Psychosomatics 46:278-280, June 2005
© 2005 The Academy of Psychosomatic Medicine
Psychoneuroendocrinology: The Scientific Basis of Clinical Practice
Edited by Owen M. Wolkowitz, M.D., and Anthony J. Rothschild, M.D., Arlington, Va., American Psychiatric Publishing, Inc., 2003, 606 pages, $78.95, ISBN 0-88048-857-3
Terry Rabinowitz, M.D., F.A.P.M., F.A.P.A.
Disturbances of endocrine function may first appear as psychiatric signs and symptoms but more often receive attention when physiological homeostasis goes awry and a cluster of nonpsychiatric symptoms—such as frequent urination, thirst, and weight loss in diabetes mellitus or fatigue, weakness, and constipation in hypothyroidism—cause concern and motivate a patient to seek help. However, whether or not the endocrine disturbance first presents with psychiatric symptoms, psychiatric complaints may often accompany endocrine dysfunction and will frequently require attention.
The field of clinical psychoneuroendocrinology is nascent, but its family tree has long and deep roots that extend back to ancient times. This fine textbook, edited by two eminent experts in the field with contributions from many others of equal stature, is a readable, practical, and well-researched volume that begins with a fascinating history of psychoneuroendocrinology and guides the reader through the various components of the endocrine system as they relate to psychopathology. This paperbound text, comprising around 600 pages, would be a great addition to the library of any consultation psychiatrist.
The book is divided into seven parts (Introduction, Peptide Hormones, Adrenocortical Hormones, Gonadal Hormones, Thyroid Hormones, Laboratory Testing, and Stress), and each part is further divided to produce a total of 19 chapters. For instance, Part III: Adrenocortical Hormones, comprises four chapters: "The Hypothalamic-Pituitary-Adrenal Axis and Psychiatric Illness"; "Psychiatric Manifestations of Hyper- and Hypoadrenocorticism (Cushing's and Addison's Disease)"; "Psychiatric Effects of Glucocorticoid Hormone Medications"; and "Dehydroepiandrosterone (DHEA) in Psychoneuroendocrinology."
This textbook is very nicely arranged, with extensive and up-to-date bibliographies. The individual chapters come together as one voice under the careful editing of Drs. Wolkowitz and Rothschild. Although all chapters are of comparable high quality, I have reviewed a few to give readers of this journal an idea of what to expect.
Steven E. Lindley and Alan F. Schatzberg cover the "Historical Roots of Psychoneuroendocrinology" in Chapter 2. They take us back to 469-399 B.C., when Hippocrates discussed black bile and melancholia. He and others opined that the four bodily humors—yellow and black bile, blood, and phlegm—could cause mental illness by influencing the brain. Later, Galen (A.D. 130-200) expanded on these ideas and suggested that certain waste products of the body were funneled down the infundibular stalk to the pituitary gland and ultimately appeared as nasal mucus or "pituita." To treat melancholia, Galen recommended phlebotomy, and this treatment persisted for the next 1,500 years.
In Paris, Théophile de Bordeu observed in 1742 that glands and other tissues could influence each other by releasing products into the bloodstream, that is, without direct contact, and in 1849 Arnold Adolf Berthold described evidence for the existence of hormones. In 1902, Bayliss and Starling investigated "chemical messengers" and used the term hormone ("I arouse to activate") to describe a chemical produced in one area of the body that influences cellular processes at a distant site.
The field of psychoneuroendocrinology came about as research in the first half of the 20th century showed a clear linkage between hormones and brain function. In the early 1900s, Walter Bradford Cannon postulated that strong emotions influenced physiology through the "sympathico-adrenal medullary system" and described the fight-or-flight response. In the late 1940s, Geoffrey W. Harris provided evidence that factors released into portal blood from the hypothalamus exerted control over pituitary secretion. Cannon hypothesized that physical and psychological stressors could disturb homeostasis, a term he coined. Later, Hans Selye examined the effects of various stressors on the anterior pituitary and adrenal cortex. Cannon’s and Selye’s work aroused a great deal of interest in psychiatry because many psychiatric disorders were felt to be due to stress, and in the 1950s, indirect and direct measures of adrenal function were linked to various psychiatric disorders, although early studies sometimes yielded conflicting results.
