient's individual psychotherapy, preceding couple therapy, only seemed to emphasize his personal, unilateral failure to both of them. The couple was helped to understand that the loss of sexual satisfaction was a mutual problem, and as such necessitated mutual efforts at resolution. The experience of this couple suggests that the evaluation of a patient with narcolepsy should include a careful examination of the effect of the symptoms on the patient's interpersonal life. When ever possible. therapeutic attention should be directed towards reducing these crippling and symptom-exacerbating interpersonal difficulties. Mass. Mental Health Center, 74 Fenwood Rd., Boston, Mass. 02115. REFERENCES 1. Passouant, P., Cadilhac, J., and Baldy-Moulinier, M.:
Physio-pathologie des hypersomnnies. Rev Neurol (Paris) 116:585-629, 1967. 2. Kales, A., and Kales, J.D.: Sleep disorders. Recent findings in the diagnosis and treatment of disturbed sleep. New Eng J Med 290:487-499, 1974. 3. Wyatt, R.J., Fram, D.H., Buchbinder, R., and Snyder, F.: Treatment of intractable narcolepsy with a monoamine oxidase inhibitor. New Eng J Med 285:987-991, 1971. 4. Dement, W., Rechtschaffen, A., and Gulevich, G.: The nature of the narcoleptic sleep attack. Neurology (Minneap.) 16: 18-33, 1966. 5. Zarcone, V.: Narcolepsy. New Eng J Med 288:1156-1161, 1973. 6. Sours, J.A.: Narcolepsy and other disturbances in the sleepwaking rhythm: A study of 115 cases with review of the literature. J. Nerv Ment Dis 137:525-542, 1963. 7. Langworthy, O.R., and Betz, B.J.: Narcolepsy as a type of response to emotional conflicts. Psychosomat Med 6: 211-226, 1944. 8. Smith, C.M., and Hamilton, J.: Psychological factors in the nnrcolepsy-eataplexy syndrome. Psychological Med 21 :40-49, 1959. 9. Bibring, E.: The mechanism of depression, in Phyllis Greenacre, ed.: Affective Disorders, New York International Universities Press, 1953, pp. 13-48.
Boston Symposium A symposium, "Combating Stress: Biofeedback, Meditation, and Self-Regulatory Therapies" is being sponsored in cooperation with the Mental Health Continuing Education Consortium associated with the Boston University School of Social Work, the McLean Hospital Facility for Continuing Education, and the Tufts-New England Medical Center Department of Psychiatry. It has been approved for 12 hours of credit toward the AMA physician's recognition award and 1.2 hours of continuing education credit for Nursing. The symposium will be held April 24-25, 1976 at the Sheraton-Boston Hotel in Boston. The speakers include: Hans Selye, M.D., Herbert Benson, M.D., Robert Ornstein, Ph.D., Johann Stoyva, PhD., Wolfgang Luthe, M.D., Margaret Brenman-Gibson, Ph.D., and Charles Swencionis. For further information, contact: Dr. Norbett L. Mintz, Consortium, 115 Mill St., Belmont, Massachusetts 02178. (617) 855-2183.
Jan./Feb./March, 1976
51
- . I ... ..... 11.
