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Current Developments in Psychopharmacology, vol 4
BOOK REVIEWS Current Developments in Psychopharmacology, vol 4 Edited by Walter B. Essman and L. Valzelli, 296 pp, $25, New York, Spectrum, 1977.
• A brief review could hardly do justice to this excellent volume, the fourth in a series on Current Developments in Psychopharmacology. Engel and Carlsson consider the relationship of catecholamines and behavior. They present evidence for the role of dopaminergic neurons in neuroleptic drug activity indicating that this does not necessarily imply a primary biochemical defect in schizophrenia in central dopaminergic neurons-a wise observation, since many other neurotransmittors have been implicated and it may well be the balance that is upset in schizophrenia. They report the potentiating effect of alpha-methyltyrosine (a tyrosine hydroxylase inhibitor) on the action of neuroleptic drugs. This is worthy of further study. Simon gives a good discussion of "Opiate Receptors in the Central Nervous System," pointing out that opiate binding sites have a high affinity for narcotic analgesics and their antagonists. These sites are stereospecific, and there is a high order of correlation between binding affinities of various ligands and pharmacologic potency. The role of sodium is discussed, along with how this property can be used to study the actual molecular structure of the opiate receptor. Endorphins are present in all vertebrate species and do indeed seem to have some relevance to pain. Cyclic nucleotides may play some role in the mechanism of opiate action. Fiori considers a much-reviewed 500
subject, "Tricyclic Antidepressants: A review of Their Toxicity," with regard to the cardiovascular, hepatic, neurologic, psychologic, and teratogenic effects. He emphasizes that with impairment of consciousness, the presence of hypotension, and arrhythmia, tricyclic poisoning should be considered. The exact manner in which tricyclic antidepressants produce cardiotoxic effects is still unclear. While they can produce many of the neuroleptic side effects seen with neuroleptic drugs, Fiori comments particularly on the neuropathies seen with tricyclic antidepressants. There is no clear-cut evidence for teratogenic effects. This review reiterates the caution necessary in treating patients suffering from cardiovascular disease, severe hypotension, glaucoma, or urinary retention. Mendlewicz discusses "Recent Advances in Genetics and Psychopharmacology." It is clear that drug metabolism and clinical response probably result from a genetic-environmental interaction. That would be the fairest statement of fact concerning such a controversial problem. Some well-known pharmacogenetic problems are discussed, such as succinylcholine sensitivity, G6PD deficiency, and isoniazid acetylation. Phenelzine was found to be more effective in slow rather than rapid acetylators. Blasy and Herz discuss "Precipitated Morphine Withdrawal in Rats as a Tool in Opiate Research." This is seen to offer a suitable technique to study the problem and to test various hypotheses. Ho reviews "Pharmacological and Biochemical Studies with ,B-carboline analogs." This refers essentially to harmaline,
yohimbine, and similar compounds, which offer a tool to study mental disorders. One should not lose sight of the tenuous relationship that exists between these particular drug-induced states and the endogenous disorders. The "Neuropharmacology of Hyperkinesis" is reviewed by Silbergeld. He brings out some of the diagnostic problems and, of course, the wide range of therapeutic modalities for the hyperkinetic disorders, such as stimulants, antihistaminic drugs, anticonvulsants, antianxiety drugs, and antidepressants. The role of chronic lead poisoning is considered. The various hypotheses of drug action are also discussed. The "paradoxical" amphetamine effect has recently been questioned, since a "calming" effect has been observed in normal children. Shepherd and Watt review "Long-term Treatment with Neuroleptics in Psychiatry," considering the various long-acting neuroleptic drugs. Most of the interesting compounds, such as pimozide, pipotiazine, penfluridol, and flupenthixol, are unavailable in the United States. Finally, the "Psychopharmacology of Aging: Current Trends," is reviewed by Sathananthan, Ferris, and Gershon, who describe studies of hyperbaric oxygen (negative), cerebral vasodilators (questionable effect), hydergine (positive), CNS stimulants (questionable), and Gerovital H3 (questionable). This volume is highly recommended with only the following reservations: (I) the bibliography apparently stops about 1975 (a fact made unavoidable by publishing time lags), and (2) the reader would PSYCHOSOMATICS
BOOK REVIEWS have been helped immeasurably if some other method had been chosen to indicate the references. Herman C.B. Denber, M.D., Ph.D. University of Louisville
Psychiatric Emergencies Edited by Robert A. Glick. Arthur T. Meyerson. Edwin Robbins. and John A. Talbott. 300 pp. S16. New York. Grune and Stratton. 1976.
