Some Selected Psychosomatic Problems of Current Interest

Some Selected Psychosomatic Problems of Current Interest E.D. WrITKOWER, M.D. • The honor to address you on this occa- psychiatrists, due to emphasis on motivation, sion is, I daresay, due to my long associa- more or less dropped out. The general trend tion to the field of psychosomatic medicine. of psychosomatic research at the conclusion During a period extending over more than of the survey, i.e. in 1959, was away from cliniforty years I have witnessed its birth as a cal research towards experimental and laboclinical approach and field of scientific en- ratory research, towards conceptualization quiry, its heyday of often highly speculative and towards confirmation, revision, or rejecclinical research, and its recent phase of tion of the concepts formulated. respectability with an application of refined This trend, as evidenced by my address laboratory techniques to psychophysiological to the International Congress for Psychostudies. During this period I have devoted a somatic Medicine held in Kyoto in 1967, has good deal of my energy to psychosomatic re- been maintained. Psychiatrists still carry out search and had opportunities to review its pro- the bulk of psychosomatic research, though as gress in our book, Recent Developments of compared with the previous decade their lead Psychosomatic Medicine, published in 1958, has been somewhat reduced at the expense of and in two major addresses presented in 1960 contributions from psychologists. This develand in 1967: opment indicates that just as in other scien('es, Today I intend to summarize very briefly so in psychosomatic medicine, a shift has the development of psychosomatic research, taken place from clinical observation to basic to identify key issues under investigation and research. Concomitantly, the contributions of then present some psychosomatic problems of psychoanalysts to psychosomatic research topical interest based on research carried out have receded into the background and reacby myself and some of my colleagues in Mon- tive somato-psychic studies have come to the treal. fore. SOME HISTORICAL CONSIDERATIONS

KEY ISSUES

In my Presidential Address to the American Psychosomatic Society in 1960, I surveyed the progress of American psychosomatic research during the period from 1939 to 1959. I found that from an initial multiple combined approach the lion's share of psychosomatic research fell increasingly to psychiatrists, among whom psychoanalysts were prominent. Psychologists maintained a steady interest, while medical specialists other than

In a recent paper Lipowski and I (1967a) have classified psychosomatic research into the following categories: 1) Laboratory research. This involves experimental manipulation of psychological variables, such as specific affective states, and simultaneous recording of physiological variables regarded as measurable indicators of the evoked psychological change. Examples of this type of research are the application of telemetry to the study of autonomic reactivity concomitant with various experiences during waking state and sleep; changes in reactivity to stress with aging; physiological measurements of social interaction between individuals in groups; and the study of altered states of consciousness brought

Dr. Wittkower is Professor of Psychiatry, McGill University, Montreal, P.Q., Canada. This paper was written in association with J.N. Fortin, P. Lefebvre and W.D. Engels and presented as the Distinguished Guest Lecture at The Seventeenth Annual Meeting of the Academy of Psychosomatic Medicine, Hamilton, Bermuda, November 1970. January-February 1971

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about by such varied conditions as intake of chemical agents, hypnosis, fatigue, etc. 2) Study of mediating mechanisms. This research activity is concerned with those neural and endocrine structures and functions which enable the necessary intermediate processes whereby mental events may have peripheral somatic consequences. These studies are exemplified by Grey Walter's work (1965) on cerebral responses to semantic stimuli, by Gloor's investigations (1963) regarding the role of the temporal lobes for emotional experience and behavior, and Maclean's research (1958) regarding the limbic system as a neural substrate of emotion. 3) Clinical psychosomatic research may be defined as the study of the interplay of biological and psychological variables in health and disease with a minimum of experimental intervention. It concerns itself with (a) the effects of psychological and social factors on the predisposition to and precipitation and maintenance of bodily dysfunction and disease, e.g. in essential hypertension, (b) psychological reactions to somatic illness and related diagnostic procedures and therapies, e.g. in pulmonary tuberculosis, as well as (c) the relationship between the patient and those taking care of him, i.e. doctors and nurses. 4) Epidemiological and crosscuIturai psychosomatic research, i.e. the study of the distribution of various psychosomatic disorders in diverse populations at risk. This approach is still in an early phase and difficulties arriving at meaningful conclusions are formidable. Examples of studies of this nature are those by Leighton and Lambo in Nova Scotia and Nigeria (1963), by Kessel in Great Britain (1964), and by Collomb in Senegal (1964). PSYCHOSOMATIC RESEARCH IN MONTREAL

