1206 PSYCHOTHERAPY FOR MULTIPLE SCLEROSIS
SIR,-Dr Kinnell (April 22, p. 882) is right to point out that opportunities to train in or practise dynamic psychotherapy are scarce in Britain. One reason seems to be the strength of British neurology abd its organic influence on the development of British psychiatry, reinforced perhaps by our deep national suspicion of anything smacking of mumbo-jumbo and emotion. However, Kinnell’s dismissal of evidence from studies from 40 years, many of them most reputable, favouring and emotional determinants in the sclerosis (M.S.) is not supported by any indication that he has comparable experience of the disorder to set against them. If he has contrary evidence he should tell us where to find it, or suspend judgment. In a disorder with as variable a course as M.S. controlled trials of treatment are both difficult and long unless restricted to a single manifestation such as retrobulbar neuritis. My suggestion for a controlled trial of dynamically oriented psychotherapy is based on personal observation over many years. I have observed the effects of more intensive therapy on 28 patients, supported lately by videotapes of interviews illustrating the childhood background and emotional stresses involved at the outset and in relapse and a close temporal relationship with remission after effective psychotherapy. Unfortunately, videotape material does not lend itself to publication, but therapists and research-workers are welcome to come and view it. On the basis of this and other evidence’Isubmitted to an M.S. association proposals for a trial of dynamically oriented psychotherapy in 50 patients against 50 matched controls over a period of 7-10 years. It is now over 20 years since I submitted proposals for a controlled trial on the influence of emotional factors in M.S. to a research board. It was then rejected on much the same grounds of incredibility that seem to dictate Kinnell’s thinking-i.e., the possibility that psychotherapy might help to slow or halt the relentless progress of a physical disease such as M.S. is so remote that it should be dismissed out of hand, and because the evidence for it is so far based only on an observation ("anecdotal"). Medical scientists nowadays decry observation as a research tool, despite the fact that most scientific advances have been based on it and still are. Indeed, without primary observation consequent studies for proof or disproof would lack genesis. sources over
premorbid personality pathogenesis of multiple
a
51 Anglesea Road, Ipswich IP1 3PJ
J. W. PAULLEY
REVIEWING THE MENTAL HEALTH ACT on my letter on comdetained Dr Francis pulsorily patients suggests that the Mental Health Act may afford inadequate protection of their rights, that the discretion given to health workers operating the Act may be too great a burden, and that, even though the difficulty of psychiatric practice is increased, more stringent legal safeguards may be required today. Under the Lunacy Act, however, stringent legal safeguards became an obstacle to medical treatment and management of patients and ineffective as a protector of their rights. Rights must be balanced against the need for care and treatment and, whatever the legal safeguards, specific training and experience are required in health workers to exercise this judgment adequately. The law should supply guidelines and a framework within which this can be done, and the Mental Health Act largely does just this. Professor Szasz’ "case against compulsory psychiatric interventions" (May 13, p. 1035), originally given at a symposium on a Balance of Views towards a better Mental Health Act, well illustrates the reasons why we should be apprehensive about the effect of public opinion on the review of the Mental Health
SIR,-In commenting (April 1, p. 721)
Act
to
which I referred in my letter. Under such
Paulley, J. W Psychother. Psychosomat. 1977, 27, 26. Paulley, J. W. Practitioner, 1977, 218, 100.
"in-
sional role. St.
John’s Hospital, Stone, Aylesbury, Bucks HP17 8PP
*** Another contribution
DAVID C. WATT to
this debate appears
on
p.
1197.-ED. L.
TRANSIENT AN-ALPHA-LIPOPROTEINÆMIA IN MAN DURING INFECTION BY PLASMODIUM VIVAX cases of acute malaria infection Plasmodium vivax no high-density lipoproteins (H.D.L.) could be detected by cellulose-acetate electrophoresis (six cases) or by lipid ultracentrifugation (two cases). In three cases no very-low-density lipoprotein v.L.D.L. could be detected. All serum samples were processed immediately. Biochemical tests for liver disturbances were negative. All the patients (Europeans) had no disease other than malaria and they had not been on antimalarial prophylaxis. After 2-7 days of chloroquine treatment in Belgium lipid electrophoresis returned to normal. Lipid electrophoresis proved to be a very sensitive test in the diagnosis of P. vivax infections. To our knowledge this observation has not been published previously. Angus et al.did lipoprotein electrophoresis studies in rhesus monkeys infected by P. knowlesi. Their results were not conclusive, however, because in normal serum the lipoprotein bands in some instances could barely be detected. Lipid metabolism plays an important role in the pathogenesis of malaria, with regard to both parasite metabolism and the responses of host tissue to the parasite.2 We suggest that changes in H.D.L. and V.L.D.L. in human serum are related to the lipid metabolism of the parasite. The parasite lipid is very high in phosphatidylcholine which constitutes some 75% of the phospholipid fraction of H.D.L. The malaria parasite takes cholesterol from its host, and our findings suggest that phospholipids are also obtained in this way, resulting in a decrease ofserum-H.D.L.
