THOMAS A. BAN, M.D.
Psychopharmacology and psychosomatic disorders Consultation liaison psychiatrists often must prescribe anxiolytic sedatives, antidepressants, and neuroleptic drugs which are additions to the pharmacologic agents required to treat patients with common somatic conditions. The interaction of these agents and their appropriate use is reviewed.
ABSTRACT:
By 1972 there were 144 million prescriptions for psychotropic medications (excluding hypnotics) written in the United States. More than 50% of the prescriptions were given to patients without a primary diagnosis of mental disorder. Most of these prescriptions were written for anxiolytic sedatives for the treatment of patients with anxiety and/or depression resulting from or associated with a wide variety of somatic complaints. The symptoms for which these drugs have been prescribed (present in approximately 30% of patients seen by general practitioners) are usually mild, have a high rate of spontaneous remission, display a placebo response in about 50% and a drug response in about 75%. The second most frequently prescribed psychotropic drugs for patients with somatic disorders are DECEMBER 1978 • VOL 19 • NO 12
tricyclic antidepressants. In some of these patients there is manifest depression in association with or as a complication of severe medical illness. In others, an underlying depression is primary and the accompanying somatic complaints or dysfunction represent manifestations of that state. Cardiovascular disorders Cardiovascular disorders are the most common of all diseases; and the physician treating these conditions is confronted with difficult therapeutic decisions because of the frequent need for psychotropic medication. With the exception of the benzodiazepines, all therapeutically effective psychoactive agents may produce cardiovascular side effects.' Hypotension, especially orthostatic hypotension, frequently occurs at the beginning of treat-
ment with both neuroleptic (phenothiazine and thioxanthene) and antidepressant (tricyclic and MAOI) drugs; and those patients who become hypotensive after taking alpha-adrenergic blocking neuroleptic agents may be especially prone to arrhythmias because of the unopposed beta-adrenergic stimulation. Reversible disturbances of cardiac conduction may also lead to arrhythmias during a treatment course with piperidylphenothiazine preparations, or after an overdose of tricyclic antidepressant drugs.2 There are indications that neuroleptic, antipsychotic, and tricyclic antidepressant drugs may cause myocardial degeneration3; and reports of congestive heart failure and cardiac infarction following administration of these drugs.4 Thioridazine and amitriptyline are among the various neuroleptics and antidepressants most frequently producing these adverse effects. The neuroleptic haloperidol and the antidepressant doxepin are unlikely to produce cardiac complications when administered within the 757
Psychopharmacology
range of therapeutic dose levels.s.6 Myocardial infarction: While neuroleptic and antidepressant drugs may produce adverse cardiac effects, the fright associated with acute myocardial infarction can lead to ventricular arrhythmia or fibrillation that cannot be reversed by psychotropic drugs. Accordingly, in the immediate postinfarct phase, a benzodiazepine is recommended for the alleviation of anxiety and mild depression, and a neuroleptic such as haloperidol is indicated for patients with hyperarousal, agitation, or psychotic
With the exception ofthe benzodiazepines, aU therapeuticaUy effective psychoactive agents may produce cardiovascular side effects. symptoms. In the convalescent stage, mild anxiety and depression may respond favorably to diazepam, and moderately severe anxiety and depression to haloperidol. I In case of severe depression during the month following a heart attack, the tricyclic antidepressant doxepin and/or electroconvulsive therapy is the treatment of choice. Moreover, neuroleptics, and especially butyrophenone neuroleptics, enhance the degradation of phenindione by enzyme induction, reduce prothrombin time, and increase the dose requirements of coumarintype anticoagulants. The same applies to anxiolytic sedative barbiturates, while anxiolytic sedative benzodiazepines are free of this effect on anticoagulant dosages. Arrhythmias: Arrhythmias also produce anxiety that responds favorably to the administration of 758
