Recent Contributions in Psychoendocrinology

MAY· JUNE, 1968

VOLUME IX - NUMBER 3

PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE

Recent Contributions in Psychoendocrinology SHELOO:,\ F. DEUTSCH, M.D., M.Med.Sci.

• The field of psychoendocrinology has not been systematically reviewed in this country since the monograph edited by Reiss"· appean.'<1 in 1958. Only the comprehensive work of Bleuler'-" (in German) has been periodically revised to keep abreast of new developments. American reviews and symposia on neuroendocrinology have accented the interrelationship between the central nervous system and the endocrine glands rather than the interplay between psychiatric disorders and hormonal dvsfunction. Their aim has been to investigate the role of neuroendocrine factors and mechanisms in the regulation of physiologic processes." In other words, the emphasis in neuroendocrinology is at present overwhelmingly on endocrinology.'" Soon after the relationship between hormones and behavior was recognized, expectations for psychoendocrinology became too optimistic. Early successes with endocrine therapy created a rush to use the new modality where it was not justified."" Consequently, results were disappointing, and the entire approach fell into disfavor. Endocrine preparations at that time were far from pure and laboratory procedures unreliable. It did not help Dr. Dcutsc·h is Executive Director of the PsychoenResearch Foundation in New York and Los Angeles. Fred E. Enjtreen, Ph.D., assisted in hihliographic f('searl'h and manuscript preparation.

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matters that many investigators too readily equated observations in animal experiments with human behavior patterns."r. Bleuler's work has been considered the source of the most important knowledge in this area. His comprehensive concept of endocrine and psychic interplay can be reduced to one basic tenet: \Vhile patients with endocrine dysfunction may also exhibit emotional disturbances, very few of those with mental disease show definite signs of endocrine imbalance. A Japanese neuropsychiatrist"" recently reported the incidence of psychiatric patients with endocrine disorders to he only 1 percent of the total case load at his clinic. Nevertheless, a single endocrine disorder can give rise to the most varied "psychosyndromes" (Bleuler 4 and, conversely, the identical psychic state may be produced by various endocrine diseases. The psychiatrist who gives at least limited attention to the endocrinologic approach is therefore to be commended. Unfortunately, these physicians tend to disregard organic factors in mental disease; at any rate, when clear-cut organic causes are found, many simply refer the case to a specialist in another field.; Granted the psychiatrist has been trained to look for the psychogenic basis of disease; but is it asking too much of him to consider also the hormonal factors which can be validated by exact laboratory procedures?

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Otherwise, psychiatry will "Iose something vital and important to its place in the practice of medicine"; and perpetuate the controversy between the proponents of the organic approach and the psychodynamic view."! Reiss:!f. drew up a useful model showing the interplay b~tween hormone equilibrium, personality pattern, and emergencv situations in precipitating mental disease: A multifaceted approach is therefore the only acceptable strategy since it combines the effort to correct the primary processes hy controlling secondary symptoms; the entrcnched ahnormal patterns may thus be resolvl'(l before leading to further aherrations in behavior."" Experimental Ill'uroendocrinology is now well-estahlished as a science. As further dinical experiencps in psychoendocrinolob'Y are accumulated, the extent to which experimental results can be applied to clinical situations can be tested. This paper discusses the thyroid and parathyroid glauds, hypoglycemia, and the sex hormones. A later study will cover changes along the pituitary-adrenal axis and the prohlems of the catl'cholamines. J)IS0RDERS OF THE TIIYHOID GLAND

No single disorder of the endocrine system can he described without considering its effect on the entire hormone equilibrium. Dysfunction of the thyroid, for example, has farreaching implications. This gland plays an essential role in almost all other organ systems and, consequently, in the development and maintenance of the organism as a whole. 44 Deviations from the euthyroid state present opposing syndromes, depending on the overor under-production of thyroid-stimulating hormone (TSH). The typical hypothUroid pattern was delineated hv Schon'" as general wl~akness, clouded thinking, insomnia, irritability, and unprovokl,d emotional outhursts. In her series of hypothyroid patients the symptoms were similar to the immature behavior of neurotics. ;\'evertheless, the hypothyroid patient was usuallv aware of his irrational hehavior and its eff~'ct on others, while neurotics often tend to hlanll' the world at large. After these patients received sufficient medication, most of their symptoms decrl'ased or disappeared. They achieVl'd significantly higher scores on various psychological tests. Schon concluded I:2S

