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On This Day … 24 January

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People (Births)

  • 1850 – Hermann Ebbinghaus, German psychologist (d. 1909).
  • 1853 – Sigbert Josef Maria Ganser, German psychiatrist (d. 1931).

People (Deaths)

  • 1971 – Bill W., American activist, co-founder of Alcoholics Anonymous (b. 1895).

Hermann Ebbinghaus

Hermann Ebbinghaus (24 January 1850 to 26 February 1909) was a German psychologist who pioneered the experimental study of memory, and is known for his discovery of the forgetting curve and the spacing effect.

He was also the first person to describe the learning curve. He was the father of the neo-Kantian philosopher Julius Ebbinghaus.

Sigbert Josef Maria Ganser

Sigbert Josef Maria Ganser (24 January 1853 to 04 January 1931) was a German psychiatrist born in Rhaunen.

He earned his medical doctorate in 1876 from the University of Munich. Afterwards he worked briefly at a psychiatric clinic in Würzburg, and later as an assistant to neuroanatomist Bernhard von Gudden (1824-1886) in Munich. In 1886, he became head of the psychiatric department at Dresden General Hospital. Among his students was neurologist Hans Queckenstedt (1876-1918).

Sigbert Ganser is remembered for a hysterical disorder that he first described in 1898. He identified the disorder in three prisoners while working at a prison in Halle. The features included approximate or nonsensical answers to simple questions, perceptual abnormalities, and clouding of consciousness. Ganser believed that these symptoms were an associative reaction caused by an unconscious attempt by the patient to escape from an intolerable mental situation. The disorder was to become known as Ganser syndrome.

Bill W.

William Griffith Wilson (26 November 1895 to 24 January 1971), also known as Bill Wilson or Bill W., was the co-founder of Alcoholics Anonymous (AA).

AA is an international mutual aid fellowship with about 2 million members worldwide belonging to approximately 10,000 groups, associations, organisations, cooperatives, and fellowships of alcoholics helping other alcoholics achieve and maintain sobriety. Following AA’s Twelfth Tradition of anonymity, Wilson is commonly known as “Bill W.” or “Bill.” In order to identify each other, members of AA will sometimes ask others if they are “friends of Bill”. Although this question can be confusing, because “Bill” is a common name, it does provide a means of establishing the common experience of AA membership. After Wilson’s death in 1971, and amidst much controversy within the fellowship, his full name was included in obituaries by journalists who were unaware of the significance of maintaining anonymity within the organisation.

Wilson’s sobriety from alcohol, which he maintained until his death, began 11 December 1934. In 1955 Wilson turned over control of AA to a board of trustees. Wilson died of emphysema complicated by pneumonia from smoking tobacco in 1971. In 1999 Time listed him as “Bill W.: The Healer” in the Time 100: The Most Important People of the Century.

On This Day … 22 January

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People (Births)

  • 1913 – Henry Bauchau, Belgian psychoanalyst and author (d. 2012).
  • 1932 – Berthold Grünfeld, Norwegian psychiatrist and academic (d. 2007).

Henry Bauchau

Henry Bauchau (22 January 1913 to 21 September 2012) was a Belgian psychoanalyst, lawyer, and author of French prose and poetry.

Henry Bauchau was born in Mechelen, Belgium on 22 January 1913. He became a trial lawyer in Brussels in 1936 and was a member of the Belgian Resistance in the Ardennes during World War II.

From 1945 to 1951 he worked in publishing. In 1946, he moved to Paris. He was a friend of Albert Camus, André Gide, Jacques Lacan, and Jacques Derrida.

He was married to Mary Kozyrev; their son is the actor Patrick Bauchau. They lived for a time in Gstaad, Switzerland.

Bauchau died in Paris, France on 21 September 2012, aged 99.

Berthold Grunfeld

Berthold Grünfeld (22 January 1932 to 20 August 2007) was a Norwegian psychiatrist, sexologist, and professor of social medicine at the University of Oslo. He was also a recognised expert in forensic psychiatry, often employed by Norwegian courts to examine insanity defence pleas.

Grünfeld was born in Bratislava in what was then Czechoslovakia. In 1939, when he was seven, he and 34 other Jewish children were separated from their families in an attempt by Nansenhjelpen to rescue them from the early manifestations of the Holocaust. The group of children was sent by train to Norway via Berlin, after having been told they would never again see their parents.

Once in Norway, Grünfeld was first placed at the Jewish children’s home in Oslo, then lived as a foster child with a Jewish family in Trondheim before returning to the orphanage. During the occupation of Norway, Grünfeld avoided capture and deportation by fleeing with members of the Norwegian Resistance in 1942 to neutral Sweden, where he stayed until the war ended. He returned to the children’s home in 1946. The Jewish community funded his education.

Berthold Grünfeld earned his medical degree in 1960, when he also met his future wife Gunhild. He was awarded his doctorate in medicine in 1973 based on a dissertation on abortion. In 1993, he was made professor of social medicine at the University of Oslo.

Grünfeld was noted for his academic contributions within sexology, on the issues of abortion and euthanasia, and within forensic psychology. In addition to his advocacy and teaching, he acted as an expert witness in criminal cases, and as a consultant on human relations and sexology for Oslo Helseråd. His dissertation influenced the reform of abortion laws in Norway.

Grünfeld and his wife had three children and six grandchildren. In 2005, his daughter Nina Grünfeld made a film, Origin Unknown, about her efforts to research her father’s background and heritage. Among other things, she found that his mother had worked as a prostitute and was murdered in the death camp at Sobibor.

What is Reaction Formation?

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Introduction

In psychoanalytic theory, reaction formation (German: Reaktionsbildung) is a defence mechanism in which emotions and impulses which are anxiety-producing or perceived to be unacceptable are mastered by exaggeration of the directly opposing tendency.

The reaction formations belong to Level 3 of neurotic defence mechanisms, which also include dissociation, displacement, intellectualisation, and repression.

Theory

Reaction formation depends on the hypothesis that:

“[t]he instincts and their derivatives may be arranged as pairs of opposites: life versus death, construction versus destruction, action versus passivity, dominance versus submission, and so forth. When one of the instincts produces anxiety by exerting pressure on the ego either directly or by way of the superego, the ego may try to sidetrack the offending impulse by concentrating upon its opposite. For example, if feelings of hate towards another person make one anxious, the ego can facilitate the flow of love to conceal the hostility.”

Where reaction-formation takes place, it is usually assumed that the original, rejected impulse does not vanish, but persists, unconscious, in its original infantile form. Thus, where love is experienced as a reaction formation against hate, we cannot say that love is substituted for hate, because the original aggressive feelings still exist underneath the affectionate exterior that merely masks the hate to hide it from awareness.