anxiolytic sedative benzodiazepine drugs. But because withdrawal of such agents can lead to recrudescence of symptoms, treatment with diazepam (which should always be short term) has been increasingly replaced by treatment with propranolol (which may be administered over an extended period).7 Hypertension: The most important findings about hypertension are that phenothiazine and thioxanthene neuroleptics can intensify the blood pressure-lowering action of thiazide diuretics, interfere with the antihypertensive action of alpha-methyldopa, and inhibit the antihypertensive action of guanethidine. Because the antihypertensive effect of adrenergic blocking agents such as guanethidine and its congeners is cancelled out by commonly used tricyclic antidepressant drugs, Simpson8 recommends the combined administration of a diuretic and a beta-receptor blocking agent or hydralazine in the treatment of hypertensive patients who are suffering from depression. Pulmonary disease Bronchial asthma: Among the bronchopulmonary disorders, bronchial asthma is probably the one most frequently encountered by practicing physicians. At the present time treatment with corticotropic hormone has been replaced by cortisone and its more concentrated congeners, and even more recently by beclomethasone dipropionate, a potent topical steroid which can be administered by inhalation with negligible systemic absorption. 9•lo While for some time the combination of Corticotropin and group therapy seemed to provide the most favorable results for patients with
chronic bronchial asthma,lI l3 more recently there has been increasing evidence that the therapeutic effects of beclomethasone can be potentiated by tricyclic antidepressants. This potentiation may be due to the bronchodilatory action of these drugs,14-16 Since anticholinergic and antihistaminic properties are associated with the catecholamine-receptor blocking effect of tricyclic antidepressant drugs, it is conceivable that they could exert both nonspecific (by lifting depression) and specific (via augmentation of catecholamine actions and anticholinergic effects) therapeutic changes in afflicted patients. 17 COPD: In contradistinction to their effect on bronchial asthma, psychotropic drugs have a slim role in the treatment of chronic obstructive pulmonary disease (COPD). In agitated patients, those showing disruptive behavior and/ o
Neuroleptics, and especiaUy butyrophenone neuroleptics, enhance the degradation of phenindione by enzyme induction and reduce prothrombin time. or psychotic symptoms, a nonsedating neuroleptic may be reasonably safe, while barbiturates depress respiratory centers. This is not true of the benzodiazepines, although nitrazepam can significantly impair respiratory performance in patients with carbon dioxide retention. u8 Gastrointestinal disorders There is substantial evidence to support the belief that antacids such as aluminum or magnesium PSYCHOSOMATICS
gel decrease gastrointestinal absorption and consequently the serum level of orally administered psychotropic drugs. In view of this, one should consider increasing the dosage of psychotropic medication when an antacid is prescribed and decreasing the dosage when the antacid is discontinued. Since functional gastrointestinal disorders are characterized by remissions and exacerbations it has
Consider increasing the dosage ofpsychotropic medication when an antacid is prescribed. been suggested that they should be treated intermittently with psychotropic drugs. Among the various psychotropic preparations that reduce gastric secretion and acid production in peptic ulcer patients, the benzodiazepines were found to slow gastric emptying and smallbowel transit time.'9.2o These effects appear to be mediated by the central-anxiolytic action of the benzodiazepine drugs. I Hepatic and renal insufficiency Marked sensitivity to a variety of drugs characterizes hepatic insufficiency. Neuroleptics are not well tolerated and even a single dose of chlorpromazine produces marked somnolence and slowing of the electroencephalogram in these patients. 21 In contrast, neither depression of consciousness nor electrophysiologic changes were observed after the administration of 5 mg of diazepam, an anxiolytic sedative drug. 22 It has also been noted that MAOls are less well tolerated than are tricyclic antidepressant (amitriptyline) drugs. 23 DECEMBER 1978· VOL 19· NO 12
