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The Psychosomatic Approach: Contemporary Practice of Whole-Person Care
·. - - - - - - - - B o o k Reviews------------i treatment consists of an overview of second-generation antidepressants. However, even if the scope of the book is not quite as broad as its title suggests, it does contain much valuable information. Chapter I, by Rush. gives an extremely comprehensive and enlightening presentation of issues important in the diagnosis of affective disorders. Theoretical factors involved in making a diagnosis. such as variance and validity, are discussed, as are clinical issues-such as the differential diagnosis of depression from other psychiatric disorders and medical illnesses-and social factors related to diagnosis. Chapter 2, by Clayton. gives a brief but lucid presentation of what is known about the prevalence and course of affective disorders. Chapter 3, by Schlesser. outlines changes in both the hypothalamic-pituitaryadrenal and the hypothalamic-pituitary-thyroid axes with depression. The basic neuroendocrinology of these axes is reviewed and is followed by a detailed discussion of the dexamethasone suppression test and the thyrotropin-releasing-hormone stimulation test from both clinical and theoretical viewpoints. The review of the literature is balanced, and the usefulness of these two tests is put into a helpful perspective. Chapter 4, by Maas, entitled "Norepinephrine and Depression," presents the evidence for an association between the two by reviewing studies of urinary MHPG. Since the data concerning urinary MHPG are confusing, the conclusions offered by the author are necessarily conservative and tentative. Chapter 5, by Janowsky and Risch, provides a clear and extensive discussion of the adrenergic-choliner-
gic balance and its putative relationship to affective disorders. There is evidence that during depression the balance tips too strongly toward the cholinergic side, while the opposite occurs during mania. Even though the neurochemical changes associated with affective disorders are probably much more complicated, the material is well-presented and of heuristic value. Chapter 6, by Kupfer, discusses depression-associated changes in the sleep EEG, such as a shortened REM latency, which the author asserts "is always suggestive of depression," while changes in sleep continuity and REM distribution appear to reflect the severity of depression. The chapter is well-written and useful. Chapter 7. by Buchsbaum et al on brain imaging, focusses chiefly on PET studies, which have found a hypofrontality in depressed patients similar to that found in PET studies with schizophrenics. The authors are rightfully cautious about these results because of the small number of patients studied and the multiple methodologic variables inherent in using such a complicated technology. Chapter 8, by Garver and Zemlan, presents a nice review of receptor studies in depression. It discusses changes in ~-, (X2-' Qt)-adrenergic, serotonergic, and dopaminergic receptors in depression before and after treatment. Unfortunately, Chapter 9, by Crowe et al on genetic marker studies of HLA antigens and affective disorders. and Chapter 10, by Pettegrew on affective disorders at a molecular level, are very technical and probably not accessible to anyone who does not possess a special interest or knowledge in these fields. The final chapter. by Feighner. is
about second-generation antidepressants. This chapter provides an overview of the variety of newer antidepressants. most of which are not available for routine use in this country. The author's conclusion that these drugs are in general "safer." "more specific with fewer clinically significant side effects." and "have a more rapid onset of action" is probably a too sanguine view. This book deals with several aspects of depression, mostly from a neuroscience viewpoint. It is by no means a comprehensive textbook on depression. but many of the chapters are well-written and full of information that is often more interesting from a theoretical than from a clinical practice standpoint. It would be useful as an auxiliary text on depression to someone interested in the more biological and theoretical aspects of the illness. Robert E. McCue. M.D. New York University
The Psychosomatic Approach: Contemporary Practice of Whole-Person Care Edited by Margaret J Christie and Peter G. Mellen, New York, John Wiley & Sons, 1986,447 pp, $59.95.
