Archive for August, 2009

Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era

Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era

Jerry M. Lewis

New York: Brunner/Mazel Publishers, 168 pp, 1991

This book is both a review and an update of the author’s seminal contributions to the psychotherapy education of psychiatrists. The title emphatically reflects what many of us who are committed to a certain vision of psychiatry feel as we attempt to educate the next generation of psychiatrists.

The literary style of Jerry Lewis is a marvelous combination of simple and direct language with highly self-revelatory content. His writing is at once very personal and very dignified. Compelling examples from his own experiences provide exquisite demonstrations of the method he proposes. Reading Lewis is more like listening to and being with a wise and close friend than just reading.

The book describes the seminar at the core of Lewis’ structured approach to psychotherapy education. Each chapter takes the reader through the content of the seminar with a clear outline of topic areas and elegantly simple concepts within each topic area.

For psychiatric educators who have found his approach useful and have modified it to fit their circumstances, this book is a pragmatic “state-of-the-process” message. We have neglected a component of values in our psychotherapy curriculum, and this book provides ideas on including relationship structure and family and marital function. For those who learned psychotherapy without the benefit of Lewis’ perspective, this book will be an exciting introduction to a new and better approach to psychotherapy education. For residents in psychiatry or other developing psychotherapists, this book offers a vision of collaborative possibilities in both the practice and learning of psychotherapy. An added bonus for all of us is the sense of being with one of the really great teachers in our field.

Principles of Geriatric Neurology

Principles of Geriatric Neurology (Contemporary Neurology Series, 38)

Robert Katzman, John W. Rowe

Philadelphia, PA: F.A. Davis Company/Publishers, 368 pp, 1992

“There is a tendency to underestimate the energies of old age, which are considerable. You won’t do what you could do, but yet you find that you need to do far more than society allows you to do” (Biythe 1979). Comments such as these are sprinkled throughout this new text on geriatric neurology and place the material presented within the spectrum of everyday life. The authors have brought together neurology and geriatrics to cover the material of this new discipline. The first part of the book places the problems in perspective by first discussing the evolving demographics of our society, with growing numbers of “old” old and the changes in neurological functioning with normal aging. This is supplemented by useful information on the neuropsychopharmacology of aging, imaging of the aging brain and neuropsychological assessment of the elderly. The approach to the neurological evaluation of the aged is discussed, in particular how it contrasts with that of younger patients.

The last section of the book deals with specific medical problems as they apply to the elderly. The first three chapters deal with disturbance in cognitive functioning, dementia, Alzheimer’s disease and delirium. Following these are briefer sections on falls and gait, syncope and urinary dysfunction. One chapter covers everything else, including sleep disorders, seizures, strokes, tumors and spinal cord problems. A brief chapter on ethical issues related to medical problems of the elderly completes the book.

On the whole, this is an excellent book that will be useful for clinical neurologists, geriatricians and other medical professionals who deal with the elderly. My only criticism is that perhaps too much space is devoted to the discussion of dementia. However, the authors qualify this in their introduction. After all, this text does not purport to completely cover the disciplines of neurology and geriatrics, but attempts to highlight the areas where they meet.

Clock Drawing: A Neuropsychological Analysis

Clock Drawing: A Neuropsychological Analysis

M. Freedman, L. Leach, E. Kaplan, G Winocur, K. I. Shulman and D. C. Delis

Oxford: Oxford University Press, 1994.

“The clock is not merely a means of keeping track of the hours, but of synchronizing the actions of men” (Mumford, quoted in Landis 1983). Measurement of time by means of a sundial goes back at least to ancient Rome, and an elaborate astronomical clock powered by a water wheel was built in China in 979 A.D. (Landis 1983). Clocks showing the time in hours and minutes on a clock face had their origin in Europe in the Middle Ages and have been universally used ever since. The development of the digital clock has raised the question of the future usefulness of the classical clock face (Clarfield and Bergman 1990) but it is generally assumed that familiarity with it is culture free.

This familiarity has encouraged neurologists, neuropsychologists and psychiatrists to evaluate cerebral and cognitive function by using the ability to draw a clock face as a specific test. Localized lesions in the brain have been shown to produce similar deficits in clock drawing, and the progressive deterioration seen in different forms of dementia is accompanied by increasing difficulties in carrying out this task. However, different investigators have used methodologies showing great variation in the instructions given to the subject and in the rating assigned to the drawing.