There is also an increased central nervous system sensitivity to a variety of drugs in patients with renal insufficiency. This is attributed to the accumulation of ordinarily detoxified products. Contrasted with hepatic insufficiency, renal insufficiency responds to neuroleptics. Low doses are well tolerated and have been given to dialysis patients successfully for the control of confusional states (such as delusions about death and dying). Chronic adaptation to dialysis requires an ability to accept a compromised life and accompanying depression. Nevertheless, antidepressants are usually not prescribed because they are poorly tolerated by this group of patients and produce distressing adverse elfects. 24
imipramine, in particular, were significantly more effective than an inactive placebo in relieving emotionally induced itch and rash. Today, sedative antihistamines (h ydroxyzine) are the most frequently used drugs in these conditions.' Moreover, on the basis of his clinical experience Musaph 29 suggests that the most suitable treatment for patients itching "with repressed anger" is narcoanalysis and short-acting barbiturates such as sodium pentothal or sodium methohexital. For patients "with repressed anxiety" sedative benzodiazepines, such as diazepam, are useful; and for patients "with delusions of parasitosis," the neuroleptic thioxanthenes such as clopenthixol are effective. 0
Gynecologic problems An increase in anxiety and hostility prior to menstruation and a transient decrease in these manifestations at the time of ovulation have been reported. 25 .26 A recent study has shown that this fluctuation has been abolished in patients who take the birth control pill Enovid, a norethynodrel and mestranol combination. On the other hand, the incidence of idiopathic pelvic pain, urinary incontinence, frigidity, and dysfunctional metrorrhagia has remained unchanged. While these symptoms usually remain refractory to the administration of anxiolytic, sedative, or neuroleptic drugs, they frequently show a favorable response to small doses of antidepressants. 27
Dr. Ban is professor ofpsychiatry, Vanderbilt University School of Medicine. Reprint requests to him at the Tennessee Neuropsychiatric Institute, 1501 Murfreesboro Road, Nashville, TN 37217.
Dermatologic disease In a carefully conducted early clinical study, Lester et aJ28 demonstrated that psychotropic drugs in general, and the neuroleptic chlorpromazine, and the antidepressant
REFERENCES 1. Solow C: PsychotropIC drugs in somatic dis· orders. in Lipowski ZJ. Lipsilt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxford University Press. 1977. 2. Lehmann HE. Ban TA (eds): Toxicity and Adverse Reaction Studies with Neuro/eptics and Antidepressants. Montreal. QPRA. 1965. 3. Crane GE: Cardiac tOXicity and psychotropic drugs. Dis Nerv Syst 31:534·539.1970. 4. Raisf,eld IH: Cardiovascular complications of antidepressant therapy. Am Heart J 83: 129·
133.1972. 5. Ban TA: Introduction to the Psychopharma· c%gyot Doxepin. Montreal. Pfizer. 1977. 6. Moir DC. Cornwall WB. Crooks J. et al: Car· diotoxicityof amitriptyline. Lancet 2:561·564.
1972. 7. won S: Cardiovascular disease. in Wittkower ED. Warnes H (eds): Psychosomatic Medi· cine. Its Clinical Applications. New York. Harper & Row. 1977. 8. Simpson Fa: Hypertension and depression and their treatment. Aust NZ J Psychiatry
7: 1·5. , 973. 9. Godfrey S. Konig P: Asthma treatment with the aerosol steroid beclomethasone dipro· pionate. Ann Allergy 33:150·154.1974. 10. Morrow·Brown J. Storey G. George WHS: Beclomethasone dipropionate: A new steroid aerosol for the treatment of allergic asthma. Br Med J 1:585·590. 1972.
759
Psychopharmacology
11. Bastiaans J. Groen J: Psychogenesis and psychotherapy of bronchial asthma. in O'Neil (ed): Modern Trends in Psychosomatic Medicine. London. Butterwonhs. 1955. 12. Groen J. Peiser HE: Experience with group psychotherapy in patients with bronchial asthma. J Psychosom Res 4:191-193.1960. 13. Sclare AB: Group therapy tor specific psychosomatic problems. in Wiltkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 14. Avni J. Bruderman I: The eHect of amitriptyline on pulmonary ventilation and the mechanics of breathing. Pharmacologia
o
16:164-192.1969. 15. Mattila MJ. Muittari A: Modification by imipramine of the bronchodilator response to isoprenaline in asthmatic patients. Ann Med Int Fennica 57: 185-167. 1968. 16. Sugihara H. Ishihara K. Noguchi H: Clinical experience with amitriptyline (Tryptanol) in treatment of bronchial asthma. Ann Allergy
23:422-423. 1965. 17. Knapp PH: Psychotherapeutic management of bronchial asthma. in Wiltkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 18. Greenblatt OJ. Shader RI: 8enzodiazepines in Clinical Practice. New York. Raven Press.
