Archive for October, 2009

Clinical Assessment of Malingering and Deception

Clinical Assessment of Malingering and Deception, 2nd edition

Rogers R, editor

New York: The Guilford Press; 1997. 525 pp with index

ISBN 1-57230-173-2 (cloth)

Malingering is somewhat of a taboo subject in clinical psychiatry and medicine. Physicians are so steeped, by history and training, in the trust and good faith that accompany the physician-patient relationship that the very idea that a patient could deliberately and maliciously mislead a doctor in a clinical setting is anathema to many physicians. The physician’s mindset is that the patient comes for help “in good faith”; an attitude of suspicion regarding motives is not likely to engender trust and promote rapport.

Human nature being what it is, however, it is clear, on a priori grounds alone, that not all who come into the office of a physician have pure and honest motives. Physicians are poorly prepared, by training and temperament, to spot such dissimulation. According to the authors of this book, this problem is becoming more prevalent, and we do our patients, our profession and our society little good by prolonging our ignorance. Our naivete was used by the antipsychiatry movement some years ago, by individuals who achieved notoriety by simulating psychiatric disorder to gain admission in a psychiatric hospital in order to condemn publicly the conditions therein.

This is the second and much expanded edition of a book first published in 1988. In his introduction, the editor estimates that the prevalence of dissimulation is approximately 15% in forensic psychiatry settings and 7% in nonforensic clinical settings. It is particularly likely to occur when the clinical setting is under outside, third-party control, rather than patient control. The author puts forward an “adaptational model” to explain why malingering occurs. This model posits that malingering is more likely in an adversarial (e.g., forensic) setting, when the stakes are high, when no other alternatives appear viable and when the aim is to cope with and if possible avoid a potentially destructive and conflictual situation. The author regards malingering and defensiveness as polar opposites: the malingerer creates or exaggerates symptoms, whereas the defensive individual denies or minimizes symptoms.

The rest of the book is divided into 4 parts. Section I contains the meat of the book and deals with diagnostic issues, including factitious disorder, malingered psychosis, the relationship of malingering to personality disorders and sociopathy, simulated amnesia and pseudomemory phenomena, misreporting of substance abuse, and post-traumatic disorder and deception in children.

Malingered psychoses (including delusions and hallucinations) are difficult to identify. Although they are not common, they should be considered in any patient with an atypical psychotic presentation, particularly when the phenomena seem bizarre and inappropriate. Concerning management, “the suspected malingerer should be given every opportunity to save face. Once feigning is denied, a malingerer may have difficulty admitting it later.” The identification of feigned psychosis is clearly an important clinical problem with many legal and other implications.

The chapter on simulated amnesia and pseudomemory includes a fascinating review of recovered memories and false-memory phenomena. Numerous studies have supported the conclusion that “confidence in a memory correlates only weakly with its fidelity.” Children who have witnessed nonsexual traumatic events, such as the assault or murder of their parents, all develop psychiatric symptoms, and none fail to recall the event, although they often engage in avoidance behaviour. Furthermore, durable, permanent memories of childhood events are not formed before the age of 3 or 4 years, when the development of the hippocampus is complete. The author concludes by emphasizing the importance of following well-established principles that govern the establishment, elaboration and reconstruction of all memories and that help to disengage the recovered memory/false memory debate from the tabloids and place it on a firm scientific foundation.

The chapter on malingering in post-traumatic disorders also provides a fine review of a controversial subject. The incidence of malingered psychological symptoms after injury is unknown, but estimates vary from 1% to 50%. The reluctance of psychiatrists to suspect malingering is exemplified by the case of a man who was presumably mute for 2 years after a head injury. Eleven psychiatric reports failed to mention the possibility of malingering; however, a skeptical neurologist observed the man speaking normally after an office visit. Recovery after settlement of litigation is often given as a justification for malingering, but recovery is likely not as common as was once thought. A minority of patients with post-traumatic somatoform pain disorder also have a post-traumatic stress disorder, and this may help to explain the pathogenesis of the pain. In complex cases, it is helpful to obtain corroborative information regarding patient behaviour in nonclinical settings, or even to admit the patient to hospital for observation and assessment. Previous history of sporadic employment, extensive absences from work and previous incapacitating injuries may also be helpful in supporting a hypothesis of malingering.

