Correspondence

well supervised situations. It also helps the understanding of adult patients' descriptive histories.
Knowledge of developmental, family and service
interaction issues can allow trainees to reappraise the
context of the histories of adult psychiatry patients,not only of those patients' adolescence but also of the
situations in which the patients now find themselves.

Despite College recommendations, many trainees
may not have the opportunity to complete their train
ing by having worked with children or particularly
with adolescents as a specialist placement.

ARTUROLANGA
Leavesden Hospital
Abbots Langlev
Watford WD50NU

References
HAS (1985) Bridges over Troubled Water. Sutton: Health

Advisory Service.
ROYALCOLLEGEOFPSYCHIATRISTS(1983) Providing a dis

trict service for child and adolescent psychiatry: medical
manpower priority? Bulletin of the Royal College of
Psychiatrists, 7,94-97.

(1990) A statement on approval of training schemes
for general professional training for the MRC Psych.
Psychiatric Bulletin. 14, 110-118.

Malignant alienation - agent and host
interaction?
DEARSIRS
Morgan & Priest (1984) coined the term "malignant
alienation" when describing patients who had com
mitted suicide while receiving in-patient care or
shortly after discharge. A theme of inexorable
alienation had been evident in many cases, whereby
ward staff became critical of the patient's behaviour.
Behaviour was construed as provocative, unreason
able and over-dependent. In some cases disability
was thought to be deliberately assumed. The process
was malignant because of the relentless drive towards
a fatal outcome. The authors felt that malignant
alienation might be provoked by recurrent relapses
or difficult behaviour-problems arising from the
patient. These patients committed suicide, but did
they truly kill themselves?

Who are these "difficult" patients, and how might
health care professionals react to them?

The characteristics of such patients might be sum
marised as follows. Patients who do not improve
with treatment, those who present challenging
behavioural problems, and those where a clear
diagnosis and/or treatment plan is lacking.

Health care professionals should be aware of their
own attitudes and feelings to all patients, but particu
larly those engendered by difficult patients. There
may be many staff whose own neurotic blindspots
actually prevent the giving of appropriate care. For
example, the doctor who habitually undertreats

579

patients for fear of hurting or upsetting them. The
nurse who over-identifies with an aspect of the
patient and tends to be overly optimistic about the
clinical outcome, or alternatively becomes irritable
with the patient when progress is slow. The doctor
who feels that a poor response to his treatment is a
personal insult, who then uses dangerous or un
warranted treatments in an attempt to salvage his
pride. Such interactions become even more testing
with difficult patients. Surely the lesson to be learned
is to become more aware of our own responses when
dealing with patients? This self-observing quality is a
most important attribute.

Sir Denis Hill put his finger on another crucial
attribute. In defining the requisites for a good psy
chiatrist he included "protection of the patient from
the negative aggressive aspects of one's self" (Hill,
1978). But what is this negative aggressive aspect?

Aggressive instincts are generally now seen as
being directed outwardly and are not necessarily
negative. Indeed, these instincts may be part of a
biological inheritance which serves to preserve us. In
this way aggression is seen as the basis for human
achievement and mastery in the world, valuable in
the process of differentiation and personal auton
omy. The complexities, hierarchies and conventions
that form the framework of society may have evolved
as a defence against negative aspects of aggression,
ensuring cooperation and the survival of the species
rather than allowing unrestrained inter-personal
destruction (Storr, 1968).

Is an awareness of the negative aspects of
outwardly directed aggressive impulses useful when
considering malignant alienation?

Not long ago a staff nurse from the psychiatric
ward telephoned me. She was distressed and upset. A
patient had just gone AWOL from the ward and she
feared for his safety. We talked it over. She had
alerted the patient's family and general practitioner,
and informed the police. I knew that this nurse was
level-headed and usually coped well with such
incidents. What was so different now? I went over to
the ward to see her. It became clear that the patient
had been "difficult" that day, threatening staff and
pushing them to their limits. This was compounded
by staff shortages through sickness. Under consider
able stress this nurse had wished the patient dead.
The feeling was conscious momentarily, and was
only a fantasy, but it had occurred. So when the
patient finally absconded the nurse felt her own
murderous feelings had played their part, and she
feared greatly for his life.

