The Canadian Journal of Psychiatry

This article reports on 95 women who were referred to an outpatient psychiatry clinic for group therapy for adult survivors of childhood sexual abuse. Criteria for exclusion in group therapy are outlined and the format of the group therapy is described. Those who completed the groups are compared to dropouts. The group's effectiveness was evaluated using measures of psychiatric symptomatology (SCL 90), depression (Zung Self-Report Depression Scale), and self-esteem (Texas Social Behaviour Inventory) with a pre/post test design. Clients' evaluation questionnaires were also used. Group therapy was found to be effective in reducing symptomatology and change was in the expected direction in terms of depression and self-esteem.

Every medical intervention is submitted to the rule of informed consent. Over the years, criteria of consent validity and exception situations have been defined. After a discussion of the difficult application of the informed consent rule in psychiatry, this article suggests an analysis of the motivations of a refusal of neuroleptic medication in 20 psychotic patients of a psychiatric hospital. The irrational motivations of refusal (particularly, denial and delusional ideation) have been evoked much more often then rational motivations (therapeutic inefficiency, secondary effects). The authors question the denial as a sufficient reason to declare a psychotic patient incompetent to consent. The consequences of the refusal of the neuroleptic treatment in some patients, mainly the risk of criminalisation, are discussed.

Buspirone has previously been demonstrated to be efficacious in the treatment of anxiety. This four-week double-blind parallel study compared buspirone to diazepam and placebo in the treatment of 119 outpatients diagnosed as having generalized anxiety disorder. After a seven-day placebo washout period, eligible patients were randomized to one of three treatment groups. Buspirone (5 mg) and diazepam (5 mg) were administered BID and individually titrated to an optimal therapeutic dose by the end of week two. Buspirone and diazepam were equally effective in reducing Hamilton Anxiety (HAM-A) total and psychic factor scores from baseline values. Buspirone alone was significantly better than plecebo in reducing the HAM-A somatic factor score. Sixty-seven percent of both active treatment groups who were classified as “ill” on the baseline global psychopathology rating scale achieved a “not ill” status by study end. There were no significant differences between treatment groups at endpoint on the 56-item Symptom Checklist self-rating scale. Buspirone was demonstrated to be as effective as diazepam in relieving anxiety in this outpatient sample.

Psychoanalysis has long distinguished between the transference neurosis and that part of the communication between therapist and patient which depends upon a relatively intact part of the patient's ego. It has been proposed that it is this capacity of the patient that sustains the difficult work of dealing with communications which are the consequence of transference, and which often threaten the viability of the treatment. This quality has been referred to variously as the unobjectionable positive transference, rational transference, mature transference, therapeutic alliance and working alliance.

The ever broadening scope of Psychoanalysis, along with our greater knowledge of early childhood development, has enhanced our understanding of the many influences affecting the treatment alliances. Newer views of the transference, which stress the significance of the therapists' contributions to the therapeutic dyad, make it clear that the therapeutic alliance can no longer be explained as some simple, reality based, conflict free, motivating force. It involves, rather, a complex interaction of several factors, to each of which one must add the therapists' reciprocal reactions. Psychotherapy outcome research will need to take all of these factors into consideration.

The concept of empathy has become a central issue in the debate between classical psychoanalysts and self psychologists. If one recognizes that dilemma is central to the human condition and that the two competing schools of psychoanalysis emphasize opposite sides of several parameters that are fraught with dilemma, it is possible to view them both as empathic. Three levels of empathy are discussed: empathizing with the patient's story as it stands; discovering new themes hidden away in the patient's narrative; and discovering significant patterns in the patient-therapist relationship itself. The concept of therapy as a self-correcting process that approaches but never quite attains objective accuracy is emphasized.

We found diurnal weight gain to be abnormal among 39 chronic schizophrenic patients. The patients were weighed and urine samples obtained weekly for three weeks at 7 a.m. and 4 p. m. We normalized the dirunal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.075 ± 1.331% for the 38 study patients, .631 ± .405% for 16 acutely psychotic controls and. 511 ± .351% for 29 normals. Seventy-seven percent of the study patients had abnormal NDWG values and 62 % were polyuric. NDWG related to urine volume (n = 39, r = .356, p = .026) with the variability in urine excretion explaining 13% of the variability in NDWG. We discuss factors that may have contributed to our findings.

