ABSTRACTS

The treatment ofpsychosomatic disorders bythe general practitionerPierloot RA. Psychiatry in Medicine 8 (I),Im-1978.

• The general practitioner is facedwith many patients whose physicalcomplaints often have a psycholog­ic basis. This report attempts todefine the psychotherapeutic ap­proaches that he can utilize intreating individuals with com­plaints diagnosed as psychoso­matic. The general practitioner hasa unique relationship to his pa­tients. In contradistinction to a psy­chiatrist, his relationship is morespontaneous, has longer continuity,has less expectations of generalhuman and social concern and,often, more tolerance for passivebehavior on the part of the patient.Balint's observation that the physi­cian acts as an important "medica­tion" in treating the patient is aconstant feature of the therapeuticrelationship in general practice.The definition of a psychosomaticdisorder is problematic for thephysician. Categorizing the patientas having a specific syndrome anddiagnosis can limit the practitionerwhen all the signs and symptomsdo not fit the categorization. Thesearch for provoking circumstancescan also be disappointing if theyare not found. Tension and stress,which are often thought to createpsychosomatic disorders, are help­ful if found, but can be masked innarrowly circumscribed syn­dromes. Training in identifying thetype of neurotic structure in psy­chosomatic patients also requirespersonal skill and experience, aswell as more time than is often

JUNE 1978 • VOL 19 • NO 6

available. Utilization of all ap­proaches-identification of a syn­drome, search for provoking cir­cumstances, identification oftensions and stress, and taking noteof neurotic structures-can servethe general practitioner well. Thetherapeutic means of the generalpractitioner also must be delin­eated. Pharmacologic treatment,psychotherapy, and social inter­vention are the mainstays of thegeneral practitioner's armamen­tarium. Psychotherapy by a generalpractitioner is often limited be­cause he has less time availablethan a psychiatrist. The use of focaltherapy on specific behaviors thatthe patient presents allows the phy­sician to treat the immediate situa­tion without looking for underlyingcauses and conducting long, in­volved interviews. In addition,medication can be used along withsocial support to alter biologic andsocial milieus. The general practi­tioner is often best equipped to ini­tiate such changes. Thus, the gen­eral practitioner has uniquecharacteristics in his therapeuticrelationship to his patients.

Thomas N. Wise, M.D.Falls Church, Va.

Protriptyline: An effectiveagent in the treatment of thenarcolepsy-cataplexysyndrome and hypersomniaSchmidt HS, Clark RW, Hyman PR: Am JPsychiatry 134:183·185, 1977.

• Five case reports are presentedillustrating that 10 to 20 mg ofprotriptyline in a single dose atbedtime can effectively controlarousal dysfunction (sleep drunk-

enness and hypersomnia) and thenarcolepsy-cataplexy syndrome.This response occurs without theapparent development of toleranceand without side effects that arefrequent complications of treat­ment with other agents such as am­phetamines, methylphenidate, orimipramine. However, protripty­line was found to have relativelypoor REM sleep-suppressing prop­erties. It was a further clinical im­pression, supported by some poly­graphic documentation, that inseveral patients, both the frequencyand severity of sleep apnea weredecreased by protriptyline.

John If. Graf, M.D.Rochester, Minn.

Biofeedback aided relaxationand meditation in themanagement of hypertensionPatel eH. Biofeedback and Self-Regulation2:1-41,1977.

• The physiology of essential hy­pertension leads to the hypothesisthat basic stress response, whenchronic, results in functionalchanges ("resetting") of the barore­ceptors and hypertrophy of the re­sistance vessels. A combined ap­proach including deconditioning,relaxation, meditation, and bio­feedback was developed to ap­proach the hypertensive patho­genic cycle at several loci. Fourphases of the evaluation of this ap­proach are reported. A pilot studyof 20 patients known to be hyper­tensive for one year, average age57.3 and average blood pressure201.5/ 121.8, was undertaken. Afterdrug treatment, average BP was160/102. Treatment was individ-

379

ABSTRACTS

ual, consisting of three half-hoursessions weekly for three months.Patients were allowed to listen to anaudio tone representing galvanicskin response and instructed to in­fluence the tone in the direction oflower arousal. They were instructedto breathe smoothly and regularly,then to make the muscles limp,then to meditate. Group averageblood pressure dropped from 160/102 to 134/86. Two controlledstudies that followed indicated thatthe experimental methods pro­vided significantly more reductionin blood pressure than did restingquietly on the couch for a similarperiod of time.

Arnold H. Gessel, M.D.Phi/adelphia

Phantom limb pain:Sub-hallucinogenic treatmentwith lysergic aciddiethylamideFanciullacci E, et aI. Headache 17: 118-119,1977.