• Psychiatric emergencies occur frequently and demand the most astute handling. This volume offers approaches to the recognition, assessment, and treatment of persons in psychiatric crisis or emergency. It is written in such a practical and easily understandable manner that even though the therapist is usually referred to as the psychiatrist, it would be of equal value, perhaps more so, to non-psychiatric physicians, psychiatric residents, nurses, social workers, psychologists, and even clergymen. The text follows a practical outline, beginning with a chapter on assessment of the emergency patient, followed by chapters on the three most commonly faced and often most difficult emergency situations: acute psychotic decompensation, potential suicide, and violent aggressive behavior. The next five chapters deal with the management of the common neurotic or anxiety-based emergencies, organic brain syndromes and related medical problems, alcoholism, drug abuse, and the socially disadvantaged. Then follows a section on age-specific problems-those encountered in children, adolescents, college students, the family, and the aged. The final chapter is deAUGUST 1978 • VOL 19' NO 8
voted to the organization of emergency facilities and presents in a very concise and yet comprehensive manner the structure, staffing, financing, and back-up facilities necessary to carry out under optimum conditions the measures recommended throughout the book. The chapter on assessment presents a rather basic review of the psychiatric examination; however, the treatment of interview technique is quite helpful. Explicit instructions are given for specific interviewing problems such as acutely disturbed patients, highly verbal paranoid patients, highly competitive and intelligent patients, and seductive patients. The subject of acute psychotic states is introduced with an overview of the psychotic process, followed by general suggestions for controlling unmanageable patients. The first step covered is making sure the patient has no chance to act on his aggressive impulses, by such means as having sufficient personnel and adequate equipment available, and a previously agreed upon and practiced plan. Physical restraints are sanctioned; however, the physician is advised not to participate in the actual restraining. The second step includes suggestions for arrangement of the setting for the evaluation, particularly one affording some degree of privacy. The third step is observation. Even before conversation is possible the author recommends looking for signs of organic brain impairment, which could herald life-threatening pathology, and for a pressing need for pharmacologic tranquilization. Though medication is considered best withheld until after dangerous
organic pathology has been excluded and an adequate picture of the basic problem has been obtained, the author concedes that there are rare cases in which immediate tranquilization is required. He recommends a sedating phenothiazine as the drug of choice. There follows a discussion of the assessment and management of each of the common categories of problems that may cause patients to present with impaired impulse control: explosive personality. acute homosexual panic, catatonic excitement, paranoid reaction, schizophrenic disorganization, agitated depression, and mania. Throughout the book the authors cover each entity in an easily understandable manner, even including suggestions for conversation with patients, with specific, direct instructions, often step by step, for therapeutic intervention. Authoritative and current references are presented at the end of each chapter, and the index renders the information on any particular topic readily accessible. If one keeps in mind that this book is written from the viewpoint of hospital-based practice, it is worthwhile reading. Furthermore, it will be of great value in the office or emergency room for quick reference when emergencies occur. Fred O. Henker. III. M.D. Little Rock. Ark.
Correction The article "Hemodialysis: Sexual functioning," which appeared in Psychosomatics 19:4, 1978, was coauthored by E. Blum, M.D. The editors regret the omission.
• A brief review could hardly do justice to this excellent volume, the fourth in a series on Current Developments in Psychopharmacology. Engel and Carlsson consider the relationship of catecholamines and behavior. They present evidence for the role of dopaminergic neurons in neuroleptic drug activity indicating that this does not necessarily imply a primary biochemical defect in schizophrenia in central dopaminergic neurons-a wise observation, since many other neurotransmittors have been implicated and it may well be the balance that is upset in schizophrenia. They report the potentiating effect of alpha-methyltyrosine (a tyrosine hydroxylase inhibitor) on the action of neuroleptic drugs. This is worthy of further study. Simon gives a good discussion of "Opiate Receptors in the Central Nervous System," pointing out that opiate binding sites have a high affinity for narcotic analgesics and their antagonists. These sites are stereospecific, and there is a high order of correlation between binding affinities of various ligands and pharmacologic potency. The role of sodium is discussed, along with how this property can be used to study the actual molecular structure of the opiate receptor. Endorphins are present in all vertebrate species and do indeed seem to have some relevance to pain. Cyclic nucleotides may play some role in the mechanism of opiate action. Fiori considers a much-reviewed 500
subject, "Tricyclic Antidepressants: A review of Their Toxicity," with regard to the cardiovascular, hepatic, neurologic, psychologic, and teratogenic effects. He emphasizes that with impairment of consciousness, the presence of hypotension, and arrhythmia, tricyclic poisoning should be considered. The exact manner in which tricyclic antidepressants produce cardiotoxic effects is still unclear. While they can produce many of the neuroleptic side effects seen with neuroleptic drugs, Fiori comments particularly on the neuropathies seen with tricyclic antidepressants. There is no clear-cut evidence for teratogenic effects. This review reiterates the caution necessary in treating patients suffering from cardiovascular disease, severe hypotension, glaucoma, or urinary retention. Mendlewicz discusses "Recent Advances in Genetics and Psychopharmacology." It is clear that drug metabolism and clinical response probably result from a genetic-environmental interaction. That would be the fairest statement of fact concerning such a controversial problem. Some well-known pharmacogenetic problems are discussed, such as succinylcholine sensitivity, G6PD deficiency, and isoniazid acetylation. Phenelzine was found to be more effective in slow rather than rapid acetylators. Blasy and Herz discuss "Precipitated Morphine Withdrawal in Rats as a Tool in Opiate Research." This is seen to offer a suitable technique to study the problem and to test various hypotheses. Ho reviews "Pharmacological and Biochemical Studies with ,B-carboline analogs." This refers essentially to harmaline,
