Parasuicide [Letter]

Downloaded By: [Westmead Hospital Library] At: 00:42 14 May 2009 528 CORRESPONDENCE I t is unfortunate that in this paper only eleven women were studied and eight of them were over the age of 50. This may have significantly biased the results. making it difficult to generalise to most women working as doctors. For example: the proportion of female medical students has been increasing steadily, so that when I went to medical school in 1984 half of the students were female. This increase presumably has decreased the discrimination faced by female students; further studies will hopefully look at this. As the proportion of female doctors has risen, it has continued to vary considerably between disciplines. Is this perpetuated by a lack of female role models? Those disciplines which are seen as too “difficult” for women - that is, too demanding on their time and too difficult to combine with outside pressures - are the disciplines which provide very few female role models. The fact that there are few women in that field will perpetuate the idca that this discipline is too difficult for women. The key aspect identificd as impacting on the career process of women was described as self-esteem. This may not be as true for a younger cohort who may feel that the lack of an appropriate role model and mentor is a greater problem. Low self esteem may also have an impact on male doctors. I t would seem to be time that these areas were studied in greater detail, and examination of medical students as well as older doctors could give an indication of any improvements, or worsening, of the situation for womcn. For example: changes in the amount of self-esteem, or in numbers and availability of role models for women may be seen in different age groups of women. Comparisons with men in similar positions will help to indicate which of these problems are inherent in medicine and which are specifically faced by women. RefCr(wcc>.s 1. Turner J. l’ippctt V , Raphael B. Women i n rncdicine: Socialisation. stereotypes and \ell perccptions. Australian and New Zealand Journal olPsychiatry 1994;2X:17-9-135. 2. lmutwh E. Yandow V. Scinilitz L, Rcrger H. Women leaders in phychiatry. Journal ol [he American Women’s Associalion I YX2: 37:275-?59. Diabetes and Tardive Dyskinesia Chuy-HooriTun, Sitiguporc.: The authors in the recent report Diubetes atid Dwelopm(vit of’ Turdil’c Dyskinesio I 1 J suggested an association between diabetes mellitis (DM) and tardive dyskinesia (TD). Analysis of our previous raw data, concerning 514 elderly patients in the State Psychiatric Hospital who had a prevalence of T D of 27.6% [ 2 ] ,revealed a total of 19 (2 Malay, 2 Indian. 15 Chinese) patients who had DM and 495 patients who did not. All 19 patients had more than 5 years history of adult onset DM and all were receiving oral antidiabetic medication without insulin injection. Only 4 patients (3 Chinese and I Malay) with DM had T D and it is statistically not significant. There was no difference in the antidiabetic medication between the patients with T D and those without TD. References 1 , Woerner MG. Saltz BL, Kane JM. Lieberman JA. Alvir JM; Diabetes and development of tardive dyskinesia. American Journal of Psychiatry 1993; 150:966-968. 2. Tan CH, Tay LK. Tardive Dyskinesia in elderly psychiatric patients in Singapore. Australian and New Zealand Journal of Psychiatry 19Y1;25:119-122. Depressionand marijuana Abraham Z e l n w . B i ~ r ~ ~Victoria: od, I report a patient of mine aged 36 who was referred after an explosive outburst at work and whose volatile moods stabilised on lithium. He improved significantly, but was also smoking marijuana quite heavily three to four times per week and claimed that this was “recreational” but I wondered whether he used it for his “dysphoric mood”. He could not tolerate the tricyclic antidepressants and 1 did try him on paroxetine 20mg in the morning recently and after a fortnight he described feeling much better and that his marijuana usage had decreased dramatically. He only had mild signs of a depressive disorder but it was of significant interest to me that he was using marijuana as a form of “antidepressant”. Parasuicide Christopher Ryan, Penrith, New South Wales: Dr Cantor is to be congratulated on his recent paper, which represents a timely and thorough review of this area [ I ] . I would though take issue with the term “Parasuicide” which he uses both in the title and liberally through the text. Dr Cantor uses the term as synonymous with suicide attempt and when used by psychiatrists this is its usual meaning. Unfortunately however the term is often used less precisely in the Emergency Department by Downloaded By: [Westmead Hospital Library] At: 00:42 14 May 2009 CORRESPONDENCE medical officers, nurses