Section II reviews the use of psychometric assessment, including the MMPI-2, the Rorschach test and neuropsychological tests. Of these, the MMPI-2 appears to have the most value in identifying malingering and defensiveness. Section III deals with specialized methods of investigating patients suspected of malingering. These include chapters on interviews assisted by drugs (particularly amy-lobarbitone sodium), polygraphy, hypnosis, structured interviews (including particularly the SADS and the SIRS), detection of dissimulation in sex offenders and the use of self-report instruments. Section IV includes a useful summary of the field and techniques that may be used to confront a patient suspected of dissimulation. The author emphasizes the importance of being judicious in such a confrontation, the goal of which is to “clarify areas of ambiguity and offer insight into possible motivation/’ The author also gives examples of the wording of questions that may be used when confronting a patient suspected of defensiveness or malingering.

The editor is a forensic psychologist who has published extensively in this field; he is also the author of 6 of the 19 chapters in this book. The remaining chapters have been authored by North American psychologists and psychiatrists. Each chapter follows a consistent format, and there is little repetition and overlap. Post-traumatic stress disorder, amnesia and recovered memories are of intense topical interest in Western society and are very well reviewed in this book, which will stimulate interest in a field largely neglected by psychiatrists. The bibliography is extensive and up-to-date. This book can be highly recommended to clinicians, particularly those with an interest in psychiatry and the law and those involved in the management of patients with disability and post-traumatic disorders.

Social Skills Training for Schizophrenia

Social Skills Training for Schizophrenia: A Step-by-Step Guide

Bellack AS, Mueser KT, Gingerich S, Agresta J

New York: The Guil-ford Press; 1997. 288 pp with index

ISBN 1-57230-177-5 (cloth)

This book is a practical guide to the delivery of skill training to patients with schizophrenia. It is one in a series of treatment manuals for practitioners and, as such, will be immensely useful in teaching rehabilitation students and refreshing the skills of practising clinicians. As the title promises, it is a step-by-step guide whose method of teaching parallels the techniques recommended for teaching patients with schizophrenia: establishing a rationale, breaking the task into small steps, modelling, engaging, reinforcing, over-learning and generalizing. These are tried-and-true educational methods and can be applied, as the book suggests, to the teaching of any number of skills: social and vocational skills, medication management, safe sex, relapse prevention, and drug and alcohol avoidance — all skills necessary for the survival of patients with schizophrenia. Navigating the complexities of the mental health, legal and financial-benefits systems, learning how to parent and volunteer — these are other essential skills that the book does not mention but which, by extension, can be taught through the same methods.

The authors are acknowledged experts in the field and have had years of experience in this area. One problem with the book is that it is dreary to read and leaves the impression that the method may also be dreary for patients to experience. The repetition becomes oppressive. Putting myself in the patient’s shoes, I would not enjoy this form of constantly enthusiastic, encouraging, optimistic, repetitive role playing. I think I would be one of the early drop-outs. But individuals differ, and many people (the large majority who like group activities, camp songs, marches and bands) would probably be pleased to be included in these uplifting, persevering, unconditionally positive efforts.

A second problem with the book is that it does not provide any evidence that these efforts actually accomplish their ends. My own clinical experience over the years, with thousands of patients with schizophrenia who attended hundreds of skill-training groups, is that they are no more skilled in the long run than those who stayed at home and watched television. On the other hand, because the patients spent more time out of the house, their families have experienced definite relief, hope for improvement has been consistently nurtured, and the patients have formed acquaintanceships and even friendships. On the whole, therefore, there is much to be said for social-skills training. One wonders, however, if there is not a large segment of the population with schizophrenia, loners by nature, who would not benefit more from the delivery of information through individualized programs via television or home computer, now that these technologies are available. Are we doing people with schizophrenia a favour by emphasizing social skills as the cornerstone of mental health? These skills do not come easily to this group of individuals. Would it not be preferable to place “official” value on the skills in which many people with schizophrenia are innately expert: the lonely but potentially rewarding pursuits of art, music, literature and fantasy?

Multi-axial Classification of Child and Adolescent Psychiatric Disorders

Multi-axial Classification of Child and Adolescent Psychiatric Disorders: The ICD-10 Classification of Mental and Behavioral Disorders in Children and Adolescents

World Health Organization

New York: Cambridge University Press; 1996. 302 pp with index

ISBN 0-521-58133-8 (cloth)

For many decades, psychiatric epidemiology involving comparisons among countries has been handicapped by different classification systems. North Americans tend to use the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria, developed primarily by committees of the American Psychiatric Association, whereas western European countries use the International Classification of Diseases system, now in its 10th revision (ICD-10). This book is the ICD-10 equivalent of the big green DSM-IV manual that lists the multi-axial classification of psychiatric disorders, together with the brief description of signs and symptoms that make up the essence of the diagnoses.

