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On This Day … 14 October

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People (Births)

Jurg Schubiger

Jürg Schubiger (14 October 1936 to 15 September 2014) was a Swiss psychotherapist and writer of children’s books. He won the Deutscher Jugendliteraturpreis (German Youth Literature Award) in 1996 for Als die Welt noch jung war.

For his “lasting contribution” as a children’s writer Schubiger received the biennial Hans Christian Andersen Medal in 2008. The award conferred by the International Board on Books for Young People is the highest recognition available to a writer or illustrator of children’s books.

What is the Community Mental Health Act of 1963?

Published on by Andrew Marshall1 Comment

Introduction

The Community Mental Health Act of 1963 (CMHA) (also known as the Community Mental Health Centres Construction Act, Mental Retardation Facilities and Construction Act, Public Law 88-164, or the Mental Retardation and Community Mental Health Centres Construction Act of 1963) was an act to provide federal funding for community mental health centres and research facilities in the United States.

Background

This legislation was passed as part of John F. Kennedy’s New Frontier. It led to considerable deinstitutionalisation.

In 1955, Congress passed the Mental Health Study Act, leading to the establishment of the Joint Commission on Mental Illness and Mental Health. That Commission issued a report in 1961, which would become the basis of the 1963 Act.

The CMHA provided grants to states for the establishment of local mental health centres, under the overview of the National Institute of Mental Health. The NIH also conducted a study involving adequacy in mental health issues. The purpose of the CMHA was to build mental health centres to provide for community-based care, as an alternative to institutionalisation. At the centres, patients could be treated while working and living at home.

Only half of the proposed centres were ever built; none were fully funded, and the act did not provide money to operate them long-term. Some states saw an opportunity to close expensive state hospitals without spending some of the money on community-based care. Deinstitutionalisation accelerated after the adoption of Medicaid in 1965. During the Reagan administration, the remaining funding for the act was converted into a mental-health block grant for states. Since the CMHA was enacted, 90% of beds have been cut at state hospitals.

The CMHA proved to be a mixed success. Many patients, formerly warehoused in institutions, were released into the community. However, not all communities had the facilities or expertise to deal with them. In many cases, patients wound up in adult homes or with their families, or homeless in large cities, but without the mental health care they needed.

What was Addington vs Texas (1979)?

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Introduction

Addington v. Texas, 441 U.S. 418 (1979), was a landmark decision of the US Supreme Court that set the standard for involuntary commitment for treatment by raising the burden of proof required to commit persons for psychiatric treatment from the usual civil burden of proof of “preponderance of the evidence” to “clear and convincing evidence”.

Background

Before Frank Addington was arrested on the misdemeanour charge of “assault threat” against his mother, Addington’s mother filed a petition with the court, in accordance with Texas law, requesting that Addington be indefinitely involuntarily committed to a state psychiatric hospital. Addington had a long history of mental and emotional problems and past psychiatric hospitalisations. The state trial court issued jury instructions that the decision be based on “clear, unequivocal and convincing evidence” that Addington was mentally ill and that hospitalisation was required for his own welfare and the welfare of others. The jury found that Addington was mentally ill and required hospitalisation. Thereupon the trial court ordered his indefinite commitment. He was indefinitely committed to Austin State Hospital.

However, Addington appealed to the Texas Court of Appeals, based on the argument the court should have used the “beyond a reasonable doubt” standard of proof. The appeals court reversed, agreeing with Addington. The Texas Supreme Court then reversed the Court of Appeals’ decision, reinstating the trial court’s orders. It concluded that the standard of proof of the preponderance of the evidence satisfied due process in a civil commitment proceeding.

Addington then appealed to the US Supreme Court on a writ of certiorari (in law, certiorari is a court process to seek judicial review of a lower court of government agency).

Opinion of the Court

The appeal was dismissed and certiorari granted; the lower court’s decision was vacated and remanded. The court said the issue of an individual’s interest in liberty is of such weight and gravity that a higher standard of proof is required than is normal in civil cases brought under state law. Because of the uncertainties of psychiatric diagnosis, the burden of proof does not need to be as high as “beyond a reasonable doubt” in criminal cases, but should be a “clear and convincing” standard of proof as required by the Fourteenth Amendment in such a civil proceeding to commit an individual involuntarily for an indefinite period to a state psychiatric hospital.

Further, the opinion touched on the issue of an involuntary commitment as primarily medical in nature and needing the expertise of mental health experts.

Whether the individual is mentally ill and dangerous to either himself or others and is in need of confined therapy turns on the meaning of the facts which must be interpreted by expert psychiatrists and psychologists.

Subsequent Developments

The court raised the bar for committing someone against their will in a civil commitment proceeding. When the stakes are exceptionally high in civil matters, the burden of proof must be “clear and convincing evidence”. The case raised important issues regarding civil commitment by placing the burden of proof on the petitioner, that is the party seeking the involuntary commitment of a person.

The opinion also suggested that it was not necessarily for the trier of facts to draw the necessary conclusions without the expertise of psychiatrists and psychologists.

The Supreme Court also cited the Addington case in Santosky v. Kramer, which set a clear and convincing evidence standard in termination of parental rights cases.

What is Self Psychology?

Published on by Andrew Marshall1 Comment

Introduction

Self psychology, a modern psychoanalytic theory and its clinical applications, was conceived by Heinz Kohut in Chicago in the 1960s, 70s, and 80s, and is still developing as a contemporary form of psychoanalytic treatment.

