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In defence of the case reportIn defence of the case report

During his ten years as Editor, GregDuring his ten years as Editor, Greg

Wilkinson worked hard to produce a mod-Wilkinson worked hard to produce a mod-

ern, polished journal with an impressiveern, polished journal with an impressive

international reputation. In his valedictoryinternational reputation. In his valedictory

editorial (Wilkinson, 2003) he sets out theeditorial (Wilkinson, 2003) he sets out the

goals he has pursued. Almost by definition,goals he has pursued. Almost by definition,an editor cannot receive universal approba-an editor cannot receive universal approba-

tion. However, while I suspect thattion. However, while I suspect that

academic/research colleagues will haveacademic/research colleagues will have

been happy with his stewardship, manybeen happy with his stewardship, many

clinicians are likely to have some reserva-clinicians are likely to have some reserva-

tions. The reason for this will be found intions. The reason for this will be found in

three lines in the middle of his final editor-three lines in the middle of his final editor-

ial: I hastened the demise of the case re-ial: I hastened the demise of the case re-

port, to exclude what I see as psychiatricport, to exclude what I see as psychiatric

trivia. I published original research . . ..trivia. I published original research . . ..

This is a cameo of the polarity thatThis is a cameo of the polarity that

exists between academic, research-orientedexists between academic, research-oriented

psychiatrists and those clinicians whopsychiatrists and those clinicians whoprovide the bulk of the service in theprovide the bulk of the service in the

National Health Service. They confirm theNational Health Service. They confirm the

contemporary ethos that the only worth-contemporary ethos that the only worth-

while form of study is that of groups. Thewhile form of study is that of groups. The

nomothetic approach takes precedencenomothetic approach takes precedence

while the detailed study of an individualwhile the detailed study of an individual

patient is marginalised as trivia.patient is marginalised as trivia.

Psychiatry is not unique in having beenPsychiatry is not unique in having been

seduced by the scientific process. Unfortu-seduced by the scientific process. Unfortu-

nately, it is doubtful how much the practicenately, it is doubtful how much the practice

of our discipline has gained from this devel-of our discipline has gained from this devel-

opment (Shooter, 2003; Wilkinson, 2003).opment (Shooter, 2003; Wilkinson, 2003).

This is not surprising. Psychiatry is a disci-This is not surprising. Psychiatry is a disci-pline in which the information is soft andpline in which the information is soft and

much of it subjective. In contrast, the scien-much of it subjective. In contrast, the scien-

tific approach insists that any parameter oftific approach insists that any parameter of

illness that cannot be measured in terms ofillness that cannot be measured in terms of

hard data is suspect.hard data is suspect.

As academic psychiatrists have becomeAs academic psychiatrists have become

more influential within the profession andmore influential within the profession and

training is more university based, researchtraining is more university based, research

and related activity are seen as the acmeand related activity are seen as the acme

of psychiatric work. Working closely withof psychiatric work. Working closely with

patients and creating enduring therapeuticpatients and creating enduring therapeutic

relationships is not valued and is sometimesrelationships is not valued and is sometimes

seen as drudgery. This is a damning para-seen as drudgery. This is a damning para-dox. Is it surprising that it is hard to recruitdox. Is it surprising that it is hard to recruit

into psychiatry a specialty that is dismis-into psychiatry a specialty that is dismis-

sive of the very core of its professionalsive of the very core of its professional

ethic?ethic?

Psychiatry needs to return to its corePsychiatry needs to return to its core

values (Simms, 2003). It needs to placevalues (Simms, 2003). It needs to place

the care and treatment of the individualthe care and treatment of the individual

patient centre-stage. Students, young doc-patient centre-stage. Students, young doc-

tors and psychiatric trainees must see attors and psychiatric trainees must see atfirst hand the fascination and reward offirst hand the fascination and reward of

working with patients, and see that theworking with patients, and see that the

work is attractive and satisfying. A part ofwork is attractive and satisfying. A part of

this process must be the rehabilitation ofthis process must be the rehabilitation of

the detailed case report.the detailed case report.

Shooter, M. (2003)Shooter, M. (2003) On Pushto, principles and passion:On Pushto, principles and passion:

just what is an advance in psychiatric treatment?just what is an advance in psychiatric treatment?

Advances in PsychiatricTreatmentAdvances in PsychiatricTreatment,, 99, 239^240., 239^240.

Simms, A. (2003)Simms, A. (2003) Back to basics: on not neglectingBack to basics: on not neglecting

the elementary in continuing professional development.the elementary in continuing professional development.

Advances in PsychiatricTreatmentAdvances in PsychiatricTreatment,, 99,1^2.,1^2.

Wilkinson, G. (2 003)Wilkinson, G. (20 03) Fare thee well ^ the Editors lastFare thee well ^ the Editors last

words.words. British Journal of PsychiatryBritish Journal of Psychiatry,, 182182, 465^466., 465^466.

D. D. R.WilliamsD. D. R.Williams Departmentof Old AgeDepartment of Old Age

Psychiatry, Cefn Coed Hospital,Waunarlwydd Road,Psychiatry,Cefn Coed Hospital,Waunarlwydd Road,

Cockett, Swansea SA2 0GH,UKCockett, Swansea SA2 0GH,UK

In defence of specialist mentalIn defence of specialist mental

health care trustshealth care trusts

Psychological medicine is an interestingPsychological medicine is an interesting

way to describe an attractive field (Lloydway to describe an attractive field (Lloyd

& Mayou, 2003). The patients are gener-& Mayou, 2003). The patients are gener-

ally interesting and engaging, the work isally interesting and engaging, the work is

usually consensual and professionally re-usually consensual and professionally re-warding. However, when mental healthwarding. However, when mental health

services are attached to general hospitals,services are attached to general hospitals,

liaison psychiatry is merely one of an arrayliaison psychiatry is merely one of an array

of specialties competing for funds. Com-of specialties competing for funds. Com-

missioners may find that more acute,missioners may find that more acute,

high-profile services that are better sup-high-profile services that are better sup-

ported by the public take priority when itported by the public take priority when it

comes to the annual funding round.comes to the annual funding round.