The introduction, by the eminent child psychiatrist Michael Rutter, is first-rate. It indicates that there has been serious corroboration with DSM-IV. The similarities, including the use of a multi-axial description of each diagnosis and brief descriptions of signs and symptoms, are much more evident than any differences. As with DSM-IV, the diagnoses are based on clinical description and not on etiology, since precise causation in psychiatric disorders cannot be determined in most diagnostic categories.

As is often the case with British medical textbooks, the language is more succinct and the book is shorter than its North American counterpart.

A compare-and-contrast exercise does reveal some interesting, although relative minor, differences. Autism or pervasive development disorder and mental retardation are placed on axis II, instead of on axis I, in the ICD-10 system.

Under conduct disorders, always a problematic diagnostic category, there is an intriguing and possibly useful category called “conduct disorder confined to the family context.” In the section on affective disorders, the ICD-10 system does not include rapid cycling bipolar disorder.

The ICD-10 system has maintained a category of neurotic disorders, which are virtually identical to the personality disorders in DSM-IV. Among the neurotic disorders described by ICD-10 is “neurasthenia.” This concept, which feels outdated from a North American perspective, is related in a fairly modern way to postviral fatigue states and depression. “Neurasthenia” appears to have resurfaced in North America as chronic fatigue syndrome.

The section in ICD-10 on personality disorders suggests that these disorders can be diagnosed as early as 16 years of age, in contrast to the North American view that personality disorders begin only at age 18. The North American approach takes into account the flexibility of adolescent minds, which we hope will not settle into permanent personality structures prematurely. The use of the term “anankastic” for obsessive-compulsive disorders is another example of the way that traditional psychiatric phenomenology is maintained in the ICD-10.

Another example of a difference in terminology, which is illustrative of British brevity, is “clumsy child syndrome,” which is the same as “developmental coordination disorder,” described in DSM-IV.

In contrast with DSM-IV, ICD-10 does not set up lists of symptoms with the instruction that 3 or more must be present. There is usually a description of the general presentation of the problem. Instead of counting up symptoms, the clinician then forms personal impressions and makes his or her own judgements.

Axis V in ICD-10 refers to associated abnormal psychosocial situations. This is virtually the same as axis IV in DSM-IV, which refers to psychosocial and environmental problems. I found, however, that the ICD-10 axis V was more specific and clearer in describing the precise problems that children and families have. For instance, there is a specific category for lack of warmth in parent-child relationships, for scapegoating of a child, for disability in a sibling, for experiential privation and even for parental overprotection. Such clear categories allow family dysfunction to be introduced diagnostically in a clearer way.

The ICD-10 text on multi-axial classification of child and adolescent psychiatric disorders is a parallel but not identical effort to the DSM-IV currently in use in North America. Each system has something to teach the other. The continuing collaboration between the two evolving systems can only be of benefit. This book is not exactly a thriller to read, but for those interested in international collaboration in clarity of diagnostic categories, it is a very important sourcebook.

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

This book describes the role of primary care physicians in the prevention of mental disorders. The literature consistently reports that 25% to 30% of patients presenting in primary care have significant psychological problems. The book is divided into 3 sections dealing with the major types of illness prevention: primary (risk factors), secondary (early identification and intervention), and tertiary (decreasing complications and recurrence). These distinctions are not consistently followed, but overlap between sections is avoided. Each chapter is well referenced, and most chapters cover the subject adequately. A preventive model of conceptualizing problems is employed, but the flaw in this approach to primary prevention is acknowledged. Many known risk factors, such as social, economic, and societal conditions and attitudes, cannot be modified by primary care professionals. Effort must be directed primarily at high-risk patients. The authors recognize that some physicians lack sufficient interest and ability to diagnose and manage psychiatric illness and throughout the book suggest ways to address this problem.

Chapters 1, 9, and 15 deal with primary, secondary, and tertiary prevention of childhood psychiatric disorders. Risk factors in the child, parenting, and environment, as well as protective factors, are very well described. Most children are seen regularly in primary care, which gives these practitioners a unique opportunity to employ all 3 types of prevention. When disorders are detected, care must be taken to avoid inappropriate reassurance and unnecessary pharmacotherapy. The role of the family in the management of chronically ill and disabled children is emphasized, along with the need to provide support to the parents. Chapter 3, on the relevance of life events in mental illness, relies mainly on the work of George Brown and his colleagues. A practical guide for intervention strategies is also included. Prevention of postnatal depression, a distinct diagnosis in British psychiatry, is discussed in Chapter 4. The unique opportunity for primary care physicians to detect this disabling condition is emphasized, but the suggested role for health care visitors is generally unavailable in this country. Chapter 5, on bereavement, has a good description of normal grief and an excellent discussion of risk factors for abnormal grief reactions. Practical suggestions for the appropriate use of counseling and medication are included.