In self psychology, the effort is made to understand individuals from within their subjective experience via vicarious introspection, basing interpretations on the understanding of the self as the central agency of the human psyche. Essential to understanding self psychology are the concepts of empathy, selfobject, mirroring, idealising, alter ego/twinship and the tripolar self. Though self psychology also recognises certain drives, conflicts, and complexes present in Freudian psychodynamic theory, these are understood within a different framework. Self psychology was seen as a major break from traditional psychoanalysis and is considered the beginnings of the relational approach to psychoanalysis.

Origins

Kohut came to psychoanalysis by way of neurology and psychiatry in the 1940s, but then ’embraced analysis with the fervor of a convert … [and as] “Mr Psychoanalysis”‘ took on an idealising image of Freud and his theories. Subsequently, “in a burst of creativity that began in the mid-1960s … Kohut found his voice and explored narcissism in new ways that led to what he ended up calling a ‘psychology of the self'”.

Major Concepts

Self

Kohut explained, in 1977, that in all he wrote on the psychology of the self, he purposely did not define the self. He explained his reasoning this way: “The self…is, like all reality…not knowable in its essence…We can describe the various cohesive forms in which the self appears, can demonstrate the several constituents that make up the self … and explain their genesis and functions. We can do all that but we will still not know the essence of the self as differentiated from its manifestations.”

Empathy

Kohut maintained that parents’ failures to empathize with their children and the responses of their children to these failures were ‘at the root of almost all psychopathology’. For Kohut, the loss of the other and the other’s self-object (“selfobject”) function (see below) leaves the individual apathetic, lethargic, empty of the feeling of life, and without vitality – in short, depressed.

The infant moving from grandiose to cohesive self and beyond must go through the slow process of disillusionment with phantasies of omnipotence, mediated by the parents: ‘This process of gradual and titrated disenchantment requires that the infant’s caretakers be empathetically attuned to the infant’s needs’.

Correspondingly, to help a patient deal in therapy with earlier failures in the disenchantment process, Kohut the therapist ‘highlights empathy as the tool par excellence, which allows the creation of a relationship between patient and analyst that can offer some hope of mitigating early self pathology’.

In comparison to earlier psychoanalytic approaches, the use of empathy, which Kohut called “vicarious introspection”, allows the therapist to reach conclusions sooner (with less dialogue and interpretation), and to create a stronger bond with the patient, making the patient feel more fundamentally understood. For Kohut, the implicit bond of empathy itself has a curative effect, but he also warned that ‘the psychoanalyst … must also be able to relinquish the empathic attitude’ to maintain intellectual integrity, and that ’empathy, especially when it is surrounded by an attitude of wanting to cure directly … may rest on the therapist’s unresolved omnipotence fantasies’.

The conceptual introduction of empathy was not intended to be a “discovery.” Empathic moments in psychology existed long before Kohut. Instead, Kohut posited that empathy in psychology should be acknowledged as a powerful therapeutic tool, extending beyond “hunches” and vague “assumptions,” and enabling empathy to be described, taught, and used more actively.

Selfobjects

Selfobjects are external objects that function as part of the “self machinery” – ‘i.e. objects which are not experienced as separate and independent from the self’. They are persons, objects or activities that “complete” the self, and which are necessary for normal functioning. ‘Kohut describes early interactions between the infant and his caretakers as involving the infant’s “self” and the infant’s “selfobjects”‘.

Observing the patient’s selfobject connections is a fundamental part of self psychology. For instance, a person’s particular habits, choice of education and work, taste in life partners, may fill a selfobject-function for that particular individual.

Selfobjects are addressed throughout Kohut’s theory, and include everything from the transference phenomenon in therapy, relatives, and items (for instance Linus van Pelt’s security blanket): they ‘thus cover the phenomena which were described by Winnicott as transitional objects. Among “the great variety of selfobject relations that support the cohesion, vigor, and harmony of the adult self … [are] cultural selfobjects (the writers, artists, and political leaders of the group – the nation, for example – to which a person feels he belongs)”.

If psychopathology is explained as an “incomplete” or “defect” self, then the self-objects might be described as a self-prescribed “cure”.

As described by Kohut, the selfobject-function (i.e. what the selfobject does for the self) is taken for granted and seems to take place in a “blindzone”. The function thus usually does not become “visible” until the relation with the selfobject is somehow broken.

When a relationship is established with a new selfobject, the relationship connection can “lock in place” quite powerfully, and the pull of the connection may affect both self and selfobject. Powerful transference, for instance, is an example of this phenomenon.

Optimal Frustration

When a selfobject is needed, but not accessible, this will create a potential problem for the self, referred to as a “frustration” – as with ‘the traumatic frustration of the phase appropriate wish or need for parental acceptance … intense narcissistic frustration’.

The contrast is what Kohut called “optimal frustration”; and he considered that, ‘as holds true for the analogous later milieu of the child, the most important aspect of the earliest mother-infant relationship is the principle of optimal frustration. Tolerable disappointments … lead to the establishment of internal structures which provide the basis for self-soothing.’

In a parallel way, Kohut considered that the ‘skilful analyst will … conduct the analysis according to the principle of optimal frustration’.

