Am
J Psychiatry
136:12,
Is Conventional SIR:
In
Subtype sue) M.D. itors
their
December
Clinical
Wisdom
response
to
of Primary
1979
Psychosocial
Wise?
a letter
Affective
LETTERS
entitled
Disorder?” M.D. , and
‘ ‘
John G. Gunderson, , indicated, “The claims for responsivity made by Klein . . .“ are contradicted
SIR:
Borderline-
(January Jonathan
1979 isE. Kolb,
to MAO
inhib-
by the prevailing clinical wisdom of drug unresponsiveness in this group. This requires clarification. As was clearly stated in my article (I) cited by Dr. Nakdimen, author ofthat letter, I believe that the unitary term borderline disorder’ confounds several distinct syndromes that also have distinct pharmacologic response patterns. Such subgroups are the “
.
.
.
‘ ‘
‘ ‘
emotionally
unstable
to lithium
(2) and
character
‘
disorder,
chlorpromazine
which
findings
have
trolled,
are
been
random
indeed
derived
assignment
drug from
which schiz-
‘
and
(5); chronic histrionic
unresponsive
clinical
trials.
anxiety character
(5).
These
placebo
con-
Yet another
com-
double-blind,
treatment
pointing differential monolithic
approaches.
as important
sponsivity
obfuscates
Gunderson wisdom,” evidence.
syndrome
the issues.
Ifthey
could
describe
‘
situation. complex
Engel (I) has suggested or disease is a multidetermined
action
among
From
biological,
this perspective,
may
not
For
be so clearly
example,
been
of psychiatric
for “internal
illness
and treatment.
psychological
What
coherence”?
has the
REFERENCES 1 . Klein
D: Psychopharmacological treatment and delineation of in Borderline Personality Disorders. EditP. New York, International Universities Press, 1977 2. Rifkin A, Quitkin F, Carrillo C, et al: Lithium in emotionally unstable character disorders. Arch Gen Psychiatry 27:519-523, 1972 3. Klein D: Importance of psychiatric diagnosis in prediction of clinical drug effects. Arch Gen Psychiatry 16: 1 18-126, 1967 4. Zitrin CM, Klein DF, Woerner MG: Behavior therapy, supportive psychotherapy, imipramine and phobias. Arch Gen Psychiatry 35:307-316, 1978 5. Klein D: Psychiatric diagnosis and a typology of clinical drug effects. Psychopharmacologia 13:359-386, 1968
borderline disorders, ed by Hartocollis
F. KLEIN, York,
Nei’
psychological.
and
the two entities
outlined
social
variables.
by Dr. Wells
author
cites
abruptness
of onset
and
mixed
to encounter
features,
and dementia the depression
with
patients of both
who an
demonstrate
affective
disorder
(2). Often these disorders arising out ofthe patient’s
of his cognitive
only potentiates terioration as personal
evidence
losses.
The
resultant
the primary deficit self-esteem-promoting
functioning
are
The identification
are self-fueling. with growing awareness pseudodementia’ not but leads to a further devocational and inter‘ ‘
‘
compromised.
of the mixed
dementia-pseudodementia
disorder may have important prognostic and therapeutic implications. These patients often seem to improve during their hospitalization and diagnostic evaluation simply as a result ofthe “enriched” environment ofthe ward milieu. For such patients, attention to psychosocial variables may prove more efficacious than ECT or antidepressant therapy, either of which may aggravate the organic deficit.
REFERENCES
I. Engel G: The need for a new medical model: a challenge for biomedicine. Science 196:126-135, 1977 2. Verwoerdt A: Clinical Geropsychiatry. Baltimore, Williams & Wilkins Co, 1976
I sug-
gest the impact of this criterion has been aesthetic and rhetorical rather than factual. The refutation of my stand is easy. All Drs. Gunderson and KoIb have to do is provide a list of facts (not persuasive hypotheses) that the use of their criterion has generated.