In a diagnostic setting, the existence of a reaction-formation rather than a ‘simple’ emotion would be suspected where exaggeration, compulsiveness and inflexibility were observed. For example:

“[r]eactive love protests too much; it is overdone, extravagant, showy, and affected. It is counterfeit, and […] is usually easily detected. Another feature of a reaction formation is its compulsiveness. A person who is defending himself against anxiety cannot deviate from expressing the opposite of what he really feels. His love, for instance, is not flexible. It cannot adapt itself to changing circumstances as genuine emotions do; rather it must be constantly on display as if any failure to exhibit it would cause the contrary feeling to come to the surface.

Reaction formation is sometimes described as one of the most difficult defences for lay people to understand; this testifies not merely to its effectiveness as a disguise, but also to its ubiquity and flexibility as a defence that can be utilised in many forms. For example:

“solicitude may be a reaction-formation against cruelty, cleanliness against coprophilia”,

and it is not unknown for an analyst to explain a client’s unconditional pacifism as a reaction formation against their sadism. In addition:

“[h]igh ideals of virtue and goodness may be reaction formations against primitive object cathexes rather than realistic values that are capable of being lived up to. Romantic notions of chastity and purity may mask crude sexual desires, altruism may hide selfishness, and piety may conceal sinfulness.”

Even more counter-intuitively, according to this model:

“[a] phobia is an example of a reaction formation. The person wants what he fears. He is not afraid of the object; he is afraid of the wish for the object. The reactive fear prevents the dreaded wish from being fulfilled.

The concept of reaction formation has been used to explain responses to external threats as well as internal anxieties. In the phenomenon described as Stockholm syndrome, a hostage or kidnap victim ‘falls in love’ with the feared and hated person who has complete power over them. Similarly, paradoxical reports exist of powerless and vulnerable inmates of Nazi camps creating ‘favourites’ among the guards and even collecting objects discarded by them. The mechanism of reaction formation is often characteristic of obsessional neuroses. When this mechanism is overused, especially during the formation of the ego, it can become a permanent character trait. This is often seen in those with obsessional character and obsessive personality disorders. This does not imply that its periodic usage is always obsessional, but that it can lead to obsessional behaviour.

What is Regression (Psychology)?

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Introduction

Regression, according to psychoanalyst Sigmund Freud, is a defence mechanism leading to the temporary or long-term reversion of the ego to an earlier stage of development rather than handling unacceptable impulses more adaptively.

In psychoanalytic theory, regression occurs when an individual’s personality reverts to an earlier stage of development, adopting more childish mannerisms.

Freud, Regression, and Neurosis

Freud saw inhibited development, fixation, and regression as centrally formative elements in the creation of a neurosis. Arguing that “the libidinal function goes through a lengthy development”, he assumed that “a development of this kind involves two dangers – first, of inhibition, and secondly, of regression”. Inhibitions produced fixations; and the “stronger the fixations on its path of development, the more readily will the function evade external difficulties by regressing to the fixations”.

Neurosis for Freud was thus the product of a flight from an unsatisfactory reality:

“along the path of involution, of regression, of a return to earlier phases of sexual life, phases from which at one time satisfaction was not withheld. This regression appears to be a twofold one: a temporal one, in so far as the libido, the erotic needs, hark back to stages of development that are earlier in time, and a formal one, in that the original and primitive methods of psychic expression are employed in manifesting those needs”.

Behaviours associated with regression can vary greatly depending upon the stage of fixation: one at the oral stage might result in excessive eating or smoking, or verbal aggression, whereas one at the anal stage might result in excessive tidiness or messiness. Freud recognised that “it is possible for several fixations to be left behind in the course of development, and each of these may allow an irruption of the libido that has been pushed off – beginning, perhaps, with the later acquired fixations, and going on, as the lifestyle develops, to the original ones”.

In the Service of the Ego

Ernst Kris supplements Freud’s general formulations with a specific notion of “regression in the service of the ego” … “the specific means whereby preconscious and unconscious material appear in the creator’s consciousness”. Kris thus opened the way for ego psychology to take a more positive view of regression. Carl Jung had earlier argued that “the patient’s regressive tendency…is not just a relapse into infantilism, but an attempt to get at something necessary…the universal feeling of childhood innocence, the sense of security, of protection, of reciprocated love, of trust”. Kris however was concerned rather to differentiate the way that “Inspiration -…in which the ego controls the primary process and puts it into its service – needs to be contrasted with the opposite…condition, in which the ego is overwhelmed by the primary process”.

Nevertheless his view of regression in the service of the ego could be readily extended into a quasi-Romantic image of the creative process, in which “it is only in the fiery storm of a profound regression, in the course of which the personality undergoes both dissolution of structure and reorganization, that the genius becomes capable of wresting himself from the traditional pattern that he had been forced to integrate through the identifications necessitated and enforced by the oedipal constellation”.

From there it was perhaps only a small step to the 1960s valorisation of regression as a positive good in itself. “In this particular type of journey, the direction we have to take is back and in….They will say we are regressed and withdrawn and out of contact with them. True enough, we have a long, long way to back to contact the reality”. Jungians had however already warned that “romantic regression meant a surrender to the non-rational side which had to be paid for by a sacrifice of the rational and individual side”; and Freud for his part had dourly noted that “this extraordinary plasticity of mental developments is not unrestricted in direction; it may be described as a special capacity for involution – regression – since it may well happen that a later and higher level of development, once abandoned, cannot be reached again”.

Later Views

Anna Freud (1936) ranked regression first in her enumeration of the defence mechanisms, and similarly suggested that people act out behaviours from the stage of psychosexual development in which they are fixated. For example, an individual fixated at an earlier developmental stage might cry or sulk upon hearing unpleasant news.

Michael Balint distinguishes between two types of regression: a nasty “malignant” regression that the Oedipal level neurotic is prone to… and the “benign” regression of the basic-fault patient. The problem then is what the analyst can do “to ensure that his patient’s regression should be therapeutic and any danger of a pathological regression avoided”.

Others have highlighted the technical dilemmas of dealing with regression from different if complementary angles. On the one hand, making premature “assumptions about the patient’s state of regression in the therapy…regarded as still at the breast”, for example, might block awareness of more adult functioning on the patient’s part: of the patient’s view of the therapist. The opposite mistake would be “justifying a retreat from regressive material presented by a patient. When a patient begins to trust the analyst or therapist it will be just such disturbing aspects of the internal world that will be presented for understanding – not for a panic retreat by the therapist”.

Peter Blos suggested that “revisiting of early psychic positions…helps the adolescent come out of the family envelope”, and that “Regression during adolescence thus advances the cause of development”. Stanley Olinick speaks of “regression in the service of the other” on the part of the analyst “during his or her clinical work. Such ego regression is a pre-condition for empathy”.