1974. 19. Birnbaum D. Ben·Menachem J. Schwanz A: The influence of oral diazepam on gastroin· testinal motility. Am J Proctol 21:263-266.
1970. 20. Birnbaum D. Karmeli F. Tefera M: The effect of diazepam on human gastric secretion. Gut 12:616-616.1971. 21. Read AE. Laidlaw J. McCanhy CF: Effects of 22.
23. 24.
25.
chlorpromazine in patients with hepatic disease. 8r Med J 3:497·499. 1969. Murray-Lyon 1M. Young J. Parker JD. et al: Clinical and electroencephalographic assessment of diazepam in liver disease. 8( MedJ4:265-266.1971. Morgan MH. Read AE: Antidepressants and liver disease. Gut 13:697-701. 1972. Abram HS: Psychiatry and medical progress: Therapeutic considerations. in Lipowski ZJ. Lipsitt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxford University Press. 1977. Gottschalk LA: Quantification and psychological indicators of emotions: The content analysis of speech and other measures of psychological states. in Lipowski ZJ. Lipsitt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxtord University Press.
1977. 26. Ivey MC. Bardwick JM: Patterns of aHective fluctuation in fhe menstrual cycle. Psychosom Med 30:336-346. 1966. 27. Molinski H: Obstetrics and gynecology. in Wittkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 28. Lester EP. Wittkower ED. Kalz F. et at: Phrenotropic drugs in psychosomatic disorders (skin). Am J Psychiatry 119:136·143.1962. 29. Musaph H: Itching and other dermatoses. in Wittkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977.
760
Manuscript Reviewers-1978 The editor would like to expres hi gratitude to the following for their valued a i tance in reviewing manuscripts during the pa t year: J. Ananth, M.D., McGill University Montreal orman Q. Brill, M.D. University of California Los Angeles Hilde Bruch, M.D. Baylor University Carroll M. Brod ky, M.D., Ph.D., University of California, San Francisco Luther Cloud, M.D. alional Council on Alcoholism Sidney Cohen, M.D., University of California, Los Angeles Herman C. B. Denber M.D., Ph.D., University of Louisville Seymour Diamond, M.D. Chicago Medical School Barney M. Olin, M.D., Temple Universit George E. Ehrlich, M.D. Temple Universit Albert Lee Fi her, M.D., La Cros e, Wis. Joseph V. Fi her, M.D. Medical Universit of South Carolina Arnold P. Friedman, M.D. University of Arizona Richard H. Gwartney, M.D. San Bernardino, Calif. Thoma P. Hackett, M.D., Harvard Medical School Fred O. HenkeT, lll, M.D., University of Arkansas for Medical Sciences Raymond A. Huger, M.D. Phoenix Ariz. William S. Kroger, M.D., Beverly Hills, Calif Henry P. Laughlin, M.D., George Washington University Sandor Lorand, M.D., State University of ew York, Brooklyn Judd Marmor, M.D. University of Southern California M. J. Manin, M.D., Mayo Clinic Roland S. Medan ky, M.D., University of l//inois John C. emiah, M.D., Harvard Medical chool Charle P. Neumann, M.D., University ofArizona L. C. Powell Jr. M.D., University of Texas, Galveston Richard T. Rada M.D., University of New Mexico Saul H. Ro enlhal, M.D., University of Texas, San Antonio Theodore E. Schlaegel, M.D., Indiana University Jerome M. Schneck, M.D. St. Vincent's Hospital, ew York John J. Schwab M.D., University of Louisville Bernard H. Smith, M.D., State University of New York, Buffalo Wendell M. Swen on, Ph.D., Mayo Clinic William L. Webb Jr., M.D. University of Tennessee Sanford R. Wolf M.D. La Mesa, California William W. K. Zung, M.D., Duke University
PSYCHOSOMATICS
Psychopharmacology and psychosomatic disorders Consultation liaison psychiatrists often must prescribe anxiolytic sedatives, antidepressants, and neuroleptic drugs which are additions to the pharmacologic agents required to treat patients with common somatic conditions. The interaction of these agents and their appropriate use is reviewed.