yohimbine, and similar compounds, which offer a tool to study mental disorders. One should not lose sight of the tenuous relationship that exists between these particular drug-induced states and the endogenous disorders. The "Neuropharmacology of Hyperkinesis" is reviewed by Silbergeld. He brings out some of the diagnostic problems and, of course, the wide range of therapeutic modalities for the hyperkinetic disorders, such as stimulants, antihistaminic drugs, anticonvulsants, antianxiety drugs, and antidepressants. The role of chronic lead poisoning is considered. The various hypotheses of drug action are also discussed. The "paradoxical" amphetamine effect has recently been questioned, since a "calming" effect has been observed in normal children. Shepherd and Watt review "Long-term Treatment with Neuroleptics in Psychiatry," considering the various long-acting neuroleptic drugs. Most of the interesting compounds, such as pimozide, pipotiazine, penfluridol, and flupenthixol, are unavailable in the United States. Finally, the "Psychopharmacology of Aging: Current Trends," is reviewed by Sathananthan, Ferris, and Gershon, who describe studies of hyperbaric oxygen (negative), cerebral vasodilators (questionable effect), hydergine (positive), CNS stimulants (questionable), and Gerovital H3 (questionable). This volume is highly recommended with only the following reservations: (I) the bibliography apparently stops about 1975 (a fact made unavoidable by publishing time lags), and (2) the reader would PSYCHOSOMATICS
BOOK REVIEWS have been helped immeasurably if some other method had been chosen to indicate the references. Herman C.B. Denber, M.D., Ph.D. University of Louisville
Psychiatric Emergencies Edited by Robert A. Glick. Arthur T. Meyerson. Edwin Robbins. and John A. Talbott. 300 pp. S16. New York. Grune and Stratton. 1976.
• Psychiatric emergencies occur frequently and demand the most astute handling. This volume offers approaches to the recognition, assessment, and treatment of persons in psychiatric crisis or emergency. It is written in such a practical and easily understandable manner that even though the therapist is usually referred to as the psychiatrist, it would be of equal value, perhaps more so, to non-psychiatric physicians, psychiatric residents, nurses, social workers, psychologists, and even clergymen. The text follows a practical outline, beginning with a chapter on assessment of the emergency patient, followed by chapters on the three most commonly faced and often most difficult emergency situations: acute psychotic decompensation, potential suicide, and violent aggressive behavior. The next five chapters deal with the management of the common neurotic or anxiety-based emergencies, organic brain syndromes and related medical problems, alcoholism, drug abuse, and the socially disadvantaged. Then follows a section on age-specific problems-those encountered in children, adolescents, college students, the family, and the aged. The final chapter is deAUGUST 1978 • VOL 19' NO 8
voted to the organization of emergency facilities and presents in a very concise and yet comprehensive manner the structure, staffing, financing, and back-up facilities necessary to carry out under optimum conditions the measures recommended throughout the book. The chapter on assessment presents a rather basic review of the psychiatric examination; however, the treatment of interview technique is quite helpful. Explicit instructions are given for specific interviewing problems such as acutely disturbed patients, highly verbal paranoid patients, highly competitive and intelligent patients, and seductive patients. The subject of acute psychotic states is introduced with an overview of the psychotic process, followed by general suggestions for controlling unmanageable patients. The first step covered is making sure the patient has no chance to act on his aggressive impulses, by such means as having sufficient personnel and adequate equipment available, and a previously agreed upon and practiced plan. Physical restraints are sanctioned; however, the physician is advised not to participate in the actual restraining. The second step includes suggestions for arrangement of the setting for the evaluation, particularly one affording some degree of privacy. The third step is observation. Even before conversation is possible the author recommends looking for signs of organic brain impairment, which could herald life-threatening pathology, and for a pressing need for pharmacologic tranquilization. Though medication is considered best withheld until after dangerous
organic pathology has been excluded and an adequate picture of the basic problem has been obtained, the author concedes that there are rare cases in which immediate tranquilization is required. He recommends a sedating phenothiazine as the drug of choice. There follows a discussion of the assessment and management of each of the common categories of problems that may cause patients to present with impaired impulse control: explosive personality. acute homosexual panic, catatonic excitement, paranoid reaction, schizophrenic disorganization, agitated depression, and mania. Throughout the book the authors cover each entity in an easily understandable manner, even including suggestions for conversation with patients, with specific, direct instructions, often step by step, for therapeutic intervention. Authoritative and current references are presented at the end of each chapter, and the index renders the information on any particular topic readily accessible. If one keeps in mind that this book is written from the viewpoint of hospital-based practice, it is worthwhile reading. Furthermore, it will be of great value in the office or emergency room for quick reference when emergencies occur. Fred O. Henker. III. M.D. Little Rock. Ark.
Correction The article "Hemodialysis: Sexual functioning," which appeared in Psychosomatics 19:4, 1978, was coauthored by E. Blum, M.D. The editors regret the omission.