a preliminary report on the use of d-desoxyephedrine hydrochloride in the study of psychopathology...

7/29/2019 A Preliminary Report on the Use of D-Desoxyephedrine Hydrochloride in the Study of Psychopathology and Psych

1/6

8o

A PREL IM INARY REPORT ON THE USE O F D -D ESOXYEPH EDR IN EHYDROCHLOR ID E IN TH E STUDY O F PSYCHO PA THOLOGY

AND PSYCHOTHERA PY JO SEPH SCH EIN , M . D ., AN D PAU L GOOLKER , M . D .

N ew Y o rk , N . Y .W e w ould like to m ake a prelim ina ry re -

po rt on ou r psych iatr ic exp erience w ith th ein trav en ous use of d -desox yephedrine hy dro -ch lo ride (Perv itin )2 fo r a period o f m orethan a y ear in a se ries o f 22 cases .

The d ru g w as firs t p repa red in 1919 byOgata . It cam e in to genera l o ra l use as as tim u lan t on the con tinen t, e sp ec ia lly in G er-m any , sho rtly b efo re the beg in n ing o f W o rldW ar II. I ts cen tra l eu phoric and w ak ingaction w ith ou t sign if ican t s ide effec ts m adeit su perio r to its re la ted com pounds, su chas b en zed rine . Th e undesirab le side e ffec tsobserv ed in tho se tak ing overdoses a re es-sen tia lly sleep lessness , p ersp ira tion , an orex ia ,pa lp ita tion , d ryn ess o f the m outh , d izz iness ,an d occasiona lly headaches .

L im ited EEG and ECG stud ies have b eenm ade w ithou t po sitive f in d ings of sign if i-cance. T he m a jo r c ircu la to ry e ffec t is p re s-so r, the site o f ac tion be ing m ost p ro bab lype riph e ra l. A d ec reased sensitiv ity to p a in ,ap pa ren tly n o t du e to psy ch ic d istrac tab ilitybu t to actio n on pe rip he ra l ne rv e end ings ,was observed . In genera l, it ha s been as-sum ed th at hyp e rtensio n , card io pa thy , thy -ro to x ico sis, an d advanced age con stitu tecon tra ind ica tio n to its use.

The drug w as em ploy ed pa ren tera lly byB ritish in ve stig ato rs( i) (D odd an d Presco tt)in 1943 as a m eans of coun te rac tin g the se -ve re hy po ten sion fo llow ing an esthesia o rsu rg ica l sho ck . T he rise in b loo d p re ssu rewas p la teau in typ e , the d uratio n of e ffec tlas ting from on e ha lf to severa l hou rs.

S imon and T aube (2 ) o bse rved 5 patientsw ith th e a id o f 15-20 m gm . do ses o f in tra -veno us m e thed rine , an d fo und it u se fu l inm aking a d iagno sis .

Lev ine et al.(3 ) rep orted o n the psycho-F rom the P sych iatr ic S e rv ice o f D r. M . R a lph

K au fm an , T he M oun t S in ai H osp ita l, N ew Yo rkCity .

2 Supp lied th roug h the cou rte sy o f Sm ith , K .line& F rench , Inc ., P h ilade lph ia , P a .

lo g ic an d physio lo g ic e ffects o f in trav en ousP e rv itin in 7 5 psych ia tr ic pa tien ts , m o st o fth em p sycho tics . T hey found tha t P e rv itinp rod uced a free flow of em otio na lly cha rgedm ate r ial, w h ich inc lud ed traum a tic exp eri-ences, fan tasie s , an d d elus iona l ideas. A f ee l-ing of g reat re laxa tio n w as fe lt by m ostpa tien ts and mild dep ressions w ere often al -layed . Th ey w ere im pressed w ith th e supe ri-ority o f Perv itin to benzedrine and so d iumamy ta l in its psy ch ic e ffec ts in tha t it a llow eda m ore spon tan eo us an d app ro pria te re spon sein a sta te o f fu ll con sc iousness.

OBSERVAT IONSM os t o f ou r pa tien ts w ere yo u th fu l ve t-

eran s o f the recen t w ar and h ad beenrece iv ing psycho th erap y fo r 2- 3 y ears in ou rspec ia l c lin ic. In the m ain , they p re sen tedvarious som atic com pla in ts , m ood d istu rb -ances , and prob lem s in in terpe rsona l re la -tionsh ips. A lthou gh the ov ert sym ptom sw ere s tim u la ted by th e ir w ar expe rien ces, itbecam e increas ing ly clear that our p atien tshad had psycho lo g ic d iff icu ltie s long befo rethe w ar.