ABSTRACT:
By 1972 there were 144 million prescriptions for psychotropic medications (excluding hypnotics) written in the United States. More than 50% of the prescriptions were given to patients without a primary diagnosis of mental disorder. Most of these prescriptions were written for anxiolytic sedatives for the treatment of patients with anxiety and/or depression resulting from or associated with a wide variety of somatic complaints. The symptoms for which these drugs have been prescribed (present in approximately 30% of patients seen by general practitioners) are usually mild, have a high rate of spontaneous remission, display a placebo response in about 50% and a drug response in about 75%. The second most frequently prescribed psychotropic drugs for patients with somatic disorders are DECEMBER 1978 • VOL 19 • NO 12
tricyclic antidepressants. In some of these patients there is manifest depression in association with or as a complication of severe medical illness. In others, an underlying depression is primary and the accompanying somatic complaints or dysfunction represent manifestations of that state. Cardiovascular disorders Cardiovascular disorders are the most common of all diseases; and the physician treating these conditions is confronted with difficult therapeutic decisions because of the frequent need for psychotropic medication. With the exception of the benzodiazepines, all therapeutically effective psychoactive agents may produce cardiovascular side effects.' Hypotension, especially orthostatic hypotension, frequently occurs at the beginning of treat-
ment with both neuroleptic (phenothiazine and thioxanthene) and antidepressant (tricyclic and MAOI) drugs; and those patients who become hypotensive after taking alpha-adrenergic blocking neuroleptic agents may be especially prone to arrhythmias because of the unopposed beta-adrenergic stimulation. Reversible disturbances of cardiac conduction may also lead to arrhythmias during a treatment course with piperidylphenothiazine preparations, or after an overdose of tricyclic antidepressant drugs.2 There are indications that neuroleptic, antipsychotic, and tricyclic antidepressant drugs may cause myocardial degeneration3; and reports of congestive heart failure and cardiac infarction following administration of these drugs.4 Thioridazine and amitriptyline are among the various neuroleptics and antidepressants most frequently producing these adverse effects. The neuroleptic haloperidol and the antidepressant doxepin are unlikely to produce cardiac complications when administered within the 757
Psychopharmacology
range of therapeutic dose levels.s.6 Myocardial infarction: While neuroleptic and antidepressant drugs may produce adverse cardiac effects, the fright associated with acute myocardial infarction can lead to ventricular arrhythmia or fibrillation that cannot be reversed by psychotropic drugs. Accordingly, in the immediate postinfarct phase, a benzodiazepine is recommended for the alleviation of anxiety and mild depression, and a neuroleptic such as haloperidol is indicated for patients with hyperarousal, agitation, or psychotic
With the exception ofthe benzodiazepines, aU therapeuticaUy effective psychoactive agents may produce cardiovascular side effects. symptoms. In the convalescent stage, mild anxiety and depression may respond favorably to diazepam, and moderately severe anxiety and depression to haloperidol. I In case of severe depression during the month following a heart attack, the tricyclic antidepressant doxepin and/or electroconvulsive therapy is the treatment of choice. Moreover, neuroleptics, and especially butyrophenone neuroleptics, enhance the degradation of phenindione by enzyme induction, reduce prothrombin time, and increase the dose requirements of coumarintype anticoagulants. The same applies to anxiolytic sedative barbiturates, while anxiolytic sedative benzodiazepines are free of this effect on anticoagulant dosages. Arrhythmias: Arrhythmias also produce anxiety that responds favorably to the administration of 758
