743

E X T E R N P S Y C H O L O G I C A L CLINICS. ~

By ROBERT THOMPSON (Armagh).

I N February, 1944, at the suggestion of the Ministry of Health, Northern Ireland, the Committee of Management of Armagh Mental Hospital established Psychological Out-Patient Clinics in connection

with Armagh Infirmary and Lurgan Hospital. These Clinics have now been in operation for some twenty months, so that a preliminary review of the clinical material encountered and of their usefulness or otherwise might be of interest.

It was decided that each Clinic should be visited at fortnightly inter- vals; this was done on the first and third and second and fourth Thurs- days of each month, each session lasting about two hours. It was further decided to inform all local practitioners that only patients who brought with them a letter of introduction from their own doctors would be seen, and that after the first visit a letter of advice would be sent to the recom- mending doctorl The latter decision was a wise one for several reasons. In the first place, it ensured that time would not be wasted on the merely curious who had decided t o t ry the new Clinic; secondly, it was art endeavour to enlist the co-operation of the local practitioners and removed any suggestion of " poaching " on their practices; and thirdly, and most important, it kept the patient definitely under the eye of his own doctor who would remain responsible for sudden and unexpected developments. In dealing with such obviously critical states as early mental or nervous disease it would be placing altogether too great a burden on the psychiatrist to ask him to accept full responsibility for a patient whom he was to see only once a fortnight.

This policy, which in practice has appeared to suit an agricultural county without any very dense concentration of population, might not be equally suitable, without modifications, to large urban or city areas.

In the hospitals concerned a consulting-room and waiting-room were placed at my disposal, and I was further informed that a nurse would be provided if I required one, for example, in the examination of an unaccompanied female patient.

Regarding working hours, except in the first few months when the local practitioners seemed to have a reserve of neurotic cases, I have found the provision of two hours quite adequate. On a few occasions I have had to deal with as many as four new patients at one sitting, but I much prefer two, and not more than three. The history taking and examination of a new case is a tedious and sometimes difficult process, and one could not possibly do justice to large numbers. After the first examination, when diagnosis is certain, a check-up on progress is a rela- tively simple matter.

In the first year of working, 37 new patients were seen at these clinics. This number is small, perhaps even disappointing, but when it is r~alised that the average number of admissions to Armagh Mental Hospital is

* A paper read at the Au~urnn (1945) meet ing of I r i sh Division, Royal Medico- Psychological Association.

744 IRISH JOURNAL OF MEDICAL SCIENCE

just under 100 per annum, it will be seen that, allowing for cases admitted fromthese clinics, the work of the hospital as regards new cases increased by 'approximately 30 per cent., which is not altogether negligible. The numbers attending during the present year and the type of case seen are almost exactly parallel wi th last year, so that I am not yet in a position to say whether the work at these clinics is likely to increase or decrease.

Regarding the type of case seen, of the 37 new patients 13 were cases of anxiety hysteria, 7 of anxiety neurosis, 3 of established melancholia, and there was at least one example of each of the following: conversion hysteria, hypomania, dementia pr~ecox, secondary dementia, paraphrenia, alcoholic confusional insanity, imbecility, epilepsy, adolescent instability, sequelae of head injury and FrShlich's syndrome.

The treatment attempted at an out-patient clinic for many of the above cases will of course be obvious to all, so that I do not propose to enter here into detail. For such cases as dementia prmcox, paraphrenia and alcoholic confusional insanity immediate certification was of course the only possible advice. The patients exhibiting imbecility, seconda~T dementia and FrShlich's syndrome were otherwise harmless and, as the relatives wished to keep them at home, they were advised on their general management. The case of hypomania was a very mild type and it was possible to allow her to remain at home until recovery took place. The case of conversion hysteria (paralysis of an arm) ceased to attend, but I believe ultimately got well. One case of post-concussion mania made a good recovery in the general hospital, but a second case with aphasic symptoms following head injury exhibited signs of pressure over the left frontal area. Owing to his age the surgeon decided against operation, and he gradually became more paralysed and died. The case of adolescent instability required only a commonsense talk. In the~ three cases of melancholia immediate admission to the mental hospital was advised, and all made uninterrupted recoveries with electric convul- mon therapy. With the enormous advantage which this mode of treat- ment now affords in depressed cases nobody, I think, would contemplate treating even the mildest case of melancholia without its aid.

I would like, however, to go into considerably greater detail regarding the cases of anxiety neurosis and anxiety hysteria, which, as will be seen from the figures, will probably form the bulk of cases seen at any extern psychological clinic. Both these affections, particularly anxiety hysteria, are encountered only rarely in ordinary mental hospital practice, but they are the stand-by of the average practising neurologist and of " specialists" of many other types, who, having attained a certain facility in dealing with them, become known as " mental specialists ", notwithstanding many obvious deficiencies in their knowledge of other forms of mental disease.

At the outset, I would stress the fact that anxiety neurosis and anxiety hysteria, although not mutually exclusive, are two absolutely distinct types of nervous affection and require psychological treatment on quite distinct lines. Before entering into a discussion of the differences between these two conditions it might be helpful to give the case his- tories of two fairly typical cases of anxiety hysteria, followed by two of anxiety neurosis.