... _ . . . 1.l
Narcolepsy, a disorder of the sleep mechanisms, is typically characterized by episodic attacks of REM sleep in situations where sleep is unexpected. Passouant1 has theorized that narcoleptic patients do not have the normal adult REM sleep schedule at night and, pre~umably, must compensate during the day. Kales and Kales have reviewed recent evidence that shows REM latency to be abnormally short in patients with narcolepsy.:! Wyatt, et ai, have demonstrated clinical improvement REM suppression with phenelzine. 3 Patients with narcolepsy often have serious psychological problems. While earlier psychiatric theorists assumed narcolepsy to be a result of psychologic disorder, Dement and Rechstchaffen,4 and Zarcone5 propose that psychological problems arise from dissociated REM sleep stages. Sours, 6 after reviewing the psychiatric literature on narcolepsy, concluded that the "emotional and psychologic facets of the disorder cannot be ignored," although psychogenetic factors pose a heuristic question. Typically, the narcoleptic's sudden and episodic failing asleep (with or without associated cataplexy) has been viewed as a neurotic defensive system against unacceptable feelings of anger, resentment, aggression or guilt. The sleep has also been considered a retreat from confrontation, dependency or other "insoluble life conflicts". Psychotherapy has been helpful in reducing th~se conflicts, although it cannot alter the neurophysiological basis of the sleep disorder. Dependency, expressions of anger, and the loss of self-esteem engendered by the illness itself have been mitigated by psychotherapeutic intervention. 7 While research to date has enriched our understanding of the intrapsychic life of the narcoleptic patient, the effect of the uncontrolled sleep and related symptoms upon interpersonal functioning has as yet commanded little psychiatric attention. Because of the seemingly inexorable nature of the episodic sleep symptom, there can be a direct threat to the family, marital, and work relationships of the narcoleptic patient. For example, Kales and Kales 2 have commented, "Narcoleptic patients, as well as their relatives, friends, and employers, freqently misconstrue the symptomatology of the disorder as indicative of laziness, irresponsibility or emotional instability. Smith and Hamilton 8 stated From the Department of Psychiatry, Harvard Medical School at the Massachusetts Mental Health Center, Boston, Massachusetts 02115. Dr. Carl Salzman is an Assistant Professor of Psychiatry. lan.lFeb.lMarch. 1976
M.D.
that the illness is "frightening, embarrassing and humiliating", and is rarely understood by the patient or others. This report will illustrate the overt consequences of narcolepsy in one marriage, and the indirect use of the symptom by both partners to obscure !>hared marital and sexual dysfunction. CASE REPORT
Mr. J., a 40-year-old professional with diagnosed narcolepsy, was referred for psychiatric treatment of his depression. His initial complaints included a sense of listlessness, inability to complete a task at work or at home, a continual sense of "falling behind," and an "inability to cope" with his job and family. Aside from his narcolepsy, he was in general good health with no other physical or emotional symptoms. Mr. 1. devloped narcolepsy at age 19. His most prominent symptoms were one-half-to two-hour periods of involuntary sleep during the day, which interrupted his work, and during the evening, which kept him from his family and social life. The latter problem caused his wife to complain that he had become withdrawn, dull and sleepy (sometimes he actually fell asleep) at social gatherings. In particular, she was bothered by his inability to stay awake at the movies or in the theatre. She was convinced that he had control over his symptoms and was manifesting them to annoy her. Mr. 1., embarrassed by his frequent falling asleep, tried to work harder, began to avoid a public social life, and developed elaborate excuses for his symptoms, which only increased his marital discord and social isolation. The symptoms of narcolepsy were moderately controlled by daily doses of psychomotor simulants, although the patient found it necessary to gradually increase the drug dosage. After attaining a daily dosage of approximately 60 mg of amphetamine, for example, he would switch to a low dose of methylphenidate and begin again to ascend the dosage ladder. Additional pm doses before social events or movies did not eliminate his falling asleep. A previous trial of imipramine (150 mg/day) offered only temporary relief and was voluntarily discontinued. During the early phases of psychotherapy, Mr. 1. focused upon his inabilities to satisfy both his own expectations for work performance and his wife's expectation for companionship. After the unsuccessful imipramine treatment plan, the patient became even more firmly entrenched in his feelings of ineffectiveness. When it became apparent that his marriage was in danger due to his diminished functioning, Mrs. J. was invited to join the therapy. At first, she considered herself a reality tester of her husband's distortions about herself, but gradually she became involved in the therapy and began to talk of her own problems in the marriage. Mr. and Mrs. J. accepted partnership in a couple's therapy relationship with a new focus on the realistic problems of living with each other and with narcolepsy. The first phase of the couple's therapy was the acceptance of narcolepsy as a chronic, somewhat disabling illness. Both came to understand that Mr. 1's functioning was indeed partially limited. Because of his need to nap, he could not be ex49
