LETTERS

TO

THE

EDITOR

Pharmacotherapeutic I wish to address

SIR:

of virtually by

Time

the issue ofthe

all phanmacotherapeutic

Lasagna

and

lustrated cotherapy.

Wardell

of the

Food

unreasonably agents.

Goldberg

antiquated

and

Goldberg

Discussions

(2)

Drug

Administration

the acceptance

dramatically

stated

that

both

law

il-

phanmasome corn-

(FDA)

of safe,

had

been

useful

thenapeu-

reason

demand

and

safety

to demonstrate

questions.

trials. Five

The

drug’s

efficacy

and

there

sponsor

initiated

were

espoused

couple,

by the group

is the latent

far

the

which

surpasses

cneativ-

singlehood and adolescence. The struggle is to move beyond the residual bisexuality of childhood. Loyalties to our families of origin that interfere with living in the present as people committed both to our gender and generation must be made conscious and discussed in the intimacy of the marital relationship.

The

results

are

reflected

not

only

in

the

marriage

regularly

to

share

process.

Inquiries

fessionals

for

Institute,

its

discoveries

can

be

addressed

in

Marriage,

Growth

Newtown

and

Square,

continue

to

Pa.

the

and meets in

the

growth

Association

Dynamic

of

Springs

Pro-

Family

19073.

unresolved

controlled

S.

IRVING

clinical

years

have

passed,

clinical

and

question

studies

that

would

not

been

completed.

have

answer

M.D.

WIESNER,

fortunate

confluence

of events

is all

too

Gold-

rare.

Ifthe public is to be served, it is clearly necessary to develop a national institute of applied pharmacotherapy as a central agency within the National Institutes of Health and also to develop large specialty research hospitals devoted to the assessment of pharmacothenapies. These premarketing procedures be supplemented

by

tematic

clinical

surveillance

present

haphazard

program

the current

situation

patients,

a computerized

postmanketing

procedure. can

only

of frustrated

foot-dragging

sys-

Persisting result

doctors,

bureaucrats,

with

the

in continuation

of

inadequately

cared

exasperated

legis-

and

Pa.

this

berg’s discussion betrayed no dissatisfaction with this intolenable state of affairs, but rather criticized the FDA for taking what he considered to be a premature action by recommending that the package insert mention the use of propranolol in angina pectonis in a very qualified way. IfGoldberg is interested in promoting the rapid introduction of safe, effective therapeutic agents, he should concentrate his fine on the delay that has ensued between the clinical finding, initiation of investigations, and their completion. To develop adequate clinical trials requires the financial support of a profit-motivated pharmaceutical firm, an interested and capable investigative team, an available clinical population, and a clinical setting that will allow systematic research. This

for

of the

Swarthmore,

important

should

concepts

potential

but in our children and our professional lives. The group publishes a journal, sponsors symposia,

adequate testing for safety and efficacy. The particular case they discussed concerned the antianginal use of propranolol. In April 1970, the FDA decreed that propranolol should not be approved because existing studies were inadequate

of the basic

creative ity of

organization

confronting American Wardell asserted that

and

delaying

One

for Change

investigations.

(1)

the stalemate Lasagna and

ponents tic

Investigation:

lators.

More

Worry

SIR: In “The Empirical Nature of Worry” (October 1974 issue) Alan Challman, M.D., described worry as “suffering imposed upon the self by the self, but attributed to necessity and the particular outside circumstance.” Worry is a symbolic homologue and analogue to sacrifice to the gods, small installments of worry serving teleologically to

appease

the

surance

powers

the financial that

that

premiums

ones)

everything as

in many

immediate about

one

aid

suspect

and

in venting

much

the

satisfies

social

serve

the

other as

needs.

Worry,

penance

masochistic

or

focus

to

role

it

well

as

particularly

self-punishment

or

tendencies.

to feel

need

or ethic

as

modating

one’s

inleast

significant

well-being may necessitate an otherwise bland fantasy

is really

(at

quasi-religious

One’s emotional worry may enliven there

as

ravages

the intuition

from

serves

may

disaster, to

for.

might worry

events,

avert

immune

Worry

paid

emotional

past

as an

be

lives,

and

one

of fate.

must

However, plays

be

render

and

to “make

the

worry. First, life, accom-

times

ofday

when

nothing to worry about intensely pleasurable, because of contrast” ( I). More important, worry enables one to deal with anxiety generated by both repressed and pressing conflicts. The Indo-European root wen” implies evasion. A concrete worry presents a “

REFERENCES

I. Lasagna

L,

Wardell

WM:

The

JAMA 232: 141-142, 1975 2. Goldberg DC: Rebuttal. JAMA

FDA,

politics,

232:143-144, DONALD

The

Importance

and

the

public.

