The Canadian Journal of Psychiatry

The increasing number of characterlogically difficult patients in psychiatric practices has produced a plethora of theoretical formulations, treatment strategies and techniques. The major shifts in theoretical emphasis from drive theory to object relations theories and self-psychology has encouraged many psychiatrists to treat these patients in psychotherapy. The heterogeneity and variability of clinical profiles represented in this group of patients, however, still prevents prescription of “the” treatment of choice for this patient population.

A major focus on treatment considerations in this paper is the assessment process with emphasis on determining the capacities for inter-personal relationships, psychological mindedness, empathy and psychological soothing of self and others. The advisability of establishing a “contract” as a prerequisite to treatment is suggested as an important factor in determining outcome. Other particular treatment issues are addressed such as frequency of sessions, “secrets”, premature provocation of intense affect, medications, consultations, hospitalization, self-mutilation, substance abuse and indications for termination. The complex vissicitudes of the transference and countertransference processes with this group of patients is pointed out especially those feelings of helplessness and range sometimes experienced in the countertransference. Long term intensive psychotherapy with many of these patients probably still belongs to the area of therapeutic heroics. Hard evidence for good and poor outcome is scarce and therapeutic zeal is too often based on anecdotal testimonial from adherents of one approach or another.

This pilot study addressed two questions. The first was whether the combination of an observer scale (Hamilton Rating Scale) and a self-rating scale (Carroll Self-Rating Scale, modelled after the Hamilton) can make a valid distinction between the frequency and severity of depressive symptomatology in adolescents not referred for treatment, and psychiatric inpatients. The second was whether Major Depressive Disorder (MDD) could be recognized and diagnosed in “non-patient” adolescents using this interview and rating scale approach.

The median Hamilton and Carroll scores of the school students differed significantly from those of the in-patients, though the scores alone did not correspond with the presence or absence of MDD. Only 1 of the 26 (3.8%) tenth grade “students interviewed appeared to have MDD, compared with 9 of 33 (27%) adolescent inpatients studied previously with the same methodology. The strength and limitations of this interview and assessment approach are discussed.

Fifty-five of the 58 adult offspring of 17 bipolar manic-depressives were studied. Fifty-three were interviewed and some data were available on the two who had committed suicide. A detailed educational history and pregnancy and birth (paranatal) history were obtained and were corroborated by records where available. Thirty-two percent of the offspring met RDC criteria for major affective disorder, and 13 percent for minor affective disorder. Paranatal and educational problems, separately and together, were not associated with an enhanced risk to affective disorder, however they were significantly associated with an earlier onset to affective disorder. This association may be partly due to a relatively lower IQ among the early onset subjects.

This paper describes the working of an oncology nurses coping group which functioned under the guidance of a consultation-liaison psychiatrist at the Toronto General Hospital. Nurses were helped to deal more effectively with the many and varied stresses which they face in treating patients with cancer. As a result ward atmosphere, patient care and inter-staff communication improved. The success of the group was due to a number of factors that included the high motivation of the staff the high level of stress on the ward, the support of the head nurse and the consistent relationship of the consulting psychiatrist.

A series of cases are presented to illustrate these points.

This study is concerned with providing quantitative information on involuntary hospitalization of the mentally ill in Canada. It presents national statistical data on involuntary hospitalization to provincial mental and psychiatric hospitals, and psychiatric units of general hospitals for the period 1970–1978. The data used are based on the statistical information on psychiatric in-patients collected by the Mental Health Program of Statistics Canada for the period 1970–1978. The data indicate a moderate decline in involuntary admission rates. Men had consistently higher involuntary admission rates and women had consistently higher voluntary admission rates for the same period. Of the total commitments 22% were to psychiatric units of general hospitals. A high commitment rate was found for the elderly. As this is the first national quantitative analysis, both in Canada and in the international literature, the information presented should provide a useful objective perspective for a historical review of involuntary admissions to mental and psychiatric hospitals and psychiatric units of general hospitals.

The “special” or favoured patient may play a very important role in the ward milieu. Such patients are discussed in terms of their adaptive function for medical and nursing staff in dealing with feelings of pessimism, anger and guilt. The attitudes of protectiveness and infantilization and staff dissention make the task of the psychiatrist hazardous when consultation is requested.

Two clinical examples are discussed: one in which the issue of “specialness” was overlooked, and one in which it was dealt with.

The consulting psychiatrist's own reactions of anger and therapeutic nihilism may alert him to such a patient. Intervention must take into account the trust implied in being asked to see a “special” patient and the tremendous emotional investment on the part of the staff. The consultant should use his own reactions to the patient to help staff identify the feelings aroused in them by such patients. Meeting with the staff collectively to share concerns and resolve conflict is productive and should be encouraged.