A number of authors have questioned the rationale for subdividing the DSM-II schizoid diagnosis into three separate personality disorders in DSM-III, the schizoid, avoidant, and schizotypal. The present study was designed to explore differences between psychiatric patients with schizoid and avoidant personalities as compared to psychiatric controls with no personality disorder. Differences were examined on demographic data, self-report measures, and clinical information. A Multivariate Analysis of Variance (MANOVA) revealed a significant overall effect for groups across MMPI subscales. However, subsequent univariate Analyses of Variance (ANOVA's) revealed that almost all differences were between the two personality disorder groups as compared to the psychiatric controls. Contrary to expectations, schizoid and avoidant personalities were found to display equivalent levels of anxiety, depression, and psychotic tendencies as compared to psychiatric control patients. No meaningful distinctions were found between the avoidant and the schizoid personalities. Results are discussed in terms of problems with the assessment methods and the diagnostic criteria.

Survey studies have pinpointed high concordance rates between affective disorder and premenstrual depression. This relationship was investigated in women with a history of both disorders. Sixteen subjects rated symptoms daily during one menstrual cycle, and were assessed on measures of mood and selective attention pre– and postmenstrually. Prospective ratings confirmed premenstrual depression in only eight of the subjects. These subjects demonstrated a significant premenstrual elevation in dysphoric affect, yet exhibited a dysphoric attentional bias both pre– and postmenstrually. These data do not suggest an interactive relationship between affective disorder and premenstrual depression along the particular cognitive dimension of study.

This study analyzed the borderline traits of a sample of community alcoholics drawn from a rural and a metropolitan area of the province of Quebec. The Diagnostic Interview Schedule and other questions from the Diagnostic Interview for Borderlines were administered. About one-third of the sample of alcoholics showed a high number of borderline traits, a proportion similar to that found in institutionalized samples elsewhere. The borderline alcoholics tended to be younger and they all came from the urban area. This result suggests that alcoholics are probably better tolerated in rural areas and are less likely to adopt a pathological behaviour.

Recruitment of Physicians/Psychiatrists to staff the Ontario Provincial Psychiatric Hospitals remains an ongoing problem despite the introduction of measures such as University Affiliation and Incentive Grants. Historically there has been heavy reliance upon Foreign Medical Graduates (GOFM's) who have been denied the possibility of professional mobility and advancement because of restrictive licences. Recent changes in regulations have severely restricted the recruitment of GOFM's. During 1987, details of all physicians employed in the provincial hospitals during the preceeding five years were entered into a computerized data base. This paper presents some initial analyses which indicate that Canadian graduates have provided low levels of service, especially outside major urban centres, quite insufficient to replace the GOFM's. These findings raise urgent social and professional concerns.

This study deals with the immediate and long lasting effects of father-daughter incest through the psychoanalytic-psychotherapeutic investigation of, firstly, a group of 12 adolescent girls during the violent crisis created by the sudden revelation of incest and, secondly, a group of 12 adult former victims with no apparent crisis in their development, the incest having remained unrevealed. Having been a practioner of psychoanalytic psychotherapy with the victims of paternal incest for the last 25 years the author's main concern in this study is to try to establish the basic theoretical issues that would favour a better understanding of incestuous trauma and a more effective approach to its treatment.

Negative symptoms are mostly associated with schizophrenic illness. This paper discusses the presence of negative symptoms in other chronic psychiatric illnesses. We have observed that logitudinally primary negative symptoms tend to be constant and are precisely symptoms which can define chronicity. They are as unspecific as positive symptoms in mental illness.

The personality characteristics of 35 consecutively assessed adolescents who met the DSM-III criteria for a current depressive disorder were assessed using independent structured interviews and paper and pencil measures. Sixty-five percent of the sample met the criteria for an Axis II personality disorder. The single most common diagnosis was borderline personality disorder (30%). Depressed adolescents with a concurrent personality disorder were less self-confident, displayed more neuroticism, and were emotionally reliant on others. They also demonstrated greater cognitive distortion. Teenagers who present with a depressive disorder warrant a comprehensive personality asessment. The combination of affective and personality disorder in such patients is associated with attitudes and interpersonal problems which should be therapeutically addressed in addition to symptomatic treatment of the depressed mood. Clinicians should be aware that depressed adolescents with personality disorder may be more likely to make a suicide attempt.