SIR,-In six consecutive
caused
by
Department of Medicine/Cardiology, University of Antwerp, B-2610 Wilrijk, Belgium
A.
J. LAMBRECHT J. SNOECK
Department of Medicine, St. Vincentiusziekenhuis,
Antwerp.
U. TIMMERMANS
Maegraith, B. G. Ann. trop. Med Parasit 1971, 65, 135. 2. Holz, G. G. Jr. Bull. Wld. Hlth. Org. 1977, 55, 237. 1. Angus, M. G N., Fletcher, K. A.,
1. 2.
terms as
voluntary psychiatry" and "compulsory psychiatric measures" Szasz includes a variety of topics which he does not distinguish one from the other-namely, compulsory detention under the law in cases of mental illness, compulsory detention by courts when a crime has been committed, compulsory administration of psychiatric treatment, and a miscellaneous collection of wrongs (illegal detention in Russia, medical abuses under the Nazis). Any argument against any of these items is taken by Szasz as a condemnation of them all under a collective rubric such as "coercive psychiatry". He refers to Solzhenitsyn’s castigation of "The incarceration of freethinking people in mad houses" as "spiritual murder". "What", says Szasz, "is there about ’mental illness’ that makes a ’mental patient’ a fit subject for a psychiatric procedure which, were he not insane, would, according to Solzhenitsyn, constitute ’spiritual murder’?" We may as well ask what is there about "surgical illness" that makes a "surgical patient" a fit subject for surgical procedure which, were he not ill, would constitute bestial torture? Surgery was abused in Nazi Germany-and is today by the performance of unnecessary operations-but does this make a case against surgical treatment? If, as Szasz maintains, mental illness does not exist compulsory admission is superfluous-but then so is Szasz’ profes-
SIR,-Dr Kinnell (April 22, p. 882) is right to point out that opportunities to train in or practise dynamic psychotherapy are scarce in Britain. One reason seems to be the strength of British neurology abd its organic influence on the development of British psychiatry, reinforced perhaps by our deep national suspicion of anything smacking of mumbo-jumbo and emotion. However, Kinnell’s dismissal of evidence from studies from 40 years, many of them most reputable, favouring and emotional determinants in the sclerosis (M.S.) is not supported by any indication that he has comparable experience of the disorder to set against them. If he has contrary evidence he should tell us where to find it, or suspend judgment. In a disorder with as variable a course as M.S. controlled trials of treatment are both difficult and long unless restricted to a single manifestation such as retrobulbar neuritis. My suggestion for a controlled trial of dynamically oriented psychotherapy is based on personal observation over many years. I have observed the effects of more intensive therapy on 28 patients, supported lately by videotapes of interviews illustrating the childhood background and emotional stresses involved at the outset and in relapse and a close temporal relationship with remission after effective psychotherapy. Unfortunately, videotape material does not lend itself to publication, but therapists and research-workers are welcome to come and view it. On the basis of this and other evidence’Isubmitted to an M.S. association proposals for a trial of dynamically oriented psychotherapy in 50 patients against 50 matched controls over a period of 7-10 years. It is now over 20 years since I submitted proposals for a controlled trial on the influence of emotional factors in M.S. to a research board. It was then rejected on much the same grounds of incredibility that seem to dictate Kinnell’s thinking-i.e., the possibility that psychotherapy might help to slow or halt the relentless progress of a physical disease such as M.S. is so remote that it should be dismissed out of hand, and because the evidence for it is so far based only on an observation ("anecdotal"). Medical scientists nowadays decry observation as a research tool, despite the fact that most scientific advances have been based on it and still are. Indeed, without primary observation consequent studies for proof or disproof would lack genesis. sources over
premorbid personality pathogenesis of multiple
a
51 Anglesea Road, Ipswich IP1 3PJ
J. W. PAULLEY
REVIEWING THE MENTAL HEALTH ACT on my letter on comdetained Dr Francis pulsorily patients suggests that the Mental Health Act may afford inadequate protection of their rights, that the discretion given to health workers operating the Act may be too great a burden, and that, even though the difficulty of psychiatric practice is increased, more stringent legal safeguards may be required today. Under the Lunacy Act, however, stringent legal safeguards became an obstacle to medical treatment and management of patients and ineffective as a protector of their rights. Rights must be balanced against the need for care and treatment and, whatever the legal safeguards, specific training and experience are required in health workers to exercise this judgment adequately. The law should supply guidelines and a framework within which this can be done, and the Mental Health Act largely does just this. Professor Szasz’ "case against compulsory psychiatric interventions" (May 13, p. 1035), originally given at a symposium on a Balance of Views towards a better Mental Health Act, well illustrates the reasons why we should be apprehensive about the effect of public opinion on the review of the Mental Health
SIR,-In commenting (April 1, p. 721)
Act
to
which I referred in my letter. Under such
Paulley, J. W Psychother. Psychosomat. 1977, 27, 26. Paulley, J. W. Practitioner, 1977, 218, 100.