• This is a collection of 19 chapters contributed by 31 authors, mostly British, published as a complement to a 1981 book, Foundations ofPsychosomatics. The main thrust of the book is whole-person care as practiced in such medical functions as obstetics, surgery. oncology. internal medicine, and general practice. The readership is envisaged as being in medical and paramedical fields, clinical psychology. and other health sciences. The first section is devoted to a (continued)
332
PSYCHOSOMATICS
-'''' BRIEF .UMIIARY
...EQUAIl-jdollpil HCII &lp••III/OIiI COle.llIIl. IMlutlllI, SINEOUAN is recommended lor the treatment 01: 1. Psychoneurotic patients with depressIon and/or anXIety. 2. D,presslon and/or anXIety associated wrth alcOholism (not to be taken concomitantly with alcohol). 3. Depression andlor anxiety associated with orgamc disease (the POSSlblirty of drug Interaction
should b' conslder,d II til, pall,nt IS receiving other drugs concomrtantly) 4. PsyChotiC depressive disorders with associated anxiety Including manlc-depreSSlv, disorders
Inyohrt~onal
depression and
Th'targ,t symptoms 01 psyChOneurOSIs tIlat respond particularly well to SINEOUAN mclud' anXIety, tensIon, d,presslon, somatic symptoms and concerns, Sltlp disturbances, gUilt, lack olenergy, 'ear, appr,h,nslon and worry. Cllnlcalexpellenc, has shown that SINEOUAN IS sat, and well tolerated ..,n In the elderly patl,nt Owing to lack 01 cllnlcalexpell,nce In th' pedlatllc population, SINEOUAN IS not recomm,ndedlor use 10 Children under 12 years 0' ag, e-11.1cIltI1I, SINEOUAN is contraindicated In IndIViduals who have shown hypersenSitivity to the drug. POSSibility of cross sensitIvity with other dibenzox.pines should be kept In mind SINEOUAN IS contramdlcated 10 pati,nts wrth glaucoma or a t,ndency to ullnary ret,ntlon. These disorders ShOuld be ruled out, particularly In Older pati,nts. ....I..., Th' once-a-day dosag, reglm,n 0' SINEOUAN 10 pat"nts with Intercurr,nt Illness or pat"nts taking other medicatIons should be carefully adlusted. ThiS IS especially Important In patients receiving other medications with anticholinergiC effects. U.." ItI S,,,,,,,": Th' use 01 SINEOUAN on a onc,·a·day dosag, reglm,n In g,IIallic pat"nts should be ad,usted carelully based on th' patl,nt's condItIon. t/Cf: Reproduction stud"s hav, btln p'l1ormed 10 rats, rabbits, monkeys and dogs and there was no evidence of harm to the animal f.tus. The r,levance to humans IS nOf known. Since there IS no exp,",nc, 10 pregnant women who have rec"v'd thiS drug, salety in pregnancy has not betn established. There are no data with respect to th' secrebOn 0' the drug 10 human milk and Its ,"ect on
U""" ""..
the nursing mfant
U.."I. CIIII...: The use 0' SINEOUAN In ChIldren under 12 years 01 age IS not recomm,nded because sate condrtlons lor Its use hav, not been established. 11M) IlIIIItbn: Slnous Side ,"lets and ..,n dealh have been reported lollowong the concomitant use ot c,rtaln drugs WltIl MAO Inhibitors. Theretore, MAO mhlbrtors should be dlsconboutelat least two _ks proor to th, caullOus onlt,atlon 01 therapy with SINEOUAN Th' ,xact I,ngth 0' bm, may vary and IS d,pend,nt upon til, particular MAO mhlbltor b"ng used, tIl"ength 01 time It has been administered, and tile dosag, mvolved u..,. wI. AIeeI/oI: II should be borne on mind that alCOhOl Ingeshon may inClease til, danger Inherent In any Intentional or untntentlonal SINEOUAN overdosage. ThIS IS especially Important In pah,nts whO may use alcohol excesslv,ly
"'."""a.
Since drowsiness may occur With the use of this drug. patients should be Wlrned ot the possibility and cautioned against drlYing acar or operating dangerous maChinery while taking the drug
Patllnts Should also b' cautioned that theU response to alcohol may be potentiated.
Since SUICide IS an Inherent fisk In any depressed patient and may remain so until Significant Improvement has occurred. patients should be closety supervised dUfing the early courSl of therapy.