Noso log ica lly , m ost o f our pa tien ts be-longed in th e group of the psychoneuroses .How ever , the c lin ica l m an ife sta tions w ereo ften d ifficu lt to cla ssify and bro ugh t up fo rcons ide ra tion the p oss ib ilitie s o f e ith er sch iz -ophren ia o r n eu ro tic d istu rb an ces in sch izo idpersonal i t ies .

O ur pa tien ts w ere sc reened by a ca re fu lh is to ry and phy sical and labora to ry ex am ina -tion s fo r p o ten tia lly s ign i f ican t card iovascu -lar abno rm ality . T he u sua l pe riod o f ve r-ba tim reco rd ed ob se rva tion w as an hou r anda ha lf . A ll p a tien ts co n tinu ed to be o bse rv edfo r an ad d itio na l 2- 3 hours. S om e p atien tsw ere seen the fo llow ing d ay . T he usu al doseof 40 m gm s . w as in jec ted w ith in 2-5 minu tes.N o an tido ta l m easu re s h av e b een n ecessa rythu s fa r in our ser ie s . In deed o n on ly 2


2/6

95 ] J. SCHEIN AND P. GOOLKER 8 5ioccasion s w as there s ign ifican t transien t p re -co rd ia l d is tres s . In 2 in stances , the ex pectedrise in b loo d pressu re d id no t take p lace .

T he drug in te rv iew s w ere a ll co ndu cted inthe presence o f at leas t 3 physic ians w ho h adhad con siderab le co n tac t w ith vary ing aspec tso f the case .

O u r a im s w ere : (i) a ttem pts to m ake un-comm unica tive pa tien ts m ore access ib le tothe rapy ; (2 ) to illum in ate fo ca l m atters o rspec ia l p ro b lem s; (3 ) to c la rify the d iagno -sis; ( to tes t th is agen t tha t seem ed espe-cia lly p rom is ing , as a too l fo r p sych ia tricobserva tion and inv es tiga tion .

It b ecam e apparen t very ear ly th at th echanges b rough t abou t by th is d rug fac ili-ta ted espec ia lly w ell the observa tion o f thedynam ics of the case , and cla rified th e de-fense s truc tu re o f the pa tien t. T ran sfe rencephenom ena becam e m ore v iv id . W ith in 2-10m inu tes af te r the adm in is tra tion of the drug ,near ly a ll p atien ts exh ib ited a sense of p ro -fou nd re laxa tion sev era l rep orted a s ta te o fdrow siness. O the rs felt ve ry ligh t. O n e p a-tien t rem arked , I cou ld jus t floa t u p to th ece iling . In m any ins tances , th e re laxa tio nan d a state o f w ell-be ing coex isted w ith ap -prehens io n , anx ie ty , an d hyperacu ity o fthough t .

W ith excep tion o f on e pa tien t a ll began a l-m o st imm ed ia te ly a f ter the in jec tio n to speakfar m ore free ly an d rap id ly than ev e r be fo re .O n n ea rly eve ry occasion , m a te ria l tha t hadtak en m onth s to e lic it w as n ow m ad e av ail-ab le w ith in an hour, the sub jec t m a tter be ingw hat is u sua lly con side red con sc io us o r p re -co nsc iou s. Th is rev iew o f d ata , fo resh ort-ened in tim e an d p re sen ted in a s tate o fa le rtness and re laxa tion , h as had a pro foun din flu en ce o n the pa tien ts. Seve ra l o f themrem ark ed spo n tan eous ly tha t th ey began fo rthe f irs t tim e to ga in a c lea r un de rs tan d ingo f the ir p rob lem s . T he fo llow ing typ ica lquo ta tio n illu s trates th is po in t:

W . K . W hen I w as a b oy , I used to p ray tha tm y paren ts sho u ld d ie so I w ould no t b e bea ten .Then I thoug h t I shou ld d ie , s ince they had o therch ild ren . I fee l a b it em otio na lly ch oked up . Ikn ow I m ad e these s ta tem en ts befo re . N ow I gu es sI rea lize the fu ll im pact.

M os t pa tien ts encoun te red d ifficu lty ins leep in g during th e n ig h t fo llow ing the in -

je c tion . T h is co u ld be con tro lled pa rtia lly b yseda tio n . O ur w ork w as don e in the even ing ,w hich w as m os t p ro bab ly an im po rtan t fac -to r in th e deg ree of s leep d istu rbance . In ou rg ro up , w h ich cons isted large ly o f am bu la -to ry , activ ely w ork in g o u tpa tien ts , w e felttha t the dura tion o f w akefu lness rep resen tedthe m ost reliab ly m easurab le pharm aco log ice ffec t. In a ll o u r pa tien ts th is d id no t ap pearto exceed 8-12 hours .