Suboptimal frustrations, and maladaptations following them, may be compared to Freud’s trauma concept, or to problem solution in the oedipal phase. However, the scope of optimal (or other) frustration describes shaping every “nook and cranny” of the self, rather than a few dramatic conflicts.

Idealising

Kohut saw idealising as a central aspect of early narcissism. “The therapeutic activation of the omnipotent object (the idealized parent image) … referred to as the idealizing transference, is the revival during psychoanalysis” of the very early need to establish a mutual selfobject connection with an object of idealisation.

In terms of “the Kleinian school … the idealizing transference may cover some of the territory of so-called projective identification”.

For the young child, “idealized selfobjects “provide the experience of merger with the calm, power, wisdom, and goodness of idealized persons””.

Alter Ego/Twinship Needs

Alter ego/twinship needs refer to the desire in early development to feel alikeness to other human beings. Freud had early noted that ‘The idea of the “double” … sprung from the soil of unbounded self-love, from the primary narcissism which holds sway in the mind of the child.’ Lacan highlighted ‘the mirror stage … of a normal transitivism. The child who strikes another says that he has been struck; the child who sees another fall, cries.’ In 1960, ‘Arlow observed, “The existence of another individual who is a reflection of the self brings the experience of twinship in line with the psychology of the double, of the mirror image and of the double”.’

Kohut pointed out that ‘fantasies, referring to a relationship with such an alter ego or twin (or conscious wishes for such a relationship) are frequently encountered in the analysis of narcissistic personalities’, and termed their transference activation ‘the alter-ego transference or the twinship’.

As development continues, so a greater degree of difference from others can be accepted.

The Tripolar Self

The tripolar self is not associated with bipolar disorder, but is the sum of the three “poles” of the body:

  • “grandiose-exhibitionistic needs”.
  • “the need for an omnipotent idealized figure”.
  • “alter-ego needs”..

Kohut argued that ‘reactivation of the grandiose self in analysis occurs in three forms: these relate to specific stages of development … (1) The archaic merger through the extension of the grandiose self; (2) a less archaic form which will be called alter-ego transference or twinship; and (3) a still less archaic form … mirror transference’.

Alternately, self psychologists ‘divide the selfobject transference into three groups: (1) those in which the damaged pole of ambitions attempts to elicit the confirming-approving response of the selfobject (mirror transference); (2) those in which the damaged pole of ideals searches for a selfobject that will accept its idealisation (idealising transference); and those in which the damaged intermediate area of talents and skills seeks … alter ego transference.’

The tripolar self forms as a result of the needs of an individual binding with the interactions of other significant persons within the life of that individual.

Cultural Implications

An interesting application of self psychology has been in the interpretation of the friendship of Freud and Jung, its breakdown, and its aftermath. It has been suggested that at the height of the relationship “Freud was in narcissistic transference, that he saw in Jung an idealised version of himself”, and that conversely in Jung there was a double mix of “idealization of Freud and grandiosity in the self”.

During Jung’s midlife crisis, after his break with Freud, arguably “the focus of the critical years had to be a struggle with narcissism: the loss of an idealized other, grandiosity in the sphere of the self, and resulting periods of narcissistic rage”. Only as he worked through to “a new sense of himself as a person separate from Freud” could Jung emerge as an independent theorist in his own right.

On the assumption that “the western self is embedded in a culture of narcissism … implicated in the shift towards postmodernity”, opportunities for making such applications will probably not decrease in the foreseeable future.

Criticism

Kohut, who was “the center of a fervid cult in Chicago”, aroused at times almost equally fervent criticism and opposition, emanating from at least three other directions: drive theory, Lacanian psychoanalysis, and object relations theory.

From the perspective of drive theory, Kohut appears “as an important contributor to analytic technique and as a misguided theoretician … introduces assumptions that simply clutter up basic theory. The more postulates you make, the less their explanatory power becomes.” Offering no technical advances on standard analytic methods in “his breathtakingly unreadable The Analysis of the Self”, Kohut simply seems to blame parental deficit for all childhood difficulties, disregarding the inherent conflicts of the drives: “Where the orthodox Freudian sees sex everywhere, the Kohutian sees unempathic mothers everywhere – even in sex.”

To the Lacanian, Kohut’s exclusive “concern with the imaginary”, to the exclusion of the Symbolic meant that “not only the patient’s narcissism is in question here, but also the analyst’s narcissism.” The danger in “the concept of the sympathetic or empathic analyst who is led astray towards an ideal of devotion and samaritan helping … [ignoring] its sadistic underpinnings” seemed only too clear.

From an object relations perspective, Kohut “allows no place for internal determinants. The predicate is that a person’s psychopathology is due to unattuned selfobjects, so all the bad is out there and we have a theory with a paranoid basis.” At the same time, “any attempt at “being the better parent” has the effect of deflecting, even seducing, a patient from using the analyst or therapist in a negative transference … the empathic analyst, or “better” parent”.

With the passage of time, and the eclipse of grand narrative, it may now be possible to see the several strands of psychoanalytic theory less as fierce rivals and more “as complementary partners. Drive psychology, ego psychology, object relations psychology and self psychology each have important insights to offer twenty-first-century clinicians.”

On This Day … 12 October

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Events

People (Births)

  • 1925 – Denis Lazure, Canadian psychiatrist and politician (d. 2008).
  • 1929 – Robert Coles, American psychologist, author, and academic.