Prescroptlons should b' wlltten lor th' smallest feaslbl' amount. Should oncleased symptoms 01 psychosIS or shift to manIc symptomatology occur, It may b' necessary to reduc, dosag, or add a malor tranqUIlizer to th' dosag, regImen. Aneru Rt.etI..l, lion: SOlo' 0' th' adverse rtaeltons noted below have not been spec~ically reported wrth SINEOUAN use. However, due to tile ClOSe pharmacologocal simltarrtles among the tliCYCllcs, the reactions ShOuld be conSidered wh,n presenblng SINEOUAN AntiClIolinetgic Elltets: Dry moutll, blurred VISion, consbpallon, and ullnary retentIon hav, betn report'd. 11 they do not subSide WltIl continued therapy, or becom, sever', It may be necessary to reduce the dosag, CentralNervous System Elltets: DrOWSiness IS th' most commonly notIced sid' ,"let. Th,s t,nds to disappear as therapy IS continued. Other mtrequ,ntly reported CNS Side ,"lets are con'uslon, disoll,n· tallOn, hallUCinations, numbness, paresthesias, atula, and extrapyramidal symptoms and seizures. Ca,diOvasculat: Cardiovascular ,"ects Including hypot,nslon and tachycardia hav, been reported occasionally
A1letgiC.· SkI" rash, edema, photosens,tlzahon, and prutitus have occaSionally occurred. HtrNtolog/c: Eosonophlila has btln reported ,n alew patllOtS. Ther' have been occaSIonal reports of bone marrow depression manlfestmg as agranulocytosIs. leukOp.n... thrombocytopenia. and purpura. Glstrointtstrn,': Nausea. YOmlttng, Indigestion. taste disturbances. diarrhea. anorex... and aphtIlous stomatrtls hav, btln reported. (Set anticholinergiC ,lIIets.) Endocfine: RaIsed or lowered libIdo, testicular swelling, gynecomastll ,n males, ,nlargement 0' brusts and galactorrhea
In
the t,mll'. raiSing or
lower~no of
blOOd su"r teveiS. and syndrome of
Inappropriate antIdiuretIc hormon, hav, betn reported wrth trocycllc admin,strat,on. Otlltl: DlUiness, tlnMus, weight gain, s_llng, chills, latlgu" _kness, "ushlng, jiundoce, alopecia. and headaChe have been occasionally observed IS adverse effects.
Witlldra..' Symptoms: Th' poSSibility 0' development 01 wrthdrawal symptoms upon abrupt cassa· tlon 0' treatm,nt after prolonged SINEOUAN (doxepm HCI) admlntstratlon should b' borne in mond. These are not Indicatlye of addIction and gradual Withdrawal of m.chcatlon should not cause these
symptoms.
Doll.....AlI.IIIIlnfI... For most pat"nts With Illness 01 mIld to moderate severity, astarling daily dOse 01 75 109,s recomm'nd'd. Oosag, may subsequently be Increased 01 decreased at appropnate InteMlsand according to IndIVidual response. The usual opIlmumdose range IS 75 mg/daytol50 mg/day. In more severely ,II pahents h,gher doses may be required with subsequenl gradual Increase to
300 mg/day If necessary. Additional tIlerapeubc '"let IS rarely to be obta,ned by ex_lng a dose of 300 mg/day. In patl'nts With very mild symplomatology or ,mobOnal symptoms accompanying organtc disease, 1000r doses may suffice. Some olth'se pablnts have betn controlled on doses as lOW as 25·50 mg/day. Th'tolal dally dosage 01 SINEOUAN may b' glVtn on adIVIded or once·a·day dosage sChedul'. 11 the once·a·day schtdult IS ,mployed th, mUlmum recommended dose IS 150 mg/day. ThIS dose may be glV,n at bedtime. TIlt 151 . . ca,..l It .............I...._tIII.." ..1y ... It l1li ..._ ..... lor 11111.11...In . Antl·an..,ty '"let is apparent before th, anlld,pressant ,"let. OptImal antld,pressant tIIIct may not be ,vld,nt 'or two to thre, _ks.
0wrNutt,
A. Signs and Symptoms
.
t, Mild: Drowsiness. stupor. blurred YISlon. excess"" dryness of mouth.