The present volume attempts to correct the resulting confusion by allowing for these differences and developing a scoring system that is not tied to any one particular approach. By and large the authors have succeeded in meeting this goal.

In the introduction they give an excellent short overview of the history of the test with a full discussion of previous work. They discuss the cerebral processes involved in drawing a clock face, and critically review different sets of instructions used by various workers.

In Chapter 2 they discuss the results of a questionnaire to find out how widely the test was used by different workers, their specific methodologies and how useful they found the test. “Results of this survey indicate[d] that a clock drawing task is frequently used throughout the world in the assessment of cognitive deficits in brain injured patients” (p 11).

In order to develop normative data they tested 348 normal volunteers stratified according to age in ten-year cohorts between 20 and 90 years, and the instructions included both free-drawn and pre-drawn conditions. A comprehensive listing of various attributes of clock drawing is provided. It includes assessment of both contour and size of the circle, presence and position of the numbers, and position and size of the hands. This listing is an excellent reference for evaluating patient-specific deficits from a clinical perspective. However, the acceptance in the normative population of three subjects from the oldest age group who drew the contours too small to accommodate all the numbers is open to criticism. In a recent study (Reichenfeld et al 1991) this finding would have been considered sufficient to justify a diagnosis of minor cognitive deficit.

To provide norms based on age may also be misleading because individuals with undetected deficits could be included in the norming process. A more appropriate stratification would be based on specific physical disorders that can interfere with carrying out the clock drawing task. Conditions such as arthritis, tremor, visual deficits, and fatigue could provide the basis for a classification system on which the norms are developed, and patients would then be compared to the norms established for the major medical conditions.

Furthermore, to be considered from a research perspective, the different attributes would need to be weighted so that they could be combined to provide some general measure of well-being. While the authors have provided a complete and comprehensive listing of the different attributes involved in clock drawing, a research agenda to develop such an index should be considered. It is only after such an index is developed that its various clinometric properties of reliability, validity and responsiveness to change can be assessed. It could then be used as a primary outcome measure in intervention studies.

Chapter 3 discusses the clock drawings produced by patients with dementia and relates the extent of the deficits to the severity of the illness. It gives examples of qualitative changes over time. In Chapter 4 the authors report the results of assessing the clock drawings of 25 healthy occupants of a seniors’ residence and conclude that this test could be used as a screening instrument to detect the earliest changes of incipient dementia. The final chapter returns full circle to the earliest use of the clock drawing test (Critchley 1953) to identify focal brain damage from a variety of causes.

This book is beautifully produced. It is full of excellent examples of clock drawings illustrating the points made in the text. Although the scoring system needs to be developed further to be useful in epidemiological and outcome studies, it is detailed and comprehensive and is appropriate for a full qualitative analysis of clock drawing by patients with a variety of neurolgical and psychiatric disorders.

The bibliography is complete and up-to-date. The book is reasonably priced and can be highly recommended to both clinicians and researchers interested in the elderly, and in patients with specific neurological disorders, focal brain lesions, and different forms of dementia.

Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors

J.P. Feighner and W.F. Boyer

Toronto, ON: John Wiley and Sons, 168 pp, 1991

In the past five years, there has been the appearance and use of new antidepressants called specific serotonin reuptake inhibitors. Dr. J.P. Feighner and Dr. W.F. Boyer, who are leading authorities and world respected clinicians, have conducted many clinical drug trials using these drugs. They have written a complete review of these drugs, which is now available in book form.

Specific serotonin reuptake inhibitors have been found to be effective in major depressive illness, panic disorder, obsessive compulsive disorder and bulimia, as well as other indications. These drugs are extremely powerful and should be used with an understanding of their indications and side-effect profile. To properly use these drugs, an understanding of the neuropharmacology of serotonin in the nervous system is essential.

Chapter 1 covers the neuropharmacology of serotonin in the central nervous system and gives a complete and detailed review of the theory, literature and latest information on what is known as the serotonin system. Dr. Marsden does this extremely well and in a very clear, concise manner.

In Chapter 2, there is a complete review of the pharmacological properties of SSRIs in the literature on animals.

Dr. Boyer and Dr. Feighner, in Chapter 3, explain why the serotonin hypothesis is necessary but not sufficient to explain some psychiatric disorders. This is done in a very easy-to-read and logical way. Even novices to the serotonin neurotransmitter system hypothesis can understand the basic foundations of this hypothesis.