People (Deaths)

  • 1948 – Susan Sutherland Isaacs, English psychologist and psychoanalyst (b. 1885).

Eastern State Hospital (Virginia)

Eastern State Hospital is a psychiatric hospital in Williamsburg, Virginia. Built in 1773, it was the first public facility in the present-day United States constructed solely for the care and treatment of the mentally ill. The original building had burned but was reconstructed in 1985.

Denis Lazure

Denis Lazure (12 October 1925 to 23 February 2008) was a Canadian psychiatrist and politician. Lazure was a Member of the National Assembly of Quebec (MNA) from 1976 to 1984 and from 1989 to 1996. He is the father of actress Gabrielle Lazure.

Lazure attended Université de Montréal and was a doctorate in medicine. He also attended the University of Pennsylvania in psychiatry as well as the University of Toronto in which he was bachelor in hospital administration.

Lazure was the founder of the infant psychiatry department of Saint-Justine Hospital in 1957. He was also the director of this hospital as well as those of Riviere-des-Prairies and Louis-Hippolyte Lafontaine all in the Montreal region. He would later be the director in 1974 of the first psychiatric hospital in Haiti. He was also a teacher at Université de Montréal and was the President of the Canadian Association of Psychiatrists.

Robert Coles

Robert Coles (born 12 October 1929) is an American author, child psychiatrist, and professor emeritus at Harvard University.

Born Martin Robert Coles in Boston, Massachusetts on 12 October 1929, to Philip Coles, an immigrant from Leeds, England, United Kingdom, and Sandra Young Coles, originally from Sioux City, Iowa. Robert Coles attended Boston Latin School where he played tennis, ran track, and edited the school literary magazine. He entered Harvard College in 1946, where he studied English literature and helped to edit the undergraduate literary magazine, The Harvard Advocate. He graduated magna cum laude and earned Phi Beta Kappa honours in 1950.

Coles originally intended to become a teacher or professor, but as part of his senior honours thesis, he interviewed the poet and physician William Carlos Williams, who promptly persuaded him to go into medicine. He studied medicine at Columbia University College of Physicians and Surgeons, graduating in 1954. After residency training at the University of Chicago in Chicago, Illinois (the University of Chicago Pritzker School of Medicine), Coles moved on to psychiatric residencies at Massachusetts General Hospital in Boston, Massachusetts, and McLean Hospital in Belmont, Massachusetts (the two hospitals are affiliates of Harvard University and the Harvard University Medical School in Cambridge, Massachusetts).

Knowing that he was to be called into the US Armed Forces under the Doctor Draft, Coles joined the Air Force in 1958 and was assigned the rank of captain. His field of specialisation was psychiatry, his intention eventually to sub-specialise in child psychiatry. He served as chief of neuropsychiatric services at Keesler Air Force Base in Biloxi, Mississippi, and was honourably discharged in 1960. He returned to Boston and finished his child psychiatry training at the Children’s Hospital. In July 1960, he was married to Jane Hollowell, and the couple moved to New Orleans.

Susan Sutherland Isaacs

Susan Sutherland Isaacs, CBE (née Fairhurst; 24 May 1885 to 12 October 1948; also known as Ursula Wise) was a Lancashire-born educational psychologist and psychoanalyst. She published studies on the intellectual and social development of children and promoted the nursery school movement. For Isaacs, the best way for children to learn was by developing their independence. She believed that the most effective way to achieve this was through play, and that the role of adults and early educators was to guide children’s play.

In 1907, Isaacs enrolled to train as a teacher of young children (5 to 7-year-olds) at the University of Manchester. Isaacs then transferred to a degree course and graduated in 1912 with a first class degree in Philosophy. She was awarded a scholarship at the Psychological Laboratory in Newnham College, Cambridge and gained a master’s degree in 1913.

Isaacs also trained and practised as a psychoanalyst after analysis by the psychoanalyst John Carl Flugel (1884-1955). She became an associate member of the newly formed British Psychoanalytical Society in 1921, becoming a full member in 1923. She began her own practice that same year. She later underwent brief analysis with Otto Rank and in 1927 she submitted herself to further analysis with Joan Riviere, to get personal experience and understanding of Melanie Klein’s new ideas on infancy. Isaacs also helped popularise the works of Klein, as well as the theories of Jean Piaget and Sigmund Freud. She was initially enthusiastic for Jean Piaget’s theories on the intellectual development of young children, though she later criticised his schemas for stages of cognitive development, which were not based on the observation of the child in their natural environment, unlike her own observations at Malting House School.

Between 1924 and 1927, she was the head of Malting House School in Cambridge, which is an experimental school founded by Geoffrey Pyke. The school fostered the individual development of children. Children were given greater freedom and were supported rather than punished. The teachers were seen as observers of the children who were seen as research workers. Her work had a great influence on early education and made play a central part of a child’s education. Isaacs strongly believed that play was the child’s work.

Between 1929 and 1940, she was an ‘agony aunt’ under the pseudonym of Ursula Wise, replying to readers’ problems in several child care journals, notably The Nursery World and Home and School.

In 1933, she became the first Head of the Child Development Department at the Institute of Education, University of London, where she established an advanced course in child development for teachers of young children. Her department had a great influence on the teaching profession and encouraged the profession to consider psychodynamic theory with developmental psychology.

What is the Eastern State Hospital (Virginia)?