A failure to secure sufficient funds inA failure to secure sufficient funds in

this situation can lead to psychiatric wardsthis situation can lead to psychiatric wards

and facilities appearing neglected and shab-and facilities appearing neglected and shab-

by compared with general medical wards inby compared with general medical wards in

the same hospital. When coupled with athe same hospital. When coupled with astaff that is liable to feel undervalued, thestaff that is liable to feel undervalued, the

quality of care can suffer and the stigmaquality of care can suffer and the stigma

of mental illness is compounded.of mental illness is compounded.

The appearance of specialist trusts inThe appearance of specialist trusts in

many different areas of medicine shouldmany different areas of medicine should

allow the strategic, systematic developmentallow the strategic, systematic development

of a comprehensive range of specialist ser-of a comprehensive range of specialist ser-

vices. Lloyd & Mayou should welcomevices. Lloyd & Mayou should welcomethe opportunity to develop their field inthe opportunity to develop their field in

such a focused setting along with othersuch a focused setting along with other

psychiatrists with different interests. Bypsychiatrists with different interests. By

seeking to make itself [liaison psychiatry]seeking to make itself [liaison psychiatry]

more acceptable to medical colleagues theymore acceptable to medical colleagues they

could be distancing themselves from thecould be distancing themselves from the

psychotic patients [historically] housed inpsychotic patients [historically] housed in

large asylums. These are the very patientslarge asylums. These are the very patients

that suffer the greatest amount of stigmathat suffer the greatest amount of stigma

and social exclusion, that form the bulk ofand social exclusion, that form the bulk of

most psychiatrists case-loads and that aremost psychiatrists case-loads and that are

the least visible to general hospitals.the least visible to general hospitals.

All psychiatrists should have the oppor-All psychiatrists should have the oppor-tunity to develop their skills by caring fortunity to develop their skills by caring for

this group of patients as part of their train-this group of patients as part of their train-

ing. It would be a pity if the views of Lloyding. It would be a pity if the views of Lloyd

& Mayou were taken to their logical& Mayou were taken to their logical

conclusion and psychological medicineconclusion and psychological medicine

divorced itself from mainstream psychiatrydivorced itself from mainstream psychiatry

and sought to become recognised as aand sought to become recognised as a

sub-specialty with our esteemed colleaguessub-specialty with our esteemed colleagues

at the Royal College of Physicians.at the Royal College of Physicians.

G. G. Lloyd & R. A. Mayou (2003)G. G. Lloyd & R. A. Mayou (2003) Liaison psychiatryLiaison psychiatry

or psychological medicine?or psychological medicine? British Journal of PsychiatryBritish Journal of Psychiatry,,

183183, 5^7., 5^7.

A. SharmaA. Sharma Community ForensicTeam, SouthCommunity ForensicTeam, South

London and Maudsley NHS Trust,108 Landor Road,London and Maudsley NHS Trust,108 Landor Road,

London SW9 9NT,UKLondon SW9 9 NT, UK

Mental incapacity and medicalMental incapacity and medical

ethicsethics

With reference to the editorial by Sarkar &With reference to the editorial by Sarkar &

Adshead (2003), we are pleased to see thisAdshead (2003), we are pleased to see this

area of discussion being raised. However,area of discussion being raised. However,

we wish to make a couple of additionalwe wish to make a couple of additional

points relating to capacity.points relating to capacity.We appreciate that a psychiatrists abilityWe appreciate that a psychiatrists ability

to override a competent refusal raises parti-to override a competent refusal raises parti-

cular ethical dilemmas and it is right thatcular ethical dilemmas and it is right that

this should be highlighted for attention.this should be highlighted for attention.

However, we felt that other points in theHowever, we felt that other points in the

section Psychiatry as a special case could,section Psychiatry as a special case could,

and do, apply to many non-psychiatricand do, apply to many non-psychiatric

patients, particularly those with acutepatients, particularly those with acute

medical illness.medical illness.

The authors assert that The most sig-The authors assert that The most sig-

nificant difference between medicine andnificant difference between medicine and

psychiatry lies in the relative incapacity ofpsychiatry lies in the relative incapacity of

psychiatric patients to make decisions forpsychiatric patients to make decisions forthemselves. Although it is true that somethemselves. Although it is true that some

8 48 4

B R I T I S H J O U R N A L O F P S Y C H I A T RYB R I T I S H J O U R N A L O F P S Y C H I A T RY ( 2 0 0 4 ) , 1 8 4 , 8 4 ^ 8 7( 2 0 0 4 ) , 1 8 4 , 8 4 8 7

CorrespondenceCorrespondence

EDITED BY STANLEY ZAMMITEDITED BY STANLEY ZAMMIT

ContentsContents && Indefence ofthe casereportIndefence ofthe casereport && In defence of specialistmental health careIn defence of specialist mentalhealth care

truststrusts && Mentalincapacity and medical ethicsMentalincapacity and medical ethics && Debate on neurosurgeryDebate on neurosurgery && Cognitive ^Cognitive ^

behavioural therapy for psychosisbehavioural therapy for psychosis && Personality assessmentPersonality assessment && Management ofManagement of

post-concussion syndromepost-concussion syndrome

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C O R R E S P O N D E N C EC O R R E S P O N D E N C E

of the most severely affected patients haveof the most severely affected patients have

impaired decision-making skills, theyimpaired decision-making skills, they

form a minority (Grisso & Appelbaum,form a minority (Grisso & Appelbaum,

1995). Most psychiatric patients (includ-1995). Most psychiatric patients (includ-

ing in-patients)ing in-patients) are perfectly capable ofare perfectly capable of

making decisions regarding treatment andmaking decisions regarding treatment and

other areas of their lives. It does not helpother areas of their lives. It does not helpthe cause of reducing stigma for our pa-the cause of reducing stigma for our pa-

tients to suggest that they cannot make suchtients to suggest that they cannot make such

decisions.decisions.