Chapter 4 details the pharmacokinetics and drug interactions of the SSRIs. This is very useful as a reference work for cases where there are some untoward interactions in clinical practice.

The remaining chapters show the efficacy of the selective serotonin reuptake inhibitors in depression, panic disorder, generalized anxiety, obsessive compulsive disorder as well as other indications. These are very well documented with the appropriate studies and thus are a very useful reference source for anyone who is interested in more detailed studies of these indications.

The side-effects of the SSRIs are reviewed in detail in Chapter 8. Chapter 9 describes the clinical experiences of Drs. Boyer, McFadden and Feighner in the use of these agents. They have a great deal of valuable clinical experience.

As well, there is an interesting subchapter on combination treatment which is important in the treatment of resistant patients.

The book is a concise and useful distillation of the state of the art in the use of SSRIs. I recommend this book for any practising psychiatrists who want to help their patients with this most modern treatment in a safe and effective way. It has my highest recommendation for both its practical and academic aspects.

Textbook of Clinical Neuropharmacology and Therapeutics

Textbook of Clinical Neuropharmacology and Therapeutics

Harold L. Klawans, Christopher G. Goetz, Caroline M. Tanner

New York: Raven Press, 686 pp, 1991

Neurology has become more a therapeutic than a diagnostic specialty, and a book on neuropharmacological treatment is timely. Two introductory chapters on the principles of neuropharmacology are followed by 46 chapters organized along disease lines. Each chapter presents a brief summary of the disease and then deals with its treatment, concentrating on the specific drugs used, their alleged efficacy and their toxicity. Other treatments are discussed to varying degrees, such as plasma exchange, carotid endarterectomy, physiotherapy and general medical and nursing care.

The strength of this book is its organization. The chapter on drug treatment for neurological problems during pregnancy was especially useful. The addition of a chapter on bacterial meningitis is an improvement over the first edition.

This book suffers from the variations in style and depth common to multi-authored books. The chapters are not all current; some were reprinted from a publication which appeared 1990, and the chapter on HIV covers developments to 1989. There is a chapter on migraines, but little space devoted to the management of other headaches.

This book will be a useful source of therapeutic information for neurologists and internists and addition to any clinical neurological library.

Clinical Neuroanatomy and Neurophysiology

Clinical Neuroanatomy and Neurophysiology, Edition 8

Sid Gilman, Sarah Winans Newman

Philadelphia, PA: F.A. Davis Company/Publishers, 328 pp, 1992

This is a 328-page, soft cover basic text on neuroanatomy and neurophysiology. The book is divided into short chapters which integrate anatomy and physiology to explain each part of the nervous system. The authors begin with the axon and the peripheral nervous system and progress through the autonomic nervous system to the pathways in the spinal cord, brainstem structures, cerebellum and finally to central and more complex functions. The numerous illustrations are a major strength, simplifying the anatomy and physiological connections of the entire nervous system. Chapters on the autonomic nervous system, the cerebellum and the basal ganglia are particularly good and make complex information about the functional connections of each area understandable. The section on neuropharmacology is an excellent introduction to a complex topic and is a real asset to the book. The new chapters describing the physiology of nerve cell and the circulation of blood are also excellent. Chapters on the brainstem and cranial nerves are somewhat repetitive and less well organized. The clinical sections, particularly those dealing with spinal and brainstem abnormalities, cover large areas and are very superficial. A section has been added on approaching patients with symptoms referrable to the nervous system. The subject is also covered superficially, but the chapter is a reasonable introduction for medical students.

This book is an ideal companion for medical students and junior residents in internal medicine. It is an excellent basic textbook for neurophysiology technologists. There is a suggested reading list, which is suitable for the student or technologist, but the book is not referenced and is therefore strictly an introductory textbook.

In summary, the strength of this book is its illustrated approach to neuroanatomy and overview of the complexities of neurophysiology.

Behavior and Medicine

Behavior and Medicine

Danny Wedding, St. Louis

Mosby Year Book, 522 pp, 185 Illustrations, 1990

This book is aimed at the first year medical student and teaching of the social and behavioral sciences and their relevance for the practice of medicine.