anxiolytic sedative benzodiazepine drugs. But because withdrawal of such agents can lead to recrudescence of symptoms, treatment with diazepam (which should always be short term) has been increasingly replaced by treatment with propranolol (which may be administered over an extended period).7 Hypertension: The most important findings about hypertension are that phenothiazine and thioxanthene neuroleptics can intensify the blood pressure-lowering action of thiazide diuretics, interfere with the antihypertensive action of alpha-methyldopa, and inhibit the antihypertensive action of guanethidine. Because the antihypertensive effect of adrenergic blocking agents such as guanethidine and its congeners is cancelled out by commonly used tricyclic antidepressant drugs, Simpson8 recommends the combined administration of a diuretic and a beta-receptor blocking agent or hydralazine in the treatment of hypertensive patients who are suffering from depression. Pulmonary disease Bronchial asthma: Among the bronchopulmonary disorders, bronchial asthma is probably the one most frequently encountered by practicing physicians. At the present time treatment with corticotropic hormone has been replaced by cortisone and its more concentrated congeners, and even more recently by beclomethasone dipropionate, a potent topical steroid which can be administered by inhalation with negligible systemic absorption. 9•lo While for some time the combination of Corticotropin and group therapy seemed to provide the most favorable results for patients with
chronic bronchial asthma,lI l3 more recently there has been increasing evidence that the therapeutic effects of beclomethasone can be potentiated by tricyclic antidepressants. This potentiation may be due to the bronchodilatory action of these drugs,14-16 Since anticholinergic and antihistaminic properties are associated with the catecholamine-receptor blocking effect of tricyclic antidepressant drugs, it is conceivable that they could exert both nonspecific (by lifting depression) and specific (via augmentation of catecholamine actions and anticholinergic effects) therapeutic changes in afflicted patients. 17 COPD: In contradistinction to their effect on bronchial asthma, psychotropic drugs have a slim role in the treatment of chronic obstructive pulmonary disease (COPD). In agitated patients, those showing disruptive behavior and/ o
Neuroleptics, and especiaUy butyrophenone neuroleptics, enhance the degradation of phenindione by enzyme induction and reduce prothrombin time. or psychotic symptoms, a nonsedating neuroleptic may be reasonably safe, while barbiturates depress respiratory centers. This is not true of the benzodiazepines, although nitrazepam can significantly impair respiratory performance in patients with carbon dioxide retention. u8 Gastrointestinal disorders There is substantial evidence to support the belief that antacids such as aluminum or magnesium PSYCHOSOMATICS
gel decrease gastrointestinal absorption and consequently the serum level of orally administered psychotropic drugs. In view of this, one should consider increasing the dosage of psychotropic medication when an antacid is prescribed and decreasing the dosage when the antacid is discontinued. Since functional gastrointestinal disorders are characterized by remissions and exacerbations it has
Consider increasing the dosage ofpsychotropic medication when an antacid is prescribed. been suggested that they should be treated intermittently with psychotropic drugs. Among the various psychotropic preparations that reduce gastric secretion and acid production in peptic ulcer patients, the benzodiazepines were found to slow gastric emptying and smallbowel transit time.'9.2o These effects appear to be mediated by the central-anxiolytic action of the benzodiazepine drugs. I Hepatic and renal insufficiency Marked sensitivity to a variety of drugs characterizes hepatic insufficiency. Neuroleptics are not well tolerated and even a single dose of chlorpromazine produces marked somnolence and slowing of the electroencephalogram in these patients. 21 In contrast, neither depression of consciousness nor electrophysiologic changes were observed after the administration of 5 mg of diazepam, an anxiolytic sedative drug. 22 It has also been noted that MAOls are less well tolerated than are tricyclic antidepressant (amitriptyline) drugs. 23 DECEMBER 1978· VOL 19· NO 12
There is also an increased central nervous system sensitivity to a variety of drugs in patients with renal insufficiency. This is attributed to the accumulation of ordinarily detoxified products. Contrasted with hepatic insufficiency, renal insufficiency responds to neuroleptics. Low doses are well tolerated and have been given to dialysis patients successfully for the control of confusional states (such as delusions about death and dying). Chronic adaptation to dialysis requires an ability to accept a compromised life and accompanying depression. Nevertheless, antidepressants are usually not prescribed because they are poorly tolerated by this group of patients and produce distressing adverse elfects. 24