DONALD
any one symptom product of the inter-
how
internal psychological coherence’ ‘ has been used as a validating criterion, I would be most interested. Psychopharmacology and genetics, as areas relevant to nosologic validation, have clearly advanced our factual
payoff
that
discontinuous.
the
‘ ‘
knowledge
Pseudodementia
nostic difficulty by constructing a dichotomy of differential clinical features. Although it might seem very useful, this simplification may obscure the true complexity ofthe clinical
to
and Kolb appear to revere ‘ ‘conventional a point ofview that ignores systematic sciTheir contention that the issue of whether a has ‘ ‘ an internal psychological coherence . . . ‘ ‘ is a validating criterion as genetics and drug re-
Drs. clinical entific
and
EDITOR
Pseudodementia’ (July 1979 issue) Charles E. attempted to clarify an important area of diag-
“
M.D.,
the geropsychiatrist
ponent of the borderline melange, the hysteroid dysphorics, are probably responsive to MAO inhibitors. This has been supported by open clinical trials; however, a definitive double-blind trial, currently underway, is needed. It should be clear that I do not claim “responsivity to MAO inhibitors” for this diagnostic potpourri; instead, I am the need for refined diagnosis and appropriate prescription rather than syncretic diagnosis and
In
Wells,
in Dementia
THE
length of symptom duration before medical assistance is sought as characteristic of pseudodementia. but many neurologists would state that dementia may go unrecognized until an environmental change or interpersonal loss precipitates an acute decompensation. In addition, it is not unusual for
is responsive
(3); panic disorder, ‘pseudoneurotic
is responsive to antidepressants (4); ophrenia,” helped by antidepressants states, benefited by benzodiazepines;
disorders,
which
Variables
TO
M.D. N.Y.
RICHARD
Dr.
Wells
H. BRENT, Neii’ York,
M.D. N.Y.
Replies
SIR: I am grateful to Dr. Brent for his comments. I agree with him that in my attempt to clarify this important area of diagnostic difficulty, I did not focus on other features that are often ofmuch significance in our understanding ofand caring for these patients. I hope nothing in my article suggests to the reader, however, that I advocate a neglect ofthe psycho-
social with
variables his
brought
valuation
to our attention
by Dr. Brent.
(‘HARLEs
F.
WELLS,
Nashville,
Hypnotizability SIR: In 1979 issue)
and ‘ ‘
I agree
of them.
Hysterical David
M.D. Tenn.
Psychosis Psychosis and Hypnotizability” Spiegel, M.D., and Robert Fink,
(June M.D.,
1613
J Psychiatry
136:12,
Is Conventional SIR:
In
Subtype sue) M.D. itors
their
December
Clinical
Wisdom
response
to
of Primary
1979
Psychosocial
Wise?
a letter
Affective
LETTERS
entitled
Disorder?” M.D. , and
‘ ‘
John G. Gunderson, , indicated, “The claims for responsivity made by Klein . . .“ are contradicted
SIR:
Borderline-
(January Jonathan
1979 isE. Kolb,
to MAO
inhib-
by the prevailing clinical wisdom of drug unresponsiveness in this group. This requires clarification. As was clearly stated in my article (I) cited by Dr. Nakdimen, author ofthat letter, I believe that the unitary term borderline disorder’ confounds several distinct syndromes that also have distinct pharmacologic response patterns. Such subgroups are the “
.
.
.
‘ ‘
‘ ‘
emotionally
unstable
to lithium
(2) and
character
‘
disorder,
chlorpromazine
which
findings
have
trolled,
are
been
random
indeed
derived
assignment
drug from
which schiz-
‘
and
(5); chronic histrionic
unresponsive
clinical
trials.
anxiety character
(5).
These
placebo
con-
Yet another
com-
double-blind,
treatment
pointing differential monolithic
approaches.
as important
sponsivity
obfuscates
Gunderson wisdom,” evidence.
syndrome
the issues.
Ifthey
could
describe
‘
situation. complex
Engel (I) has suggested or disease is a multidetermined
action
among
From
biological,
this perspective,
may
not
For
be so clearly
example,
been
of psychiatric
for “internal
illness
and treatment.
psychological
What
coherence”?
has the
REFERENCES 1 . Klein
D: Psychopharmacological treatment and delineation of in Borderline Personality Disorders. EditP. New York, International Universities Press, 1977 2. Rifkin A, Quitkin F, Carrillo C, et al: Lithium in emotionally unstable character disorders. Arch Gen Psychiatry 27:519-523, 1972 3. Klein D: Importance of psychiatric diagnosis in prediction of clinical drug effects. Arch Gen Psychiatry 16: 1 18-126, 1967 4. Zitrin CM, Klein DF, Woerner MG: Behavior therapy, supportive psychotherapy, imipramine and phobias. Arch Gen Psychiatry 35:307-316, 1978 5. Klein D: Psychiatric diagnosis and a typology of clinical drug effects. Psychopharmacologia 13:359-386, 1968
borderline disorders, ed by Hartocollis
F. KLEIN, York,
Nei’
psychological.