2. Severe: Respuatory dlpresslon, hypotenSion, coma. convulSIOns, cardiac arrhythmlls and tachycardias. Also: urinary re"ntlon (bladd,r atony), decreased gastrointestinal motlloty (paralytIc II",s), hyper· tIltrmll (or hypotlltrmla), hypertenSIon, dIlated pUPils, hyperlCllve rlffexes. 8. Manag,ment and Treatm,nt 1. Mild: Obse",atlon and SUpportive therapy IS all Ihat IS usually necessary. 2. Severe: MedIcal managem,nt 01 severe SINEOUAN overdosag, conSISts 01 aggressIve supporhv, tIlerapy. II Ih' pat"nt IS conSCIOUS, gastliC lavege, Wltll appropnate precautions to prevent pulmonary aspuation. should be pel10rrned ..,n tIlough SINEOUAN IS rapIdly absorbed. Th' use 01 actIvated charcoal has been recomm,nded, as has betn conllnuous gastric lavage w,tIl saline for 24 hours or more. An adequat, airway should be establish'd in comatose pati,nts and assisted ventilation used II necessary. EKG mOOlloling may b' requued 'or several days, slnca relapse after apparent recov,ry has betn reported. Arrhythmias should b'treated wrth tilt appropriate antIarrhythmic ag,nt. It has btln reported that many 01 til, cardIovascular and CNS symptoms 01 tllcyclic antid,pressant poIsoning In adults may be reversed by tilt slow Intrav,nous admmistration 0' 1 mg to 3 lOgo' physostIgmIne salicylate. Because physost'gmln"s rapidly m,taboloZecl, tilt dosag, should be repeated as requlled. ConvulSIons may respond to standard antIconvulsant tIlerapy, _ r , barbiturates may pot,nbat, any respllatory degresslon. DIalysiS and forced dIuresIS g.n,rally are not 01 vllu, In th' man.gement of overdosag, du, to high bSSU' and prole," binding 01 SINEOUAN.
ROeRIG_
........n.. ,..........II.......... mn...... "'_,
A d,VISIQn of Pl,zer Pharmaceuticals New York. New York 10017
EBOOk ReViewsj treatment of the tenn "psychosomatic" and the underlying concept and presents arguments for and against its appropriateness. The editors endorse the tenn to the extent of its use in the title. There follows a section on the beginnings of life, with chapters on care in labor, genetic counseling, and pediatric hospitalization. The next fascinating section covers obesity and abnonnal eating behavior. Cardiovascular disorders are dealt with through chapters on hypertension and alteration of type A behavior. Next come sections dealing with pain and anxiety and community medicine. The final section contains chapters on the whole-person approach to surgery, psychosomatic aspects of cancer, and philosophy oftenninal care. Each topic is presented comprehensively, covering both the physical (somatic) and personal (psychic) aspects. Rather than stating the author's own viewpoint, the chapters summarize well-documented developments and research, affording the reader sufficient foundation to fonnulate his or her own approach. Generally the background and foundation data are thorough, while actual treatment coverage is rather general. For detailed treatment procedures one will probably have to resort to the ample references at the end of each chapter. The authors have done an excellent job of bringing out the contemporary status of the intimate interaction of psychic and somatic factors in all disorders and the need for thorough attention to both components in the delivery of conscientious health care. It is well worth serious study by every physician, whether student or veteran. FredO. Henker. M.D. University ofArkansas
PSYCHOSOMATICS
gic balance and its putative relationship to affective disorders. There is evidence that during depression the balance tips too strongly toward the cholinergic side, while the opposite occurs during mania. Even though the neurochemical changes associated with affective disorders are probably much more complicated, the material is well-presented and of heuristic value. Chapter 6, by Kupfer, discusses depression-associated changes in the sleep EEG, such as a shortened REM latency, which the author asserts "is always suggestive of depression," while changes in sleep continuity and REM distribution appear to reflect the severity of depression. The chapter is well-written and useful. Chapter 7. by Buchsbaum et al on brain imaging, focusses chiefly on PET studies, which have found a hypofrontality in depressed patients similar to that found in PET studies with schizophrenics. The authors are rightfully cautious about these results because of the small number of patients studied and the multiple methodologic variables inherent in using such a complicated technology. Chapter 8, by Garver and Zemlan, presents a nice review of receptor studies in depression. It discusses changes in ~-, (X2-' Qt)-adrenergic, serotonergic, and dopaminergic receptors in depression before and after treatment. Unfortunately, Chapter 9, by Crowe et al on genetic marker studies of HLA antigens and affective disorders. and Chapter 10, by Pettegrew on affective disorders at a molecular level, are very technical and probably not accessible to anyone who does not possess a special interest or knowledge in these fields. The final chapter. by Feighner. is
about second-generation antidepressants. This chapter provides an overview of the variety of newer antidepressants. most of which are not available for routine use in this country. The author's conclusion that these drugs are in general "safer." "more specific with fewer clinically significant side effects." and "have a more rapid onset of action" is probably a too sanguine view. This book deals with several aspects of depression, mostly from a neuroscience viewpoint. It is by no means a comprehensive textbook on depression. but many of the chapters are well-written and full of information that is often more interesting from a theoretical than from a clinical practice standpoint. It would be useful as an auxiliary text on depression to someone interested in the more biological and theoretical aspects of the illness. Robert E. McCue. M.D. New York University
The Psychosomatic Approach: Contemporary Practice of Whole-Person Care Edited by Margaret J Christie and Peter G. Mellen, New York, John Wiley & Sons, 1986,447 pp, $59.95.