In accordance with the present trend in clinical psychosomatic research studies carried out at the two universities in Montreal, McGill University and the University of Montreal have concerned themselves with reactive phenomena rather than with etiological considerations. In what follows I shall report on 22

resear~b\carrieci out by Dr. J. N. Fortin and myself on the side-effects of contraceptive medication, by Dr. P. Lefebvre on the psychological effects of hemodialysis and renal transplantation, and by Dr. W. D. Engels on the psychological effects of the jejunocolic bypass in obesity. SIDE-EFFECTS OF ORAL CONTRACEPTIVE MEDICATION

The aim of my joint study with Dr. Fortin was to assess the relevance of emotional factors to the appearance of side-effects of oral contraceptive medication and to explore the manner in which these emotional factors operate. Because the primary objective of this medicatioR is contraception all phenomena other than contraception, be they biological or psychological, set into motion by and occurring concomitantly with the administration of the drug can be regarded as side-effects. Our study is based on a cross-sectional and longitudinal examination of 70 women either attending a gynecologist in his private practice or at a community family planning clinic. Women with organic gynecological illness and with a history of psychiatric illness were excluded from our series. Proven fertility and medication for at least 3 months were conditional criteria for inclusion. Each of these women was interviewed by two of our associates (Dr. J. Paiement and Dr. J. LaPierre) for several hours. Only a brief resume of some of our findings can be given. 1) Because a fair number of women in our series complained of "side-effects" shortly after starting on oral contraceptives-sometimes after a few days or after a few weeks of medication-and because these early manifestations often subsided or disappeared afterwards, it appeared unlikely that they were due to estrogen effects and more probable that they were due to fear and anticipation of ill effects. Such fears fostered by mass media are of course common. Prominent among them are fears of cancer and of pregnancy despite the pill. Less common was fear of having malformed children on cessation of the medicaVolume XU

PROBLEMS OF CURRENT INTEREST-WITTKOWER

tion and fear of doing permanent damage to one's procreative system. The repeatedly made statement: "It can't be natural, one shouldn't tamper with things that should be left alone," not only indicates such fear but also a hidden regret for not having another baby. Correlation of fear and anticipation of ill effects with their appearance was high in our series. That is, a woman who is afraid of having sideeffects from taking oral contraceptives is likely to have transient disturbing sensations or manifestations during the first three months of medication. 2) Should it be true that side-effects of oral contraceptive medication be due to some extent or largely to emotional factors, it could be assumed that emotionally maladjusted women have more severe side-effects than emotionally well adjusted women. With this hypothesis in mind we divided the women in our series according to their personality adjustment into those regarded as well adjusted and those regarded as maladjusted and according to the severity of side-effects manifested into those with no or minimal sideeffects and those with mild or moderate sideeffects. (Time consideration does not allow me to go into the details of these classifications.) Correlation of the two sets of variables shows that the better emotionally adjusted a woman is, the less likely she is to have sideeffects from taking oral contraceptives, that emotional adjustment does not exempt a woman from having mild or moderate sideeffects, and that minor side-effects quite commonly occur in women rated as emotionally maladjusted. This statement should not be misunderstood as meaning that all side-effects are due to emotional factors. Such an assumption would be clearly absurd as regards such side-effects as fullness of breasts, weight gain, and some of the menstrual disturbances. 3) A multitude of somatic and psychological side-effects was noted in our series. Very commonly reported at the somatic level are nausea and/or vomiting, swelling of the breasts and weight gain, and at the psychological level changes in mood and decline in libidinal interest. Common in the somatic January-February 1971

