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), Correspondence the approach towards German psychiatry should certainly be a most critical one. HANSFÖRSTL ROBERTHOWARD OSVALDOP. ALMEIDA ADRIANOWEN ALISTAIRBURNS JOHNO'BRIAN Institute of Psychiatry De Crespigny Park London SE58A F References K.AMANITZ, J. R., EL-MALLAKH, R. S. & TASMAN, A. ( 1989) Delusional misidentification involving the self. The Journal of Nervous and Mental Disease, 177, 695-698. MARKIDIS, M. (1986) Ego, my double (The Golyadkin Phenomenon). Bibliotheka Psychiatrica, 164,136-142. SILVA, J. A., LEONG, G. B., SHANER, A. L. & CHANG, C. Y. (1989) Syndrome of intermetamorphosis: a new perspective. Comprehensive Psychiatry, 30,209-213. A full list of references is available on request from Dr Förstl. DEARSIRS I thank Dr Förstlet al for their interesting and educational reply to my letter. I wonder whether a syndrome has been described which might be applied to a psychiatrist who mistak enly identifies two almost identical syndromes? If so, perhaps this is what I am suffering from. JOHNOwen University Department of Mental Health 41 St Michael's Hill Bristol BS28DZ A register of Munchausen cases? DEARSIRS Davey (Psychiatric Bulletin, March 1991, 15, 167) adds his voice to those calling for a register of Munchausen cases. An interesting natural exper iment with such a register took place some years ago when a knowledgeable patient with feigned Zollinger-Ellison syndrome frequented many hospi tals demanding Omperazole, a drug under investi gation with the details of all receiving patients held on a central register (Daly et al, 1989). This register enabled the patient's travels to be recorded in some detail and the authors comment that he would not have been identified without a register. However, in their letter they suggest that the diagnosis of factitious illness was made before consulting the register. Further evidence that a 'black-list' is not essential for diagnosis is provided by the fact that this same man had already made an inconspicuous entry into the medical literature (Lovestone, 1987). 581 The arguments against a register are strong. We should be cautious at any such breach of confiden tiality and the legal complications may be serious. I wonder at the effect of having a list of patients with feigned physical illness on the practice of liaison psy chiatry. It might contribute to increasing the "is it psychological or organic" type of referral - an often unhelpful dichotomy. Although Davey calls for a register, he fails to actually state why. Making a diagnosis of Munchausen syndrome is in itself not particularly helpful to the patient as we do not know how to treat this condition. Protecting the patient from iatrogenic harm is important, but we can trust our colleagues only to perform invasive procedures when a diag nosis of Munchausen syndrome is not yet being con sidered - and hence a register not consulted. Jones (1988), quoted by Davey, is more explicit. The benefits of a register are economic and to be calcu lated in terms of cost benefit analysis. This is a poor reason - even in the new NHS doctors must strive to be more than accountants. I suspect the reason underlying calls for a register lie within the physician and not the patient. Being 'caught out' or 'conned* is an unpleasant experience and it is understandable that doctors should wish to avoid it. In the spirit of Asher I would propose a fourth variant of Munchausen syndrome 'Homo connus phobia et registerphilia'- a disorder of doctors. SIMONLOVESTONE The Maudsley Hospital Denmark Hill London SES 8A F References DALY, M. J., CARROL, N. J. H., FORRET, E. A. e/a/(1989) Munchausen Zollinger-Ellison syndrome. Lancet 1,853. JONES, J. R. (1988) Psychiatric Munchausen's syndrome: a College register? British Journal of Psychiatry, 153,403. LOVESTONE,S. (1987) Munchausen syndrome presenting as Zollinger-Ellison Syndrome. Southampton Medical Journal, 4, 59-61. The use of carpets in geriatric and psycho-geriatric wards DEARSIRS It is to be hoped that the eloquent and passionate protestations of Dr David Jolley (Psychiatric Bull etin, March 1991, 15, 168-169) do not obscure the issues relating to the use of carpets in geriatric and psycho-geriatric hospital wards. He is partially right. Anyone who has worked in institutions caring for elderly people knows that offensive smells are not uncommon. While carpets are often associated with these smells, the smells are not confined to wards