ABSTRACTS

Features of patientswith psychogenicabdominal painOrossman OA: Patients with psychogenicabdominal pain: Six years' observation inthe medical setting. Am J Psychiatry139: 1549-1557, 1982.

• This article, written by a psycho­somatically-trained gastroenterolo­gist, examines the clinical course of24 patients with psychogenic ab­dominal pain who were followed bynonpsychiatric physicians for up tosix years. The author used criteriacompatible with those for psycho­genic pain disorder in DSM-III toestablish the diagnosis at the be­ginning of the study period. Fur­ther information about the clinicalcourse was obtained by various ap­propriate means. Twenty womenand four men with a mean age of33.9 years at the time of initialexamination had experienced painfor a mean of 4.6 years (range sixmonths to 22 years) by the time ofadmission to the study. Sixty-sevenpercent reported antecedent eventsexperienced as losses, and they dis­played evidence of incompletegrieving. A large number of thewomen reported events relating tochildbearing or its disruption, andhalf of them had pregnancy fanta­sies. The symptoms of eight pa­tients related to the death or deathanniversary of a close familymember. Seven women and oneman had histrionic personality fea­tures. All four men and two womenhad pain-prone personality fea­tures. Depressive features were ini­tially observed in four women, andhypochondriasis in two women andone man. No one was diagnosed ashaving schizophrenia or organic

APRIL 1983 • VOL 24 • NO 4

brain syndrome. It is notable thatabout 40% of the patients had nopsychiatric diagnosis besides thatof psychogenic pain disorder. Nopatient accepted psychiatric care,although four eventually requiredpsychiatric hospitalization. Twomanifested diagnosed medical dis­orders that were thought to con­tribute to their symptomatology,although the degree of dysfunctionwas not appropriate to the physicalfindings. One of these patientseventually died of a carcinoma. Inonly one patient did the pain re­solve, but psychosocial functioningimproved in 12 (50%). The physi­cians' attitudes toward the patientsare reviewed in detail by the authorand in general reflect lack of satis­faction in the care of these personsby nonpsychiatric physicians. Theauthor concludes that these pa­tients require a type of psychologi­cal care by nonpsychiatric physi­cians but will reject overtly psycho­logically oriented approaches. Thisarticle reminds the practitioner thatsatisfaction derived from the careof such patients will require thatthe physician set realistic goals intreatment, such as improvement inthe level of psychosocial function­ing despite persistent pain, ratherthan resolution of the pain.

Jarrell W. Richardson III, M.D.Mayo Clinic

Diabetic impotence:Clinical featuresFairburn CG, Wu FCW, McCulloch OK, etal: The clinical features of diabetic impo­tence: A preliminary study. Br J Psychiatry140:447-452. 1982.

• The results of an intensive physi­cal and psychological evaluation of

27 diabetic men with erectile impo­tence are presented. Testing in­cluded a full medical history andphysical examination, autonomicfunction tests, and a psychosexualassessment conducted by a psychi­atrist using a semistructured inter­view. Almost half of the diabeticmen complaining of impotencewho were invited to participate inthe study declined. The findings ofthis study differed from the classicpicture of diabetic impotence inseveral ways: Over half of the sub­jects continued to experiencemorning erections, and almost onethird had normal spontaneouserections. Erectile failure was notalways the first symptom of sexualdysfunction in these patients. Otherpresenting problems included pre­mature ejaculation, ejaculatorydisturbance, and development ofnumerous erections in the absenceof sexual stimulation. Ejaculatorydisturbance was present in almosthalf of the patients. The most com­mon complaint here was the ab­sence of the pumping sensationthat normally accompanies ejacu­lation. Three patients had absentejaculation and one had retrogradeejaculation. In almost half the pa­tients, there was a decline in sexualinterest. This occurred after the de­velopment of the sexual dysfunc­tion and seemed to be reactive ei­ther to the problem itself or to theadverse response of the spouse.Only a minority of the patientswere able to achieve an adjustmentto the sexual problem. There wasno correlation between the sexualproblems and the presence or ab­sence of other diabetic complica­tions. such as retinopathy and car­diovascular automonic function

(continued)

417

Capsules manufactured by R P Scherer-North Ameflca St PeterSburg. Flortda 33702lor