Chapter 6, on prevention in ethnic minorities, is quite specific to British society, although the principles of how physicians perceive, interpret, and treat psychiatric problems in ethnic patients are universally applicable. The chapter on “learning disability” is initially confusing because in Britain, unlike North America, the term refers to developmental delay. The references suggest that 33% to 66% of children with “learning disability” have significant psychopathology. The important role of primary care practitioners in secondary prevention is discussed, but the use of a team for management is seldom feasible for Canadian family doctors. Chapter 8 contains a general discussion of the importance of good counseling skills but again assumes the existence of a primary care “team” of professionals.

Chapters 10, 16, and 17 describe secondary and tertiary prevention of depression. This common and treatable disorder is frequently unrecognized in general practice both because of the symptoms presented (often somatic) and the knowledge, skills, and attitudes of physicians. Ways to improve the detection rate are described, and an excellent section on long-term drug management is presented. The particularly important role of general practitioners in encouraging compliance is acknowledged. Discussion of psycho-therapeutic interventions in the management of depression is limited to a good description of cognitive therapy. Primary and secondary prevention of anxiety disorders is addressed in Chapter 11, which includes a discussion of the physical, behavioral, and environmental factors that maintain anxiety symptoms. The author recommends and briefly describes nonpharmacological management techniques, although the use of a team approach is again assumed. Chapter 12, on eating disorders, addresses the well-recognized problems in primary prevention that deeply ingrained societal attitudes are impossible to change and that prevention programs sometimes increase unwanted behaviors (for example, binging and purging). The physical consequences of these disorders are well outlined, but little reference is made to the psychological and social sequelae. Detection of eating disorders is a major responsibility of general practitioners but requires a high level of awareness of risk factors and signs and symptoms — these patients are often very secretive. Not discussed is the role of physicians in monitoring physical health or supportive counseling as an adjunct for their patients who attend specialized treatment programs. Chapter 13, on alcohol and drugs, describes the detection and management of alcohol abuse, as well as the primary prevention of medication abuse by judicious prescribing practices. Because drug seeking from multiple physicians is uncommon under the British system, the problem is not mentioned in this book. Psychosis, primarily schizophrenia, is discussed in Chapters 14, 18, 19, and 20. As in Canada, general practitioners are now expected to detect and treat 1st-episode psychosis, and the importance of early pharmacological treatment is emphasized. Increasingly, patients are managed for the long term in primary care, and physicians must be aware of the special physical, psychological, and social needs of this vulnerable group and be cognizant of the high suicide risk. Social management of patients with schizophrenia is well described, with emphasis on the role of families. In Canada, the functions proposed for primary caregivers are provided, if at all, by specialized mental health services. Finally, Chapter 21 briefly discusses suicide prevention in primary care. The major roles are to recognize patients at risk, provide treatment and/or referral, and offer support for staff and families when suicide occurs.

The authors of this book are academics from general practice and psychiatry backgrounds. The intended audience is primary care physicians and their teams, but the book should also be read by psychiatrists and mental health professionals who treat patients also seen by family doctors and who teach medical students and residents. In conclusion, this is a very readable volume which is well researched and which provides good recommendations, although some are not applicable to the Canadian system.

The Clarke and Its Founders: The Thirtieth Anniversary

The Clarke and Its Founders: The Thirtieth Anniversary. A Retrospective Look at the Impossible Dream

D Frayn, editor

Toronto: Coach House Press; 1996.181 p

This is a book about the Clarke Institute of Psychiatry. Essentially, it presents a series of interviews of past and present luminaries, with Doug Frayn acting as interviewer and editor. Frayn, as a distinguished psychoanalyst, allows himself a piece of puffery regarding the title. Noticeably, all the comments in the book, and more so in the references, are idiosyncratic. Each of us trained, matured, and gilded at the Clarke will cherish different memories. That they may matter to others is a nice thought, but not critical. As Frayn would endorse, our memories are our delight as well as torment.

