Letters Concerns and Issues ojthe Diagnostic Category ojOrganic Mental Disorders in the DSM-IV SIR: "Is 'Organic' Obsolete?'" Dr. Lipowski's thoughtful examination of the organic mental disorders and their possible fate under DSM-IV addresses issues that are of concern to consultation-liaison (C-L) psychiatrists. Dr. Lipowski points out that major revision of this diagnostic category will have particular impact on C-L and geriatric psychiatrists. both due to the proportion of organic disorders seen by these clinicians and to the close working relationship with nonpsychiatric colleagues that is crucial to such work. It is worth noting that Popkin et al} in their update on the DSM-IV Work Group on Organic Mental Disorders. reported that "only work group members engaged in consultation work were concerned about how their medical and surgical colleagues would perceive the loss of the organic label... 2 Their concern. and Dr. Lipowski ·s. indicate the perceived impact that the elimination of the organic designation would have on C-L psychiatry. One need only read relevant literature such as Cummings's "Organic Psychosis"] to realize that this diagnostic category adds clinical. investigational. and educational validity to the field of C-L psychiatry. which can sorely use it in a time of economic and academic uncertainty. Interaction with my nonpsychiatric colleagues in the clinical and educational realms clearly indicates their grasp and appreciation of the philosophical basis of the "organic" distinction. Further. it reinforces for these colleagues that the psychiatrist remains. first and foremost. a physician trained in the recognition of medical illness. One can only imagine what an internist would say about a diagnostic schema that would assign myocardial infarction. reflux esophagitis. and costal chondritis to the same general disorder category because all three conditions involve chest pain; such a situation would exist for a psychiatrist with the symptom of "delusion." if one is reading the Work Group progress report correctly. Reisberg et al. 4 indicated that 48% of their symptomatic Alzheimer's disease patients 112

had a "people are stealing things" delusion; so might a chronic paranoid schizophrenic. Does that make these two disorders related in any etiologic. diagnostic. clinical. or treatment sense. other than that they share a common symptom? It is hoped that Psychosomatics. as "The Journal of Consultation and Liaison Psychiatry." will continue to serve both as a forum on this crucial issue and. possibly. as a barometer for membership opinion about the organic category. It is further hoped that such information will be acknowledged by the DSM-IV Work Group on Organic Mental Disorders in their deliberations. Stephen A. Goldman. M.D. Departments of Psychiatry and Medicine Indiana University School of Medicine Indianapolis. Indiana References I. Lipowski ZJ: Is "organic" obsolete? Psychosomatics 31:342-344.1990 2. Popkin MK. Tucker G. Caine E. el al: The fate of organic mental disorders in DSM-IV: a progress repon. Psychosomatics 30:438--44 J. 19B9 3. Cummings JL: Organic psychosis. P.~."ch().wm(J(ics 29: 16--26.1988 4. Reisberg B. Borenstein J. Salob SP. et al: Behavioral symptoms in Alzheimer's disease: phenomenology and treatmenl. J Clin Psychiatry 48 (May suppll:9-15. 19B?

Liver Transplantationjor the Alcoholic Patient SIR: As a psychiatrist who has been involved in the evaluation and treatment of liver transplant patients. I welcome the contribution of Dr. Beresford and his colleagues on the controversial subject of liver transplantation for the alcoholic patient.' However. aspects of the methodology employed and assumptions made must be questioned. The authors failed to clarify how they determined preoperative abstinence. This is especially significant because they did not observe any relationship between this factor and transplant outcome. If abstinence was based on patient self-reports. it should be noted that others discount the reliability of this method among this PSYCHOSOMATICS

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patient cohort. 2 Though corroboration of alcohol use by family members may be of assistance, the possibility still exists that they may be unaware of continuing alcohol use or that they may fear that by reporting such use, they would imperil the patient's chances of being transplanted. Beresford et al. also state that the absence of participation in any alcoholism treatment program prior to the pretransplant evaluation is considered to be "a positive sign prognostically" (p. 248). First, it is unclear what in their view constitutes a treatment program. More importantly, this belief appears to be contrary to the current alcoholism literature that strongly supports the role of treatment programs in achieving and maintaining sobriety.1,4 Unfortunately, the authors fail to supply any references for their viewpoint. Although, as the authors note, thus far alcoholic transplant patients as a group have tended to have good outcomes, my own experience indicates that as the number of liver transplants performed has grown, so has the percentage of alcoholic patients who fit into the poorer prognostic profile, especially with regard to the issue of denial of alcohol dependence. With this apparent change in the patient population, the ability of psychiatrists to differentiate between the subgroups of alcoholic patients becomes even more important. Steven A. King, M.D. Department of Psychiatry Maine Medical Center Portland. Maine

References I. Beresford TP. Turcotte JG. Merion R. et al: A rational approach 10 liver Iransplantation for the alcoholic patient. Psvchosoma/iC,\' 31 :241-254. 1990 2. Slarzl TE. Van Thiel D. Tzakis AG. et al: Onholopic liver transplantation for alcoholic cirrhosis. lAMA 260:25422544. 1988 3. Zimberg S: Individual managemenI and psychotherapy: psychoactive substance use disorders (alcohol). in hea/mt'll/s of Psychialric Disorders. Edited by the American Psychiatric Association. Washington. DC. American Psychiatric Association. 1989. pp 1093-1103 4. Schuckit MA: Drug and Alcohol Ahuse: A Clinical Guide /0 Diagnosis and Trea/melll. 3rd edition. New York. Plenum. 1989

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In Reply SIR: The other authors and I thank Dr. King for his interest in our recent paper on liver transplantation. His first point, on the matter of corroboration of abstinence, is a perennially difficult one for anyone working in this area. In our study, the two sources for assessing preoperative abstinence were the patient's history and a corroborating history from a close family member. While it is true that historical data such as these can be falsified by both patient and family, this type of information remains our best source. Many investigators, including our group, have been searching for a biological method of assessing length of abstinence, to no avail so far.' I must add that Dr. King seems to underrate the family's corroborative role. In my view, a carefully done interview focusing on the symptoms of uncontrolled drinking noted in our paper and a review of these symptoms before patient and family make a very effective clinical method in this setting. As to Dr. King's question about the absence of prior alcohol treatment as a favorable prognostic sign, I refer him to a long-term study by Smith and Cloninger, from which we derived this observation. 2 These investigators found that repetitive contacts with treatment facilities predicted a poor short-term remission from alcoholism. By contrast, Vaillant has noted that the frequency of visits to Alcoholics Anonymous (AA) meetings predicts long-term remission but that alcoholic patients generally come to AA late in the course 1 of the illness: Clinically, our experience is consistent with both studies: "fresh" cases diagnosed and treated early in the progression, when family, physical, and social resources remain relatively intact, have a better short-term outcome than do the "revolving-door" patients. There is much room for error in this as in other factors noted in our study. We look to minimize error by emphasizing prognostic factors for long-term remission. Finally, Dr. King mentions "denial" of the alcoholism by the patient. This. when present, is a very serious sign once the psychiatrist makes a diagnosis, as we said in our discussion of patient 113