The Canadian Journal of Psychiatry

Two separate lines of evidence converge to suggest that insight cannot properly be considered to be the crucial condition for behavioural change in psychotherapy. All major psychotherapeutic systems recognize that ‘intellectual’ insight alone is ineffective, and make careful provision for interpersonal interaction. Current research on personality development suggests that understanding is not enough to assure adaptive learning. Adjustment to reality depends on opportunity for the repeated trial-and-check of an individual's expectations. In psychotherapy, this implies opportunity for interpersonal interaction in a consistently warm and accepting social environment.

It is necessary to establish the presence or absence of a borderline schizophrenic reaction early, for it is of great importance in deciding on the treatment program for the patient. Its presence is suspected if there are symptoms that indicate that the patient is developing a thought disorder, and/or a disturbance of affect of schizophrenic type, and/or is beginning to detach from reality. It is also suspected if there is a persistence of such symptoms as disturbances of judgment, poor empathy and understanding of others, an absence of enjoyment, periods of seclusiveness, or sexual and philosophical preoccupations. Mixtures of the neuroses, with free-floating anxiety often indicates an underlying schizophrenic process.

In the treatment of a patient with a borderline schizophrenic reaction, the prime focus should be on the prevention of a psychosis. The child should be protected against severe stresses, which may involve some environmental manipulation. Anxiety has a deteriorating effect and tranquillizers may have to be used.

Supportive psychotherapy is of great value. It is essential that the relationship with the therapist be a positive one. The therapist should be a real person who offers the adolescent patient someone with whom to identify. One strengthens useful defences and lessens the need for the other defences by reducing the ego's needs for those defences, e.g. by reality testing the fantasied threats, by offering a less punitive and less rigid superego, and by manipulating the environment to reduce stress. It is often helpful to orient the patient towards pleasurable experiences which have an ego-strengthening effect.

Here then, in the handling of the defences and in the management of anxiety, can be seen a major difference in the treatment of patients with a borderline schizophrenic reaction, from the treatment of patients with psycho-neuroses or personality disorders. Failure to recognize the presence of an underlying schizophrenic process may lead to the choice of the wrong treatment program for the patient, with a resultant worsening of his condition and the onset of a psychosis.

A brief initial interview with a regressed paranoid schizophrenic woman has been reported. Its contents have been examined with emphasis upon some of the ways in which the patient communicated. Attention has been directed to the demands made upon the therapist-interviewer by the patient's total behaviour. These in the main have been demands for a rigid objectivity and the making of necessary and continuing self-examinations by the interviewer. The self-examinations led to successful empathic contact which has been detailed and explained, as has some of the psychopathology uncovered in the interchanges.

In the concise presentation of our program and its preliminary results we do not intend to offer a ‘cure-all’ method. We perceive it rather as an experimental endeavour in educational therapy with the intention of contributing to some of the pressing problems regarding the treatment of mentally subnormal children.

The improvement we observe in our children derived both from measurable data and clinical observation, points out that educational methodology when properly applied in educational therapy with mentally subnormal children — serves a twofold purpose:

1) Exposure to conditions which foster experiencing of primary cognitive functions help the child to develop better intentional and differentiative behaviour and facilitates more meaningful cognitive and functional relationships with the environment. As such it gives the professional worker insight into the basic problem in clinical psychology and special education, namely, the qualitative functional aspect of intelligence.

2) Exposure to the program proves to be a useful way to differentiate among clinical manifestations of different symptomatologies which, at the outset, are clustered around a general and diffuse behavioural and learning dysfunction.

Some practical and theoretical aspects of the use of electroencephalography in criminology are reviewed. Examples are given of various factors in the EEG pattern and in certain activation techniques showing correlation with certain attributes of personality structure. Briefly presented are EEG studies of psychopathic populations and those of convicted criminals, including murderers. The relatively high incidence, among murderers, of clinical epileptics and persons with EEG's showing epileptic implications, is discussed, as well as the significance of the 14 and 6 cycles per second positive spike complex, which is still a controversial issue.

In spite of widely divergent findings, it is generally agreed that there is a relatively high incidence of abnormal EEG's among criminal and delinquent populations, though without a specific and consistent EEG pattern characterizing these groups; that the most often seen abnormalities are the presence of excessive theta activity, focal temporal lobe pathology, and instability of the patterns, often epileptic in nature; that the age factor needs special consideration in the EEG appraisal of criminal or delinquent populations, and that aggressive behaviour, continuous or episodic, appears to be the common denominator in the personality structure of these populations.

