- Email: [email protected]
TREATMENT OF COMPULSIVE GAMBLING
926 addition local inflammation occurs in about 50% of cases, but rarely necessitates removal of the tablets. Further implantations are made every four to six months. Reactions to alcohol can be severe, especially in the early stages. Our patient had been admitted 15 times in ten years, since when he had been divorced, had been made bankrupt, and had become a vagrant. He had attempted suicide repeatedly, and by the stage at which this treatment was initiated he was unable to stop drinking even in hospital. Oral disulfiram had been tried twice unsuccessfully. However, in the social field there were grounds for hope if abstinence could be achieved. He has now had the implantation for three months with 1 relapse recently; apparently this produced a reaction sufficient to prevent further drinking. It seems that this method of disulfiram treatment is worth further assessment in patients in whom oral disulfiram has been tried, has not produced side-effects, and has failed because of failure to take the tablets. As with oral disulfiram it is likely to be only a supportive measure, and treatment of the underlying cause will still be needed. A full account of this case will be published in the Journal of Alcoholism. The implants, called Espéral " were obtained from Laboratoires Thersa, 15 Rue des Champs, Ansieres, Seine, France.
Morgannwg Hospital,
Bridgend, Glamorgan.
A. M. P. KELLAM J. M. WESOLKOWSKI.
therapy and paradoxical intention." Although the might well be comparable, the duration of aversion therapy necessary to effect lasting improvement is likely to be much shorter than with alternative treatments. Perhaps the time is now approaching when a prospective trial should be undertaken to compare aversion therapy with,the Gamblers Anonymous method of treating compulsive gamblers. Alternatively, psychiatrists using the different approaches might, with advantage, arrange to take on each other’s failures. group
results
Shelton Hospital,
J. C. BARKER
Shrewsbury, Shropshire.
M. E. MILLER.
THYROXINE-BINDING PREALBUMIN IN ALCOHOLIC CIRRHOSIS SIR,-Patients with liver cirrhosis may have abnormally low serum-protein-bound-iodine (S.P.B.I.) levels. However, it has lately been shown that absolute thyroxine disposal in these patients is normal .12 l3 In fact cirrhotic patients with low s.p.B.l. and l31J-uptake levels have a raised proportion of free serumthyroxine that results in a normal total free-thyroxine-iodine concentration.l2 Oppenheimer et al.14 have suggested that " the principal factor responsible for the diminished binding appears to be a lowered concentration of thyroxine-binding prealbumin (T.B.P.A.) ". However, as indicated by Hollander et
TREATMENT OF COMPULSIVE GAMBLING
SIR,-While decidedly opposed to prefrontal leucotomy for treating a compulsive gambler, we would not accept that self-help group therapy, as suggested by Dr. Casson (April 13, p. 815), necessarily " offers the best chance of rehabilitation to the compulsive gambler ". At present, we incline to the view of Seager et aLl that it is essential to preserve an eclectic approach towards all potentially therapeutic techniques. We have treated several compulsive gamblers by electrical aversion therapy, which is generally regarded as preferable to other aversive techniques,23 and the results have hitherto proved encouraging. Our first " fruit-machine " gambler, who received only 12 hours’ aversion therapy in z,4did not gamble for 18 months and then relapsed once. 6 hours’ booster treatment using the same fruit-machine has suppressed further gambling for another year. Unfortunately, he has certain other psychopathic features which have impeded his rehabilitation. The betting-shop gambler we treated using the film technique5 relapsed once after a year but responded to a boost and has not gambled for a further year. A "one-armed bandit" gambler has not gambled for 2l f2 years following treatment, and a pin-table addict has not relapsed for several months. A man who had spent more than E60,000 in betting-shops during 10 years preceding aversion therapy 6 has not gambled for a year and is awaiting a routine boost. Others have reported compulsive gamblers successfully treated by aversion therapy.1 7-9 We will be treating further compulsive gamblers as part of a research project into the general applicability of this treatment.10 We have found the technique effective in treating compulsive over-eaters, and have also used aversion therapy to treat certain repetitive criminal disorders. In October, 1967, we successfully treated a habitual car stealer referred from court. His complicated thieving procedure was realistically reproduced on video tape while he underwent electric shocks; he has not relapsed. Clearly, there is a need to evaluate aversion therapy against other methods of treatment for compulsive gambling such as 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Seager, C. P., Pokorny, M. R., Black, D. Lancet, 1966, i, 546. Barker, J. C. Br. J. Psychiat. 1965, 111, 268. Rachman, S. Behavl Res. Ther. 1965, 2, 289. Barker, J. C., Miller, M. Lancet, 1966, i, 491. Barker, J. C., Miller, M. Br. med. J. 1966, ii, 115. Barker, J. C., Miller, M. Ass. Adv. behavl. Ther. Newsl. 1968, 111, 2. Koller, M. Personal communication. Cross, I. Nurs. Mirror, 1967, 123, 159. Goorney, A. B. Br. J. Psychiat. 1968, 114, 329. Barker, J. C., Miller, M. (in the press).