In seve ra l pa tien ts , a sta te o f w e ll-be in g ,red uc tion or d isappea rance o f sym ptom s, an da susta in ed in creased in tere st, n ot on ly inou tside ac tiv itie s bu t in the the rapeu tic w o rk ,la sted as long as 2 w eeks . T h is u ndoub ted lyw as fa r beyond the ph arm aco log ica l effec tsof the drug .

W ith the ease in v e rba liza tion , 5 patientsw ho are stamm ere rs lo st th eir speech d is-ab ility eith er com ple te ly o r to a m arked d e -g ree . T he sudd en ch ange w rough t b y th ed rug struck th e pa tien ts w ith the im p ac t o fcom ple te su rp rise . I t im pressed them withthe po ten tia lity o f sym p tom chang e a t am om ent o f inc reased ale rtness, acu ity , andh ig h ly cha rged affec t. T hey w ere ch argedw ith con fidence and hope by ex perien c in gv iv id ly the ir ab ility to be norm al aga in .M o st pa tien ts underes tim ated b y fa r thepassag e of tim e during ou r se ssio ns. S ev era lexpe rien ced changes in p e rcep tion o f th efo rm and qua lity o f ob jec ts.

In g ene ra l, th e im pres sion w as g ain ed tha tm en ta tion , no ted b y an arithm etica l te st, w asim prov ed . Th ere have b een , h ow ev er , s ev era lex cep tio ns an d certa in ly th is req u ire s fu rthe rs tudy .

A ltho ugh a ll pa tien ts com p lain ed o f so -m a tic sym ptom s, the on ly o ne tha t cou ld berep rodu ced c lear ly , ap pa ren tly as a re su lto f the p r# {233}s so r e ffect o f the d ru g , w as head-ache . T h is o ccu rred on ly in 2 pa tien ts w hohad fo cal h ead aches, po und ing in typ e .

A ll p atien ts have had , as a u sua l reac tionto the P erv itin , a gen era l sensa tion of ting -ling , accom pan ied or occasio na lly sub stitu tedby num bness. Th is has nearly a lw ays passedaw ay after severa l m inu tes. W e have , inad d ition , repea ted ly observed an in te res tin gphenom enon w hich w e have called fo r thep re sen t a re -aw aken ing of foca l m em ory .B y this we m ean the reapp ea ran ce o f the


3/6

8 52 PERVITJN IN PSYCHO PATHOLOGY AND PSYCHOTHERAPY [Maysam e qu ality o f ting lin g , at a tim e com ple te lyrem oved from th e orig ina l reac tion andsha rp ly lim ited to a p rev iou sly traum atizeda r ea , e.g. , scars o f the body su rface . Fu rth erinv es tiga tion of these areas, h ere to fo re silen t,h as sh ow n th em to have been h igh ly cha rgedem otio na lly . Tw o ex am ples o f m any w illb e used to illu strate th is b rie f ly .

S. A ., su b ject to anx ie ty phenom ena and a moodd is tu rbance , experienced a m ark ed tin g lin g sensa -tion in a sca r on th e r igh t side o f th e neck a fte rthe gene ral effec t had worn o ff. T h is sca rring w asth e re su lt o f a lym phadenec tom y , frau gh t w ith fea r,a t the ag e o f 6 . A pprox im ately 45 m inu te s late r ,wh i le ta lk ing ab ou t fea r o f d oc to rs , he aga in ex -p erienced a ting lin g , th is tim e on the o ppo site sideo f the neck . It w as on ly afte r th is tha t h e recalled ,w ith som e d iff icu lty , th at a sm a ll cyst, w ho se scarco u ld n ow hard ly b e m ade ou t, h ad been r emov edfrom th is area m any years befo re .M . P ., sub jec t to h eadache an d hype rirritab iitya ssoc iated w ith pugnac i ty , de velo pe d pa re sthe sia sin a su prao rb ita l an d low er lim b sca r, the re su ltso f w ar w ounds, w h ile m anifesting an x ie ty in re la -tion to agg re ssion . I t w as pa rticu la r ly n o tew orth y#{149}th a t he d eve loped a sim ila r phenom enon a t thep en ile tip an d c ro tch in the m idst o f anx iety - ladenm a te r ial co nce rn in g a sexu a l su b ject.

Th e num b er o f p a tien ts s tud ied thu s fa rdoes no t pe rm it o f an y gene ral va lid op in ionas to the la stin g effec ts o f th is agen t on th eclin ica l co u rse. H ow ev er , it app ea rs to h av eprom ise in th is rega rd , an d w e hope to b eab le to ev a lua te th is m ore c ritic a lly in tim e .

