Archive for November, 2009

Problem Drinking

Problem Drinking, 3rd edition

Heather N, Robertson I

New York: Oxford University Press; 1997. 226 pages

ISBN 0-19-262861-5 (paper)

This book was somewhat of a challenge to review. Increasingly, recent empirical literature on substance-related cravings and relapses transcends the ideological boundaries and rivalries among 2 schools of thought: one characterizing addiction as a disease and one characterizing it as a learned behaviour. Recently, there has been increased recognition of the complementary nature of these approaches and a promise of improved patient outcome; Problem Drinking is a setback from this position. The authors, Nick Heather and Ian Robertson, are well-known exponents of a social-learning theory in the United Kingdom, although, surprisingly, their credentials are not mentioned in the book. They present a sustained argument that problem drinking is best regarded as a learned behavioural disorder rather than a disease.

The book is divided into 2 parts: the first is “unapologetically destructive” and reviews the current evidence countering the position that problem drinking is a disease. This is accomplished in 4 chapters, which account for 60% of the book. The first chapter reviews the changes in alcohol consumption in Britain and the influence of the temperance and prohibition movements on the disease concept. The second chapter presents a critical overview of selected literature in which alcoholism is looked upon as a physical shortcoming, a mental illness or psychopathology, or an acquired addiction or dependence. The possibility that recovering alcoholics can drink normally is addressed in the third chapter, and evidence derived from epidemiological surveys and laboratory investigations is presented. The fourth chapter outlines the potential detrimental effects of considering problem drinking a disease, including the licence to abrogate responsibility, the labelling of problem drinkers and the requirement for abstinence, and discusses the legal and preventive implications.

This literature review is a selective one. Of note is the limited reference to the neuroscientific research supporting the disease concept. Much work has been conducted on the notion of acquired addiction or dependence since the publication of works by E.M. Jellinek and G. Edwards. The findings of the current systematic research program, backed by neuroimaging and largely funded by National Institute on Drug Abuse, are not mentioned. Regarding the presence of a possible physical marker of vulnerability, the work of investigators such as Begleiter and Schuckit are omitted. Of particular interest to psychiatrists, the review of the evidence of alcoholism as a psychopathology is limited to the conclusions of Freud, Adler and Menninger. Has anybody made a more recent contribution? This portion of the book does not shy away from statements against phenomena such as “12 step hysteria” and “medical imperialism.” The perception of a conspiracy theory emerges from this book, where holders of the truth are ignored by the field at large, if not victimized.

Feeling somewhat chastised, one looks forward to the book’s briefer second part where the new paradigm is described: the social-learning theory. After a brief historical introduction, the applications of several types of learning theory to alcohol use are described. In classical conditioning, for example, new stimuli or “cues” evoke the desire to consume alcohol. Problem drinking arises when people interpret manifestations of withdrawal as cues to drink. Tolerance arises because of the homeostatic processes produced by the body to counter the action of drinking. Cue-exposure treatments owe their effectiveness in part to the extinction of conditional tolerance and withdrawal. Alcohol, by acting as either a positive or negative rein-forcer, also exposes a person to instrument learning. Community-reinforcement programs and aversive treatment harness this form of learning to promote abstinence. Higher forms of learning include modelling after, say, a parent’s behaviour, and self-regulation, lack of which prevents the person from stopping drinking. Higher cognitive processes, such as expectations, learned helplessness and the reasons for helplessness, also determine how alcohol is abused. Popular therapeutic approaches such as Marlatt’s relapse prevention and Beck’s cognitivenbehavioural therapy have focused on countering these effects.

The last chapter outlines other potential applications of social-learning theory: treatment programs, non-medical staffing, counselling and social policies. Even the results of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), which showed no difference between 12-step facilitation, cognitivenbehavioural coping skills and motivational enhancement therapy are interpreted in support of a more cost-effective social-learning theory. In fact, the media in North America have opted to perceive the results as a vindication of Alcoholics Anonymous!

My overall concern about this book is the deliberate effort to present evidence against the disease model and in support of the social-learning theory. In effect, most of the clinical programs I know have incorporated quite successfully therapeutic approaches from both schools of thought. Currently, moderate problem drinkers are likely to be advised by their physicians to set a “sensible drinking” goal, whereas heavy drinkers will be counselled to abstain. The spectrum of alcohol-related disorders is well recognized. Most therapists will not exclusively use 12-step facilitation, cognitivenbehavioural coping skills or motivational enhancement therapy, but will use each of these approaches at different phases of treatment. The case for polarization may not be as excessive as the authors purport, and the complementary nature of these approaches is not addressed.

In 1993, the Sobells published a book entitled Problem Drinkers. In the first 30 pages they discussed the lack of differentiation between problem drinkers and chronic alcoholics and for the rest of the book described useful treatment approaches for problem drinkers. I found this publication much more clinically relevant, but would recommend Heather and Robertson’s Problem Drinking to students who are eager to steep themselves in one of our field’s controversies. The price is appropriate for a library.

Handbook of child psychiatry for primary care

Handbook of child psychiatry for primary care

B. Robertson

New York: Oxford University Press; 1997. 368 pp

ISBN 0-19-571372-9 (paper)

This is a well written, concise book about psychiatric disorders of children and adolescents. It is written for the primary care physician, but it would be useful to medical students and psychiatric residents. The author is a child psychiatrist and head of the department of psychiatry at the University of Cape Town Medical School in Cape Town, South Africa. His many research interests and extensive travel experience make him very well qualified to write this book.

Not only are the various disorders and their management described, but there is also a chapter on assessment and the management of psychosocial problems in general. Parent education and education about illness are emphasized and expensive management approaches (e.g., individual psychotherapy) are mentioned, even though these apply to only a small number of patients. The disorders covered included attention deficit disorder, mood disorders, anxiety disorders, eating and somatoform disorders, dissociative disorders and culture-bound disorders. The latter are specific to South Africa and the chapter is very short but interesting. The substance-related disorders are especially well presented. All chapters are up to date, which is a remarkable achievement for a book with a single author.

The appendices list DSM-IV diagnoses and the Global Assessment of Functioning for children, which are useful, and the bibliography is selective but recent.