Serum concentration of T.B.P.A. in normal with alcoholic cirrhosis.
Mean values indicated
by
subjects
and in
horizontal solid lines and
patients S.D.
by
interrupted lines. "
no data exist to substantiate their claim that thyroxinebinding prealbumin is present in lowered concentration in such patients ". We present here the results of quantitative determinations of T.B.P.A. in the serum of twenty-eight patients with hepatic cirrhosis associated with alcoholism. Cirrhosis was diagnosed by typical physical findings and confirmatory laboratory evidence and, in 5 patients, with the aid of liver biopsy. Twenty-
al.,15
studied. To avoid the influence of levels 16 all subjects selected for this study were adult men. Serum-T.B.p.A. concentrations were determined quantitatively by single radial immunodiffusion on cellulose-acetate strips .17 The specific anti-T.B.P.A. serum (Behringwerke, Marburg/Lahn, Germany) was diluted 1/6. Calibration curves were obtained by using a standard human
two
normal controls
age and
were
sex on T.B.P.A.
Victor, R. G., Krug, C. M. Am. J. Psychother. 1967, 21, 808. Hollander, D., Meek, J. C., Manning, R. T. New Engl. J. Med. 1967, 276, 900. 13. Inada, M., Sterling, K. J. clin. Invest. 1967, 46, 1442. 14. Oppenheimer, J. H., Bernstein, G., Surks, M. I. New Engl. J. Med. 1967, 277, 211. 15. Hollander, D., Meek, J. C., Manning, R. T. ibid. p. 212. 16. Stabilini, R., Vergani, C., Agostoni, A., Pugno Vanoni Agostoni, R. Clin. chim. Acta 1968, 20, 388. 17. Vergani, C., Stabilini, R., Agostoni, A. Immunochemistry, 1967, 4, 233.
11. 12.
Morgannwg Hospital,
Bridgend, Glamorgan.
A. M. P. KELLAM J. M. WESOLKOWSKI.
therapy and paradoxical intention." Although the might well be comparable, the duration of aversion therapy necessary to effect lasting improvement is likely to be much shorter than with alternative treatments. Perhaps the time is now approaching when a prospective trial should be undertaken to compare aversion therapy with,the Gamblers Anonymous method of treating compulsive gamblers. Alternatively, psychiatrists using the different approaches might, with advantage, arrange to take on each other’s failures. group
results
Shelton Hospital,
J. C. BARKER
Shrewsbury, Shropshire.
