688
CORRESPONDENCE
in k a e i g h t in m2, reflecting body shape) is a significant contributor to the phenomenology of fat phobia and bulimic behaviour [7]. Whitaker et a1 [8] similarly demonstrated that, irrespective of social class, 95% of American adolescent girls above the median body mass index of 20.5 k g / d feared fatness and wanted to weigh less. Unfortunately, no weight indices were examined by Russell and Gilbert. Crisp [9] theorised that anorexia nervosa represents a psychobiological regressive and phobic stance towards the tasks of adolescence, and this can occur in subjects of all ages. Nonetheless, tardive anorexia is a potentially useful subgroup to study seriously. I suggest that Russell and Gilbert should put their findings into perspective, and examine more closely clinical features (eg. fear of obesity, bulimia) and long-term outcome in their future endeavours. References 1. Russell J, Gilbert M. Is tardive anorexia a discrete diagnostic entity? Australian and New Zealand Journal of Psychiatry 1992; 26:429-435. 2. Kendall RE. Clinical validity. Psychological Medicine 1989; 19:45-55. 3. Hsu LKG. Outcome of anorexia nervosa - a review of the literature. Archives of General Psychiatry 1980; 37:1041-1046. 4. Lee S. Anorexia nervosa in Hong Kong - a Chinese perspective. Psychological Medicine 199 1 ; 2 1 :703-71 1 . 5. Khandelwal SK, Saxena S. Anorexia nervosa in people of Asian extraction. British Journal of Psychiatry 1990; 157:784. 6. Ong YL, Tsoi WF.A clinical and psychosocial study of seven cases of anorexia nervosa in Singapore. Singapore Medical Journal 1982; 23:255-261. 7. Lee S. How abnormal is the desire for slimness? A survey of eating attitudes and behaviour among Chinese undergraduates in Hong Kong. Psychological Medicine (in press). 8. Whitaker A, Davies M. Shaffer D e t a / .The struggle to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population. Psychological Medicine 1989; 19:143-163. 9. Crisp AH. Anorexia nervosa: let me be. London: Plenum, 1980.
Professional accountabilityand peer review Peter Wurth, Chatswood, New South Wales: Twelve months ago I accepted the responsibility for coordinating peer review activities at a small private hospital. I phoned the Chairman of the NSW Branch of the College with a number of questions about this vexed area, seeking the official view of the College, if indeed one existed. At his invitation I put my questions in writing to him in December. In February I phoned him as I had received no reply and he was unaware of my letter. I wrote back to him in May enclosing a copy
of the original letter and I have still had no reply of any sort. I am compelled to reach the conclusion that the College is still not really serious about the issue of professional accountability and review. From what I have been able to establish there is no method or process of peer review that has the sanction of the College, and in particular the difficult question of what steps should be taken to deal with colleagues identified as falling below acceptable standards has yet to be addressed satisfactorily. At a recent meeting the Section of Psychotherapy of the NSW Branch, there was a resolution to further investigate the possibility of establishing Peer Review Meetings for members of the Section in order to help allay Medicare concerns about unnecessarily prolonged or intensive therapies at public expense. Everyone seems to be talking about peer review but no-one is able to say exactly what it means. Can the College help?
The changing nature of psychiatry Gavin Andrews, Darlinghurst, New South Wales: It is interesting when an article still excites correspondence 12 months after it was published. The changing nature ofpsychiatry (25: 453-459,1991) has been the focus of such continuing attention. It argued that new developments in diagnosis and psychological treatments would change the nature of psychiatric practice. The article contains one error concerning the case of Dr. Osheroff who received intensive psychotherapy without benefit and was finally diagnosed and his illness relieved by antidepressants. As the Editor and Gaughwin (26: 132-134, 1992) pointed out, his case was heard before a tribunal and settled out of court, thus providing no precedent in law. Moms (26: 322-323,1992) and Blom (26: 323-326, 1992) question whether a structured diagnostic interview such as the CIDI (and in particular the computerised CIDI-Auto) can be a valid diagnostic measure. The CIDI was conceived as an epidemiological tool and functions as a clinician’s aid by identifying symptoms and matching them to diagnostic criteria, although whether the patient suffers from the condition whose diagnostic criteria are satisfied is for a clinician to decide. The CIDI is in wide use and it is estimated 100,000 will have been administered throughout the world by the end of 1992. The instrument is sophisticated. It asks questions about symptoms that are pertinent to each ICDlO and
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
SHORT TERM THERAPY FOR ANXIETY SEREPAX HELPS CALM ANXIOUS PATIENTS
Please review fully revised Product Information before prescribing. Product information can be found by referring to the Advertisers’ Index. Wyeth Pharmaceuticals Pty Limited, ACN 000 296 211, Gregory Place, Parramatta, NSW 2150. Telephone: 635 7144. *Registered trademark. WSER3904/MSV&P 06/92.