As further studies of the hypothalamic-pituitary-adrenal (HPA) axis took place, evidence accumulated in support of this important axis and its disruption on mood and other psychiatric parameters and vice versa. From these studies emerged the dexamethasone suppression test (DST), described by Lindley and Schatzberg as "one of the most widely studied measurements in biological psychiatry." From this book, one learns about the DST in the context of its research and clinical determinants as well as its relative value. It is not particularly useful in the clinical setting but has documented utility in the differential diagnosis of psychotic depression (rate of nonsuppression is high) and schizophrenia (rate of nonsuppression is much lower), making it especially useful for a patient with first-break psychosis who cannot give a cogent history.
Melatonin, produced by the pineal gland, is one of a new class of drugs called chronobiotics that may be useful in adjusting the timing of circadian rhythms, thus "resetting" the biological clock. Chapter 4, "Chronobiology and Melatonin," contributed by Robert L. Sack, Alfred J. Lewy, Magda Rittenbaum, and Rod J. Hughes, covers this interesting hormone in detail and from a useful clinical perspective. Because of its properties, melatonin may be especially useful for circadian rhythm sleep disorders such as jet lag and advanced and delayed sleep-phase pattern. Melatonin’s usefulness as a "phase resetter" was only recently discovered, but the hormone is promising either as monotherapy or in combination with other drugs for some sleep or circadian rhythm disorders. The authors believe that melatonin use is generally safe and that, because it is a naturally occurring hormone, its administration would likely cause fewer problems than many "synthetic" hypnotics. Included in this chapter is a helpful and practical table for the use of melatonin to counteract jet lag that might occur following a long eastward or westward flight. This table is representative of many useful tables and figures found throughout the text.
In Chapter 14, "Thyroid Function in Psychiatric Disorders," David O'Connor, Harry Gwirtsman, and Peter T. Loosen tell us that the prevalence of one or more thyroid abnormalities in acutely hospitalized psychiatric patients ranges from 6% to 49%. The most common thyroid abnormality among these patients is the euthyroid sick syndrome, which has been observed in both depression and schizophrenia. Of note, this disorder often normalizes upon symptom resolution. Thus, they stress the importance of interpreting thyroid function tests with caution in newly hospitalized or acutely ill patients.
Disturbances of thyroid function are common in eating disorders and occur at twice the rate of the healthy population. In anorexia nervosa, for example, patients may often have signs and symptoms consistent with hypothyroidism including bradycardia, slowed deep tendon reflexes, and constipation. In some cases, savvy patients with anorexia nervosa may abuse prescription or over-the-counter thyroid supplements with the aim of inducing a hypermetabolic state and subsequent weight loss. Another potentially confounding situation may arise when a patient with anorexia nervosa also has hyperthyroidism (i.e., Graves’ disease). In such a situation the hypermetabolic state of Graves’ disease may mask the hypometabolic state often seen in anorexia nervosa—consultation psychiatrists, beware!
Chapter 16 by Steven Sokolov and Russell Joffe covers the important domain of "Thyroid Hormone Treatment of Psychiatric Disorders." The well-established usefulness of thyroid hormone augmentation of tricyclic antidepressants, even in euthyroid patients, is nicely covered and is itself augmented by a handy table of clinical recommendations for T3 augmentation in refractory depression. Of note is the authors’ caveat that the only clinical trials of T3 efficacy in refractory depression occurred with tricyclic antidepressants; evidence of efficacy with other antidepressant classes is thus far documented only in case reports. The authors believe that T3 augmentation is likely but recommend controlled trials to confirm its effectiveness. In fact, the authors recommend a trial of lithium augmentation to precede T3 augmentation of SSRIs, given the presence of controlled data to support lithium’s effectiveness.
As Drs. Wolkowitz and Rothschild state in their introduction, "The importance of endocrinology for psychiatric practice has never been stronger than it is now." I agree and would add that this is especially important for the consultation psychiatrist, who oftentimes is requested to help a medical or surgical patient with one or more disorders of endocrine function, either chronic or a consequence of their acute illness.
Knowing how an endocrine disturbance might affect psychiatric equilibrium, or conversely, how a psychiatric condition might impact endocrine function, enables the consultation psychiatrist to play a key role in optimizing health and quality of life for acutely ill patients. In addition, armed with this textbook, he or she will be better prepared to educate residents, fellows, and attending staff about the important and interesting field of psychoneuroendocrinology.
FOOTNOTES
Dr. Rabinowitz is Associate Professor of Psychiatry and of Family Medicine, University of Vermont College of Medicine, and Director of the Psychiatric Consultation Service and Director of Telemedicine, Fletcher Allen Health Care, Burlington, Vt.
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