LETTERS
TO
him or her prospective safeguards
airtight trusted
THE
Am
EDITOR
not to communicate with the employer about employee is asking too much. Furthermore, regarding medical documents are by no means
as we would like to think. with the task of screening’
Any
physician
who
the the as
is en-
a prospective applicant is primarily serving the company, not the applicant. His access to private and therefore potentially prejudicial past information is no different from the access ofthe potential em‘ ‘
‘
ployer. In my view, judgments should be made on the information available at that time, even if it means overlooking potentially troublesome material. The alternative is a return to the system we have now, wherein a person’s medical history can be used against him. A simple and effective way around the difficulty, which has
already
been
adopted
by a number
of agencies,
who
conceals
ately subject concealment with des.
such
to penalty. of uncontrolled
information
An
would
is to in-
example epilepsy
the operation of hazardous I think it is fair to expect
be
or
motor applying
No other
society. I hope
that
system
others
chiatric
Association
protect
the rights
is acceptable
will respond will
add
in an open
vehifor
and that
its voice
SIR:
The
Demetrios
and Research esting
features,
case
for
Syndromes
and
of intermetamorphosis E.
Malliaras,
Reports,
M.D.
August
particularly
those
,
and
to
M.D.
Rochester,
N. Y.
Symptoms
of
Dis-
syndrome
reported
colleagues
(Clinical
1978 issue)
has several
suggesting
a possible
interorgan-
ic component of the illness. An aspect that was not discussed is the patient’s delusional notion that her theology instructor (the subject of her misidentifications) was in love with her, a symptom often linked with the name de Cl#{233}rambault (1). That this association of delusional phenomena may not be entirely fortuitous is suggested by a previous report (2) of their coexistence, although in that case the misidentification was of the symptoms
Capgras of both
type. In yet another report delusional hyperidentification
(3),
metamorphosis) and hypoidentification (Capgras) were ent, the author thought that repressed erotic desires’ an important psychopathological factor. ‘ ‘
Aficionados
of the
syndrome
of doubles
will
also
‘
preswere
recall
J Ment
Sci
4. Capgras J, Carrette P: Illusion des sosies et complexe d’Oedipe. Ann Med Psychob (Paris) 82:48-68, 1924 5. Flor-Henry P: Epilepsy and psychopathology, in Recent Advances in Clinical Psychiatry. Edited by Granvilbe-Grossman K. New York, Churchill Livingstone, 1976 JOHN
L.
M.B.,
BARTON,
More
on a Neglected
CH.D.,
M.R.C.PSYCH.
Louis,
Mo.
Problem
SIR: The article ‘ ‘ Father-Son Incest: Underreported Psychiatric Problem?” by Katharine N. Dixon, M.D., and associates (July 1978 issue) was ofgreat interest to mc. We have seen a case in our child guidance clinic that involved two brothers, aged 15 and 9, who had been used sexually by their father for at least 4 years, with their mother’s full knowledge. The case came to our attention after the older boy informed his minister of his experiences. Needless to say, the case presented serious management problems. The parents had maintained a conspiracy of silence for years and were enraged that this matter had come to the attention of people outside the family. Although the case was reported to the Child Protective Services as one of child abuse, the court made only a mild recommendation that the children obtain psychotherapy, a suggestion the parents angrily rejected. Like the cases reported by Dr. Dixon and associates, this
one emphasizes
the extreme
delicacy
and complexity
AARON
a
of such
will be alerted to the neglected. Dr. Dixon a valuable service
H.
ESMAN,
New
York,
M.D.
N.Y.
‘ ‘
served affect, and lack of incoherence of either spoken or written language) suggest a psychomotor component to the illness. A review of Fbor-Henry’s recent writings (5) on temporal-
1438
and non-recognition.
situations. I hope others in the field existence of a problem that has been and her coworkers have performed through their paper.
where (inter-
case described by Capgras and Carrette (4) in which the patient made flagrantly erotic advances toward her father, whom she perceived as a ‘double. In this case, like that reported by Dr. Malliaras and associates, a number of features (false feelings of strangeness and familiarity, olfactory hallucinations, episodic outbursts of aggression, well-pre‘
Misidentification
1936
St.
of individuals.
Neurological Basis ordered Recognition?
SM:
Psy-
attempting
RACY,
1973
free
the American
to those
JOHN
by
and
1978
1. Dc Cb#{233}rambault GG: Les Psychoses Passionelbes. Paris, Presses Universitaire, 1942 2. Sims A, White A: Coexistence of the Capgras and de Cl#{233}rambault syndromes: a case history. Br J Psychiatry 123:635-637,
82:63-66,
responsible and sensitive jobs would have the integrity to reveal those problems which could interfere with the discharge oftheir duties. The responsibility should be left to the individual.
