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Megavitamin therapy andchildhood psychoses andlearning disabilitiesStatement of the Committee on Nutrition,American Academy of Pediatrics. PostgradMed 61 :230-233, April 1977.

• Vitamins are recognized for theirunique role in human nutrition.Adequate amounts to meet theneeds of healthy persons of all ageshave been defined by the Food andNutrition Board of the NationalAcademy of Sciences as the "Rec­ommended Dietary Allowances"(RDA). The consistent opinion ofthe Committee on Nutrition of theAmerican Academy of Pediatricshas been that normal children re­ceiving a normal diet do not needvitamin supplements over andabove RDA levels. Some clinicalconditions necessitate special con­sideration. Fat-soluble vitaminsmay be needed in the steatorrheasand in the autosomally-recessiveselective malabsorption of vitaminBI2. Rarely, drug treatment re­quires supplementation, e.g., pyri­doxine with isoniazid, and folicacid and vitamin D with phenytoinsodium. Rare inborn errors of me­tabolism are another exception.With the advent of orthomolecularmedicine, a term coined by Pauling(1968), there have been reports ofremarkable benefits with large sup­plemental doses of water-solublevitamins for a wide variety of con­ditions. These inexpensive vitaminsplus trace minerals have also beenused in children for treatment ofmental retardation, psychoses, au­tism, hyperactivity, or dyslexia. TheAmerican Psychiatric AssociationTask Force on Vitamin Therapyhas carefully evaluated the claim of

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orthomolecular psychiatrists in thetreatment of schizophrenia. Theirstatement was emphatic that thetreatments studied were withoutvalue. Although no comparableevaluation has been carried out onchildren for autism and learningdisabilities, megavitamin therapy isnot justified by documented clinicalresults to date.

Gary S. Nye. M.D.Orinda, Calif.

The threatened staff: Apsychoanalytic contributionto medical psychologyGunther MS. Compr Psychiatry 18:385-359.1977.

• The author draws on his 20 yearsas psychiatric consultant to a phys­ical medicine and rehabilitationhospital to formulate the nature ofstaff stress in such an environment.The patients are characterized bythe suddenness of the injury, themajor loss of function, and theirlong hospital stay. As a result, theyundergo a normal regression whichstimulates the normal, uncon­scious, narcissistic vulnerability ofthe staff. The high physical de­mands and subsequent fatiguemake the staff especially suscepti­ble to anxiety, while the patients'regressions provoke unconsciouscountertransference feelings in thestaff. As the patients deal with theirfragmented self-image and weak­ened self-esteem, each staff mem­ber's own sense of psychic andbodily integrity is threatened. Fur­ther, the unpredictability of out­come threatens self-esteem withfeelings of professional disappoint­ment and shame. The staff mem­bers commonly react to these in-

trapsychic stresses with selective ig­norance, blocks to learning, mul­tiple defenses against their feelings,and the abandonment of empathy.The need for an extensive, psycho­logically-oriented staff educationprogram is pointed out.

Paul C. Mohl. M.D.San Antonio, Tex.

The treatment of enuresis:An overviewFreeman ED. Internat J Psychiatry in Med6:403. 1975.

• Enuresis remains a commonproblem for which the child psy­chiatrist is consulted. Some inves­tigators believe that from 7% to15% of all children past the age ofthree have urinary incontinenceduring sleep. Although this symp­tom usually disappears at puberty,it is often considered part of a morecomplicated behavioral disorder,and a variety of theories and treat­ment approaches have been sug­gested. Psychodynamic theoristshave postulated that wetting is amechanism for the expression ofanger, often resulting from thebirth of a sibling. Older childrenwho are persistently enuretic oftenhave psychopathic personalitytraits, such as stealing, fire-setting,and aggressive behavior. One seriesshowed an unusually high numberof abnormal EEGs, implying thatthere might be an organic predis­position. Urologists have noted thatthis symptom may come from de­creased bladder capacity or an ob­structive uropathy. Sleep physiol­ogy investigations have shown thatenuresis occurs most often duringstages three and four of non-REMsleep. Treatment approaches range

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from punitive techniques to the useof imipramine to behavioral modi­fication programs. Enuresis is bestviewed as a symptom with multiplecausation rather than as a disease.It may be primary or secondary,occasional, persistent, situational,or a result of organic immaturity.Successful management combinesconcurrent evaluation and treat­ment for associated psychopathol­ogy, along with use of imipramine.Ongoing collaboration betweenpediatrician and psychiatrist is ofgreat importance.

