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-

Letter: Confidentiality in the military.

LETTERS TO Ei)ITOR in the Military Confidentiality SIR: THE As a psychiatrist and currently serving in the I concur Navy, fully with the...
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