M eth od o f D e linea ting D efensesW e hav e com e to fee l tha t th is agen t, in

p rov id ing a rap id free -flow ing v erba lizatio n ,ha s mad e it p ossib le to ob se rv e g rap h icallyand o ften d ram a tically th e cha rac te ris tic de -fenses o f a g iven pa tien t. W e h ave th us farhad the op portun ity to stu dy on ly a fewpa tien ts in m o re than on e in te rv iew , an d a tin te rv als o f seve ra l m on th s. In these , theessen tia l de fense tend enc ies rem a ined co n-s tan t. T h e stu dy o f de fenses is ax iom a tic fo rp sychopa tho lo g ical re search and scien tif icpsycho therapy . It is n o t ou r a im a t thep re sen t tim e to d iscuss the in te rrela tion sh ip sb e tw een d e fen se m ech an ism s an d sym ptomfo rm a tion . W e are rath e r con cen tra ting nowon the obse rva tion of reactio ns to stres s .

P a tien ts tend to m a in ta in charac ter ist icm odes o f de fen ses and these g en era lly de -te rmine the clin ica l p ic tu re . T he P erv itin

in te rv iews , co verin g large segm en ts o f th epa tien ts c lin ica l h is to ry , affo rd ed us an op -po rtu n ity to stu dy th e em erg ence o f de fensesa t c lose hand and in a c ircum sc rib ed pe riodof tim e .

W e are now ch ief ly co nce rned w ith anana lysis o f th e m eth ods o f d efense u tiliz edby the ind iv idua l p atien ts in the stre ss situ -a tion o f the in te rv iew . Th e pro tec tive ph e -n om ena w ere rela ted in d ifferen t pa tien ts top recip itan t facto rs , w h ich in c lu ded curren tpsy ch ic tension s as such , reactio ns to the ex -pe rim en t, an d espec ia lly the d istu rb ed equ i-lib r ium brough t abou t by the d is ap pearance ,a s the re su lt o f th e d ru g , o f a c lear ly ob -se rv ed pe rsis ten t an d cha rac te ris tic de fense ,e .g . , sm ilin g . Th e fo llow ing c lin ical da ta w illillu stra te the la tter .

J. N . is a 3 1 -y ea r- ol d m arried ve te ran who c ameto the c lin ic in i6 w ith d iff icu ltie s o f ad ju stm en ta t hom e and a t w o rk . H e at t r ibu ted the se part lyto h is stamm ering , p resen t since ch ildh ood . A bro adand pe rsis ten t sm ile b ecam e the m ost s tr ik ing fea-ture of h is ap pea rance . H is ea rly y ears w ere trau -m atic o nes becau se o f th e m en tal illn ess o f hi smo th e r who s e in stitu tion aliza tion led to th e d is so lu -tio n o f the h om e . F o llow in g a m ino r sh rap ne lw ound in h is ank le s h e deve lop ed n euro tic sym ptom sl eading to h is discharge.

It w as ev iden t tha t in th is pa tien t the sm ile , w h ichwas never accomp anied by an e lation, was a pro-te c tion aga inst an an ticip ated rid icu le, esp ecia llyrela ted to h is s tamm ering . I t served as a d isarmingp ass ive cou n te ragg re ssion . Th e pa tien t sta ted : Iused to sm ile w henever I g o t in to troub le .my sm ilin g isn t becau se o f ne rvo usn es s. I can texplain it. .. . every t ime I wan t to [s ta rt ta lk in g],I laugh ab ou t it b ecause I w an t peop le to knowth at I know it . I do nt m ind them lau gh in g a t m e .

Th is pa tien t had tw o Perv itin in te rv iew s abou to ne yea r apa rt. T h e d isapp ea ran ce o f th e sm ilew as d ram a tica lly ab rup t in b o th . H is exp re ssio nim m ed ia tely becam e sob er and re sem b led th a t o f adepress ion . O n seve ra l occas ions, w hen the sm iled id re tu rn , it w as i n r es po ns e to a pp ro pr ia te s ti mu li .T here w ere m arked im provem en t or , for lo ng p e-r iods , com p lete d isappea rance o f h is sp eech d isa -b ility . A t m om en ts o f he igh tened e motio na l te nsio n,hi s s tammer ing retu rned . H ow ever , it n o longerw as accom pan ied by the de fens ive sm ile .