Demonstration of pain, impairment, etc. also relates to regression. When regression becomes the cornerstone of a personality and the life strategy for overcoming problems, it leads to such an infantile personality.

  • A clear example of regressive behaviour in fiction can be seen in J.D. Salinger’s The Catcher in the Rye. Holden constantly contradicts the progression of time and the ageing process by reverting to childish ideas of escape, unrealistic expectations and frustration produced by his numerous shifts in behaviour. His tendencies to reject responsibility and society as a whole because he ‘does not fit in’ also pushes him to prolonged use of reaction formation, unnecessary generalisations, and compulsive lying.
  • A similar example occurs in Samuel Beckett’s Krapp’s Last Tape. Krapp is fixated on reliving earlier times, and re-enacts the foetal condition in his ‘den’. He is unable to form mature relationships with women, seeing them only as replacements for his deceased mother. He experiences physical ailments that are linked to his foetal complex, struggling to perform digestive functions on his own. This literal anal retentiveness exemplifies his inefficacy as an independent adult.

What is the Revolving Doors Agency?

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Introduction

Formed on 17 August 1993, the Revolving Doors Agency (RDA), also known as Revolving Doors, is a charitable organisation in the United Kingdom which works across England and Wales.

Through research, policy and campaigning work, the organisation aims to improve services for people with multiple needs who are in repeat contact with the criminal justice system.

Vision

The vision of the organisation is that by 2025 there is an end to the revolving door of crisis and crime, when anyone facing multiple problems and poor mental health is supported to reach their potential, with fewer victims and safer communities as a result.

Activities

To fulfil its vision, Revolving Doors organises its work around three areas:

AreaDescription
Policy and CommunicationsWorking with policymakers in national and local government, across Whitehall and in local and regional authorities, to improve responses for the revolving doors group. This work is informed by their research, the work of the organisation’s service user forums and their partnership and development work across the country.
Service User InvolvementThe organisation operates a national service user forum and a young peoples’ forum. The Forums bring together individuals from different areas of the country who have experienced mental health and other problems and have had contact with the criminal justice system. The forums are designed to root the organizations work in the reality of people’s experiences.
Local Partnerships and DevelopmentRevolving Doors works with organisations and individuals across England and Wales to demonstrate solutions for the revolving doors group.

Definition

The revolving door group refers to the experiences of people who are caught in a cycle of crisis, crime and mental illness, whereby they are repeatedly in contact with the police and often detained in prison as well as being victims of crime themselves. This is a group that often has multiple problems for which they need the input of a wide range of agencies, including housing, drugs, mental health, and benefits. The mental health problems of the group are usually a core or exacerbating factor. Routinely, they fall through the gaps of existing mental health service provision, as their mental health problems are not considered sufficiently “severe” to warrant care from statutory services; but they are frequently excluded from mainstream services in the community, such as GPs and Housing Associations, on account of the perceived complexity of their needs and their often challenging behaviour. Consequently, the lack of support contributes to a downward spiral that brings people into contact with the criminal justice system. It is estimated that the number of individuals within the revolving door group is approximately 60,000 at any one time.

Organisation

Formation

In 1992 a report undertaken by NACRO (a social justice charity) and an ITV Telethon identified a group of people who were caught in a downward cycle of homelessness and found themselves in repeat contact with both the mental health and criminal justice system. This group was identified as the ‘revolving doors’ group, which subsequent research has estimated to include 60,000 people at any one time.

Following the publication of the report in 1993, the Revolving Doors Agency was established by some of the parties involved in the initial publication who sought to demonstrate new ways of working in these three areas of criminal justice, mental health and homelessness. The focus of the organisation was on the people who kept falling between the mainstream services in the community.

Initially, the organisation conducted research in prisons and police stations to identify the needs of the revolving doors group and establish the issues they faced.

In the late 1990s the organisation established a series of experimental services, called Link Worker Schemes, to test effective interventions for their target group. The schemes offered individuals practical and emotional support, assisting them to access appropriate services and to address the underlying causes of their offending behaviour. An independent evaluation conducted by the Home Office found that the scheme cut reoffending by 22%.

Following a strategic review in 2006, the organisation adjusted its focus to research, policy and campaigning work in relation to people who become stuck in a cycle of mental health problems and crime. The Link Worker Schemes were passed over to other voluntary sector providers.

Funding

The organisation is funded by charitable donations from individuals, grants from statutory bodies and applications to charitable foundations. Recent funders include the Big Lottery Fund, the Esmée Fairbairn Foundation, The Henry Smith Charity, the Paul Hamlyn Foundation, the Pilgrim Trust and Trusts for London. The organisation has previously received funding from Comic Relief.

Revolving Doors has also received pro-bono support from Clifford Chance who, in partnership with the University of Cambridge Pro Bono Society, assisted the organisation with additional research.

Governance

Revolving Doors is governed by a Board of Trustees who oversee the activities of the organisation, which itself is run by a team of nine members of staff who are supported by associates across the country. The organisation is a registered private company limited by guarantee, with no share capital, which means it is run for non-profit purposes. It is a recognised as a charity by the Charities Commission.

Partnerships

The organisation affiliates itself to the Criminal Justice Alliance, a coalition of 58 organisations involved in policy and practice across the criminal justice system, the Mental Health Alliance, a coalition of 75 organisations which aims to secure a better mental health legislation, and the Transition to Adulthood Alliance, which works to improve the opportunities and life chances of young people in their transition to adulthood, who are at risk of committing crime and falling into the criminal justice system.

Patrons

The current patrons of Revolving Doors are Lord David Ramsbotham GCB CBE (Former Chief Inspector of Prisons), the Rt Hon. Hilary Armstrong (Former Member of Parliament for North West Durham and Cabinet Minister for Social Exclusion and Duchy of Lancaster), Ian Bynoe (Former Acting Deputy Chair of the Independent Police Complaints Commission), Rose Fitzpatrick (Acting Assistant Commissioner for the Metropolitan Police), Professor John Gunn (Professor of Forensic Psychiatry at the University of Birmingham), Dru Sharpling CBE (London Director of the Crown Prosecution Service), His Honour Judge Fabyan Evans, Bharat Mehta OBE (Chief Executive of Trusts for London), Joe Simpson (Consultant) and Peter Wrench, Consultant and Writer, former Prison Service and Home Office Director.

Publications

Revolving Doors has published a number of works with a focus on the revolving doors group who have mental health problems within the criminal justice system, including a report on the financial impact of supporting women with multiple needs in the criminal justice system. This report established that an investment of £18 million per year England-wide in interventions could reduce the cost to the state by £384m over three years and almost £1 billion over five years.

