Australasian Psychiatry 21(6)

Evidence from the profile of candidates selected for training in South Australia in 2013 would suggest that at least half of this cohort had spent an additional year working as junior medical officers prior to committing to specialist psychiatry training. Despite this, there is a lack of formal initiatives that target junior medical officers in attempts to increase the desirability of psychiatry as a career choice. While several services offer junior medical officer positions in psychiatry, these are rarely supported by robust academic programmes geared at improving psychiatric skill or mentoring that might encourage the ambivalent.4 TAPPP provides a safe, supported and sufficiently prolonged training experience to help the undecided commit to informed decisions about future vocational options. TAPPP has attracted a wide spread of individuals, including those interested in future specialist psychiatry training, general practice and emergency medicine trainees, as well as the undecided. Importantly, it also served as a holding area for individuals who had not been successful in their first attempts at applying for specialist psychiatry training and prevented attrition in other specialist training programmes. Despite early evidence of strategies that increase recruitment and retention in psychiatry training,5 the uptake of such measures has been slow. It would be interesting to follow closely both the programmes that target pre-vocational trainees in psychiatry and to review the impact they make. With the increasing number of graduates exiting medical schools in Australia and in the absence of a corresponding increase in specialist training positions, there is likely to be a burgeoning population of junior medical officers requiring work opportunities. This provides psychiatry with an ideal opportunity to provide positions that enhance skills in mental health for a wider range of doctors. This will impact positively on the profile of psychiatry and

increase the number of doctors able to provide quality mental health services even without specialist training in psychiatry. References 1. Cohen M, Llewellyn A, Ditton-Phare P, et al. Hunter New England Training (HNET): How to effect culture change in a psychiatry medical workforce. Australas Psychiatry 2011; 19:531–534. 2. Medical Education Unit, Mental Health Services Psychiatry JMO. The Adelaide Pre-vocational Psychiatry Programme (TAPPP), (2012, accessed 20 May 2013). 3. Malhi GS, Parker GB and Parker K. Shrinking away from psychiatry? A survey of Australian medical students’ interest in psychiatry. Aust N Z J Psychiatry 2002; 36: 416–423. 4. Manassis K, Katz M, Lofchy J, et al. Choosing a career in psychiatry: Influential factors within a medical school program. Acad Psychiatry 2006; 30: 325–329. 5. Weintraub W, Balis G and MacKie J. The combined accelerated program in psychiatry: A progress report. Am J Psychiatry 1974; 131: 1213–1216.

Shuichi Suetani Woodville, SA Jacob Alexander Glenside, SA DOI: 10.1177/1039856213497813

My friend’s brave assertion did not make headlines. By contrast, interest in Asperger’s over recent years could scarcely have been better orchestrated by a skilled public relations team! ‘A Syndrome for Success … what Mozart, Andy Warhol and Bill Gates all have in common’.1 Albert Einstein is virtually proclaimed patron saint of the syndrome. The tone of the journalism is more than sympathetic – alike to the sufferers and to their suffering families. Support groups have sprung up both for ‘Aspies’ themselves and for their spouses. Obedience to the DSM is not enforceable by law. I have little doubt that the term ‘Asperger’s’ will remain in currency. For so many people it has brought understanding and indeed become a part of their identity. Reference 1. Molloy F. A syndrome for success. Sydney Morning Herald, 9 June, 2005.

John Parkinson Wollongong, NSW DOI: 10.1177/1039856213497815

In Memoriam: Asperger’s Dear Sir, There is much to be lamented in the loss of Asperger’s syndrome from the latest version of the DSM. The learned committee responsible may understandably have seen it as a label whose popularity has got out of hand. That very popularity, however, can be viewed as a turning point, a victory in overcoming the stigma of psychiatric illness. What other psychiatric diagnosis can be seen to promise compensations, even advantages, along with the problems and the pain? I am reminded of an old friend who, despite two major episodes of schizophrenia in his student days, went on to have a distinguished scientific career. He would say that a touch of schizophrenia was an asset in research. ‘We see things’, as he put it, ‘that other people don’t see’.

Behaviour theory and attachment theory Dear Sir, Johns and Levy1 provide a sensitive description of what should probably be a standard intervention for children exhibiting extreme emotional outbursts. They describe a cure for what might have been mislabelled and medicated as attention deficit disorder or paediatric bipolar disorder and, in that respect at least, I suppose the new DSM-5 label of disruptive mood regulation disorder serves a useful function. In describing their intervention as a combination of behavioural and attachment approaches, however, they perpetuate (in their description, if not in their personal understanding) a polarisation between attachment theory and behaviour theory that need not exist.

