Am
J Psychiatry
trum,
to
tion
135:/I,
love
and
at the other
November
affection
/978
primarily
LETTERS
motivating
identifica-
end.
Implications for future research are suggested in several areas. First, the age of onset of transvestism (or other sexual deviation), including the detail and circumstances ofthe first episode, whether being self-initiated, being cross-dressed by
the mother, or after observation of this behavior in some important figure. The specific relationships with both mother and father and their interrelationship are critical. Transvestism determined
may
patient
have several in an individual.
who
began
meanings I now
as well as being multihave in analytic therapy a
cross-dressing
when
his mother
suddenly
died at his age 10, and the dressing has been only in her clothes and served the purpose of the perpetuation of her image in his mind and denial of her death. The ‘ ‘bottom-line dynamic’ ‘ of relieving castration anxiety by acting out the fantasy of the phallic woman with whom the man can then identify should receive increasing skepticism as a ubiquitous and primary pathological force in sexual deviation. Other areas of study might include family studies, including naturalistic observation of sexual behavior, normal and
abnormal, such
as well as data
as the
that
unconscious
the psychoanalyst
processes
can collect,
ofchildhood
motivational
influences that determine present behavior and fantasy. Close collaborative observations between therapists when both child and parent have been treated, especially focusing on the dynamic emotional interplay between child and both parents,
may
be fruitful.
choice.
A: Factors J Am
that her termined contribute
(presumably) new and enthusiastic doctor was deto take her off medications? Could such anxiety to, or wholly explain, the more unusual signs and observed, e.g. irregular breathing, aerophagia people do swallow air), as well as the vomiting and
symptoms
,
(anxious
retching (in itself possibly secondary to aerophagia-just watch a baby regurgitate if it is not burped)? X rays, ECG, gastroscopy, barium swallow, etc. , were given, but no psychiatric interview was reported. Finally, all signs are attributed to tardive dyskinesia, more
by a process ofelimination (not ofpsychogenic factors, ever) than by positive evidence. True, an enlightening cussion
on
tered
sensitivity
tions
how
is
as
an
offered.
and
could
Apparently
elation,
or what
aware
to deal
is
you)
does
patient’s
in the
etiology Assoc
of fixations
1:475-496,
and
symptom
1953
2. Biller
H: Father absence and the personality development of the male child. Developmental Psychology 2: 181-202, 1970 3. Liten E, Giffen M, Johnson A: Parental influence in unusual sexual behavior in children. Psychoanal Q 25:37-55, 1966 4. Emch M: On ‘ ‘The need to know’ ‘ as related to identification and acting out. Int J Psychoanal 24:13-19, 1944 5. Cramer B: Outstanding developmental progression in three boys: a longitudinal study. Psychoanal Study Child 30:15-48,
an
W.
KRUEGER.
SIR:
That
Objective
tardive
Analysis
Tex.
dyskinesia
of Patients can
be more
than
and that it can threaten life is important information. E. Casey, M.D., and Peter Rabins, M.D., deserve discerning Dyskinesia
this and sharing as a Life-Threatening
with
(and
bartender
glory
I
psy-
that
my quarrel
is the
is with
in the name would make
an
of “returnbiochemists
of “science”
F. KAL, Cupertino
EDMUND
the
experience
to do both
pillpushers of us all, for the greater the detriment of our patients.
Drs.
Casey
a nuisance Daniel
credit for ‘Tardive
us their report ‘ Illness’ ‘ (April 1978
issue).
I am alarmed, however, that practically nothing is reported about what this particular patient felt and thought or what she may have worried about, nor did there seem to be any inquiry into the possible connection between these psychological factors and her physiological signs and symptoms. Perhaps it was merely the editorial restriction to 1 ,000 words that deterred the authors. But in light of the currently raging controversy about the ‘ ‘medical model’ ‘ in psychiatry (of which the Letters to the Editor section in the same issue is
an eloquent example) I worry that the purely physiological approach ofthis report is an omen ofthings to come, if these are not already present. Even from a purely biochemical point of view, the treat-
and
We agree
SIR: and
eliminate level
‘
that
M.D. ,
Calif.
M.D.