Can a synthesis be achieved here? Malignant
alienation may be the harbinger of suicide with dif
ficult patients. Staff feelings could play a part in
fueling the process. Negative feelings towards the
patient initially lie hidden. With further adverse
interaction these feelings may tumble briefly into



580

consciousness, albeit as fantasies. As with the nurse
in the story above, such feelings are immensely
powerful. If the patient is the host to difficult behav
iour or recurrent relapses, then perhaps the staff
are the agents of malignant alienation via negative
aggressive feelings. Who is to say that these feelings
might not actually begin to "kill off" the patient,
inexorably driving the process of alienation to a
malignant end? Such an idea may be uncomfortable
to even consider; and thus worth consideration.

DARRYLWATTS
Ham Green Hospital
Pill, Bristol BS200HW

References
HILL, D. (1978) The qualities of a good psychiatrist. British

Journal of Psychiatry, 133,97-105.
MORGAN, H. G. & PRIEST, P. (1984) Assessment of suicide

risk in psychiatric in-patients. British Journal of
Psychiatry, 145,467^469.

STORR. A. (1968) Human Aggression. London: Penguin.

Assessment of parenting
DEARSIRS
Reder & Lucey provide a timely consideration of
some key ideas in an interactional framework for
the assessment of parenting (Psychiatric Bulletin,
June 1991, 15, 347-348) and with the rapid incor
poration of some of the Children's Act provisions
into our practice, the era of impressionism as regards
assessment of parenting ability must needs pass.

In addition to the logical progression expounded
by Reder & Lucey, three further headings ought to
be borne in mind, even if as child psychiatrists we
honestly say we do not know their full import.

(a) The setting or context in which the assess
ment occurs and this includes the contri
bution of the assessor.

(b) Cultural factors and differences, which have
to include the diversity of influences as well
as the assumed norms.

(c) The child, whose own individual character
and temperament may be such that he or she
tests parenting ability and limits of safety
beyond imagining.

LAWRENCEMCGIBBEN
TOMHUGHES

Gulson Hospital
Coventry CV12HR

Intermetamorphosis of Doubles or
Double-Golyadkin Phenomenon - a
new syndrome?
DEARSIRS
Owen wonders (Psychiatric Bulletin, May 1991, 15,
302) if he is suffering from Fregoli's syndrome as he

Correspondence

has become convinced that Mr Thomson, the
gentleman who appears wearing a bowler hat is
in reality a man with a moustache called Mr
Thompson. As Dr Owen is an avid student of
Merge, he must know that Thompson and
Thompson tend to appear in duplicate forms (see
Fig. 1). It is thus far more likely, that they are mis
taken each for the other! While this is certainly a
variant of a misidentification syndrome or a re
duplicative phenomenon, it cannot be considered
as Fregoli's syndrome in which Dr Owen (or some
body else) would have to be convinced that a sub
ject kept his identity but changed his bodily
appearance. If Dr Owen mistakes Thomson for
Thompson (the one with the stick; Fig. 1) he has to
also mistake. Thompson for Thomson-both in
terms of physical appearance and actual identity.
In this case we are dealing with intermetamorpho-
sis (Silva et al, 1989), or, to be completely accurate,
'intermetamorphosis of doubles'. Again, Herge has
made an important contribution to the existing
body of specialist literature (Kamanitz et al, 1989)
by extensive reports of numerous dramatic inci
dences caused by Thomson's and Thompson's con
fusing experience of being doubles. We suggest the
scholarly term 'Double-Golyadkin Phenomenon'
for this widely underestimated but highly distress
ing condition (modified after Markidis, 1986, after
Dostoyevski, 1846, see Förstl et al, Psychiatric
Bulletin, 14, 705-707).

Fig. I. Thomson (moustache, hat) and Thompson
(with a stick).

As shown by Dr De Pauw's further study in the field
of 'Psychiatry in Literature' (Psychiatric Bulletin,
May 1991, 15, 302 after March 1991, 15, 167-168),