In 2012, Revolving Doors Published Integrated Offender Management – Effective alternatives to short sentences. It also published Ending the Revolving Door – guidance for Police and Crime Commissioners.

Reception

Revolving Doors is widely regarded as one of the UK’s leading charities concerned with mental health and the criminal justice system.

In 2002 the organisation received two UK Charity Awards, which are given for outstanding achievements within the UK not-for-profit sector, in the category of Research, Advice and Support, as well as being the Overall Winner.

In 2006 the Revolving Doors Agency received an award from the Care Services Improvement Partnership, part of the Care Services Directorate at the Department of Health, for their Link Worker Scheme in the London Borough of Islington. The same year, the organisation was also highly commended by the Centre for Social Justice.

In 2010, Neighbourhood Link, a scheme in the Islington developed in partnership by St. Mungo’s and the Revolving Doors Agency, was highlighted as evidence of good-practice by the Cabinet Office. The scheme helps people with multiple and complex needs who are either involved in crime or at risk of becoming involved in crime and becoming homeless. As a result of the project, contact with the police amongst the users has fallen from 31% to 9%.

On This Day … 21 January

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People (Births)

Wolfgang Kohler

Wolfgang Köhler (21 January 1887 to 11 June 1967) was a German psychologist and phenomenologist who, like Max Wertheimer and Kurt Koffka, contributed to the creation of Gestalt psychology.

During the Nazi regime in Germany, he protested against the dismissal of Jewish professors from universities, as well as the requirement that professors give a Nazi salute at the beginning of their classes. In 1935 he left the country for the United States, where Swarthmore College in Pennsylvania offered him a professorship. He taught with its faculty for 20 years, and did continuing research. A Review of General Psychology survey, published in 2002, ranked Köhler as the 50th most cited psychologist of the 20th century.

Joseph Nicolosi

Joseph Nicolosi (24 January 1947 to 08 March 2017) was an American clinical psychologist who advocated and practised “reparative therapy”, a form of the pseudoscientific treatment of conversion therapy that he claimed could help people overcome or mitigate their homosexual desires and replace them with heterosexual ones. Nicolosi was a founder and president of the National Association for Research and Therapy of Homosexuality (NARTH). Medical institutions warn that conversion therapy is ineffective and may be harmful, and that there is no evidence that sexual orientation can be changed by such treatments.

Nicolosi described his ideas in Reparative Therapy of Male Homosexuality: A New Clinical Approach (1991) and three other books. Nicolosi proposed that homosexuality is often the product of a condition he described as gender-identity deficit caused by an alienation from, and perceived rejection by, formative individuals of the subject’s gender which interrupts normal masculine or feminine identification process. He also held that adaptation to gender trauma during formative years could alienate a child from their “fundamental nature.” His goal was to restore “that which functions in accordance with its biological design.”

What is Phenobarbital?

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Introduction

Phenobarbital, also known as phenobarbitone or phenobarb, or by the trade name Luminal, is a medication of the barbiturate type.

It is recommended by the World Health Organisation (WHO) for the treatment of certain types of epilepsy in developing countries. In the developed world, it is commonly used to treat seizures in young children, while other medications are generally used in older children and adults. It may be used intravenously, injected into a muscle, or taken by mouth. The injectable form may be used to treat status epilepticus. Phenobarbital is occasionally used to treat trouble sleeping, anxiety, and drug withdrawal and to help with surgery. It usually begins working within five minutes when used intravenously and half an hour when administered by mouth. Its effects last for between four hours and two days.

Side effects include a decreased level of consciousness along with a decreased effort to breathe. There is concern about both abuse and withdrawal following long-term use. It may also increase the risk of suicide. It is pregnancy category B or D (depending on how it is taken) in the United States and category D in Australia, meaning that it may cause harm when taken by pregnant women. If used during breastfeeding it may result in drowsiness in the baby. A lower dose is recommended in those with poor liver or kidney function, as well as elderly people. Phenobarbital, like other barbiturates works by increasing the activity of the inhibitory neurotransmitter GABA.

Phenobarbital was discovered in 1912 and is the oldest still commonly used anti-seizure medication. It is on the WHO’s List of Essential Medicines.

Brief History

The first barbiturate drug, barbital, was synthesized in 1902 by German chemists Emil Fischer and Joseph von Mering and was first marketed as Veronal by Friedr. Bayer et comp. By 1904, several related drugs, including phenobarbital, had been synthesized by Fischer. Phenobarbital was brought to market in 1912 by the drug company Bayer as the brand Luminal. It remained a commonly prescribed sedative and hypnotic until the introduction of benzodiazepines in the 1960s.

Phenobarbital’s soporific, sedative and hypnotic properties were well known in 1912, but it was not yet known to be an effective anti-convulsant. The young doctor Alfred Hauptmann gave it to his epilepsy patients as a tranquiliser and discovered their seizures were susceptible to the drug. Hauptmann performed a careful study of his patients over an extended period. Most of these patients were using the only effective drug then available, bromide, which had terrible side effects and limited efficacy. On phenobarbital, their epilepsy was much improved: The worst patients suffered fewer and lighter seizures and some patients became seizure-free. In addition, they improved physically and mentally as bromides were removed from their regimen. Patients who had been institutionalised due to the severity of their epilepsy were able to leave and, in some cases, resume employment. Hauptmann dismissed concerns that its effectiveness in stalling seizures could lead to patients suffering a build-up that needed to be “discharged”. As he expected, withdrawal of the drug led to an increase in seizure frequency – it was not a cure. The drug was quickly adopted as the first widely effective anti-convulsant, though World War I delayed its introduction in the US.

In 1939, a German family asked Adolf Hitler to have their disabled son killed; the five-month-old boy was given a lethal dose of Luminal after Hitler sent his own doctor to examine him. A few days later 15 psychiatrists were summoned to Hitler’s Chancellery and directed to commence a clandestine programme of involuntary euthanasia.

In 1940, at a clinic in Ansbach, Germany, around 50 intellectually disabled children were injected with Luminal and killed that way. A plaque was erected in their memory in 1988 in the local hospital at Feuchtwanger Strasse 38, although a newer plaque does not mention that patients were killed using barbiturates on site. Luminal was used in the Nazi children’s euthanasia programme until at least 1943.

Phenobarbital was used to treat neonatal jaundice by increasing liver metabolism and thus lowering bilirubin levels. In the 1950s, phototherapy was discovered, and became the standard treatment.

Phenobarbital was used for over 25 years as prophylaxis in the treatment of febrile seizures. Although an effective treatment in preventing recurrent febrile seizures, it had no positive effect on patient outcome or risk of developing epilepsy. The treatment of simple febrile seizures with anticonvulsant prophylaxis is no longer recommended.