Houston,
Subjective
or
‘
1975 DAVID
not
fact
of the signs anxiety, de-
interpersonal
ominous trend in psychiatry which, ing to the mainstream ofmedicine”
and and
the
subjective
mean more than just bedside manners’ chology’ ‘). In fact, it is the competence special expertise of the psychiatrist. My quarrel is not with the authors:
al-
the observa-
mechanisms state (be that
have it on
and
explain
ignored
ofthe with
howdis-
of neurotransmitters
sites
the physicochemical of a psychological
to be fully well
imbalance
of receptor
understanding and symptoms pression,
Psychoanal
EDITOR
ticipation of no longer seeing the doctor, possibly the only remaining supportive figure in her widowhood? Would it be so strange if her ‘ ‘ separation anxiety’ ‘ (that old psychoanalytic myth) reached extreme degrees once she realized
‘ ‘
1 . Johnson
THE
ment ofdepression and some anxiety with chlorpromazine is puzzling, unless one assumes that in 1958 phenothiazines were the only widely known psychotropic medications. But why no attention to the obvious reactive (grief) elements of the presenting symptoms? Why no concern that the patient’s recurrent anxiety upon reduction of medication was her an-
need REFERENCES
TO
its special expertise ological dimensions dualism argument
view
and
misses
beings. Patients uals with unique
Rabins Reply that
psychiatry
is uniquely
the
important
are best viewed empathically
unifying
concept
subjectively, understandable i.e. , as organisms
responses, and objectively, interrelated functional systems. Issues ofpersonality, psychological ation assure
characterized
by
in dealing with psychological and physiofpatients. To take sides in a mind-body both neglects the relevant other point of
are crucial in the care of all Dr. Kal that we have attended
needs, patients,
of human
i.e. , as individpsychological made up of
and social and
we
situwould
to these aspects. However, the compelling aspect of this patient’s condition that we emphasized in our report was the unusual and debilitating constellation of symptoms and their increasing severity. Although her symptoms increased with anxiety, there was no evidence that the etiology of her symptoms derived from psychological conflicts. To be blind to the life-threatening physiological nature of the findings that formed the basis of this
case
and
psychological
report
could
have
led
to more
serious
physiological
sequelae. 1427
LETTERS
TO
THE
Am
EDITOR
J Psychiatry
135:1/,
November
1978
We disagree with the notion that psychiatry’s returning to the mainstream of medicine would make biochemists and pillpushers of us all, for the greater glory of ‘science’ and the
impulse control that was worse when he drank alcohol, which he used to self-medicate for his subjective depression. Psychological testing showed that the patient had a verbal
detriment
of 124 and a performance IQ of 106. The Graham Kendall Memory Test reflected normal perceptual motor abilities. The Bender-Gestalt was normal. Neurological and physical examinations were within normal limits. All laboratory tests,
‘ ‘
stream
of our
patients.
of medicine
and
improved
ties.
The
standing
indications
biological
lead for
returning
rather
than
the
criteria
available
treatment
modali-
to our have
advanced
under-
immeasurably
to the detriment
of our
been
PETER
to
patients.
E. CASEY, Portland,
DANIEL
IQ
main-
diagnostic
our
illnesses
to
to better
contributions
of psychiatric
the benefit
Rather,
‘ ‘
should
RABINS,
Baltimore,
M.D.
Ore. M.D.
Md.
skull series, and CT scan were within normal limits except for a bromide level of 42 mg/100 ml. The patient was kept in the hospital (medication-free) for 1 month, with resolution of his episodes of depression. The bromide level gradually decreased to 30 over 2 weeks. The patient did not evince any of
the impulsivity that had been reported prior to admission, and his ability to concentrate appeared to return by the time of discharge. Short-term follow-up at 1 month has disclosed the
Generic SIR:
Versus
The
Brand
Name
spreading
legalization
of the
substitution
of ge-
nenic for brand-name drugs, including psychotropics, is responsible for an escalating number of patients receiving genenic rather than the prescribed brand-name drug from the dispensing pharmacist. In the case of tricyclic antidepres-
sants, this practice can be hazardous because, as the Food and Drug Administration has stated in the Federal Register of February 17, 1978, ‘available data suggest that the various marketed brands of the same oral tricyclic antidepressant may not have comparable therapeutic effects’ ‘ (due to bioequivalence differences) and “the substitution ofa poorly bioavailable form in the regimen of a patient controlled on a fully available form would result in reversion to the depressed state.” I am gathering instances of I) depressed patients who did not respond to initial treatment with a generic tricyclic anti-
depressant
but
did
respond
to a subsequently
administered
brand-name tricyclic antidepressant, and 2) depressed patients who responded to a brand-name tricyclic but relapsed when a generic form was substituted. I would be grateful if my fellow psychiatrists who have had patients adversely affected by treatment with a generic tricyclic antidepressant would share their data with me. FRANK