There are, however, some contentious statements. For example, I do not think that family therapy needs 2 highly skilled therapists; many programs only have 1 therapist per family. And the assertion that group therapy is “not commonly being offered,” may apply in South Africa, where primary care physicians are not be trained in this modality, but does not apply in North America.

This book is attractively presented and can fit into a jacket pocket (11 cm X 18 cm). Overall, I would strongly recommend this book; it is germane to countries other than the author’s home of South Africa and it is competitively priced.

Recovered memories and false memories

Recovered memories and false memories

Conway MA, editor

Don Mills (ON): Oxford University Press; 1997. 313 pp

ISBN 0198523866 (paper)

Freud’s theory of repression is a less homogeneous concept than one might think. Erdelyi, for instance, has shown that Freud used a wide range of descriptive terms in writing about the mechanisms of repression, ranging from unconscious to conscious suppression. Yet for more than 100 years Freud’s theory, or something similar, was accepted, at first quite gradually, then vigorously until it dominated the nonbiological half of psychiatry in the form of “dynamic psychiatry.” The theory has now suffered a precipitous decline in prestige and importance outside psychiatry, and seems likely to go the same way inside psychiatry, except that many psychiatrists — possibly the majority — have not yet recognized the bombshell about to explode, or do not appreciate its potential impact. This bombshell is the rejection of the main ideas of repression and dissociation as conceived to date, which has developed from 2 very different lines of enquiry.

The first line, which is less well known among psychiatrists, is the new Freud scholarship. This comprises a variety of biographical studies of Freud’s publications; accounts of his dealings with his patients as they saw themselves and as others saw them; important segments of his correspondence, which has shed quite a different light on his techniques and activities, compared with the impression conveyed by Ernest Jones in his famous (and sometimes very misleading) biography; the failure of scientific studies to demonstrate the occurrence of repression; and the close study of what Freud actually said rather than what he led his readers to believe. Taken together, the material is devastating to Freudian theory and to our belief in repression.

Little note of these changes has been taken by psychiatrists. Those already disillusioned with psychoanalysis have focused on the increasing number of alternatives, such as biological psychiatry, which has increased inexorably in strength and in clinical usefulness on cognitive and social measures as well as on some behavioural techniques. However, the multivolume multi-authored textbooks in English continue to favour dynamic ideas, even though psychoanalysis has long had problems demonstrating its value as a treatment.

The issue that is making medicine recognize that literary, historical, semantic and philosophical studies are relevant to psychiatry is the phenomenon of recovered memory of childhood sexual abuse.

The theory of recovered memory relied heavily on psychoanalytic ideas, and differed in only one major respect. Advocates of recovered memory therapy for childhood sexual abuse were unabashed in their suggestive efforts to find repressed memories of sexual abuse, and naturally succeeded. After a few years, the result was an eruption of false accusations, reports of multiple personality disorder (because only repressed childhood sexual abuse could explain it), memories of satanic ritual abuse, recollections from early childhood before the brain could fix permanent episodic memories, discoveries of past lives, alien abductions, criminal charges, civil lawsuits, a series of witch hunts in the US (and 1 or 2 in Canada) and an epidemic of needlessly broken families.

The necessary correction came from accused parents and their spouses, who were assisted by psychiatry and cognitive psychology professionals. In March 1992 the False Memory Syndrome (FMS) Foundation was founded, leading the way in a critical examination of the recovered memory phenomenon on which the theory of repression is based.

By 1996 more than 6 professional societies had issued guidelines of varying degrees, had warned against suggestive treatment and effectively rejected the recovered memory phenomenon. Over time, there was a tendency for the admonitions against recovered memory therapy to become stronger. The Canadian Psychiatric Association adopted a very firm position in 1996, and the Royal College of Psychiatrists outdid us in 1997 with stronger guidelines and in 1998 published a very critical report by Brandon et al. Of course, not everyone is convinced and a rearguard action continues at different levels.

The story has been superbly documented by Pendergrast, and now psychiatry and psychology may begin to look again at dissociation and repression to understand where psychiatric theory is going. Recovered Memories and False Memories belongs to the first half of the recent story rather than to the second half. An introduction and 10 chapters express concern about what exists rather than where things might be going, not recognizing that the controversy is past its peak, if not over. The editor’s introduction paints the picture of a dialogue between psychiatrists and memory researchers, tactfully, but not very convincingly, praising the merits of such disparate contributors as Christine Courtois and Daniel Schacter.

The main proponents of recovered memory refer to partial or fragmentary memory as well as delayed disclosure in normal and traumatized people, and say that abuse memories may emerge in response to a wide array of cues or triggers, some of which might occur in therapy. In contrast, Schooler, Norman and Koutstaal, who seem to approve of the recovered memory theory, conclude that the recovery of highly traumatic incidents over a period of years is very unlikely to occur in the absence of previous dissociative pathology.

Some chapters reflect a patchwork, such as the ones by Yapko and by Fivush et al dealing with the “troublesome unknowns.” Fivush et al, considering children’s memories, leave a door partly open for some of the recovered memory ideas, as does the editor in his chapter on the past and present. Kihlstrom is the only contributor who is on the Scientific Advisory Board of the FMS Foundation, but he is joined to a considerable extent by Schacter et al and Roediger et al in his skepticism of recovered memory phenomenon. In other chapters, such as the ones by Brewin and Andrews, and by Christianson and Engelberg, the authors appear unconverted but much more cautious than in the recent past.

The final chapter by Schooler et al on “taking the middle line” tries to show that psychological causes of recovered memory have been corroborated. These authors identify 4 features that require attention to appraise and corroborate memories: the recovery experience; the subject’s perception of the extent of prior forgetting; the existence of sources corroborating the event; and the existence of sources corroborating the forgetting. All 4 cases they present are strikingly similar in that the recovery is reported as a private emotional experiential state. The authors compare this state with insight experiences that sometimes occur during problem solving and make a weak analogy with flashbacks. Three of their subjects had actually indicated previous memories, which later appeared to them to be new. Correspondingly, the actual corroboration of abuse appears quite good (but perhaps weakest in the case without prior recall). The authors believe that they have found corroboration of the phenomenology of the recovered memory experience. They discuss alternative possibilities for the special emotional experience they attribute to discovering a memory. Altered mood states are known to cause vivid emotional experiences, which may not persist (whether pleasant or unpleasant); so too are drugs. One of the cases that occurred after sleep raises the possibility of cataplexy (with hallucinatory experience founded on a known past event producing heightened emotion). This is particularly plausible in the light of Peter Hays’s4 description of false but sincere accusations of abuse related to narcolepsy. But a special feeling called a flashback may have nothing to do with their views.

