Cómo usar ZYPREXA

of Neurosis

T h o m a s M . L i n g , M.D., M.R.C.P. *

I feel very honored to be giving a paper at the Second International Con-ference on the use of L S D 25 and happy to be back in the United States, particularly in New York State.

Like many others, I had the opportunity of extensive post-graduate training in psychiatry in North America between the wars, and lived here for three years. I have also visited the United States to lecture and meet colleagues eight times since World War II; in addition I have lectured on two occasions in nearly all the major cities of Central and South America.

I mention these facts as evidence that I have some knowledge of the cultural background in both North and South America, which is relevant in trying to understand the therapeutic procedure in using L S D in Western culture. Psychotherapy is not, in my opinion, a rigid static procedure that is inseparable from the cultural and religious background of the patient, or of the therapist. This is even more relevant when using L S D , which speeds up and accentuates the interpersonal relationship of therapist and patient.

It is also significant that all of us are investigating a drug that is closely allied to Nepenthe, well known to Homer in 640-558 B. C. In The Odyssey, Homer describes how Helen, the wife of Menelaus, prepared the potion:

Then Helen, daughter of Zeus, turned to new thoughts. Presently she cast a drug into the wine whereof they drank, a drug to lull all pain and anger and bright forgetfulness of every sorrow. Whoso should drink a draught thereof, when it is mingled in the bowl, on that day he would let no tear fall down his cheeks, not though men slew his brother or dear son with the sword before his face and his own eyes beheld it. Medicines of such virtue and so helpful had the daughter of Zeus which Polydamna, the wife of Thor, had given her, a woman of Egypt, where earth, the grain giver, yields herbs in greatest plenty, many that are healing in the cup, and many baneful.

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* Consultant Psychiatrist, Marlborough Day Hospital, London.

Hashish, often called Marihuana, or in common jargon, "Indian Hemp, " has been consumed in India and the Middle East since time im-memorial. Its utilization and export from one country to another is illegal and is the subject of various inquiries by W. H. O. Commitees. It is cer-tainly widely used in Egypt and a number of reputable doctors in that country have expressed their conviction that it is habit-forming, but, in stable personalities, not deteriorating.

A more acceptable hallucinogen, the psilocybe of Southern Mexico, formed an important part of local religious rites, before the Aztec civiliza-tion. Hundreds of stone mushroom carvings in Mexico and Guatemala offer proof of its importance long before the white man occupied the Americas. According to Dr. Hoffman of Basle, who synthesized L S D in 1938, there is a close chemical affinity between psilocybin and LSD. There is a good deal of research work being done currently on psilocybin but in the United Kingdom it is regarded as therapeutically unpredictable.

The synthesis of L S D is a landmark in psychopharmacology and has provided us with ample quantities of a drug capable of great good, or great harm.

My experience with the drug dates from 1953 and follows the publi-cation of a thoughtful article in The British Journal of Mental Science by Sandison in that year.

Since then we have all learned a great deal as to the cases that will benefit and probably be cured and those that cannot tolerate the upsurge of unconscious material. The latter may be disintegrated.

This discrepancy is most important because L S D is an extremely powerful drug and it is essential to follow the old Roman saying, "Nil Nocere, " which means "do no harm. " This concept in medicine is even more important now than it was in Roman days, because in all fields of medicine our weapons are much more powerful. In no sphere is this more true than in psychopharmacology and one is forcibly reminded of the saying from St. Matthew's gospel: "Unto everyone that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath. " (XXV; 29)

PROCEDURE IN THE UNITED KINGDOM

In the United Kingdom, the drug is sold directly to mental hospitals, and to approved psychiatrists. The manufacturer's medical staff satisfy themselves that the individual psychiatrist is reliable and really knows how to use the drug. The company reserves the right to sell or withhold the drug from any psychiatrist, and it is never on sale through any ordi-nary pharmacist, or to lay psychologists.

Unfortunately, like most international cities, London and other big cities have their "black market" where it is said that all vices and all drugs can be bought, if you know where to go and can pay for them.

Without posing as virtuous, I personally do not know where one would get black market drugs, although cynics would reply that I do not

need to know, as I can buy L S D from the manufacturer and prescribe legally other drugs as required.

The North American culture is very different from ours and, judging by some of the journalists' reports and the irresponsible magazines, drugs, including LSD, could be bought without difficulty on many campuses and in most cities in the United States.

Responsible United States doctors were as disturbed about this state of affairs as was the Food and Drug Administration in Washington or professional friends in Europe. It is scarcely surprising that the United States has had the regrettable episode of the two psychologists, Leary and Alpert, being asked to leave Harvard for giving L S D to undergradu-ates experimentally. There were also reports circulating in Europe of orgies in the United States, under black market LSD, that seem far re-moved from the Oath of Hippocrates.

No doubt these latter problems will be cleared up in the near future, but the immediate result is unfortunate in giving L S D an erotic and sensa-tional image. As doctors, we are only concerned with its clinical and re-search interest.

Theoretical Background of L S D

There are already thousands of references to this drug in the world literature, and it is evident that it is used in widely different ways and on different sorts of cases.