Medical Uses

Phenobarbital is used in the treatment of all types of seizures, except absence seizures. It is no less effective at seizure control than phenytoin, however phenobarbital is not as well tolerated. Phenobarbital may provide a clinical advantage over carbamazepine for treating partial onset seizures. Carbamazepine may provide a clinical advantage over phenobarbital for generalised onset tonic-clonic seizures. Its very long active half-life (53-118 hours) means for some people doses do not have to be taken every day, particularly once the dose has been stabilised over a period of several weeks or months, and seizures are effectively controlled.

The first-line drugs for treatment of status epilepticus are benzodiazepines, such as lorazepam or diazepam. If these fail, then phenytoin may be used, with phenobarbital being an alternative in the US, but used only third-line in the UK. Failing that, the only treatment is anaesthesia in intensive care. The WHO gives phenobarbital a first-line recommendation in the developing world and it is commonly used there.

Phenobarbital is the first-line choice for the treatment of neonatal seizures. Concerns that neonatal seizures in themselves could be harmful make most physicians treat them aggressively. No reliable evidence, though, supports this approach.

Phenobarbital is sometimes used for alcohol detoxification and benzodiazepine detoxification for its sedative and anti-convulsant properties. The benzodiazepines chlordiazepoxide (Librium) and oxazepam (Serax) have largely replaced phenobarbital for detoxification.

Phenobarbital is useful for insomnia and anxiety.

Other Uses

Phenobarbital properties can effectively reduce tremors and seizures associated with abrupt withdrawal from benzodiazepines.

Phenobarbital is a cytochrome P450 inducer, and is used to reduce the toxicity of some drugs.

Phenobarbital is occasionally prescribed in low doses to aid in the conjugation of bilirubin in people with Crigler-Najjar syndrome, type II,[26] or in people with Gilbert’s syndrome. Phenobarbital can also be used to relieve cyclic vomiting syndrome symptoms.

Phenobarbital is a commonly used agent in high purity and dosage for lethal injection of “death row” criminals.

In infants suspected of neonatal biliary atresia, phenobarbital is used in preparation for a 99mTc-IDA hepatobiliary (HIDA; hepatobiliary 99mTc-iminodiacetic acid) study that differentiates atresia from hepatitis or cholestasis.

Phenobarbital is used as a secondary agent to treat newborns with neonatal abstinence syndrome, a condition of withdrawal symptoms from exposure to opioid drugs in utero.

In massive doses, phenobarbital is prescribed to terminally ill people to allow them to end their life through physician-assisted suicide.

Like other barbiturates, phenobarbital can be used recreationally, but this is reported to be relatively infrequent.

Side Effects

Sedation and hypnosis are the principal side effects (occasionally, they are also the intended effects) of phenobarbital. Central nervous system effects, such as dizziness, nystagmus and ataxia, are also common. In elderly patients, it may cause excitement and confusion, while in children, it may result in paradoxical hyperactivity.

Phenobarbital is a cytochrome P450 hepatic enzyme inducer. It binds transcription factor receptors that activate cytochrome P450 transcription, thereby increasing its amount and thus its activity. Due to this higher amount of CYP450, drugs that are metabolised by the CYP450 enzyme system will have decreased effectiveness. This is because the increased CYP450 activity increases the clearance of the drug, reducing the amount of time they have to work.

Caution is to be used with children. Among anti-convulsant drugs, behavioural disturbances occur most frequently with clonazepam and phenobarbital.

Contraindications

Acute intermittent porphyria, hypersensitivity to any barbiturate, prior dependence on barbiturates, severe respiratory insufficiency (as with chronic obstructive pulmonary disease), severe liver failure, pregnancy, and breastfeeding are contraindications for phenobarbital use.

Overdose

Refer to Barbiturate Overdose.

Phenobarbital causes a depression of the body’s systems, mainly the central and peripheral nervous systems. Thus, the main characteristic of phenobarbital overdose is a “slowing” of bodily functions, including decreased consciousness (even coma), bradycardia, bradypnea, hypothermia, and hypotension (in massive overdoses). Overdose may also lead to pulmonary oedema and acute renal failure as a result of shock, and can result in death.

The electroencephalogram (EEG) of a person with phenobarbital overdose may show a marked decrease in electrical activity, to the point of mimicking brain death. This is due to profound depression of the central nervous system, and is usually reversible.

Treatment of phenobarbital overdose is supportive, and mainly consists of the maintenance of airway patency (through endotracheal intubation and mechanical ventilation), correction of bradycardia and hypotension (with intravenous fluids and vasopressors, if necessary), and removal of as much drug as possible from the body. In very large overdoses, multi-dose activated charcoal is a mainstay of treatment as the drug undergoes enterohepatic recirculation. Urine alkalisation (achieved with sodium bicarbonate) enhances renal excretion. Haemodialysis is effective in removing phenobarbital from the body, and may reduce its half-life by up to 90%. No specific antidote for barbiturate poisoning is available.

Mechanism of Action

Phenobarbitol is as an allosteric modulator which extends the amount of time the chloride ion channel is open by interacting with GABAA receptor subunits. Through this action, phenobarbital increases the flow of chloride ions into the neuron which decreases the excitability of the post-synaptic neuron. Hyperpolarising this post-synaptic membrane leads to a decrease in the general excitatory aspects of the post-synaptic neuron. By making it harder to depolarise the neuron, the threshold for the action potential of the post-synaptic neuron will be increased. Phenobarbital stimulates GABA to accomplish this hyperpolarisation. Direct blockade of excitatory glutamate signalling is also believed to contribute to the hypnotic/anticonvulsant effect that is observed with the barbiturates.

Pharmacokinetics

Phenobarbital has an oral bioavailability of about 90%. Peak plasma concentrations (Cmax) are reached eight to 12 hours after oral administration. It is one of the longest-acting barbiturates available – it remains in the body for a very long time (half-life of two to seven days) and has very low protein binding (20 to 45%). Phenobarbital is metabolized by the liver, mainly through hydroxylation and glucuronidation, and induces many isozymes of the cytochrome P450 system. Cytochrome P450 2B6 (CYP2B6) is specifically induced by phenobarbital via the CAR/RXR nuclear receptor heterodimer. It is excreted primarily by the kidneys.

Veterinary Uses

Phenobarbital is one of the initial drugs of choice to treat epilepsy in dogs, as well as cats. It is also used to treat feline hyperesthesia syndrome in cats when anti-obsessional therapies prove ineffective.

It may also be used to treat seizures in horses when benzodiazepine treatment has failed or is contraindicated.

Society and Culture

Names

Phenobarbital is the INN and phenobarbitone is the BAN.

