In This Issue

Pharmacological treatment of alcoholism now utilizes a wide variety of agents with different therapeutic mechanisms. The article by Johnson (p. 630) describes three clinical subsyndromes of alcoholism and recommends a different pharmacological treatment regimen for each, following appropriate goal setting, clinical monitoring, and psychotherapeutic support with the patient. For a middle-age drinker who consumes steadily over the weekend, he recommends topiramate. For a patient with an extensive family history of alcoholism whose own alcoholism is characterized by daily drinking and heavy binge drinking in college, naltrexone is recommended. Finally, for an elderly patient who has begun to drink daily in her retirement community, he recommends injectable long-acting naltrexone. For patients who were both depressed and alcohol dependent, Pettinati et al. (p. 668) found that a combined sertraline and naltrexone treatment was more effective than placebo or either drug alone for producing alcohol abstinence (see figure). There was also indication of enhanced antidepressant effect with the combination.

Gardner et al. report a consensus study of antipsychotic dosing (CME, p. 686) that used an international panel to recommend doses of a wide range of antipsychotic drugs, relative to a standard dose of olanzapine (20 mg/day) for an adult man with more than 2 years of illness who is not considered treatment resistant. Doses were similar for manic patients but reduced 25% for psychotically depressed patients. Doses were also reduced 25% for more responsive patients and increased 25% for more resistant patients. For children 6–12 years old a 60% reduction is recommended, for elderly persons more than 65 years old a 50% reduction is recommended, and for women a 10% reduction is recommended. Wang et al. (p. 676) found in a prospective comparative study that continuing the optimal therapeutic dose of risperidone that produced resolution of the acute episode was more effective for preventing relapse than reducing the dose at 4 or 26 weeks after hospital discharge, without an increase in side effects. The 4.3-mg mean daily dose of risperidone was lower than the 6-mg dose recommended for most men by the consensus study, but it was consistent with the panel’s recommended 20% reduction for Asians.

Clinical and neurobiological studies identify two patterns of emotional dysregulation in posttraumatic stress disorder (PTSD). Classical PTSD involves emotional excess, reexperiencing of the trauma, and physiological hyperarousal. A second subtype proposed by Lanius et al. (p. 640), which is termed dissociative, involves extreme detachment from the trauma combined with fragmented memory and perception. Patients with the two subtypes of PTSD response—hyperarousal and dissociation—show opposite patterns of activation in the frontal cortex: failure of prefrontal inhibition of limbic regions in the classical hyperaroused type and overmodulation by the prefrontal cortex of limbic regions in the dissociative type. In an editorial on p. 615, Dr. James Chu notes that dissociation is more often found in children with PTSD and suggests that it may have a protective role that should not be ignored in therapy.

Ten years after hospitalization for borderline personality disorder, 86% of 290 patients had sustained symptom remissions but only 50% had also recovered social and vocational functioning. However, Zanarini et al. (p. 663) also found that once recovery was attained it was likely to be stable. Two-thirds of the patients who were functionally recovered remained so, as did 85% of those with symptom remissions lasting at least 4 years. The editorial by Dr. Michael Stone on p. 618 points out that many of the traits of borderline personality disorder, such as irritability, moodiness, demandingness, manipulativeness, and mercuriality, are ego-syntonic and thus persist after the remission of other symptoms. These traits are more difficult to treat, yet they also account for the continuing psychosocial disability.