LETTERS
TO
Ei)ITOR
in the Military
Confidentiality SIR:
THE
As
a psychiatrist
and
currently
serving
in the
I concur
Navy,
fully with the observation of Drs. Schuekit and Gunderson in “Suicide in the Naval Service” (December 1974 issue) that potentially suicidal servicemen need to be identified more often. The authors did not mention an obstacle to this process that is perhaps unique to the military, i.e., the complete lack of physician-patient confidentiality. Every encounter a serviceman has with a physician is recorded in his health record. This record-and any psychiatric consultation it might contain-is available not only to his commanding officer but to promotion boards, ancillary health care personnel, clerical personnel, etc. Many servicemen believe that the mere presence of a psychiatric consultation in a man’s record will result in lack of promotions, granting of less responsibility, increased scrutiny of performance, and other difficulties. Compounding the problem is the fact that our cultural masculine role stereotype-that “real men” do not seek help, complain, or acknowledge emotional distress-exists in an intensified form in most military settings. A serviceman exhibiting grossly disturbed behavior will virtually always be referred for psychiatric intervention, as will the troublesome individual with a character disorder, but deviation from the norm may not be seen in the depressed potentially suicidal individual. One can readily postulate the existence of a subpopulation within the military which, because of the necessity of publicly acknowledging distress in order to obtain psychiatric help, chooses instead not to seek it. I feel that depressed individuals probably make up a significant percentage of this population. THOMAS
M.
DUFFY,
Cdr.,
Lt.
Camp Editor’s author ofthe
Note: The opinions
and do not necessarily Department ofthe Navy.
Electroconvulsive
Therapy
expressed reflect
herein
mg
of
diphenhydramine
at
bedtime
Psychiatric
symptoms,
paranoid
and
delusional,
with
auditory
hallucinations,
consistent
with
tology
Parkinson’s
values,
skull
films,
disease;
thyroid
EEG,
studies,
brain
scan,
blood
reduction
or
discontinuation
as a review
cerning
the
(ECT)
use,
in treating
son’s disease,
of
efficacy,
and
L-dopa
and
lumbar
psychotically
we wish to report
test
hema-
for
puncture
tion
of
L-dopa
from
amitniptyline
mental seven
at
status ECT
5 to
2 g a day,
bedtime
and
resulted
or behavior. treatments
in
institution
no
(140-volt
in
over
shocks
patient
5 years reduc100 mg of
of
change
Consequently,
syphilis,
(the
had had a simple mastectomy for mammary carcinoma earlier) were normal. Discontinuation of amantadine and diphenhydramine, the
patient’s
a 3-week
of 2 seconds
period, duration)
were administered. Medications given intravenously during each treatment were .5 mg of atropine, 60 mg of sodium methohexital, and 50 mg of succinylcholine. All treatments resulted in
well-modified
patient. markedly;
seizures
and
were
excellently
Mood, affect, appetite, and delusions, paranoid ideation,
appeared;
and
the patient
became
tolerated
by
the
sleep pattern improved and hallucinations dis-
communicative,
friendly,
and
cooperative. During the 3-week course of ECT, L-dopa was gradually increased to the previous level of 5 g a day in divided doses, with resultant good control of the patient’s parkinsonism and no return of psychiatric symptomatology. Although
drug-induced certained, Parkinson’s
the
etiology
of hen psychotic
or endogenous ECT proved safe disease.
are those
Calif
depression-whether
and involutional-cannot and effective in this
patient
be aswith
REFERENCES
of the
or endorsement
of depression,
or
provided
safety
had
I.
Murphy DL: Mental effects of i-dopa. 1973 2. Schwab RS, Poskanzer DC, England Parkinson’s disease. JAMA 222:792-795, 3. Yahr MD, Duvoisin RC: Drug therapy Med 287:20-24, 1972
Annu
Rev
Med
24:209-2
16,
AC,
et al: Amantadine in 1972 of parkinsonism. N EngI J
with Parkinsonism
particularly
of the literature
Al-
and
chemistries,
serological
fre-
LIPPER,
amantadine
(3).
no references
ofelectroconvulsive
depressed
the following
patients
Pu.D. M.D.
M.D.,
C. BERMANZOHN,
PAUl.
quenthy accompany L-dopa therapy of Parkinson’s disease ( 1) and occur also with administration of the adjuvant drug amantadine (2). These symptoms are generally reversible with a asmuch
I week.
ingested 250 mg of diphenhydramine hydrochloride in an admitted suicide attempt. Physical examination on admission was
STEVEN SIR:
for
USNR
Pendleton,
the views
in Patients
MC,
50
though she was described as having been depressed for years, she had recently begun having crying spells, developed insomnia, and become uncommunicative and anoreetic (losing 20 pounds). Four days prior to admission she had become acutely
Chapel
Hill.
