The Canadian Journal of Psychiatry

The differentiation of the distinct clinical syndrome of anorexia nervosa from atypical cases is based on the following distinguishing features: a relentless pursuit of thinness; an almost delusional disturbance of body image; an inability to correctly identify hunger from other bodily or tension states; a lack of an identity awareness; and a paralyzing sense of ineffectiveness. This sense of ineffectiveness, pervasive of all thought and action, is connected with the perception of the self as acting only in response to the demands of others and is camouflaged by negativism and defiance. The core developmental issues of being unable to experience the control over one's own body and of lacking the conviction of living one's own life are based on the severe deficits in autonomy and initiative, originating from the distortion and mislabeling of feelings, sensation and moods in early childhood. The treatment process focuses on evoking awareness in these patients of their impulses, feelings and needs as originating within themselves as an essential step in the development of a sense of competence and self-esteem.

Studies of diagnostic subtypes within the anorexia nervosa syndrome has given rise to the differentiation of a bulimic subgroup as distinct from the restrictive type of anorexia nervosa. The bulimic subtype is characterized by the use of vomiting and laxatives to induce weight loss; a display of impulse-related behaviours; extraversion and sexual activity in contrast to the isolation of the restrictive group; and a family history of obesity in the mother, all suggesting a subcategory within the primary anorexia nervosa syndrome.

Investigation of behaviours and attitudes related to anorexia nervosa in a group of dancers disclosed a significantly elevated attitude toward food and body image characteristic of anorexia nervosa in this group and ten times the expected prevalence of the disorder itself. This is suggestive of the relative importance of cultural pressures towards thinness and anorexia nervosa in certain populations as one factor amongst others in the multi-determined origin of this condition. This cultural pressure is consistent with a disturbance of body image perception in anorexia nervosa. This disturbance seems to be stable in the same individual over a period of one year, is related to a poor prognosis and is correlated with measures of psychopathology including helplessness, depression and anhedonia. It is also correlated with a satiety defect as reflected in a failure to develop an aversion to sucrose when directly tested.

Despite much recent interest in the objective measurement of body image in anorexia nervosa, many questions remain regarding basic mechanisms responsible for the findings as well as their meaning in the disorder. It is unclear if “whole body” measures assess the same underlying phenomena as the “body part” method, and it is unclear if body image disturbances are etiologic or a byproduct of anorexia nervosa. The possible association between self-esteem and body satisfaction and the relationship of the latter variable to actual size estimation supports the hypothesis that size perception may be closely tied to satisfaction with non-physical aspects of self. Finally it must be determined if over estimation is a function of a general psychological disturbance or of a deficit of specific interest in this disorder. Despite these questions, the way in which anorexic patients see themselves as well as the cognitive and affective responses to this perception remains an interesting and potentially fruitful area of study with this disorder.

An attempt is made to demonstrate the interrelationship between the phenomena which occur in repetitive dreams and the processes which are involved in the creation of symptoms in several patients with the anorexia nervosa syndrome who were studied during a prolonged bulimic phase. The outstanding feature of the repetitive dreams was the undisguised and unrestricted instinctual expression which they contained. The dreams were divided into three main categories: dreams of violence in which the dreamer is depicted as the aggressor; dreams of violence in which the dreamer is described as victim; and finally, sexual dreams which are frankly incestuous. The failure of the dreaming ego to repress the powerful aggressive and sexual drives is accompanied by a concomitant failure of the waking ego in various manifestations of defensive processes. This failure operates within the intrapsychic realm and is accompanied by the utilization of a supplementary process such as bulimia involving the mobilization of resources from the outside world.

There are no controlled studies of the outcome of treatment for anorexia nervosa. An early study showed that biologically recovered anorectics were, as a group, socially phobic four years following the completion of treatment. This position is more sophisticated and mature than that at the time of their original anorexia and one shared by many “normal” people. A recent study evaluated treatment in terms of strict criteria for good outcome: all the patients had been severely ill with anorexia nervosa when first seen. Four to seven years later, 84% were holding a body weight above the pubertal threshold but of these, 2% were obese and 18% were well below average adult weight. Sixty-four percent, therefore, were sustaining a normal and stable body weight and the majority of these had regular menses. Quite a number were preoccupied with body shape, but their psychosocial adjustment was reasonable. In contrast, 14% had remained severely ill and only 2% had died. These findings suggest that treatment aims at altering the long term cause of the disorder for the better is probably effective in (a) helping about 20 to 30% of the population to recover who would not otherwise have done so; and(b) in preventing some deaths.

Three videotaped practice clinical, oral examinations were rated by 9, 9 and 11 raters respectively. Raters were all certified specialists engaged in training residents for the certification examinations. In two of the simulated examinations considerable differences in rating scores, to the extent of pass/fail disagreement, were found. The significance of the findings, including the possibility that one examiner may “contaminate” another, is discussed. Further work is essential to develop reliable instruments for rating certification examinations, whatever their format, as the Royal College policies evolve.

There is a fundamental difference between nosology and a statistical classification, and the two should not be confused. The discipline of nosology uses scientific methods to arrive at a classification of psychiatric disorders and is concerned with the validity of its entities. A statistical classification aims to attain the widest compliance in spite of differences in the theoretical orientation of its users. It must therefore be atheoretical, and must represent a widely negotiated agreement between its future users.

The most important statistical classification is the “International Classification of Diseases, Injuries and Causes of Death” (ICD-9) endorsed by the member states of the World Health Organization. The DSM III (Diagnostic and Statistical Manual), a newly accepted classification of the American Psychiatric Association, departs in many ways from the ICD-9, and Canada will have to decide whether adherence to ICD-9 should continue, or be replaced by the adoption of DSM III. Advantages and disadvantages of the DSM III are briefly discussed.