Overall this book is a mixed bag. The emphasis of some chapters is seriously misdirected or simply cannot be relied upon. Other chapters, particularly the ones by Kihlstrom, and by Schacter and Roediger, contain solid material, and Schooler’s is at least interesting. Anyone wishing to find their way around the false memory story would be better advised to read the book by Mark Pendergrast, which still provides an outstanding overall account of the topic. Recovered Memories and False Memories provides significant information on both approaches to the topic; but only one of these approaches is likely to be reliable and accurate.

The Maudsley Handbook of Practical Psychiatry

The Maudsley Handbook of Practical Psychiatry, 3rd edition

D. Goldberg, editor

New York: Oxford University Press; 1997

ISBN 0192628534 (hard cover)

Often when residents begin training in psychiatry there is a great deal of anxiety, particularly related to the first on-call experience. Most training in medical school focuses on the skills used to take patient histories and conduct medical examinations; these need to be modified when dealing with psychiatric patients.

Residents who have been comfortable with the medical model are frequently unsure about how to elicit information from patients with psychiatric difficulties. And most introductory psychiatry textbooks contain a great deal of factual information but do not provide practical advice. The widely used Synopsis of the Comprehensive Textbook of Psychiatry by Kaplan and Saddock is an example of a work that began as a condensed version of a larger textbook but has grown to such a size that there will soon be a need for a synopsis of the Synopsis of the Comprehensive Textbook.

In the Maudsley Handbook of Practical Psychiatry, David Goldberg, director of medical education at the Bethlehem Maudsley NHS Trust in London, has attempted to provide a comprehensive yet accessible introductory textbook for residents as they begin training. The book was developed in consultation with staff psychiatrists and house officers from the Maudsley to ensure that the book meets the needs of house officers and residents. It attempts to provide a comprehensive guide to psychiatric and neuropsychiatric examinations and guidelines for the clinical management of common psychiatric presentations in the emergency setting and in the early phases of treatment. It is meant to be a guide for doctors beginning their training in psychiatry and for those preparing for professional examinations, and although written in the United Kingdom, is intended to be used elsewhere.

The structure of the book reflects these objectives. There is a section on the psychiatric interview and assessment, which includes the mental status examination as well as some aspects of neuropsychiatric assessment. The section on early treatment is less extensive and focuses primarily on the initial stages of management. There are also sections on referring patients to specialists and on the medicolegal issues related to psychiatry in the UK.

The most valuable section of the book is on interview and assessment; it provides practical guidelines for the assessment of children, adults and geriatric patients. Although written for the beginning trainee, a review of this section would be valuable for residents preparing for their oral examinations. There are well-written discussions of difficult situations in the interview setting, and of issues such as gifts, disinhibited patients, violence and sexual involvement with patients.

The issue of false memory and repressed memory is certainly a controversial one in the field of psychiatry. This handbook provides one of the better overviews of this area, discussing the evidence for repressed memory and for concerns about false memory. Practical discussions about the impact of these issues on the psychiatric interview are clear, as are discussions of cross-cultural issues and their impact on the psychiatric assessment.

Unfortunately, other sections of the book are not as helpful. The sections on medico-legal issues are relevant largely to the UK. Although there is some interesting discussion of such things as consent and hospitalization, these are presented within the context of UK laws rather than in terms of general principles. The section on referral is largely unhelpful in the Canadian context; many of the suggested indications for specialist referral are in fact issues that residents are directly involved with.

Because drug therapy evolves so rapidly, by the time a book is in print, aspects of it are already out of date. This fact has limited the usefulness of the section on early treatment. For example, haloperidol is recommended for patients who present with acute psychosis, and for patients who are unresponsive, treatment with chlorpromazine and clozapine is recommended. Obviously, this does not take into account the impact of newer atypical antipsychotic agents on the management of patients in the acute treatment setting or in first-episode psychoses. There is even less discussion of medication use, probably because the goal of the book is to focus on early management, the assumption being that residents will discuss the initiation of such treatments as antidepressant medication with a staff psychiatrist. In many cases the treatment plans outlined are general, probably insufficient to allay the anxiety of a beginning resident, and lack sufficient complexity to be of use to a senior resident.

The final difficulty I had with this book is related to one of its strengths. As noted above, there is an unfortunate tendency in the medical field for handbooks and synopses to rapidly balloon into tomes large enough that no hand could easily encircle their girth. The Maudsley Handbook is in fact a book that could slip quite comfortably into the pocket of a lab coat. Because of that, however, the layout is very tight and the margins are small. This makes it difficult to find things quickly when leafing through it. Breaks are not obvious and sections blend together.

The Maudsley Handbook is, I believe, a valuable introductory handbook in terms of its discussion of the psychiatric interview and assessment. For this reason alone I would recommend it for beginning residents and those preparing for their oral examinations. It does not, however, live up to its billing as a provider of extensive and practical management guidelines for a variety of psychiatric conditions, and is limited by the fact that it is written primarily for the UK audience, despite its claim to do otherwise.

The Millon Inventories: Clinical and Personality Assessment

The Millon Inventories: Clinical and Personality Assessment

Millon T, editor

New York: The Guilford Press; 1997. 552 pp

ISBN 1572301848 (hard cover)

This book provides an overview of the growing family of personality inventories developed by Theodore Millon and members of the Institute for Advanced Studies in Personology and Psychopathology. Chief among these instruments is the Millon Clinical Multiaxial Inventory (MCMI), which is one of the 2 or 3 of the most widely used personality assessment methods in the world; 16 chapters of the book are devoted to it. While there are 6 books describing the inventory, this is the only one edited by Millon himself. The introductory chapter reviews Millon’s theoretical approach to personality assessment, which balances the nomothetic and idiographic traditions; the chapter illustrates how this theory guided the design of the assessment inventories.