sphere are gastrointestinal complaints, such as disturbances of appetite and stomach pains and in the psychological sphere anxiety, irritability and/or nervousness. Uncommonly reported side-effects were dizziness, headache and break-through bleeding. A glance at these side-effects suggests that some of them such as weight gain and swelling of the breasts are biological in origin, that others such as depression, irritability and decline in libidinal interest are psychological in origin while still others such as fatigue, nausea and vomiting may be of both or either origin. Should this be true, one would expect an accumulation of psychological side-effects in emotionally maladjusted women, no correlation between biological side-effects with either emotional adjustment or maladjustment, and differential results regarding side-effects regarded as of doubtful origin. This hypothesis was confirmed. In confirmation of it, it was found that depressive symptomatology and decline in libidinal interest on oral contraceptive medication are significantly correlated with emotional maladjustment; that no such correlation exists between weight gain and emotional maladjustment; and that nausea and vomiting are associated with emotional maladjustment while fatigue is not. 4) Two side-effects deserve special attention: depression and decline in libidinal interest. (a) Depression. Roughly a quarter of the women studied displayed depressive symptomatology while on oral contraceptive medication. They felt unhappy and dejected, lost appetite, weight, and sexual interest, cried a great deal, had self-accusatory ideas, and some of them had suicidal ruminations. Some of these women had depressive states long before they started on the drug. These states continued, improved, or became worse without any demonstrable connection with the medication. Others during the many years of medication had depressive reactions apparently unrelated to the drug, in response to environmental stress, as in the case of the woman whose grief over her father's death passed into a state of melancholia. But there 23

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remains still another group of women whose depressive symptoms started shortly after being placed on the oral contraceptive pill, continued during this medication but lifted when such a woman was taken off the pill, and especially when she became pregnant. This last group is of special interest. While the possibility can of course not be excluded that in these cases the depressive spell is due to alteration in the hormonal system, a psychological explanation can also be offered. Careful study of the case histories shows that this type of reaction occurs in women who reluctantly forced by circumstances agreed to take the pill. There is therefore good reason to believe that the limitation of the depressive symptomatology to the period of oral contraceptive medication is not due to the drug but to a conflict between the professed desire for birth control and an unrecognized desire for more children. (b) Decline in libidinal interest. Because fear of a further pregnancy was the main reason for taking oral contraceptives in the women of our series, we assumed that the safety of the pill, as compared with other contraceptive measures, would increase their libidinal interest and their pleasure in sexual intercourse. This was found to be true but only in slightly over 30% of the total. In the remainder libidinal interest either remained unchanged or decreased. Prominent among those whose libidinal interest remained unchanged are those who failed to trust the effectiveness of the pill, i.e. in whom the fear alleviating effect of taking it did not materialize, and those who had been frigid previously; which goes to show that a woman who is frigid is not likely to be less frigid because she takes the pill. As regards a decline in libidinal interest, three factors, in isolation or in combination, contribute to it: previous emotional maladjustment, previous sexual maladjustment, and marital discord. In this respect two constellations are commonly encountered, one related to reduction in restraint on sexual activities and the other, strangely enough, related to the effectiveness of the pill as a contraceptive agent. Typical of the former constellation is 24

the story of an anxious, irritable, ill-tempered neurotic woman whose relationship with her husband has been strained for years. After the birth of three children husband and wife decide to have no more children. She has neve.r been ''keen on sex" or at least less keen than her husband. Quarrels ensue with the result that the misery of the marriage and concomitantly her aversion to sexual intercourse increase. Typical of the latter situation is the woman who after the birth of two children has bowed to the financial necessity to have no more children. She has asked for an effective contraceptive method, but in deep layers of her mind and perhaps not even so unconsciously, she longs for more children. In response to her sense of frustration she passes into a state of depression with concomitant decrease in sexual interest.

Psychiatric Implications 01 Hemodialysis and Renal Transplantation The next study on which I shall report has been carried out by Dr. Paul Lefebvre and his associates at the Notre Dame Hospital in Montreal. This study, which extends over three years, concerns itself with the psychiatric implications of hemodialysis and of renal transplantation. During this period Dr. Lefebvre has not confined himself to the traditional role of a consultant but has, as a psychiatrist, participated as an integral part of a unit treating patients with irreversible renal failure; as a member of the team he was involved in the constant on-going daily decision making concerning patient and personnel problems. Dr. Lefebvre's study is based on experience with 22 patients undergoing hemodialysis, 7 patients who received a kidney transplant, and 8 patients who were awaiting transplantation. A.) Hemodialysis Dr. Lefebvre concerned himself with the selection of patients for hemodialysis and with the emotional response of patients undergoing this treatment procedure. This treatment entails, as may not be generally known, visits of the patients to the hospital unit two or three times a week for several hours on each visit. Interference with Volume XU