I was at the Clarke Institute for almost a quarter of a century, and I savor some memories, laugh at others, and see poignancy in yet others. I remember Robin Hunter, on my coming from Australia in 1971, looking astounded at the cost of removal and declaring he never had such an expensive relocation. Shortly after my arrival, I recall having been honored with an invitation to the monthly Friday-night poker game at his house and being mortified at being jejune, not having played for many years. In the end, however, by 06:00 on Saturday, I’d only lost $100! As I reflect on the decency of Robin Hunter, who always ate at noon at the same table on the 12th floor and was patient about and receptive to anxious questions, crass remarks, and timid jokes, I bear in mind his concerns expressed at the same table before his exploratory surgery, which led to his premature death.

Other events have become a kaleidoscope. Harvey Stancer ran the research ward and was a great chief. He always had his staff back to his house for parties and genuinely cared for them: he was the quintessential chief of service. I remember antivivisectionists bombing the research wing with a very serious risk to life and limb there; Ben, the barber, who cut our hair and would look pained if we went elsewhere; Molly, who presided over the cafeteria; and Siebert, who delivered the mail while singing hymns. I recall the ongoing obsession with rebuilding — the Clarke must have been built and rebuilt many times from within, producing many rooms with no soundproofing so that the secretaries had to play their radios to avoid hearing their bosses’ psychotherapy interpretations. There were also the maintenance staffs Christmas parties in the basement; the Christmas shows; the transsexuals with skirts and large boots waiting on the 4th floor for treatment; the patients with schizophrenia who used the place as a hotel; and the staff and patients who smoked outside the building together when the no-smoking legislation was passed.

Now we are somewhat at a nadir. The Clarke as I knew it has changed and is due to merge with Queen Street Mental Health Centre. The scenario will change, and things may never be the same again. Nevertheless, the same thing must have been said many times in the past 30 y. Change has been inevitable at the Institute, without necessarily being beneficial. Ironically, Charlie Roberts, the Clarke Institute midwife, recently died at about the time the Clarke was told it would lose its free-standing, unique place in Canadian psychiatry. Although he was not seen much at the Clarke during its 3 decades of existence, he surely would be 1 of the only people who could have said what the original dream was.

Those wanting to see how the work tallies with their own dreams and memories should read the book.

Hyperactivity Disorders of Childhood

Hyperactivity Disorders of Childhood

S Sandberg, editor

New York: Cambridge University Press; 517 p

This book reveals some of the differences in the approach to diagnosis and treatment of attention-deficit hyperactivity disorders (ADHD) between the clinicians and researchers from Europe and those from the United States. The Australian and Canadian contributors seem to bridge these different approaches. The book is edited by a British psychiatrist from the Royal London Hospital. She has worked with E Taylor, who has spent some of his time in the United States.

The book has 13 chapters, of which 3 very good ones are written by the editor with some of her colleagues. One of these is on the historical development of the diagnosis, etiology, and treatment of ADHD, 1 on its clinical aspects, and another on the psychosocial contributions to the hyperactive child. Other chapters include the epidemiology, developmental aspects, sex differences, and cross-cultural aspects of hyperactive children and children with associated conditions such as conduct disorders and reading disability. There are 3 excellent chapters: 1 on the treatment of ADHD by the Canadians Schachar, Tannock, and Cunningham, 1 on outcomes by Swedish researchers Gilberg and Hellgren, and 1 on biological aspects by Tagade and Takagi. Overall, the book has a rich international flavor. Only 1 chapter (on the developmental aspects of ADHD) was rather densely written; its author did not indicate what she felt were the most important research findings on this subject, but rather gave a long list of findings. Further, a citation in this chapter (p 153) to Biederman, Newcord, and Sprich (1990) is not listed in the reference section, which is somewhat irksome. In addition, some of the developmental findings are covered in an earlier chapter on the clinical aspects of ADHD.

In contrast, the chapter on the biological aspects was clear and interesting, and that on gender differences by Heppinstrall and Taylor showed some fascinating results “which may well give clues to the etiology of the disorder” (p 344). They suggest that girls do not have an overrepresentation of hyperactivity in their families and that mild degrees of hyperactive behaviour in girls should not be “given undue weight as peer relationship impairment and educational failures may be more important targets for therapy.”

It was particularly useful to find all the epidemiological studies and the basic investigations on attention reviewed in 1 place. The book was equally comprehensive in its review of several other topics, which makes it an invaluable resource text.