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The tendency to seek out attachments is innate in most mammals, but the way in which an individual maintains a relationship with their attachment figure is learnt by trial and error according to the principles of operant conditioning. Predictably useful attachment figures evoke secure attachment, predictably less useful ones evoke more avoidant attachment and unpredictable ones evoke the push–pull of ambivalent attachment by way of intermittent positive reinforcement, very much the picture described in this case. The explicitly ‘behavioural’ elements the authors describe have enabled the mother to become more structurally consistent in her interactions with the child. The ‘attachment’ elements have enabled her to be more emotionally consistent – the ‘big enough’ concept from ‘Circle of Security’. The challenge in applying any behavioural intervention is to discern what needs are operating and what contingencies are actually reinforcing or punishing, what in attachment theory would be labelled discernment or sensitivity. ‘Time out’ for the child can work if the child is exaggerating emotion for effect and monitoring outcome. It cannot work if the child is too overwrought to track outcome. ‘Time in’ is a useful intervention then (to contain arousal) but its deployment when a child is exaggerating for effect will potentially reinforce the cycle. ‘Time out’ for the parent might give them a moment to ease their arousal and do the discerning, but deployed too often it makes the parent predictably less available and will foster avoidant attachment. Reference 1. Johns A and Levy F. ‘Time-in’ and ‘time-out’ for severe emotional dysregulation in children. Australas Psychiatry 2013; 21: 281–282.

Paul Dignam Adelaide, SA DOI: 10.1177/1039856213498290

Australia’s gardens, slugs and snails: the risks of pica and rat-lungworm infection Dear Sir, Ingestion of non-nutritive substances can be inherently dangerous, with effects ranging from heavy metal exposure (e.g. with lead), puncture or blockage of the gastrointestinal tract, to various parasitic helminth and nematode infections.1 While oral exploration of almost anything within reach is part of expected development, in the first months and years of life, pica is a recognised mental health disorder, defined by persistent eating of nonnutritive substances.2 Prevalence studies found pica in autistic and learning disabled institutionalised individuals occurs at a rate between 9.2%3 and 21.8%.4 Infection with Angiostrongylus cantonensis (commonly known as the rat-lungworm) may cause severe and long-lasting neurological impairment, as exemplified by a recent case in Sydney,5 but also often-fatal eosinophilic meningitis or encephalitis.6 Humans are accidentally infected when they ingest raw snails, slugs or vegetation covered with mollusc slime harbouring the larval form of the parasite. Rats are the main reservoir of infection, excreting infective larvae in faeces which subsequently penetrate or are ingested by the snail or slug intermediate host. The first Australian human case of this disease was reported in Brisbane in 1971,6 with a fatal report in 1999 in a child who ingested molluscs in a suburban Brisbane garden.7 Infection is thought to occur predominantly along the central east coast of Australia (southeast Queensland and northern New South Wales). In addition to the recent case,6 an adolescent “bravado case” was reported 10 years ago also in Sydney.8 A report of A. cantonensis infection in an adolescent in Taiwan with pica

disorder was published in 2013, highlighting the potential risk of exposure to this parasite in patients with pica in other endemic areas.9 Since molluscs that carry A. cantonensis are endemic in even metropolitan areas of Australia, psy­­cho­­education beyond the usual behavioural1 and medical advice to parents, carers and clients with pica in Australia should include a warning regarding the risks associated with accidental ingestion of slugs and snails and their secretions. References 1. McAdam DB, Sherman JA, Sheldon JB, Napolitano DA. Behavioral interventions to reduce the pica of persons with developmental disabilities. Behav Modif 2004; 28: 45. 2. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. WHO, 1992. 3. McAlpine C and Singh NN. Pica in institutionalized mentally retarded persons. J Ment Defic Res 1986; 30: 171–178. 4. Ashworth M, Hirdes J and Martin L. The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Res Dev Disabil 2009; 30: 512–520. 5. Blair NF, Orr C F, Delaney AP, et al. Angiostrongylus meningoencephalitis: Survival from minimally conscious state to rehabilitation. Med J Aust 2013; 198: 440–442. 6. Gutteridge B, Bhaibulaya M and Findlater C. Human larval meningitis possibly following lettuce ingestion in Brisbane. Pathology 1972; 4: 63–64. 7. Prociv P. Parasitic meningitis: Crossing paths with the rat lungworm (Angiostrongylus cantonensis). Med J Aust 1999; 170: 517–518. 8. Senanayake S, Pryor D, Walker J, et al. First report of human angiostrongyliasis acquired in Sydney. Med J Aust 2003; 179: 430–431. 9. Hsueh C, Chen H, Li C, et al. Eosinophilic meningitis caused by Angiostrongylus cantonensis in an adolescent with mental retardation and pica disorder. Paediatr Neonatol 2013; 54: 56–9.

Klaus Martin Beckmann Logan, QLD Jeanine Maree Bygott Brisbane, QLD DOI: 10.1177/1039856213505687

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Behaviour theory and attachment theory.

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