NC.
In-
con-
Accuracy
of Diagnosis
and Genetic
Factors
in Schizophrenia
therapy with
Parkin-
case.
The patient, a 54-year-old woman with a documented 7-year history of Parkinson’s disease, had been taking 4 to 5 g of Ldopa a day in divided doses for 4 years prior to her hospitalization, 100 mg of amantadine three times a day for 3 months,
SIR:
tember gue for
In
his
article
1974 issue), the reliability
“From
Seymour of the
presence of a “strong schizophrenia. I believe
genetic that
Rationalization
to
Reason”
Kety, M.D., presented diagnosis of schizophrenia
component” these
data
data
(Sep-
to anand the
in the etiology are subject
to other
of in-
terpretations.
A m J Psychiatry
/32:4, April
1975
457
LETTERS
TO THE
Dr.
Kety
nosis
of
contends
the for
and
own
suggest
phrenia
is modest
It appears did
which
at
agreement ability
lower
the
for
Dr.
made
a diagnosis
other
raters
rater all
the
Dr.
inadequate
category
their not
if the
incidence
of
factors
ofthe
argues
ophnenia;
two
findings
Kety
in
Moreover, tives
in the
does
Kety
nonschizoph
Dr.
Kety
feels
interpretation utero
the
and same
etc.),
sharing
fathers
--
women
with
of than
a
strong
Dr.
paternal mothering
genetic
of
child of
disturbed
psychodynamics.
likely
Thus,
half-siblings
were the
probably
theory
that
remains,
at
value
sharing socio-
eluded
on
in all the
the
132.4.
April
1975
have
getheir
family
and
the
inter-
read
6, and
based
on
the we to of
5, respectively),
population.
or could
occurred
Where
diagnosis
“chronic”
and
If
that
not be recog-
randomly.
A coinci-
there
was
of”deflnite
was
schizophrenia,
schizophrenia
made
by
on
and all rat-
schizophrenia.”
of definite “latent”
disagreement
was small,
each
which
and rater
“acute
in about
in-
sehiz4 percent
subjects.
diagnosis. the
that
agreement
among
argument
for
cites
by
population
unreliability
pairs
Beck
and
of psy-
of
in our study
psychiatrists
outpatient
of the reliability between
he
raters
on
was 70 per-
associates,
the
for definite diagnoses was 81 percent, hardly
of diagnosis,
especially
since
in an
neither
population would be expected to contain mental illness as severe or as typical as that in a hospitalized population. Whether the reliability of psychiatric diagnosis is high enough for every purpose stantial
diagratings.
concordance
study
In
more tenable
The
schizophrenia
is a matter
permit
of opinion,
demonstration number
diagnoses
made
not
of
of drugs
Of course,
patients.
and
I would
by all
but to
guide
not
wish
been
sufficiently
efficacy
the
therapy
to defend
psychiatnists-especially
that psychiatric suggest
it has
the therapeutic
that
individual
the accuracy those
nosology
we should
of
high
of a sub-
is useless
be satisfied
who
of have
on spurious. with
reliability
which is only reasonably good, or that diagnostic reliability cannot be improved. The very essence of the medical model requires constant sharpening and further characterization of the phenomenological syndromes, and I indicated that some of our studies
may
Turning
A in J P.st’c’hiatrt’
(3,
of definite
far
R F I F R F NC F
458
sample
the diagnosis
to
N. Y.
a nonhospitalized
confidence of more than 99.999 percent. Dr. Litwack also raises the question
early
Pii.D.
were
a diagnosis
of disagreement
category
I did
R. L1TwAK, New York,
made
I been
from
another
raters
had no validity,
broader
been persuaded
TiloslAs
and
the
12,000.
reaction,”
the
the
M: Reliability of psychiatric of clinical judgments and 1962
by
biologi-
subjects removed
Three
in
the range
a psychiatric
hypothesis.