• This is a collection of 19 chapters contributed by 31 authors, mostly British, published as a complement to a 1981 book, Foundations ofPsychosomatics. The main thrust of the book is whole-person care as practiced in such medical functions as obstetics, surgery. oncology. internal medicine, and general practice. The readership is envisaged as being in medical and paramedical fields, clinical psychology. and other health sciences. The first section is devoted to a (continued)
332
PSYCHOSOMATICS
-'''' BRIEF .UMIIARY
...EQUAIl-jdollpil HCII &lp••III/OIiI COle.llIIl. IMlutlllI, SINEOUAN is recommended lor the treatment 01: 1. Psychoneurotic patients with depressIon and/or anXIety. 2. D,presslon and/or anXIety associated wrth alcOholism (not to be taken concomitantly with alcohol). 3. Depression andlor anxiety associated with orgamc disease (the POSSlblirty of drug Interaction
should b' conslder,d II til, pall,nt IS receiving other drugs concomrtantly) 4. PsyChotiC depressive disorders with associated anxiety Including manlc-depreSSlv, disorders
Inyohrt~onal
depression and
Th'targ,t symptoms 01 psyChOneurOSIs tIlat respond particularly well to SINEOUAN mclud' anXIety, tensIon, d,presslon, somatic symptoms and concerns, Sltlp disturbances, gUilt, lack olenergy, 'ear, appr,h,nslon and worry. Cllnlcalexpellenc, has shown that SINEOUAN IS sat, and well tolerated ..,n In the elderly patl,nt Owing to lack 01 cllnlcalexpell,nce In th' pedlatllc population, SINEOUAN IS not recomm,ndedlor use 10 Children under 12 years 0' ag, e-11.1cIltI1I, SINEOUAN is contraindicated In IndIViduals who have shown hypersenSitivity to the drug. POSSibility of cross sensitIvity with other dibenzox.pines should be kept In mind SINEOUAN IS contramdlcated 10 pati,nts wrth glaucoma or a t,ndency to ullnary ret,ntlon. These disorders ShOuld be ruled out, particularly In Older pati,nts. ....I..., Th' once-a-day dosag, reglm,n 0' SINEOUAN 10 pat"nts with Intercurr,nt Illness or pat"nts taking other medicatIons should be carefully adlusted. ThiS IS especially Important In patients receiving other medications with anticholinergiC effects. U.." ItI S,,,,,,,": Th' use 01 SINEOUAN on a onc,·a·day dosag, reglm,n In g,IIallic pat"nts should be ad,usted carelully based on th' patl,nt's condItIon. t/Cf: Reproduction stud"s hav, btln p'l1ormed 10 rats, rabbits, monkeys and dogs and there was no evidence of harm to the animal f.tus. The r,levance to humans IS nOf known. Since there IS no exp,",nc, 10 pregnant women who have rec"v'd thiS drug, salety in pregnancy has not betn established. There are no data with respect to th' secrebOn 0' the drug 10 human milk and Its ,"ect on
U""" ""..
the nursing mfant
U.."I. CIIII...: The use 0' SINEOUAN In ChIldren under 12 years 01 age IS not recomm,nded because sate condrtlons lor Its use hav, not been established. 11M) IlIIIItbn: Slnous Side ,"lets and ..,n dealh have been reported lollowong the concomitant use ot c,rtaln drugs WltIl MAO Inhibitors. Theretore, MAO mhlbrtors should be dlsconboutelat least two _ks proor to th, caullOus onlt,atlon 01 therapy with SINEOUAN Th' ,xact I,ngth 0' bm, may vary and IS d,pend,nt upon til, particular MAO mhlbltor b"ng used, tIl"ength 01 time It has been administered, and tile dosag, mvolved u..,. wI. AIeeI/oI: II should be borne on mind that alCOhOl Ingeshon may inClease til, danger Inherent In any Intentional or untntentlonal SINEOUAN overdosage. ThIS IS especially Important In pah,nts whO may use alcohol excesslv,ly
"'."""a.