November
bimbic laterality and psychopathology suggests a link not only between the phenomenon of disordered recognition and the nondominant temporal lobe but also between hypersexuality and the right hemisphere. Nondominant temporal dysfunction may also be reflected by the marked verbal-performance discrepancy of the patient described by Dr. Malliaras and associates. It is tempting to speculate not only that symptoms of misidentification and erotic delusions might logically coexist but that the common pathology might be localized in the nondominant temporal lobe.
3. Coleman
appropri-
might be the willful by a person entrusted
machinery that individuals
135:1/,
REFERENCES
dude a question asking applicants whether they to the best of their knowledge have any medical condition that would interfere with safe and successful discharge ofthcir duties. A person
J Psychiatry
Medical
Information
Card
for Patients
Taking
Lithium
SIR: At the Gcnesee Mental Health Center, we recently designed a wallet-sized information and warning card for our patients who are taking lithium carbonate. The card, which is analogous to those carried by patients taking disulfiram, was designed to alert these patients and their physicians
Am
J Psychiatry
about
the
/35:/i,
unique
November
cautions
that
/978
must
LETTERS
be observed
when
pa-
tients are on maintenance lithium therapy. In addition, the card serves to inform others (e.g., family, ambulance drivers, police officers) about certain symptoms of lithium toxicity so that they can be recognized and medical evaluation and treatment can be instituted without unnecessary delay.
One
side
of the card
contains
the following
information:
“I
am on lithium carbonate. At any Signs of diarrhea, nausea, vomiting, visual disturbance, tremor, unsteady walk, drowsiness, weakness, slurred speech, or mental confusion, please call my therapist. ‘ ‘ The phone number of the center and of an emergency room arc then given. The reverse side gives the patient’s name, address, and phone number, the name of his or her primary therapist, and a list of incompatible drugs (diuretics, sodium, potassium, and weight reduction pills).
We
would
might
be happy
have
about
to hear
this
any
comments
that
readers
idea.
E. HANSON, M.D. Mental Health Center 224 Alexander St. Rochester, N. Y. 14607
SUSAN
Genesee
cordial
pain,
The
Taste
Aversion
Therapy
for
most
widely
used
emetic
in alcohol
Alcoholism
aversion
pibocarpine
widely given
dosage
W: The
mum course.
emetine
is absorbed,
recommended
In attempting
total
to develop
approaches
or exceeds
emetinc
dosage
a more
conservative
a
Raleigh
Hills
Hospital,
across
pibocarpinc and with the emetine.
sessions
from
9 to
of alcoholism
by establishing
Sci 199:802-810,
a con-
1940
131:1204-1207,
1974
4. Rollo I: Drugs used in the chemotherapy of amebiasis, in The Pharmacological Basis ofTherapeutics, 4th ed. Edited by Goodman L, Gibman A. New York, MacMillan Publishing Co, 1125-1 143, 1970 TIMOTHY
DALE GARY
M.
B.
S.
BAKER,
PH.D. PH.D.
CANNON,
STEPHENSON,
M.D.
ESSIE DROUBAY, RN. Rehabilitation Program
Alcoholism
Veterans Salt
Administration Lake City,
Hospital Utah 84/48
Corrections
10-day
regimen,
Portland,
abnormalities)
2. Barker L, Best M, Domjan M: Learning Mechanisms of Food Selection. Waco, Tex, Baylor University Press, 1977 3. Garb JL, Stunkard AJ: Taste aversions in man. Am J Psychiatry
we
There was an error in the author affiliations for ‘ ‘ Erythrocyte Concentrations of the Lithium Ion: Clinical Correlates and Mechanisms of Action’ ‘ by Frazer and associates in the September issue. Dr. London is Chief, Computer Section, Department of Radiology, Hospital of the University of Pennsylvania, There was Karasu
Ore.