Bromism
from
Over-the-Counter
absence
The counter
Psychotropics
J. AYD, JR., M.D. Baltimore, Md.
Medications
SIR: In his article ‘Bromism: Alive in Well’ ‘ (July 1978 issue) Ira Brenner, M.D. , pointed out that neuropsychiatric symptoms can occur below the normally accepted cut-off point of 50 mg/lOO ml. We have reason to believe that bromism is not a rare disorder and have recently seen a case here.
of attempting
relief.
The
patient
reported
a his-
tory of diminished libido and decreased concentration over the previous 2 years, although he denied sleep or appetite disturbance, suicidality, delusions, or hallucinations. He was unable to perform his work as an engineer and was socially
1428
withdrawn
from
his
premorbid
life
style.
He
had
poor
on
no
medications.
of his anxiety.
This
behavior
had
they
evaluated
him,
but the patient
reports
that he
did not consider over-the-counter medications as the type of medication the physicians were asking about. This suggests that in all evaluations patients should be directed to inform
the
physician
about
all pills
over-the-counter medications etc.) since the patients may they went to see the physician.
they ,
are
ingesting
vitamins, not relate
Another
Reason
for
(including
oral contraceptives, these to the reason
ROBERT
H.
GERNER,
M.D.
Los
Angeles,
Calif.
Partial
Hospital-
Underutilization
of
ization?
SIR: I would like to comment on the article titled ‘ ‘The Paradoxical Underutilization of Partial Hospitalization” by Edward B. Fink, M.D. , Richard Longabaugh, Ed.D. , and Robert Stout, Ph.D. (June 1978 issue). The authors conclude
that the underutilization to be largely attributable
of partial to the
hospitalization ‘appears subjective discomforts of
physicians and ment setting. ‘
families
with
have
hospitalization important
group age
‘
enough
In a brief providers that Blue
patients’
The refusals
been
psychiatric
no
to get control
at the time
Ohio
with
symptoms
continued for 7 or 8 months before admission and had not been detected by previous psychiatrists or in previous hospitalizations over the six months before admission. Contact with the patient’s previous physicians revealed that they had appropriately asked him about any medication he was taking
antidepressants,
‘
previous
bromide probably came from this source. After his recovery, discussion with the patient revealed that he had been feeling anxious about his job performance and started taking these over-the-counter preparations, which did not initially relieve his anxiety ; he increased the frequency of ingestion as a way
The patient, a 33-year-old man, was admitted for treatment ofa depression that had been intermittent and manifested by sudden episodes of his feeling ‘very depressed,’ which lasted minutes to hours and occurred several times weekly. The patient had had these episodes for approximately 3 months and had been treated previously in a hospital. He is now an outpatient and has been given adequate doses of tnicyclic ‘
of his
patient reported that he had been taking an over-thesedative but was unable to remember the name; the
authors only of third-party
telephone
survey
ofhospital
Prudential
alternative
Department)
will pay
Blue bills
Shield and
depending
and Travelers some
percentage
treat-
mention that there to finance partial
of six major
federal medical Mutual, and
hospitalization:
policy,
this
briefly payers
treatment and do not seem to feel to include in their conclusions.
and state and Cross, Midland
Welfare
‘
health providers Medicaid
no percentage on
the
that
it is
insurance I found (State of
of partial individual
or
will pay no percentofphysicians’
bills;
will pay some percentage: and Aetna will pay 50%-80% but does not cover meals. Medicaid (U.S. government for patients over 65 or disabled for 2 years or longer)
J Psychiatry
trum,
to
tion
135:/I,
love
and
at the other
November
affection
/978
primarily
LETTERS
motivating
identifica-
end.