A distinguishing feature of the MCMI and the more recent Index of Personality Styles is that they are systematically linked to a comprehensive theory of personality. This has an evolutionary base that draws parallels between the phylogenetic evolution of a species and the development of adaptive strategies for a person or a group, including personality style. The evolution of personality style is honed by a formative process involving biological endowment, social experience and interaction with the environment, both at the personal level and as a facet of culture. Millon identified 3 “motivating aims” that prompt and direct human behaviour: preservation of life, adaptation to change, and reproduction or replication. In this model, personality is dynamic; it includes behavioural elements (expressive behaviour and interpersonal conduct), phenomenological aspects (cognitive style, self-image and object representations), intrapsychic elements (covering the person’s regulatory mechanisms such as projection, exaggeration or acting out) and, at a biophysical level, mood and temperament.

The MCMI translates these theoretical insights into a diagnostic instrument suited for clinical populations; it is not intended for use as a general personality assessment. Rather than classify people into set personality types, the MCMI follows a prototypal approach that scores them along 11 personality dimensions, such as schizoid, avoidant, depressive, dependent or narcissistic. The emphasis is on identifying elements of multiple patterns that may co-exist in the person; the goal is to emphasize quantitative gradations rather than qualitative, all-or-none distinctions. Of the many theoretically possible permutations of personality types, about 20 cover over 80% of cases. Assessments can be linked to the DSM taxonomy of personality disorders. The MCMI is heuristic and seeks to provide clinicians with a “means for understanding the principles that underlie their patients’ functional and dysfunctional behaviors, thoughts and feelings.” The dynamic formulation of personality addresses the question “what functional processes and structural attributes are necessary for the client’s personality pattern to exist as an organic whole?” The process of interpreting the MCMI is complex (and is illustrated rather than explained in full in this book); it also takes account of scores indicating severe personality pathology and clinical syndromes. As well, the MCMI includes items designed to identify various response biases.

In addition to covering the MCMI, the book devotes 6 chapters to reviewing other scales developed by Millon’s group. These include the Millon Adolescent Clinical Inventory, intended for measuring adolescent personality and adjustment, and the Behavioral Health Inventory, which covers styles of coping with physical illness. The book also briefly describes 3 other personality scales: the Millon Personality Diagnostic Checklist, the Personality Adjective Check List and the Index of Personality Styles. Each assessment inventory is described only in general terms and the scales themselves are not shown. For this the reader would have to turn to the existing manuals for each instrument; this book does not address any of the practical details of how to obtain copies of the instruments. Somewhat more attention is paid to the clinical interpretation of scores, which is illustrated by case reports. Summary information on reliability and validity is provided and fairly extensively referenced.

The book is written for people who are already familiar with the Millon Inventories. Indeed, one weakness of the book may be that it assumes undue familiarity with the scales: the chapter headings refer to abbreviated titles of the scales, which are, in some instances, not spelled out in the chapter. The reader is assumed to understand chapter titles such as “The Role of Psychological Assessment in Health Care: the MBHI, MBMC, and Beyond.” Furthermore, descriptions of the purpose of each instrument are often sketchy. The chapter on the Millon Behavioral Health Inventory, for example, describes it as “a standardized, objective psychological assessment tool that offers significant utility in the assessment of medical patients and as such may be a significant addition to the assessment technologies of the primary care physician” (page 389). Later clarification doesn’t help very much: the MBHI is “designed to assess the personologic and psychological coping factors related to the physical health of adult medical patients” (page 391). One has the impression that the authors were perhaps too close to their subject, and there seems a risk that this book may fall between the cracks: it does not provide sufficient information for the neophyte to decide whether a scale will suit a particular purpose, nor does it offer a full review of the latest information on each scale for the experienced user seeking an update.

Nonetheless, the book is useful in drawing together in one source a wide range of general information on these scales. The book is technical and scholarly but still very readable. Although it is an edited volume, the style and content are successfully integrated, and one can sense Millon’s guiding hand in each of the chapters. The book offers useful background reading for practising psychometricians; it will provide a good introduction to Millon’s approach for students taking courses on psychological assessment. The book might also benefit the reader with a general interest in psychological and health measurement: many insights lie in these pages. The introductory discussion on the role of theory in developing personality assessments, for example, is excellent, and so is the discussion in chapter 14 on issues in assessment in different cultural settings. This is a book to encourage your library to buy as a general reference rather than a “must have” for your own bookshelf.

General Psychopathology [Allgemeine Psychopathologie]

General Psychopathology [Allgemeine Psychopathologie], Volume 1, 7th edition

Karl Jaspers. Translated by John Hoenig and Marian W. Hamilton

Baltimore (MD): Johns Hopkins University Press; 1997. 448 pp

ISBN 0-8018-5775-9

We take issue … with every treatment of psychology that is based on simple self-observation or on philosophical presuppositions.

Wilhelm Max Wundt (1832-1920)

Over the years I have had several German-speaking psychiatrists say to me, in so many words, “How can you possibly practise psychiatry without having studied philosophy?” This is a very European attitude and one not well understood in English-speaking psychiatry. We believe that we study psychiatry from an empirical or common sense viewpoint, and we see it as a virtue that we are not programmed by a particular set of organized beliefs. Of course, we are not free of prejudice, and our own idiosyncrasies may profoundly influence our understanding of what we read, and what we observe in our patients.

The philosophically minded psychiatrist sees him- or herself as provided with an arsenal of techniques, a system of logic and a methodology by means of which he or she can organize observations and communicate them meaningfully to others. The pragmatist will say that this is more likely to be a distorting mirror and that it provides the ever-present temptation to “explain” in terms of one’s philosophical beliefs when, in fact, no explanation is possible with the flimsy data we possess.

Throughout the years, I have maintained a simple-minded belief that the scientific medical model is in fact a reasonable basic belief system for someone practising psychiatry. For a long time that was an unpopular viewpoint: How on earth could the medical plodder ever understand the metaphysical world of the mind? Well, surprise! It turns out that the mind is indeed a product of the brain and that brain, although incredibly complex, can be studied like other organs with techniques that have served the rest of medicine well.

However, it will be a long time before clinical psychiatry can benefit from these techniques as radically as other aspects of medicine have. One very good reason for this is that we are terrible diagnosticians. As a former colleague of mine used to say, “You can’t get a touch of pregnancy but you can certainly still get a touch of schizophrenia.”