that the thyroid hormone facilitates personality integration. Aside from certain psychological factors which determine personality characteristics, emotional stability depends on adequate hormonal function. The pattern of the hypothyroid patient was again well described in a case reported by Bernstein. 3 A 47-year-old woman, with a history of nervous and psychosomatic disease, was seen by the psychiatrist because of persistent insomnia, lethargy, and depression. A laboratory examination revealed only one abnormal finding-a radioactive iodine uptake of 18 percent (euthyroid, 20-50 percent). Thyroid supplementation (2 grains daily) resulted in dramatic symptomatic improvement within a few days. HypothyrOidism may exist for several years before gross clinical signs develop. Without these signs, the diagnosis of myxedema concomitant with mental disease may be missed. ls Yet, thyroid replacement is least likely to result in full remission of psychiatric symptoms once hypothyroidism has reached an advanced stage. Gibson 18 claimed that no evidence has been offered to show that emotional stress produces clinical hypothyrOidism. Schon: o however, suggested that hypothyroidism is a defensive mechanism aimed at protecting the patient from overwhelming emotions and disturbing conflicts. Lethargy and inactivity help the hypothyroid patient psychologically by enabling him to withdraw from unmanageable pressures. The type of psychiC disturbance arising from thyrOid deficiency depends to a great extent on the age of the patient,36 In children it may take the form of retarded brain development; between 20 to 30 years it may be manifested as schizophrenia, while hypothyroid patients over 45 years of age tend to be depressed. Thyroid replacement has been shown to be significantly more effective in confused and disoriented patients with primary organic disease than in those with diagnoses of schizophrenia, depression, or other types of psychiatric iIlnessY Hypothyroidism can therefore be confirmed as the cause of mental illness only when the symptoms of mental disturbance disappear completely after the patient has become euthyrOid. Before starting treatment, the type of thyVolume IX

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roid disease should be determined and medication selected accordingly. For example, primary hypothyroidism due to decompensated failure of the thyroid gland must be distinguished from secondary hypothyroidism due to failure of the anterior lobe of the pituitary.:\I; Sometimes the peripheral tissues do not respond adequately to thyroid hormone and the thyroid secretion itself is occasionally of subnormal quality. Three cast's of psychosis without clinical signs of myxedema were reported by Logothetis."; Hypothyroidism was discovered later, and thyroid replacement therapy brought improvement in two patients; the third was completely relieved of symptoms. During the hypothyroid phase, the electroencephalogram (EEG) in two of these patients showed lowvoltage. slow, irregular alpha activity of diminished amplitude. With the patients' emotional progress, amplitude and frequency increased and finally returned to normal. Electroencephalographic changes produced hy primary hypothyroidism in adults are principally a reduction in the frequency and am· plitude of the normal background rhythms, with generalized slow-wave abnormalities."" However, EEG disturbances do not occur in all patients with thyroid deficiency. When encountered, such changes are indistinguishable from those occurring with other metabolic or neurolo~ical disorders. The correction of thyroid deficiency by hormone supplementation is usually accompanied by a complete reversal of these abnormalities. The EEG can be used as a sensitive indicator of changes in thyroid status when serial readings are taken, each patient serving as his own control. Failure to reverse the hypothyroid wave-pattern with hormone replacement may he due to an insufficient dose or too brief a treatment period. Excessive medication will usually he reflected in the EEG by changes characteristic of hyperthyroidism: increased fast activity, high alpha frequency, paroxysmal slow waves, and general instability. This was confirmed by an autocorrelation procedure to show that the alpha wave frequency and thyroid indices (BMR and PBI) remained positively correlated throughout the entire range of varying thyroid levels."" One of the difficulties in electroencephalography is that hypothyroidism makes the patient drowsy and inattentive."" Such a state May-Jullt>, 1968