~.~~~mfV1GCAPSULES

fA/IMNTADNE I-CJIBRIEF SUMMARY OF PRESCRIBING INFORMATION

INDICATIONS. Parkinsons Disease/Syndrome and Drug·lnduced E,rrapyram'daf Reac·t,ons SYMMETREL IS IMlcaled In the treatment ol,d,opalh,c Parklnson's disease (Paral.YSls Agitans). postencephalitic parkinsonism, drug-Induced exttapyramldal reactions. andsymptomatic parkInsonism whICh may follow Injury to the nervous system by carbon monoOXide InlO)(lcatlon It 1$ IndiCated In those elderly patients believed to develop parkinsonismIn assoClallon wllh cerebral arteriosclerOSIS, In the treatment 01 Parkinson s diseaseSYMMETREL IS less effective \han levodopa 1·}·3·13 4·dlhydro,yphenyl)·L·alan,ne and'tsefficacy In companson WItt"! the antiChOlinergic anti parkinson drugs has not yet been estab­liShed AlthOugh ant,ChOllnerglC type s'de effects have been nOled wllh SYMMETREL whenused In patients with drug-Induced extrapyramidal reactions {here 1$ a lower InCidence 01these SIde effects tt'lan thai Observed With antIcholinergic antlparklnson drugsCONTRAINDlCATlONS. SYMMETREL IS con\lalndlcated In pat,ents w,th known hypersen·S,IIVlty to the drugWARNINGS. Pallenls w,'h a hlSlory 01 epilepsy or othersellures ShOUld be ObservedClosely for POSSible Increased se,zure activity

Pat.enlS With a hlSlory Of congestive heart fat lure or peripheral edema Should be fOllowedclosely as there are pallenlS who developed congestive heart failure WhIle receIvingSYMMETREL

Pat,ents With Parkinson s dIsease tmprQ\llng on SYMMETREL should resume normalaCllvllles gradually and cautiously consISlent WIth other medIcal conSiderations SuCh asthe presence 01 osteoporosIs or phlebOthrombosts

PallenlS receiving SYMMETREL who note central nervouS system effects or blurrIng 01VISion should be cautioned agalnsl driVing or working In SituatIons where alertness ISImportantPRECAUTIONS. SYMMETREL (amantadine hydrOChlOride) should nol be d,scont,nuedabrup[ly Since a few patients With Parkinson s disease experienced a parkinsonIan crISISI e a sudden marked clinIcal deteriorallon when th.s medicalIon ..... as suddenly SloppedThe dose of anllChOlinerglc drugs or 01 SYMMETREL ShOuld be reduced If alroplne·hkeeffecls appear when these drugs are used concurrently

The dose 01 SYMMETREL may need carelul adJustment1n patlenrs WIth renal Impair­ment congestIve heart lallure peripheral edema or orthosta[lc hYPolenSlon SinceSYMMETREL IS not metaOOllzed and IS mainly exCreted In the Uflne It may accumulatewhen renal tunclion IS InadeQuafe

Care Should be exerCIsed when administering SYMMETREL to patients ..... Ith liver diS­ease a history Of reCurrent eczematOld rastl or to pallents WIth psycnosls or severe psy·ct'loneurOSIS nOf controlled by Chemotherapeutic agenlS Careful ObServation IS reqUiredwhen SYMMETREL IS administered concurrently With central nervous system sllOlulanlS

No long-term stUdIes In animals have been performed 10 evaluate the carCinogeniCpotentJal of SYMMETREL The mutagenIc potenhal 01 the drug nas nOt yel been determinedIn experimental systems

Pregnency Cetegory C: SYMMETREL lamantad,ne hydrOChlOride} has oeen shOwn tobe emOryOloxlc and teratogeniC In rals at 50 mg/kg/day aDoul12 times the recommendedhuman dose but not at 37 mg/kg/day EmbryotoxlC and TeraTOgeniC drug effects were- notseen In rabbIts WhiCh receIved up 10 25ltmes the recommended human dose There are noadequate ana well·contrOlled studies In pregnanr .....ornen

SYMMETREL shOuld be used during pregnancy only II me pOlenllal beneflf Justifies thepotentIal risk 10 Ihe embryo or the fetus

Nursing Mothers: SYMMETREL IS excreted In numan milk Cdutlon shOula oe exerCisedwhen SYMMETREL IS admIn,stered to a nurSing .....oman