The purpose in writing this paper is two-fold:

1) To clarify the origin of the Day Hospital and further to consider those factors which brought it into existence. It is these factors with which we must reckon when we move on to the devising of still newer forms of setting;

2) To direct attention to the most exciting part of the idea of the Day Hospital. This is its opening of the door to a new dimension. This dimension is the setting. The setting constitutes a field force. Within this field force and affected by it, the diagnostic and therapeutic exchanges taking place between the staff and the patient go forward, and in doing so are moulded by this field force of which they are constituent parts.

Disorders of interpersonal communication, as measured by a content analysis of the verbal behaviour elicited by a structured interview technique, were studied in a sample of 101 first admissions to a psychiatric hospital.

Diagnostic groups were found to differ on several objective dimensions of verbal interaction. Schizophrenics had a lower total output of verbal units and they, as well as psychotics in general, had a lower over-all rate of usage of self (I, we) as the subject of their units. Selective verbal reinforcement of self-referred affect statements in one period of the interview produced an increase in the total output of verbal units, and a decrease during subsequent interviewer silence; these changes were more marked for the specific class reinforced than for other verbal units over the population as a whole. However, diagnostic groups differed in the extent to which their response to reinforcement was a specific change in output of self-referred affect statements or a non-specific change in other units.

Ratings of the clinical EEG, based on the content of alpha and beta frequencies, also yielded groups which were significantly different in regard to their specific or non-specific verbal responsiveness in interview.

Munchausen's Syndrome, which has been described by numerous writers, is the syndrome of the imposter. Generally characterized by multiple complaints, Pseudologia fantastica, wandering and stubbornness; patients thus afflicted cause the medical community much concern and annoyance.

Emergency medical or surgical treatment proves valueless in dealing with fraudulent symptoms. In addition, the patient's identity and past history usually turns out false. Confrontation leads to quick departure and repetition of the play-acting in another locality.

The authors believe that these curious patterns of behaviour can be understood as schizoid mechanisms. To illustrate this view, they present detailed psychiatric and psychological investigation of such a case.

In reviewing the patient's early life and present situation, the authors demonstrate schizoid attitudes of omnipotence, detachment, identity diffusion and dependency. When the significant figures in the patient's life died, his marginal adjustment collapsed and the onset of the syndrome was noted. Virtually all his time was spent between hospital admissions and jail sentences.

The authors interpret these wanderings as a search for a depersonalized-all-healing mother. The ‘symptoms’ (usually centering around the genito-urinary system) reflect confusion of sexual identity. Their fabrications (pseudologia fantastica) may be mistaken for malingering but correspond more to schizoid role-playing and exhibitionism. Through victimizing people by false pretences, such patients assume omnipotence in so far as they prove that nobody can help them.

Nine cases of transient toxic-delirious reactions during combined antipsychotic-antiparkinsonism treatment have been described. A few days prior to the onset of the reaction, all patients had been placed on an antiparkinsonian drug.

Three clinical phases were observed: an autonomic stage (sympathicotonic signs: mydriasis, dry mouth, anorexia, excitement, disorientation, insomnia, severe constipation); a strio-thalamic phase (dyskinesias, visual and tactile hallucinations) and a post-delirious state (increased sleep and integration).

The pathogenic factors which play a role in this atropine-like toxic condition, such as age, individual susceptibility, drug response per se and the influence of rapid dose changes were briefly discussed.

The hypothesis tested in this study was that: The sex of a delusional persecutor will have a relationship to the sex of the most fear-inspiring parent or parent surrogate. Twenty-eight patients with delusions of persecution were evaluated by different interviewers who were unaware of what material to uncover in order to fulfil the hypothesis. It was found that when the father or father surrogate was most fear inspiring, the patient later would develop delusional fears of men only; that when the mother or mother surrogate was most fear inspiring, the patient would develop delusional fears of both men and women, but predominantly of women.

The findings are discussed in relation to cultural studies of delusions, certain aspects of learning theory and the concepts of Freud relating homosexuality to paranoid delusions.

An incidence of nine cases, or 20 per cent of a group of 45 phenylketonuric children showing autistic behaviour patterns has been reported. Most of these children have tended to lose the autistic behaviour patterns over time without psychotherapeutic intervention. The question of etiology and factors affecting the course of their development has been raised.