Since drowsiness may occur With the use of this drug. patients should be Wlrned ot the possibility and cautioned against drlYing acar or operating dangerous maChinery while taking the drug
Patllnts Should also b' cautioned that theU response to alcohol may be potentiated.
Since SUICide IS an Inherent fisk In any depressed patient and may remain so until Significant Improvement has occurred. patients should be closety supervised dUfing the early courSl of therapy.
Prescroptlons should b' wlltten lor th' smallest feaslbl' amount. Should oncleased symptoms 01 psychosIS or shift to manIc symptomatology occur, It may b' necessary to reduc, dosag, or add a malor tranqUIlizer to th' dosag, regImen. Aneru Rt.etI..l, lion: SOlo' 0' th' adverse rtaeltons noted below have not been spec~ically reported wrth SINEOUAN use. However, due to tile ClOSe pharmacologocal simltarrtles among the tliCYCllcs, the reactions ShOuld be conSidered wh,n presenblng SINEOUAN AntiClIolinetgic Elltets: Dry moutll, blurred VISion, consbpallon, and ullnary retentIon hav, betn report'd. 11 they do not subSide WltIl continued therapy, or becom, sever', It may be necessary to reduce the dosag, CentralNervous System Elltets: DrOWSiness IS th' most commonly notIced sid' ,"let. Th,s t,nds to disappear as therapy IS continued. Other mtrequ,ntly reported CNS Side ,"lets are con'uslon, disoll,n· tallOn, hallUCinations, numbness, paresthesias, atula, and extrapyramidal symptoms and seizures. Ca,diOvasculat: Cardiovascular ,"ects Including hypot,nslon and tachycardia hav, been reported occasionally
A1letgiC.· SkI" rash, edema, photosens,tlzahon, and prutitus have occaSionally occurred. HtrNtolog/c: Eosonophlila has btln reported ,n alew patllOtS. Ther' have been occaSIonal reports of bone marrow depression manlfestmg as agranulocytosIs. leukOp.n... thrombocytopenia. and purpura. Glstrointtstrn,': Nausea. YOmlttng, Indigestion. taste disturbances. diarrhea. anorex... and aphtIlous stomatrtls hav, btln reported. (Set anticholinergiC ,lIIets.) Endocfine: RaIsed or lowered libIdo, testicular swelling, gynecomastll ,n males, ,nlargement 0' brusts and galactorrhea
In
the t,mll'. raiSing or
lower~no of
blOOd su"r teveiS. and syndrome of
Inappropriate antIdiuretIc hormon, hav, betn reported wrth trocycllc admin,strat,on. Otlltl: DlUiness, tlnMus, weight gain, s_llng, chills, latlgu" _kness, "ushlng, jiundoce, alopecia. and headaChe have been occasionally observed IS adverse effects.
Witlldra..' Symptoms: Th' poSSibility 0' development 01 wrthdrawal symptoms upon abrupt cassa· tlon 0' treatm,nt after prolonged SINEOUAN (doxepm HCI) admlntstratlon should b' borne in mond. These are not Indicatlye of addIction and gradual Withdrawal of m.chcatlon should not cause these
symptoms.