Synthesis

Barbiturate drugs are obtained via condensation reactions between a derivative of diethyl malonate and urea in the presence of a strong base. The synthesis of phenobarbital uses this common approach as well but differs in the way in which this malonate derivative is obtained. The reason for this difference is due to the fact that aryl halides do not typically undergo nucleophilic substitution in Malonic ester synthesis in the same way as aliphatic organosulfates or halocarbons do. To overcome this lack of chemical reactivity two dominant synthetic approaches using benzyl cyanide as a starting material have been developed:

  • The first of these methods consists of a Pinner reaction of benzyl cyanide, giving phenylacetic acid ethyl ester. Subsequently, this ester undergoes cross Claisen condensation using diethyl oxalate, giving diethyl ester of phenyloxobutandioic acid. Upon heating this intermediate easily loses carbon monoxide, yielding diethyl phenylmalonate. Malonic ester synthesis using ethyl bromide leads to the formation of α-phenyl-α-ethylmalonic ester. Finally a condensation reaction with urea gives phenobarbital.
  • The second approach utilises diethyl carbonate in the presence of a strong base to give α-phenylcyanoacetic ester. Alkylation of this ester using ethyl bromide proceeds via a nitrile anion intermediate to give the α-phenyl-α-ethylcyanoacetic ester. This product is then further converted into the 4-iminoderivative upon condensation with urea. Finally acidic hydrolysis of the resulting product gives phenobarbital.

Regulation
The level of regulation includes Schedule IV non-narcotic (depressant) (ACSCN 2285) in the United States under the Controlled Substances Act 1970—but along with a few other barbiturates and at least one benzodiazepine, and codeine, dionine, or dihydrocodeine at low concentrations, it also has exempt prescription and had at least one exempt OTC combination drug now more tightly regulated for its ephedrine content.[63] The phenobarbitone/phenobarbital exists in subtherapeutic doses which add up to an effective dose to counter the overstimulation and possible seizures from a deliberate overdose in ephedrine tablets for asthma, which are now regulated at the federal and state level as: a restricted OTC medicine and/or watched precursor, uncontrolled but watched/restricted prescription drug & watched precursor, a Schedule II, III, IV, or V prescription-only controlled substance & watched precursor, or a Schedule V (which also has possible regulations at the county/parish, town, city, or district as well aside from the fact that the pharmacist can also choose not to sell it, and photo ID and signing a register is required) exempt Non-Narcotic restricted/watched OTC medicine.[64]

Selected Overdoses

The Japanese officers aboard the German submarine U-234 killed themselves with phenobarbital while the German crew members were on their way to the US to surrender (but before Japan had surrendered).

A mysterious woman, known as the Isdal Woman, was found dead in Bergen, Norway, on 29 November 1970. Her death was caused by some combination of burns, phenobarbital, and carbon monoxide poisoning; many theories about her death have been posited, and it is believed that she may have been a spy.

British veterinarian Donald Sinclair, better known as the character Siegfried Farnon in the “All Creatures Great and Small” book series by James Herriot, committed suicide at the age of 84 by injecting himself with an overdose of phenobarbital. Activist Abbie Hoffman also committed suicide by consuming phenobarbital, combined with alcohol, on 12 April 1989; the residue of around 150 pills was found in his body at autopsy. Also dying from an overdose was British actress Phyllis Barry in 1954 and actress/model Margaux Hemingway in 1996.

Thirty-nine members of the Heaven’s Gate UFO religious group committed mass suicide in March 1997 by drinking a lethal dose of phenobarbital and vodka “and then lay down to die” hoping to enter an alien spacecraft.

What is Phenazolam?

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Introduction

Phenazolam, (Clobromazolam, DM-II-90, BRN 4550445) is a benzodiazepine derivative which acts as a potent sedative and hypnotic drug.

Background

It was first invented in the early 1980s, but was never developed for medical use. It has been sold over the internet as a designer drug, first being identified in seized samples by a laboratory in Sweden in March 2016.

Legality

Clobromazolam was made illegal in Serbia in May 2019, and in Italy in March 2020.

What is Paranoid Anxiety?

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Introduction

Paranoid anxiety is a term used in object relations theory, particularity in discussions about the Paranoid-schizoid and depressive positions.

The term was frequently used by Melanie Klein, especially to refer to a pre-depressive and persecutory sense of anxiety characterised by the psychological splitting of objects.

Further Developments

Donald Meltzer saw paranoid anxiety as linked not only to a loss of trust in the goodness of objects, but also to a confusion between feeling and thought.

For the extreme forms of such anxiety, he coined the term ‘terror’, to convey something of the qualitatively different intensity of their nature.

External Sources

Sigmund Freud considered that there was generally a small kernel of truth hidden in the exaggerated anxiety of the paranoid – what Hanns Sachs described as an amoeba about to become monster.

The anti-psychiatrist David Cooper argued indeed that “The therapist in working with people might far more often have to confirm the reality of paranoid fears than in any sense disconfirm or attempt to modify them”, but most family therapists would probably agree that this is an extreme and one-sided position.

Defensive Functions

Idealisation (as in the transference) can be used as a defence against deeper paranoid anxieties about the actual presence of a destructive, denigrating object.

Conversely, paranoid fears, especially when systematised, may themselves serve as a defence against a deeper, chaotic disintegration of the personality.

Persecutory Anxiety State (Panic Attack) and Persecutory Delusion

Paranoid anxiety may reach the level of a persecutory anxiety state (a form of panic attack), including various levels of persecutory delusions (the preferred term to paranoid delusions).

Heavy drinking is said to sometimes precipitate acute paranoid panic – the protagonist’s unconscious hostile impulses being projected onto all those around.

Literary Examples

Hamm in Endgame by Samuel Beckett has been singled out as a character driven by paranoid anxiety.

Noboru in The Sailor Who Fell from Grace with the Sea by Yukio Mishima is shown to have persecutory anxiety.

What is the Pan American Health Organisation?

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Introduction

The Pan American Health Organisation (PAHO) is an international public health agency working to improve the health and living standards of the people of the Americas.

It is part of the United Nations system, serving as the Regional Office for the Americas of the World Health Organisation (WHO) and as the health organisation of the Inter-American System. It is known in Latin America as the OPS or OPAS (Spanish: Organización Panamericana de la Salud; Portuguese: Organização Pan-Americana da Saúde).

Brief History

The organisation was founded in December 1902. It was originally called the Pan-American Sanitary Bureau.  In 1949, PAHO and WHO signed an agreement making PAHO the American Regional Office (AMRO) of WHO. Today the usual phrasing is “Regional Office for the Americas”. The first hemisphere-wide effort to eradicate smallpox was made in 1950 by the PAHO. The campaign was successful in eliminating smallpox from all countries of the Americas except Argentina, Brazil, Colombia, and Ecuador.