There are five major sections. The first section, “Human Development”, reviews the life span and provides medically relevant information about each life stage. “Love and Work” is the title of the second section, covering human sexuality, sexual dysfunction, family relationships, work adjustment and mental health in medicine. The third section is entitled “Assessing Patients” and examines clinical interviewing, physician/patient relationships, the mental status examination, personality assessment and psychodynamic formulations of human behavior. The fourth section: “Behavioral Medicine” looks at stress and stress management, addictions, chronic benign pain, placebo response, cardiovascular risk and health behavior, and Aids. The final section: “Behavioral Science Foundations” looks at brain and behavior, neurochemistry, sleep and sleep disturbances, Sociology and Anthropology in relationship to medicine and Medical Economics. I found the book very readable; it is multi-authored by many M.D.’s and P.h.D’s, and is concise in its coverage of the topics mentioned above.

Each chapter has several study questions, and a very complete list of appropriate references.

The book is very well illustrated with a wide range of classic works of art, indeed the book is almost a short course in art, painting, lithography etc, the 185 illustrations coming from the classics of the art world, and selected very appropriately for the particular behavioral topic under discussion.

I think it is a excellent book, and will find its place in first year medical school programs in behavioral medicine. It will also be of great value to other professionals working in the health and medical fields. It purposely avoids any depth of psychopathology, as the editor points out that a good basic knowledge of behavior and its relationship to medicine is essential before the students get into more grossly abnormal behavior.

Static Encephalopathies of Infancy and Childhood

Static Encephalopathies of Infancy and Childhood

G. Miller, J.C. Kamer

New York, NY: Raven Press, 384 pp, 1992

This book dedicates itself to a review of the mental retardation and cerebral palsy syndromes, topics which tend to receive short shrift in textbooks of pediatrics and pediatric neurology, despite the high incidence and attendant socioeconomic costs of these disorders. Drs. Miller and Ramer are members of the medical faculty of Pennsylvania University (Hershey); in addition to contributing several key chapters, each recruited chapters from many authorities in pediatric neuroscience.

The first section of the book is an overview of the mental retardation and cerebral palsy syndromes, with consideration given to neurodevelopmental evaluation, radiologic investigation, orthopedic management, behavioral therapies and communication with parents and ethical issues. Later sections deal systematically with specific disorders, ranging from chromosomal anomalies and cerebral dygeneses to acquired hyroxicischemic and traumatic encephalopathies, CNS infections, toxic disorders (alcohol, cocaine) and CNS manifestations of hereditary and congenital neuromuscular disorders.

On the whole, despite the number of authors, there is a remarkably homogeneous approach to the organization of the chapters. The writing is concise, clear and usually free of unnecessary jargon The illustrations are good, and there is extensive use of tables, many of which are very helpful. With each topic there is invariably a review of recent neurobiological research relevant to the pathogenesis of the encephalopathies being considered. The reference lists are extensive and up to date. The editors have succeeded admirably in integrating the content of the chapters, the main exception being a double presentation of the mechanism of calcium-mediated delayed neuronal necrosis.

To keep a review of such a wide range of disorders to a manageable size cannot have been easy. At times, the book suffers from being too concise; the educational value of the chapter on the cerebral palsies, for example, would have been enhanced by the addition of a few photographs (for example, postural reflexes).

In summary, this book is a significant contribution to a somewhat neglected area of pediatric neurology; it will be useful for pediatricians, pediatric neurologists, trainees in these disciplines and allied health professionals.

Neurobiology of Learning, Emotion, and Affect

Neurobiology of Learning, Emotion, and Affect

John Madden IV

New York, NY: Raven Press, 368 pp, 1991

This book comes at a time of progress and exciting new discoveries in the field of research involving the neural basis of learning, emotion and affect. The study of learning and memory has flourished for many years within the neuroscientific community. Although long neglected by all but a handful of neuroscientists, emotion and affect have begun to attract attention. A clear summary of the status of this recent work is therefore particularly welcomed.

The book is divided into three parts. The first part is devoted to recent advances in the research of the neural mechanisms of fear conditioning, in both invertebrates and vertebrates. Most exteroceptive stimuli we encounter in our life are affectively “neutral”. However, they can take on emotional properties and elicit emotional reactions, such as defence or approach responses, through association with other stimuli or events that are affectively charged. It is possible to study experimentally the ways in which the brain forms such associations through the use of Pavlovian conditioning techniques, whereby a “neutral” stimulus, the conditioned, or conditional stimulus (CS), is paired with a biologically significant (affectively charged) stimulus, the unconditional or unconditioned stimulus (US).