We are only beginning to establish a widely accepted lexicon of technical terms in psychiatry. We have spurious diagnostic systems, currently crystallized in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, whose criteria for diagnosis are so crude that, if we were automobile engineers, we would still be having difficulty distinguishing a Chevy truck from a breadmaker.

Our method of diagnosis is to form a vague gestalt of a disorder, then try to figure out if the phenomena we think we observe fit with the description in the textbook. Then, before we can confirm that these phenomena are actually present, we modify them out of recognition with powerful drugs. And, in any case, many psychiatrists nowadays cannot recognize, or even name, the phenomena that presumably do make up illness patterns.

For half a century we have failed to observe systematically and we have failed to derive numbers from the observations we have made. So here we are, at the end of the 20th century, feeding junk into our evermore sophisticated computers and expecting them to tell us what schizophrenia is, how common it

may be and how it responds to treatment. And hoping that delusions, thought disorder, abnormal affect an’ stuff like that will somehow be explained by abnormal neurotransmitter function in areas of the brain that we are hurriedly having to mug up on.

Such iconoclastic thoughts have been running through my head while I have been re-reading volume 1 of Karl Jaspers’ General Psychopathology, the monumental work first written in 1913 and gradually (although not fundamentally) revised in subsequent editions until 1959. The original German version, Allgemeine Psychopathologie, is one of the most influential but misquoted works on psychopathology, and English-language psychiatry owes a great debt to Professor John Hoenig and Ms. Marian Hamilton for their scholarly translation of the seventh edition from the German. The translation first appeared in 1963. This book is a reissue of the English translation, with an amiable and balanced foreword by Dr. Paul R. McHugh.

When I first read General Psychopathology in the mid-1960s, I found the task laborious, and it hasnit got much easier with time. However, it was a rewarding read because I discovered that much of what I was reading agreed with what I had been taught as a resident in Scotland. So, somehow, my teachers had been able to delve into Jaspers’ writings before they had been adequately translated into what passes for English in Scotland.

But — and this is a very big but — I realized that what I had been taught was largely the phenomenological material, and that much of the psychopathology had been selectively culled. This book is a treasure-trove of psychiatric phenomena, described in the days when phenomena were phenomena and could be observed over years without interference by effective treatments. It can only do the present-day psychiatrist good to read about them as they are described here.

On the other hand, the psychopathology is speculative, based on traditional belief and strongly influenced by 19th-century German philosophy. This is not surprising, since Jaspers was a philosopher of his time. Like many philosophers then, he believed his methods of psychological dissection to be highly scientific. He was very critical of the spurious explanations produced by the psychoanalytic school, but unfortunately he was also prone to explaining, although his explanations often end with the “black box” approach — “This cannot be explained.” Not surprisingly, this somewhat nihilistic attitude, natural enough in a time of therapeutic nihilism, really leads us nowhere. Despite its influence, Jaspers’ approach has led to little continuing experimentation or observation.

Pity! If you simply took the phenomena he describes and started counting their occurrence in your everyday patients, you would have the beginnings of a basic science. But that would be laborious, unglamorous and unlikely to be supported by today’s big-money sources.

If we think we are good at observing psychiatric phenomena we should go back to this book and be humbled. We should go back to this book anyway and, using our critical faculties, try to sort out the lasting wheat from the ephemeral chaff. It will take a long time, but it will be good for the soul. At the end of the day, perhaps we might be a little better at distinguishing between schizophrenia and a hole in the ground.

Unfortunately, few people will take the time and, if they are interested, may want to rely on the commentaries on Jaspers’ contributions contained in the few modern works on descriptive psycho-pathology, such as Andrew Sim’s Symptoms in the Mind. That’s a start, but not enough to experience the richness and depth of Jaspers’ phenomenological descriptions.

Nowadays, there are umpteen CDs of “The Best of . . .” various composers. I am grateful to Johns Hopkins Press for reissuing this work, and I look forward to seeing volume 2 appear before long. But I would look forward even more to “The Best of Karl Jaspers” if someone could spend the time to review this masterpiece objectively and sift the relevant from the redundant and the passe, with unbiased and atheoretic commentary.

Come on! Surely one of you reading this is just gasping to undertake such a task.

The Neuropsychiatry of Limbic and Subcortical Disorders

The Neuropsychiatry of Limbic and Subcortical Disorders

Salloway S, Malloy P, Cummings JL, editors

Washington (DC): American Psychiatric Press; 1997. 217 pp with index

ISBN 0-88048-942-1 (cloth)

The limbic system is a topic of considerable interest to both psychiatrists and neurologists. For biologically oriented clinicians, one can barely go a week without encountering some reference to a limbic disorder. The explosion of information about the interconnectedness of various brain regions is forcing both practising clinicians and neuroscientists to grapple with all brain regions, not just a favorite few. Inevitably, one is confronted with the need to understand the function of the limbic system. The definition of the limbic system has steadily broadened over time to include not just the medial circuit of Papez, but structures that are functionally associated with it. In common usage then, the term “limbic system” speaks to a set of cognitive functions; these functions are subserved by a network of cortical and subcortical structures.

In this spirit, The Neuropsychiatry of Limbic and Subcortical Disorders represents a snapshot of the state of knowledge of the limbic system. This book expands on the summer 1997 special issue of The journal of Neuropsychiatry and Clinical Neurosciences on the same topic. Published by the American Psychiatric Press, it is a high-quality book at a reasonable price, with many colour figures and photomicrographs.

This book is not an easy introduction to the anatomy and function of the limbic system. As the editors state in their introduction, “The essays in the volume cover a broad range of basic and clinical material at various levels of difficulty. … Some of the chapters present complex material requiring careful study and perhaps a second reading.” This is not an understatement. The book is divided into 2 sections: Anatomy and Neurochemistry, and Clinical Syndromes. It is the first, more technical section that presents the most difficult material. For neuroscientists familiar with the terminology, these chapters represent an excellent resource. They are good summaries of the anatomical literature with extensive references. Most chapters have 50 to 100 well-selected references, though a few contain up to 300. There is an abundance of photomicrographs, many of which have been previously published and retain an alphabet soup of anatomical abbreviations. This may present a problem, primarily to the student of behaviour wanting to learn more about the neural substrates.