I . Beck AT, Ward CH, Mendelson nosis: II. A study of consistency Am J Pschiatry I 19:351 357,
adopted
in
would
ofover
agreed
paired
a
the
The
cent.
schizophrenia best,
ens
their
to remarry
since
expected
diagnosis
same
since
been
no Had
ofthese
had
blindly
has
provided
nized,
with
and
bearing,
-are
in
nutrition,
mothering,
to
dental agreement by three raters would be expected only once in more than 500,000 subjects. In our sample, the diagnosis was made by all three raters in 3 of the 365 subjects, yielding a ehi-
“the same
in utero
percent who
and
and
were a myth,
chiatnic
share
But the
affect
type
component
only
sharing
standards
recognized,
not
overlap.”
in turn
are
did
share
genetic
of
pathology.
experiences the
means
if they
a higher
environmental
half-siblings
of
rela-
than
renic
an early
because
same
the Kety
schizoph
justification
The coincidence of 3 such diagnoses would be expected only once in more than 15,000 subjects. All three of our raters made this diagnosis in 10 ofthe 365 subjects, yielding a chi-square of oven 3,700. On the basis of either of these nesuIts, the dictum ofSzasz and Rosenhan can be rejected with a
at all?
that
be
ophrenic
of schizo-
finding
30
life
schizophrenia
would
of
biological
of schizophrenic
excludes
the
similar
environments similar
same
especially
on the
evidence
(which
sharing
whose ofschizophrenia
to rely
birth
experiences.
the development
evidence
amount
as
consistently.
recognized
schizophrenic.
syndrome
Dr.
with a
factors
mothering
ofadoptees
generally
the
probability
explain
i.e.,
father
such early
As
in
became
the diagnosis,
[3.5
“latent”
are fully compatible
early
conditions
either
is a myth,
( I ). The study
square
schiz-
data
the
and
of
2.9 percent
“chronic”
were
subis the of
these
finding
a certain
economic
to exhibit
half-siblings
half-siblings
father
found
than
influence
(only
schizophrenia
a person
independently
chronic as
relatives
schizophrenia).
adoptees
influences
ofan
is
biologi-
only
biological much
the
an opportunity to examine validity of the traditional concept of schizophrenia, which called “chronic schizophrenia” and which was similar Kraepelin’s description. Each rater made very few diagnoses
that first
all
not
nor
be
About to
early
later
DSM-IJ
at this
among
percent]
no
because
adopted
the
diagnoses
one
this
use
homes.
related
views
unre-
[7.5
forced
renic
and
However,
to posit
and
of paternal
who
reason-
cannot
in their
environment
percent)
ofschizophrenia
majority
is thus
percentage
percent)
them.
low were
exhibit
view
not included
The
(13.9
emphasizing
great
apparently
Dr.
(2.7
influences,
how
phrenia
reli-
in the
adoptees
relatives’
utero
the
the conclusion
schizophrenia
among
hypothesis
trauma,
of
to
too
recognizes,
nongenetic
in little
that
and
netically
component.
time
able to present more data, Dr. Litwack might have been spared the necessity of making inferences, some of which were ennoneous. In our study, 365 people participated in a psychiatric inter-
respectively, basis,
significantly
its
the
schizo-
“schizophrenia
against
neither
cal
cases
were
was
7 of 24
demonstrated
to support
relatives
“uncertain”
himself
its
genetic
related
other
or
the
strongly
a strong
relatives
the
percent]
were
terms
There
schizo-
purposes.
in the etiology
biological
SIR:
present in my address to the APA annual meeting on in my Journal article all of the data that my collaborators and I have been gathering over the past 10 years. The data I did present were very pertinent to the claims of Szasz, Laing, and Rosen-
was of
be
of schizophrenia
research
adoptees
genetic
41
ratings
conditions,
schizophrenia
schizophrenic
of there
would he
diagnosis
practice
adoptive
in only
17
personalities
idealized
biologically
in
overall
of what
involves
among
of
of “definite”
schizophrenia
is a higher incidence relatives of schizophrenic
jects
no
that
of
that and
Kety’s
of
presents
diagnosis
schizophrenia,
there
cal
cites
study,
raters.
that
than
schizophrenia
concur,
perceived
and
other
he
Replies
once
han,
rater
under
Kety
the
one
in actual
time
of
presentation
Even
However,
Dr. Kety
diaghigh
relevant
Kety’s
overall
reliable
liability
reliability
diagnosis
spectrum.”
has
best.
one
the
on. most
Dr.
if schizoid
within
that
the
at
suggest
of
ably
that
among
I would
agreed The
from the
least
of independent is reasonably
( I ), contradicts his assertion. Moreover, although too sketchy for detailed eval-
data
in which
phrenia
been
proposition.
associates
uation
reliability
syndromes
has
this
Dr. Kety’s
the
psychotic
nosology
support
cases
that
major
a standard Beck
EDITOR
ponent an
contribute to
in the
incidence
the etiology of
I 3.9
to that evidence
end. I cited
for
ofschizophrenia, percent
(definite
a strong Dr.
or
Litwack
uncertain)
genetic argues in the
comthat biolog-