Two hundred persons over 80 in two urban communities were interviewed. Of those interviewed, 21% evidenced psychological impairment as defined by the presence of at least one of the following self-report symptoms: 1) depression; 2) periods of inability to function; 3) suicidal ideation; 4) alcohol problems and 5) use of psychotropic medication. A profile of the psychologically impaired group compared to the psychologically healthy showed that accidents (mostly falls), eye problems and few social contacts were significantly associated with impairment. Approximately 75% had some restrictions on activity due to physical health problems. Social isolation was marked: 54% either had no children or saw them less than once a month; 38% visited with close friends or relatives less than once a month; 19% were rated as having very little or no social support; and 23% socialized beyond the household less than once a week. Social interaction was the strongest predictor of psychological well-being (Affect Balance Scale) in a multiple regression analysis that included physical health and socioeconomic variables. Questions about service needs and utilization indicated unmet needs in the areas of transportation, house maintenance, medical services, and a regular visiting service.

The authors surveyed the reactions toward commitment of 61 respondents out of a sample of 100 patients who had been committed to hospital during a one year period. The patients reported little change in their life situation as a result of committal and most viewed committal quite neutrally. They generally felt uninformed of their rights and indicated little intent to appeal the commitments, but wished to be assured that their rights were being considered and protected. Most saw psychiatrists as the professional group best equipped to bring about a committal. The importance of consumer surveys in controversial areas such as this is underscored.

L'effet de messages subliminaux auditifs sur le niveau d'activation a été évalué par une étude à double-insu, Vingt sujets volontaires ont été alternativement soumis à des messages subliminaux activateurs et à des messages subliminaux désactivateurs. Les variations du niveau d'activation ont été mesurées par les changements au Mood Adjective Check List. Cinq des six facteurs de ce test visés par le contenu des messages subliminaux ont varié différemment selon la nature de ces messages, et quatre ont répondu d'une façon statistiquement significative. Ces résultats semblent indiquer que des perceptions subliminales auditives peuvent influencer le niveau d'activation. Les auteurs soulèvent plusieurs interrogations, soulignant que les paramètres contrôlant la réponse et la susceptibilité subliminales demeurent largement inconnus et requièrent une investigation systématique.

The influence of the auditory subliminal messages on the level of activation has been evaluated through a double-blind study. Twenty consenting subjects were alternately submitted to activating and deactivating subliminal messages. Activation changes were estimated through the variations in the scores at the Mood Adjective Check List. Five out of this test's six factors concerned by the content of the subliminal messages responded differently according to the nature of these messages; four factors did so to a statistically significant degree. These results tend to indicate that auditory subliminal perceptions can influence the level of activation. The authors raise several questions, especially stressing that the parameters regulating subliminal response and susceptibility remain largely undefined and in need of systematic investigation.

Over the past three years we have seen twelve patients who have become depressed while taking cimetidine. Clinically the depression is similar to that seen in a Primary Affective Disorder. Two representative cases are presented. It is suggested that cimetidine has precipitated a depressive reaction in vulnerable patients. Tricyclic antidepressants are effective in relieving the depression. It is postulated that cimetidine, by blocking H₂ receptors in the CNS, produces an imbalance between₁ and H₂. This imbalance may be an etiological factor in precipitating the depression. Tricyclic antidepressants have little effect on H₂ but are potent H₁ receptor blockers. This H₁ blockade could restore the balance between H₁ and H₂, thereby relieving the depression.

Psychiatric disorder in relation to Klinefelter's syndrome is reviewed. A well documented case report is presented of a schizophreniform illness in a patient with Klinefelter's.

An overview of research involving pharmacotherapy in infantile autism is presented. Methodological issues relating to experimental design, rating instruments and ecological factors are considered. Classification of infantile autism and diagnostic problems are discussed. Research investigations conducted in order to define diagnostic subgroups in the etiologically heterogeneous population of autistic children are described. An attempt is made to relate biochemical findings to clinical drug response. Recent findings are presented indicating that a potent neuroleptic is able to yield simultaneously significant decrease of behavioural symptoms and improved learning under both clinical and laboratory conditions. The drug can be effective in conservative doses and administered over a period of 14 weeks without untoward effects. New research plans are introduced where attentional learning will be assessed in an operant conditioning paradigm using automated procedures.

“General hospitals” for the care of the helpless poor, the aged and infirm, lunatics and idiots, which were developed in the mid-17th century by Louis XIV of France, soon spread to the colony in New France. Francois Charon, a wealthy businessman, built the Hôpital Général de Ville Marie, Montreal, which was opened in 1694 to care for impoverished and helpless men.

The Hospital Register, discovered in the Archives of the Soeurs Grises, Montreal, provides details of the patients’ names, dates of and reasons for admission and the dates of discharge or death. An analysis of the Register, covering the 45 years of the Charon period, reveals that among the 66 boys and men admitted, from 1694 to 1738, at least seven inmates suffered from some form of mental disorder or retardation. This suggests that the Hôpital Général de Ville Marie, together with the Hôpital Général de Québec, were the first Canadian institutions to provide care for the mentally disordered.

Pierre Chevallier, who was retarded, lived in the hospital for 44 years until his death at the age of 85. The length of stay in the hospital indicates that the early settlers of New France were men of robust constitution and that the regime provided by the Frères Charon was physically as well as spiritually sustaining.