Just as not all psychiatric patients lackJust as not all psychiatric patients lack

capacity, not all medical patients havecapacity, not all medical patients have

capacity. This particularly applies to in-capacity. This particularly applies to in-

patients in whom factors such as cognitivepatients in whom factors such as cognitive

impairment and delirium can affect theimpairment and delirium can affect the

ability to make decisions. A recent surveyability to make decisions. A recent survey

of medical in-patients found that mental in-of medical in-patients found that mental in-

capacity was a very common problem, andcapacity was a very common problem, and

one that was frequently overlooked byone that was frequently overlooked by

medical staff (further details available frommedical staff (further details available fromV.R. upon request). These patients are par-V.R. upon request). These patients are par-

ticularly vulnerable to medical paternalismticularly vulnerable to medical paternalism

if this problem is not recognised andif this problem is not recognised and

appropriately managed.appropriately managed.

We agree with Sarkar & Adsheads callWe agree with Sarkar & Adsheads call

for a code of ethics for British psychiatry,for a code of ethics for British psychiatry,

and hope that it will address this difficultand hope that it will address this difficult

area of incapacity. Incidentally, we are alsoarea of incapacity. Incidentally, we are also

watching with interest the progress of thewatching with interest the progress of the

draft Mental Incapacity Bill. However, wedraft Mental Incapacity Bill. However, we

suggest that this area requires careful scru-suggest that this area requires careful scru-

tiny not because psychiatry is a special casetiny not because psychiatry is a special case

but because these issues affect all health carebut because these issues affect all health careprofessionals. In this way we could help toprofessionals. In this way we could help to

lead the way for our non-psychiatric collea-lead the way for our non-psychiatric collea-

gues rather than concentrating on ourgues rather than concentrating on our

differences.differences.

Grisso,T. & Appelbaum, P. S. (1995)Grisso,T. & Appelbaum, P. S. (1995) The MacArthurThe MacArthur

Treatment Competence Study. III: Abilities of patients toTreatment Competence Study. III: Abilities of patients to

consent to psychiatric medical treatments.consent to psychiatric medical treatments. Law andLaw and

Human BehaviorHuman Behavior,, 1919, 149^174., 149^174.

Sarkar, S. P. & Adshead,G. (2 003)Sarkar, S. P. & Adshead,G. (2 003) Protectingaltruism:Protectingaltruism:

a call for a code of ethics in British psychiatry.a call for a code of ethics in British psychiatry. BritishBritish

Journal of PsychiatryJournal of Psychiatry,, 183183, 95^97., 95^97.

S. A. HudsonS. A. Hudson Maudsley Hospital, Denmark Hill,Maudsley Hospital, Denmark Hill,London SE5 8AZ,UKLondon SE5 8AZ,UK

V. RaymontV. Raymont Institute of Psychiatry,London, UKInstitute of Psychiatry,London, UK

Debate on neurosurgeryDebate on neurosurgery

The debate on the future of neurosurgeryThe debate on the future of neurosurgery

for psychiatric disorders (R. Persaud/for psychiatric disorders (R. Persaud/

D. Crossley & C. Freeman, 2003) is curiousD. Crossley & C. Freeman, 2003) is curious

in many ways. Much of the criticism ofin many ways. Much of the criticism of

neurosurgery still relies upon its historicalneurosurgery still relies upon its historical

excesses (Pressman, 1998) rather than theexcesses (Pressman, 1998) rather than the

contemporary caution. The lack ofcontemporary caution. The lack of

evidence argument sets up an unrealisticevidence argument sets up an unrealisticstandard that most surgical treatments arestandard that most surgical treatments are

unable to meet. The progress in psychiatricunable to meet. The progress in psychiatric

treatments argument fails to recognise thattreatments argument fails to recognise that

recent drug treatments are but incrementalrecent drug treatments are but incremental

advances over drugs that have been aroundadvances over drugs that have been around

for some decades, and there are manyfor some decades, and there are many

patients who continue to suffer chronicallypatients who continue to suffer chronically

from depression, obsessivecompulsive dis-from depression, obsessivecompulsive dis-order and other illnesses. For those of usorder and other illnesses. For those of us

who practise in tertiary referral centres,who practise in tertiary referral centres,

encounters with their suffering are frequentencounters with their suffering are frequent

and heart-wrenching. Do we wish to takeand heart-wrenching. Do we wish to take

away all their hope?away all their hope?

I am not arguing for a return to theI am not arguing for a return to the

past. Modern neuroscience is fast remov-past. Modern neuroscience is fast remov-

ing, in a practical sense, the distinctioning, in a practical sense, the distinction

between brain and mind. It is now quitebetween brain and mind. It is now quite

acceptable to consider neural transplants,acceptable to consider neural transplants,

gene therapy and neural prosthetics asgene therapy and neural prosthetics as

neuropsychiatric treatments. Is this not theneuropsychiatric treatments. Is this not the

right era to revisit surgical interventionsright era to revisit surgical interventionson the brain? We are already excited abouton the brain? We are already excited about

developments such as vagus nerve stimula-developments such as vagus nerve stimula-

tion and deep brain stimulation for psychi-tion and deep brain stimulation for psychi-

atric disorders (Malhi & Sachdev, 2002).atric disorders (Malhi & Sachdev, 2002).