Peelletnc Use: The safely and efficacy 01 SYMMETREL In newborn Infants and ,nfanlSbelow the age of 1year have not been establishedADVERSE REACnONS. The most freQuenlly occurrrng serious advelse reactions aredepreSSIon congestIve near! failure orthoslallC hypotensIve epISOdes. psyChOSIS and uri­nary retention Rarely conVUlSIons, leukopenia and neuiropenla have been reponed

Other adverse reacllons 01 a less seriOus nalure WhiCh have been observed are lhe fOI.lOWIng hallUCinat,ons confUSion anxiety and IrritabIlity anoreXIa nausea and constlpa·han ataxIa and diZZIness (lightheadedness), hvedo reflcularJ$ and peripheral edemaAdverse reacttons observed less IreQuenlly are the fOllOWing vomIting dry mouth head­aChe, dyspnea. fallgue InsomnIa and a sense of weakness Infrequently skIn raSh slurredSpeeCh and v.sual dIsturbances have been observed Rarely eczematold dermatllts andOCulogyrIC episodes have been reportedDOSAGE AND ADMINISTRATION. Adult Douge 'or Perklnsonism: The usual dose ofSYMMETREL (amantadine hydrochlOfidel tS 100 mg [wlce a day wtlen used aloneSYMMETREL has an onsel 01 actton usually Within 48 hours

The Inlllal dose 01 SYMMETREL IS tOO mg dally for patrents Wlltl sertous assOCiated medi­ca' Illnesses or who are receiving high doses of other anhparklnson drug£ Aller one to sev­eral weeks al tOO mg once dally the dose may be Increased to tOO mg tWice dally Ifnecessary

OccaSionally patients whose responses are nor optimal With SYMME TREL af 200 mgdally may benellt from an Increase up to 400 mg dally In dIVided doses However suChpallents should be superVised ClOsely by the.r phySICIans

Patients Inl[lally denvlI)g oenellt Irom SYMMETREL nOI uncommonly expertence a lall-oftof elfecllveness after a few months Benelll may be regaIned by ,ncreasing the dose to300 mg dally Alternallvely lemporary discontInuatIon 01 SYMMETREL for several weeksfOllowed by relnillahon of the drug may result In regalr'llng benefit In some pallents A deCI­SIon to use other anllparklnson drugs may be necessary

Dosage'or Concomltllnt Therepy: Some patients who do not respond to antlchollner­OJc anllparklnson drugs may respond 10 SYMMETREL When SYMMETREL or anllcholJner·glc antlparklnson drugs are each used wllh marglf1al benefit. concomllant use mayproduce addillonal benefll

When SYMMETREL and levodopa are Inlllated concurrently. Ihe pallent can exhibit rapidtherapeultC benef,ls SYMMETREL should be held cons fa'll all00 mg dally or tWIce dallywhile the dally dose of levodopa IS gradually Incedsed to opllmal beneht

When SYMMETREL IS added 10 optImal well-tolerated doses ollevodopa. addlltOnafbenefl: may resull. InCluding smoolhlng oullhe Iluctuations In Improvement WhiCh some­times occur In patients on levodooa alone PatlenlS who require a reduchon In Ihea usualdose ollevodopa because 01 development of SIde effects may pOSSibly regaIn lost benetltw,th Ihe addl\'on of SYMMETREL

Dosege 'or Drug-Induced Eltrepyremldel Reactions: Adull The usual dose 01SYMMETREL (amanlad,ne hydrochloflde) IS 100 mg tw,ce a day OccaSionally pallenlSwhOse responses are not opt,mal With SYMMETREL al200 mg dally may benelr[ Irom an,ncrease up to 300 mg dally In diVided doses 6043.tOBSP

Du Pont Phannaceuticals8Iochemlcela Depertment£.1..... Pont de l'Iemours r. Co. (Inc.)WIlmington, DeIe...e 19898

<[[~Bl>....... _._0'.

ABSTRACTS

abnormalities. There were, howev­er, preexisting physical or psycho­logical problems in many of thepatients. These included maritaldisharmony, previous sexual diffi­culties, heavy drinking, and coro­nary heart disease. The authorsconclude that diabetic impotence isa complicated problem requiringcareful assessment of its sexual,physical, and psychiatric compo­nents.

Francis P. LeBuffe, M.D.Georgetowtl University

Cortisol and mental functionCarpenter WT, Gruen PH: Cortisol's effectson human mental functioning. J C/in Psy'chopharmacoI2:91.IOl, 1982.