In the preface, the editor states that this is the 2nd of a monograph series “aimed at practitioners in child and adolescent mental health services and researchers in development and clinical neuroscience” and that “it is intended that there should be detailed consideration of topics less commonly found in standard texts” (p xix). This book accomplishes these goals admirably. It is interesting, different, and well presented, and for the most part, the contributions are of an evenly high standard. I would strongly recommend it for clinicians and researchers who deal with children who have behavior disorders.

Biology of Schizophrenia and Affective Disease

Biology of Schizophrenia and Affective Disease

SJ Watson, editor

Washington (DC): American Psychiatric Press; 1996. 540 p

Over the past 30 y and particularly over this last decade — the decade of the brain — there has been marked acceleration of research efforts in the fields of neuroscience, molecular genetics, and biochemistry of mental disorders. Coupled with increasing sophistication in clinical observations, there has been an explosion of information about mechanisms of normal and pathological brain function. Although we are still far away from a clear understanding of the psychopathology behind 2 of the major psychiatric disorders, schizophrenia and affective disorders, substantial information already exists linking subcellular biological activities and the functioning of the neurons. The integration of information from molecular genetics, biochemistry, pharmacology, brain anatomy, and neuroimaging has advanced our knowledge about the impact of mental illness on specific brain neural circuits and their response to treatment. The recent and evolving knowledge about such specific brain circuits has inspired a new strategy of pharmacological targeting in the treatment of mental disorders. In this context, this book has its major strength focusing on the interface between several mental disorders and the genetics, pharmacology, neurochemistry, brain imaging, and postmortem studies reported by the researchers themselves, who are active in these fields.

The book emanates from contributions by a number of well-known and accomplished researchers in neuroscience to the 73rd meeting of the Association for Research in Nervous and Mental Disease, which took place in New York in 1993. One major feature of that meeting was that speakers were asked not only to present an overview of their field and their own work but also to provide their views on future developments. The book includes 17 chapters that deal with topics related to schizophrenia, affective disorders, infantile autism, an introductory chapter by the editor himself, and an overview chapter with discussions at the end. The introductory chapter by Watson presents an overview of mood disorders, autism, and schizophrenia from a clinical perspective and sets the stage for the basic science chapters that follow. The chapter written by Akil, “Biology of Stress from Periphery to the Brain,” explores the concept of “stress” as a trigger for psychiatric illnesses. The contributor documents her extensive work on the regulation of the limbic-hypothalamic pituitary-adrenal access and makes clear the well-known point that “the stressful nature of any given stimulus resides less in its objective characteristics and more in the organism’s ability to cope with it” (p 15).

The 5 chapters that relate to affective disorders include a contribution by Blakely about norepinephrine and serotonin transporters that highlights the progress on the molecular targeting of antidepressant effects. Another chapter, by Owens and others, deals with peptides and affective disorders and concludes with an account of future directions in the area based on the development of such new approaches as the application of ribonuclease (RNASE) protection assay, the expanding knowledge of the peptidergic brain circuits, and the ability to image central nervous system tissue with magnetic resonance imaging and positron emission tomography technology. The chapter about the mechanism of action of antidepressants by Berman and others elegantly reviews information, both basic and clinical, about well-known monoamines that have been explored in terms of their mechanism of action: serotonin, norepinephrine, dopamine, and neuropeptides. The chapter delves beyond the monoamines theory, however, by exploring postreceptors signal transduc-tion and neuroanatomy of antidepressant action and their relevance for the development of novel treatment approaches to depressive disorders. The chapter by Raichle and Drevets maps brain circuits relative to brain function and explores its implication for psychiatric illnesses. Another excellent chapter, by Mann and others, presents an up-to-date review of available information spanning more than 2 decades about postmortem studies of suicide victims.