We are quite comfortable with ablativeWe are quite comfortable with ablative

surgery for epilepsy when there issurgery for epilepsy when there is

functional disturbance, even in the absencefunctional disturbance, even in the absence

of structural abnormality. The neuro-of structural abnormality. The neuro-

anatomical models of psychiatric disordersanatomical models of psychiatric disorders

are becoming increasingly sophisticatedare becoming increasingly sophisticated

(Mayberg, 2001). Should we not be work-(Mayberg, 2001). Should we not be work-

ing towards a new era of direct brain inter-ing towards a new era of direct brain inter-

vention, with surgery being an importantvention, with surgery being an importantaspect of this strategy? This surgery mayaspect of this strategy? This surgery may

or may not be ablative, or follow an initialor may not be ablative, or follow an initial

period of brain stimulation, or be guided byperiod of brain stimulation, or be guided by

sophisticated functional imaging. If deepsophisticated functional imaging. If deep

brain stimulation, for example, is demon-brain stimulation, for example, is demon-

strated to produce a therapeutic responsestrated to produce a therapeutic response

without adverse effects, but only tempora-without adverse effects, but only tempora-

rily, would there not be an argument to pro-rily, would there not be an argument to pro-

ceed with focal ablation? The brain is, afterceed with focal ablation? The brain is, after

all, not inviolable, and the evidence is con-all, not inviolable, and the evidence is con-

vincing that focal and targeted brain lesionsvincing that focal and targeted brain lesions

can spare both intellect and personality.can spare both intellect and personality.

The answer to the question, shouldThe answer to the question, shouldneurosurgery for mental disorder be al-neurosurgery for mental disorder be al-

lowed to die out? is surely, Definitelylowed to die out? is surely, Definitely

not. Let us, however, move towards anot. Let us, however, move towards a

new neurosurgery that is bold but not mis-new neurosurgery that is bold but not mis-

informed, and that keeps abreast of theinformed, and that keeps abreast of the

developments in our understanding of braindevelopments in our understanding of brain

function.function.

Malhi, G. S. & S achdev, P. (2 002)Malhi, G. S. & S achdev, P. (2 002) Novel physicalNovel physical

treatments for the management of neuropsychiatrictreatments for the management of neuropsychiatric

disorders.disorders.Journal of Psychosomatic ResearchJournal of Psychosomatic Research,, 5353,,

709^719.709^719.

Mayberg, H. (2001)Mayberg, H. (2001) Depression and frontal^Depression and frontal^

subcortical circuits: focus on prefrontal ^ limbicsubcortical circuits: focus on prefrontal ^ limbic

interactions. Ininteractions. In Frontal^Subcortical Circuits in PsychiatricFrontal^Subcortical Circuits in Psychiatric

and Neurological Disordersand Neurological Disorders (eds D.G. Lichter & J.(eds D.G. Lichter & J.

Cummings), pp.177^206. NewYork: Guilford Press.Cummings), pp.177^206. NewYork: Guilford Press.

Persaud, R./ Crossley, D. & Freeman, C. (20 03)Persaud, R./ Crossley, D. & Freeman, C. (20 03)

Should neurosurgery for mental disorder be allowedShould neurosurgery for mental disorder be allowed

to die out? (debate).to die out? (debate). British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,

195^196.195^196.

Pressman, J. D. (1998)Pressman, J. D. (1998) Last Resort: Psychosurgery andLast Resort: Psychosurgery and

the Limits of Medicinethe Limits of Medicine.Cambridge: Cambridge University.Cambridge: Cambridge University

Press.Press.

P. SachdevP. Sachdev Neuropsychiatric Institute,The PrinceNeuropsychiatric Institute,The Prince

of Wales Hospital, Barker Street, Randwick,NSWof Wales Hospital, Barker Street, Randwick,NSW

2031, Australia2031, Australia

Cognitive ^ behavioural therapyCognitive ^ behavioural therapy

for psychosisfor psychosis

Like a magician pulling a rabbit from hisLike a magician pulling a rabbit from hishat, Turkington draws a positive resulthat, Turkington draws a positive result

for cognitive therapy for schizophreniafor cognitive therapy for schizophrenia

from the literature only for McKennafrom the literature only for McKenna

to put it back in again (Turkington/to put it back in again (Turkington/

McKenna, 2003). Does it exist or not?McKenna, 2003). Does it exist or not?

McKennas arguments and table look con-McKennas arguments and table look con-

vincing as, by excluding any study thatvincing as, by excluding any study that

does not have an active control, he reducesdoes not have an active control, he reduces

the number of studies he considers. Butthe number of studies he considers. But

would he do the same for studies of anti-would he do the same for studies of anti-

psychotic medications? Or does he assumepsychotic medications? Or does he assume

that patients, and raters evaluating pa-that patients, and raters evaluating pa-

tients, can detect no difference betweentients, can detect no difference betweentaking, for example, placebo and haloperi-taking, for example, placebo and haloperi-

dol, or even haloperidol and olanzapine?dol, or even haloperidol and olanzapine?

In which case why are we giving them soIn which case why are we giving them so

much of the latter?much of the latter?

But even focusing only on the studiesBut even focusing only on the studies

that he finds acceptable, he dismisses onethat he finds acceptable, he dismisses one

(SoCRATES; Lewis(SoCRATES; Lewis et alet al, 2002) for having, 2002) for having

a positive effect over active control on audi-a positive effect over active control on audi-

tory hallucinations (oh, for a drug that hadtory hallucinations (oh, for a drug that had

such an effect over and above those cur-such an effect over and above those cur-

rently available!) and another (Senskyrently available!) and another (Sensky etet

alal, 2000) where a differential benefit of, 2000) where a differential benefit of

cognitivebehavioral therapy over befriend-cognitivebehavioral therapy over befriend-ing only became apparent 9 months aftering only became apparent 9 months after

therapy ended. He completely omits othertherapy ended. He completely omits other

widely cited studies with active placeboswidely cited studies with active placebos

and positive effects (e.g. Druryand positive effects (e.g. Drury et alet al, 1996)., 1996).