Thomas N. Wise, M. D.Falls Church, Va.

Rehabilitation aftercardiac transplantationChristopherson LK, Griepp RB, StinsonEB. JAMA 236:2082-2084. 1976.

• The rehabilitation status of 56patients who survived six or moremonths after cardiac transplanta­tion at Stanford University MedicalCenter is reviewed. The patientsranged in age from 15 to 59 years.All but six were male. Fifty-one(91%) were able both physicallyand psycRologically to lead activelives identical to or equivalent totheir lives before the onset ofseverecardiac disease. Of these 51 recipi­ents, 26 returned to full-time workfollowing transplantation. Thirteenrecipients chose active retirementpost-operatively. Eight returned toschool full time after cardiac trans­plantation, adjusted well, andearned grades compatible withtheir abilities. Four recipients werehomemakers. Five of the 56 pa­tients were disabled, but in nonewas cardiac disability a primaryfactor. Each patient was required to

MAY 1978· VOL 19· NO 5

learn self care, which was critical tosurvival. When the recipient re­turned home, the new status of"cardiac transplant recipient" wasinitially attractive, but later thiscategorization interfered with moremeaningful roles. The majority ofrecipients avoided association withother recipients because the illnessor death of one with whom theyclosely identified would be doublypainful. Most recipients and theirspouses experienced more opencommunication as a result of trans­plantation. Activities previouslytaken for granted assumed newmeaning because of the recipients'heightened sensitivity to andawareness of the significance thateach day of life held for them.

Mary A. Lenkay, M.D.Toledo, Ohio

Growth honnone treatmentin hypopituitary dwarfs:Longitudinal psychologicaleffectsKusalic M, Fonin C. Can Psychiatr Assoc J20:325-531, 1975.

• The authors describe a study ofII hypopituitary dwarfs, nine boysand two girls, who were treated formore than five years with humangrowth hormone (HGH). Each ofthe subjects was found to be psy­chologically immature and hy­poactive, to have no manifestationof aggressive drives, and to havelow self-esteem. There was poorfamily structure in nine of the IIdwarfs. Common parental prob­lems included parental schism,over-protectiveness, ambivalenceand, in some, covert rejection oftheir child's dwarfism. Althoughthe HGH led to increase in height,

there was very little improvementin psychological maturity. The twoyoungest subjects showed the mostimprovement psychologically andthe authors propose that the othernine members had to cope with thelow self-esteem of dwarfism toolong. The authors emphasize thedevastating effect dwarfism has onidentity, psychosocial maturity,and relationships. They emphasizethe need for early diagnosis andtreatment with human growth hor­mone and family counseling tolimit the possible life-long effects ofthis problem for the patient.

David L. Keegan, M.D.Saskatoon, Canada

Precursors of prematuredisease and death. Thepredictive potential of habitsand family attitudesThomas CB. Ann Intern Med 85:653-658,1976.

• The youthful habits and familyattitudes of medical students wholater developed or died from one offive disease states were different tobegin with from those of healthyclassmate controls. In medicalschool, the disorder group as awhole had significantly more ner­vous tension, more anxiety andanger under stress, and more in­somnia, smoked more cigarettes,and took alcoholic drinks more fre­quently. Individual disorder groupmeans were significantly differentfrom one another. The mental ill­ness group showed the most ner­vous tension, depression, and angerunder stress, and the malignanttumor group, the least. The ma­lignant tumor group resembled the

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healthy control group in these re­spects. The suicide, mental illness,and malignant tumor groups hadlow mean scores for closeness toparents, while the hypertensionand coronary occlusion groupmeans were slightly higher than thecontrol group mean. Thus, psycho­logical differences in youth havepredictive potential in regard topremature disease and death.