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Introduction

Eastern State Hospital is a psychiatric hospital in Williamsburg, Virginia. Built in 1773, it was the first public facility in the present-day United States constructed solely for the care and treatment of the mentally ill. The original building had burned but was reconstructed in 1985.

Francis Fauquier and the Enlightenment

Eastern State Hospital traces its foundation to a speech by Francis Fauquier, Royal Governor of the colony of Virginia, on 06 November 1766. At the House of Burgesses’ first meeting since the Stamp Act and Virginia Resolves, Fauquier primarily discussed the relationship between the Mother Country and these colonists, and expressed optimism for their future. His speech also unexpectedly addressed the mentally ill, as follows:

“It is expedient I should also recommend to your Consideration and Humanity a poor unhappy set of People who are deprived of their senses and wander about the Country, terrifying the Rest of their fellow creatures. A legal Confinement, and proper Provision, ought to be appointed for these miserable Objects, who cannot help themselves. Every civilized Country has an Hospital for these People, where they are confined, maintained and attended by able Physicians, to endeavor to restore to them their lost reason.”

About a year later, on 11 April 1767, Governor Fauquier addressed the same issue before the next House of Burgesses, thus:

“There is a subject which gives me concern, on which I shall particularly address myself to you, as it is your peculiar province to provide means for the subsistence of the poor of any kind. The subject I mean is the case of the poor lunatics. I find on your journals that it was Resolved, That an hospital be erected for the reception of persons who are so unhappy as to be deprived of their reason; And that it was Ordered, that the Committee of Propositions and Grievances do prepare and bring in a bill pursuant to the above resolution. But I do not find that any thing more was done in it. It was a measure which I think could offend no party, and which I was in hopes humanity would have dictated to every man, as soon as he was made acquainted with the call for it. It also concerns me much on another account; for as the case now stands, I am as it were compelled to the daily commission of an illegal act, by confining without my authority, a poor lunatic, who, if set at liberty, would be mischievous to society; and I would choose to be bound by, and observant of, the laws of the country. As I think this is a point of some importance to the ease and comfort of the whole community, as well as a point of charity to the unhappy objects, I shall again recommend it to you at your next meeting; when I hope, after mature reflection, it will be found to be more worth your attention than it has been in this.”

Governor Fauquier’s benevolent and bold expressions did eventually lead to the establishment of the Eastern State Hospital, although he died 03 March 1768, before it was built. His compassion and humanitarian care for those who needed it the most, made it easier for his ideas to be developed and a facility built.

Fauquier’s concern probably rested in Enlightenment principles, which were so widespread throughout the time. The 18th century was a time for rejecting superstitions and religions, and substituting science and logical reasoning. The philosophers David Hume and Voltaire were studying and investigating the worth of human life, which would ultimately alter perceptions of the mentally ill. During this time in London, insane people were viewed and used for as entertainment and comical relief. The Bethlehem Royal Hospital (sometimes called Bedlam) attracted many tourists and even held frequent parades of inmates. Enlightenment attitudes encouraged more sensitivity towards the mentally ill, rather than treating them as outcasts and fools. Some started to believe that being mentally ill was, in fact, an illness of the mind, much like a physical disease or sickness, and that these mental illnesses were also treatable.

Before Governor Fauquier’s speeches, a person who was mentally ill was not diagnosed by a doctor, but rather judged by 12 citizens, much like a jury, to be either a criminal, lunatic or Idiot. Most classified as lunatic were placed in the Public Gaol in Williamsburg. Taxpayers probably appreciated the hospital idea only if they had a family member or close friend who was mentally ill. The only hospital where mentally ill patients were sometimes taken before Eastern State Hospital was built, was the Pennsylvania Hospital, a Quaker institution in Philadelphia. Until a campaign by Benjamin Rush in 1792 to establish a separate treatment wing, mentally ill patients were kept in the basement and out of the way of regular patients who needed medical assistance.

Percival Goodhouse was is thought to be one of the first patients admitted to the Eastern State Hospital after its opening on 12 October 1773.

Civil War and Decline

In 1841, Dr. John Galt was appointed superintendent of the hospital, with roughly 125 patients (then called “inmates”) at the time. Dr. Galt introduced Moral treatment practices, a school of thought which viewed those with mental illness as deserving of respect and dignity rather than punishment for their behaviour. Galt provided his patients with talk therapy and occupational therapy, and argued for in-house research. He decreased the use of physical restraints, even going an entire year without using them, relying instead on calming drugs (including laudanum), and also proposed deinstitutionalizing patients in favour of community-based care, though this proposal was repeatedly rejected. As the head of the hospital, Galt was successful in pressing for admission for enslaved people with mental illness, and taught the enslaved people owned by the hospital to provide talk therapy alongside nurses and aides. Although he claimed to treat patients equally regardless of their race, Galt did not publish racial breakdowns of his patients.

When the Civil War came to Williamsburg, the hospital found itself alternately on one side of the lines and then the other. On 06 May 1862, Union troops captured the asylum. Two weeks later, on 17 or 18 May, Dr. Galt died of an overdose of laudanum, though it is unclear whether this was intentional or accidental. When the hospital was captured, Union soldiers found that the 252 patients had been locked in without food or supplies by the fleeing white employees. Somersett Moore was the only non-African American employee to return following the capture, and he gave the keys to release the patients to the occupying men.