He then does an unusual meta-analyticHe then does an unusual meta-analytic

exercise in dismissing two small pilot studiesexercise in dismissing two small pilot studies

by weighing them against each other andby weighing them against each other and

finding them to cancel out. Other meta-finding them to cancel out. Other meta-

analyses (e.g. Pillinganalyses (e.g. Pilling et alet al, 2002) using more, 2002) using more

conventional methodology have concludedconventional methodology have concluded

differently and, fortunately, so has thedifferently and, fortunately, so has the

National Institute for Clinical Excellence.National Institute for Clinical Excellence.

The rabbit exists and is multiplyingThe rabbit exists and is multiplyingrapidly (e.g. Durhamrapidly (e.g. Durham et alet al, 2003)., 2003).

8 58 5

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C O R R E S P O N D E N C EC O R R E S P O N D E N C E

Declaration of interestDeclaration of interest

D.K. has published books and gives work-D.K. has published books and gives work-

shops on cognitivebehavioural therapyshops on cognitivebehavioural therapy

for schizophrenia.for schizophrenia.

Drury,V., Birchwood, M., Cochrane, R.,Drury,V., Birchwood, M., Cochrane, R., et alet al(1996)(1996)

Cognitive therapy and recovery from acute psychosis: aCognitive therapy and recovery from acute psychosis: a

controlled trial. II.Impact on recovery time.controlled trial. II. Impact on recovery time. BritishBritish

Journal of PsychiatryJournal of Psychiatry,, 169169, 602^607., 602^607.

Durham, R. C., Guthrie, M., Morton, R. V.,Durham, R. C., Guthrie, M., Morton, R. V., et alet al

(2003)(2003) Tayside^ Fife clinical trial of cognitive Tayside^ Fife clinical trial of cognitive

behavioural therapy for medication-resistant psychoticbehavioural therapy for medication-resistant psychotic

symptoms: results to 3-month follow-up.symptoms: results to 3-month follow-up. British JournalBritish Journal

of Psychiatryof Psychiatry,, 182182, 303^311., 303^311.

Lewis, S., Terrier, N., Haddock, G.,Lewis, S., Terrier, N.,Haddock, G., et alet al (2002)(2002)

Randomised controlled trial of cognitive ^ behaviouralRandomised controlled trial of cognitive ^ behavioural

therapy in early schizophrenia: acute-phase outcomes.therapy in e arly schizophrenia: acute-phase outcomes.

British Journal of PsychiatryBritish Journal of Psychiatry,, 181181 (suppl. 43), s91^ s97.(suppl. 43), s91^ s97.

Pilling, S., Bebbington, P., Kuipers, E.,Pilling, S., Bebbington, P., Kuipers, E., et alet al (2002)(2002)

Psychological treatmentsin schizophrenia:I. Meta-Psychological treatments in schizophrenia:I.Meta-analysis of family intervention and cognitive behaviouranalysis of family intervention and cognitive behaviour

therapy.therapy. Psychological MedicinePsychological Medicine,, 3232, 763^782., 763^782.

Sensky,T.,Turkington, D.,Kingdon, D.,Sensky,T.,Turkington, D.,Kingdon, D., et alet al(2000)(2000) AA

randomized controlled trial of cognitive^ behaviouralrandomized controlled trial of cognitive^ behavioural

therapy for persistent symptoms in schizophreniatherapy for persistent symptoms in schizophrenia

resistant to medication.resistant to medication. Archives of General PsychiatryArchives of General Psychiatry,, 5757,,

165^172.165^172.

Turkington, D./McKenna, P. J. (2003)Turkington, D./McKenna, P. J. (2003) Is cognitive Is cognitive

behavioural therapy a worthwhile treatment forbehavioural therapy a worthwhile treatment for

psychosis? (debate).psychosis? (debate). British Journal of PsychiatryBritish Journal of Psychiatry,, 182182,,

477^479.477^479.

D. KingdonD. Kingdon University of Southampton, RoyalUniversity of Southampton,Royal

South Hants Hospital, Southampton SO14 0YG,UK.South Hants Hospital, Southampton SO14 0YG,UK.

E-mail: dgkE-mail: dgk@@soton.ac.uksoton.ac.uk

Authors reply:Authors reply: Actually, the study ofActually, the study of

DurhamDurham et alet al (2003) which was carried out(2003) which was carried out

under blind conditions failed to find a signif-under blind conditions failed to find a signif-

icant advantage for cognitive therapy overicant advantage for cognitive therapy over

active placebo. The authors state that Re-active placebo. The authors state that Re-

peated measures analyses of variance werepeated measures analyses of variance were

first conducted with three levels of treatmentfirst conducted with three levels of treatment

(CBT(CBT vv. SPT. SPT vv. TAU) and three time points. TAU) and three time points

(baseline, post-treatment, follow-up). There(baseline, post-treatment, follow-up). There

were significant effects for time for allwere significant effects for time for allvariables except the GAS but no significantvariables except the GAS but no significant

timetime66treatment interaction effects or con-treatment interaction effects or con-

trasts for any of the measures. This wastrasts for any of the measures. This was

for Changes in severity from baseline,for Changes in severity from baseline,

with an essentially similar finding forwith an essentially similar finding for

Clinically significant improvement.Clinically significant improvement.

Durham, R. C., Guthrie, M., Morton, R. V.,Durham, R. C., Guthrie, M., Morton, R. V., et alet al

(2003)(2003) Tayside^ Fife clinical trial of cognitive Tayside^ Fife clinical trial of cognitive

behavioural therapy for medication-resistant psychoticbehavioural therapy for medication-resistant psychotic

symptoms. Results to 3-month follow-up.symptoms. Results to 3-month follow-up. British JournalBritish Journal

of Psychiatryof Psychiatry,, 182182, 303^311., 303^311.