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
SEREPAX* Tablets. Fully Revised Product information.
Wveth
Wveth Pharmaceuticals Ptv Limited A C N 000296 211 Giegory Ploce Parramatto N S W 2150 Telephone: 6357144
'Reg~iterodTrademark
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
CORRESPONDENCE
DSMIIIR diagnostic criterion and then checks appropriately to see if the symptom was of sufficient severity and not likely to be due to physical illness or injury or to the effects of medications, drugs or alcohol. This sequence of questions is complex and interviewers require some days of detailed training to learn the steps involved. The computer does these steps automatically. The CIDI-Auto is now available from the author. The CIDI cannot be better than the classifications that it seeks to illuminate. It uses symptom patterns to generalise about particular patients and the results appear, on the basis of the validity trials so far completed, to be mostly concordant with the principal clinical diagnoses. It is interesting that many patients tell more to a computer than to a clinician at first interview. Some of this is valuable, some is not and one needs clinical skill to decide what is important. Morris’s fear that computerised interviews might lead to a new world order of big brother medicine is a reductio ad ahsurdum. We have discussed the ethics of the computerised medical record elsewhere (Andrews and Wilkins, 1992) and are concerned about protecting patient privacy but not about the possibility of doctors and patients being dehumanised. Such issues were of concern thirty years ago when computers were first introduced to medicine but do not seem to be a current focus of concern. Patients accept the CIDI-Auto very well, equating the experience to their clinician being thorough and being concerned about them. The discussion about the efficacy of, and hence training in, dynamic psychotherapy was not mischievous (Parkinson, this issue) but quite serious. Since the Current Opinion in Psychiatry evaluation of psychotherapy (Andrews 1991) was written two other evaluations of dynamic psychotherapy have appeared. Both were written by supporters of dynamic psychotherapy and neither provided evidence that dynamic psychotherapy was better than a placebo treatment (Svartberg and Styles, 199 1; Crits-Christoph, 1992). I suspect that there are three effective classes of treatment in psychiatry: good clinical care, drug treatments, and cognitive behaviour therapy. The elements of good clinical care are very poorly researched. This should be rectified and elsewhere we have argued seriously for such research and teaching (Andrews, in press). In randomised placebo controlled trials drug treatments have been shown to reduce handicap and
69 I
disability in schizophrenia, depression and anxiety disorders. In randomised placebo controlled trials cognitive behaviour therapies have been shown to potentiate the action of drugs in schizophrenia, and to be effective in anxiety disorders and in alcoholism. Within the immediate future it seems that cognitive behaviour therapies will rank equally with drug therapies in terms of efficacy in relieving the mental disorders (Andrews e t a l , 1 9 9 2 ) . D y n a m i c psychotherapy has been shown to do none of these things. Usage, despite Blom’s and Gaughwin’s claims, is no excuse for failure to demonstrate effectiveness. References 1. Andrews G. The evaluation of psychotherapy. Current Opinion in
Psychiatry, 1991; 4:379-383. 2. Andrews, G. The essential psychotherapies. British Journal of Psychiatry, in press. 3. Andrews G, Crino R, Hunt C, Lampe L, Page A. Essential treatments in psychiatry. Symposium presented at the 28th Annual Congress of the Royal Australian and New Zealand College of Psychiatrists, Canberra. 1992. 4. Andrews G . Wilkins GEI. Privacy and the computerised medical record. Medical Journal of Australia, 1992: 157:223-225. 5. Crits-Christoph P. The efficacy of brief dynamic psychotherapy. American Journal of Psychiatry, 1992; 149:151-158. 6. Svartberg M, Styles TC. Comparative effects of short term dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 1991; 59:704-7 14.