EXTERN PSYCHOLOGICAL CLINICS 745

CASE 1.--Mrs. M.E.R. Age 44. First symptoms 18 months previously Dis- covered husband in fainting attack. Pat ient then began to develop " weak tu rns ' ' (used to faint herself as young girl). "Vv'eak turns" once or twice weekly. Would have to throw herself down on couch. Consulted doctor who said she had"nerves and blood pressure." Later lost power of r ight leg in attack. Used to " stagger about ." Gradually began to improve, but relapsed 8 weeks ago. " Weak turns " all over again. Can hardly get out of bed in the morning. Dry vomiting in middle of the night. Broken sleep. Nightma~res. Appetite fair. Menses regular. In spite of at tacks still able to supervise her house and do shopping. A brother commit ted suicide by drowning 8 months previougly, and recently she had begun to dwellmore on this. ] tappily married. No financial worries. Physically a well-nourished woman. Neurological and physical examination negative. Blood pressure normal.

CASE 2.--Miss E.R. Ago 19. Three months previously took a rather strong pur- gative. Since that time unable to resist impulse to run to w.c. Would go to w.c. 4 or 5 times in an hour. Thinks bowels will stop. Again, fears she will soil herself. Sleeps badly. Distressed about her condition. Physical examination quite negative. Formerly a bright and useful girl, but of a somewhat simple type, displaying a degree of feeble-mlndedness.

The following two cases are fairly typical of anxiety neurosis ,,

Cxs~. 3.mMrs. G.S. Age 48. Not well since death of husband six months pre. viously. Very attached to husband. Worried a lot about his death. Thought she had not paid enough at tention to him. Could not continue work as a warp winder. Sometimes has to shout. Thinka her mind is giving way. Depression obvious. A poorly nourished woman, but otherwise physical examination negative,

CASE 4.mMrs. M.K. Age 35. " Something came over her t ha t she could not stay in her home." (She had moved to a new farm 4 months previously.) Very happy in old home. Far too lonely in new place. No interest in anything. No interest in children. (Recently, just before present illness, she had nursed her youngest child through critical at tack of pneumonia.) Cannot sleep at night. Wakes up early. Appetite fair. Gives excellent account of herself, but tearful and obviously depressed. Happily married. No domestic difficulties. Physical examination negative.

The above descriptions are of course far too brief to bring out all the differences between the two conditions, but they will serve as a basis for discussion.

In my experience in out-patient psychological practice anxiety hysteria is by far the most common ailment met with. If properly understood and treated, it is one of the simplest of all affections to cure; if not, it is one of the most heartbreaking.

Patients suffering from anxiety hysteria complain of an amazing variety of symptoms: of sleeplessness, depression, restlessness, inability to concentrate, muddled thinking, headaches, giddiness, fainting attacks, vomiting, loss of power in limbs, etc. As many of these symptoms are common to much graver conditions, diagnosis as a rule cannot be made on the symptoms complained of, but unless a diagnosis can be made with absolute confidence treatment will be "quite ineffective.

To understand hysteria one must have a keen appreciation .~f the p~wer of suggestion in all mental activity. Suggestion is merely one of the channels which normally subserve the working of the instincts, especially the instinct of flight, and therefore everyone is to some extent suggestible, but patients with an hysterical make-up remain unduly so and have usually exhibited this tendency from an early age. Therefore, I am in complete agreement with the dictum of Babinski that hysteria is caused by suggestion and can be cured by suggestion.

In the consulting-room hysterical patients pour forth their worries in an endless stream. The strange feature, however, soon becomes apparent that notwithstanding their protes~tations of depression, anxiety, inability

746 IRISH JOURNAL OF MEDICAL SCIENCE

to concentrate, and so forth, there is little or no obvious sign of all this in their demeanour. When allowed to ramble on they can be easily diverted, will often respond to a joke and admit a point against them- selves, but will immediately afterwards buttress up their story with a new array of facts. The essential point to note is that the signs of obvious depression, anxiety and mental suffering, which are almost constantly displayed by anxiety neurotic and melancholic patients, and which in the latter cases vary extremely little throughout the whole examination, are in hysterical cases either almost completely absent or, if present, show astonishing fluctuations. The hysterical patient also often gives the impression of getting considerable satisfaction from the interview; his story is excellently put together and he makes sure that you miss none of it. Usually you drag the story somewhat painfully from the anxiety neurotic and melancholic patient, except perhaps from the talkative, slightly agitated type.