of
Philadelphia, Pa. also an error in the book Therapeutic Partnership:
review Ethical
Psychotherapy by Carl Goldberg in the the next to last paragraph the quotation therapist
power protocol,
increases
therapy
found that bower dosages failed to produce reliable emesis, which is crucial to this treatment because of the quantity of alcohol consumed during conditioning. Syrup of ipecac, a much safer emetic, did not seem to produce good conditioning, perhaps owing to the short duration of its effects. Currently we employ both 20 ml of ipecac p.o. and 42 mg ofemetine I.M. The ipecac produces reliable emesis and the emetine prolongs the malaise. Strong aversions develop, but none of the symptoms of emetine toxicity (hypotension, pre‘Unpublished
procedure, injection
J Med
the maxi-
over
used in the
treatment
reflex. Am
is emetinc HC1. A frequently used regimen’ consists of 5 treatments over a 10-day period. The oral dose of emetine is 100 mg per session, and the I.M. dose increases from 52 to 78 mg. The total treatment dosage during the series is 345 mg I.M. and 500 mg p.o. Rollo (4) has stated that emetinc dosage should not exceed 60 mg/day I.M. or 600 mg I.M. in 10 days. Thus this treatment exceeds the maximum recommended daily emetine dosage and, depending on how much of the
oral
ECG
REFERENCES
SIR: Taste aversion therapy, one ofthe earliest attempts to apply experimentally derived principles of learning to clinical treatment (1), involves the pairing ofthe sight, smell, and taste of alcohol with the effects of an emetic. Recent basic research into the acquisition of taste aversions (2) has led to suggestions that taste aversion therapy be used more frequently (3).
The
and
EDITOR
18 mg, and the ephedrine dosage increases from 25 to 60 mg. Pibocarpine prevents the absorption of alcohol through the small intestine by closing the pyboric sphincter, and cphedrinc protects against shock. In some cases we find it necessary to reduce the pibocarpine dosage because of its unpleasant side effects (e.g. , abdominal cramping). Five mmutes after the oral ipecac and the emetinc injection, patients arc given about 2400 ml of a variety of alcoholic beverages. The inpatient course of 5 treatments is followed by 5 outpatient treatment sessions over the next 6 months. Preliminary results of a clinical research project currently in progress suggest that taste aversion therapy is a valuable adjunctive therapy in a comprehensive alcoholism rehabilitation program. Additional information on the treatment procedures may be obtained from the authors.
ditioned
for
dyspnea,
THE
has
I . Voegtlin Procedures
tachycardia,
been observed. As in the more ephedrinc are also
TO
The
must
or how staff
teach
the
to regain
regrets
these
client
how
by Toksoz Concerns
September
should to
rationally
B. in
issue.
read, use
In ‘
‘the his
his lost power.” errors.
1439
TO
him or her prospective safeguards
airtight trusted
THE
Am
EDITOR
not to communicate with the employer about employee is asking too much. Furthermore, regarding medical documents are by no means
as we would like to think. with the task of screening’
Any
physician
who
the the as
is en-
a prospective applicant is primarily serving the company, not the applicant. His access to private and therefore potentially prejudicial past information is no different from the access ofthe potential em‘ ‘
‘
ployer. In my view, judgments should be made on the information available at that time, even if it means overlooking potentially troublesome material. The alternative is a return to the system we have now, wherein a person’s medical history can be used against him. A simple and effective way around the difficulty, which has
already
been
adopted
by a number
of agencies,
who
conceals
ately subject concealment with des.
such
to penalty. of uncontrolled
information
An
would
is to in-
example epilepsy
the operation of hazardous I think it is fair to expect
be
or
motor applying
No other
society. I hope
that
system
others
chiatric
Association
protect
the rights
is acceptable
will respond will
add
in an open
vehifor
and that
its voice
SIR:
The
Demetrios
and Research esting
features,
case
for
Syndromes
and
of intermetamorphosis E.
Malliaras,
Reports,
M.D.
August
particularly
those
,
and
to
M.D.
Rochester,
N. Y.
Symptoms
of
Dis-
syndrome
reported
colleagues
(Clinical
1978 issue)
has several
suggesting
a possible
interorgan-
ic component of the illness. An aspect that was not discussed is the patient’s delusional notion that her theology instructor (the subject of her misidentifications) was in love with her, a symptom often linked with the name de Cl#{233}rambault (1). That this association of delusional phenomena may not be entirely fortuitous is suggested by a previous report (2) of their coexistence, although in that case the misidentification was of the symptoms
Capgras of both
type. In yet another report delusional hyperidentification
(3),
metamorphosis) and hypoidentification (Capgras) were ent, the author thought that repressed erotic desires’ an important psychopathological factor. ‘ ‘
Aficionados
of the
syndrome
of doubles
will
also
‘
preswere
recall
J Ment
Sci
4. Capgras J, Carrette P: Illusion des sosies et complexe d’Oedipe. Ann Med Psychob (Paris) 82:48-68, 1924 5. Flor-Henry P: Epilepsy and psychopathology, in Recent Advances in Clinical Psychiatry. Edited by Granvilbe-Grossman K. New York, Churchill Livingstone, 1976 JOHN
L.