P. J. McKennaP. J. McKenna Fulbourn Hospital,CambridgeFulbourn Hospital, Cambridge

CB1 5EF. E-mail: peter.mckennaCB1 5EF. E-mail: peter.mckenna@@virgin.netvirgin.net

Personality assessmentPersonality assessment

In their description of the StandardisedIn their description of the Standardised

Assessment of Personality AbbreviatedAssessment of Personality Abbreviated

Scale (SAPAS) MoranScale (SAPAS) Moran et alet al (2003) write(2003) write

that, to the best of their knowledge, onlythat, to the best of their knowledge, only

two other interviewer-administered screenstwo other interviewer-administered screens

for personality disorder have been pub-for personality disorder have been pub-

lished. I would like to draw attention to alished. I would like to draw attention to a

third, the Personality Structure Question-third, the Personality Structure Question-

naire (PSQ) (Pollocknaire (PSQ) (Pollock et alet al, 2001), which, 2001), which

consists of eight bipolar items scored 15consists of eight bipolar items scored 15

and is similarly quick to administer and toand is similarly quick to administer and to

score. The scores of four clinical and fourscore. The scores of four clinical and four

non-clinical samples are reported in the pa-non-clinical samples are reported in the pa-

per. Two samples of patients meeting diag-per. Two samples of patients meeting diag-

nostic criteria for borderline personalitynostic criteria for borderline personality

disorder had mean scores of over 30,disorder had mean scores of over 30,

whereas the non-clinical samples scored be-whereas the non-clinical samples scored be-

tween 19.7 and 23.3. Scores on the PSQtween 19.7 and 23.3. Scores on the PSQ

were shown to correlate with a number ofwere shown to correlate with a number of

measures of multiplicity, dissociation andmeasures of multiplicity, dissociation and

identity disturbance.identity disturbance.

Most of the items on the questionnaireMost of the items on the questionnaire

describe the respondents awareness of adescribe the respondents awareness of a

discontinuous sense of self. This reflectsdiscontinuous sense of self. This reflects

the multiple self states model of borderlinethe multiple self states model of borderline

personality disorder (Ryle, 1997personality disorder (Ryle, 1997aa), in), in

which alternations in the operation ofwhich alternations in the operation of

recognisable, discrete self states, each withrecognisable, discrete self states, each with

a characteristic mood, sense of self anda characteristic mood, sense of self and

mode of relating to others, are seen tomode of relating to others, are seen to

account for much of the experience andaccount for much of the experience and

confusion of patients and of those treatingconfusion of patients and of those treating

them. The PSQ is similar to the SAPAS inthem. The PSQ is similar to the SAPAS in

being a screening, not a diagnostic instru-being a screening, not a diagnostic instru-

ment. It differs in that it focuses on the spe-ment. It differs in that it focuses on the spe-

cific feature of self state instability typicalcific feature of self state instability typical

of Cluster B disorders. This can be anof Cluster B disorders. This can be an

advantage in that these patients presentadvantage in that these patients present

the greatest difficulty to clinicians. Bythe greatest difficulty to clinicians. By

drawing attention to this characteristic thedrawing attention to this characteristic the

PSQ can initiate further enquiry leading toPSQ can initiate further enquiry leading to

the detailed description of an individualsthe detailed description of an individuals

self states and state switches, which canself states and state switches, which can

provide a basis for management andprovide a basis for management and

treatment directed towards personalitytreatment directed towards personality

integration (Ryle 1997integration (Ryle 1997bb).).

Moran, P., Leese , M., Lee, T.,Moran, P., Leese, M., Lee, T., et alet al(2003)(2003)

Standardised Assessment of Personality AbbreviatedStandardised Assessment of Personality Abbreviated

Scale (SAPAS): preliminary validation of a brief screenScale (SAPAS): preliminary validation of a brief screen

for personality disorder.for personality disorder. British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,

228^232.228^232.

Pollock, P., Broadbent, M., Clarke, S.,Pollock, P., Broadbent, M., Clarke, S., et alet al(2001)(2001)

The Personality Structure Questionnaire (PSQ): aThe Personality Structure Questionnaire (PSQ): a

measure of the multiple self states model of identitymeasure of the multiple self states model of identity

disturbance in cognitive analytic therapy.disturbance in cognitive analytic therapy. ClinicalClinical

Psychology and PsychotherapyPsychology and Psychotherapy,, 88, 59^72., 59^72.

Ryle, A. (1997Ryle, A. (1997aa)) The structure and development ofThe structure and development of

borderline personality disorder: a proposed model.borderline personality disorder: a proposed model.

British Journal of PsychiatryBritish Journal of Psychiatry,, 170170, 82^87., 82^87.

Ryle, A. (1997Ryle, A. (1997bb)) Cognitive Analytic Therapy andCognitive AnalyticTherapy and

Borderline Personality Disorder: the Model and theBorderline Personality Disorder: the Model and the

MethodMethod. Chichester: J.Wiley & Sons.. Chichester:J.Wiley & Sons.

A. RyleA. Ryle South London and Maudsley NHS Trust,South London and Maudsley NHS Trust,

Co-ordinated Psychological Treatments ServiceCo-ordinated Psychological Treatments Service

(CPTS),The Munro Centre, Snowsfields,London(CPTS), The Munro Centre, Snowsfields, London

SE1 3SS,UKSE1 3SS, UK

Management of post-concussionManagement of post-concussion

syndromesyndrome

In his editorial King (2003) gave an excel-In his editorial King (2003) gave an excel-

lent overview of the post-concussion syn-lent overview of the post-concussion syn-

drome, an area of neuropsychology anddrome, an area of neuropsychology and

psychiatry that is fraught with difficultypsychiatry that is fraught with difficulty

and controversy. King pointed out that bothand controversy. King pointed out that both

biological and psychological factors are atbiological and psychological factors are at

play in post-concussion syndrome. Of greatplay in post-concussion syndrome. Of greatimportance was his integration of time sinceimportance was his integration of time since

injury into a model and outlining windowsinjury into a model and outlining windows

of vulnerability for the development ofof vulnerability for the development of

symptoms. It is likely that most clinicianssymptoms. It is likely that most clinicians

treating patients with post-concussion syn-treating patients with post-concussion syn-

drome will find this model of real valuedrome will find this model of real value

for understanding and possibly preventingfor understanding and possibly preventing

some of the difficulties resulting from thesome of the difficulties resulting from the

syndrome.syndrome.