even in a l'uthyroid suhject would produce similar changes in the EEG. The characteristic daytime lethargy of patients with thyroid deficiency seems to be related to a significant decrease in stage-3 and stage-4 sleep (considered to be the periods of deepest sleep) ."' Patients who had become euthyroid following several months of therapy with desiccated thyroid spent more time in stage-3 and stage4 sleep than before treatment. Concomitantly, alpha wave frequency in the waking EEG rose, and psychologic testing showed improved intellectual performance in hoth verhal and non-verbal areas. Hormone replacement therapy nevertheless carries some risk. In the event that such treatment precipitates or worst'ns psychosis. continuation of replacement therapy with smaller doses of thyroid is recommendNI."· Hyperthyroidism is characterized hy a definite acceleration of neural processes, hrought about in an indirect way:l; Overproduction of thyroid hormone induces Iiheration of excess catecholamines which, in turn. act on thl' brain, causing hyper-alertness, anxiety, and nervousness. In experiments with dogs, ShiZllmt' and Okinaka'~ demonstrated that thyroid hormone production is under nervous control. EIl'c· trical stimulation of the anterior hypothalamus and the hippocampus resulted in increased output of TSH. By stimulating the cervical sympathetic and the vagus nerves, they produced a similar effect through the autonomic nervous system. Patients with acute untreated hyperthyroidism (PBI > 9 p.gm) reacted to a stressful motion picture with significantly greatt'r changes in thyroid production and autonomic responses than when they viewed a relatively unstimulating travelogue. IIi This experiment also demonstrated that PBP" was a much more sensitive indkator of thyroid function than untagged PBI. During a particularly exciting sequence of the stressor film, average thyroid output was 310 percent greater than during a quiet scene. This was determined hy a rise in the PBI1:n lewl accompanied hy a decrease in the Illlmber of ionizing particles registered on a Geiger counter placed over the thyroid gland. Thyroid output was greatt'st in patients who initially showed mOrt' emotional disturbance. Thyroid and autonomic nervous system responses were minimal in normal suh129

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jects and in formerly hypothyroid patients who had remained euthyroid for at least one year following radioactive iodine therapy. Abnormalities in EEG patterns are more frequent in young women « 50 years) than in postmenopausal women or in men of any age." ll1is may mean that endocrinological factors other than overproduction of thyroid hormone play a part in causing EEG abnormalities. Female steroids may have a greater sensitizing effect than the male steroid. In follow-up studies after treatment with radioactive iodine, the EEG patterns of all patients showed a trend toward normal. A schizophrenic patient with alternating phases of psychotic behavior was followed in order to study the relationship between thyroid gland activity and psychiatric illness.~" Each time the patient became mute and retarded, the 24-hour uptake of J131 doubled. These synchronous manifestations suggest "an underlying neurophysiological change in the brain, perhaps in the hypothalamus," which triggers both the increased secretion of TSH and the behavioral changes. This investigation was later extended to include three additional patients also suffering from functional psychoses of an episodic or periodic natme. H In all of them, thyroid function fluctuated with the onset or subsidence of psychotic attacks. The authors proposed that thyroid function may provide a lever by which neural mechanisms can be controlled. \Vhatever organic process is involved, any treatment which inhibits overactivity of the thyroid is generally considered successfu\.3" The accompanying psychic symptoms may be attrihuted to an extreme emotional reaction following a pathologic rise in metabolism. On the other hand, correction of hyperthyroidism alone does not always bring improvement in mental health." A 45-year-old male, presenting the classical physical signs of hyperthyroidism, was acutely anxious and restless, with prominent paranoid mechanisms. A battery of psychological tests prior to any medical treatment suggested an organic brain syndrome. After approximately three weeks of medication with propylthiouracil and radioactive iodine, a euthyroid state was produced. However, the patient had become more depressed and delusional, with fewer ego controls. Although the "organic" deficit had been removed, the patient was now overtly psychot130

ic. In some patients the psychosomatic mo< of ego functioning acts as a support; attenu tion of the psychosomatic illness by medic means is tantamount to exposure to oV€ whelming stress. DISORDERS OF THE PARATIlYROID GLANDS