Hallucinogens such as L S D and certain other drugs have been used for centuries to produce transcendental experiences, relieve anxiety, pro-duce religious states and enhance self understanding. As Cerletti (1963) has pointed out, the first scientific description of the hallucinogenic drugs was by Spanish conquerors of the Aztecs in the 16th century.

In 1898 Havelock Ellis described an experiment with Mescaline that he had conducted on himself and at about the same time Weir Mitchell (1897) described analogous experiences. Amongst the known hallucino-gens the most widely used in recent years is lysergic acid ( L S D 25). As yet its mode of action on the central nervous system is not fully under-stood, despite investigations going back for forty years.

In 1923 it was found that ergot alkaloids possess central non-toxic action, and inhibition of pressor reflexes was described. L S D 25 is the link between the naturally dehydrogenated and partially synthetic alka-loids of ergot.

An indole ring in L S D 25, producing its resemblance to serotonin and reserpine, has suggested some of the mechanisms by which the drug may act. Whether given by mouth, intravenously or intramuscularly, it is rapidly circulated to all the tissues of the body and broken down within three hours.

In my experience this drug is extremely powerful for good and ill.

Schizoid or pre-psychotic individuals can be disintegrated and rendered definitely psychotic, which is tragic and ethically indefensible.

It appears from some of the articles in the lay press in the United States that L S D has been obtained and taken by individuals without

previous psychiatric investigation and continued psychiatric supervision.

In some cases this has been in the form of a mixed orgy, because with certain people it is a strong erotic stimulant. I suggest that this is danger-ous, irresponsible and certainly not medicine as understood from the days of Hippocrates. Many of the people wanting to behave in this way are so unstable, or else pre-psychotic, that they are clinically unsuitable for taking such a drug.

A careful psychiatric and social appraisal should be made of each potential case to assess the conscious problems, the ego-strength, the tendency to depression and the total social situation.

Treatment with L S D is not the last resort of the incurable or a magic cure for the deteriorated schizophrenic. Given good intelligence and ego-strength, it is capable of giving remarkable insight and revealing to the patient the infantile and childish roots of the neurosis.

It is my belief that it is essential to assess the ego-strength to be sure that the patient can tolerate and digest the unpleasant revelations that he will receive about himself.

This ego-strength is determined by clinical experience in assessing the total life history of the patient and his capacity for dealing with conscious stress. If he has always escaped from his day-to-day difficulties through alcohol or drugs, he is probably too frail to face up to the self-understanding that L S D provides.

This same adverse comment applies to the professional failure, e.g.

the man who can never pass his law or medical exams, and takes on a succession of semi-skilled jobs.

Use of Projective Tests on Border-line Cases

Help can be obtained from projective tests, particularly the Rorschach test. If the psychologist detects incipient schizophrenia, poor motivation or poor ego-strength, such cases are rejected for treatment.

It is impossible to be dogmatic as to how helpful the psychologists can be, because one frequently loses sight of the rejected cases. In addi-tion, some of the cases given treatment with the psychologist's support have proved so resistive that they have not been helped. A great deal de-pends on the skill of the psychologist, and an individual who has taken a short course in the Rorschach is dangerous. Until her death three years ago, I had the help of the late Dr. Elaine Gladstone, Secretary of the Rorschach Society of Great Britain, who was particularly skilful in her predictions.

In the absence of really skilled psychological help, it is wiser to rely on clinical judgment alone than on inexperienced psychologists.

Apart from the risk of precipitating a psychosis, the other major danger is suicide. The risks of this are assessed in the clinical survey and it is frequently advisable to see a patient at length two or three times before deciding on his suitability for treatment. Those who have attempted suicide in the past are nearly always rejected as are those with marked cyclo-thymic mood swings. In many cases the self-understanding occurring during L S D treatment can be very depressing and needs considerable

therapeutic and domestic support. This paper is based exclusively on treating out-patients in a private clinic, or in a Day hospital.

Conditions of Treatment

In my opinion, L S D is a remarkably effective drug when given to the right person under safe conditions by psychiatrists who have themselves selected the cases, and who have themselves taken a full course of treat-ment or had a full analysis.

Experience has shown that the best results are obtained with the patient in bed in a single, quiet, pleasantly furnished room. Each bed is provided with a bell, so no patient is at any time out of touch with the staff.

Occasional aggressive and suicidal attempts are made during treatment so the windows are barred, with muslin curtains to soften the effect. As pa-tients' behavior is sometimes unpredictable, the door of the treatment unit is kept locked. In early days one woman patient put on her overcoat over her nightdress, and shoes, slipped out of the building and was next heard of in the casualty department of a well known teaching hospital. The young doctor on duty was uncertain whether she was psychotic or intoxicated or both. Such episodes are potentially dangerous and are to be avoided.

Some patients bring their own gramophones and discs, but piped music is not used. Musical people often find classical music helpful, although one business executive gave up its use as he felt he was delaying his recovery by being sexually stimulated by Wagner.