A further point that is often of assistance, although in all cases the general picture must be the final word, is the relatively much greater frequency with which bodily symptoms (e.g., fainting, vomiting, head- aches, giddiness, breathlessness, choking, weakness of limbs, spasms of heat, numbness, paralysis, tremors, palpitation, sweating) are incor- porated into the hysteric's story. A little investigation often throws considerable light on such symptoms, which can often be shown to be due to pure suggestion from some trivial bodily ailment or from the symptoms displayed by a sick relative, as for example in Case 1 the genuine faint- ing fit of the husband leading to the hysterical fainting fits of the wife, and in Case 2 the attack of diarrhoea leading on to hysterical tenesmus. Similarly in cases of hysterical palsy, blindness or mutism, the so-called "conversion hysteria ", investigation often reveals some trivial disorder or accident as the starting point of the malady. A further example is afforded by the majority of medical students who on beginning to read clinical medicine develop mild hysterical phobias of tuberculosis, diabetes, mental disease, cancer, septic~emia and intestinal obstruction.

When the nature of hysteria, whether anxiety or conversion, is fully appreciated, namely, that it is entirely due to "suggestion, then the obvious fact emerges that i t can be cured, and quickly cured, by counter- suggestion. In the treatment of these cases by suggestion, however,

m a n y points must be borne in mind. Elementary or crude suggestion, e.g., that there is nothing wrong after perhaps a perfunctory examina- tion, is quite useless. The confidence of the patient must first be obtained by a sympathetic listening to his story and by a careful clinical examina- tion. Then, before any suggestion is attempted, the doctor must be absolutely convinced of the correctness of his diagnosis. If he has the faintest doubt that there may be more in it than hysteria his suggestion will be entirely unconvincing. No one can read the mind of a doctor more quickly than the hysterical patient, and no reassurances that there is no danger of mental disease, that the condition will quickly clear up, that there is absolutely no cause for worry, will carry the slightest weight if there is the faintest doubt in the doctor's mind. The patient senses the doubt and the power of the suggestion vanishes.

A few cases of anxiety hysteria, and even cases of palsy, may be cured at one sitting, but far more frequently the patient appears to get enor-

EXTERN PSYCHOLOGICAL CLINICS 747

mous relief, to go out smiling, only to return a week or two later with all the symptoms redoubled. This is the patient's counter-attack, and if the doctor wavers all is lost. If, however, the doctor can remain supremely confident, and sometimes it is not easy when the patient has added several new and alarming symptoms, the counter-attack fails and con- siderable progress is made. A few more counter-attacks may be launched, but the steady confidence of the doctor is now taking effect and in a few weeks all the symptoms vanish. I had only one interview with the first patient (Mrs. M.E.R.) and did not hear until over a year later that she had experienced no further fainting attaeks. The case of hysterical tenesmus resisted suggestion for three interviews, but on the fourth admitted she was free from all symptoms. The psycho-analysts of course say that one should spend a year finding out the "fixations " of these patients. They also tell us that the hysteric enjoys his illness, that he uses it as a means of dominating his family or as a deeply-laid plot to cover up some deficiency he is secretly ashamed of, etc. One has only to see the happiness and relief of the recovered hysteric to put at its true worth such pseudo-philosophic speculation.

Hysterical states, as may be expeeted, are not infrequently partly the result of a period of undue stress which has sensitized the nervous system to increased suggestibility, and it must be borne in mind that patients who are inclined to react to stress by anxiety hysteria are not absolutely immune from the graver symptoms of neurosis or psychosis. Such a combination, however, is fortunately rare.

Hysterical palsies are treated on exactly similar lines. It is perhaps not usually wise to attempt a complete cure of the palsy at one sitting. Some simple physiological explanation should be given with the absolute assurance that power will quickly return, and the patient must be en- couraged, by enlisting the aid of sensible relatives, to persevere with the simplest coarse movements of the part, progressing to more subtle exer- cises which can be quickly improvised. Just as in cases of anxiety hysteria, normal work and responsibility should be encouraged by every means to help remove the feeling of invalidism. I f a set-back occurs, disappointment or irritation on the part of the doctor, or any suggestion that the patient is malingering or not trying, will be fatal. The whole secret of success is to retain the confidence of the patient so that he will persevere with the simplest voluntary movements.

Anxiety neurosis I regard as fundamentally in no way different from a very early stage of melancholia and requiring similar treatment and safeguards. Very mild cases may be treated as out-patients with re- peated reassurance, perhaps a bromide mixture or tonic and, if required, adequate barbiturates to ensure a good night's sleep, but any of the more pronounced cases should be urged to enter hospital for convulsion therapy. Both the cases I have quoted came in as voluntary patients and did very well with convulsion therapy, rapidly losing all depression and anxiety. The other five anxiety neurotic cases all did quite well with out-patient treatment. None of the anxiety hysteria cases called for admission to hospital, and I am of the opinion that either in-patient treatment or convulsion therapy is rarely likely to be of benefit to these patients, as it would only serve to increase the suggestion of illness.

I have discussed, perhaps at tedious length, some of my experiences

748 IRISH JOURNAL OF MEDICAL SCIENCE

and impressions of work in an extern psychological department. Had I had the assistance of a psychiatric social worker to follow up the cases I could have given a more detailed account of percentages recovered and relieved. However, I think it will be agreedthat as soon as the general medical profession is more educated as to its possibilities out-patient psychological work should contribute in no small degree to the mental health of the community, and, especially if these clinics axe staffed by psychiatrists, it should make for greater understanding between our specialty and practitioners in other fields of medicine.