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work, family, and social life are therefore significant factors. He found that there are but few valid reasons for excluding a patient from dialysis on psychiatric grounds. Overt psychosis and psychopathy constitute contraindications as well as marked mental deficiency which would render cooperation difficult or impossible. As regards the reaction of the patients to the illness and their treatment, Dr. Lefebvre noted, contrary to his original expectations, a marked poverty of emotional response. As he puts it, they seem to identify with the impassivity of the dialysing machine. They often appear emotionally dull, interact poorly, and displaya good deal of inertia. Actually this behavior is a facade. Hidden behind it are marked depressive trends. Unrecognized by themselves these patients defend themselves against fear of death and despair. As might be expected, they feel bitter about their fate but their resentful response to their suffering and the treatment procedure imposed upon them usually does not pass the threshold of consciousness. It may be deflected into and reflected by feelings of guilt over past misbehavior; or both resentment and feelings of guilt may find projective expression in a tendency to blame others, especially doctors, for incompetence, faulty treatment, or lack of consideration. The experience of hemodialysis also reactivates important conflicts concerning sexuality. In male patients the illness and the dialysis are experienced as an emasculation. Impotence which may result is a further blow to their self-esteem already lowered if they are unable to serve any longer as an adequate breadwinner. In female patients sexual interest tends to wane, though in contrast to males a belief in their procreative ability is maintained as evidenced by occasional fantasies, wishes or worries concerning future pregnancies. Regressive reactions, when they occur, indicate that the ego of the patients is no longer capable of withstanding the pressures imposed upon it. The regressive symptomatology January-February 1971

usually takes the form of passive-dependent manifestations. Other regressive phenomena indicative of an impending ego collapse are phobic reactions to injections and disregard of dietary instructions. Most important of all is of course the appearance of manifest depressive symptoms. The manifest depressive symptomatology of patients under dialysis has some special characteristics. Depressive feelings are rarely verbalized. Somatizations frequently occur and disguised gestures, such as dietary indiscretions, are noticeable. Dr. Lefebvre believes that the blandness of affect in these patients is partly, due as stated before, to a massive denial of the inevitable outcome but that beyond this the hemodialysis as such is experienced as a continual rebirth which has the effect of suspending mourning over anticipated death. The dialysed patient neither leads a really normal life nor is death sensed as an imminent threat. This situation often changes when the inevitability of the outcome dawns on these patients. They then display what Schmale and Engel (1967) have described as the givingup given-up syndrome in which feelings of helplessness and hopelessness are prominent. At this stage psychiatric intervention becomes essential. Many of these patients become increasingly self-destructive, even suicidal, or simply die, at times irrespective of the physical and biochemical state of affairs. One way out of this frequent depressive dilemma is the prospect of a kidney transplantation. B) Renal transplantation. As regards renal transplantation, the aim of the Notre Dame project was to study behavioral reactions as reflected in the fantasy and dream activities of both recipients and donors. A factor of considerable relevance to the response to the transplantation is of course the nature of the donor, i.e. whether the donor is a living relative or whether a cadaver has been used as the organ donor. In contrast to hemodialysis, renal transplantation evokes abundant fantasy material, and conflicts are much more patent in the latter than in the former. This contrast appears to be related to the fact that transplanation is experienced as a much more definitive attempt at dealing with renal 25