and
the two entities
outlined
social
variables.
by Dr. Wells
author
cites
abruptness
of onset
and
mixed
to encounter
features,
and dementia the depression
with
patients of both
who an
demonstrate
affective
disorder
(2). Often these disorders arising out ofthe patient’s
of his cognitive
only potentiates terioration as personal
evidence
losses.
The
resultant
the primary deficit self-esteem-promoting
functioning
are
The identification
are self-fueling. with growing awareness pseudodementia’ not but leads to a further devocational and inter‘ ‘
‘
compromised.
of the mixed
dementia-pseudodementia
disorder may have important prognostic and therapeutic implications. These patients often seem to improve during their hospitalization and diagnostic evaluation simply as a result ofthe “enriched” environment ofthe ward milieu. For such patients, attention to psychosocial variables may prove more efficacious than ECT or antidepressant therapy, either of which may aggravate the organic deficit.
REFERENCES
I. Engel G: The need for a new medical model: a challenge for biomedicine. Science 196:126-135, 1977 2. Verwoerdt A: Clinical Geropsychiatry. Baltimore, Williams & Wilkins Co, 1976
I sug-
gest the impact of this criterion has been aesthetic and rhetorical rather than factual. The refutation of my stand is easy. All Drs. Gunderson and KoIb have to do is provide a list of facts (not persuasive hypotheses) that the use of their criterion has generated.
DONALD
any one symptom product of the inter-
how
internal psychological coherence’ ‘ has been used as a validating criterion, I would be most interested. Psychopharmacology and genetics, as areas relevant to nosologic validation, have clearly advanced our factual
payoff
that
discontinuous.
the
‘ ‘
knowledge
Pseudodementia
nostic difficulty by constructing a dichotomy of differential clinical features. Although it might seem very useful, this simplification may obscure the true complexity ofthe clinical
to
and Kolb appear to revere ‘ ‘conventional a point ofview that ignores systematic sciTheir contention that the issue of whether a has ‘ ‘ an internal psychological coherence . . . ‘ ‘ is a validating criterion as genetics and drug re-
Drs. clinical entific
and
EDITOR
Pseudodementia’ (July 1979 issue) Charles E. attempted to clarify an important area of diag-
“
M.D.,
the geropsychiatrist
ponent of the borderline melange, the hysteroid dysphorics, are probably responsive to MAO inhibitors. This has been supported by open clinical trials; however, a definitive double-blind trial, currently underway, is needed. It should be clear that I do not claim “responsivity to MAO inhibitors” for this diagnostic potpourri; instead, I am the need for refined diagnosis and appropriate prescription rather than syncretic diagnosis and
In
Wells,
in Dementia
THE
length of symptom duration before medical assistance is sought as characteristic of pseudodementia. but many neurologists would state that dementia may go unrecognized until an environmental change or interpersonal loss precipitates an acute decompensation. In addition, it is not unusual for
is responsive
(3); panic disorder, ‘pseudoneurotic
is responsive to antidepressants (4); ophrenia,” helped by antidepressants states, benefited by benzodiazepines;
disorders,
which
Variables
TO
M.D. N.Y.
RICHARD
Dr.
Wells
H. BRENT, Neii’ York,
M.D. N.Y.
Replies
SIR: I am grateful to Dr. Brent for his comments. I agree with him that in my attempt to clarify this important area of diagnostic difficulty, I did not focus on other features that are often ofmuch significance in our understanding ofand caring for these patients. I hope nothing in my article suggests to the reader, however, that I advocate a neglect ofthe psycho-
social with
variables his
brought
valuation
to our attention
by Dr. Brent.
(‘HARLEs
F.
WELLS,
Nashville,
Hypnotizability SIR: In 1979 issue)
and ‘ ‘
I agree
of them.
Hysterical David
M.D. Tenn.
Psychosis Psychosis and Hypnotizability” Spiegel, M.D., and Robert Fink,
(June M.D.,
1613
