882 LOW-DOSE ORAL PROPRANOLOL
SIR,-The observations by Dr Davies and his colleagues (Feb. 25, p. 407) of partial blockade of the p-adrenergic receptors in association with plasma levels of propranolol below 10 ng/ml accord with our results in healthy volunteers with conventional and long-acting propranolol formulations.’ We observed a linear correlation between the logarithm of the propranolol blood level and the degree of p-adrenergic receptor blockade over the concentration range 05-70 ng/ml. The observations were facilitated by the high sensitivity of our gasliquid chromatographic method. We agree with Professor George (April 1, p. 715) that the results of studies by Davies et al. and ourselves do not question the existence of a threshold for the hepatic first-pass effect of propranolol in man. We also agree that it is not yet possible to define the ideal therapeutic concentration of propranolol on the basis of pharmacokinetic studies. The dosage regimens recommended for propranolol in the treatment of angina and hypertension are based on the results of controlled clinical trials,2-5 Imperial Chemical Industries Limited, Pharmaceuticals
Division,
Alderley Edge, Cheshire SK10 4TG
N. S. BABER J. MCAINSH
SCHIZOPHRENIC BIRTHS
SiR,—Your editorial on the seasonality of schizophrenic (March 4, p. 481) is to be commended. However, you
births
imply that the now clearly documented winter-spring excess of schizophrenic births in the northern hemisphere may be somehow related to the excess of general births also found in the winter-spring months in Europe. This is probably not true. In the United States the peak of general births is in August and September,1-4 but the schizophrenic birth peak is in the winter-spring, as elsewhere in the northern hemisphere.’ If the causes of schizophrenia are the same in Europe as they are in the United States, this implies that the cattse of the seasonality of schizophrenic births is not the same as the cause of the seasonality of general births. Evidence from both hemispheres suggests that the schizophrenic birth peak is related to temperature-i.e., the peak in schizophrenic births occurs during and just after the coolest months. Whether the temperature is directly related (e.g., by affecting the abortion-rate in fetuses genetically predisposed to schizophrenia) or indirectly (e.g., by affecting dietary factors or the prevalence of infectious agents) remains to be ascertained. The point to be emphasised is that the cause of the seasonality of schizophrenic births is probably not the same as the cause of the seasonality of general births. St. Elizabeths
Hospital,
Washington, D.C. 20016,
U.S.A.
E. FULLER TORREY
ADMISSION TO SPECIAL HOSPITALS
PSYCHOTHERAPY FOR MULTIPLE SCLEROSIS
SIR,-The Commentary from Westminster on a 16-year-old girl in Broadmoor (April 8, p. 781) raises many issues of major importance to forensic psychiatry. This girl may or may not be correctly placed in Broadmoor Hospital. If she clearly has a mental disorder requiring treatment which can be provided at Broadmoor, and in addition she is dangerous, it might well be appropriate for her to be there. Without knowledge of the facts or of the girl’s mental condition neither I nor anybody else can assess the decision which has been made. For this girl to have been sent to Broadmoor a doctor recognised as having special experience in psychiatry must have decided that she did have a mental illness and could be treated in that hospital. Whether this doctor was or was not on the staff of Broadmoor Hospital, again we do not know. The Butler report (the major non-event in forensic psychiatry in the past 50 years) argued that a psychiatrist recommending to the court a hospital order should be on the staff of the receiving hospital. This rarely happens with the special hospitals. The "dumping syndrome" is now well-recognised outside the specialty of gastroenterology. In forensic psychiatry it takes the form of a doctor recommending to the court an offender’s
SiR,—Your editorial of March 11 may have misled non-psychiatrists. . You say that psychotherapy involves a manipulation of the patient’s environment. Does it not rather involve a readjustment of his attitudes, based on insight, to his environmental circumstances? Then you say that psychiatrists regard psychotherapy as a standard part of clinical practice. This is palpably false if you mean interpretive psychotherapy, for only a tiny minority of British psychiatrists have received psychotherapy training and even fewer probably apply it in a formal way. If you refer to simple explanatory or supportive psychotherapy, all good physicians surely practise these reflexly in an intuitive manner anyway. The papers you cite refer to a hotch-potch of techniques from group didactic counselling through individual hypnotherapy to full-blown psychoanalysis. Paulley’s paper6 is a classic instance of the analytic-anecdotal approach, and is replete with such gems as "His response to separation anxiety has been to incorporate his mother within himselfAgain, Paulley supposes, without providing evidence from controls, that sexual conflicts of various sorts can precipitate the crippling disorder of multiple sclerosis. He also adheres to the pathological premorbid-personality hypothesis, which you rightly dismiss. After that how can you take seriously Paulley’s main tenetthat analytic therapy helps physical disease such as multiple sclerosis? A careful reading of Kellner’s review article’ on the use of psychotherapy in so-called psychosomatic disorders shows how few, ill-designed, and, at best, inconclusive the controlled studies have been. Finally, to argue, as you do, that since multiple sclerosis is virtually untreatable we should therefore try psychoanalysis, is surely to be sidetracked up the blindest of alleys.