In contrast to the complex relationships b tween the thyroid and the central nervous sy tern, the parathyroid glands do not seem to 1 activated by a trophic hormone originating: the pituitary!" Normally, the output of par thyroid hormone is regulated by changes the homeostasis of the serum calcium ion. Hypoparathyroidism is easily discovered the presence of tetany or following total 1 subtotal thyroidectomy. Yet, in idiopathic h poparathyroidism, psychic disturbances m~ be the first and only manifestations of the lJJ derlying disease. Sedivec'l and his group r, ported a case of acute psychosis (catatoni2 which developed during the puerperium in 24-year-old woman who had been treated fe grand mal seizures for 11 years. Anti-epilept and anti-psychotic therapy with thioridazir and electroshock were ineffective. After lal oratory investigation disclosed parathyroi hormone deficiency, intravenous calcium il jections were started; the psychotic sympton hegan to improve within a few days. Add tional treatment with dihydrotachysterol rl suIted in improvement of other persistent pe sonality changes. According to Cohen,1I long-standing hypl calcemia leads to irreversible mental deter oration. Chromylo attempted to claSSify tt most frequently encountered mental complic: tions of hypocalcemia. He described halluc native paranoid psychosis in a patient wit hypocalcemia as "pseudohypoparathyrodisn and urged psychiatrists to be alert for syml toms of latent tetany. Hypoparathyroidism is too seldom consi( ered in the differential diagnosis of psychia ric disorders.'" It produces a wide array ( symptoms and is often difficult to diagnose Intellectual impairment is the most frequer psychiatric disturbance accompanying idi( pathic hypoparathyroidism and may be con bined with emotional dysfunction describe as neurotic, hysteric, or hypochondriac. Trea ment for hypoparathyroidism offers a chane of reversing the psychiatric changes, ofte with dramatic results. I ' Volume I:

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Hyperparathyroidism is now increasingly recognized as the cause of otherwise unexplaim'<.l psychic disturbances. Initial complaints include anorexia and listlessness, accompanied by sudden behavioral changes or psychotic episodes with paranoid delusions or agitated depression. After surgical removal of a parathyroid adenoma, the patient's condition improves considerably, particularly in young people.~:< Overactivity of the parathyroid glands should he suspected when osteoporosis is noted. Mental symptoms do not relate directly to the serum calcium level; 1 very high levels may produce only minimal symptoms, while values barely ahove the normal range may accompany a psychosis characterized hy severe depression and frequently by paranoid delusions. IIYPOGLYCE~nA

Hypoglycemia is characterized by an ahnormally diminished blood sugar concentration, but its other manifestations are so variable that the diagnosis is often missed. The condition has been referred to as the "stepchild of medicine."!" Functional hypoglycemia, in particular, is not well understood. Its presence is marked by an increased output of endogenously produced insulin. Emotional turmoil and stress can intensify or precipitate this condition. 46 In a series of 350 patients with hypoglycemia, Buehler" noted that carbohydrate ingestion failed to produce the expected rise in blood sugar. He proposed the term "relative hypoglycemia" to describe a common condition, often mistakenly diagnosed as neurosis, where the patient is referred for psychiatric therapy. Hypoglycemia is indeed difficult to detect, since the fasting blood sugar may be within the normal range. However, all patients in the Buehler series showed abnormal curves in the five-hour glucose-tolerance test. These findings cannot be considered specific, and the diagnosis must he based largely on clinical symptoms, such as nervousness, tension, headaches and neck pain, excessive malaise or fatigue, and other neurologic and mental manifestations. Treatment follows the usual regimen for hyperinsulinism: a diet high in protein and fat, low in carbohydrates. This is aimed at avoid~fay-June,

1968

ing excessive stimulation of the pancreas and may be combined with heavy doses of vitamins and supplementary protein feedings. As a rule, no coffee is permitted, and mild sedation may be prescribed. In Buehler's series, symptoms disappeared within three months in half the patients; another 25 per cent were markedly improved. Salzer~' devised the following diagnostic criteria: Relative hypoglycemia is indicated by a drop of 2Omg/per cent or more helow the fasting hlood sugar level during a six-hour glucose-tolerance test; a drop of 10 to 20 mg/per cent is interpreted as "potential" relative hypoglycemia. Among 275 patients in private neuropsychiatric practice, 31 per cent had relative hypoglycemia and an additional 8 per cent, potential relative hypoglycemia. Depression was the most frequent psychiatric symptom in this series (60 per cent). In addition to the usual corrective diet, patients were given 6 to 12 intragluteal injections of calcium-glycerophosphate (10 cc) on the theory that calcium levels control the activity of an enzyme which elevates blood sugar levels. Complete recovery or improvement occurred in approximately 85 per cent of the series. SEX HORMONES