J. C. PecknoJd, M.D.Montreal

Tardive dyskinesia.Are first signs reversible?Quitkin F, Rifkin A, Gochfeld L, et al: Am JPsychiatry 134:84-87, 1977.

• Twelve psychiatric patients withdiagnoses of schizophrenia and/oraffective psychosis with tardivedyskinesia'were observed from theinception of movement disorder.Findings suggest that the first signsof tardive dyskinesia may be re­versible and that the length of timesymptoms have been present priorto drug discontinuation, not age ofonset, may be the major variabledetermining reversibility of thesyndrome. In several cases, psy­chotic exacerbation required theinstitution of drug treatment, buttardive dyskinesia was prevented orminimized by the use of antipsy­chotics in lower doses or in combi­nation with lithium.

John A. Graj, M.D.Rochester, Minn.

Psychiatric morbidity andhostility in hypertensionMan AH. Psychol Med 7:653-659, 1977.

• Two questions are examined­the relationship of hypertension to

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psychiatric morbidity and to hostil­ity. The first question was investi­gated by administering a short ver­sion of the General HealthQuestionnaire to 12,700 subjectsattending the blood pressurescreening clinic sponsored by theMedical Research Council (U.K.).This questionnaire has been founda "reasonably reliable indicator ofpsychiatric morbidity," Scorescould be compared between sub­jects with diastolic pressures belowand above 90 mm Hg, and betweenthose with transitory versus sus­tained elevations. Some of thecenters conducting the study ex­cluded patients with known hyper­tension. This allowed the effect ofawareness of illness to be dis­counted. No difference was ob­served. The relationship of hostilityto hypertension was investigated ina subgroup of 55 hypertensive pa­tients compared with a matchedgroup of 53 normotensive patients.The Hostility-Direction HostilityQuestionnaire was used to measure"acting out hostility," "criticism ofothers," and "self criticism," threeof the five scales. This question­naire is considered to overcome theshortcoming of other studies whichlack a suitable scale to measurehostility; and is thought to be a"moderately objective measure." Itis, however, influenced by psychi­atric illness. Therefore, the Stan­dard Psychiatric Interview was ad­ministered to divide the populationinto neurotic, dysthymic, and non­neurotic subgroups. Hypertensivepatients as a group had a signifi­cantly lower score in self-criticism,and the non-neurotic subgroupscored significantly higher than thenormotensive patients in acting-out

hostility score. This finding runscontrary to the general theory ofrepression of hostility by hyperten­sive patients. A possible effect onthe outcome may have been ex­erted by the fact that all hyperten­sive subjects had been told of theircondition and entered clinical trialbefore taking the questionnaire.

Arnold H. Gessel, M.D.Philadelphia

Prophylaxis of migraine inchlldrenBillie B, Ludvigsson J, Sanner G. Headache17:61-63, 1977.

• The authors report migraine in­cidence of4% among 9,000 Swedishchildren ages seven to 15. For pro­phylaxis against attacks, they rec­ommend personality adjustmentand medical measures. Personalityadjustment measures include asound rhythm for work, rest, meal­times, and sleep. Measures tocounteract the triggering mecha­nism vary greatly. The commontriggering factor is school stress,with the attack developing after thestressful situation; also, visualstress due to improper seating inmovies, watching television in adark room, or bright sun reflec­tions; and physical stress, such ashunger, motion sickness, and cer­tain foods, must all be dealt with. Ifattacks are severe or frequent, pro­phylactic drugs are used. Cypro­heptadine 0.2 to 0.4 mg/kg/day intwo or three divided doses for threeto six months, pizotyline 0.5 mg twoor three times daily, and propran­010120 to 40 mg/day all gave goodresults, the authors report.

Fred O. Henker III, M.D.Little Rock, Ark.

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