Th e lo ss o f th is fix ed defense in the na tu re ofa d isa rm in g sm ile b rou gh t fo rth m a te ria l tha t, onan aly sis , cou ld b es t be cha rac ter ized as a searchfo r new pro tec tive m easu re s, w h ich co u ld no t c rys-ta lliz e in to a su stain ed specif ic de fen se. A n in -h ib ito ry te nd en cy c ame in to p lay . N o t on ly d id hebecom e gu arded an d h es itan t, b u t a t tim es hes h owed a d iscon tinu ity o f thou gh t tha t re semb ledincoh erence. Th ere w as an a lte rna tio n be tw eenb lankn es s o f m ind w ith accom pany in g inab ility to


4/6

J. SCHE IN AND P. GOOLKER 85 3concen trate , and a free -flow ing v erba liza tion . A tmoments he became open ly ag gres sive in h isr emark s .

The secon d exp erim en t a f ter a lm o st a y ear o fth erap y d id n o t b ring ou t to the sam e d eg ree thed isp lay o f sh iftin g , pa rtia l de fenses, ev en tho ughthe d isa rm ing sm ile d isappeared as qu ick ly as be-fo re. His behavior co rre spo nded to the am elio ra tio nin h is clin ica l p ictu re.

A no ther p a tien t, M . L ., w ho se in g ra tia ting sm iled isappeared under P erv itin dem onstra ted m orec lea rly th e em ergence o f flee ting defensive m easures .T hey inc luded an inh ib ito ry tren d w ith a sen sa tiono f a presleep s ta te , depen dency , and som atiza tio n .Here to o , th e d isp lay of partia l and sh ifting se lf-pr otective reactio ns characteri zed the po ten t ial i t iesand lim ita tion s o f the pa tien ts p erson ality .

The fo llow ing p atien t illu stra te s the m a-n eu ve rab ility o f even v ery h igh ly re sis tan tdefenses :

D . N . is a 32-y ear -o ld m arried ve te ran , su b jectto sev e re le f t fron to tem pora l h ead ache . H e sawcom ba t se rv ice bu t w as n o t w ound ed .

U nde r th erapy , it becam e appa ren t tha t th ispa tien t w ho had undergon e a grea t dea l o f p hysica labuse and m altrea tm en t had becom e incapab le ofexpressing h is resen tm en t. In deed , h is attitude w asfixedly that of ex treme c om plian ce an d ing ra tiatio n.

H is neve r-absen t ing ratia ting sm ile d isappea red2-3 m inu tes a f ter the in jec tion . An excruciat ing ,sh arp ly localized h eadache ap pea red im m ed ia te ly ,h av ing the iden tica l b u t h igh ly in ten sified charac te rof hi s ch ie f com p lain t. T h is w as asso c ia ted w ithex t r eme anx ie ty an d res tle ssness, in te rspersed w ithlou d , in sis ten t p leas fo r foo d . T hu s, a reg ress ivep henom enon cam e to the fo re . H e co n tinu ed toe xp re ss d ra ma tic ally aggress ive ideas f irs t tow ardh im se lf, an d then tow ard o the rs . I w ish youw ou ld k ill m e I fee l like k illing som ebody .

T he re fo re, the usua l m ode o f reac tio ns, h is ex -trem e com p liance and in gra tia ting sm ile , g av e w ayunde r th e d ru g . H e , a s th e o the rs no ted ab ove ,cou ld no t c rys talliz e ou t any o th er spec ific an dla sting d efense . Th e o ra l reg ress ion w as on ly flee t-ing . A nx ie ty an d lab ile ag gress ion dom ina ted thep ic tu re an d w ere u tiliz ed in an abreac tive w ay .

Th e drug produced in the first 2-3 minutes wha thad no t been poss ib le to ach ieve in over a year o fd ilig en t p sycho th erapy . F or 1-2 weeks there after,patie nt experienc ed great relaxa tion, and a strangere lie f. T he break in the frozen de fen se gave a tre -m endou s im pe tus to ab reac tion .

O n the o the r hand , the fo llow ing pa tien tw as ab le to m ain tain h is cha rac te ris tic sin g lede fense, in the face o f bo th a rad ica l chang ein m ood and a re sto red feelin g of ad eq uacyand pow er.

J. K . is a 29 -yea r-o ld m arr ied N egro ve te ranw ith th e ch ie f com p lain ts o f sexua l im po ten ce , afee ling of w eak ness, and s tu tte rin g . H e h ad b een

a h igh ly success fu l p ro fess iona l p rize -figh te r fo rseveral years and ha d su sta ined no in ju ries . H ispo tency d ifficu lty star ted w hile on fu rlou gh hom eand has rem a ined the m os t d istu rb in g s ymp tom .C oncurren tly , h e has been unab le to resum e hisp ro fession as prize fig h ter .