admission to a hospital from which he is totally detached geographically, clinically, and professionally. He has no interest in the patient’s subsequent treatment, rehabilitation, or aftercare ; indeed in many cases he will never set eyes on the patient again after seeing him for the purposes of the psychiatric
report. Unless decisions about the admission of special hospital pauents are taken by the psychiatrists who staff these hospitals we must expect (indeed applaud) the intervention of MIND and members of Parliament. In Scotland we are gradually learning of the consequences, sometimes tragic, of admitting to special hospitals the "wrong" patients; and in the past few years steps have been taken to exercise some control over the matter.
University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
Northgate Hospital, Morpeth, Northumberland NE61 3BP
H. G. KINNELL
DEREK CHISWICK
1. McAinsh, J., Baber, N. S., Smith, R., Young, J. Br. J. Clin. Pharmac. (in the press). 2. Prichard, B. N. C., Gillam, P. M. S. Br. Heart J. 1971, 33, 473. 3. Hebb, A. R., Godwin, T. F., Gunton, R. W. Can. med. Ass. J. 1968, 98, 246. 4. Zacharias, J., and others. Am. Heart. J. 1972, 83, 755. 5. Berglund, G., and others. Acta med. scand. 1973, 194, 513.
1. 2. 3. 4. 5.
Cowgill, U. M. Ecology, 1966, 47, 614. Rosenberg, H. M. Vital Hlth Stat. 1966, 21, 1. Slatis, H. M. Am. J. hum. Genet. 1953, 5, 21. Lyster, W. R. Am J. Obstet. Gynec. 1971, 110, 1025. Torrey, E. F., Torrey, B. B., Peterson, M. R. Archs gen. Psychiat. 1977, 34,
6. 7.
Paulley, J.
1065.
W. Psychother. Psychosom. 1976/77, 27, 26. Kellner, R. Archs gen. Psychiat. 1975, 32, 1021.
SIR,-The observations by Dr Davies and his colleagues (Feb. 25, p. 407) of partial blockade of the p-adrenergic receptors in association with plasma levels of propranolol below 10 ng/ml accord with our results in healthy volunteers with conventional and long-acting propranolol formulations.’ We observed a linear correlation between the logarithm of the propranolol blood level and the degree of p-adrenergic receptor blockade over the concentration range 05-70 ng/ml. The observations were facilitated by the high sensitivity of our gasliquid chromatographic method. We agree with Professor George (April 1, p. 715) that the results of studies by Davies et al. and ourselves do not question the existence of a threshold for the hepatic first-pass effect of propranolol in man. We also agree that it is not yet possible to define the ideal therapeutic concentration of propranolol on the basis of pharmacokinetic studies. The dosage regimens recommended for propranolol in the treatment of angina and hypertension are based on the results of controlled clinical trials,2-5 Imperial Chemical Industries Limited, Pharmaceuticals
Division,
Alderley Edge, Cheshire SK10 4TG
N. S. BABER J. MCAINSH
SCHIZOPHRENIC BIRTHS
SiR,—Your editorial on the seasonality of schizophrenic (March 4, p. 481) is to be commended. However, you
births
imply that the now clearly documented winter-spring excess of schizophrenic births in the northern hemisphere may be somehow related to the excess of general births also found in the winter-spring months in Europe. This is probably not true. In the United States the peak of general births is in August and September,1-4 but the schizophrenic birth peak is in the winter-spring, as elsewhere in the northern hemisphere.’ If the causes of schizophrenia are the same in Europe as they are in the United States, this implies that the cattse of the seasonality of schizophrenic births is not the same as the cause of the seasonality of general births. Evidence from both hemispheres suggests that the schizophrenic birth peak is related to temperature-i.e., the peak in schizophrenic births occurs during and just after the coolest months. Whether the temperature is directly related (e.g., by affecting the abortion-rate in fetuses genetically predisposed to schizophrenia) or indirectly (e.g., by affecting dietary factors or the prevalence of infectious agents) remains to be ascertained. The point to be emphasised is that the cause of the seasonality of schizophrenic births is probably not the same as the cause of the seasonality of general births. St. Elizabeths
Hospital,
Washington, D.C. 20016,
U.S.A.