Psychotropic drug use in Saskatchewan during 1977, 1978, 1979 and 1980 was determined. Approximately one in five prescriptions dispensed was for a psychotropic. About 20% of the population received psychotropic drugs in each year but use has declined slightly, especially that of tranquilizers. Psychotropic use increased with the patient's age and nearly two-thirds were women.

Considerable caution should be exercised in making comparisons with other drug utilization studies. There may be substantial differences in the drugs selected for study, the categorization of these drugs, and the methodology used to analyze drug use. Also, most studies are based on data that is from a decade old or older. Moreover, most if not all other studies on drug use are based on sample surveys (from different sampling universes), whereas the present study is based on the entire population. Nevertheless, some generalizations may be valid.

Since non-formulary drugs are excluded, the findings should be regarded as conservative. Examples of non-formulary drugs considered to be psychotropic include antispasmodic / tranquilizer / sedative combinations (example: Librax, Donnatal), combination hypnotics (example: Tuinal, Mandrax), and some combination analgesics (example: propoxyphene compounds, pentazocine compound, oxycodone compound).

The attitude of physicians toward retirement was studied using a questionnaire sent to physicians aged 65 and older. The information obtained was supplemented by organizing a study group of interested doctors. Of the 58 respondents whose average age was 71, 54 were still in practice and 65% had no plans for retirement. There was a strong urge to maintain the status quo. The group discussion centered around the loss of control over one's declining practice and the fear of diminishing competence with advancing age. The dedicated lifetime pursuit of a medical practice makes retirement extremely difficult for today's older physician. This study supports surveys on the working life span, longevity and mortality of North American physicians.

Maprotiline is a tetracyclic antidepressant which appears to have accounted for a relatively large proportion of the seizures associated with antidepressant use. The literature proposes two mechanisms of seizure induction: interaction with other medications and concomitant medical conditions lowering the seizure threshold. Observations during a study of maprotiline blood levels suggest that elevated serum concentrations achieved with therapeutic doses may also be linked to the seizure-induction mechanism. Monitoring of maprotiline blood levels may help to identify patients at risk.

This paper describes the “mutual story telling” therapy as it is used to aid the young child Joshua in finding healthy ways of dealing with conflicts that cause disruptions in his home and school life.

In this therapeutic process, Joshua's stories illustrate growth in ability to integrate good and bad parts of himself, to acknowledge his own anger and to express it without fear of annihilation; to feel the ego strength necessary to allow him to explore his external world.

Carbamazepine has been used in the treatment of temporal lobe epilepsy since 1963. It has also been found effective in the treatment of psychiatric disorders accompanying epilepsy. Patients with nonspecific EEG abnormalities without overt epilepsy but with behavioral problems, including gross psychopathology and violent behavior, improve on carbamazepine. These findings prompted us to use it in the treatment of aggressive behavior in a schizophrenic patient. Due to the frequency and severity of aggressive behavior in this patient, maintenance ECT was given. However, when carbamazepine was instituted, ECT was discontinued and the patient has been virtually free from aggressive behavior since this medication has been instituted. The authors conclude that carbamazepine may be used in the treatment of aggressive behavior in schizophrenic patients.

Although there have been previous reports of decreased sexual capacity as a side effect of anti-depressants (1–3), the authors know of no previous records of increased capacity of the type described in the following reports, or of reports of side effects associated with yawning. Observation of unusual yawning-associated side effects is now reported, in order to alert clinicians to a possible side effect that can influence patient-compliance with the prescribed medication regimen.

The purpose of this paper is to investigate Philippe Pinel's psychiatric experience, his practice in “la maison de santé Belhomme” and his first publications which were concerned with the treatment of mental patients and appeared in “La Gazette de Santé” which he edited between 1785 and 1789. During that time, the main preoccupation of the future head doctor of “La Salpétrière” had been to ensure the application and the development of moral treatment, in its practical modalities as well as its theoretic rationalization. Meanwhile, the institutional aspect of this therapy had the upper hand over the individual cure. This evolution brought Pinel and his successors to neglect the latter. In this connection we can regret that Philippe Pinel did not continue to have more private practice for this allowed him to follow first his experience and research (individual cure) in this field of rational psychotherapy, that of moral treatment.

Self-esteem is a concept which is central to our understanding of a person's sense of well-being. Impairments to self-esteem due to the effects of past experience coupled with the impact of present circumstances often precipitate the entry into psychotherapy. The psychotherapy situation itself can be a potent source of self-esteem for both patient and therapist because it involves the two major factors that energize self-esteem needs: engagement in an important activity and involvement in an intimate relationship. This paper suggests that whether or not they are the focus of the therapy, self-esteem needs can be exacerbated due to the context of the situation and the fit between patient and therapist, as well as the transference and countertransference.