M.B.,
BARTON,
More
on a Neglected
CH.D.,
M.R.C.PSYCH.
Louis,
Mo.
Problem
SIR: The article ‘ ‘ Father-Son Incest: Underreported Psychiatric Problem?” by Katharine N. Dixon, M.D., and associates (July 1978 issue) was ofgreat interest to mc. We have seen a case in our child guidance clinic that involved two brothers, aged 15 and 9, who had been used sexually by their father for at least 4 years, with their mother’s full knowledge. The case came to our attention after the older boy informed his minister of his experiences. Needless to say, the case presented serious management problems. The parents had maintained a conspiracy of silence for years and were enraged that this matter had come to the attention of people outside the family. Although the case was reported to the Child Protective Services as one of child abuse, the court made only a mild recommendation that the children obtain psychotherapy, a suggestion the parents angrily rejected. Like the cases reported by Dr. Dixon and associates, this
one emphasizes
the extreme
delicacy
and complexity
AARON
a
of such
will be alerted to the neglected. Dr. Dixon a valuable service
H.
ESMAN,
New
York,
M.D.
N.Y.
‘ ‘
served affect, and lack of incoherence of either spoken or written language) suggest a psychomotor component to the illness. A review of Fbor-Henry’s recent writings (5) on temporal-
1438
and non-recognition.
situations. I hope others in the field existence of a problem that has been and her coworkers have performed through their paper.
where (inter-
case described by Capgras and Carrette (4) in which the patient made flagrantly erotic advances toward her father, whom she perceived as a ‘double. In this case, like that reported by Dr. Malliaras and associates, a number of features (false feelings of strangeness and familiarity, olfactory hallucinations, episodic outbursts of aggression, well-pre‘
Misidentification
1936
St.
of individuals.
Neurological Basis ordered Recognition?
SM:
Psy-
attempting
RACY,
1973
free
the American
to those
JOHN
by
and
1978
1. Dc Cb#{233}rambault GG: Les Psychoses Passionelbes. Paris, Presses Universitaire, 1942 2. Sims A, White A: Coexistence of the Capgras and de Cl#{233}rambault syndromes: a case history. Br J Psychiatry 123:635-637,
82:63-66,
responsible and sensitive jobs would have the integrity to reveal those problems which could interfere with the discharge oftheir duties. The responsibility should be left to the individual.
November
bimbic laterality and psychopathology suggests a link not only between the phenomenon of disordered recognition and the nondominant temporal lobe but also between hypersexuality and the right hemisphere. Nondominant temporal dysfunction may also be reflected by the marked verbal-performance discrepancy of the patient described by Dr. Malliaras and associates. It is tempting to speculate not only that symptoms of misidentification and erotic delusions might logically coexist but that the common pathology might be localized in the nondominant temporal lobe.
3. Coleman
appropri-
might be the willful by a person entrusted
machinery that individuals
135:1/,
REFERENCES
dude a question asking applicants whether they to the best of their knowledge have any medical condition that would interfere with safe and successful discharge ofthcir duties. A person
J Psychiatry
Medical
Information
Card
for Patients
Taking
Lithium
SIR: At the Gcnesee Mental Health Center, we recently designed a wallet-sized information and warning card for our patients who are taking lithium carbonate. The card, which is analogous to those carried by patients taking disulfiram, was designed to alert these patients and their physicians
Am
J Psychiatry
about
the
/35:/i,
unique
November
cautions
that
/978
must
LETTERS
be observed
when
pa-
tients are on maintenance lithium therapy. In addition, the card serves to inform others (e.g., family, ambulance drivers, police officers) about certain symptoms of lithium toxicity so that they can be recognized and medical evaluation and treatment can be instituted without unnecessary delay.
One
side
of the card
contains
the following
information:
“I
am on lithium carbonate. At any Signs of diarrhea, nausea, vomiting, visual disturbance, tremor, unsteady walk, drowsiness, weakness, slurred speech, or mental confusion, please call my therapist. ‘ ‘ The phone number of the center and of an emergency room arc then given. The reverse side gives the patient’s name, address, and phone number, the name of his or her primary therapist, and a list of incompatible drugs (diuretics, sodium, potassium, and weight reduction pills).
We
would
might
be happy
have
about
to hear
this
any
comments
that
readers
idea.