Some writers claim success with L S D given in groups, but this has not been my experience. The drug makes patients unduly suggestible so that if one individual verbalizes with great emotion a particular experience, the others are likely to imitate the experience. It is my belief that each in-dividual needs psychiatric help with current problems, and unconscious background experiences, in early childhood or infancy, that have contrib-uted to current neurotic reactions.

The Role of the Therapeutic Staff

It is essential to secure a good rapport with the patient before starting with LSD, and this frequently necessitates two or three interviews of about an hour each. About 20 percent of fee-paying patients have had a variable amount of analytically oriented psychotherapy which has been marginally helpful. Such individuals have some insight into their deeper difficulties and are used to verbalizing their thoughts. Some are referred by orthodox psychotherapists who perhaps find the patient's resistance too strong.

Others have abandoned their analysis after a year or two as they feel that progress is too slow, or the cost prohibitive.

Once a decision is made to proceed with L S D therapy, an outline of its effects is given in a spirit of reasonable optimism. This proves very difficult because it seems impossible to find words to convey the L S D experience. Nearly all of us using the drug in the United Kingdom have ourselves taken a course of treatment, and have acquired a deep under-standing of our own problems. I think this is essential if we are really going

to help people. Patients are enormously helped in a difficult situation when they learn that the therapist has really taken the drug himself with a suc-cessful result.

Treatment is most effective when the psychiatrist is working in close cooperation with a mature nurse, and the more motherly she is the better.

After a few treatments the psychiatrist and the nurse symbolize the pa-tient's parents. On one occasion, my nurse and I were treating a 40-year-old woman with anxiety dating from a very disturbed early childhood.

She became frightened, and suddenly said out of her reverie: "Why do you two hate each other so much?"

The next day, when the session was reviewed, she saw spontaneously that she was not talking to us at all but to her parents, both of whom are dead. From her pre-treatment history, it was evident that her father, an M. D., had suffered "shell shock" in World War I and had been in a psychiatric hospital for some months. She had always known that her parents' marriage was unhappy and under L S D she worked through, in four successive sessions, her feelings of guilt, anxiety and sexual stimula-tion, induced by his sexually molesting her when she was a child. She was married unhappily to a man her own age and was always attracted to men a good deal older than herself, until she was released from her deeply ambivalent attitude toward her father.

The Significance of Transference

Once patients have broken through into their unconscious they de-velop patterns of behavior reminiscent of the nursery. They usually like to have the same room and the same staff to treat them. They get seriously disturbed if their appointment is put off or a member of the staff is absent.

One or the other situation is regarded as a rejection and can be strongly verbalized by the patient. Intellectually they realize their attitude is irra-tional, but emotionally the attitude is outspoken and aggressive.

From the beginning, emphasis is placed on the fact that treatment is a cooperative effort between patient and therapist and not something that is done by the latter to the former. Each therapist develops differences of his own and in our clinic some psychiatrists are much more permissive than others. Thus, in every case, I discuss dosage with each patient prior to the session until the optimum level is found.

Sometimes patients will ask for more as they feel incapable of being carried through their resistance into their unconscious problems. Once the right dosage is determined, it is usual to remain at this level.

Some patients develop a relative resistance to the drug. In such cases it is advisable to give them about six weeks' rest from L S D therapy, with a variable number of psychotherapeutic sessions in between. In my ex-perience many patients become impatient with frequent analytically oriented sessions. Thus a senior executive of an international advertising agency who had had two years of analysis, four days a week, stated that he had derived more insight in his third L S D session than in the two years analysis. As a busy man, he made it clear he was not going to spend

PSYCHOLYTIC THERAPY

"endless hours" between sessions in view of his failure to improve previously with one of the leading orthodox analysts in London.

Selection of Patients

The selection of cases for out-patient treatment is all-important. Psychiatric diagnosis is notoriously inexact, so that it is more helpful to list the symptomatic and social factors influencing this decision.

The following are favorable indications:

1. Good motivation

2. Adequate ego-integration, good boundaries and defenses 3. Adequate perception of reality

4. The absence of marked schizoid features or early schizophrenia 5. The absence of previous genuine suicidal attempts

6. A regular job to which the patient has at least made a moderate adjustment

7. The presence of an understanding spouse who can give adequate support between treatments

8. Good intelligence and reasonable education

Cases that under my "open hospital" conditions are unsuitable for treatment include the following:

1. Markedly schizoid or schizophrenic individuals. The history of a previously schizophrenic episode is a warning as there is a real risk of precipitating another schizophrenic breakdown.

2. Patients who have made one or more genuine attempts at suicide or who admit to planning suicide.

3. Poor motivation. This may include patients referred from Courts and who take on treatment as preferable to prison. Poor motivation is frequently found among young people who are pressed to have treatment by parents.

4. Poor level of intelligence. There is no clear level of intelligence below which treatment is likely to be ineffective, but genuine insight is much more effective among those capable of thinking through their

4. Poor level of intelligence. There is no clear level of intelligence below which treatment is likely to be ineffective, but genuine insight is much more effective among those capable of thinking through their