and social workers to mean suicide attempts where it is felt that the patient meant other than to kill themselves. Often in this context it is used as a diagnosis. and a rationale for offering little further assessment or management. “It was only a parasuicide, so I let him go.” This confusion is understandable. The term does not appear in either standard or specialist medical dict i o n a r i e s a n d its e t y m o l o g y s u g g e s t s that a “parasuicide attempt” would refer to an attempt to “almost ornearly” kill oneself [ 2-41. Ofcourse patients do not as a rule attempt to “almost” end their lives, they attempt to kill themselves, though they may do so with varying degrees of ambivalence, intent and lethality. People who try to kill themselves are best described as having attempted suicide. Those people who had no intention of dying, but rather wished to lose consciousness or harm themselves in some other way, are better described by some other 1erm entirely. Like “hysteria” and “neurosis’’, “parasuicide” is apt t o c a u s e m o r e h a r m than g o o d b e c a u s e of misunderstanding and misuse of the term in the nonpsychiatric community. Unlike the first two however “parasuicide” has little historical or etymological worth to argue for its retention. I suggest therefore that it be expunged from o u r lexicon and replaced by “suicide attempt”. Refereric.c~s I . Cantor CH. Clinical manngcment of parasuicides: critical ishues in the 1990s. Austrnlian and New Zealand Journal of P\ychiatry 1994;2X:212-221. 2. The Oxford English dictionary. 2nd cd. Oxford: Clarendon. 19x9, 3. The Macquarie dictionary. Sydncy: Macquarir, I9X I . 4. Blakiston’s Gould mcdical dictionary. 4th cd. New York: McGraw-Hill. 1979. Dr Cantor’s reply Chris Cutilor, Woollootiguhhu. Qirvc~iislutid: 1 thank Dr Ryan lor his sentiments, and am glad of the opportunity to revisit the parasuicide terminology debate. To use the term parasuicide (para=near) as implying not at risk would indeed be inconsistent with mortality research. Kreitman et ul. I I 1, who coined the term, expressed outrage at the suggestion that their term implied “not a suicide attcmpt”. although they accepted the potential for confusion as illustrated by Dr Ryan’s experiences with casualty officers. Dr Ryan’s suggestion that all cases of non-fatal deliberate self harm (the term I , but few others. would prefer!) were seeking death is too dogmatic and likely s29 to promote categorical thinking. Assessment of risk needs to take a dimensional approach. All these people are at increased risk of suicide - the issue is by how much. Answering this question is difficult as there are numerous reliability and validity problems with assessment of intent. 1 believe that for moral reasons dating back centuries we are excessively preoccupied with intent. If a drunken overwhelmed husband beats his wife, do we need to get fixated with what was intended? Only if wife bashing is considered OK so long as i t is not fatal! ( I jest.) The behaviour alone tells us that his wife is at further risk of violence and that his coping strategy is maladaptive. If he continues talking of wanting to do her more harm or killing her, the situation is even more grave. All the proposed terms for non-fatal suicidal behaviour have problems. I am happy for individuals to choose whichever term they consider least unsatisfactory so long as they do not distort clinical understanding to fit the words. Ref t I etice I . I . Krcitman N. Philip A. Greer S. Bagley C. Parasuicide. British Journal of Psychiatry 1970; I 16:460-46I . Eye movement desensitisation processing for mSD C h r i s t op h e I’ W i I I ia ni L e , N e d l u ti ds Westerti Austruliu; Heleri Gaigriel, Rockirighuni Western Austruliu; .IejfRicAards, Curtiti Western Austruliu: In a recent paper [ 11, Page and Crino described the eye movement desensitisation procedure (EMD) and its application to post traumatic stress disorder. They argued that although EMD is a promising procedure, to date its efficacy remains to be demonstrated because of several methodological difficulties with past research. They also made some recommendations for directions for future research. We would concur with Page and Crino’s general comments about the validity of what Shapiro now calls eye movement desensitisation and reprocessing (EMDR) (21, however, we would like to suggest alternative rexearch directions. Firstly they propose several designs for component analysis to determine which aspects of the EMDR are critical or essential for the treatment’s effectiveness. Conversely we would argue that the effectiveness of the procedure be demonstrated first before it makes sense to analyse what may or may not be critical in the process. This would be accomplished by comparing (1