If the anatomy section suffers from over-inclusion of information, then the clinical section suffers from a lack of rigour, and must be taken as hypothetical in many cases. There are interesting ideas here, and the authors have put forth several theories regarding the pathology of syndromes including temporal lobe epilepsy, emotional experience, recovered memory and religious experience.

While many of the chapters focus purely on the anatomical or clinical aspects of the limbic system, a few successfully link anatomy and function. The chapter entitled “Neurobiology of Fear Responses,” by Michael Davis, is a particularly cogent exposition of the role of the amygdala in fear. This chapter, appropriately positioned between the 2 major sections, introduces concepts such as classical conditioning, and outlines the evidence from lesion and excitation studies for the amgydala’s function. It is accessible to both anatomists and behaviourists. The chapter entitled “The Neurobiology of Emotional Experience,” by Kenneth Heilman, lucidly outlines several theories of emotion, ultimately arriving at the modular theory. One version of the modular theory states that emotions are mediated by anatomically distributed modular networks, and it is the relative activation of these modules that gives rise to the variety of human emotion. The location of the modules, of course, overlaps with the limbic system. The chapter entitled “Limbic-Cortical Dysregulation,” by Helen Mayberg, is an excellent exposition of a theory of the functional organization of medial cortical and limbic structures. This theory, based largely on human functional imaging (positron emission tomography and functional magnetic resonance imaging), is quite successful in unifying often contradictory studies regarding cingulate function. Finally, the chapter by Koob and Nestler entitled “The Neurobiology of Drug Addiction” is a good summary of the neural substrates that underlie reward behaviour, and how drugs of abuse affect them.

All of the authors in this book have published extensively in their fields. Consequently, most of the material has appeared in other review articles. Nevertheless, it is convenient to have the information all in one place, together with the colour reproductions.

In a book that juxtaposes both anatomical and syndromic chapters, it becomes painfully obvious that our knowledge of brain wiring is fast outpacing our ability to describe behaviour. A great deal is known about connectivity, neurotransmitters and gene expression, but how can these be related to only a crude description of human experience? Saver and Rabin, in their chapter on religious experience, offer several convincing descriptions that would suggest that the mystical quality of a religious experience is a manifestation of limbic activity, if not outright seizure activity. While quite reductionist, it may even be true, but something is lost in the characterization of the experience. It is no coincidence that virtually every work of fiction is fundamentally concerned with “limbic function.” The conclusions of all classical tragedies are known — it is the human experience that captures our interest. When speaking about the function of the limbic system, one quickly realizes that the putative functions, emotion, memory and motivation, are difficult to describe, let alone quantify — hence, an unlimited supply of literature. Unlike other cognitive functions such as perception, language and motor behaviour, these limbic processes do not lend themselves easily to experimentation.

Are these processes unquantifiable? Perhaps the language is wrong. For example, anxiety is an emotion variously localized to the limbic system. One can go to great lengths using different rating scales to quantify the severity of anxiety, but ultimately one relies upon individual interpretation of crude descriptions. What if an emotion like anxiety were compacted to a measure of probability? For example, “I feel like I’m going to die,” represents the assignment of a non-zero probability to the outcome of death. While the individual may know death is unlikely, it nevertheless creates a situation of uncertainty: “I know I won’t die, but then again, what if I do?” Measures of uncertainty, while not in the usual parlance of emotion, do lend themselves to quantification, and ultimately correlation with neural activity. Perhaps it is time for a shift in the description of limbic behaviour. Only when these phenomena are accurately described will we be able to relate them to brain function and dysfunction.

Brain Repair

Brain Repair

Donald G. Stein, Simon Brailowsky, Bruno Will

New York: Oxford University Press; 1995. 156 pp. with index

ISBN 0-19-511918-5

In the 16th century, Theofrastus Bombastus Paracelsus openly burned the works of Galen because they had become church dogma and thus had a paralyzing effect upon progress. By approximation, this is what Stein, Brailowsky and Will have done to the neurophysiological concepts we all learned in medical schools: that, once damaged, the neurons in the brain and spinal cord do not regenerate. In 10 chapters and an enlightening epilogue, these 3 prominent neuroscientists have marshalled a vast accumulation of knowledge, starting with Ramon y Cajal’s pessimism on the issue at the turn of the centure and continuing to the sophisticated research strategies of our times. This book should be on the “must-have” list of anyone interested in biological psychiatry.

The 140 pages of text, plus notes, references and indices, are printed in fairly small, uncomfortable-to-read type and densely packed pages, void of any illustrations or graphics. However, the visual style, reminiscent of that in Scientific American, is eminently clear and simple.

Brain injury is justly portrayed as a major public health problem. The term takes in not only traumatic brain lesions but also Parkinson’s and Alzheimer’s diseases and all other conditions that damage a sizeable number of nerve cells. The authors emphasize neural plasticity, its intricacies and, in the past, its poorly understood peculiarities. This is the epicentre of the book. Stein, Brailowsky and Will confidently get the reader to walk through the bridge of the successive epoches, as the idea has bounced from one research group to another. The authors highlight that, following the description of the Wallerian degeneration and chromatolysis, the first observation hinting at possible neuronal regeneration has been the discovery of the collateral sprouting: a spontaneous, seemingly purposeless propagation of axonal tangles. These cellular proliferations, called “neurites,” were regarded in the past by many neurologists as a mere nuisance. But further research found them potentially useful. Rita Levi-Montalcini was able to enhance or inhibit the development of these cellular proliferations by various neurotrophic factors. Franz Hefti’s discovery with regard to Alzheimer’s disease — the remarkable neuronal descruction occurring in the nucleus basalis Meynert, diagonal band of Broca and medial septum — is captioned, indicating that different brain parts do require diverse types of growth factors. The work of Anders Bjorklund, Fred Gage and Donald Stein is discussed, and the exploration of the specificity of trophic factors in the work of Carl Cotman is summarized. The now-classic research of J.R. McWilliams and Gary Lynch on hippocampal lesions and memory is mentioned, and the outcome of the serial lesion studies is abridged.

