Bulimia. An underlying behavioral disorder in hyperlipidemic pancreatitis: a prospective multidisciplinary approach.

Between 1978 and 1985, we conducted a prospective study of 21 patients who survived several attacks of pancreatitis and were diagnosed as having primary hyperlipidemia. None of the patients suffered from chronic alcoholism, primary diabetes, or cholelithiasis or was receiving prolonged steroid therapy. Lowering of plasma lipid values toward normal was achieved in all patients following a program of combined dietary and drug (bezafibrate) therapy. Five patients had recurrent episodes of pancreatitis during the treatment program. These patients were diagnosed subsequently as suffering from bulimia and were all given cognitive behavioral therapy. One patient died following an attack of pancreatitis. An underlying eating disorder should be suspected in patients who relapse after treatment for pancreatitis and hyperlipidemia. Multidisciplinary treatment should be used in these patients to improve therapeutic efficacy and uncover behavioral patterns that have a direct impact on their life expectancy.

[Depersonalization after withdrawal from cannabis usage].

The phenomenon of depersonalization during cannabis usage (intoxication) is commonly known. However, its appearance after drug stoppage is relatively unknown. This article reviews the literature on depersonalization after cannabis withdrawal and discusses three representing cases demonstrating the severity of the problem. Clinical features are described as well as effects on functioning and the long-term nature of this disorder. The treatment approach in each case is also presented.

The efficacy of naltrexone in preventing reabuse of heroin after detoxification.

The efficacy of Naltrexone in preventing reabuse of heroin among heroin addicts in Israel was studied in a double-blind, controlled design. Naltrexone (or placebo) treatment was given as part of a general treatment plan that continued for 12 weeks. Thirty-two addicts who successfully completed a detoxification program and met research criteria, were included in the study. Fifty milligrams of Naltrexone were taken orally three times a week (25 mg twice a week for the first 2 weeks). The follow-up procedure included an interview, urine tests, and screening for possible adverse effects. In addition, social and psychological parameters were evaluated. Fewer heroin-positive urine tests were found the Naltrexone group than in the placebo group. Throughout the entire study, the number of drug-free patients in the Naltrexone group was higher than in the placebo group. The Naltrexone group showed a significant improvement in most psychological parameters as compared with the placebo group. No differences were found in compliance or ratio of adverse effects between the Naltrexone and placebo groups. The concept "heroin abuse load" based on daily heroin consumption and duration of addiction enabled us to predict which addicts would complete the treatment program. The results suggest that heroin addicts in Israel may benefit from treatment with Naltrexone.

Long-term effects of sibling incest.

Although sexual abuse of children is recognized as a serious problem, sibling incest has received relatively little attention. A distinction has been made between power-oriented sibling incest and nurturance-oriented incest. The authors review the relevant literature and present four clinical examples. The cases illustrate the broad range of sibling incest and demonstrate its effects, including the long-term consequences for the perpetrator. Lasting difficulties in establishing and maintaining close relationships, especially sexual ones, are prominent features of each case. Without denying the occurrences of benign sex-play between siblings, the authors emphasize exploitation and abuse as pathogenic aspects of sibling incest.

Hoarding as a psychiatric symptom.

Collecting is a normal behavior in childhood and adulthood, while hoarding--the gathering, ordering, and disposal of articles without clear conscious motivation or control--is characterized as the pathologic counterpart of collecting. The literature describing the characteristics of collecting and the theories concerning its underlying mechanisms is presented along with eight case studies of adults who exhibited hoarding as a prominent symptom. It is apparent that hoarding is the final common pathway for a variety of processes: compulsive hoarding in obsessive compulsive disorder, fears of theft and poisoning in paranoid delusions, and the deterioration of habits in organic mental disorder.

Frozen stored Leishmania tropica vaccine: the effects of dose, route of administration and storage on the evolution of the clinical lesion. Two field trials in the Israel Defense Forces.

The first field trial of frozen vaccine against cutaneous leishmaniasis yielded a 100% take rate and a high ulceration rate at a dose of four million units. Two further trials were designed to investigate differences in response rates on the basis of duration of storage, sex of vaccinee, vaccination dose and method of administration. 257 soliders (151 males and 106 females) were inoculated in 1978 with an isolate of Leishmania tropica major that had been stored at the temperature of liquid nitrogen for 11 months before use. Those inoculated with an intradermal jet injector and those receiving half a million units by conventional injection yielded very low take rates. For those receiving two million and one million units, no difference in response was demonstrated between males and females or between doses. The over-all take rate for these groups after six months of follow-up was 71.6% with an ulceration rate of only 23.7%. In a subsequent trial in 1979, 131 men were inoculated with one of two frozen isolates of L. tropica major that had been stored for 11 and 18 months, respectively, at doses of either two million or four million units. The take rate after 12 months of follow-up was 91% and 93% for the four and two million units dose, respectively. The corresponding ulceration rates were 39.5% and 25%. The lesions produced by the higher dose developed more rapidly than those produced by the lower dose. The ability of the parasites to produce lesions rapidly with high ulceration rates appears to decline during prolonged storage, even in the frozen state.

