The American Journal of Psychiatry Residents’ Journal July 2015 Volume 10 Issue 7 Inside IN THIS ISSUE 2 New Formats and New Opportunities: The Time to Get Involved is “Now”! Rajiv Radhakrishnan, M.B.B.S., M.D. 3 Prevention of Posttraumatic Stress Disorder: Predicting Response to Trauma Jennifer H. Harris, M.D. 7 Weight Gain in Patients With Schizophrenia: A Recipe For Timely Intervention Ammar El Sara, M.B.Ch.B. 10 Hyperprolactinemia and Antipsychotics: Update for the Training Psychiatrist Stephanie Pope, M.D. 13 A Clinical Case Conference on Spiritual Growth and Healing Elizabeth S. Stevens, D.O. This issue of the Residents’ Journal features a variety of topics. Jennifer H. Har- ris, M.D., discusses prevention of posttraumatic stress disorder, with an overview 15 Priapism: A Rare but Serious of various responses to trauma. Ammar El Sara, M.B.Ch.B., presents a review of Side Effect of Trazodone clinically applicable evidence-based interventions targeting obesity in schizophre- Kamalika Roy, M.D. nia patients. Stephanie Pope, M.D., examines antipsychotic-induced hyperprolac- 17 Classifying Psychopathology: tinemia, including variables affecting prolactin and clinical implications. Elizabeth Mental Kinds and Natural Kinds S. Stevens, D.O., discusses several psychological, social, and spiritual developmen- Reviewed by Aaron J. Hauptman, tal frameworks in a clinical case conference. Kamalika Roy, M.D., presents a case M.D. of priapism as a side effect of trazodone in a middle-aged patient. Lastly, Aaron J. Hauptman, M.D., offers his review of the book Classifying Psychopathology: Mental 18 Residents’ Resources Kinds and Natural Kinds. Editor-in-Chief Associate Editors Editors Emeriti Rajiv Radhakrishnan, M.B.B.S., M.D. Rafik Sidaros, M.B.B.Ch. Sarah B. Johnson, M.D. Janet Charoensook, M.D. Senior Deputy Editor Molly McVoy, M.D. Katherine Pier, M.D. Staff Editor Joseph M. Cerimele, M.D. Deputy Editor Angela Moore Sarah M. Fayad, M.D. Hun Millard, M.D., M.A. Monifa Seawell, M.D. Misty Richards, M.D., M.S. EDitORIAL New Formats and New Opportunities: The Time to Get Involved is “Now”! Rajiv Radhakrishnan, M.B.B.S., M.D., Editor-in-Chief It is an exciting time at the American We have seen volved with the journal. Once you have Journal of Psychiatry Residents’ Journal successfully published in the journal, Editorial Board as we plan ahead for the remarkable growth we offer additional opportunities to new academic year. This is also a special serve as a Guest Section Editor, receive year, since it marks the 10th year of the in the journal over a free book for writing a book review, journal since its inception in 2006. the past year. and join the Editorial Board. This year, We have seen remarkable growth in we had 14 applicants who competed to the journal over the past year, with ap- secure a place on the Editorial Board. proximately three-fold greater engage- cal students, residents, and fellows will I’m very happy to introduce our fab- ment by residents and fellows. Many have an opportunity to submit reviews ulous new Editorial Board for this aca- of our Guest Section Editors and Edi- of pharmacological medications in the demic year: Senior Deputy Editor, Kath- torial Board members of the past year new manuscript type called “Drug Re- erine Pier, M.D., from the Icahn School of have gone on to obtain fellowship posi- view,” as well as articles in another new Medicine at Mount Sinai; Deputy Editor, tions and many academic awards at the manuscript type called “History of Psy- Hun Millard, M.D., M.A., from Yale Uni- national level. Hearty congratulations chiatry.” These new formats, along with versity School of Medicine; and Associ- to them on their outstanding achieve- our existing formats on “Treatment in ate Editors, Rafik Sidaros, M.B.B.Ch., ments and a heartfelt thank you for their Psychiatry” and “Clinical Case Confer- from SUNY Downstate Medical Cen- contributions to the journal! The above ence,” will allow us to cover topics on ter, and Janet Charoensook, M.D., from facts speak to not only the educational psychopharmacology, clinical treat- the University of California, Riverside. content of the journal but also to the im- ment, neuroscience, and DSM-5. Soon, We look forward to working with you mense academic opportunities that par- each article will be accompanied by to transform the Residents’ Journal into ticipation with the journal provides. a table that lists “Key Points/Clinical a leading educational resource for resi- At the beginning of the year, we Pearls” to enable readers to peruse key dents and fellows. asked ourselves, “What can we do to teaching points despite their busy sched- The time to get involved is now! further improve the educational content ules. Readers will also have an opportu- of the