• Cortisol, an essential hormone,has numerous metabolic functionsand it exerts widespread influenceson metabolic processes. This articlefocuses on its brain effects. Theauthors state that a neuroendocrinesystem's playing such a centralmetabolic role in adaptation will bean important component in thebiochemical substrate of behavior.Cortisol influences waking percep­tion and sleep patterns. A linkagemay exist between dysphoric moodand disordered information pro­cessing. The literature cited statesthat depressed affect is a frequentconcomitant of hypocortisolism.Nonspecific mental status changesare frequently associated with cor­tisol excess. Various studies giveincidences of 36% to 50%. Thesechanges include euphoria, and alsosevere depression. Data from theBoston Collaborative Drug Sur­veillance Program showed thatmental disturbance in patients

419

ABSTRACTS

treated with prednisone is probablydose-related. However, since themajority of patients exposed to ex­cessive cortisol do not develop psy­chiatric illness, the authors statethat at least three factors are impli­cated in the pathogenesis of a dis­order: cortisol excess, environmen­tal stress, and preexisting vulnera­bility. In one study, all patients whodeveloped psychiatric symptom­atology on steroids recovered whenthey were discontinued. The indi­ces of cortisol metabolism have re­ceived the greatest attention interms of affective disorders. Dis­turbed functioning of the limbic­hypothalamic- pituitary- adrenal(LHPA) axis appears operative inaffective disorders for several rea­sons. First is the well-establishedrelationship between stress andcortisol production. Next, clinical

manifestations of primary affectivedisorders suggest LHPA dysfunc­tion. Vegetative signs of depressioninclude disturbances in appetite,autonomic activity, and sexual andaggressive drives, and a diurnalpattern to mood dysfunction. Fi­nally, the norepinephrine and sero­tonin systems believed so impor­tant in mood disorders are impor­tant regulators of the hypothalamicneuroendocrine cells which, inturn, are the major regulators ofsecretion of adrenocorticotropichormone secretion from the an­terior pituitary. The dexametha­sone suppression test as presentedby Carroll and associates hasshown that by giving I mg of dexa­methasone at II PM, drawing re­sponse samples at 4 and II PM thefollowing day, and using a cortisollevel of more than 5 mg/dL as a

criterion for failure to suppress, onefinds sensitivity ofgreater than 65%and specificity of 95% for depres­sive illness. In consultation for ex­ogenous hypercortisolism, often themost immediate issues are assessingsuicide risk and managing disrup­tive behavior. If the steroid dose isgradually reduced to physiologiclevels, the patient generally returnsto normal adrenal and mentalfunctions. Abrupt cessation of theexogenous steroids may result inprecipitating a crisis of adrenal in­sufficiency. A history of severe psy­chiatric disturbances unrelated tosteroid therapy or of adverse men­tal effects in prior steroid therapymay suggest a higher risk for corti­sol-induced mental dysfunctionduring steroid therapy.

Donald L. Feinsilver, M. D.Medical College of Wisconsin

INDEX TO ADVERTISERS

420

IBA PHARM CE TI L'l OMP Y

Lithobid 380-3 2

Ludiomil 350-351

D PO T PHARMA Eun ALS

ymmelrel PS 418-419

IVES L BORATORI S. IN .

Surmontil. 3.5

LEOERLE L BOR TORI •

A. endin _ 316-31

L xilan 340-342

M,NEIL PH RM E fI L

Hald I. 334-336

MEAD JOH aPH RMA EUTI L OIVI ION

De 'yrc I. . . . . . . . . . .. . . . .. 409-412

MER K HARP & OOHME

incmel 3 6-3 8

MERREU 0 W

PH R.MAC UTI .<\L • I

rpramin 374-376

PE N ALT PH RMA 'EUTI01\'1 ION

dapin ] 14.360-]62

RO HE LAB RATORI-

Dalmane.. _ lhird c vcr­

fourth co\'erMedical Director's Page _399

alium 404-406

ROERIG

a anel inequan 37]

Navane 'ccond cover-

312

Sinequan 414-416

S "IDOZ PHARMA flC L

RC~lOril. . . . . . . . . . . . . . . .. 346-34

MITH KLI 'f & FRE CH

LABOR rORIE.

Eskalilh 400-401

E. R. SQ IBB SO.. IN .

Prolixin 364-366

I HF PJOHN OMPA Y

Halcion _ 32 -330

Xana _.. 35 -35

WYErIl LABOR TORIES

Ativan 369-370

PSYCHOSOMATICS