Background

PAHO has scientific and technical expertise at its headquarters, in its 27 country offices, and its three Pan American centres, all working with the countries of the Americas in dealing with priority health issues. The health authorities of PAHO’s Member States set PAHO’s technical and administrative policies through its Governing Bodies. The PAHO Member States include all 35 countries in the Americas; Puerto Rico is an Associate Member. France, the Kingdom of the Netherlands, and the United Kingdom of Great Britain and Northern Ireland are the Participating States, and Portugal and Spain are the Observer States.

The Organization’s essential mission is to strengthen national and local health systems and improve the health of the peoples of the Americas, in collaboration with Ministries of Health, other government and international agencies, non-governmental organisations (NGO), universities, social security agencies, community groups, and many others.

PAHO promotes universal health coverage and universal access to health and strengthening of health systems based on primary health care strategies. It assists countries in fighting infectious diseases such as malaria, cholera, dengue, HIV and tuberculosis as well as the region’s growing epidemic of noncommunicable diseases such as cardiovascular disease, cancer and diabetes. PAHO engages in technical cooperation with ministries of health and facilitates coordination with other sectors to promote health in all policies. PAHO also promotes the use of research evidence to inform health care decisions and policymaking through the implementation of knowledge translation strategies such as the Evidence-Informed Policy Network – EVIPNet Evipnet. Through the Elimination Initiative, it targets HIV/AIDS.

In its efforts to improve health, PAHO targets the most vulnerable groups including mothers and children, workers, the poor, the elderly, and refugees, and displaced persons. It focuses on issues related to equity for those who lack access to health, and on a Pan American approach, encouraging countries to work together on common issues and build lasting capacities.

Specific initiatives spearheaded by PAHO include the Expanded Programme on Immunisation, which played a major role in the elimination of smallpox and polio from the Americas; the Tobacco-free Americas initiative; the Regional Coalition for Water and Sanitation to Eliminate Cholera in Hispaniola; the Salt Smart Consortium; the Pan American Network for Drug Regulatory Harmonization; and a blood safety initiative that seeks to improve blood safety and efficiency by helping countries reach 100% blood supplies from unpaid voluntary donors.

A major priority for the Americas is cutting infant mortality, and PAHO is mobilising new political, institutional, and financial resources to prevent an additional 25,000 infant deaths every year through the application of the Integrated Management of Childhood Illness strategy, a simple and practical approach in which primary health care workers are taught a complete process to evaluate the health status of children brought to a health post or clinic. They learn to recognise signs of disease and evaluate and treat them. They learn to give parents information on how to prevent disease in the home. If they see danger signs indicating the infant could die, they are taught to treat the child immediately or take him or her to a hospital.

Improvement of drinking water supplies, adequate sanitation, and increased access to health care for the poor are still top priorities for PAHO, with a focus on equity. The Organisation is intensifying its efforts to have countries know the true state of health of their populations and where the inequalities lie. Programme efforts focus on correcting inequality, taking into account decentralisation and change of state functions, on showing that health has a role to play in the success of other sectors, and on how attention to health affects positively other aspects of human development. Advocacy in this area is also directed to reducing pernicious gender inequity, which reflects in some health problems of women.

The Pan American approach is a part of PAHO history and the spirit of Panamericanism continues to stimulate technical cooperation among countries in health. PAHO has helped countries work together toward common goals, and to initiate multi-country health ventures in Central America, the Caribbean, the Andean Region, and the Southern Cone. Experience has shown practical benefits such as the solidarity that helped Central America after hurricane Mitch, and there are numerous other examples. Health collaboration found expression at the highest political level when American heads of state in their Summit in Santiago accepted a health initiative called “Health Technology Linking the Americas.”

The countries of Latin America and the Caribbean joined together over 20 years ago to buy vaccines through a revolving fund, bringing them tangible benefits and helping advance PAHO’s efforts to eliminate or control vaccine-preventable diseases. These are among the Organisation’s most notable successes, starting with the eradication of smallpox from the Americas in 1973; a triumph followed five years later by global eradication of the dreaded disease.

A major effort committing the Americas to embark on polio eradication in 1985 succeeded in September 1994, when a distinguished International Commission declared the Americas officially polio-free. The last case of polio in the Americas was identified on August 23, 1991, in a young boy named Luis Fermín Tenorio Cortez, in Junín, Peru. Since then, despite intensive surveillance, no cases of polio have been detected anywhere in the Americas, and the WHO is now working toward the goal of eradicating polio globally. PAHO assists the countries in mobilising the necessary resources to provide immunisation and treatment services for all vaccine-preventable diseases. PAHO is close to accomplishing the goal of eliminating measles from this hemisphere and is pressing on with the introduction of new vaccines that are currently available, such as Haemophilus influenzae B. to reduce meningitis and respiratory infections. PAHO works to reduce the toll of death and illness from diarrheal diseases, including cholera, through case management and oral rehydration therapy to prevent deaths from dehydration, and to provide adequate diagnosis and treatment of acute respiratory infections, thus saving the lives of hundreds of thousands of children each year.

PAHO disseminates scientific and technical information through its publications program, its Internet site, and a network of academic libraries, documentation centres, and local health care libraries.

The Organisation provides technical collaboration in a variety of specialised public health fields and organises emergency preparedness and disaster relief coordination. It supports efforts to strengthen national health systems, develop national health research systems, control malaria, Chagas’ disease, urban rabies, leprosy, and other diseases that affect the people of the Americas. PAHO collaborates with governments, other agencies, and private groups to address major nutritional problems including protein-energy malnutrition, and is now working to eliminate iodine and vitamin A deficiencies.

It engages in and facilitates health promotion to help countries deal with health problems typical of development and urbanisation, especially non-communicable diseases (NCDs) such as cardiovascular diseases, cancer, accidents, smoking, addiction to drugs and alcohol, and injuries among others. Beyond health promotion, PAHO also addresses health systems and quality of care issues in support of national efforts to respond to the NCD pandemic.

The Organisation also executes projects for other United Nations agencies, for international organisations such as the World Bank and Inter-American Development Bank, for official development cooperation agencies of various governments, and for philanthropic foundations.

PAHO strengthens the health sector capacity in the countries to advance their priority programmes through intersectoral action, promoting an integrated approach to health problems. It also works to improve women’s health, promoting the greater integration of women in society, as well as awareness of their importance as both recipients and providers of health services.

PAHO trains health workers at all levels, through fellowships, courses and seminars, and the strengthening of national training institutions. It leads to the use of advanced communications technologies for information, health promotion, and education, working with journalists in many countries.