journal and improve participa- nity to answer quiz questions related Dr. Radhakrishnan is a fourth-year psy- tion by medical students, residents, and to an issue. Additionally, authors will chiatry resident in the Department of fellows?” To answer these questions, have an opportunity to create podcasts Psychiatry, Yale University School of we conducted a nation-wide survey of for their articles that would be featured Medicine. He is the past Senior Deputy- medical students, residents, and fellows on our Facebook page (https://www. Editor (2014–2015), and new Editor-in- and received an impressive number of facebook.com/AJPResidentsJournal). Chief (2015–2016) of the American Jour- nal of Psychiatry Residents’ Journal. responses. The majority of respondents We also have a new landing page that indicated that they would like to see lists the article titles of an issue. The Dr. Radhakrishnan is supported by an more articles on psychopharmacology, titles are hot-linked and take the reader NIMH-R25 IMPORT grant (R25 MH071584) and the Thomas P. Detre Research clinical treatment, neuroscience, and directly to the article when clicked. Fellowship. DSM-5. (Check it out here: http://ajp.psychiatry- In response to the survey, we are online.org/residents_journal). in the process of implementing some This is indeed an exciting time for changes to the format of articles in the the American Journal of Psychiatry Resi- journal. In the coming months, medi- dents’ Journal and a great time to get in- The American Journal of Psychiatry Residents’ Journal 2 ARtiCLE Prevention of Posttraumatic Stress Disorder: Predicting Response to Trauma Jennifer H. Harris, M.D. “Although the world is full of suffer- symptoms (5). The presence of avoid- Yet a resilient response is in fact more ing, it is full also of the overcoming ance (group C) symptoms in particular common (35%–65%), suggesting that of it.” has been strongly associated with meet- the majority of the population possesses —Helen Keller ing the full diagnostic criteria for PTSD the capacities to adapt quickly to stress- (5). This suggests that intrusion and ful events (8). Most people in their lifetime will expe- hyperarousal are normal responses to rience a traumatic event. In one study, trauma and that avoidance may actually PATHOPHYSIOLOGY OF PTSD 69% of people experienced “a violent comprise the pathological part of PTSD. encounter marked by sudden or extreme Several studies have consistently Sensory input is appraised as stressful force and involving an external agent of shown that PTSD develops in about one- by the limbic brain structures, which in- nature, technology, or humankind” (1). third of those exposed to trauma (1, 6, 7). clude the amygdala, hippocampus, and But what determines why people re- spond so differently to trauma? Why FIGURE 1. Hypothesized Trajectories of the Course of Stress Responses With are some people able to maintain nor- Posttraumatic Stress Disorder Symptoms on the Y-Axisa mal functioning, while others respond Resistance Relapsing/remitting pathologically with posttraumatic 12 12 stress disorder (PTSD)? 10 10 8 8 6 6 RESPONSES TO TRAUMA 4 4 Researchers continue to debate about 2 2 the exact nature of resilience, but most 0 0 Pre- Post- Post- Post- Pre- Post- Post- Post- definitions include a concept of healthy, disaster T1 T2 T3 disaster T1 T2 T3 adaptive, or integrated positive func- Resilience Delayed dysfunction tioning over time in the aftermath of ad- 12 12 versity (2). Resilience is not simply “lack 10 10 of psychopathology.” Resilience is one of 8 8 several possible trajectories in response 6 6 to traumatic events characterized by 4 4 a brief period of disequilibrium after 2 2 trauma followed by continued health 0 0 (Figure 1) (2). Pre- Post- Post- Post- Pre- Post- Post- Post- The ideal response to stress is resis- disaster T1 T2 T3 disaster T1 T2 T3 tance, a trajectory in which adaptive ca- Recovery Chronic dysfunction pacities have absorbed the impact of the 12 12 stressor and there is no dysfunction at 10 10 all (3). In reality, some level of distress is 8 8 universal immediately after the trauma. 6 6 A total of 96% of individuals directly ex- 4 4 posed to the Oklahoma City bombing re- 2 2 ported at least one posttraumatic symp- 0 0 tom (4, 5). Immediately after trauma Pre- Post- Post- Post- Pre- Post- Post- Post- disaster T1 T2 T3 disaster T1 T2 T3 exposure, most individuals meet DSM a Reprinted with permission from Norris FH, Tracy M, Galeo S: “Looking for Resilience: Understanding the criteria for intrusive (group B) symp- Longitudinal Trajectories in Response to Stress.” Soc Sci Med 2009; 68:2190–2198. Copyright © Social toms and cognitive and mood (group D) Science and Medicine 2009. The American Journal of Psychiatry Residents’ Journal 3