Pavlovian conditioning procedures have been used to study the biology of learning in many species. Whether or not it is reasonable to speak of Pavlovian conditioning as a process of emotional learning is debatable for invertebrates, many vertebrates, and even many mammalian species, if emotion is restricted to subjective, experiential factors. However, if by emotion we also mean the neural mechanisms by which stimuli are evaluated for their significance (LeDoux 1990), it is possible to view all animals as engaging in a form of emotional processing. What is different about humans and possibly higher primates is that the emotional processing of stimulus significance becomes represented as conscious content. This view is advantageous in that it places emotional processes on a continuum and allows for studies of emotion throughout the animal kingdom.

In the Aplysia model, described in detail by Hawkins, the cellular mechanisms and neural loci responsible for associative learning are, without a doubt, understood more than in any other animal model. Are the same basic mechanisms discovered in this simple model in operation also in more complex organisms? Hawkins believes that classical conditioning in Aplysia, Hermissenda, cat and rabbit involve the same neural mechanisms. In Aplysia, the US plays a modulatory role in stimulating the facilitator neurons. The convergence of this input with the appropriate CS input (the one that was paired with the US) increases presynaptic facilitation and produces classical conditioning. A similar mechanism is acting in vertebrate models as well, Hawkins suggests. The aminergic and cholinergic systems in the vertebrate nervous system can behave like the facilitator neurons of Aplysia. One challenge for the future is to test this simple and attractive theory.

Another elegant invertebrate model is Drosophila melanogaster. An advantage of this model is the possibility of using genetic tools. In recent years, the isolation of mutations that affect an aversive conditioning task in the fruit fly has considerably increased our understanding of the molecular mechanisms of learning and memory. Tim Tully reminds us that with Drosophila research, we probably have the only evidence that short-term and long-term memory are indeed two genetically distinct processes.

Our understanding of the molecular and underlying elementary neural mechanisms which make learning possible in an individual is far less developed in vertebrate models. In recent years, however, simple vertebrate model systems have been worked out, and important neural structures and pathways essential in learning have been shown. It now appears that different types of learning are mediated by different but, in some cases, overlapping neural circuits.

One promising vertebrate model is the conditioned fear-potentiated startle paradigm. In this behavioral model, the conditioned stimulus (usually a light) is paired with a shock and startle response elicited by a noise burst in either the presence or absence of the light. If the startle response is greater when elicited in the presence of the light, the fear-potentiated startle has occurred.

The role of the amygdala in this reflex has been demonstrated by Davis and collaborators; in this book they review the current state of affairs. The amygdala is the centerpiece of the neural pathway involved in fear-potentiated startle, as well as in other fear conditioning situations (Kapp et al 1990; LeDoux 1990). Davis and collaborators show that the activation of the amygdala from the visual conditioned stimulus pathway triggers the startle reflex pathway. The central nucleus of the amygdala carries this out through its connection with the nucleus reticularis pontis caudalis (a nucleus in the startle circuit). Davis and colleagues believe that the visual input comes to the amygdala through cortical pathways. However, findings from our laboratory suggest that visual fear conditioning can be mediated by subcortical visual inputs to the amygdala (LeDoux 1990).

There is a general consensus about the involvement of the amygdala in mediating the acquisition of autonomic responses in the aversive classical conditioning. These responses are defined as “non-specific” and include heart rate, generalized motor activity (freezing, startle response) and skin resistance. They all develop rapidly after a few trials, sometimes requiring just a single contingent pairing. “Specific” responses, on the other hand, are discrete, skeletal muscle responses elicited by specific aversive stimuli. They are much slower to develop and are more specifically adaptive for the organism.

Steinmetz and Thompson describe how the cerebellum, in particular the interpositus nucleus, is an important site for the acquisition of these discrete, specific responses. Using a multi-technique approach (recording, stimulation, lesion studies) they developed a detailed anatomical map of the circuitry involved in the adaptation to aversive events for these behavioral responses. According to Steinmetz and Thompson, the cerebellum plays an “informational” role in the learning of the organism. It is activated in conjunction with the aversive system that involves higher brain regions (the amygdala, for example). These two systems in the brain are distinct, but they interact in the adaptive learning phase. The US pathway activates both systems. And while the cerebellum appears to play an important role in learning the specific response, recent studies also suggest that the amygdala is involved in the early phases of learning. The final attempts to relate these ideas to the popular Rescorla-Wagner learning theory.

