AG Awad, MD, FRCPC, Professor of Psychiatry, Director, Psychopharmacology Program, University of Toronto, Clarke Institute of Psychiatry; Past-President, Canadian College of Neuropsychopharmacology, Toronto, Ontario.
Does Adjunctive Fluoxetine Influence the Post-Hospital Course of Restrictor-type Anorexia Nervosa?: A Twenty-Four-Month Prospective Longitudinal Follow-Up and Comparison With Historical Controls
Strober M, Freeman R, De Antonio M, and others. Psychopharmacology Bulletin 1997;33:425–31.
This article reports on a 24-month naturalistic prospective longitudinal study that was conducted on 33 patients with anorexia nervosa. These patients had participated in an intensive multidisciplinary inpatient treatment program and were receiving fluoxetine as part of their continuing treatment regimen.
Data on course, outcome, and treatment exposure in this cohort were obtained using standardized comprehensive interviews that were administered at 6-month intervals after hospital discharge. Longitudinal course data for these patients were compared with data for matched historical controls, who had received identical inpatient and follow-up treatment, but had not received adjunctive fluoxetine.
Analysis failed to show that fluoxetine significantly affected the cumulative probability of remaining at target weight during the follow-up period, the risk of sustained weight loss, or other clinical measures of outcomes. Thus, adjunctive treatment with fluoxetine may not have additive long-term therapeutic benefit when measured against the effects of sustained and intensive follow-up treatment.
Several studies have provided evidence of beneficial effects of the adjunctive use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of anorexia nervosa. This study was undertaken as part of a larger perspective naturalistic study of the long-term outcome of patients after discharge from an inpatient specialized treatment program.
While in hospital, the 60 patients in this study received intensive individual, group, and family therapy in conjunction with supervised meals and dietary counselling. Details of this UCLA program are described by Strober and Yager in the Handbook of Psychotherapy for Anorexia Nervosa and Bulimia (1).
Patients were restored to a target weight of 90% average for age and height before their discharge. All patients were female, had amenorrhea, and were severely malnourished at the time of admission to the hospital. Only patients with the restricting subtype were included in light of earlier suggestions that anorexics with binge eating had a less favourable response to serotonergic agents. The initial dose of fluoxetine for most of the patients was 10 mg daily and was increased to a predetermined target maximum of 60 mg daily if tolerated. Remarkably, no patient in this study was lost to follow-up, no subject refused any of the follow-up assessments, and all 66 patients remained in treatment throughout the 2-year study. Although the study showed no statistically significant difference between fluoxetine-treated patients and controls for any of the outcome measures at any of the follow-up assessments, patients receiving fluoxetine seem to have had a somewhat longer survival time before dropping below target weight. Similarly, the post-hoc analysis raises the possibility that fluoxetine can improve the immediate post-hospital course, at least regarding mood-related symptoms.
Although the study suffers from several limitations, including the lack of blindness as well as the use of historical controls, the results are significant in terms of the survival of the non-fluoxetine group for 2 years and achieving similar outcomes as in the fluoxetine group. Further studies in controlled clinical trials are clearly warranted, particularly in view of the high morbidity and mortality as well as the high cost of medical care for this group of patients with anorexia. Identifying the particular subgroups that may derive more benefits from adjunctive medications may be useful.
Divalproex. A Possible Treatment Alternative for Demented, Elderly, Aggressive Patients
Haas S, Vincent K, Holt J, Libpman S. Annals of Clinical Psychiatry 1997;9:145–7.
Elderly demented people often exhibit behavioural dyscontrol. Divalproex appears to be safe and effective in the management of this presentation.
This study reports on 12 cases that were treated with divalproex. All patients responded with improved emotional control, became less verbally and physically disruptive, and became more socially appropriate. Divalproex was well tolerated in this population, and none of the subjects experienced significant medicinal side effects. This uncontrolled report suggests that divalproex should be considered as a pharmacotherapy for aggressivity in cognitively impaired elderly people.
Aggression and other forms of behavioural dyscontrol are common in elderly demented people. Such behaviour frequently compromises the ability to keep such patients at home with their family or in the community. Common psychopharmacological approaches have frequently relied on the use of neuroleptics and benzodiazepines; however, these medications have not been proven to be very effective. They also have potentially serious side effects which may not only further incapacitate patients but can also become a source of frustration for families and caregivers.
In this context, the present clinical case studies, although uncontrolled, suggest another approach that may be promising and better tolerated. Although divalproex has been frequently used over the past few years as a mood stabilizer in the treatment of affective disorders and as an anticonvulsant in seizure disorders, the literature regarding any beneficial effects in the control of aggression and behavioural dyscontrol in the demented geriatric population has been sparse and mostly single-case reports. In these clinical case studies, divalproex (a form of valproic acid) was administered in a dose of 600 to 1000 mg daily. All of the patients showed good response, with the exception of one 85-year-old patient, diagnosed with Alzheimer’s disease, who experienced only a fair response. All the subjects seem to have tolerated the medication reasonably well and none of the patients required discontinuation of the medication because of adverse reactions. Clearly, well-controlled studies are required, yet this preliminary evidence is worth considering as an additional approach for the management of aggressive behaviour in the demented geriatric population, particularly when other approaches seem ineffective.