The book includes 8 chapters related to schizophrenia. The chapter by Benes entitled “Excitotoxicity in the Development of Cortico Limbic Alterations in Schizophrenia” examines both the proposition that schizophrenia is a neurodegenerative disorder and the evidence for glutamatergeric dysfunction in schizophrenia. Goldman-Rakic, in her chapter, “Dissolution of Cerebral Cortical Mechanisms in Schizophrenia,” advances the argument from a neurocognitive perspective about the importance of frontal cortex and the role of working memory in the disordered thinking of patients with schizophrenia. Using postmortem studies, Kleinman and Nawroz provide evidence for the involvement of dorsal lateral prefrontal cortex, the hippocampus, and the entrorhinal cortex in the pathology of schizophrenia. An up-to-date review of the “Epidemiology and Behavioral Genetics of Schizophrenia” is provided by Tsuang and Faraone. Khan and her colleagues, in their excellent chapter, “Revisiting the Dopamine Hypothesis in Schizophrenia,” advance the argument for schizophrenia as both a hyper- and hypodopamine state, thus linking such diverse elements of the broad spectrum of symptomatology as positive and negative symptoms as well as neurocognitive deficits. The contributions of neuroimaging to the understanding of the psychopathology of schizophrenia is well presented in a chapter by Van Horn and colleagues. “Abnormal Frontotemporal Interactions in Patients with Schizophrenia,” by Friston and others, provides results of their extensive work using neuroimaging in examining functional connectivity by studying corticocortical interactions in patients with schizophrenia. The last contribution related to schizophrenia is the excellent chapter by Meltzer and others, “Exploring the Mechanism of Atypical Anti-psychotic Medications,” which provides evidence for Meltzer’s recent argument for a major role for serotonergic mechanics in the improved therapeutic effects of atypical antipsychotics, particularly their tendency to produce significantly fewer extrapyramidal side effects.

The chapter devoted to “Linkage and Molecular Genetics of Infantile Autism” by Ciaranello reports the results of extensive linkage studies of 1 of the least understood disorders: infantile autism. This chapter, coming after the recent sudden and untimely death of its author, serves as a memorial to a distinguished scientist.

Overall, the book is a significant contribution, providing valuable information for understanding the mechanisms of normal and pathological brain function and its relevance to schizophrenia and affective disorders. The book makes a good attempt to integrate information at the level of functional neurocircuits. It should be of interest not only to neuroscientists but also to psychiatrists, neurologists, and psychologists. Although the book is about basic neuroscience, its relevance to clinicians is obvious because it explores the basic biological brain functions in relation to mental

illness. The book reads well, which reflects the skills of its editor, Stanley Watson. The only regret I have is that it took 3 y to publish the proceedings of that 73rd meeting of the Association for Research in Nervous and Mental Disease, which is rather a relatively long time in terms of the rapidly evolving neuroscience research. Nevertheless, the book is a valuable contribution and continues to be equally relevant today.

Essential Psychopharmacology: Neuroscientific Basis and Practical Applications

Essential Psychopharmacology: Neuroscientific Basis and Practical Applications

SM Stahl

New York: Cambridge University Press; 1996. 379 p

If you, like many others, admired Stephen Stahl’s beautiful slides on neuropharmacology during one of his many lectures at psychiatric meetings, you can now have his graphics in 1 book, all 300 of them. His charming drawings intelligently reduce very technical neuroscience concepts to very comprehensible illustrations.

The book will appeal to a wide readership. It provides an easily readable introduction to neurobiological concepts for the novice, and for the practicing psychiatrist, it offers a quick review of the principles. Never before have I had such an enjoyable refresher course on neuropsychopharmacology. The book will also appeal to educators, whether they are teaching nurses, medical students, residents, or physicians taking continuing medical education.

The text is remarkably lucid, instructive, and entertaining, and yet it remains an authoritative representation of the field. In the rapidly expanding arena of neurosciences, where it is so difficult to keep up with the explosion of knowledge, the book is commanding yet easy to assimilate. The text will certainly prepare the reader well for dealing with more complex professional literature. The reader can sense that the material has been tested in many lectures and polished for clarity.

One particularly delightful aspect of the book is its attempt to apply the principles of programmed learning. Thus it is possible to acquire a good overview of the material by 1 st going through the book from beginning to end and reviewing only the color graphics and the corresponding legends. In the 2nd reading, the graphics may be reviewed while the text is read in detail. Finally, a rapid review of the graphics can serve ‘ as a solid refresher.

The text is accompanied by a wealth of high-quality color graphics, simplified diagrams, and funny cartoons. This whimsical approach serves the author very well when dealing 1 with the neuroscience issues, although some of his clinical points come across as less happy that way. In the clinical parts, there are a few inaccuracies, and some oversimplifications went, in my opinion, a bit too far (for example, “virtually every known antidepressant has the same response rate namely . . . 67%”; or suggestions of the genetic basis of posttraumatic stress disorder). If you are a visual learner and are looking for an excellent book on the basic neuropharmacology of psychotropic drugs, I suggest you buy this one.