1975

F. KLEIN, M.D. Glen Oaks, N. Y.

SIR:

The An

issues,

problem.

Most

“Marital

Overview”

by

Therapy Ellen

M.

I. Lief, M.D., (June 1975 issue) was growing focus on the importance therapeutic endeavors. Your readers might be interested

from Berman, a welcome

of the

a Psychiatric M.D.,

and

addition

couple

PerHarold to

the

in psycho-

nebulous

psychological

therefore

never

to know

of a group

called

974

AmJ

Psychiatry

132:9, September

1975

anxiety even are

generated averting

more

they

decision

ticipation

is needed.

situation, helplessness-to

even

in

so,”

by further

are

Further,

worry

powers tion. direct recipient

the

powers

one’s

are

“up

replaced

by

the worrier Their

there”

familiar

also

insoluble

implies

fantasy

compliance

plea, of

for succor

to

people

induces

power one This and

a

relief.

in the

feelings

potentially to

real than and

to

Here,

immediate

elevates

benefactor

of

the

sense

of sense

or

sense

of

“I

told

worth.

Worriers it aloft,

to

supernatural environment,

of responsibility

gratifying

alter

of any mystical

it coming,”

life

their

is more it

the

and

Worry is most potent and subtle as a manipulator. tend not to hide their light under a bushel but to hang light

sub-

face

and the need to be and that one’s par-

to say, “I saw

able

stoking

to

on action.

a magical way, relieving worry is to do something. being

intolerable

need

tangible

conflicts;

require

by the

Worry satisfies a sense of responsibility needed, for the very act implies participation

whom

the Association of Professionals for Growth in Marriage. The uniqueness of this group of couples lies in its commitment to the psychobiological reality and complementanity of a male husband and female wife.

allay

perhaps worries

is heightened

of the Couple

article

and

conscious

you spective:

divert

than

compliance

the

worrier

concern,

in

and obliga-

wisdom,

to from

a and

foresight.

One

can get too much

of any good

thing

and incessant

a

won-

LETTERS

nying is a common

precedent to psychosomatic

positive feedback nature of worry, makes it (like other characterological tory to intervention. Ubiquitous

worry,

the host” functioning.

because

although

unpleasant,

of its utility

problems. The

as Dr. Challman noted, aberrations) very refracis

in several

by

“entertained

areas

of psychological

hysterical

personality

I. Thomas

The

EDITOR

stereotype

of the

fe-

personality

type.

The

new

symptomatology

appears

to be a concession to changing cultural expectations. I would be interested to know if other readers have observed the eye sign and the changing sexual functioning of patients

RENCE

L: On transcendental metaworry

291:779,

changing.

THE

male hysteric as “flirtatious and frigid” does not seem to hold true among the young adult population. I more frequently see the determinedly nonflirtatious woman who speaks with indifference of multiple orgasms but who otherwise demonstrates the narcissism and shallow affect commonly associated with the histrionic

REFE

are

TO

(TMW).

N EngI J Med

diagnosed

as hysterical.

1974 REFERENCE GARFIELD

M.D. Canada

PICKEIL,

Halifax.

N.S.,

I. Abse

DW:

Hysterical

conversion

and

dissociative

the hysterical character. in American ed, vol 3. Edited by Arieti 5, Broth Dr. Challman

fertile

mind

has discerned

many

the wornywant harvests from his ritual. He quite religious sacrifice as a homologue or analogue

Their

similarity

and ubiquity

that

ualizations

of

one’s

needs

period

of

they the

have

among

the human ancestor

and

experience

during

infancy

on miraculously hoc ergo propter

correctly to worry.

race lead to the are both nit-

a common

universal

unaccountably suffering. Post

of having

fulfilled following a hoc. I do not see how

hypothesis can be proved or disproved. There is always the rather unpleasant alternative possibility that men engage in self-torment simply because they have an inner drive for suffering as well as for comfort. If that is the case, the attribution of the gods taking pleasure in human suffering could be merely a projection of our own mental operation.