King rightly pointed out the need forKing rightly pointed out the need for

studies investigating treatment and man-studies investigating treatment and man-

agement of post-concussion syndrome.agement of post-concussion syndrome.

New and future research findings nowNew and future research findings nowneed to be incorporated into Kings mod-need to be incorporated into Kings mod-

el. For example, Ponsfordel. For example, Ponsford et alet al (2002)(2002)

in a randomised controlled trial foundin a randomised controlled trial found

that the provision 1 week post-injury ofthat the provision 1 week post-injury of

an information booklet to patients whoan information booklet to patients who

suffered a mild head injury reduced anxi-suffered a mild head injury reduced anxi-

ety and reporting of ongoing problems atety and reporting of ongoing problems at

3 months post-injury. Against a back-3 months post-injury. Against a back-

ground of windows of vulnerability forground of windows of vulnerability for

the development and maintenance ofthe development and maintenance of

symptoms, providing written informationsymptoms, providing written information

to patients in addition to the early inter-to patients in addition to the early inter-

ventions reviewed by King can further im-ventions reviewed by King can further im-prove outcome in post-concussionprove outcome in post-concussion

syndrome.syndrome.

A recent example identifying a poten-A recent example identifying a poten-

tial lack of evidence for an interventiontial lack of evidence for an intervention

perhaps also needs mentioning. De Kruijkperhaps also needs mentioning. De Kruijk

et alet al (2002) investigated the effect of bed(2002) investigated the effect of bed

rest on outcome following mild traumaticrest on outcome following mild traumatic

brain injury. Bed rest has been recom-brain injury. Bed rest has been recom-

mended as an intervention to improvemended as an intervention to improve

outcome following head injury; however,outcome following head injury; however,

the effectiveness of this intervention hasthe effectiveness of this intervention has

not been investigated. De Kruijk andnot been investigated. De Kruijk and

colleagues did not find significantcolleagues did not find significantdifferences in outcome between theirdifferences in outcome between their

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C O R R E S P O N D E N C EC O R R E S P O N D E N C E

bed rest and no bed rest groups at 3bed rest and no bed rest groups at 3

months post injury. However, they con-months post injury. However, they con-

cluded that bed rest might have somecluded that bed rest might have some

palliative effect during the initial weekspalliative effect during the initial weeks

following injury.following injury.

New and future research findings onNew and future research findings on

management, integrated into Kings model,management, integrated into Kings model,can potentially enhance the prevention ofcan potentially enhance the prevention of

chronic symptomatology developing inchronic symptomatology developing in

post-concussion syndrome. This might alsopost-concussion syndrome. This might also

inform our understanding of cases whereinform our understanding of cases where

post-concussion symptoms persist beyondpost-concussion symptoms persist beyond

1 year following injury.1 year following injury.

De Kruijk, J. R., Leffers, P., Meerhof, S.,De Kruijk, J. R., Leffers, P., Meerhof, S., et alet al (2002)(2002)

Effectiveness of bed rest after mild traumatic brainEffectiveness of bed rest after mild traumatic braininjury: a randomised trial of no versus six days of bedinjury: a randomised trial of no versus six days of bed

rest.rest.Journalof Neurology, Neurosurgery and PsychiatryJournal of Neurology, Neurosurgery and Psychiatry,, 7373,,

167^172.167^172.

King, N. S. (2003)King, N. S. (2003) Post-concussion syndrome: clarityPost-concussion syndrome: clarity

amid the controversy?amid the controversy? British Journal of PsychiatryBritish Journal of Psychiatry,, 183183,,

276^278.276^278.

Ponsford, J.,Willmott, C., Rothwell, A.,Ponsford, J.,Willmott, C., Rothwell, A., et alet al (2002)(2002)

Impact of e arly intervention on outcome following mildImpact of early intervention on outcome following mild

head injury in adults.head injury in adults.Journal of Neurology, NeurosurgeryJournal of Neurology, Neurosurgery

and Psychiatryand Psychiatry,, 7373, 330^332., 330^332.

B. R. CoetzerB. R. Coetzer North Wales Brain Injury Service,North Wales Brain Injury Service,

Colwyn Bay Hospital,Hesketh Road,Colwyn BayColwyn B ay Hospital, Hesketh Road, Colwyn Bay

LL29 8AY, UKLL29 8AY,UK

One hundred years agoOne hundred years ago

Review ofReview of Hypnotism, its History,Hypnotism, its History,

Practice, and TheoryPractice, and Theory..

By J. Milne Bramwell, MB,CM, Edin., author ofBy J. Milne Bramwell, MB,CM, Edin., author of

numerous articles on the Practice and Theorynumerous articles on the Practice and Theory

of Hypnotism. London: Grant Richards. 1903.of Hypnotism. London: Grant Richards. 1903.

Pp. 477. Price18s. net.Pp. 477. Price18s. net.

The author of this book, we are told byThe author of this book, we are told by

the publisher, has devoted the last 12the publisher, has devoted the last 12

years to hypnotic practice and researchyears to hypnotic practice and research

and his personal observations of the practi-and his personal observations of the practi-

cal work done in France, Germany, Swe-cal work done in France, Germany, Swe-

den, Holland, Switzerland, and Belgiumden, Holland, Switzerland, and Belgium

should also make the volume a valuable ad-should also make the volume a valuable ad-

dition to the science of a subject which isdition to the science of a subject which is

exciting much interest at the present time.exciting much interest at the present time.