In the following decades, the increasingly crowded hospital saw a regression in methodology as science was increasingly viewed as an ineffective means of dealing with mental illness. During this era of custodial care, the goal became not to cure patients, but to provide a comfortable environment for them, separate from society. On 07 June 1885, the original 1773 hospital burned to the ground due to a fire that had started in the building’s newly added electrical wiring, a consequence of the great expansion of facilities at this time.

Restoration

By 1935 Eastern State Hospital housed some 2,000 patients with no more land for expansion. The restoration of Colonial Williamsburg and development of the Williamsburg Inn resulted in the facility being at the centre of a thriving tourist trade. The hospital’s location and space issues made a move necessary. Between 1937 and 1968, all of Eastern State’s patients were moved to a new facility on the outskirts of Williamsburg, Virginia, where it continues to operate today.

In 1985, the original hospital was reconstructed on its excavated foundations by the Colonial Williamsburg Foundation.

On This Day … 10 October

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Events

  • World Mental Health Day.

People (Deaths)

  • 1979 – Christopher Evans, English psychologist, computer scientist, and author (b. 1931).

World Mental Health Day

World Mental Health Day (10 October) is an international day for global mental health education, awareness and advocacy against social stigma.

Christopher Evans

Christopher Riche Evans (29 May 1931 to 10 October 1979) was a British psychologist, computer scientist, and author.

Born in Aberdyfi, Christopher Evans spent his childhood in Wales and was educated at Christ College, Brecon (1941-1949). He spent two years in the RAF (1950-1952), and worked as a science journalist and writer until 1957, when he began a B.A. course in Psychology at University College, London, graduating with honours in 1960.

After a summer fellowship at Duke University in the United States, where he first met his American wife, Nancy Fullmer, he took up a Research Assistant post in the Physics Laboratory, University of Reading, working on eye movements under Professor R. W. Ditchburn. Upon receiving his PhD (the title of his thesis was “Pattern Perception and the Stabilised Retinal Image”), he went to the Division of Computer Science, National Physical Laboratory, Teddington, in 1964, where he remained until his death from cancer in 1979.

He had two children, Christopher Samuel Evans and Victoria Evans-Theiler.

On This Day … 09 October

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People (Births)

  • 1900 – Joseph Zubin, Lithuanian-American psychologist and academic (d. 1990).
  • 1943 – Douglas Kirby, American psychologist and author (d. 2012).

Joseph Zubin

Joseph Zubin (09 October 1900 to 18 December 1990) was a Lithuanian born American educational psychologist and an authority on schizophrenia who is commemorated by the Joseph Zubin Awards.

Zubin was born 09 October 1900 in Raseiniai, Lithuania, but moved to the US in 1908 and grew up in Baltimore. His first degree was in chemistry at Johns Hopkins University in 1921, and he earned a PhD in educational psychology at Columbia University in 1932. In 1934 he married Winifred Anderson (who survived him) and they had three children (2 sons, David and Jonathan, and a daughter, Winfred). At his death on 18 December 1990, he had seven grandchildren. In addition, his great-grandson is Adam Chapnik, counsellor of the Abbey Unit at Massachusetts Audubon Society’s Wildwood Camp.

Zubin was President of both the American Psychopathological Association (1951-1952) and the American College of Neuropsychopharmacology (1971-1972) and received numerous awards for his work. In 1946 he was elected as a Fellow of the American Statistical Association.

Douglas Kirby

Douglas Bernard Kirby, Ph.D. (09 October 1943 to 22 December 2012) was senior research scientist for ETR Associates in Scotts Valley, California, and one of the world’s leading experts on the effectiveness of school and community programmes in the reduction of adolescent sexual risk-taking behaviours. In recent years he had also undertaken research and analysis on the impact of HIV/AIDS prevention programmes in Uganda under the auspices of the World Health Organization, USAID, and other organisations.

Kirby authored over 100 articles, chapters and monographs on these programmes including the widely acclaimed Emerging Answers 2007: Research Findings on Programmes to Reduce Teen Pregnancy and Sexually Transmitted Diseases which he produced for the National Campaign to Prevent Teen and Unplanned Pregnancy. It is a comprehensive review of 115 programme evaluations to help determine the most effective approaches to preventing teen pregnancy and STDs. It paints a detailed picture of the protective factors associated with adolescent risk taking behaviour and identifies important characteristics of effective sexuality and HIV education programmes. His recent research has shown strong evidence for the effectiveness of comprehensive sex and STD/HIV programs and limited evidence for the effectiveness of sexual abstinence programmes.

What is Reboxetine?

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Introduction

Reboxetine, sold under the brand name Edronax among others, is a drug of the norepinephrine reuptake inhibitor (NRI) class, marketed as an antidepressant by Pfizer for use in the treatment of major depression, although it has also been used off-label for panic disorder and attention deficit hyperactivity disorder (ADHD).

It is approved for use in many countries worldwide, but has not been approved for use in the United States. Although its effectiveness as an antidepressant has been challenged in multiple published reports, its popularity has continued to increase.

Brief History

Reboxetine was discovered at Farmitalia-Carlo Erba and was first published in 1984; Farmitalia did the first clinical studies. Farmitalia was acquired by Pharmacia in 1993, and Pharmacia in turn was acquired by Pfizer in 2003.