• The authors report a series ofseven phantom limb patientstreated with a single daily oral sub­hallucinogenic dose of 25 mg LSD­25 for one week and 50 mg for twoweeks, preceded and followed byone week of placebo administra­tion. In five of the patients therewas improvement in pain and re­duced use of analgesics. Treatmentwas ineffective in two. Explanationof phantom limb pain is offered,based on a central biasing concept,in which brain-stem reticular for­mation inhibits, or biases, trans­mission of the somatic projectionsystem. When a large number ofsensory fibers are destroyed at am-

380

putation, the input to the reticularformation is reduced and its inhib­itory influence is decreased. Sero­tonin is held to be the most impor­tant neurotransmitter in centralmodula.tion of pain. The authorsmaintain that their findings indi­cate that the analgesic properties ofLSD-25 in phantom limb pain re­sult from central potentiation ofserotonin activity in pathways in­volved in central pain regulation.

Fred O. Henker III, M.D.Little Rock, Ark.

The use of sodium Amytalinterviews in a short-termcommunity orientedinpatient unitMarcos L, et aI. Dis Nerv Syst 38:282-286,1977.

• Interest in the Amytal interviewis again increasing. Current dataindicate that Amytal-assisted diag­nostic interviews are both safe andeffective in selected patients. Theauthors studied 31 psychiatric in­patients with Amytal interviews.Patients were selected if, after 72hours of hospitalization, they re­mained uncommunicative, withoutdiagnosis, and without adequatehistory. The authors feel thatwithin 72 hours most hystericalcatatonic patients will show consid­erable improvement. Up to 500 mgof sodium Amytal (as a 10% solu­tion in distilled water) is intrave­nously administered after estab­lishing an interview plan andobtaining consent. Final diagnosesof the 31 patients studied includedschizophrenia, 14; schizoaffectivedisorder (depressed), 6; psychoticdepression, 2; unipolar manic-de-

pression, 2; involutional melancho­lia, 1; depressive neurosis, I; andhysterical neurosis, 1. The Amytalinterview was helpful in establish­ing diagnosis, in obtaining usefulhistorical and psychodynamic in­formation, and in formulatingtreatment plans. Therapeutic ef­fects are only indirect. No adversephysical effects occurred. (No men­tion is made of occurrence of cata­tonic excitement.) Finally, as notedby other authors, it is concludedthat the success ofsuch interviews isprimarily a function of the inter­viewer's skill and is only secondar­ily dependent on the drug utilized.

Albert V. Vogel, M.D.Albuquerque, N.M.

Identity of emotionaltriggers in epilepsyFeldman RO, Paul NL. J Nerv Ment Dis162:345-353, 1976.

• The authors describe a treatmentmethod for recurrent psychologi­cally triggered psychomotor epi­leptic attacks in five patients. Thepatients ranged from age 27 to 48years and all had seizures for morethan 13 years. It was felt that emo­tional conflict played a role in thepoor long-term treatment results inthese patients, even though theycomplied with treatment by anti­convulsant drugs and all had pre­vious psychotherapy. Althoughpast psychotherapy had uncoveredconflicts, the amnesia following theseizures was felt to have erased thememories of input surrounding theemotional events setting them off.Treatment involved exploratoryinterviews to uncover the emo­tional conflict that set off the sei-

PSYCHOSOMATICS

ABSTRACTS

zure. When a particular topic wasuncovered, the patient underwent astress interview leading to the sei­zure. The process was videotaped.A simulated recall situation was setup when the patient viewing theseizure tape was videotaped. Nextthe patient observed both tapesthrough a split screen technique.The subject then went through aperiod of self-confrontation inwhich he watched himself have aseizure, and observed the periodleading up to the seizure and alsohis expression while watching theseizure tape. The fourth stage con­sisted of reinforcement of thislearning at future times so that thepatient learns which events lead upto a seizure, so as to avoid respond­ing in the same way. The patientswere followed for an average ofthree years and seizure frequencywas drastically reduced in all five.

David L Keegan, M.D.Saskatoon, Canada

Intestinal bypass surgeryfor morbid obesity­long-term resultsDeWind Lt, Payne JH. JAMA 236:2298­230i,1976.

• Since 1962, jejunoileal bypasssurgery has been performed on 230patients (59 men and 171 women).Maximum weight reduction wasachieved in the first two years. Sideeffects of the procedure are ac­cepted by patients if discussed inadvance. Side effects and suggestedtreatment are described. Compli­cations included arthritis syn­drome, urinary calculi, cholelith­iasis, liver impairment, and majoremotional upset. Hospitalization to

JUNE 1978 • VOL 19 • NO 6

manage complications was re­quired by 49% of the men and 51%of the women. There were 19 by­pass-related deaths, including 10from liver failure. The death ratefrom bypass-related complicationsshould diminish with earlier resto­ration of the intestinal continuity inthe presence of nutritional failure.