Implications for future research are suggested in several areas. First, the age of onset of transvestism (or other sexual deviation), including the detail and circumstances ofthe first episode, whether being self-initiated, being cross-dressed by
the mother, or after observation of this behavior in some important figure. The specific relationships with both mother and father and their interrelationship are critical. Transvestism determined
may
patient
have several in an individual.
who
began
meanings I now
as well as being multihave in analytic therapy a
cross-dressing
when
his mother
suddenly
died at his age 10, and the dressing has been only in her clothes and served the purpose of the perpetuation of her image in his mind and denial of her death. The ‘ ‘bottom-line dynamic’ ‘ of relieving castration anxiety by acting out the fantasy of the phallic woman with whom the man can then identify should receive increasing skepticism as a ubiquitous and primary pathological force in sexual deviation. Other areas of study might include family studies, including naturalistic observation of sexual behavior, normal and
abnormal, such
as well as data
as the
that
unconscious
the psychoanalyst
processes
can collect,
ofchildhood
motivational
influences that determine present behavior and fantasy. Close collaborative observations between therapists when both child and parent have been treated, especially focusing on the dynamic emotional interplay between child and both parents,
may
be fruitful.
choice.
A: Factors J Am
that her termined contribute
(presumably) new and enthusiastic doctor was deto take her off medications? Could such anxiety to, or wholly explain, the more unusual signs and observed, e.g. irregular breathing, aerophagia people do swallow air), as well as the vomiting and
symptoms
,
(anxious
retching (in itself possibly secondary to aerophagia-just watch a baby regurgitate if it is not burped)? X rays, ECG, gastroscopy, barium swallow, etc. , were given, but no psychiatric interview was reported. Finally, all signs are attributed to tardive dyskinesia, more
by a process ofelimination (not ofpsychogenic factors, ever) than by positive evidence. True, an enlightening cussion
on
tered
sensitivity
tions
how
is
as
an
offered.
and
could
Apparently
elation,
or what
aware
to deal
is
you)
does
patient’s
in the
etiology Assoc
of fixations
1:475-496,
and
symptom
1953
2. Biller
H: Father absence and the personality development of the male child. Developmental Psychology 2: 181-202, 1970 3. Liten E, Giffen M, Johnson A: Parental influence in unusual sexual behavior in children. Psychoanal Q 25:37-55, 1966 4. Emch M: On ‘ ‘The need to know’ ‘ as related to identification and acting out. Int J Psychoanal 24:13-19, 1944 5. Cramer B: Outstanding developmental progression in three boys: a longitudinal study. Psychoanal Study Child 30:15-48,
an
W.
KRUEGER.
SIR:
That
Objective
tardive
Analysis
Tex.
dyskinesia
of Patients can
be more
than
and that it can threaten life is important information. E. Casey, M.D., and Peter Rabins, M.D., deserve discerning Dyskinesia
this and sharing as a Life-Threatening
with
(and
bartender
glory
I
psy-
that
my quarrel
is the
is with
in the name would make
an
of “returnbiochemists
of “science”
F. KAL, Cupertino
EDMUND
the
experience
to do both
pillpushers of us all, for the greater the detriment of our patients.
Drs.
Casey
a nuisance Daniel
credit for ‘Tardive
us their report ‘ Illness’ ‘ (April 1978
issue).
I am alarmed, however, that practically nothing is reported about what this particular patient felt and thought or what she may have worried about, nor did there seem to be any inquiry into the possible connection between these psychological factors and her physiological signs and symptoms. Perhaps it was merely the editorial restriction to 1 ,000 words that deterred the authors. But in light of the currently raging controversy about the ‘ ‘medical model’ ‘ in psychiatry (of which the Letters to the Editor section in the same issue is
an eloquent example) I worry that the purely physiological approach ofthis report is an omen ofthings to come, if these are not already present. Even from a purely biochemical point of view, the treat-
and
We agree
SIR: and
eliminate level
‘
that
M.D. ,
Calif.
M.D.