Doll.....AlI.IIIIlnfI... For most pat"nts With Illness 01 mIld to moderate severity, astarling daily dOse 01 75 109,s recomm'nd'd. Oosag, may subsequently be Increased 01 decreased at appropnate InteMlsand according to IndIVidual response. The usual opIlmumdose range IS 75 mg/daytol50 mg/day. In more severely ,II pahents h,gher doses may be required with subsequenl gradual Increase to
300 mg/day If necessary. Additional tIlerapeubc '"let IS rarely to be obta,ned by ex_lng a dose of 300 mg/day. In patl'nts With very mild symplomatology or ,mobOnal symptoms accompanying organtc disease, 1000r doses may suffice. Some olth'se pablnts have betn controlled on doses as lOW as 25·50 mg/day. Th'tolal dally dosage 01 SINEOUAN may b' glVtn on adIVIded or once·a·day dosage sChedul'. 11 the once·a·day schtdult IS ,mployed th, mUlmum recommended dose IS 150 mg/day. ThIS dose may be glV,n at bedtime. TIlt 151 . . ca,..l It .............I...._tIII.." ..1y ... It l1li ..._ ..... lor 11111.11...In . Antl·an..,ty '"let is apparent before th, anlld,pressant ,"let. OptImal antld,pressant tIIIct may not be ,vld,nt 'or two to thre, _ks.
0wrNutt,
A. Signs and Symptoms
.
t, Mild: Drowsiness. stupor. blurred YISlon. excess"" dryness of mouth.
2. Severe: Respuatory dlpresslon, hypotenSion, coma. convulSIOns, cardiac arrhythmlls and tachycardias. Also: urinary re"ntlon (bladd,r atony), decreased gastrointestinal motlloty (paralytIc II",s), hyper· tIltrmll (or hypotlltrmla), hypertenSIon, dIlated pUPils, hyperlCllve rlffexes. 8. Manag,ment and Treatm,nt 1. Mild: Obse",atlon and SUpportive therapy IS all Ihat IS usually necessary. 2. Severe: MedIcal managem,nt 01 severe SINEOUAN overdosag, conSISts 01 aggressIve supporhv, tIlerapy. II Ih' pat"nt IS conSCIOUS, gastliC lavege, Wltll appropnate precautions to prevent pulmonary aspuation. should be pel10rrned ..,n tIlough SINEOUAN IS rapIdly absorbed. Th' use 01 actIvated charcoal has been recomm,nded, as has betn conllnuous gastric lavage w,tIl saline for 24 hours or more. An adequat, airway should be establish'd in comatose pati,nts and assisted ventilation used II necessary. EKG mOOlloling may b' requued 'or several days, slnca relapse after apparent recov,ry has betn reported. Arrhythmias should b'treated wrth tilt appropriate antIarrhythmic ag,nt. It has btln reported that many 01 til, cardIovascular and CNS symptoms 01 tllcyclic antid,pressant poIsoning In adults may be reversed by tilt slow Intrav,nous admmistration 0' 1 mg to 3 lOgo' physostIgmIne salicylate. Because physost'gmln"s rapidly m,taboloZecl, tilt dosag, should be repeated as requlled. ConvulSIons may respond to standard antIconvulsant tIlerapy, _ r , barbiturates may pot,nbat, any respllatory degresslon. DIalysiS and forced dIuresIS g.n,rally are not 01 vllu, In th' man.gement of overdosag, du, to high bSSU' and prole," binding 01 SINEOUAN.
ROeRIG_
........n.. ,..........II.......... mn...... "'_,
A d,VISIQn of Pl,zer Pharmaceuticals New York. New York 10017
EBOOk ReViewsj treatment of the tenn "psychosomatic" and the underlying concept and presents arguments for and against its appropriateness. The editors endorse the tenn to the extent of its use in the title. There follows a section on the beginnings of life, with chapters on care in labor, genetic counseling, and pediatric hospitalization. The next fascinating section covers obesity and abnonnal eating behavior. Cardiovascular disorders are dealt with through chapters on hypertension and alteration of type A behavior. Next come sections dealing with pain and anxiety and community medicine. The final section contains chapters on the whole-person approach to surgery, psychosomatic aspects of cancer, and philosophy oftenninal care. Each topic is presented comprehensively, covering both the physical (somatic) and personal (psychic) aspects. Rather than stating the author's own viewpoint, the chapters summarize well-documented developments and research, affording the reader sufficient foundation to fonnulate his or her own approach. Generally the background and foundation data are thorough, while actual treatment coverage is rather general. For detailed treatment procedures one will probably have to resort to the ample references at the end of each chapter. The authors have done an excellent job of bringing out the contemporary status of the intimate interaction of psychic and somatic factors in all disorders and the need for thorough attention to both components in the delivery of conscientious health care. It is well worth serious study by every physician, whether student or veteran. FredO. Henker. M.D. University ofArkansas
PSYCHOSOMATICS