DSM-III-R Axis IV: clinician reliability and comparability to patients' reports of stressor severity.

Stress has long been considered an important precipitant to the development or exacerbation of psychopathology (Selye 1980). However, it has been difficult to reach agreement on how to measure stressors reliably, and whether stressors should be assessed using an objective clinical rating or a subjective appraisal (Mazure and Druss 1995). When the DSM-III multiaxial diagnostic system was derived, Axis IV was designed to provide a mechanism for objectively rating the severity of psychosocial stressors that contributed to the development or exacerbation of psychiatric disorders (Williams 1985). With the continued use of this nosological system, DSM-III-R Axis IV has become the most commonly used assessment of stressors in clinical settings today. The current work focuses on whether DSM-III-R Axis IV can be used reliably by clinicians generating objective ratings, and on whether these objective ratings reflect patients' appraisals of the severity of their psychosocial stressors. Based on this work, options for future use of Axis IV are discussed.

The relationship between blood perphenazine levels, early resolution of psychotic symptoms, and side effects.

Serum perphenazine concentrations and early resolution of psychosis were examined to determine if blood level monitoring could be used to maximize drug efficacy while limiting extrapyramidal side effects (EPS). Sixty-six acutely psychotic inpatients were given perphenazine 0.5 mg/kg/day for 10 days, and their response was rated blind to blood level. Although 36 of 66 patients showed resolution of psychosis, neither perphenazine nor N-dealkylated perphenazine levels were related to global response or to Brief Psychiatric Rating Scale (BPRS) totals. Improvement in two individual BPRS items (hallucinations and conceptual disorganization) was related to serum perphenazine levels and suggestive of a lower therapeutic threshold of 0.8 ng/mL. Perphenazine level was not correlated with EPS; but benztropine, given only if required for serious EPS, was more likely to be used when perphenazine levels were elevated. The data suggest that higher perphenazine levels were no more effective than moderate levels but that higher levels may be associated with increased EPS; the data also suggest that individual symptoms rather than global response were associated with a lower therapeutic perphenazine threshold.

Treatment of catatonia with low-dose lorazepam.

The authors describe three patients who each had a catatonic syndrome associated with affective psychosis and who responded dramatically to low doses of lorazepam.