T he p atien t, w ho is a lw ays a rese rved , w ell-con-ta in ed ind iv idua l, show ed a rad ica l transfo rm ationsho rtly a fte r the first in jec tion . H e co mp lim en te dan d then a ttem pted to m ake adv an ces to a fem aleand th en a m a le observe r. H e w as, how eve r , ea silyre str ain ed . S im ulta ne ou sly , anx ie ty deve loped . Hetried hard to d efend h im se lf by self-reass urance asto th e p ro fe ssio na l cha rac ter o f th e gro up , an d asto h is ow n cod e of e th ic s . Subsequen t m ate ria l con -tin ued in th e ve in o f rem o rse , an d a long the lin e o finh ib ition o f agg ress io n . T h e seco nd Perv itin in te r-v iew , con duc ted m on ths late r , b ro ug h t ou t afee l ing o f buoyancy and a rec rudescence o f h isfo rmer phys ical p ow ers . In sp ite o f th is , the re w asno ev id en ce of the p rev ious ov e rt am orou s b eh av io rshow n in th e firs t in te rv iew . In deed , he apo log izedcon t inuous ly fo r it.

The pa tien ts essen tia l d efen se in h is n eu rosish as b een an inh ib ition (sexua l im po tence an d ag-g re ssive im po te nc e, i.e., inab ility to figh t). U nderth e in flu ence of P erv itin , on l y the iden tica l de fen seme chanism came in to play, i.e. in h ib itio n of ag -g re ssio n . T h is wa s a graphic, ob jec tive , concen-tra ted de mon stra tion , foreshortened in time, ofp atien ts ch ie f s ing le m ode o f d efen se . It is worthn o ting th at thou gh the d rug in fluen ced m arked lyh is speech im pa irm en t, it le ft th e m a in d efenseun touched .

O n the co n tra ry , the fo llow in g pa tien tillu stra te s the em ergence of seve ra l w e ll-crysta lliz ed de fens ive m easu re s:

M . P . is a 25 -yea r-o ld ve te ran , sub jec t to head -ache and tem per ou tb u rs ts . H e h ad c lose -qua rterac tive com ba t a s a ran ge r and had k illed m any o fthe en em y. H e , h im self , w as w ound ed in the th ighs ,th e head , an d e lsew h ere .

The th erap y revo lved abou t the pa tien ts hand lingo f h is aggress ion as he w as cons tan tly and eas ilyprov oked in to f igh ts . H e rem a ined , how eve r , in avery fea rfu l passive a ttitude tow ard h is fathe r and ina depen den t so n-like re la tio nsh ip tow ard h is w ife .T he p ic tu re w as thu s of a subm issive person undertens ion w ith o u tburs ts o f v io len ce . P atien t m adea definite imp ro v emen t . The headaches becam em uch le ss seve re and h is in te rp ersona l re la tionsh ipsat h om e and a t w ork ap proached a no rm al lev el.

T h is pa tien t had 3 Perv itin in te rv iew s w ith in6 m on ths tim e . T he re w as an in itia l chest co n -str ictio n in a ll 3, esp ecia lly m ark ed in the la st.T he th ird ex pe rim en t, w h ich w as assoc ia ted w ithmuch more sev ere ch es t pa in , b roug h t o u t sp on-taneous imag e ry of a bayone t at tack , o f w h ich hesa id , S udd en ly , I can t p ro tec t m y self . In th ism o st recen t in te rv iew , th e n a tu re o f the pa tien tsremarks, especial ly when com pared with materiale lic ited in the firs t 2, demonstr ated cle arly the


5/6

85 4 PERV IT IN IN PSYCHO PATHOLOGY AND PSYCHOTHERA PY [M ayem erg en ce of a fea r o f an a ttack on h is pass ivese lf , a p ro bab le transfe rence phen om enon . T hed om inan t d efen se w as an iden tifica tion w ith theag gress ive fath er in w hich he s tressed h is m ascu-lin ity and devo tion to h is w ife .

It is in teres ting to no te tha t, in the first the ra -peu tic g rou p sess ion afte r th e second in jec tion , h em ain ta ined th e sam e them e, tha t o f bo lste ring h ism ascu lin e aggressiven ess, citing exp lo its in w hichhe defended w om en aga ins t p ow erfu l in trud ers. A naux ilia ry defense during each observa tio n w asstron g den ia l. T h is w as esp ecia lly d ram atized inthe th ird exp er im en t w here the pa tien t w as ab le tom ain ta in a mood of exh ila ra tion desp ite d is tu rb ingm ate ria l. A n increase in anx ie ty w as often ac-com pan ied characte ris tica lly by a s trik ing osc illa -tion f rom a hom osexu al to a he te rosex ua l o rien ta -tion . It is rem arkab le tha t h is m ain com plain t, aheadach e , d id no t appear in the co n ten t o f any ofh is in te rv ie ws .