Houston,
Subjective
or
‘
1975 DAVID
not
fact
of the signs anxiety, de-
interpersonal
ominous trend in psychiatry which, ing to the mainstream ofmedicine”
and and
the
subjective
mean more than just bedside manners’ chology’ ‘). In fact, it is the competence special expertise of the psychiatrist. My quarrel is not with the authors:
al-
the observa-
mechanisms state (be that
have it on
and
explain
ignored
ofthe with
howdis-
of neurotransmitters
sites
the physicochemical of a psychological
to be fully well
imbalance
of receptor
understanding and symptoms pression,
Psychoanal
EDITOR
ticipation of no longer seeing the doctor, possibly the only remaining supportive figure in her widowhood? Would it be so strange if her ‘ ‘ separation anxiety’ ‘ (that old psychoanalytic myth) reached extreme degrees once she realized
‘ ‘
1 . Johnson
THE
ment ofdepression and some anxiety with chlorpromazine is puzzling, unless one assumes that in 1958 phenothiazines were the only widely known psychotropic medications. But why no attention to the obvious reactive (grief) elements of the presenting symptoms? Why no concern that the patient’s recurrent anxiety upon reduction of medication was her an-
need REFERENCES
TO
its special expertise ological dimensions dualism argument
view
and
misses
beings. Patients uals with unique
Rabins Reply that
psychiatry
is uniquely
the
important
are best viewed empathically
unifying
concept
subjectively, understandable i.e. , as organisms
responses, and objectively, interrelated functional systems. Issues ofpersonality, psychological ation assure
characterized
by
in dealing with psychological and physiofpatients. To take sides in a mind-body both neglects the relevant other point of
are crucial in the care of all Dr. Kal that we have attended
needs, patients,
of human
i.e. , as individpsychological made up of
and social and
we
situwould
to these aspects. However, the compelling aspect of this patient’s condition that we emphasized in our report was the unusual and debilitating constellation of symptoms and their increasing severity. Although her symptoms increased with anxiety, there was no evidence that the etiology of her symptoms derived from psychological conflicts. To be blind to the life-threatening physiological nature of the findings that formed the basis of this
case
and
psychological
report
could
have
led
to more
serious
physiological
sequelae. 1427
LETTERS
TO
THE
Am
EDITOR
J Psychiatry
135:1/,
November
1978
We disagree with the notion that psychiatry’s returning to the mainstream of medicine would make biochemists and pillpushers of us all, for the greater glory of ‘science’ and the
impulse control that was worse when he drank alcohol, which he used to self-medicate for his subjective depression. Psychological testing showed that the patient had a verbal
detriment
of 124 and a performance IQ of 106. The Graham Kendall Memory Test reflected normal perceptual motor abilities. The Bender-Gestalt was normal. Neurological and physical examinations were within normal limits. All laboratory tests,
‘ ‘
stream
of our
patients.
of medicine
and
improved
ties.
The
standing
indications
biological
lead for
returning
rather
than
the
criteria
available
treatment
modali-
to our have
advanced
under-
immeasurably
to the detriment
of our
been
PETER
to
patients.
E. CASEY, Portland,
DANIEL
IQ
main-
diagnostic
our
illnesses
to
to better
contributions
of psychiatric
the benefit
Rather,
‘ ‘
should
RABINS,
Baltimore,
M.D.
Ore. M.D.
Md.
skull series, and CT scan were within normal limits except for a bromide level of 42 mg/100 ml. The patient was kept in the hospital (medication-free) for 1 month, with resolution of his episodes of depression. The bromide level gradually decreased to 30 over 2 weeks. The patient did not evince any of
the impulsivity that had been reported prior to admission, and his ability to concentrate appeared to return by the time of discharge. Short-term follow-up at 1 month has disclosed the
Generic SIR:
Versus
The
Brand
Name
spreading
legalization
of the
substitution
of ge-
nenic for brand-name drugs, including psychotropics, is responsible for an escalating number of patients receiving genenic rather than the prescribed brand-name drug from the dispensing pharmacist. In the case of tricyclic antidepres-
sants, this practice can be hazardous because, as the Food and Drug Administration has stated in the Federal Register of February 17, 1978, ‘available data suggest that the various marketed brands of the same oral tricyclic antidepressant may not have comparable therapeutic effects’ ‘ (due to bioequivalence differences) and “the substitution ofa poorly bioavailable form in the regimen of a patient controlled on a fully available form would result in reversion to the depressed state.” I am gathering instances of I) depressed patients who did not respond to initial treatment with a generic tricyclic anti-
depressant
but
did
respond
to a subsequently
administered
brand-name tricyclic antidepressant, and 2) depressed patients who responded to a brand-name tricyclic but relapsed when a generic form was substituted. I would be grateful if my fellow psychiatrists who have had patients adversely affected by treatment with a generic tricyclic antidepressant would share their data with me. FRANK