Psychiatry or “psychatries”? N . McLaren, Derby, Western Australia: Dr John Spencer [ 11 took exception to my assertion that since psychiatry lacks a unified theoretical base, it is merely protoscience [2]. He was of the view that we ought to accept there are different “psychiatries”. While he may find that a comforting resolution to some of the problems I pointed out, I most certainly do not. Because if we follow his prescription, the Chelmsford disaster becomes not just an ugly aberration in our history, but a “scientific psychiatry” in its own right. Without wishing to cause more ill-feeling than is necessary, psychiatrists are generally astoundingly naive in the philosophy of mind and of science, two areas in which we cannot afford to fall behind. For example, Dr Spencer erred in his use of the term “existential statement” on which most of his argument depended. More importantly, science does not, under any circumstances, ratify his notion that “anything goes” [3]. The whole purpose of my saying that psychiatry is a process of rational enquiry into an
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
CORRESPONDENCE
in k a e i g h t in m2, reflecting body shape) is a significant contributor to the phenomenology of fat phobia and bulimic behaviour [7]. Whitaker et a1 [8] similarly demonstrated that, irrespective of social class, 95% of American adolescent girls above the median body mass index of 20.5 k g / d feared fatness and wanted to weigh less. Unfortunately, no weight indices were examined by Russell and Gilbert. Crisp [9] theorised that anorexia nervosa represents a psychobiological regressive and phobic stance towards the tasks of adolescence, and this can occur in subjects of all ages. Nonetheless, tardive anorexia is a potentially useful subgroup to study seriously. I suggest that Russell and Gilbert should put their findings into perspective, and examine more closely clinical features (eg. fear of obesity, bulimia) and long-term outcome in their future endeavours. References 1. Russell J, Gilbert M. Is tardive anorexia a discrete diagnostic entity? Australian and New Zealand Journal of Psychiatry 1992; 26:429-435. 2. Kendall RE. Clinical validity. Psychological Medicine 1989; 19:45-55. 3. Hsu LKG. Outcome of anorexia nervosa - a review of the literature. Archives of General Psychiatry 1980; 37:1041-1046. 4. Lee S. Anorexia nervosa in Hong Kong - a Chinese perspective. Psychological Medicine 199 1 ; 2 1 :703-71 1 . 5. Khandelwal SK, Saxena S. Anorexia nervosa in people of Asian extraction. British Journal of Psychiatry 1990; 157:784. 6. Ong YL, Tsoi WF.A clinical and psychosocial study of seven cases of anorexia nervosa in Singapore. Singapore Medical Journal 1982; 23:255-261. 7. Lee S. How abnormal is the desire for slimness? A survey of eating attitudes and behaviour among Chinese undergraduates in Hong Kong. Psychological Medicine (in press). 8. Whitaker A, Davies M. Shaffer D e t a / .The struggle to be thin: a survey of anorexic and bulimic symptoms in a non-referred adolescent population. Psychological Medicine 1989; 19:143-163. 9. Crisp AH. Anorexia nervosa: let me be. London: Plenum, 1980.
Professional accountabilityand peer review Peter Wurth, Chatswood, New South Wales: Twelve months ago I accepted the responsibility for coordinating peer review activities at a small private hospital. I phoned the Chairman of the NSW Branch of the College with a number of questions about this vexed area, seeking the official view of the College, if indeed one existed. At his invitation I put my questions in writing to him in December. In February I phoned him as I had received no reply and he was unaware of my letter. I wrote back to him in May enclosing a copy
of the original letter and I have still had no reply of any sort. I am compelled to reach the conclusion that the College is still not really serious about the issue of professional accountability and review. From what I have been able to establish there is no method or process of peer review that has the sanction of the College, and in particular the difficult question of what steps should be taken to deal with colleagues identified as falling below acceptable standards has yet to be addressed satisfactorily. At a recent meeting the Section of Psychotherapy of the NSW Branch, there was a resolution to further investigate the possibility of establishing Peer Review Meetings for members of the Section in order to help allay Medicare concerns about unnecessarily prolonged or intensive therapies at public expense. Everyone seems to be talking about peer review but no-one is able to say exactly what it means. Can the College help?
The changing nature of psychiatry Gavin Andrews, Darlinghurst, New South Wales: It is interesting when an article still excites correspondence 12 months after it was published. The changing nature ofpsychiatry (25: 453-459,1991) has been the focus of such continuing attention. It argued that new developments in diagnosis and psychological treatments would change the nature of psychiatric practice. The article contains one error concerning the case of Dr. Osheroff who received intensive psychotherapy without benefit and was finally diagnosed and his illness relieved by antidepressants. As the Editor and Gaughwin (26: 132-134, 1992) pointed out, his case was heard before a tribunal and settled out of court, thus providing no precedent in law. Moms (26: 322-323,1992) and Blom (26: 323-326, 1992) question whether a structured diagnostic interview such as the CIDI (and in particular the computerised CIDI-Auto) can be a valid diagnostic measure. The CIDI was conceived as an epidemiological tool and functions as a clinician’s aid by identifying symptoms and matching them to diagnostic criteria, although whether the patient suffers from the condition whose diagnostic criteria are satisfied is for a clinician to decide. The CIDI is in wide use and it is estimated 100,000 will have been administered throughout the world by the end of 1992. The instrument is sophisticated. It asks questions about symptoms that are pertinent to each ICDlO and
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
SHORT TERM THERAPY FOR ANXIETY SEREPAX HELPS CALM ANXIOUS PATIENTS
Please review fully revised Product Information before prescribing. Product information can be found by referring to the Advertisers’ Index. Wyeth Pharmaceuticals Pty Limited, ACN 000 296 211, Gregory Place, Parramatta, NSW 2150. Telephone: 635 7144. *Registered trademark. WSER3904/MSV&P 06/92.