PSYCHOSOMATICS

failure than the protracted, long-clrawn-out dialysis. When transplantation is suggested to the patient the initial reaction is usually euphoria. Afterwards, as the date of the ()peration approaches, justifiable fear is experienced regarding the recipient's or the live donor's safety, and especially regarding the possibility of tissue rejection. In the case of a live familial donor a complex selection process begins among consanguineous relatives. Past and present intrafamilial conflicts unfailingly determine the outcome of this family selection process. The final decision on whom is to be chosen based on immunological and medical considerations depends of course on the medical team. Should a family-selected donor be rejected on medical grounds, renewed conflicts are set off in the family circle. Recipient-clonor conflicts concern on the one hand guilt and shame over aggressive impulses and sexual rivalry on the other. As evidenced by fantasies and dreams, fears emerge in both donor and recipient that one might cause the death of the other. This situation augments already existing feelings of guilt in donors who feel that they "must" give their kidney out of a sense of duty. Hostile feelings in the donor towards the recipient and guilt over hostile feelings of the recipient towards the donor may be expressed in the fear that tissue rejection may occur and that "it was all for nothing." Pre-existing sexual conflicts, as in dialysis, are re-activated by the operation. However in contrast to the effect of dialysis, transplantation is usually experienced as strengthening virility, though this euphoric response is tainted by fear of loss of virility along with organ rejection. Female patients at times unconsciously tend to equate the implantation of the new organ with impregnation. In general there is an initial euphoric phase following transplantation. Erotic fantasies and increase in sexual interest are fairly common. Most of these patients experience a veritable redemption and rebirth, termed by some workers as the Lazarus reaction. Denial of danger and of potential death are implicit 26

in this reaction. Anxiety and depressive trends reoccur if and when organ rejection symptoms appear. As in the case of hemodialysis, Dr. Lefebvre believes that the appearance of the giving-up given-up affective syndrome is of ominous significance. He also believes, in accordance with other researchers in this field that emotional factors may play a contributing role in the development of rejection phenomena and regarding the success and failure of the operation. Transplantation is a somatic and psychological experience. Not only must the new kidney be accepted by the recipient's body but it must also become an integral part of the recipient's body ima~. Thus transplantation invariably provokes conflicts regarding body image and body integrity. The findings of this study should not be taken as a suggestion that all patients undergoing dialysis or transplantation become psychiatrically ill. In fact a number of patients adjust quite well to the treatments. However the study does indicate that all these patients experience considerable conflicts which often result in important complications. Experience at the renal unit at the Notre Dame Hospital has convinced Dr. Lefebvre that a psychiatrist in such therapeutic teams can play a highly significant role in dealing with the complex problems encountered and presented by the patients. ]ejurwcolic Bypass in Obesity

The third and last project on which I am going to report has been carried out by Dr. Dennis Engels, a close associate of mine at McGill. As an outgrowth of a major study concerning the psychodynamics of obesity on which we were both engaged, he has recently focussed his interest on the psychological reverberations of a surgical jejunocolic bypass in superobese patients. * This operation, as it impairs fat absorption, effects a marked weight loss without a need to reduce from excessive food intake. ·Dr. Engels is indebted to Dr. H. Shibata, Surgeon at the Royal Victoria Hospital, Montreal, for his collaboration in this stUdy. Volume

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Fourteen grotesquely obese personsmany suffering serious social and physical handicaps on account of their obesityformed the basis of Dr. Engels' study. They had all been on dietary regimes without sustained success. They had volunteered for this operation despite due warnings regarding possible adverse sequelae. All of them have been psychiatrically examined pre-operatively and at varying intervals post-operatively. Their pre-operative diagnoses ranged from moderate neurotic depression to severe depression of a near psychotic type. Most of them gave histories of significant losses and deprivations early in life. Clinical outcome of the operation and psychological changes due to it will be discussed. A) Clinical outcome. As a result of the operation all the patients studied lost more weight than they had ever done before; most of them maintained the weight loss for several years. Uusually the weight stabilized within two years after the operation. One of the patients died of acute hepatic degeneration; others developed various disorders, such as severe diarrhea and general weakness. In fact only 4 of the 14 were spared discomfort and complications post-operatively. Nevertheless 9 out of the 14 patients stated that they were pleased with the outcome. When the possibility of restorative surgery was raised some of them protested vehemently that they would prefer the discomforts of the sid~ffects rather than regain the lost weight. B) Psycholo~icalchan~. Turning now to psychological changes it is of course wellknown that dietary restriction regimes call forth a variety of disturbing sensations and pathological reactions-depression, irritability, anxiety and behavior disorders. These reactions are usually attributed to the experience of oral deprivation combined with the loss of an ego defence provided by the large body size. A fat person carries much weight. Since Dr. Engels' patients, after the jejunocolic bypass, could continue to eat as much as they liked, no oral deprivation was experienced by them and consequently the psychological effect of reduction in body size could be studied in isolation. January-February 1971