Fourteen males with major depressive illness (DSM-III) received a course of electroconvulsive therapy (ECT). Serum prolactin (PRL), luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone (T), were measured 15 minutes before and 15 minutes after each treatment. The severity of depression was assessed with the Hamilton Rating Scale for Depression (HRSD) two to three days before the first and two to three days following the last treatment. Post-ECT levels of PRL and LH were significantly higher than pre-ECT levels across every treatment. Changes in FSH and testosterone were not significant. There were no relationships between hormone levels (first versus last ECT) and severity of depression, including sexual functioning.

It is argued that the relatively greater increases of LH than FSH is due to an acute antidopaminergic action of ECT which acts selectively on the secretion of the former. The blunted testosterone response to the increase of gonadotropins may be due to ECT-induced hyperprolactinemia.

Numerous endocrine abnormalities are found in depressive illness and, among these, several have been proposed as useful markers in diagnosis, prediction of treatment response, monitoring treatment outcome or in understanding of etiology. This paper reviews five endocrine systems — the hypothalamic-pituitary-adrenal axis, hypothalamic-pituitary-thyroid axis, growth hormone regulation, prolactin regulation and pineal function, in which such abnormalities have been reported.

The dexamethasone suppression test (DST) results are affected by a variety of other diseases and confounding conditions. Furthermore, variability in dexamethasone availability has recently been shown to be an important factor, influencing post-DST cortisol levels. Refined tests, taking into account all these factors, or alternative tests of hypothalamic-pituitary-adrenal function may lead to improved clinical utility.

Pineal function is now the focus of considerable investigation. Low nocturnal output of melatonin is found in unipolar and bipolar affective disorder and is normalized by treatment with antidepressant drugs which block re-uptake of noradrenaline. These findings support the hypothesis of noradrenergic abnormality in depression. In seasonal affective disorder there is evidence for a phase delay in the melatonin rhythm which may be a key factor in the seasonal disorder. Effective light therapy causes a phase advance in the abnormal melatonin rhythm. Whether the normalization of the melatonin rhythm is instrumental in producing the antidepressant effect is yet to be determined.

There are wide spread neuroendocrine abnormalities in depressive illness. These abnormalities encompass many different pituitary hormones, as well as the pineal. Major theories of affective disorder attribute the mood and visceral changes to disruption in central neurotransmitter regulation or to altered central regulation of body rhythms, or to both. It is thought that disruption of these central systems give rise not only to the mood and visceral changes, but to the accompanying changes in endocrine regulation.

Current diagnostic practice is to use clinical history and observation to identify typical forms of depression. Such an approach to diagnosis is less useful in delineating atypical, borderline or sub-clinical affective disorder. For these reasons, the endocrine changes have been proposed as biological markers to be used as clinical aids in diagnosis, prediction of treatment response, monitoring treatment outcome and in understanding etiology.

This paper reviews and evaluates published data on five such endocrine measures.

Methylphenidate (MPT) was prescribed four days after an uncomplicated appendectomy in a 27 year old woman who had suffered from bulimia nervosa (BN) for at least nine years. Before the onset of appendicitis, her bingeing and self-induced vomiting had occurred several times daily. With MPT the patient reported a calm emotional state and an absence of temptation to binge or to induce vomiting. Previously published reports of treatment of BN with MPT could not be found. This may be the first. Vulnerability to surgical disorders and to postoperative complications as well as the safety and efficacy of MPT in patients suffering from BN deserve further study.

Organic Mood Disorder of the manic type is a syndrome which resembles a manic episode but is due to a specific organic factor. Organic mania may be associated with a variety of physical illnesses such as temporal lobe epilepsy, multiple sclerosis, neoplasms and hyperthyroidism. In addition, organic mania can be associated with drugs including L-dopa, decongestants, sympathomimetics, steroids, baclofen withdrawal, cimetidine, and possibly captopril. This report describes a case of a 74 year old female who presented with a full syndrome of mania soon after being started on Phenytoin. Neither the clinical picture, Mini-mental state score, nor EEG findings were suggestive of delirium. The syndrome resolved soon after the phenytoin was discontinued. This case suggests that phenytoin should be added to the list of medications capable of producing Organic Mood Syndrome, manic type.

This paper was prepared for the Professional Standards and Practice Council, chaired by Dr. Werner J. Pankratz. It was approved by the Board of Directors of the Canadian Psychiatric Association on June 3, 1989.