This leads the authors to the section on therapy, in which they outline the lack of immune reactions and thus the absence of tissue rejection in the cerebrum. The idea of embryonic brain-tissue transplantation to relieve symptoms is considered. The first cell transplants in cases of human Parkinson’s disease were performed in Mexico and Sweden. Eric-Olaf Backhand’s work — transplanting dopamine-producing cells from the patientis own adrenal glands — circumvented the objections of anti-abortion groups. Monkey-to-human tissue transplant results are also elaborated. A great deal of space is spent discussing the fascinating issue of how sex-specific hormones influence brain plasticity and the transplantation process. The higher efficacy of brain tissue from female donors is emphasized, a finding which, as Brian Kolb pointed out, may well be a mixed benefit because it may result in excess tissue production. Recent results of Patricia Goldman-Rakic’s work investigating prefrontal lesions in infant animals are presented in an interesting way. Different treatment strategies, the adverse role of the free radicals (unbound hydrogen, oxygen and iron molecules), lipid peroxidation and the beneficial effects of antioxidants are contrasted with the deleterious influence of sedation and the extensive use of benzodiazepines in brain-injury cases.

Preventive measures are also elaborated. Some of these reach far back, all the way to Donald Hebb’s environmental-deprivation experiments, conducted in the 1950s, and the venerable, classic research of Mark Rosenzweig and Bruno Will on the “enriched milieu,” with its beneficial effects on nerve-growth factor and other parameters of brain development. Similarly, the book discusses Michael Gazzaninga and Joseph Zihl’s findings on the positive effects of mental training and study sessions on animals with brain injuries.

It is impossible to ferret out all of the details of this useful little book in a brief review. There are no final answers in this work, but no such answers are expected in any scientific writing. At the price of $19.50, as a summation of major research work in the last 50 years, this book is a bargain.

The only misgiving I have is the inelegant title, Brain Repair. Somehow it reminds me of those utilitarian books that discuss the finesse of mending ruptured bicycle tires. Never mind; buy it.

Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

Philadelphia: WB Saunders; 1997. 509 pp. with index

ISBN 0-7216-5749-4

This book represents the state of the art in childhood psychopharmacology. Well written and capturing the highest level of existing evidence in the field, it serves as a reference text as well as an instructive how-to manual for those practising childhood psychopharmacology.

The text is organized into five sections. Section 1 is very brief and introduces the book by outlining the move toward empiricism in child and adolescent psychopharmacology, specifically, and childhood psychiatric disorders, generally. A broad clinical model is emphasized, to bring the science of the controlled experimental study into the realm of the clinical environment by combining medication with other empirical interventions.

Section 2 deals with baseline assessment before beginning psychopharmacological treatment. The section begins with general issues and then moves to more specific assessment, both in terms of rating scales for different disorders as well as more specialized ancillary assessments such as family, social and interpersonal, academic, speech and language and institutional assessments. The fourth chapter of the section covers baseline medical assessment for psychopharmacological treatment. Useful pointers in the medical history, exclusion of medical illness, baseline investigations and monitoring (including principles of therapeutic drug monitoring) are covered extensively.

Highlighted summaries allow quick rereading of a chapter. In addition, chapter 3, which deals with individual baseline psychiatric assessment for psychopharmacological treatment, has several useful tables with pointers to the psychiatric diagnosis. The reader is referred to relevant rating scales contained in the appendices. Of great use to the busy clinician is the visual analog scale, which allows for baseline rating and monitoring of specific target symptoms. Chapter 3 uses case examples and commentaries to illustrate points made in the text. These cases are relevant and reminiscent of my own day-to-day practice. Each raises important clinical examples and dilemmas. Rather than distracting from the text, in most cases they reinforce the text and make the book more readable. This excellent technique continues through the rest of the book.

Section 3 covers the planning, initiation and provision of psycho-pharmacological treatment. Although superficially this section seems to repeat some of the content of the previous section, it does in fact offer additional wisdom and deals with important practical issues in the treatment of children and adolescents generally and psychopharmacology more specifically. The principles of patient and family education are clearly articulated, as are the standards of informed consent. While legislation may vary in different jurisdictions, a useful set of guidelines is provided for obtaining informed consent from both the child and family, taking into account the developmental and cognitive status of the child. Throughout, the book adopts a respectful client-centred philosophy. This attitude is well reflected in the clinical case examples.

Section 4, appropriately the most dense segment of the book with 10 chapters, deals with the clinical practice of child and adolescent psychopharmacology. Each chapter outlines the treatment of a particular disorder, with 3 chapters devoted to the anxiety disorders; the first of these very briefly describes the general issues in the psychopharmacological treatment of the anxiety disorders, followed by a chapter devoted to the treatment of panic disorder and the third to other anxiety disorders. The author emphasizes the high morbidity of anxiety disorders beginning in childhood and suggests that evidence supporting the principle of least intrusive intervention first is lacking. Combined interventions (pharmacological and psychological) applied aggressively, especially when symptoms and functional impairment are significant, may lead to better outcomes. This principle is applied in the subsequent 2 chapters. In keeping with the format of the book, these 2 chapters guide the clinician — with the use of case material — through the management of these disorders, providing a framework for assessment and measurement of outcome, as well as the specifics of drug choice, augmentation techniques, dosage ranges and some principles for treatment duration.

Other chapters that are highly recommended are those on the treatment of depressive disorders and bipolar disorder. In chapter 11, the author takes the reader through the standard management of depressive disorders in childhood and adolescence using 2 case examples and commentaries, which highlight treatment issues. The text is written like an expanded step-wise treatment manual but remains interesting and readable. The chapter focus is on the use of selective serotonin reuptake inhibitors (SSRIs). While the author clearly outlines alternative and augmentative treatment strategies, he completely dismisses the use of tricyclic antidepressants (TCAs) as alternatives, although there may still be a role for these drugs — for example, the use of desipramine or nortriptyline to treat dysthymia in adolescents with comorbid attention deficit hyperactivity disorder. There is only a single line devoted to the newer-generation antidepressant venlafaxine, and this appears odd and out of context. Nefazodone is not mentioned at all, perhaps because of its novelty.

Chapter 12 is thorough in its review of the thymoleptics and ancillary treatments for bipolar disorder. A subsequent edition will likely review the use of the novel antipsychotics, especially risperidone and olanzapine in the treatment of bipolar disorder with psychosis. These drugs are not mentioned, perhaps as a result of the author’s use of the highest available level of evidence in outlining psychopharmacological treatment of children.