PSYCHOSOMATICS pected to he the most productive member of his firm nor the most scintillating guest at a prolonged evening social event. Like all sufferers of a chronic disability, Mr. and Mrs. J. had to mourn the partial loss of his functional capacity and to express anger at the illness: "Why me? Why us?". Through the shared expressions of sadness and rage, the couple became less embarrassed and secretive about Mr. 1's symptoms. Neighbors and friends were accepting and empathic when the disease was explained, and the J's shared fear of social ostracism and ridicule vanished. Mrs. J. began to understand that her husband's social withdrawal or somnolence during theatrical performances were not passive-aggressive communications of hostility directed towards her, but were a common, involuntary symptom of narcolepsy. Knowing that others with narcolepsy also fell asleep in the movies (even during exciting films) helped alIeviate Mr. 1's guilt and quiet Mrs. 1's suspicions. The couple were then ready to discuss their sexual difficulties. Because of the long-standing marital grievances, the depression and anger of each, and the soporific symptoms of narcolep~y, there had been an almost complete cessation of sexual activity. Shame and inhibition had prevented them from openly discussing their sexual difficulties, and Mr. J's narcolepsy, as usual, was blamed for all of the problems. As the couple gradually accepted joint responsibility for their lack of sexual activity, they became willing to work together towards a solution. Mr. 1's depression and the danger of a failing marriage both disappeared as he began to share the burden of sexual problems with his wife. Improvement was rapid and dramatic; sexual frequency and pleasure were restored to the marriage. Shortly thereafter, the couple decided by mutual consent to terminate treatment, feeling that they had achieved their therapeutic goals. It was most interesting to observe the effect of open communication and shared responsibility for sexual problems upon the narcolepsy symptoms. Mr. J. reported a decreased need for amphetamines and reduced his daily dosage by one half. His daytime sleeping was reduced to one one-halfhour nap in the early afternoon. He began to stay awake at evening social events, participate in them, and even, in one case, became "the life of the party". It was clear, therefore, that his depression, resulting from a diminished self-esteem over reduced personal and professional functioning, was expressed through a worsening of narcolepsy and increased sleep. Like other families containing a depressed member, Mr. 1's family was initially sympathetic but soon became angry and frustrated. EventualIy, they shared the patient's sense of helplessness, hopelessness and worthlessness. This, in turn, increased the patient's sense of guilt and further reducd his already marginal self-esteem. Sleep became a means of escape, as well as a clinical symptom of a neurological illness. During the termination interview, Mr. and Mrs. J. mentioned a neighbor who had just learned that he had narcolepsy. He and his wife seemed to be deeply embarrassed by the oddity of his symptoms, as they had withdrawn from all neighborhood social activities. Mr. and Mrs. J. recognized themselves in this couple and concluded that narcolepsy, while a problem per se, often was a distraction from more important personal and interpersonal problems. They commented that psychotherapy might be useful to other narcoleptic persons, or to couples and families with a narcoleptic member. A six-month folIow-up revealed both the patient and his wife to be functioning well at work, play and sex. The symptoms of narcolepsy remained in good control with moderate doses of psychomotor stimulants. 50
COMMENT
The psychologic consequences of Mr. J's narcolepsy can be separated into three distinct phases, each requiring a particular kind of psychiatric intervention. The first was the development of depression. Like many others with narcolepsy, or other chronic physical disabilities, this patient suffered from a loss of selfesteem. Bibring9 has described the development of depression when one's capacity for self-achievement does not meet one's personal goals or when one's fear of being defective seems to come true. In an attempt to overcome a growing sense of worthlessness, the patient worked harder, but achieved less. His attempts at compensation only produced an increase in narcoleptic symptoms and, consequently, less achievement. Guilt, and shame over his self-perceived inadequate functioning fueled a sense of growing despair which in tum led to withdrawal. At this point, therapeutic goal was to help the patient acknowledge