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Psychiatric Case Studies: Treatment, Drugs and Outcome

Donald F. Klein with the collaboration of Alfreda Howard.
Psychiatric Case Studies: Treatment, Drugs and Outcome. 
Williams & Wilkins, Baltimore, 1972. (491 pages).

INFORMATION ON CONTENTS:

Forward - Jonathan O. Cole: "….. the only text in which theories and principles of psychopharmacological therapy are illustrated by good examples of their application to individual patients".

The Psychiatric Case Study-Discussion

     Schizophrenia-Diagnostic Issues

          Schizoaffective- 6 Cases with Comments

          Childhood Asocial -3 Cases with Comments

          Fearful Paranoid-2 Cases with Comments

    Recurrent Affective Disorders-Diagnostic Issues

          Retarded Depression- Two Cases with Comments

          Agitated Depression- Three Cases with Comments

          Dysphoric States- Two Cases with Comments

          Bipolar Type= Manic States- Two Cases with Comments

    Late Life Onset

          Schizoid Personality with Depressive-Paranoid Exacerbation- One Case with Comment

          Paranoid Personality with Involutional Psychosis- One Case with Comment

          Agitated Depression during Involutional Period-One Case with Comment

    Neuroses and Character Disorders - Diagnostic Issues

          Phobic Anxiety Reaction (Agoraphobia) - Three Cases with Comments

          Emotionally Unstable Character Disorder- Two Cases with Comments

          Passive - Aggressive Character Disorder-Two Cases with Comments

          Hysterical Character Disorder-Two Cases with Comments

          Pseudo-Schizophrenic Neurosis - Two Cases with Comments

Diagnoses & Prevention of Diagnostic & Medication Treatment Errors

References

This text is partly derived from a double-blind, randomized, placebo-controlled clinical trial of imipramine, chlorpromazine, and placebo conducted during 1960-1961 at Hillside Hospital. The  psychiatric inpatients were  at the 200-bed long term psychoanalytic inpatient facility of the Federation of Jewish Philanthropies. Uniquely, there was a Department of Experimental Psychiatry whose Director was Max Fink M.D. Just as uniquely, the new Director of the Hospital, was Lew Robbins M.D., an open minded  training analyst from  the Topeka School who recognized the clinical importance of psychotropic drugs as well as the necessity of properly done, placebo controlled,  clinical trials to evaluate their pluses and minuses.  This required randomization without regard to the very shaky psychiatric diagnoses, since two years of pilot work indicated that remarkable errors, based on these clinical, observational beliefs were often incurred.

 The Principal Investigators were Max Pollack PhD and Max Fink MD, USPHS MH-2715. This study was replicated by Donald F. Klein MD, USPHS MH 08004, in 1964-1966. This remains probably the largest single clinical trial carried out at a single inpatient facility. A number of useful discoveries were made.. These included the utility of imipramine for spontaneous panic attacks, which led to the formulation of panic disorder and agoraphobia. Other findings were the equivalence of chlorpromazine to imipramine for the normalization of the mood of severely depressed patients, as well as the lack of utility of chlorpromazine for schizophrenics with childhood in asociality.

Both groups were systematically followed up three years later by Sidney Levenstein D.S.W. USPHSMH-10191. Many had, somewhat more unsystematic, follow up evaluations, up to eleven years after treatment.

AUTHOR’S COMMENTS: The anonymized material was used in a didactic course for psychiatric residents. The residents received the information up to the point of hospitalization and asked to predict the likely course. For many this was a humbling, if illuminating, experience. The point was that even a detailed well-written case study is often insufficient to serve as a solid predictive, causal document. Post hoc ergo propter hoc remains a key critical principle for psychiatry .However the course was not repeated.

The motivation to put this material into a book (effectively facilitated by Alfreda Howard) was largely to flesh out the somewhat abstract descriptions given by the Klein and Davis text. Also it demonstrated the complex, often obscure, demands placed on attempting to systematically formulate descriptive diagnoses.

It cannot claim to be a success since it sold poorly and was infrequently referred to, although I confess a paternal fondness. At least, it casts some light on the psychiatric attempts of the 1960s to deal with the revelations of the paradigm destroying psychotropic drugs.

Donald F. Klein
January 2, 2014