Unfortunately the psychological response to the weight reduction as such is somewhat tainted by the psychological response to the previously mentioned numerous physical complaints which developed post-operatively. On account of them most of the patients on and off felt sick, unhappy, and depressed. Beyond this some general observations can be noted. No psychotic reactions were observed with the exception of two episodes of delirium, one in extreme electrolyte disorder and the other in terminal liver failure. Several patients perpetuated after surgery a lifelong depressive state. Some transient reactions were clearly weight loss related. For instance, a woman. while expressing pleasure at her weight reduction, had terrifying dreams of being a skeleton. Another felt small, weak, frail, and vulnerable and had recurrent nightmares in which she was crawling helplessly in supplication to a sadistic man who wielded a riding crop. A successful businessman who stated how pleased he was with his weight loss became panicky, felt that he was "losing everything" and manifested a moderately severe depressive reaction, while a woman whose chronic respiratory condition was vastly improved by the post-operative loss of over 100 pounds reported that she felt unaccountably sad and cried in her sleep. She felt more illat-ease in crowds now than she did before when she was grossly obese. The occurrence of these depressive reactions was not surprising. As stated before, many authors have described the "defensive" function of obesity and have attributed depressions encountered in the course of weight loss by dieting to the loss of this defence. Less expected by those of us who view obesity as an expression of an emotional conflict, was the degree to which several obese patients experienced favorable changes in their lives following their reduction in weight. A typical example is that of a youngster, who, previously a "clown" and "fifth wheel", changed after the operation into an aggressive, active, independent "leader." Several women after their reduction in weight extricated themselves from exploitative and humiliating 27

PSYCHOSOMATICS

relationships with their male partners. A forty year old businesman reorganized his social and business life after the operation. "I'm no longer the ]ollly Fat Man who is the life of the party," he said; "I'm no longer the one who has to carry the rest of the group," On the basis of his study Dr. Engels arrived at the following conclusions: ( 1) The various adverse psychological reactions after weight reduction through surgery lend support to the longstanding view that for some patients, obesity serves a defensive function against such painful feelings as insignificance, weakness or frailty. (2) The absence of psychotic reactions to the operation and the transient nature of psychiatric disturbances due to it suggest that the maintenance of oral gratification by overeating has an important stabilizing effect on these patients, all of whom had failed on previous dietary regimes. (3) Several patients were conspicuously aided by marked weight loss in terms of selfimage, social behavior, and achievement. In short they were enabled to find realistic gratification and enjoyments which had previously been unavailable to them. This was felt to provide some indirect support for the "vicious circle" theory of obesity in which loneliness leads to overeating, overeating to obesity and obesity to isolation and loneliness. CONCLUSION

In the preceding a brief outline of the history of psychosomatic research has been given and key issues under investigation have been identified. A few selected samples of psychosomatic research carried out in Montreal have been presented. It remains for me to say a few words about the future of psychosomatic research. There is plenty of evidence that research possibilities in psychosomatic medicine are growing in extent, in diversity and in methodological sophistication. A present trend in psychosomatic medicine is to avoid formulation of high-level hypotheses. The emphasis is on validation of limited hypotheses and on datagathering. Laboratory research is in the ascendency and will continue to be so. It has yield28

ed valuable results and will bridge the gap between corticovisceral medicine in the East and psychosomatic medicine in the West. But it should be borne in mind that psychosomatic medicine came into being as a reaction to the laboratory era of medicine and that, unless we remain on guard, we may end where we started. I still hanker for the days of early psychosomatic research when undoubtedly many of our ideas and conclusions were wrong, but when the excitement of novelty, sparks of originality and a missionary spirit permeated our field. Statistically proven irrelevancies may be science, but they do not necessarily constitute progress. Moreover, respectability, both in science and in women, breeds a bit of boredom. There is plenty of room for clinical psychosomatic research in all the areas mentioned. After all we are physicians and not neurophysiologists, and our prime task as such is to help those who are ill in body and mind. Contrary to some of my junior colleagues I am convinced that irrespective of the pluralistic etiology of psychosomatic disorders much can be learned from psychodynamic studies, and that, although our initial expectations may have been exaggerated, there is a place for psychotherapy and psychoanalysis in their treatment. A new dimension regarding the care of psychosomatic patients, ably explored and propagated by your President (Schwab 1968) and my colleague Lipowski (1967b, 1967c, 196'8), has been the development of psychiatric consultation liaison services in general hospitals. Finally in keeping with my recent interests a plea may be made for comparative studies of psychosomatic disorders in different cultures. McGill University 1266 Pine Ave. W. Montreal, 109 Canada. REFERENOES