Does

this

ALAN

Our

SIR:

collect while niques

experience

Because

of the

fluidity

and

interchangeability

of symp-

toms and signs in hysteria, a diagnosis usually cannot be made on phenomenology alone. In some cases, however, symptoms are characteristic enough and frequently enough encountered to be almost pathognomonic. Among such symptoms, known as “stigmata,”

are

globus

hystenicus,

stocking

and

glove

anes-

thesia, and tunnel vision ( I ). Hysteria is known, however, as a “great imitator,” and many so-called stigmata can anise as a resuIt of questioning, a form of iatrogenic suggestion. There is one sign that I have observed often enough in hystenical patients to include it as one of the stigmata, although I have not seen it described in the literature. This sign is directly observable and therefore not influenced by the physician’s inquiry.

It consists

extent sclena

that there is an appreciable circular border of white around the cornea. This produces a staring look that is

reminiscent ing

is, in

of a widening

of exophthalmos. fact,

under

the

of the

This

name

palpebral

abnormal

Dalnymple’s

aperture

to the

palpebral sign,

one

widenof the

clas-

of a hyperactive thyroid. In hysteria, it is an interpersonal sign precipitated by the encounter with another person. It has the hallmarks ofboth drive and defense, i.e., it is a combination of flirting (“making eyes”) and hypervigilance. The eyelids are controlled by both voluntary and involuntary sic

signs

muscles,

autonomic I have

so that

the

eye sign

may

be partially

but

not

wholly

an

response. also

observed

that

the

classical

characteristics

of the

(January work may

place,

a research

unit designed

characteristics.

settings

today

obvious

differences

tions

call

acute schizophrenic patients psychosocial treatment techcontrary to those stated by Louis

1975 account

seem

to have

is a relatively

homogeneous

Many,

most,

if not

themselves to achieve

in their article, Community:

issue). We believe for their findings.

therapeutic

in treatment

undertaken

to

on

the authors

community

uniform

SIR:

in operating

Care?

H. Reich, M.D., and Brian L. Weiss, M.D., “The Clinical Research Ward as a Therapeutic

In the first

Sign

with Patient

psychobiological data relying on predominantly leads us to conclusions

therapeutic

Hysterical

Interfere

Research

Incompatibilities” comings in their

M.D. Minn.

CHAI.LMAN,

Minneapolis.

An Unreported

and

MARY V. SEEMAN, M.D. Department of Psychiatry Toronto Western Hospital Toronto, Ont. M5T2K2, Canada

secondary

gains labels

assumption

syndromes

of Psychiatry, 2nd York, Basic Books,

1974, pp 155- 194

Replies

Dr. Pickell’s

SIR:

Handbook EB. New

assumed

defined

short-

that

entity

inpatient

a

with

treatment

communities,

philosophies

the

two

and

despite in the

clinical

goals.

opera-

There-

fore, in writing about their own therapeutic community, Drs. Reich and Weiss should have stated clearly what their therapeutic assumptions were and how the unit was organized to accomplish their goals. Only then could one conflicted with the therapeutic goals search constitutes such an interference.

understand and whether

what or

factors not re-

Throughout their article, the authors referred to milieu treatment in a manner which implies that their own therapeutic assumptions the

paradox, least

wand ofthe

do

treatment

not

favor

of the

insofar

classically-is

or rely

functional

on psychosocial psychoses.

as the therapeutic basically

the end of their article, therapeutic community

psychosocial

This

techniques is an

community

approach

in nature.

the authors questioned approach with psychotic

for

interesting

Indeed,

-at to-

the utility

and borderline patients. This leaves the reader wondering if they are describing research as incompatible with the therapeutic cornmunity or the therapeutic community as incompatible with

good clinical cane. A second problem is that Drs. Reich and Weiss described research interference as though it were different from other interferences in a treatment milieu. It is too simplistic to state that an unlocked door implies that patients should be free to come and go on their own cognizance and that a research protocol which requires their presence on the unit is therefore antitherapeutic. If this were true, one should also concede that mandaAmJ

Psychiatry

132:9, September

1975

975