P a tien t sta ted sp on taneous ly a fter the secon din jec tion tha t, altho ugh he had b een in psycho-th e rap y fo r 2 years , he had g ained n o ins igh t u n tilaf te r the firs t Perv itin in jec tio n .

C OMMENTO rig ina lly , D -desox yephedrine has been

used abroad in o ra l fo rm prim arily to in -crease w ork effic ien cy , to m ain ta in w ak efu l-ness , and to e leva te the m ood . M yerso n (4 )used th is d rug to adv an tag e in con junc tionw ith sod ium am yta l fo r th e trea tm en t o f 2cases o f am nes ia .

In its pa ren te ra l fo rm , it has been u tilizedch ie fly by surgeon s as a presso r ag en t duringan esthesia an d sh ock , w h ere its ch ief ad -van tage lay in th e p roduc tion of a re la tiv elyand p la teau- like susta ined hyp er tens ive leve l.

W e have been ab le to confirm in essenceth e ob serva tions by L ev ine et al . of facilita-tion o f v erb a liza tio n and re lax atio n of ten -sio n fo llo win g in trav en ous P erv itin . B u t w ew ish to n o te tha t the b lood pressu re eleva tiond id no t genera lly last beyo nd the first 3ho urs . In 2 in s tances the re w as no sign ifican trise a t a ll desp ite the in jec tio n of 40 mgms .o f th e dru g . T h is do sage has seem ed safeand op tim al fo r p rod uc in g effec tive resu lts.

O ur observ a tion s led us to b elieve tha tth is agen t p osse ssed ev en greate r investiga -tive and therap eu tic po ten tia litie s. T he un-inh ib ited verba liza tion in the presence o f ana le rt s ta te o f m ind , covering la rg e areas o fthe pa tien ts ideas, experiences, an d affec tsw ith in a de lim ited space of tim e , p ro v idedan unusu al oppo rtun ity to s tu dy psychopa tho -

lo g ical e lem en ts . T he jux tap osition o f ideasand affec ts po ss ib le under these c ircum stancesp rov ed to be of d iagn ostic an d the rap eu ticimportance.

T he imm ed iate th erapeu tic e ffect in m o st o fou r p atien ts w as a sa lu to ry o ne . T h is w en tbey ond the d irec t p harm aco log ica l ac tion ofthe drug . T he dram atic changes tha t gen-e ra lly ocurred w ere c lea rly p erce ived b y th epa tien ts, and in stilled in th ese chro n ically illpeo p le new confidence in them se lves and th etherap ist. M ore im portan tly , p rev ious lyga ined u nderstand in g becam e fo rtified an den riched w ith m ore a ffect. In seve ral in -stances, th is e ffec t w as n o ted fo r a s long as2 weeks su bsequ en t to the in jec tio n . H ow -ever , the p rob lem s of long -la sting in f luenceand th e p ro pe r spac ing of P erv itin in te rv iew sneed lo ng-term stud ies , now in prog re ss .

The d rug w as d iag nostica lly he lp fu l in re -so lv ing qu estions o f p sycho tic invo lv em en tin cases cons ide red bo rder-line . Th is p er -m itted a m uch g reate r la titud e in subseq uen tpsy ch o therapeu tic in te rven tions . It p rodu cedno ser io us repercussions in our m os t un stab lepa t ien ts .

This agen t p rov id es an e ff icien t m eth od offo llow in g dyn am ic m echan ism s of psy ch o-pa tho log y , and thus affo rds resea rch possi-b ilitie s . T he d efenses o f an ind iv id ua l andthe m anne r in w h ich they are em p loyed co n-stitute the essen tia l co re o f th e struc tu re o fa p sych ic illne ss o r ch a rac ter , and p lay am ajor ro le in the the rapeu tic p roces s. T hecon t igu i ty an d con tinu ity o f the com pressedm ate rial a ffo rd an unu sua l op portun ity fo r as tu dy o f the em ergence and use of the pa-tien ts de fenses . In the cases reported , thecon tras t be tw een p atien ts using one defenseprim arily and those em ploy in g severa l w asvery illum ina ting . In add itio n , the vary in glab ility o f the de fen se struc tu re a s ev id en cedby the rap id sh ifting from one to th e o therw as very ins truc tiv e. It sho u ld be no ted tha ta v alid p ic tu re o f the defenses s tud ied in th ism anner requ ires a thoro ugh know ledg e o fthe c lin ica l course , and an in tens ive rev iewof the verba tim transc rip ts, p re fe rab ly o fm ore than on e in te rv iew .