Consciousness, Dreams, and Self: A Transdisciplinary Approach

Consciousness, Dreams, and Self: A Transdisciplinary Approach

JB Arden

Madison (CT): Psychosocial Press; 1996. 192 p

This book about consciousness is more than transdisciplinary; it examines consciousness from evolutionary viewpoints, mathematical perspectives, biopsychosocial perspectives, self and other psychology theories and indeed, it seems, from just about every point of view that exists. Even if you learn nothing about consciousness by reading this book, you will become educated to the ideas of Niels Bohr, Heisenberg’s Uncertainty Principle, neuroanatomy and neurophysiology, expanding into sociocultural dynamics and the self system and dreams. I don’t know what is not covered, and I found the book, for the most part, intensely taxing to read but very worthwhile. There are a few chapters that are less sophisticated, but these really do not detract from the value of the book as a whole; in fact, they give the reader time to breathe. Philosophy and religion are mentioned (less adequately), but since the book is only 192 pages (including the index), you cannot expect a comprehensive treatment.

The author’s concept of consciousness is thoroughly explored, although never well defined or explained. The nature of consciousness is suggested in many different ways, but no satisfactory answer is found. The title of the book includes “Dreams” and “Self.” Dreams do take up several chapters, but neither self nor dreams are well integrated into the material, and although there is new information, or at least interesting information, on dreams and dream content, including the sociocultural significance of dreams, the author could have chosen another title; as long as he included “consciousness,” it may have been equally worthwhile.

The Introduction is fascinating but might turn off some readers. It contains headings such as on page 11, “Complexity, Chaos and Nonlinear Dynamics,” and on page 16, “Incompleteness and Computational Complexity.” Section 1 attempts to explore the meaning and function of dreams from various perspectives “in order to demonstrate that the aspects of consciousness that are related to dreaming are multi-varied and co-evolve with nonlinearity.”

Chapter 2 presents an overview of the major aspects of consciousness, with an effort being made to highlight the interdependence of biopsychosocial factors. Later chapters discuss human evolution, making it seem more dynamic than Darwinian natural selection. There is discussion of consciousness related to dreaming and biophysiology, with a social psychology bent to this research. This discussion is too limited. There is also more discussion of sociocultural influences affecting the content of dreams. Toward the end of the book, traditional trends in psychology are developed to show the increasing fragmentation of schools of psychological approach and to allow the author to attempt what is earlier referred to as “a theoretical paradigm shift” (p 22).

The final 2 chapters are more traditionally psychologic, and the last chapter is an excellent discussion of “the ausculating process of’self-organization.’”

The book at times seems like a wild though slow-paced ride. There are parts of the book that require concentration and some lines that must be read several times. At the end of the book, the reader will feel much better acquainted with the concept of consciousness and the different ways that it can be examined. The book is, therefore, worthwhile although not always easy to read.

Psychiatry in Progress

Psychiatry in Progress, Volume 3: Neuropsychiatry in Old Age

C Stefanis, H Hippius, editors

Toronto: Hogrefe &Huber; 1996. 171 p

This slim volume contains the proceedings of a symposium sponsored by Ciba-Geigy and held on the island of Rhodes, Greece, in April 1994. Its aims are both to outline the current state of scientific knowledge on the biology of aging and to address major issues relating to neuropsychiatric disorders in the elderly. Unlike the published proceedings of many other symposia, this volume is well written, well edited, and flawlessly produced.

Internationally recognized experts, most from Europe, distill knowledge on selected topics that range from molecular biology to ethical issues near the end of life. For example, Wisniewski writes on the neuropathology of Alzheimer’s disease caused by fibrillation of A, p, and tau proteins; Copeland writes on the comparative epidemiology of dementia and depression in old age; Ritchie writes on psychological testing, and Gottfries writes on the pharmacotherapy of cognitive deficits. Each chapter begins with a useful summary and finishes with pertinent references and discussion from the floor.

The chapters are concise and informative but not comprehensive. Usually, each chapter presents a point of view or develops a theme that summarizes current knowledge and highlights a topic or issue requiring further research. For example, Bar and Gispen cite evidence that neuroplasticity exists throughout the life span and may be modifiable with calcium channel-blocking drugs; Muller-Spahn and Hock examine the spectrum of dementia and depression and propose biological approaches to the differential diagnosis of these disorders.

Obviously, this book is neither a text of neuropsychiatry in old age nor a reference work. Rather, it contains a series of interesting and authoritative reports on 13 selected topics. It is therefore a valuable book for the geriatric psychiatrist or psychologist who wants some challenging recreational reading or even for the general psychiatrist who wants to explore more recent developments in the neuropsychiatry of old age.