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
SEREPAX* Tablets. Fully Revised Product information.
Wveth
Wveth Pharmaceuticals Ptv Limited A C N 000296 211 Giegory Ploce Parramatto N S W 2150 Telephone: 6357144
'Reg~iterodTrademark
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
CORRESPONDENCE
DSMIIIR diagnostic criterion and then checks appropriately to see if the symptom was of sufficient severity and not likely to be due to physical illness or injury or to the effects of medications, drugs or alcohol. This sequence of questions is complex and interviewers require some days of detailed training to learn the steps involved. The computer does these steps automatically. The CIDI-Auto is now available from the author. The CIDI cannot be better than the classifications that it seeks to illuminate. It uses symptom patterns to generalise about particular patients and the results appear, on the basis of the validity trials so far completed, to be mostly concordant with the principal clinical diagnoses. It is interesting that many patients tell more to a computer than to a clinician at first interview. Some of this is valuable, some is not and one needs clinical skill to decide what is important. Morris’s fear that computerised interviews might lead to a new world order of big brother medicine is a reductio ad ahsurdum. We have discussed the ethics of the computerised medical record elsewhere (Andrews and Wilkins, 1992) and are concerned about protecting patient privacy but not about the possibility of doctors and patients being dehumanised. Such issues were of concern thirty years ago when computers were first introduced to medicine but do not seem to be a current focus of concern. Patients accept the CIDI-Auto very well, equating the experience to their clinician being thorough and being concerned about them. The discussion about the efficacy of, and hence training in, dynamic psychotherapy was not mischievous (Parkinson, this issue) but quite serious. Since the Current Opinion in Psychiatry evaluation of psychotherapy (Andrews 1991) was written two other evaluations of dynamic psychotherapy have appeared. Both were written by supporters of dynamic psychotherapy and neither provided evidence that dynamic psychotherapy was better than a placebo treatment (Svartberg and Styles, 199 1; Crits-Christoph, 1992). I suspect that there are three effective classes of treatment in psychiatry: good clinical care, drug treatments, and cognitive behaviour therapy. The elements of good clinical care are very poorly researched. This should be rectified and elsewhere we have argued seriously for such research and teaching (Andrews, in press). In randomised placebo controlled trials drug treatments have been shown to reduce handicap and
69 I
disability in schizophrenia, depression and anxiety disorders. In randomised placebo controlled trials cognitive behaviour therapies have been shown to potentiate the action of drugs in schizophrenia, and to be effective in anxiety disorders and in alcoholism. Within the immediate future it seems that cognitive behaviour therapies will rank equally with drug therapies in terms of efficacy in relieving the mental disorders (Andrews e t a l , 1 9 9 2 ) . D y n a m i c psychotherapy has been shown to do none of these things. Usage, despite Blom’s and Gaughwin’s claims, is no excuse for failure to demonstrate effectiveness. References 1. Andrews G. The evaluation of psychotherapy. Current Opinion in
Psychiatry, 1991; 4:379-383. 2. Andrews, G. The essential psychotherapies. British Journal of Psychiatry, in press. 3. Andrews G, Crino R, Hunt C, Lampe L, Page A. Essential treatments in psychiatry. Symposium presented at the 28th Annual Congress of the Royal Australian and New Zealand College of Psychiatrists, Canberra. 1992. 4. Andrews G . Wilkins GEI. Privacy and the computerised medical record. Medical Journal of Australia, 1992: 157:223-225. 5. Crits-Christoph P. The efficacy of brief dynamic psychotherapy. American Journal of Psychiatry, 1992; 149:151-158. 6. Svartberg M, Styles TC. Comparative effects of short term dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 1991; 59:704-7 14.
Psychiatry or “psychatries”? N . McLaren, Derby, Western Australia: Dr John Spencer [ 11 took exception to my assertion that since psychiatry lacks a unified theoretical base, it is merely protoscience [2]. He was of the view that we ought to accept there are different “psychiatries”. While he may find that a comforting resolution to some of the problems I pointed out, I most certainly do not. Because if we follow his prescription, the Chelmsford disaster becomes not just an ugly aberration in our history, but a “scientific psychiatry” in its own right. Without wishing to cause more ill-feeling than is necessary, psychiatrists are generally astoundingly naive in the philosophy of mind and of science, two areas in which we cannot afford to fall behind. For example, Dr Spencer erred in his use of the term “existential statement” on which most of his argument depended. More importantly, science does not, under any circumstances, ratify his notion that “anything goes” [3]. The whole purpose of my saying that psychiatry is a process of rational enquiry into an
Downloaded from anp.sagepub.com at University of British Columbia Library on June 25, 2015