The hypothalamo-gonadal system controls the hormonal and behavioral aspects of reproduction. Nevertheless, the so-called sex hormones are not specific for male or female sexual behavior but act more or less as general stimulants.:
PSYCHOSm.IATICS

doses sufficient to produce an increase in libido usually result in virilizing phenomena. Furthermore, the psychic effect is only partially dependent on the type of hormone; the woman's personality, age, mental state, psychosexual maturity, and the existing erotic situation may also play decisive roles."' The administration of estrogenic hormones to adult females is of doubtful henefit in influencing sexuality. Similarly, the psychic reaction of adult men to large doses of estrogenic hormones depends largely on the existent psychosexual pattern. In a large series of patients with carcinoma of the prostate. polvestradiol (Estradurin®) hrought ahout diminution or complete extinction of psyclwsexuality. without the developll11'nt of any "feminine" traits."n Changes in alh,ct uSllally did occur, hut the direction was de'termirwd hy the' personality and prior experieJl(:es of each patient. Sex hormone levels were studied in a series of 64 WOlllen with mental diseases: Deficiency of pituitary gonadotropin was more pronOlmced in acute psychosis and in neurosis than in chronic schizophrenia and the depressive syndrome'S. Quantitative determinations indicated that estrogen secretion was reduced due to gonadotropin hlock and that pregnane(liol was totally lacking, pointing to an absence of ovulation and corpus luteum formation. Hormone suhstitution is, therefore, an indispensable prerequisite to specific psychiatric treatment methods; this (>nahles the patient to respond mOT{' rapidly and with a longer lasting effect. :\. further relationship hetween psychic distmhances and gonadal function was demon· stratl'd hy Suwa, et al.':: In a longitudinal study of 23 suhjects, including schizophrenic, manic-depressive, and neurotic patients with a few nomnl controls, the excretory patterns of sex hormones were determin:"d every second or third day and correlated with the psychic conditions. In the normal suhjects as wplI as in stabilized patients, urinary output of pituitary gonadotropin remained constant. In the majority of the other patients-irrespective of diagnosis or type of psychic manifestation-hormonal output was depressed although it increased temporarily during periods of acut<' psychic aggravation. A definite connection between emotiornl disturhances and changes in hormone excretion was ob132

served, and the release of pregnanedio seemed to be determined primarily by the se verity and duration of psychiatric disease Contrary to earlier assumptions, emotiona stress may have a stimulating effect on gonad otropin secretion. A 24-year-old divorced mother, subject t( recurrent, severe premenstrual tension and associated disturbances, was studied over a period of 67 days."" A rise in urinary aId oster one and estrogen secretion was ohserved during the second half of the menstrual cycle, coinciding with her emotional upsets. The un derlying somatic factor of such psychiatric dis organization is possibly the presence of inade quately antagonized, active adrenocortica hormones, such as aldosterone. The frequent Iy reported efficacy of oral progestogens prob ably lies in their ability to antagonize or in directly hind adrenal steroids. The \Vilsonsl!' described the serious conse quences of the drastic decline in body estro gens wbich takes place at the time of meno pause. A negative nitrogen balance result~ in muscle weakness and osteoporosis; thl cholesterol level rises, carbohydrate metaho lism is impaired, and hypertension develop~ Skin and mucous membranes hecome dry am inelastic, producing senile vaginitis. Involu tional changes occur in the breasts and in th_ external and internal genital organs. Cessa tion of estrogen production leads to disturb ances of the autonomic nervous system, thcontrol center for the emotions. Hence, post menopausal depression may be due to a de cline in body estrogen. Estrogen supplemen tation is recommended to restore the vitalit, of menopausal and postmenopausal women well as to control mild and moderately severe involutional melancholia. Unless contraindi cated, it should be tried before resorting h shock therapy or other radical modalitie~ Since estrogen levels are quickly and easi1~ ascertained by cytologic examination of vagi nal smears, the proper dosage need not be it doubt. Hypopituitarism is a polyglandular disorder covering a range of hormonal dysfunctions. I is usual to institute a delicately balanced sub stitution therapy, including desoxycorticoste rone, methyltestosterone, stilbestrol, thyroid and cortisone. Michael and Gibbons"" re ported marked improvement with cortisonl alone, given in small doses. The condition ()