imipramine, in particular, were significantly more effective than an inactive placebo in relieving emotionally induced itch and rash. Today, sedative antihistamines (h ydroxyzine) are the most frequently used drugs in these conditions.' Moreover, on the basis of his clinical experience Musaph 29 suggests that the most suitable treatment for patients itching "with repressed anger" is narcoanalysis and short-acting barbiturates such as sodium pentothal or sodium methohexital. For patients "with repressed anxiety" sedative benzodiazepines, such as diazepam, are useful; and for patients "with delusions of parasitosis," the neuroleptic thioxanthenes such as clopenthixol are effective. 0
Gynecologic problems An increase in anxiety and hostility prior to menstruation and a transient decrease in these manifestations at the time of ovulation have been reported. 25 .26 A recent study has shown that this fluctuation has been abolished in patients who take the birth control pill Enovid, a norethynodrel and mestranol combination. On the other hand, the incidence of idiopathic pelvic pain, urinary incontinence, frigidity, and dysfunctional metrorrhagia has remained unchanged. While these symptoms usually remain refractory to the administration of anxiolytic, sedative, or neuroleptic drugs, they frequently show a favorable response to small doses of antidepressants. 27
Dr. Ban is professor ofpsychiatry, Vanderbilt University School of Medicine. Reprint requests to him at the Tennessee Neuropsychiatric Institute, 1501 Murfreesboro Road, Nashville, TN 37217.
Dermatologic disease In a carefully conducted early clinical study, Lester et aJ28 demonstrated that psychotropic drugs in general, and the neuroleptic chlorpromazine, and the antidepressant
REFERENCES 1. Solow C: PsychotropIC drugs in somatic dis· orders. in Lipowski ZJ. Lipsilt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxford University Press. 1977. 2. Lehmann HE. Ban TA (eds): Toxicity and Adverse Reaction Studies with Neuro/eptics and Antidepressants. Montreal. QPRA. 1965. 3. Crane GE: Cardiac tOXicity and psychotropic drugs. Dis Nerv Syst 31:534·539.1970. 4. Raisf,eld IH: Cardiovascular complications of antidepressant therapy. Am Heart J 83: 129·
133.1972. 5. Ban TA: Introduction to the Psychopharma· c%gyot Doxepin. Montreal. Pfizer. 1977. 6. Moir DC. Cornwall WB. Crooks J. et al: Car· diotoxicityof amitriptyline. Lancet 2:561·564.
1972. 7. won S: Cardiovascular disease. in Wittkower ED. Warnes H (eds): Psychosomatic Medi· cine. Its Clinical Applications. New York. Harper & Row. 1977. 8. Simpson Fa: Hypertension and depression and their treatment. Aust NZ J Psychiatry
7: 1·5. , 973. 9. Godfrey S. Konig P: Asthma treatment with the aerosol steroid beclomethasone dipro· pionate. Ann Allergy 33:150·154.1974. 10. Morrow·Brown J. Storey G. George WHS: Beclomethasone dipropionate: A new steroid aerosol for the treatment of allergic asthma. Br Med J 1:585·590. 1972.
759
Psychopharmacology
11. Bastiaans J. Groen J: Psychogenesis and psychotherapy of bronchial asthma. in O'Neil (ed): Modern Trends in Psychosomatic Medicine. London. Butterwonhs. 1955. 12. Groen J. Peiser HE: Experience with group psychotherapy in patients with bronchial asthma. J Psychosom Res 4:191-193.1960. 13. Sclare AB: Group therapy tor specific psychosomatic problems. in Wiltkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 14. Avni J. Bruderman I: The eHect of amitriptyline on pulmonary ventilation and the mechanics of breathing. Pharmacologia
o
16:164-192.1969. 15. Mattila MJ. Muittari A: Modification by imipramine of the bronchodilator response to isoprenaline in asthmatic patients. Ann Med Int Fennica 57: 185-167. 1968. 16. Sugihara H. Ishihara K. Noguchi H: Clinical experience with amitriptyline (Tryptanol) in treatment of bronchial asthma. Ann Allergy
23:422-423. 1965. 17. Knapp PH: Psychotherapeutic management of bronchial asthma. in Wiltkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 18. Greenblatt OJ. Shader RI: 8enzodiazepines in Clinical Practice. New York. Raven Press.