Although patients in this study seem to have tolerated the medication well, divalproex is known to have several side effects, including sedation, gastrointestinal upset, and haematological abnormalities. It is prudent to ensure that if divalproex is to be used in this population, it is started with a low dose of 250 mg daily. The dose can be slowly and gradually increased as tolerated. As in the usual use of these anticonvulsants, patients have to be monitored closely, particularly in terms of haematological and liver function. Although there exist established therapeutic blood levels for divalproex in the treatment of seizure disorder, it does not seem that such blood levels relate to the anti-aggressive effects.
The author’s experience showed that frequently the anti-aggressive effects can be achieved with much lower blood levels than are recommended for seizure disorder.
1. Strober, Yager. In: Garner D, Garfinkel P, editors. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press; 1984.
Andrzej Kubacki, MD, FRCPC, Saint John, New Brunswick
For Safeguards Against “Brainwashing”
While on some level of generalization everyone just wants “the same thing—to love and be loved,” this wish is rarely granted fully and unconditionally (1, p116). Psychotherapy, fashioning itself as love’s labour, purports to address this want (2). By virtue of the transferential character of therapeutic alliance, however, the needy and admittedly troubled recipients of any type of psychotherapy are in a subordinate, dependent, and susceptible position. This can set a stage for easy domination by psychotherapy providers, who are presumed to know more (or know better) than their patients (1). Knowledge is power and power corrupts.
Any intervention that is based on an inherent imbalance of power is capable of inducing change (1,3). With this in mind, and given that all forms of psychotherapy employ suggestion, there is a risk of violating the first Hippocratic principle (primum non nocere), especially with the “psychologically prone” individual (4). Psychotherapy may cause harm in lieu of the promised help by encouraging dependency by creating “therapy junkies” or addicts, inducing false optimism, and externalizing responsibility; it may also stifle the development, or even cause regression, instead of promoting growth (4,5).
In an extreme situation, such a systematic influence process, especially in a context of group pressure or in socially isolated settings suffused in a combination of intimacy and terror, creates an opportunity for exploitation and abuse under the guise of acting for the patient’s own good (1,6,7).
Malevolent and oft politically motivated forceful indoctrination, as well as other deceptive and indirect persuasive techniques of thought reform or mind control are seen by the tragic legacies of the Unification Church of Reverend Sun Myun Moon, Silva Mind Control, feeling therapy, and the Jones’ People’s Temple (1,6). Such examples of psychotherapeutic alliance gone awry militate against uncritical acceptance of utopian claims of outcomes, such as perpetual happiness, absolute equality, utmost maturity, or even perfect sanity (1). This is particularly true if total submission to some arbitrary and rigid rules, usually enforced by a combination of carrot and stick paradigms, is demanded in return.
It is crucial to develop safeguards against the abuse of psychotherapeutic alliance and its inadvertent vitiation. Intuitively, such safeguards should amount to a fully informed consent to what is being offered upon disclosure of the technique(s), expected outcomes, and alternatives. The evanescent effect of early remoralization, known as the “honeymoon” phase of therapy, needs to be addressed (8, p20). A warning of the following subjective deterioration, including the return or intensification of the original distress with the removal of symptoms, is required.
Diverse sensitivity to the potentially harmful influence of therapies must be borne in mind, as for some perhaps even “reframing” might constitute breach enough in their autonomy and integrity (cpr3). And at the very least, immunity from reprisals of any sort must be safeguarded for those who decline the favour of having us act for their own good, so that they do not lose access to other forms of help or healing.
1. Mithers CL. Therapy gone mad: the true story of hundreds of patients and a generation betrayed. Addison Wesley Publishing Co; 1994.
2. Greben SE. Love’s labour: twenty-five years of experience in the practice of psychotherapy. New York: Schocken Books; 1984.
3. Watzlawick P, Weakland J, Fisch R. Change: principles of problem formation and problem resolution. New York: WW Norton and Co; 1974.
4. Dineen T. Manufacturing victims: what the psychology industry is doing to people. Montreal: Robert Davies Publishing; 1996.
5. Kubacki A, Jankowski K. Victim subculture or the “poor me” syndrome [letter]. Can J Psychiatry 1996;41:414–5.
6. Thomas G. Journey into madness: medical torture and the mind controllers. London: Corgi Books; 1988.
7. Miller A. For your own good. New York: The Noonday Press; 1990.
8. Basch MF. Understanding psychotherapy: the science behind the art. New York: Basic Books; 1988.