Patients, chaperons and healers: enlarging the therapeutic encounter.

The common assumption in most therapy is that the process is initiated by a need in the patient and managed or directed by the therapist. If there are other people involved, except for the case of group or family therapy, they are at best marginal to the ongoing process as conducted in the therapy room. This paper, jointly written by a social anthropologist and psychiatrist, presents a model of therapy in an ultra-Orthodox Jewish community in which chaperons accompanying the patient (a common feature in the setting) may fulfil important functions as cultural bridges, sometimes even going so far as serving as active co-therapists. Ethnographic data is offered to demonstrate how chaperons may assist in enabling the healers to overcome feelings of 'cultural distress' and discomfiture on the part of the patients and how they assist the therapists to be 'culturally sensitive' in their use of psychiatric methods in a population which has deep misgivings about such procedures. The paper concludes with an argument for increased openness and flexibility in the practice of psycho-therapy, particularly in cross-cultural encounters, which would allow for greater use of chaperons.

The erroneous diagnosis of malingering in a military setting.

The paper describes difficulties in diagnosing individuals from different cultures, focusing specifically on cases of erroneous diagnosis of malingering among ultraorthodox Jewish inductees. During one year, 24 inductees diagnosed as malingerers by several army psychiatrists were re-examined by the authors and subsequently re-diagnosed as psychotic, suffering from a personality disorder, or mentally retarded. Factors underlying the misdiagnosis are discussed.

Recent trauma in psychiatric outpatients.

Psychiatric clinic outpatients were screened for recent traumatic events, and post-traumatic symptomatology was evaluated in those reporting occurrence of one or more events within the two years prior to screening. Clear symptoms of post-traumatic stress disorder were revealed in 18% of the reporting patients, and the distribution of diagnoses was found to be different in the trauma-reporting group than it was in a comparison diagnostic group.

The association between adolescents' attitudes toward suicide and their psychosocial background and suicidal tendencies.

The present study examined the relationship between adolescents' attitudes toward suicide and their psychosocial background. It also evaluated the association between attitudes toward suicide and the subjects' own suicidal tendencies. A questionnaire assessing these issues was administered to 525 Israeli adolescents. Results indicated that significantly more females, nonreligious adolescents, those exposed to suicidal behavior, and those with increased suicidal risk held more accepting attitudes. Ethnic origin, socioeconomic status, and living in intact/nonintact families were not associated with adolescents' attitudes toward suicide.

Problems in the treatment of religious patients.

Members of religious groups are bound together by doctrine, ritual, and social organization. These factors also separate religious people from members of other groups or cultures. This division is apparent during interactions with other groups, and critical when members of religious groups are referred for help for psychiatric problems. In this paper we discuss four problems that therapists may encounter with strictly religious patients. Religious patients are often suspicious of secular therapists and therapy, and therapists too, may be influenced by their personal attitudes toward religion. Differentiating religious beliefs and rituals from delusions and compulsions is difficult for therapists ignorant of the basic tenets of that religion. Clinical examples of the four problems are presented from our work with patients from the ultra-orthodox Jewish community of North Jerusalem and we provide guidelines for their resolution. Therapists need a basic knowledge of the religion's doctrines and rituals, should assess patients using its terminology, and approach the patients through the social organization of their religious group. We consider that attention to these issues is vital for effective communication and assessment of strictly religious patients.

Short-term strategic treatment in traumatic conversion reactions.

The therapists applied the strategic approach in four cases that demonstrate a variety of traumatic and conversion reactions. The therapists accepted the definition of the problem as presented by the patients or their families at the overt level, and were able to treat the conversion symptoms. At the latent level, however, there were additional system-focused goals. In the first stage, the therapists strove to understand the inner world and cultural background of their patients, their dynamics and the circumstances surrounding the event that led to the conversion reaction, or the traumatic significance of the event when it was a posttraumatic conversion. It was then possible to develop a strategy for treatment and to decide which treatment techniques were appropriate. The therapists created situations that encouraged change and pushed the patients to abandon the symptom. This therapy model is composed of behavioral and paradoxical techniques based on the understanding of the dynamic material and cultural content.

Use of a metaphor in the treatment of combat-induced posttraumatic stress disorder.

In this case of posttraumatic stress disorder, instead of interpretation, we used a metaphor that was indirectly yet concretely related to the patient's trauma. It subsequently became a symbol for other crucial events and situations in the patient's life. Mann's original approach to this type of patient had to be modified since the traumatic experience was not only too painful and isolated but also untouchable. The use of metaphor was thus a viable, indirect approach. Matching the metaphor to the therapeutic situation of patients with severe trauma, makes successful treatment possible where other approaches are excessively painful or almost impossible. The use of metaphor offers a solution to the therapeutic dilemma of too much resistance to brief therapy versus dependency-inducing long-term therapy for the patient suffering from posttraumatic stress disorder.

Value-sensitive therapy: learning from ultra-orthodox patients.