his depression and confront a very real compromise in performance due to a chronic illness. The second phase was necessitated when the patient's wife, no longer able to understand her husband's illness, became frustrated in her attempts to help him with his depression and began to share his sense of hopelessness. The marital relationship, which once might have survived either partner's periods of depression, began to disintegrate. Therapy in this phase of the illness focused on helping the patient's wife enter the therapeutic alliance and share her feelings about the illness and its effects on her life. In this phase, both partners were given specific medical information about narcolepsy. Both learned that the unusual symptoms were not under voluntary control, nor were they deliberate attempts by the patient to "escape". Rather, there were practical ways for both of them to cope with narcolepsy, such as daytime naps, sharing the domestic chores normally allotted to the husband, and sharing the automobile driving. It was particularly necessary for this couple to realize that boring situations were likely to induce a sleep attack. A rearrangement of social activities was begun in order to minimize the patient's participation in theatre and film activities. He no longer felt guilty about falling asleep. His wife was able to enjoy these activities more by herself or with friends, than she had with the constant irritation of her husband snoring in the seat beside her. An additional goal of this phase of therapy was to help both partners support each other's expression of anger, frustration and guilt at the symptoms and the inevitable compromise in function that they implied At this stage of successful therapeutic intervention, the third phase of psychotherapy was initiated in the area of serious progressive erosion of marital intimacy. Mutual withdrawal of sexual interest, with a tacit Volume XVII
INTERPERSONAL PROBLEMS IN NARCOLEPSY-SALZMAN
assumption of culpability on the part of the narcolepsy patient, caused the patient to employ the narcolepsy symptoms as protection against further sexual failure and loss of self-esteem. In return, his wife became increasingly angry and decreasingly interested in sex, and assumed that the marriage was irreversibly failing. The patient's individual psychotherapy, preceding couple therapy, only seemed to emphasize his personal, unilateral failure to both of them. The couple was helped to understand that the loss of sexual satisfaction was a mutual problem, and as such necessitated mutual efforts at resolution. The experience of this couple suggests that the evaluation of a patient with narcolepsy should include a careful examination of the effect of the symptoms on the patient's interpersonal life. When ever possible. therapeutic attention should be directed towards reducing these crippling and symptom-exacerbating interpersonal difficulties. Mass. Mental Health Center, 74 Fenwood Rd., Boston, Mass. 02115. REFERENCES 1. Passouant, P., Cadilhac, J., and Baldy-Moulinier, M.:
Physio-pathologie des hypersomnnies. Rev Neurol (Paris) 116:585-629, 1967. 2. Kales, A., and Kales, J.D.: Sleep disorders. Recent findings in the diagnosis and treatment of disturbed sleep. New Eng J Med 290:487-499, 1974. 3. Wyatt, R.J., Fram, D.H., Buchbinder, R., and Snyder, F.: Treatment of intractable narcolepsy with a monoamine oxidase inhibitor. New Eng J Med 285:987-991, 1971. 4. Dement, W., Rechtschaffen, A., and Gulevich, G.: The nature of the narcoleptic sleep attack. Neurology (Minneap.) 16: 18-33, 1966. 5. Zarcone, V.: Narcolepsy. New Eng J Med 288:1156-1161, 1973. 6. Sours, J.A.: Narcolepsy and other disturbances in the sleepwaking rhythm: A study of 115 cases with review of the literature. J. Nerv Ment Dis 137:525-542, 1963. 7. Langworthy, O.R., and Betz, B.J.: Narcolepsy as a type of response to emotional conflicts. Psychosomat Med 6: 211-226, 1944. 8. Smith, C.M., and Hamilton, J.: Psychological factors in the nnrcolepsy-eataplexy syndrome. Psychological Med 21 :40-49, 1959. 9. Bibring, E.: The mechanism of depression, in Phyllis Greenacre, ed.: Affective Disorders, New York International Universities Press, 1953, pp. 13-48.
Boston Symposium A symposium, "Combating Stress: Biofeedback, Meditation, and Self-Regulatory Therapies" is being sponsored in cooperation with the Mental Health Continuing Education Consortium associated with the Boston University School of Social Work, the McLean Hospital Facility for Continuing Education, and the Tufts-New England Medical Center Department of Psychiatry. It has been approved for 12 hours of credit toward the AMA physician's recognition award and 1.2 hours of continuing education credit for Nursing. The symposium will be held April 24-25, 1976 at the Sheraton-Boston Hotel in Boston. The speakers include: Hans Selye, M.D., Herbert Benson, M.D., Robert Ornstein, Ph.D., Johann Stoyva, PhD., Wolfgang Luthe, M.D., Margaret Brenman-Gibson, Ph.D., and Charles Swencionis. For further information, contact: Dr. Norbett L. Mintz, Consortium, 115 Mill St., Belmont, Massachusetts 02178. (617) 855-2183.
Jan./Feb./March, 1976
51
- . I ... ..... 11.
... _ . . . 1.l