Archive for December, 2009

The Cytokine Network and Immune Functions

The Cytokine Network and Immune Functions

J. Thèze, editor

New York (NY): Oxford University Press; 1999. 373 pp with index

ISBN 0-19-850136-6 (cloth)

Like the brain, which orchestrates behaviour principally through the secretion by neurons of various neurotransmitters that act on other neurons, the immune system displays similar finesse by synthesizing and secreting a large variety of chemical messengers, generically referred to as “cytokines.” As readers of The Cytokine Network and Immune Functions will appreciate, this function of the immune system is no less complex and exquisitely sophisticated than the exchange of information between neurons in the brain or the response of endocrine tissues to hormones. Indeed, from a behavioural perspective, the immune system — like the brain — evolved to mediate defensive functions that would optimize successful adaptation and survival. Whereas the brain scans and processes information in response to stimuli with circumscribed physical and sensory dimensions, the immune system performs similar functions at a molecular level, responding to viruses and bacteria that our more traditional senses are unable to perceive. Ultimately, the “foreigness” of viruses and bacteria elicits a coordinated set of defensive actions (what immunologists call an effector function) by a variety of immunological cells that ultimately rids our bodies of the would-be colonizers.

What this book summarizes in some detail, is that from the point of initial pathogenic stimulus exposure to the ultimate effector response, the defensive functions of the immune system are orchestrated by several families of cytokines, acting in coordinated fashion — as a network — and mobilizing in cascade fashion, and according to specific needs, the fatal blow to foreign microorganisms.

However, all networks possess the potential for dysregulation. Hence, aberrant cytokine responses are believed to be responsible for allergies, asthma and numerous autoimmune disorders. Moreover, there is a growing recognition that cytokines can affect brain function. Unfortunately, this is exclusively addressed in only a single — and lamentably, brief — chapter (”Cytokines in the brain” by Laye et al). Additional indirect treatment of the relation between neuroendocrine function (e.g., the hypothalamic-pituitary-adrenal axis) and cytokines is rendered in a chapter on cytokines and inflammation (”Cytokines and the cellular mechanisms of inflammation” by Cavaillon and Duff). Therefore, for researchers and practitioners in the brain sciences, there is little in this volume that cannot be obtained in other publications that provide a more comprehensive discussion of the relation between the immune system, cytokines and neural and behavioural functions.

Alternatively, a considerable amount can still be learned about basic cytokine biology, receptors and signal transduction mechanisms. To echo the foreword by William Paul, which was perhaps directed to a more immunological audience, there is much in this book that can greatly inform and equip those of us involved in research in neuroimmunology and the behavioural consequences of immune responses and inflammation. Indeed, subsets of mood disorders, such as dysthymia, have been hypothesized to involve an autoimmune component that is mediated by cytokine dysregulation. Similarly, multiple sclerosis is an autoimmune disorder, but with severe depressive symptomatology and cognitive deficits. A greater knowledge of cytokines and their cellular actions at the molecular level would certainly enhance efforts toward understanding central nervous system diseases that involve the immune system. In fact, this book is probably indispensable to all whose work involves cytokines, no matter what biological system is being scrutinized.

As witnessed in recent years, the leaps-and-bounds advance in molecular biology has not so much rippled, as ripped its way through much of the biological sciences, and as readers of The Cytokine Network and Immune Functions will no doubt appreciate, has also served to propel the study of cytokines. For example, it was not that long ago that the number of known cytokines could be counted on a single hand. However, currently, and as well described in the book, cytokines are bunched into at least 6 families, based on the structure and characteristics of the receptors to which they bind (i.e., the hematopoietin, interferon, tumour necrosis factor, interleukin-1 and chemokine receptor families and the immunoglobulin superfamily). For the uninitiated, this may be somewhat perplexing and confusing, but an introductory overview chapter (”General aspects of cytokine properties and functions” by Dy et al), although not exactly smooth sailing because of a plethora of abbreviations and acronyms that do not fall immediately into coherent place, does prepare the reader for the tone and level of complexity in subsequent chapters. For those comfortable with molecular levels of analysis, these should not be turbulent waters. However, those wishing a more superficial description of cytokines and their functions may find the going tough. This book is not light reading, but it is a well-organized and broad overview for those who are serious about wanting to know more about cytokine biology. Indeed, seasoned researchers and teachers of immunology will easily find it a valuable resource in a field that is incredibly dense with information and complexity.