Bromism
from
Over-the-Counter
absence
The counter
Psychotropics
J. AYD, JR., M.D. Baltimore, Md.
Medications
SIR: In his article ‘Bromism: Alive in Well’ ‘ (July 1978 issue) Ira Brenner, M.D. , pointed out that neuropsychiatric symptoms can occur below the normally accepted cut-off point of 50 mg/lOO ml. We have reason to believe that bromism is not a rare disorder and have recently seen a case here.
of attempting
relief.
The
patient
reported
a his-
tory of diminished libido and decreased concentration over the previous 2 years, although he denied sleep or appetite disturbance, suicidality, delusions, or hallucinations. He was unable to perform his work as an engineer and was socially
1428
withdrawn
from
his
premorbid
life
style.
He
had
poor
on
no
medications.
of his anxiety.
This
behavior
had
they
evaluated
him,
but the patient
reports
that he
did not consider over-the-counter medications as the type of medication the physicians were asking about. This suggests that in all evaluations patients should be directed to inform
the
physician
about
all pills
over-the-counter medications etc.) since the patients may they went to see the physician.
they ,
are
ingesting
vitamins, not relate
Another
Reason
for
(including
oral contraceptives, these to the reason
ROBERT
H.
GERNER,
M.D.
Los
Angeles,
Calif.
Partial
Hospital-
Underutilization
of
ization?
SIR: I would like to comment on the article titled ‘ ‘The Paradoxical Underutilization of Partial Hospitalization” by Edward B. Fink, M.D. , Richard Longabaugh, Ed.D. , and Robert Stout, Ph.D. (June 1978 issue). The authors conclude
that the underutilization to be largely attributable
of partial to the
hospitalization ‘appears subjective discomforts of
physicians and ment setting. ‘
families
with
have
hospitalization important
group age
‘
enough
In a brief providers that Blue
patients’
The refusals
been
psychiatric
no
to get control
at the time
Ohio
with
symptoms
continued for 7 or 8 months before admission and had not been detected by previous psychiatrists or in previous hospitalizations over the six months before admission. Contact with the patient’s previous physicians revealed that they had appropriately asked him about any medication he was taking
antidepressants,
‘
previous
bromide probably came from this source. After his recovery, discussion with the patient revealed that he had been feeling anxious about his job performance and started taking these over-the-counter preparations, which did not initially relieve his anxiety ; he increased the frequency of ingestion as a way
The patient, a 33-year-old man, was admitted for treatment ofa depression that had been intermittent and manifested by sudden episodes of his feeling ‘very depressed,’ which lasted minutes to hours and occurred several times weekly. The patient had had these episodes for approximately 3 months and had been treated previously in a hospital. He is now an outpatient and has been given adequate doses of tnicyclic ‘
of his
patient reported that he had been taking an over-thesedative but was unable to remember the name; the
authors only of third-party
telephone
survey
ofhospital
Prudential
alternative
Department)
will pay
Blue bills
Shield and
depending
and Travelers some
percentage
treat-
mention that there to finance partial
of six major
federal medical Mutual, and
hospitalization:
policy,
this
briefly payers
treatment and do not seem to feel to include in their conclusions.
and state and Cross, Midland
Welfare
‘
health providers Medicaid
no percentage on
the
that
it is
insurance I found (State of
of partial individual
or
will pay no percentofphysicians’
bills;
will pay some percentage: and Aetna will pay 50%-80% but does not cover meals. Medicaid (U.S. government for patients over 65 or disabled for 2 years or longer)