In the introductory chapter the author tellsIn the introductory chapter the author tells

us that in the course of the volume he pro-us that in the course of the volume he pro-

poses to refer not only to his own hypnoticposes to refer not only to his own hypnotic

12 years practice and research but also to12 years practice and research but also to

give such a general account of the subjectgive such a general account of the subject

as can be brought within reasonable com-as can be brought within reasonable com-

pass. Examining Dr. Bramwells book inpass. Examining Dr. Bramwells book in

the light of his own account of his inten-the light of his own account of his inten-

tions we doubt if he has fulfilled the pro-tions we doubt if he has fulfilled the pro-

mises made. One chapter is devoted to themises made. One chapter is devoted to the

early history of hypnotism; it is short andearly history of hypnotism; it is short and

very incomplete; for example, the accountvery incomplete; for example, the account

given of Mesmer is fragmentary. The workgiven of Mesmer is fragmentary. The work

of Elliotson, of Esdaile, and of Braid isof Elliotson, of Esdaile, and of Braid is

more fully treated. The section on the latermore fully treated. The section on the later

History of Hypnotism contains an accountHistory of Hypnotism contains an account

of the practice of Dr. A. A. Liebeault ofof the practice of Dr. A. A. Liebeault of

Nancy. A section follows entitled HistoryNancy. A section follows entitled History

of My Own Practice. The remaining partof My Own Practice. The remaining part

of the book is devoted to dissertations onof the book is devoted to dissertations on

the methods of inducing and terminatingthe methods of inducing and terminating

hypnosis, susceptibility to hypnosis andhypnosis, susceptibility to hypnosis and

the causes which influence it, the experi-the causes which influence it, the experi-

mental phenomena of hypnosis, and themental phenomena of hypnosis, and the

management of hypnotic experiments andmanagement of hypnotic experiments and

an account of the different stages of hyp-an account of the different stages of hyp-

nosis. The therapeutic use of hypnotismnosis. The therapeutic use of hypnotism

is dealt with in chapters on hypnotism inis dealt with in chapters on hypnotism in

medicine and surgery and in one on themedicine and surgery and in one on the

management of medical and surgical cases.management of medical and surgical cases.

This is followed by a disquisition on hypno-This is followed by a disquisition on hypno-

tic theories which occupies 150 pages, ortic theories which occupies 150 pages, or

nearly a third of the whole work. A chapternearly a third of the whole work. A chapter

is devoted to the so-called dangers of hyp-is devoted to the so-called dangers of hyp-

notism and this is followed by a summary,notism and this is followed by a summary,

conclusion, and list of references. Of theconclusion, and list of references. Of the

two appendices one is the late Dr. William-two appendices one is the late Dr. William-

sons account of the origin of Braids worksons account of the origin of Braids work

and the other is a note on spiritualism,and the other is a note on spiritualism,

clairvoyance, and telepathy.clairvoyance, and telepathy.

The general effect produced by thisThe general effect produced by this

book is a feeling of wonder that such abook is a feeling of wonder that such a

subject, with all its suggestions of mysterysubject, with all its suggestions of mystery

and occultism bred of our imperfectand occultism bred of our imperfect

knowledge, can have led to the productionknowledge, can have led to the production

of so unstimulating a book. Doubtless Dr.of so unstimulating a book. Doubtless Dr.

Bramwell was particularly right to treatBramwell was particularly right to treat

his subject very seriously, but he might havehis subject very seriously, but he might have

taken more steps to arouse and to hold ourtaken more steps to arouse and to hold our

interest. The work would gain much if itinterest. The work would gain much if it

were rearranged and rewritten so that thewere rearranged and rewritten so that the

history of the subject and the theories ofhistory of the subject and the theories of

its various exponents were placed together.its various exponents were placed together.

For example, the life of Esdaile is given inFor example, the life of Esdaile is given in

one place, while his theories will be foundone place, while his theories will be found

in another. The authors views naturallyin another. The authors views naturally

pervade the book, but while lessons frompervade the book, but while lessons from

personal experience are of the utmost valuepersonal experience are of the utmost value

in all medical treatises, an author shouldin all medical treatises, an author should

beware lest the actors of the past should ap-beware lest the actors of the past should ap-

pear merely as puppets in his play. Dr.pear merely as puppets in his play. Dr.

Bramwell is, we are sure, unaware howBramwell is, we are sure, unaware how

strongly the impression is produced thatstrongly the impression is produced that

views contrary to his own are erroneousviews contrary to his own are erroneous

and misleading.and misleading.

REFERENCEREFERENCE

LancetLancet, 2 January1904, 30., 2 January1904, 30.

Researched by Henry Rollin, Emeritus ConsultantResearched by Henry Rollin, Emeritus Consultant

Psychiatrist, Horton Hospital, Epsom, Surrey.Psychiatrist, Horton Hospital,Epsom, Surrey.

CorrigendumCorrigendum

Disintegration of the components of lan-Disintegration of the components of lan-

guage as the path to a revision of Bleulersguage as the path to a revision of Bleulers

and Schneiders concepts of schizophrenia.and Schneiders concepts of schizophrenia.

Linguistic disturbances compared withLinguistic disturbances compared with

first-rank symptoms in acute psychosis.first-rank symptoms in acute psychosis.

BJPBJP,, 182182, 233240. Summary (p.233),, 233240. Summary (p. 233),

Results should read: Strong positive corre-Results should read: Strong positive corre-

lations were found between the CLANGlations were found between the CLANG

factor poverty and first-rank delusions offactor poverty and first-rank delusions of

control and between semantic/phonemiccontrol and between semantic/phonemic

paraphasias and verbal auditory hallu-paraphasias and verbal auditory hallu-

cinations. Language disturbances werecinations. Language disturbances were

superior to nuclear symptoms in discrimi-superior to nuclear symptoms in discrimi-

nating ICD10 schizophrenia from othernating ICD10 schizophrenia from other

psychoses.psychoses.

8 78 7