It was first approved in Europe in 1997 and was provisionally approved by the US Food and Drug Administration (FDA) in 1999. In 2001 the FDA issued Pfizer a “not approvable” letter based on clinical trials the FDA had required when it issued the preliminary approval letter.

In 2010, the German Institute for Quality and Efficiency in Health Care (IQEHC) published results of a meta-analysis of clinical trial data for reboxetine in acute depression, which included data on about 3,000 subjects that Pfizer had never published but had mentioned; IQEHC had combed through Pfizer’s publications and reboxetine approvals and had determined this data was missing from the publication record. The analysis of the complete data set yielded a result that reboxetine was not more effective than placebo but had more side effects than placebo and more than fluoxetine; the paper led to widespread and sharp criticism of Pfizer, and stronger calls for publication of all clinical trial data.

Medical Uses

Major Depressive Disorder

There has been much debate as to whether reboxetine is more efficacious than placebo in the treatment of depression. According to a 2009 meta-analysis of 12 second-generation antidepressants, reboxetine was no more effective than placebo, and was “significantly less” effective, and less acceptable, than the other drugs in treating the acute-phase of adults with unipolar major depression.

The UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) said in September 2011 that the study had several limitations, and that “Overall the balance of benefits and risks for reboxetine remains positive in its authorised indication.” A UK and Europe-wide review of available efficacy and safety data has confirmed that reboxetine has benefit over placebo in its authorised indication. Efficacy was clearly shown in patients with severe or very severe depression.

According to a systematic review and meta-analysis by IQWiG, including unpublished data, published data on reboxetine overestimated the benefit of reboxetine versus placebo by up to 115% and reboxetine versus SSRIs by up to 23%, and also underestimated harm, concluding that reboxetine was an ineffective and potentially harmful antidepressant. The study also showed that nearly three quarters of the data on patients who took part in trials of reboxetine had not been published by Pfizer.

A 2018 systematic review and network meta-analysis comparing the efficacy and acceptability of 21 antidepressant drugs concluded that reboxetine was significantly less efficacious than other antidepressants tested.

Panic Disorder

In a randomised double-blind placebo-controlled trial reboxetine significantly improved the symptoms of panic disorder. Another randomised controlled trial that compared paroxetine to reboxetine found that paroxetine significantly outperformed reboxetine as a treatment for panic disorder. Despite this discouraging finding an open-label trial examining the efficacy of reboxetine in SSRI-resistant panic disorder demonstrated significant benefit from reboxetine treatment.

Attention Deficit Hyperactivity Disorder

Numerous clinical trials have provided support for the efficacy of reboxetine in the treatment of attention deficit hyperactivity disorder (ADHD) in both the short and long-term and in both children/adolescents and adults.

Other Uses

A case series and open-label pilot study demonstrated the efficacy of reboxetine in treating bulimia nervosa. Reboxetine may also have efficacy in treating therapy-resistant paediatric nocturnal enuresis. A pilot study demonstrated the efficacy of reboxetine in the treatment of narcolepsy. Individual trials and meta-analysis suggest that reboxetine can attenuate antipsychotic-induced weight gain and there is some evidence of a benefit on depressive, and possibly other symptoms of schizophrenia when added to antipsychotic treatment.

Contraindications

Reboxetine is contraindicated in narrow-angle glaucoma, cardiovascular disease, epilepsy, bipolar disorder, urinary retention, prostatic hypertrophy, patients concomitantly on MAOIs and those hypersensitive to reboxetine or any of its excipients.

Adverse Effects

Very common (>10% incidence) adverse effects include insomnia, dizziness, dry mouth, constipation, nausea, and excessive sweating.

Common (1-10%) adverse effects include loss of appetite, agitation, anxiety, headache, restlessness, tingling sensations, distorted sense of taste, difficulty with seeing near or far (problems with accommodation), fast heart beat, heart palpitations, relaxing of blood vessels leading to low blood pressure, high blood pressure, vomiting, rash, sensation of incomplete bladder emptying, urinary tract infection, painful or difficult urination, urinary retention, erectile dysfunction, ejaculatory pain or delay, and chills.

A 2009 meta-analysis found that reboxetine was significantly less well tolerated than the other 11 second-generation antidepressants compared in the analysis

Overdose

Reboxetine is considered a relatively low-risk antidepressant in overdose.[26] The symptoms are as follows:

  • Sweating.
  • Tachycardia.
  • Changes in blood pressure.

Interactions

Because of its reliance on CYP3A4, reboxetine O-desethylation is markedly inhibited by papaverine and ketoconazole. It weakly inhibits CYP2D6 and CYP3A4.[25] Reboxetine is an intermediate-level inhibitor of P-glycoprotein, which gives it the potential to interact with ciclosporin, tacrolimus, paroxetine, sertraline, quinidine, fluoxetine, fluvoxamine.

Pharmacology

Pharmacodynamics

Reboxetine is a fairly selective norepinephrine reuptake inhibitor (NRI), with approximately 20-fold selectivity for the norepinephrine transporter (NET) over the serotonin transporter (SERT). Despite this selectivity, reboxetine does slightly inhibit the reuptake of serotonin at therapeutic doses. It does not interact with or inhibit the dopamine transporter (DAT).

Reboxetine has been found to inhibit both brain and cardiac GIRKs, a characteristic it shares with the NRI atomoxetine.

