August 2013

Vol. 25. No. 3


Changes to DSM-5 are not as drastic as they may seem

DSM-5 is out. Apart from the writings of a cranky few, the manual mostly has been greeted with a collective yawn. Critics implied that the sky would fall, but nothing of the sort happened. I have co-authored the DSM-5 Guidebook (with Annals Editorial Board member Jon E. Grant, MD, JD, MPH). Let me briefly summarize what I consider the most important changes:
• The manual’s organization has changed (ie, “metastructure) so that diagnostic chapters follow the developmental lifespan; thus the childhood disorders chapter (“Neurodevelopmental disorders”) appears first.
• The multiaxial system has been scrapped. Although it was included in DSM-III to elevate developmental issues and personality disorders, over time it had the opposite— and detrimental—effect. I doubt it will be missed.
• New chapters: Obsessive-compulsive and related disorders and Trauma- and stressor-related disorders are examples
• New disorders or consolidated disorders: disruptive mood dysregulation disorder (for irritable kids who might have been called “bipolar”); premenstrual dysphoric disorder; somatic symptom disorder (which consolidates 5 former somatoform disorders); hoarding disorder; and mild neurocognitive disorder are a few examples.
• Substance abuse and dependence have been merged into a single “use disorder” diagnosis.



A prospective study of the onset of PTSD symptoms in the first month after trauma exposure

Jeannie B. Whitman, PhD | Carol S. North, MD, MPE | Dana L. Downs, MA, MSW | Edward L. Spitznagel, PhD

BACKGROUND: The course of posttraumatic stress disorder (PTSD) symptoms in the month after trauma exposure has not been determined adequately. Symptom group C (avoidance/numbing) has been identified retrospectively as a marker for PTSD, but prospective studies are needed to determine whether these symptoms can provide substantially earlier identification of those who will have PTSD 1 month after trauma exposure.

METHODS: We evaluated 42 patients hospitalized for traumatic injuries over the first post-injury month to track development of posttraumatic symptoms.

RESULTS: Symptoms emerged rapidly, with group B (intrusion) and group D (hyperarousal) symptoms occurring earlier than group C symptoms. At 1 week, group C criteria accurately predicted who would develop PTSD by 1 month, and by 2 weeks, group C criteria also predicted who would not develop PTSD by 1 month.

CONCLUSIONS: The findings, if replicated, may permit earlier identification of PTSD and more timely, appropriate treatment.


Metabolic and body mass parameters after treatment with JNJ-37822681, a novel fast-dissociating D2 receptor antagonist, vs olanzapine in patients with schizophrenia

Ella J. Daly, MB, MRCPsych | Justine M. Kent, MD | Luc Janssens, MSc | John W. Newcomer, MD | Gitta Hüsken, PhD | Peter De Boer, PhD | Luc Tritsmans, MD | Mark E. Schmidt, MD

BACKGROUND: The highly selective and fast dissociating D2 receptor antagonist JNJ-37822681 may be associated with lower risk for weight gain and undesirable metabolic effects compared with available antipsychotics.

METHODS: In this double-blind, randomized study, patients were randomly assigned (1:1:1:1:1) to 12 weeks of JNJ-37822681 (10 mg, 20 mg, or 30 mg, twice daily) or olanzapine (10 mg/d during week 1; 15 mg/d after week 1), or 6 weeks of placebo (followed by 6 weeks of olanzapine, 15 mg/d). Metabolic and body mass parameters were assessed at weeks 6 and 12.

RESULTS: For metabolic parameters, at week 6 none of the JNJ-37822681 groups demonstrated significant change vs placebo; however, significant changes (P < .05) were observed in the olanzapine vs placebo group in triglycerides, low-density lipoprotein (LDL) and very LDL cholesterol, and free fatty acids. For all JNJ-37822681 groups, mean weight changes at week 12 (-0.3 [10 mg], + 0.3 [20 mg], + 0.8 kg [30 mg]) were significantly less (P < .001) than for the olanzapine group (+ 2.7 kg). A higher percentage of overweight or obese patients (baseline body mass index: ≥25 kg/m2) receiving olanzapine had ≥7% increase in weight than those receiving JNJ-37822681 (9.8% vs 2.3%, respectively).

CONCLUSIONS: JNJ-37822681 treatment was associated with a more favorable outcome on weight and metabolic adverse effects vs olanzapine for treating schizophrenia; the 10 mg twice-daily dose demonstrated minimal to no weight gain.


Antidepressant-induced excessive sweating: Clinical features and treatment with terazosin

Rajnish Mago, MD | Michael E. Thase, MD | Barry W. Rovner, MD

BACKGROUND: Antidepressant-induced excessive sweating (ADIES) occurs in 5% to 14% of patients taking antidepressants, usually persists throughout treatment, and causes subjective distress and functional impairment. We conducted the first clinical trial of any treatment for ADIES.

METHODS: Clinical features of ADIES were assessed using a semistructured form. Twenty-three patients with moderate or greater ADIES were assessed for a 2-week baseline period , followed by 6 weeks of openlabel treatment with flexible dose terazosin, 1 to 6 mg/d. Improvement in ADIES was measured by the Clinical Global Impressions (CGI) scale and other measures.

RESULTS: ADIES commonly was prominent in the scalp (62%), face (95%), neck (48%), and chest (57%); usually occurred either episodically or with episodic bursts (82%); and was persistent (median 63 months). Twentytwo of the 23 patients responded to terazosin (CGI-I scores 1 or 2), with CGI-Severity improving from median of 5 to median of 2 (P < .0001). Patient-rated daytime and nighttime severity of ADIES and proportion of time in ADIES also improved significantly. The most common adverse effects of terazosin therapy were dizziness/lightheadedness (n = 9) and dry mouth (n = 4). No patient dropped out because of adverse effects. Sitting and standing systolic blood pressure decreased by median values of 3 (P = .044) and 5 (P = .063) mm Hg, respectively.

CONCLUSIONS: Terazosin may be an effective treatment for ADIES. Although dizziness/lightheadedness may occur in some patients, the treatment generally was well tolerated.


Compulsive sexual behavior in young adults

Brian L. Odlaug, PhD, MPH | Katherine Lust, PhD | Liana R. N. Schreiber, BA | Gary Christenson, MD | Katherine L. Derbyshire, BS | Arit Harvanko, BA | David Golden, BA | Jon E. Grant, JD, MD, MPH

BACKGROUND: Compulsive sexual behavior (CSB) is estimated to affect 3% to 6% of adults, although limited information is available on the true prevalence and impact of CSB in young adults. This epidemiological study aims to estimate the prevalence and health correlates of CSB using a large sample of students.

METHODS: The survey examined sexual behaviors and their consequences, stress and mood states, psychiatric comorbidity, and psychosocial functioning.

RESULTS: The estimated prevalence of CSB was 2.0%. Compared with respondents without CSB, individuals with CSB reported more depressive and anxiety symptoms, higher levels of stress, poorer self-esteem, and higher rates of social anxiety disorder, attention deficit/hyperactivity disorder, compulsive buying, pathological gambling, and kleptomania.

CONCLUSIONS: CSB is common among young adults and is associated with symptoms of anxiety, depression, and a range of psychosocial impairments. Significant distress and diminished behavioral control suggest that CSB often may have significant associated morbidity.