T ransfe rence phenom ena ten ded to ap pea rin un usu ally c lear fo rm , an d w hen in te rp retedw ere eas ily perce ived by the pa tien ts . Th e


6/6

95] J. SCHE IN AND P. GOOLKER 85 5d ru g undoub ted ly con tribu ted to th is fac ilita -tion of respon se .

U sed thus , the d ru g a ffo rds ex cellen t op -por tu n itie s fo r dem ons tra tio n and teach ing .I t also pro v ides a m ed ium for eva lu atingprogress . Th e in te rv iew s w ere m ost o ftencarried o u t in the presen ce of severa l sta ffm em bers o f bo th sexes w ith ou t in te rfe ringw ith the pa tien ts f low of th ough t an d evena t tim es h igh-ligh ting the c lea r and rap idin te rp lay of defenses.

W e have o bserv ed in te resting sensoryphenom en a produ ced by th e drug . Am ongth ese is a decrease in th e pa tien ts sensitiv ityto pa in . T h is has been no ted befo re b y L e-v ine and s tu d ied b y o thers(5 ), w ho haveco nsidered th is action to be a pe rip he ra l on e.Thus fa r, w e have no ted th is change on lyin re la tion to su rface areas. W e are no t ce r-ta in o f an y changes in the deeper tis su es.S om e ev idence sugges ted tha t the m uscu la rache co nseq uen t to a traum a w as unaffec tedas com pared to sim ila r m uscu la r aches sec -o ndary to tension s tates .

W e have o bserv ed rep eated ly s till ano therty pe o f sensory p henom enon which w e haverefer red to as aw aken ing of foca l m em ory .T h is h as been ap p lied to the re tu rn a t s tress -fu l m om ents o f paresthe tic phenom en a totraum atized su rface areas tha t have rem ainedprev ious ly silen t fo r lon g periods . W e haveno t th us fa r encou n tered th is in re la tio n top rev ious v isce ra l traum ata . It has seemedto us to o ffe r a p rom is in g m ean s o f stud y ingob jec tive ly phenom en a inv o lved in the co n-cep t o f p sych ic rep resen ta tion . A s su ch , ithas im po rtan t th eo re tical im p lica tion s.

S UMMARY D -d esoxy ep hedrine h ydroch lo rid e w as

em ployed in traveno usly in an in tensive stud yof 22 p atien ts w ith p sychoneuro tic illne ss .

2. I t w as fou nd inv alu ab le a s a w ork in gto o l fo r-

(a) the de lin ea tion of defenses av ailab leo the p atien t, and th e ro le o f th isde lin ea tion in d iagnos is and re -sea rch .

(b ) a noso log ica l d ifferen tia tion in so -ca lled b ord e r- line syn drom es.

(c ) th e v iv id c lar ific a tion o f tran sfe r-e nc e re actio ns.

(d ) the u nexpec ted confro n ta tion of th ea ler t p atien t w ith a d ram a tic changein h is ch ron ic sym ptom s, and itscon sequen t im p etu s tow ard re-covery .

(e ) the m arked reduc tion in tim e co n-sum ed in ob tain ing va lu ab le con -sc io us and precon sc ious m ater ia l.

3 . A repea ted phenom enon , w hich w e h av elabe led reaw ak en ing of foca l m em ory , h asbeen freq uen tly o bserv ed , an d represen ts acha lleng e to the stud y of reca ll, and psy ch icrep resen ta t ion .

4 . I t a llow s fo r c lear ly o bserv ab le phe-nom ena even in the presence of a g roup , an dthus affo rds an exce llen t m ed ium for teach-ing purpo ses.

B IBL IOGRAPHY Dodd , H ., and P resco tt, F . U se o f m eth ed rin e,a new b lood pres su re ra is ing dru g , in su rg ical

operations. Brit. M ed. J., M arch 20, 19 43.2. Sim on , J . L ., an d Taube, H. A pre l iminary

study on th e use of m ethedrine in p sych ia tric d iag -nos is. J . N erv . & M ent. D is ., IO4 593 , D ec. 1946 .

3. Lev ine, L ., e t a l. P sycho log ica l an d p hysio lo g i-c al e ff ec ts of in travenou s perv itin . Am . J. P sych iat.,io g, Dec . 1948 .

4. M yerson , A brah am . T he trea tm en t o f h yste r icamnes i a by p ur el y p ha rm ac ol o gi c m eans . N ew Eng .J . M ed ., 2 36: 821, May 29 , 1947 .

5 . K iessig , H . J ., and O rzechow sk i, G . A rch . F .ex per. Pa th . u . Ph armako i , 1 97: 3 91 , 1 941 .

a preliminary report on the use of d-desoxyephedrine hydrochloride in the study of psychopathology...

Documents