E. HANSON, M.D. Mental Health Center 224 Alexander St. Rochester, N. Y. 14607
SUSAN
Genesee
cordial
pain,
The
Taste
Aversion
Therapy
for
most
widely
used
emetic
in alcohol
Alcoholism
aversion
pibocarpine
widely given
dosage
W: The
mum course.
emetine
is absorbed,
recommended
In attempting
total
to develop
approaches
or exceeds
emetinc
dosage
a more
conservative
a
Raleigh
Hills
Hospital,
across
pibocarpinc and with the emetine.
sessions
from
9 to
of alcoholism
by establishing
Sci 199:802-810,
a con-
1940
131:1204-1207,
1974
4. Rollo I: Drugs used in the chemotherapy of amebiasis, in The Pharmacological Basis ofTherapeutics, 4th ed. Edited by Goodman L, Gibman A. New York, MacMillan Publishing Co, 1125-1 143, 1970 TIMOTHY
DALE GARY
M.
B.
S.
BAKER,
PH.D. PH.D.
CANNON,
STEPHENSON,
M.D.
ESSIE DROUBAY, RN. Rehabilitation Program
Alcoholism
Veterans Salt
Administration Lake City,
Hospital Utah 84/48
Corrections
10-day
regimen,
Portland,
abnormalities)
2. Barker L, Best M, Domjan M: Learning Mechanisms of Food Selection. Waco, Tex, Baylor University Press, 1977 3. Garb JL, Stunkard AJ: Taste aversions in man. Am J Psychiatry
we
There was an error in the author affiliations for ‘ ‘ Erythrocyte Concentrations of the Lithium Ion: Clinical Correlates and Mechanisms of Action’ ‘ by Frazer and associates in the September issue. Dr. London is Chief, Computer Section, Department of Radiology, Hospital of the University of Pennsylvania, There was Karasu
Ore.
of
Philadelphia, Pa. also an error in the book Therapeutic Partnership:
review Ethical
Psychotherapy by Carl Goldberg in the the next to last paragraph the quotation therapist
power protocol,
increases
therapy
found that bower dosages failed to produce reliable emesis, which is crucial to this treatment because of the quantity of alcohol consumed during conditioning. Syrup of ipecac, a much safer emetic, did not seem to produce good conditioning, perhaps owing to the short duration of its effects. Currently we employ both 20 ml of ipecac p.o. and 42 mg ofemetine I.M. The ipecac produces reliable emesis and the emetine prolongs the malaise. Strong aversions develop, but none of the symptoms of emetine toxicity (hypotension, pre‘Unpublished
procedure, injection
J Med
the maxi-
over
used in the
treatment
reflex. Am
is emetinc HC1. A frequently used regimen’ consists of 5 treatments over a 10-day period. The oral dose of emetine is 100 mg per session, and the I.M. dose increases from 52 to 78 mg. The total treatment dosage during the series is 345 mg I.M. and 500 mg p.o. Rollo (4) has stated that emetinc dosage should not exceed 60 mg/day I.M. or 600 mg I.M. in 10 days. Thus this treatment exceeds the maximum recommended daily emetine dosage and, depending on how much of the
oral
ECG
REFERENCES
SIR: Taste aversion therapy, one ofthe earliest attempts to apply experimentally derived principles of learning to clinical treatment (1), involves the pairing ofthe sight, smell, and taste of alcohol with the effects of an emetic. Recent basic research into the acquisition of taste aversions (2) has led to suggestions that taste aversion therapy be used more frequently (3).
The
and
EDITOR
18 mg, and the ephedrine dosage increases from 25 to 60 mg. Pibocarpine prevents the absorption of alcohol through the small intestine by closing the pyboric sphincter, and cphedrinc protects against shock. In some cases we find it necessary to reduce the pibocarpine dosage because of its unpleasant side effects (e.g. , abdominal cramping). Five mmutes after the oral ipecac and the emetinc injection, patients arc given about 2400 ml of a variety of alcoholic beverages. The inpatient course of 5 treatments is followed by 5 outpatient treatment sessions over the next 6 months. Preliminary results of a clinical research project currently in progress suggest that taste aversion therapy is a valuable adjunctive therapy in a comprehensive alcoholism rehabilitation program. Additional information on the treatment procedures may be obtained from the authors.
ditioned
for
dyspnea,
THE
has
I . Voegtlin Procedures
tachycardia,
been observed. As in the more ephedrinc are also
TO
The
must
or how staff
teach
the
to regain
regrets
these
client
how
by Toksoz Concerns
September
should to
rationally
B. in
issue.
read, use
In ‘
‘the his
his lost power.” errors.
1439