1. Collomb, H. 1964.: Psychosomatic conditions in Africa. Transcultural Psychiatric Research Review, 1: 130-34.

2. Gloor, P., and Feindel, W. 1963.: Affective behaviour and temporal lobe. In M. Monnier, ed., Physiologie und Pathophysiologie des vegetativen Nervensystems. 11. Band: Pathophysiologie. Stuttgart: Hippokrates-Verlag.

3. Grey Walter, W. 1965.: Brain responses to Volume XII

PROBLEMS OF CURRENT INTEREST-WlTI'KOWER semantic stimuli. J. Psychosomat. Res., 9: 5761. 4. Kessel, N., and Munro, A. 1964.: Epidemiological studies in psychosomatic medicine. J.

m. 10.

Psychosomat. Res., 8:67.

5. Leighton, A.H., and Lambo, T.A., Hughes, Ch. C., Leighton, D. C., Murphy, J. M., and Macklin, D. B. 1963.: Psychiatric Disorder Among the Yoruba. Ithaca, New York: Cornell University Press. 6. Lipowski, Z. J., and Wittkower, E. D. 1967a.: Research possibilities in psychosomatic medicine. Medeoine et Hygiene, 25: 141-42. 7. Lipowski, Z. J. 1967b.: Review of consultation psychiatry and psychosomatic medicine. I. General principles. Psychosomat. Mea., 29: 153-71. 8. Lipowski, Z. J. 1967c.: Review of consultation psychiatry and psychosomatic medicine. n. Clinical aspects. Psychosomat. Mea., 29: 201-24. 9. Lipowski, Z. J. 1968.: Review of consultation psychiatry and psychosomatic medicine.

11.

12.

13.

14.

15.

Theoretical issues. Psychosomat. Mea., 30: 359-422. Maciean, P. D. 1958.: Contrasting functions of limbic and neocortical systems of the brain and their relevance to psychophysiological aspects of medicine. Am. J. Mea., 25: 611-26. Schmale, A. H. Jr., and Engel, G. L. 1967.: The giving-up given-up complex. Dlustrated on fUm. Arch. Gen. Psychtat., 17: 135-145. Schwab, J. J. 1968.: Handbook of Psychiatric Oonsultation. New York: Appleton-CenturyCrofts. Wittkower, E. D., and Cleghorn, R. A. (eds.) 1958. : Recent Developments of Psychosomatic M eaicine. PhiladelphiajMontreal: J. B. Lippincott Company. Wittkower, E. D. 1960.: Twenty years of North American psychosomatic medicine. Psychosomat. Mea., 22: 308-16. Wittkower, E. D., Cleghorn. J. M., Lipowski, Z. J., Peterfy, G., and Solyom, L. 1969.: A global survey of psychosomatic medicine. 1nternat. J. PsycMat., 7: 499-516.

Psychiatric Institute The New York State Psychiatric Institute, the world's first multidisciplinary iJlstitute for the purpose of research in psychiatry, will celebrate its 75th Anniversary on November 21,22, and 23,1971. A Symposium Program with the theme: "Seventy-Five Years of Progress in Psychiatric Research and Teaching" is planned. Professor LopezIbor, Dr. Ewald Busse, Dr. Edward Stainbrook, Professor Dennis Leigh and numerous others have already agreed to speak at this meeting. The dates of the symposium will permit international guests to stop by in New York on their way to the World Congress in Psychiatry in Mexico City. A preliminary program will be available in the near future and will be pUblished in Psychosomatics.

J&Jluary-February 1911