1974. 19. Birnbaum D. Ben·Menachem J. Schwanz A: The influence of oral diazepam on gastroin· testinal motility. Am J Proctol 21:263-266.
1970. 20. Birnbaum D. Karmeli F. Tefera M: The effect of diazepam on human gastric secretion. Gut 12:616-616.1971. 21. Read AE. Laidlaw J. McCanhy CF: Effects of 22.
23. 24.
25.
chlorpromazine in patients with hepatic disease. 8r Med J 3:497·499. 1969. Murray-Lyon 1M. Young J. Parker JD. et al: Clinical and electroencephalographic assessment of diazepam in liver disease. 8( MedJ4:265-266.1971. Morgan MH. Read AE: Antidepressants and liver disease. Gut 13:697-701. 1972. Abram HS: Psychiatry and medical progress: Therapeutic considerations. in Lipowski ZJ. Lipsitt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxford University Press. 1977. Gottschalk LA: Quantification and psychological indicators of emotions: The content analysis of speech and other measures of psychological states. in Lipowski ZJ. Lipsitt DR. Whybrow PC (eds): Psychosomatic Medicine. New York. Oxtord University Press.
1977. 26. Ivey MC. Bardwick JM: Patterns of aHective fluctuation in fhe menstrual cycle. Psychosom Med 30:336-346. 1966. 27. Molinski H: Obstetrics and gynecology. in Wittkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977. 28. Lester EP. Wittkower ED. Kalz F. et at: Phrenotropic drugs in psychosomatic disorders (skin). Am J Psychiatry 119:136·143.1962. 29. Musaph H: Itching and other dermatoses. in Wittkower ED. Warnes H (eds): Psychosomatic Medicine. Its Clinical Applications. New York. Harper & Row. 1977.
760
Manuscript Reviewers-1978 The editor would like to expres hi gratitude to the following for their valued a i tance in reviewing manuscripts during the pa t year: J. Ananth, M.D., McGill University Montreal orman Q. Brill, M.D. University of California Los Angeles Hilde Bruch, M.D. Baylor University Carroll M. Brod ky, M.D., Ph.D., University of California, San Francisco Luther Cloud, M.D. alional Council on Alcoholism Sidney Cohen, M.D., University of California, Los Angeles Herman C. B. Denber M.D., Ph.D., University of Louisville Seymour Diamond, M.D. Chicago Medical School Barney M. Olin, M.D., Temple Universit George E. Ehrlich, M.D. Temple Universit Albert Lee Fi her, M.D., La Cros e, Wis. Joseph V. Fi her, M.D. Medical Universit of South Carolina Arnold P. Friedman, M.D. University of Arizona Richard H. Gwartney, M.D. San Bernardino, Calif. Thoma P. Hackett, M.D., Harvard Medical School Fred O. HenkeT, lll, M.D., University of Arkansas for Medical Sciences Raymond A. Huger, M.D. Phoenix Ariz. William S. Kroger, M.D., Beverly Hills, Calif Henry P. Laughlin, M.D., George Washington University Sandor Lorand, M.D., State University of ew York, Brooklyn Judd Marmor, M.D. University of Southern California M. J. Manin, M.D., Mayo Clinic Roland S. Medan ky, M.D., University of l//inois John C. emiah, M.D., Harvard Medical chool Charle P. Neumann, M.D., University ofArizona L. C. Powell Jr. M.D., University of Texas, Galveston Richard T. Rada M.D., University of New Mexico Saul H. Ro enlhal, M.D., University of Texas, San Antonio Theodore E. Schlaegel, M.D., Indiana University Jerome M. Schneck, M.D. St. Vincent's Hospital, ew York John J. Schwab M.D., University of Louisville Bernard H. Smith, M.D., State University of New York, Buffalo Wendell M. Swen on, Ph.D., Mayo Clinic William L. Webb Jr., M.D. University of Tennessee Sanford R. Wolf M.D. La Mesa, California William W. K. Zung, M.D., Duke University
PSYCHOSOMATICS