The Organisation recognises the role of the private sector in the delivery of services and fosters dialogue and partnerships with the Ministries of Health. In addition to its core budget financed by quota contributions from its Member Governments, PAHO also seeks outside funding to help implement special programmes and initiatives in response to vital health needs. Voluntary tax-deductible contributions for PAHO health and education projects in the Americas may be made to the PAHO Foundation.

Headquarters Building

In March 1960, President Eisenhower signed into law a bill passed by the US Congress authorising the US government to purchase and donate a lot for the PAHO headquarters in Washington, D.C. At the meeting of its Executive Committee in April 1960, the PAHO decided to accept the USG’s offer and set forth parameters for proceeding with the project of a new headquarters building. PAHO decided to use an international open competition as the means of selecting an architect for the project, following the recent successful model of other international organisations (most notably the United Nations New York headquarters inaugurated in 1952, and the UNESCO Paris headquarters in 1953 – both resulting in landmark designs of modernist architecture). PAHO framed the competition based on standards developed by the International Union of Architects and determined that the competition should be open to architects from all countries of the Americas. The vision was that “the new building should be a monument to international health cooperation.”

Following a review of 58 entries, the PAHO in October 1961 declared Uruguayan architect Román Fresnedo Siri the winner of its competition. At the ceremony announcing him as a winner, the organization’s Director Abraham Horwitz said “this beautiful building will become a monument to the ideal of better health for the peoples of the Americas.” He described the winning design as one of “both grace and utility,” and said, “it reflects the high ideals of the Pan-American spirit in an age when we must move ahead to build a better future for our peoples.”

The building was designed in a modernist style by Fresnedo Siri in part as a tribute to Le Corbusier, a key influence on Fresnedo Siri’s work. Constructed in 1965, the exterior features 29 round bronze seals of the founding nations of the Pan American Health Organisation set in black stone. Each medallion is 2.5 feet (0.76 m) in diameter and were designed by American sculptor Michael Lantz. They were originally meant to be carved in granite. The east side of the south façade (left to right) seals are for: France, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, the Netherlands, Nicaragua, Panama, Paraguay, Peru, Trinidad and Tobago, United Kingdom, United States, Uruguay, and Venezuela. The west side of the south façade seals are for: Argentina, Barbados, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, and El Salvador. In 1993 the seals were surveyed by the Smithsonian Institution’s Save Outdoor Sculpture! program and were described as needing conservation treatment.

The building is situated on a triangular lot of just over one acre nestled between Virginia Avenue, E Street, and 23rd Street, Northwest, in the Foggy Bottom neighbourhood of Washington. Constructed of reinforced concrete over a steel frame with an exterior of glass and marble, the building is one of Washington’s most recognised examples of mid-century modern architecture. The building is divided into two distinct volumes: a gracefully curved ten-story building that hosts the organization’s main offices, and an adjoining four-story cylindrical annex that serves as the congress hall for formal assemblies of the PAHO member state delegates, as well as other meetings and events. It is surrounded by George Washington University to the north and east, the Columbia Plaza office/residential complex to the west, and the State Department to the south across the E street expressway underpass.

The main building features soaring white vertical columnar ribs evenly separating dark vertical columns of glass. There are no horizontal lines to compete with the vertical symmetry; the building’s vertical ribs disappear along “blind gables” into an invisible roofline. In the formalism and attention to symmetry, Fresnedo Siri said he was trying to stay true to the “classic spirit of the city of Washington.” The interplay of light and dark is accentuated by the use of white American marble, black Mexican granite, and dark gray glass. The building’s slender, windowless west and east sides are clad in white marble, while the black granite frames all the ground floor elements, including the entry portico, the hidden downward ramp to an underground garage, and the reflecting pool and garden elements.

Fresnedo Siri placed the main building on 20 rounded pilotis (columns) that lift it a full story above ground level. He employed this signature element of mid-century modernist design to maximise the open pedestrian plaza space on the relatively small and unusually shaped lot while enhancing visual transparency and flow. He added reflecting pools with fountains at the base of each building – his vision was that the cylindrical congress hall, in particular, would appear to be “emerging from the water.” The thin vertical streams spurting up from the fountains would echo the symmetry of the columns and vertical ribbing of the main building. A row of 42 flag poles (representing each PAHO member state) reinforces still further the building’s dancing array of vertical symmetries, while also gracefully delineating the Northeastern edge of the property site. Unfortunately, the reflecting pools years later were eliminated, filled in and replaced by garden plots.

Fresnedo Siri purposefully placed the convex side of the curved main office building to the north, smoothly integrating it into the urban streetscape of similarly sized office, university and residential buildings. This allowed the concave side of the building to face the open side of the lot, gently cradling the congress hall annex while framing the contours of the small but appealing pedestrian plaza area that flows toward the site’s open southern side.

The cylindrical annex’s around the central congress hall are about 92 feet (28 m) in diameter and seat up to 300 people. The single open space soars upward, filling the top three levels of the building. Fresnedo Siri designed a dramatic spider web-like steel structure to support the building, allowing the entire interior space to be free of any supporting columns. The resulting internal space, naturally lit by windows throughout the cylinder’s full 360 degrees, achieves an impressive sense of openness and purity of design. The cylindrical building is encased on the outside by a lattice-like grill of diamond-shaped hexagons composed of white marble, quartz and Portland cement. The recessed ground floor space of the cylinder is encased in the same Mexican black granite used for all the site’s ground-level elements, creating a striking contrast with the white honeycomb grill of the upper levels it supports.

After studying the main diplomatic congress halls at the UN, State Department, the OAS and elsewhere, Fresnedo Siri devised a “floating seat” solution for the chairs in the PAHO’s hall. The seats are all anchored to the floor in the rear to curved latitudinal support elements running behind each row (and serving as hidden conduits for the simultaneous translation cabling), achieving what he described as “a great functional and aesthetic purity.” All of the furnishings for the main halls and meeting rooms were designed under his specifications by Knoll Associates, a leading New York-based producer of modernist furniture including landmark designs of the era like the Saarinen womb chair and Mies Van de Rohe’s Barcelona chair. Fresnedo Siri designed the magisterial backdrop to the presidium of the Congress hall, using vertical slats of six different kinds of wood including Honduran mahogany, Brazilian jacaranda, American walnut and oak, arranged in his words “to accentuate the dimension of the space and the importance of the function it served.” Fresnedo Siri also designed the central chandelier of the Congress hall, calling the piece “a sculpture in light.” Measuring 20 feet in diameter and weighing 16,000 pounds (7,300 kg), it consisted of 3000 long rectangular pieces of Lucite, the translucent acrylic resin invented by Dupont in the 1930s for industrial and military uses then enjoying an early-60’s boom as a “space age” material for vanguard furniture and art.