Part II of the book deals with experimental situations in which the animal is allowed little or no control over the aversive stimulation How do the subjects cope with stressful events when species-specific defense responses are not helpful? What kind of behavioral and biochemical changes will stressful events elicit? Results from these experimental studies are particularly valuable for their clinical implications. Weiss, using an uncontrollable shock paradigm, suggests in fact that stressed animals show symptoms closely corresponding to those developed by depressed individuals. Moreover, the author proposes that stressful events (for example, uncontrollable shock) elicit both anxiety and behavioral depression. In his analysis, Weiss shows how the locus coeruleus seems to be a key structure in the neurochemical unbalance produced by the uncontrollable shock.

Cognitive deficits may also occur as part of the response to stress. Animals that are exposed to shocks that they cannot avoid or escape later fail to escape shock in a situation in which escape is possible. They also fall well behind control animals (that were allowed to escape or avoid shock in the first phase of the experiment) in Y-maze or water-maze learning tests. Some researchers have explained these results in terms of a simple motoric impairment: the shocked animals learn a coping response in the new situation, but they cannot perform it. Maier rejects this hypothesis; his work suggests that inescapable shock gives rise to learning deficits that cannot be explained by a motor activity deficit.

However, the impairment is not the result of associational learning between the first phase of the experiment and later test situations, as it was suggested in the early explanations of this phenomenon. What is impaired in these subjects, according to Maier, is the capacity to attend the salient external cues; the deficit is then a cognitive one, not an associative one (the learned helplessness hypothesis). Whether this cognitive deficit will be connected to some neural loci or biochemical systems will have to be determined in future studies.

More complex issues of depression and human affect disorders, which involve multiple interactions between emotional and cognitive systems operating at conscious and unconscious levels, are difficult to probe with vertebrates too distant from us in the evolutionary ladder and in social habits. Suomi describes a primate model of affective disorders, the separation model. Humans share over 90% of non-replicated DNA material with higher primates. In addition, the behavior of these animals is characterized by advanced and dynamic social interactions among members of the same species. Rhesus monkeys, in particular, have been studied extensively in the wild and in laboratory settings. Stressful events caused by social relationships among individuals closely resemble human social life. Separation from an attachment object, such as a mother or a loved conspecific, produces profound behavioral and physiological effects, both in the wild and in the laboratory. The evidence of individual differences in these animals makes this model particularly interesting. Not all subjects respond to the same social separation in the same manner. There is also consistency in this behavior in individuals. The same monkeys “at risk” are more readily aroused by and behaviorally fearful of other stressful events. Having individuated the groups “at risk” in the rhesus monkeys population, it may be possible to forecast or even prevent the affective disorder. The “separation/risk” model in monkeys, as Suomi defines it, seems to be extremely promising for improving our understanding of the psychobiology of human affective disorders.

There is evidence from this primate model that the noradrenergic system is involved in mediating depressive states. Matthysse reaches the same conclusion in his analysis of mood disorders. In particular, the locus coeruleus, an important source of forebrain noradrenalin, is advanced as a candidate for depression, as Weiss also proposed for the helplessness model. According to Matthysse, this nucleus becomes activated by excited unhappy memories, which are the result of early loss or other traumatic events. Cerebral activation is then reduced by the increased firing of the locus coeruleus. At this point, physostigmine, the cholinergic agent, enters the circuit to produce the physiological symptoms of depression. In Matthysse’s view, while the memories are the primary cause of noradrenergic changes, the biogenic amines are only the effectors in this theory. Matthysse points out that human studies suggest that decreased cerebral activation is produced by physiostigmine in normal subjects (for example, the subjects feel “apathy, slowness of speech and movement”). Physiostigmine physiological symptoms closely resemble those of depression. In his fascinating theory, however, Matthysse does not tell us where these memories may be stored in the brain or why, at a certain point, they overflow to reach the locus coeruleus. Also, it will be interesting to try to define the role of anxiety in this context. Under identical conditions of stress some people respond only with anxiety; do they have the capacity to deal with the unhappy memories activation in a different way? Interesting questions arise from this theory that only future experiments can elucidate.