E. FULLER TORREY
ADMISSION TO SPECIAL HOSPITALS
PSYCHOTHERAPY FOR MULTIPLE SCLEROSIS
SIR,-The Commentary from Westminster on a 16-year-old girl in Broadmoor (April 8, p. 781) raises many issues of major importance to forensic psychiatry. This girl may or may not be correctly placed in Broadmoor Hospital. If she clearly has a mental disorder requiring treatment which can be provided at Broadmoor, and in addition she is dangerous, it might well be appropriate for her to be there. Without knowledge of the facts or of the girl’s mental condition neither I nor anybody else can assess the decision which has been made. For this girl to have been sent to Broadmoor a doctor recognised as having special experience in psychiatry must have decided that she did have a mental illness and could be treated in that hospital. Whether this doctor was or was not on the staff of Broadmoor Hospital, again we do not know. The Butler report (the major non-event in forensic psychiatry in the past 50 years) argued that a psychiatrist recommending to the court a hospital order should be on the staff of the receiving hospital. This rarely happens with the special hospitals. The "dumping syndrome" is now well-recognised outside the specialty of gastroenterology. In forensic psychiatry it takes the form of a doctor recommending to the court an offender’s
SiR,—Your editorial of March 11 may have misled non-psychiatrists. . You say that psychotherapy involves a manipulation of the patient’s environment. Does it not rather involve a readjustment of his attitudes, based on insight, to his environmental circumstances? Then you say that psychiatrists regard psychotherapy as a standard part of clinical practice. This is palpably false if you mean interpretive psychotherapy, for only a tiny minority of British psychiatrists have received psychotherapy training and even fewer probably apply it in a formal way. If you refer to simple explanatory or supportive psychotherapy, all good physicians surely practise these reflexly in an intuitive manner anyway. The papers you cite refer to a hotch-potch of techniques from group didactic counselling through individual hypnotherapy to full-blown psychoanalysis. Paulley’s paper6 is a classic instance of the analytic-anecdotal approach, and is replete with such gems as "His response to separation anxiety has been to incorporate his mother within himselfAgain, Paulley supposes, without providing evidence from controls, that sexual conflicts of various sorts can precipitate the crippling disorder of multiple sclerosis. He also adheres to the pathological premorbid-personality hypothesis, which you rightly dismiss. After that how can you take seriously Paulley’s main tenetthat analytic therapy helps physical disease such as multiple sclerosis? A careful reading of Kellner’s review article’ on the use of psychotherapy in so-called psychosomatic disorders shows how few, ill-designed, and, at best, inconclusive the controlled studies have been. Finally, to argue, as you do, that since multiple sclerosis is virtually untreatable we should therefore try psychoanalysis, is surely to be sidetracked up the blindest of alleys.
admission to a hospital from which he is totally detached geographically, clinically, and professionally. He has no interest in the patient’s subsequent treatment, rehabilitation, or aftercare ; indeed in many cases he will never set eyes on the patient again after seeing him for the purposes of the psychiatric
report. Unless decisions about the admission of special hospital pauents are taken by the psychiatrists who staff these hospitals we must expect (indeed applaud) the intervention of MIND and members of Parliament. In Scotland we are gradually learning of the consequences, sometimes tragic, of admitting to special hospitals the "wrong" patients; and in the past few years steps have been taken to exercise some control over the matter.
University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
Northgate Hospital, Morpeth, Northumberland NE61 3BP
H. G. KINNELL
DEREK CHISWICK
1. McAinsh, J., Baber, N. S., Smith, R., Young, J. Br. J. Clin. Pharmac. (in the press). 2. Prichard, B. N. C., Gillam, P. M. S. Br. Heart J. 1971, 33, 473. 3. Hebb, A. R., Godwin, T. F., Gunton, R. W. Can. med. Ass. J. 1968, 98, 246. 4. Zacharias, J., and others. Am. Heart. J. 1972, 83, 755. 5. Berglund, G., and others. Acta med. scand. 1973, 194, 513.
1. 2. 3. 4. 5.
Cowgill, U. M. Ecology, 1966, 47, 614. Rosenberg, H. M. Vital Hlth Stat. 1966, 21, 1. Slatis, H. M. Am. J. hum. Genet. 1953, 5, 21. Lyster, W. R. Am J. Obstet. Gynec. 1971, 110, 1025. Torrey, E. F., Torrey, B. B., Peterson, M. R. Archs gen. Psychiat. 1977, 34,
6. 7.
Paulley, J.
1065.
W. Psychother. Psychosom. 1976/77, 27, 26. Kellner, R. Archs gen. Psychiat. 1975, 32, 1021.