"in-
sional role. St.
John’s Hospital, Stone, Aylesbury, Bucks HP17 8PP
*** Another contribution
DAVID C. WATT to
this debate appears
on
p.
1197.-ED. L.
TRANSIENT AN-ALPHA-LIPOPROTEINÆMIA IN MAN DURING INFECTION BY PLASMODIUM VIVAX cases of acute malaria infection Plasmodium vivax no high-density lipoproteins (H.D.L.) could be detected by cellulose-acetate electrophoresis (six cases) or by lipid ultracentrifugation (two cases). In three cases no very-low-density lipoprotein v.L.D.L. could be detected. All serum samples were processed immediately. Biochemical tests for liver disturbances were negative. All the patients (Europeans) had no disease other than malaria and they had not been on antimalarial prophylaxis. After 2-7 days of chloroquine treatment in Belgium lipid electrophoresis returned to normal. Lipid electrophoresis proved to be a very sensitive test in the diagnosis of P. vivax infections. To our knowledge this observation has not been published previously. Angus et al.did lipoprotein electrophoresis studies in rhesus monkeys infected by P. knowlesi. Their results were not conclusive, however, because in normal serum the lipoprotein bands in some instances could barely be detected. Lipid metabolism plays an important role in the pathogenesis of malaria, with regard to both parasite metabolism and the responses of host tissue to the parasite.2 We suggest that changes in H.D.L. and V.L.D.L. in human serum are related to the lipid metabolism of the parasite. The parasite lipid is very high in phosphatidylcholine which constitutes some 75% of the phospholipid fraction of H.D.L. The malaria parasite takes cholesterol from its host, and our findings suggest that phospholipids are also obtained in this way, resulting in a decrease ofserum-H.D.L.
SIR,-In six consecutive
caused
by
Department of Medicine/Cardiology, University of Antwerp, B-2610 Wilrijk, Belgium
A.
J. LAMBRECHT J. SNOECK
Department of Medicine, St. Vincentiusziekenhuis,
Antwerp.
U. TIMMERMANS
Maegraith, B. G. Ann. trop. Med Parasit 1971, 65, 135. 2. Holz, G. G. Jr. Bull. Wld. Hlth. Org. 1977, 55, 237. 1. Angus, M. G N., Fletcher, K. A.,
1. 2.
terms as
voluntary psychiatry" and "compulsory psychiatric measures" Szasz includes a variety of topics which he does not distinguish one from the other-namely, compulsory detention under the law in cases of mental illness, compulsory detention by courts when a crime has been committed, compulsory administration of psychiatric treatment, and a miscellaneous collection of wrongs (illegal detention in Russia, medical abuses under the Nazis). Any argument against any of these items is taken by Szasz as a condemnation of them all under a collective rubric such as "coercive psychiatry". He refers to Solzhenitsyn’s castigation of "The incarceration of freethinking people in mad houses" as "spiritual murder". "What", says Szasz, "is there about ’mental illness’ that makes a ’mental patient’ a fit subject for a psychiatric procedure which, were he not insane, would, according to Solzhenitsyn, constitute ’spiritual murder’?" We may as well ask what is there about "surgical illness" that makes a "surgical patient" a fit subject for surgical procedure which, were he not ill, would constitute bestial torture? Surgery was abused in Nazi Germany-and is today by the performance of unnecessary operations-but does this make a case against surgical treatment? If, as Szasz maintains, mental illness does not exist compulsory admission is superfluous-but then so is Szasz’ profes-