Control over stressors is a critical factor that influences biological functions which regulate adaptive and maladaptive behaviors. Bandura states that the ability to control stress effects is the principal factor that makes a person cope with stress events. It is the ability to control the stress effects that prevents the release of stress-related hormones or the impairment of the immune system. With the support of human quasi-experimental studies, Bandura describes the effect of being able to gain control over the stressful situation. For instance, catecholamine levels in phobic patients dropped after allowing them to acquire controlling efficacy. Pain tolerance was increased in normal subjects when there was self-efficacy, even in those subjects to whom naloxone was administered to block opioid activation. Self-efficacy mechanisms play an essential role in the individual’s well-being. Bandura’s theory proposes an entire psychological approach to deal with stressful events that deteriorate our biological systems. This approach provides an intelligent stimulus to operate in the sphere of human maladaptive behaviors with “clean” psychological tools but with an attentive eye on the neurobiological domain.

Part III of the book explores broader issues in the field of emotion and affect and presents two models. Gray describes three systems that control emotional behavior. Each of these systems is associated with a particular area in the brain. One of these systems, the behavioral inhibition system, is thought by Gray to be centered around the hippocampal formation. This system is responsive to stimuli associated with punishment or with the conditioned aversive stimuli and is involved in increasing the level of arousal and increasing attention to the environment to cope with the new situation. Anxiolytic drugs affect the septohippocampal system, and lesions of this system lead to a behavioral syndrome similar to that seen after the administration of anxiolytic drugs. These results are the strong-hold of Gray’s theory. The amygdala, a structure that has long been considered to play a pivital role in fear, including fear learning, is not included in the behavioral inhibition system. It is involved instead in the second system, the fight/flight system, which is responsive to unconditioned punishment and non-reward, that is, to issue commands either for fight or for flight depending on the context and type of punishment received. Gray dismisses fear conditioning studies as irrelevant to the problem of anxiety and relegates them to elicitor of a more species-specific type of defence or attack responses. We do not agree with such a view. Nevertheless, Gray’s model is commendable in its breadth and attempt to synthesize divergent findings into a unified theory of anxiety. The second model uses the opponent-process theory to explain a large set of affective phenomena, taken from everyday life and experimental settings. This model states that it is possible to produce acquired motives by non-associative mechanisms alone. The mechanism is repetition, not conditioning (association). Solomon believes that his approach can explain food intake, drug addiction and related phenomena that Pavlovian conditioning is not able to explain. An important question that the author raises is whether or not the opponent-process states are predictable. He is convinced that they are and analyzes the process of food intake and obesity following the logic of opponent-process theory.

Neurobiology of Learning, Emotion, and Affect is a well organized, multi-disciplinary book. It presents a range of approaches and contributions. The literature on behavioral neuroscience, in general, has increased tremendously in the last few years. Moreover, there is a growing interest in research on emotion, which has been somewhat neglected in the age of cognition. This book will help bring research on emotion into the limelight. The book will be very useful as an introduction to research on the biology of emotion and learning and will also be useful as reference point for future research.

The Course of Life, Vol. 4, Adolescence

The Course of Life, Vol. 4, Adolescence

Stanley I. Greenspan, George H. Pollock

Madison, CT: International Universities Press Inc., 519 pp., 1991

About ten years ago The National Institute of Mental Health published “The Course of Life: Psychoanalytic Contributions Towards Understanding Personality Development,” edited by Drs. Greenspan and Pollock. These volumes were very popular as a description of psychoanalytic thinking in a developmental model. The various volumes of this series have now been reissued in a series and expanded in a new publication. Of the series, The Course of Life, Volume 1, Infancy, consisted of a number well-received articles. Volume n, Early Childhood, was made up of a number of articles that were similarly valued. Both volumes received good reviews. Volume HI, Middle and Late Childhood was equally well reviewed.

Volume IV, Adolescence, like the others in the series, is a collection of essays to be read separately but in the context of this particular stage of development. There are twenty-four contributions by Peter Bios, Judith Kestenberg, Helen Beiser, Joseph Noshpitz, Daniel Offord, Hilde Bruch, Richard Isay, and Melvin Lewis. The twenty-four articles cover the development of the adolescent from the pubescent years and early adolescence through mid-adolescence to late adolescence and early adulthood. The articles provide an excellent overview of adolescence and youth. They highlight the important problems and present very effectively classical and modern views of development.

I would recommend that anyone practising child and adolescent psychiatry should have all four of these volumes in their own library. For anyone else practising psychiatry, this series represents an excellent reference source for consultation on any question of developmental concern.