M. E. MILLER.
THYROXINE-BINDING PREALBUMIN IN ALCOHOLIC CIRRHOSIS SIR,-Patients with liver cirrhosis may have abnormally low serum-protein-bound-iodine (S.P.B.I.) levels. However, it has lately been shown that absolute thyroxine disposal in these patients is normal .12 l3 In fact cirrhotic patients with low s.p.B.l. and l31J-uptake levels have a raised proportion of free serumthyroxine that results in a normal total free-thyroxine-iodine concentration.l2 Oppenheimer et al.14 have suggested that " the principal factor responsible for the diminished binding appears to be a lowered concentration of thyroxine-binding prealbumin (T.B.P.A.) ". However, as indicated by Hollander et
TREATMENT OF COMPULSIVE GAMBLING
SIR,-While decidedly opposed to prefrontal leucotomy for treating a compulsive gambler, we would not accept that self-help group therapy, as suggested by Dr. Casson (April 13, p. 815), necessarily " offers the best chance of rehabilitation to the compulsive gambler ". At present, we incline to the view of Seager et aLl that it is essential to preserve an eclectic approach towards all potentially therapeutic techniques. We have treated several compulsive gamblers by electrical aversion therapy, which is generally regarded as preferable to other aversive techniques,23 and the results have hitherto proved encouraging. Our first " fruit-machine " gambler, who received only 12 hours’ aversion therapy in z,4did not gamble for 18 months and then relapsed once. 6 hours’ booster treatment using the same fruit-machine has suppressed further gambling for another year. Unfortunately, he has certain other psychopathic features which have impeded his rehabilitation. The betting-shop gambler we treated using the film technique5 relapsed once after a year but responded to a boost and has not gambled for a further year. A "one-armed bandit" gambler has not gambled for 2l f2 years following treatment, and a pin-table addict has not relapsed for several months. A man who had spent more than E60,000 in betting-shops during 10 years preceding aversion therapy 6 has not gambled for a year and is awaiting a routine boost. Others have reported compulsive gamblers successfully treated by aversion therapy.1 7-9 We will be treating further compulsive gamblers as part of a research project into the general applicability of this treatment.10 We have found the technique effective in treating compulsive over-eaters, and have also used aversion therapy to treat certain repetitive criminal disorders. In October, 1967, we successfully treated a habitual car stealer referred from court. His complicated thieving procedure was realistically reproduced on video tape while he underwent electric shocks; he has not relapsed. Clearly, there is a need to evaluate aversion therapy against other methods of treatment for compulsive gambling such as 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Seager, C. P., Pokorny, M. R., Black, D. Lancet, 1966, i, 546. Barker, J. C. Br. J. Psychiat. 1965, 111, 268. Rachman, S. Behavl Res. Ther. 1965, 2, 289. Barker, J. C., Miller, M. Lancet, 1966, i, 491. Barker, J. C., Miller, M. Br. med. J. 1966, ii, 115. Barker, J. C., Miller, M. Ass. Adv. behavl. Ther. Newsl. 1968, 111, 2. Koller, M. Personal communication. Cross, I. Nurs. Mirror, 1967, 123, 159. Goorney, A. B. Br. J. Psychiat. 1968, 114, 329. Barker, J. C., Miller, M. (in the press).
Serum concentration of T.B.P.A. in normal with alcoholic cirrhosis.
Mean values indicated
by
subjects
and in
horizontal solid lines and
patients S.D.
by
interrupted lines. "
no data exist to substantiate their claim that thyroxinebinding prealbumin is present in lowered concentration in such patients ". We present here the results of quantitative determinations of T.B.P.A. in the serum of twenty-eight patients with hepatic cirrhosis associated with alcoholism. Cirrhosis was diagnosed by typical physical findings and confirmatory laboratory evidence and, in 5 patients, with the aid of liver biopsy. Twenty-
al.,15
studied. To avoid the influence of levels 16 all subjects selected for this study were adult men. Serum-T.B.p.A. concentrations were determined quantitatively by single radial immunodiffusion on cellulose-acetate strips .17 The specific anti-T.B.P.A. serum (Behringwerke, Marburg/Lahn, Germany) was diluted 1/6. Calibration curves were obtained by using a standard human
two
normal controls
age and
were
sex on T.B.P.A.
Victor, R. G., Krug, C. M. Am. J. Psychother. 1967, 21, 808. Hollander, D., Meek, J. C., Manning, R. T. New Engl. J. Med. 1967, 276, 900. 13. Inada, M., Sterling, K. J. clin. Invest. 1967, 46, 1442. 14. Oppenheimer, J. H., Bernstein, G., Surks, M. I. New Engl. J. Med. 1967, 277, 211. 15. Hollander, D., Meek, J. C., Manning, R. T. ibid. p. 212. 16. Stabilini, R., Vergani, C., Agostoni, A., Pugno Vanoni Agostoni, R. Clin. chim. Acta 1968, 20, 388. 17. Vergani, C., Stabilini, R., Agostoni, A. Immunochemistry, 1967, 4, 233.
11. 12.