Mary A. Lenkay. M.D.Toledo. Ohio

Psychologic effects of oraldelta-9-tetrahydrocannabinolin advanced cancer patientsNoyes R Jr, Brunk SF, Aver DH, el al.Compr Psychiatry 17(5):641-646, 1976.

• The authors administered 10­and 20-mg doses of delta-9-tetra­hydrocannabinol (THC), 20-, 60-,and lOO-mg doses of codeine, andplacebo on successive days in adouble-blind random sequence to46 terminal cancer patients ex­periencing pain of moderate sever­ity attributable to the cancer. Twosubjects had previously been ex­posed to marijuana. None were re­ceiving large doses of narcotics. Anexperienced registered nurse inter­viewed the subjects hourly regard­ing severity of pain, extent of reliefexperienced, and subjective andobjective side effects. She also ad­ministered an II-item subjectiveeffects questionnaire and side ef­fects inventory at the end of eachobservation period. Subjects takingTHC reported feeling calm andhappy; in addition, some reporteddepersonalization experiences. ThelO-mg dosage of THC producedmaximum side effects of sedation,dullness, dreaminess, and im­paired thinking at 3 hours, while

the 20-mg dose was 3 times as po­tent in regard to these side effectsand peaked 5 hours after adminis­tration. Approximately one third ofthe patierits became severely intoxi­cated following 20 mg of THC, butless than 8% following 10 mg. Fourpatients experienced adverse anxi­ety reactions to the 20-mg dosage ofTHC but only one to the lO-mgdosage. Most patients reportednumbness and pain reduction atboth dosage levels. The authorsconclude that the lO-mg dosage ofTHC is helpful as an analgesic,producing concurrent relaxation,euphoria, and appetite stimulation.However, a 20-mg dose of THC isoverly sedating and intoxicating.

Paul C. Mohl, M./).San Antonio. Tex.

Infectious complications ofalcoholismHurley DL. Postgrad Med 61:160-162, May1977.

• Infectious diseases are amongthe most widely recognized compli­cations of alcoholism. The causeappears to be multifactorial, in­cluding environmental factors, nu­tritional effects, and toxic effects.However, many of the mechanismsare poorly understood. Those dis­eases clearly more prevalent in al­coholics include pneumonia, duemostly to gram-negative and pneu­mococcal bacteria and associatedwith a higher death rate than in thegeneral population. The alcoholicis also more likely to have meningi­tis or acute endocarditis as a com­plication. Tuberculosis is still seenin alcoholics, and these patientshave poor compliance with treat­ment. Bacterial peritonitis with

383

ABSTRACTS

bacteremia remains an elusivediagnosis because as many as 8% ofalcoholic patients have, ascites andcirrhosis. Fever and the usual signsand symptoms are absent, but in­adequate or delayed treatment canresult in a mortality rate of 80% to95%. Other infections that are re­portedly associated with alcohol­ism, but in which the primary factoris unclear, include pyelonephritis,subacute bacterial endocarditis, lis­terial infections, salmonellosis,candidiasis, and sporotrichosis.

Multiple detrimental effects onhost defenses and the immune sys­tem by alcohol are documented.Since administration of alcohol hasnot been studied very much in nor­mal subjects, specific effects cannotbe distinguished. Ingestion of largeamounts of ethanol decreasesglottis closure. Pulmonary clear­ance of bacteria 'is reduced. Smok­ing, which is more common in al­coholics, decreases ciliary activity.Measurements in vivo show pro­found reduction of polymorphonu-

clear leukocyte mobilization afteronly modest ingestion of alcohol.There is also decreased serum bac­tericidal activity, which seems to bedue to reduced serum complement.Leukopenia occurs in chronic alco­holism, and cirrhosis decreases innumber and activity the compo­nents of cell-mediated immunity.Precise mechanisms are unclear,but the need for early diagnosis andvigorous treatment is evident.

Gary S. Nye, M.D.Orinda, Calif.

Academy of Psychosomatic Medicine25th Anniversary Meeting

November 15-19, 1978, Atlanta, Georgia"Psychosomatic Medicine-Tempo of the Times"

Featuring distinguished speakers on:

EDUCATION-With particular emphaSIS ontraining of pnmary care physicians bypsychia rists and behavioral sCientists.

RESEARCH-Recent advances of relevanceand utili y to the practitioner.

PSYCHOSOMATIC problems in children,adolescents, and families, With specialemphasis on diagnostic, treatment, andresearch methods

TREATMENT-Preventive and therapeutic

- - - - - - - For further Information, use the coupon.- - - - - - ­

Academy of Psychosomatic Medicine4902 Tollview DriveRolling Meadows, IL 60008

Please send program and registration information on the 25th Anniversary Meeting of theAcademy.Name _

Address _

City State Zip __

o I would also like information on Academy membership.

384 PSYCHOSOMATICS