Pharmacokinetics

Both the (R,R)-(–) and (S,S)-(+)-enantiomers of reboxetine are predominantly metabolised by the CYP3A4 isoenzyme. The primary metabolite of reboxetine is O-desethylreboxetine, and there are also three minor metabolites – Phenol A, Phenol B, and UK1, Phenol B being the most minor

Chemistry

Reboxetine has two chiral centres. Thus, four stereoisomers may exist, the (R,R)-, (S,S)-, (R,S)-, and (S,R)-isomers. The active ingredient of reboxetine is a racemic mixture of two enantiomers, the (R,R)-(–)- and (S,S)-(+)-isomer.

Society and Culture

Brand Names

Edronax is the brand name of reboxetine in every English-speaking country that has approved it for clinical use. Brand names include (where † denotes a product that is no longer marketed):

  • Davedax (IT).
  • Edronax (AU, AT, BE, CZ, DK, FI, DE, IE, IL, IT, MX, NZ, NO, PH, PL, PT, ZA, SE, CH, TH, TR, UK).
  • Irenor (ES).
  • Norebox (ES).
  • Prolift (AR,† BR, CL, VE†).
  • Solvex (DE).
  • Yeluoshu (CN).
  • Zuolexin (CN).

On This Day … 08 October

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1888 – Ernst Kretschmer, German psychiatrist and author (d. 1964).

Ernst Kretschmer

Ernst Kretschmer (08 October 1888 to 08 February 1964) was a German psychiatrist who researched the human constitution and established a typology.

Life

Kretschmer was born in Wüstenrot near Heilbronn. He attended Cannstatt Gymnasium, one of the oldest Latin schools in Stuttgart area. From 1906 to 1912 he studied theology, medicine, and philosophy at the universities of Tübingen, Munich and Hamburg. From 1913 he was assistant of Robert Gaupp in Tübingen, where he received his habilitation in 1918. He continued as assistant medical director until 1926.

In 1926 he became the director of the psychiatric clinic at Marburg University.

Kretschmer was a founding member of the International General Medical Society for Psychotherapy (AÄGP) which was founded on 12 January 1927. He was the president of AÄGP from 1929. In 1933 he resigned from the AÄGP for political reasons.

From 1946 until 1959, Kretschmer was the director of the psychiatric clinic of the University of Tübingen. He died, aged 75, in Tübingen.

Cooperating with the Nazis

After he resigned from the AÄGP, he started to support the SS and signed the “Vow of allegiance of the professors of the German universities and high-schools to Adolf Hitler and the National Socialistic state.” (German: “Bekenntnis der Professoren an den deutschen Universitäten und Hochschulen zu Adolf Hitler und dem nationalsozialistischen Staat”).

Scientific Contribution

Persistent Vegetative State and Sensitive Paranoia Research

Kretschmer was the first to describe the persistent vegetative state which has also been called Kretschmer’s syndrome. Another medical term coined after him is Kretschmer’s sensitive paranoia. This classification has the merit of singling out “a type of paranoia that was unknown” prior to Kretschmer, and which “does not resemble the stereotypical image […] of sthenic paranoia”. Furthermore, between 1915 and 1921 he developed a differential diagnosis between schizophrenia and manic depression.

Types of Physique

Kretschmer is also known for developing a classification system that can be seen as one of the earliest exponents of a constitutional (the total plan or philosophy on which something is constructed) approach. His classification system was based on four main body types:

  • Asthenic (thin, small, weak).
  • Athletic (muscular, large-boned).
  • Pyknic (stocky, fat).
  • Dysplastic (unproportionate body).

The concept of two great psychopathological types of manic-depressive or ‘circular’ insanity and dementia praecox (i. e. schizophrenia) was developed by Emil Kraepelin.

Each of these body types was associated by Kretschmer with certain personality traits and, in a more extreme form, mental disorders. He wrote that there is only a weak relation between Schizophrenics and pyknic body type on the one hand, and between Circulars (with the tendency to circular type of manic-depressive psychosis) and asthenics, athletics, and dysplastics on the other.[4] Among the schizophrenics also the asthenico–athletic types are very prevalent.[4] Kretschmer believed that pyknic persons were friendly, interpersonally dependent, and gregarious. In a more extreme version of these traits, this would mean for example that the obese are predisposed toward manic-depressive illness. Thin types were associated with introversion and timidity. This was seen as a milder form of the negative symptoms exhibited by withdrawn schizophrenics. However, the idea of the association of body types with personality traits is no longer influential in personality psychology.

The Temperaments

Kretschmer divided the temperaments into the two “constitutional groups”: schizothymic, which contain a “psychaesthetic proportion” between sensitive and cold poles, and cyclothymes which contain a “diathetic” proportion between raised (happy) and sad. The modern term for light version of ‘circular’ insanity is cyclothymia. Psychic tempo of schizothymic people is between unstable and tenacious and they have alternation mode of feeling and thought, and cyclothymes psychic tempo is between mobile and comfortable. Schizothymic’s psychomotility is often inadequate to stimulus: inhibited, restrained, lamed, stiff, etc., and psychomotility of cyclothymes is adequate to stimulus and natural. Cyclothymes are often pyknics, schizothymes – athletic, asthenic, dysplastic, and their mixtures.

The Schizoids consist of the hyperaesthetic (sensitive) and anaethetic (cold) characters.