This paper explores the issues that arise when psychotherapists and patients do not share a common value system. Using three case studies of ultra-Orthodox Jewish patients who hold religious values and beliefs, the paper illustrataes and defines a strategy of "value-sensitive therapy." It argues for treating patients without demeaning or discounting their values and beliefs.

Summoning a punishing angel: treatment of a depressed patient with dissociative features.

The authors describe their treatment of a 24-year-old repentant, extremely observant Jewish man with major depressive disorder who complained of persecution by a personal angel. The therapists initiated a culturally sensitive psychotherapy of the patient, enacting a ritual summoning of the angel that resulted in the angel's transformation into an ally. The authors discuss the relationship of the patient's symptomatology to pathological mourning, trance, and dissociation. They advocate the use of a strategic combination of culture-specific concepts with modern psychiatric approaches in similar cases.

Ethnic background and antecedents of religious conversion among Israeli Jewish outpatients.

This study explored the association of ethnocultural background (Ashkenazi vs Sephardi origin) with antecedents of religious conversion among Israeli Jewish penitents who applied for psychiatric help in an outpatient clinic. A basic assumption underlying the comparison was that Sephardic Jews in Israel are more inclined toward Jewish tradition and collectivistic than Ashkenazim. The interview data indicated that for both groups emotional factors were more dominant in the conversion process than cognitive ones; however, cognitive factors were more strongly present in the conversion process of the Ashkenazim whose prepenitence cultural orientation had been more secularized and individualistic. In both groups a high prevalence of problematic relations with the father (but not with the mother) during childhood was noticed. Over-all, conversion tended to be gradual rather than abrupt and devoid of mystical experiences.

The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society.

Judaism is one of many religions that demand cleanliness and exactness, inculcate the performance of rituals from childhood and view their non-performance as wrong or sinful. Rituals concerning cleanliness and exactness are the commonest presentations of OCD. In a sample of 34 psychiatric out-patients with OCD in north Jerusalem, religious symptoms were found in 13 of the 19 ultra-orthodox patients, and in one of the 15 non-ultra-orthodox patients. Nine of the 15 OCD patients with religious symptoms also had non-religious symptoms. Four main topics of religious symptomatology were found: prayer, dietary practices, menstrual practices and cleanliness before prayer. The dictates of religious codes regarding these topics are presented and the law is rigorous in its demands, in many cases encouraging repeating rituals. Nevertheless, repetitive performance of religious rituals is recognized by OCD sufferers and their rabbis as expressing psychopathology rather than heightened spirituality. The forms of the religious obsessions and the associated rituals in this sample were similar to the presentation of OCD in non-religious patients. Religion appears not to be a distinctive topic of OCD, rather it is the setting for the condition in very religious patients.

Ideology and budgeting.

Israel has undergone rapid change and development during the last few decades, and extraordinary advances have been made in the field of psychiatry. At the same time, however, it is this progress that has outdated certain methods and styles of public service planning. Universal accessibility to good treatment is put at risk by the centralized planning that is more concerned with bed utilization and less so with community services, now the heart of the psychiatric system. While general health services are undergoing reorganization, progress has been slow in the restructuring of the psychiatric system.

Culturally sensitive therapy with ultra-orthodox patients: the strategic employment of religious idioms of distress.

The article deals with the problem of administering therapy in multicultural settings where the therapist and the patient hold divergent explanatory models in regard to the patient's symptoms. Different conceptualizations of the universal structure of symbolic healing stress the importance of therapist-patient compatibility for therapeutic success. In order to reach this compatibility, strategic therapists seek to join the patients' explanatory models and employ metaphors and symbols derived from their cultural world. From a psychodynamic perspective, strategic techniques are often presented as superficial treatments limited to the symptomatic level. In order to deal with this argument, we present a case study of an ultra-orthodox patient with a major depressive episode and describe the treatment which was based on a strategic, culturally sensitive approach. We use the case to discuss theoretical issues arising in the context of multicultural therapy such as the translatability of culturally divergent idioms of distress and the possibility to bring about significant, nonsymptomatic changes through strategic employment of culturally congruent metaphors and symbols.

The "Jerusalem syndrome"--fantasy and reality a survey of accounts from the 19th century to the end of the second millennium.

The so-called "Jerusalem Syndrome" is behavioral phenomena observed in eccentric and psychotic tourists with religious delusions. A significant number of pilgrims and tourists have been visiting the Holy City, at least since the beginning of the 19th century, including some delusionary and eccentric characters. The authors present a selection of vivid descriptive accounts of such 19th century visitors, by six local residents and writers about Jerusalem (including one psychiatrist). It should be noted that those writers already noticed and documented the so-called syndrome more than a century ago. In comparison to modern research of the phenomena in contemporary Jerusalem, a striking similarity in the narrative and the clinical picture emerges. However, based on accumulated data, the authors suggest that in most cases the religious atmosphere of the city is not the primary cause for the disorder. The psychotic visitors had set out for their journey to the Holy City already guided by a delusionary system derived from their religious belief and cultural background.