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patient, admitted in coma, wag diagnosed as )riginating from a postpartum hemorrhage 10 lears earlier. In addition to cessation of lactaion and menstruation, the patient complained )f loss of energy and initiative, absence of ibido, and decaying memory. When stabiized on a maintenance dose of 25 mg of corisone daily, she returned to full health. After I lapse of 10 years, her energy, libido, and ~heerfulness were completely regained. The psychic effects of changes along the )ituitary-adrenal axis cover a large area of ~oncern. Together with the subject of the :atecholamines, they will be taken up in a :orthcoming paper. I

REFERE:\CES

1. A!lras, S. and Oliveau, D. C.: Primary HYPt'rparathyroidism and Psychosis. Canad. Med. A~s. j. 91:1366-1367,1964. 2. Bauer, H. G.: Introduction. In Bajusz, E., ed.: Clinical Neuroendocrinology, New York: S. Kar!ler, 1967, pp. 1-15. 3. Bernstein, I. C.: A Case of Hypothyroidism PfI'sentin!l as a Psychiatric Illness. PsycllOsomatics, 6:215-216, 1965. 4. Bleuler, ~1.: Enclokrinologische Psychiatrie, Stull!lart: Thieme, 1954, 5. Bleuler, ~1.: Endokrinologische Psychiatrie. In Gruhle, H. W., Jung, R., ~layer-Gross, W. and Miiller, ~l., eds.: Psychiatrie der Gegenwert, Vol. II1B, Berlin: Sprinlter, 1964, pp. 162-252. 6. Bowers, M" Jr. and Singer, D.: Thyrotoxicosis and the Psychological State: A Case Report. Psyclwsomatics, 5:322-324, 1964. 7. Bowman, K. M.: Sakel and Biological Treatment of Schizophrenia. In Rinkc1, :\1., ed.: Biological Treatment of Mental Illness, New York: L. C. Page & Co., 1966, pp. 54-61. 8. Brambilla, F.: Studio DelJc Secrezioni Ipo!isoGonadiche in Corso di ~Ialallie ~Ientali. Folia Endocr. (Pisa), 17-:692-714, 1964. 9. Buehler, ~1. S.: Relative HYP0!llycemia. A Clinical Review of 350 Cases. journal-Lancet, 82: 289-292, 1962. lO. C~r<,Jmy, K.: Psyc~osis in Pseud~hypoparathy­ rOldlsm. Cs. Psyc1l1at., 60: 193-19.~, 1984. Ahstracted in Excerpta ~Ied., Sec. VIII, 18:582. 1965. 11. Cohen, S.: The Toxic Psychoses and AlJied States. Amer.). Med., 15:813-828, 1953. 12. Denko, J. D. and Kaelblin!l, R.: The Psychiatric Aspect.s of Hypoparathyroidism. Acta Psycltiat. Scandlnav. (Suppl. 164), 1962, p. 20. 13. Deutsch, S. F.: Endocrinologic Evaluation as an Essential Factor in Managin!l Emotional Disturbance. Psychosomatics, 7 :29-35, 1966. 14. DurelJ, J., Libow, L. S., KelJam, S. C. and Shader, R. 1.: Interrelationships Between Reltulation of Thyroid Gland Fundion and Psychosis. In Levine. R., I'd.: Endocrines and the Central Nervous System. Res. Publ. Ass. Res. Nerv. ~Ient. Dis., 43:387-399, 1966. May-June, 1968

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9730 Wilshire Boulevard Beverly mils, California 90212

SECOND INTERNATIONAL CONGRESS The Academy of Psychosomatic ~1edicine will hold its Second International Congress in Florence, Italy, from October 11-20, 1968. Three half-day sessions are planned in which the concepts of comprehensive medicine and recent advances in psychopharmacolo~y will he explored by leading clinicians and educators both from the U. S. and Europe. After the sessions in Florence are completed, the ~roup will be transported to Rome by bus, via Perugia, Assisi, and other historic sites. A comprehensive tour of Rome and its surroundings will be included in the itinerary. It should be emphasized that all arrangements will be made hy Professional Seminar Consultants, a well-established organization specializin~ in international mel'tings which has a reputation for arran~in~ many successful meetin~s abroad. Further information can be obtained by writing to Professional SC'minar Consultants, 3194 Lawson Boulevard, Oceanside, L. I., N. Y. 11572. Future issues of PSYCHOSOMATICS will contain specific details as to the pro~ram and the speakers. Volume