If this book has any drawbacks, it is a tendency to be long-winded and repetitive. For example, the last paragraphs of the 2 case commentaries in the chapter on acute schizophrenia (chapter 13) are almost identical. While each of these paragraphs (page 224 and page 225) “emphasize[s] the importance of using proper pharmacological treatment within the context of optimal and comprehensive care” “and keeping in mind the expected paradigm of chronic care with the goal of controlling acute symptoms, preventing relapse, and optimizing patient function,” a single statement would suffice. Occasionally, terminology is used loosely; for example, neuroleptic malignant syndrome is referred to as a “true psychiatric emergency” when it is better defined as a true medical emergency. The section describing “initiating and optimizing methylphenidate treatment” (on page 279 of chapter 15, “Psychopharmacologic Treatment of Attention-Deficit Hyper-activity Disorder”) is quite unclear: 2 potential strategies are outlined (1 and 2) and then strategy 3 (which appears to be strategy 1) is referred to in the case example. Furthermore, it is difficult to determine any real difference between strategies land 2.

There are 7 appendices, which provide an inclusive array of potential rating scales available for the use of psychopharmacologists treating children. The book is well indexed, and a useful reference list can be found at the conclusion of each chapter.

Overall, this book is a very useful addition to the growing library of texts on child and adolescent psychopharmacology. I strongly recommend it as a useful and practical guide for practitioners prescribing psychopharmacologic agents to children and adolescents. I look forward to an updated and perhaps more streamlined edition in a few years’ time.

Impulsivity: Theory, Assessment, and Treatment

Impulsivity: Theory, Assessment, and Treatment

CD Webster and MA Jackson, editors

New York: Guilford Press; 1997. 462 pp. with index

ISBN 1-57230-225-9

Webster and Jackson have made a bold attempt at editing a multi-disciplinary book on the construct of impulsivity. The book focuses on impulsive individuals and their speed of judgement. It approaches the construct of impulsivity by covering a broad range of problematic behaviours that have impulsive components. The editors seem to take the view that, if several blindfolded individuals feel different body parts of a large animal such as an elephant, each will describe the respective body part, and the reader will then have a collection of descriptions that can be combined to form a holistic concept of the construct.

The first section of the book deals with the diverse theoretical perspectives on the construct of impulsivity. There are chapters on the clinical, social, sociological, legal and “cybonautical” (computer technologies involving cyberspace, virtual reality and information technology) perspectives on impulsivity. I singled out the chapter on “social perspectives,” in which the content, in my view, is incongruent with the focus of the book. The author seems to have an axe to grind about psychiatrists and the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for intermittent explosive disorder. He mistakenly takes the view that “psychiatrists” see “wife batterers” as individuals who have an intermittent explosive disorder. He then attempts to apply this psychiatric concept to 2 of his case studies of wife batterers. My concern lies in the author’s ludicrous view that the psychiatric explanation of all spousal assault lies in interpreting that these individuals fall within the boundaries of the DSM-IV diagnostic criteria for intermittent explosive disorder. The author also appears to be misinformed about such psychiatric terminology as the difference between a delusion and an overvalued idea.

The second section, on the foundations of impulsivity, provides 2 well-written chapters on the biology of impulsivity. The first chapter focuses on serotonin mediation of various neurophysiological processes. It traces the complex relations between the neurochemical substrates in the brain and impulsivity. The second chapter looks at the role of organic brain syndrome in impulsive violence. Researchers attempting to understand the nature of the connection between neurochemical factors and brain damage have concluded that these elements are mere components of a complex whole, rather than adequate explanations for certain types of behaviour. There is also a comprehensive and informative chapter on the measurement approaches used by researchers studying impulsivity. Unfortunately, the lack of definitional constructs has led to multiple self-reports and behavioural measures with poor and inconsistent inter-correlations. Unless we can overcome our definitional problems, we are unable to construct reliable and valid measurement instruments. The following 3 chapters look at major mental disorders, impulse-control disorders, and psychopathology. The relation of these 3 diagnostic groups provides the reader with insight into the complex interrelation between impulsivity and other psychopathology. The final chapter looks at a conceptual model for the study of violence and aggression. This author proposes the use of facet analysis to clarify the poor definitional issues that have plagued the study of risk research. A facet is defined as the basic unit of an enquiry into a specific phenomenon of interest. Facet analysis involves mapping the conceptually independant facets into a “mapping sentence/’ thereby enabling researchers to engage in a evolving dialogue on risk research.

The third section is entitled “Practise: Assessment” and focuses on assessment of violence. Empirically, we know that there is a link between impulsivity and violence. There is, however, a lack of clarity on the exact nature of this association and the operational definitions of the respective elements. There are 4 chapters addressing assessment of risk of violence to self, others and wives (spouses), as well as the risk of the patient committing sexual assault. These chapters are devoted mainly to descriptions of the respective authors’ assessment instruments or checklists. There is also a chapter giving some useful suggestions on how not to conduct a risk assessment.

The final section focuses on the treatment of patients with impulsive behaviour. The diverse chapters discuss effective services for offenders with mental disorders, pharmaco-logic approaches to impulsive and aggressive behaviour, and a case management system to approach people with “multiproblems” and “impulsive driven” people. In the final chapter, Webster ends on an upbeat note, remarking that, although the concept of impulsivity has not yet been adequately defined, researchers have accumulated enough information about impulsivity and disorders that involve impulsive elements to lead to better solutions than are now available. He provides a guide for professionals who are interested in creating treatment programs for people with problems related to impulsivity.

The lack of consensus on the definition of this construct is apparent from the diversity of chapters in this book. The authors address topics such as spousal abuse, violence and aggression, offenders with mental disorders, psychopathology, suicide and sexual violence. It is uncertain whether impulsivity is a behaviour, a symptom of a broad range of psychiatric disorders, or a component of many functional and dysfunctional behaviours. This book is therefore as much about these other topics as about impulsivity per se. Readers who are looking for a book focused on impulsivity will likely find this book a disappointment. This is not a criticism, but rather a reflection of the poor definitional and operational concepts when approaching such a task. For readers who want a good overview of the current state of knowledge of the concept, this book is an interesting read.