The organization of chapters revolves around 3 sections, beginning with basic, fundamental discussions and moving on to more immunobiological and clinical considerations. In the first and largely molecular section, chapters are devoted to classes of cytokines, such as the hematopoietin or class I receptor family of cytokines (e.g., interleukins 2,4, 7,9,13 and 15), as well as specific chapters on individual cytokines, including tumour necrosis factor, interleukin-1, interleukin-6, interleukin-10, inter-leukin-12 and transforming growth factor (3. There is also a chapter devoted to the Type I (wherein there are up to 21 different types) and Type II (viz., interferon y) interferons, as well as an update on more recently discovered cytokines (interleukins 16, 17 and 18). These chapters characterize the biochemical structure, genetics and cellular origins of these cytokines as well as describe the localization and structure of their receptors. Additional chapters also address signal transduction mechanisms, the role of accessory surface molecules (e.g., CD40) in cytokine regulation of function and cytokine gene regulation.

These initial 13 chapters are followed by 7 chapters that consider cytokines within their biological context, largely the immune system, but as mentioned above, also in the brain. The immunological profile of mice with deletions and/or overexpression of various cytokine genes and/or their receptors is discussed, as is the role of cytokines in immunological development. In addition, separate chapters address the way in which cytokines regulate specific (e.g., T cells) and nonspecific (e.g., macrophages) arms of the immune system. This segregation ultimately reveals a great deal of overlap, because it has become clear that many cytokines are pleiotropic and redundant.

The book concludes with a section on pathological conditions, wherein cytokine dysregulation is believed to either be at the root of various diseases (i.e., allergies, asthma, infectious disease, autoimmune disorders and cancer) or, conversely, where their immunotherapeutic use may promote recovery from disease.

The book accomplishes its goal of attempting to provide a more synthetic and “network-oriented” view of how cytokines serve their purpose. The treatment is broad, and of course, at some expense. There appears to have been a conscious effort to emphasize facts and predominant points of view, giving the book a textbook quality. In-text citations are not provided, although each chapter does conclude with a reference list. Therefore, one should look to this book, not as a literature review, but more an informed statement of the current state of knowledge in cytokine immunobiology.

Neurodevelopmental Disorders

Neurodevelopmental Disorders

Tager-Flusberg H, editor

Cambridge (MA): The MIT Press; 1999. 614 pp with index

ISBN 0-262-20116-X (cloth)

This book presents an account of recent advances in the knowledge and understanding of neurodevelopmental disorders. At the same time, it raises questions to be addressed by ongoing research endeavours.

The great advances during the past decade in molecular biology, behaviour genetics, developmental neurobiology, neuroimaging technology, cognitive science and developmental psychology have allowed exploration from various angles of a wide spectrum of disorders, from Down syndrome to dyslexia to autism. The authors bring together new knowledge for the “creation of a new scientific frontier: the integration of molecular genetics with developmental cognitive neuroscience.”

The book’s ultimate goal — “to understand the basic mechanisms that explain how genes and environmental processes contribute to the development of specific structures and regions of the brain” and to explain how these brain structures and associated functions are directly related to specific cognitive processes (p. 4).

In the introductory chapter, the editor addresses methodological issues with clarity and conciseness and lays the groundwork for the 23 chapters which follow. The contributing authors are all distinguished researchers in their fields.

The book is divided into 3 main sections: neurodevelopmental disorders of known genetic etiology (fragile X, Williams, Prader-Willi, Down and Turner syndromes), disorders of unknown or complex genetic etiology (dyslexia, specific language impairment and autism) and 6 chapters on broader perspectives on neurodevelopmental disorders (teratology, environmental toxicants, synesthesia, congenital hydrocephalus, neural mediation of language development and advances in cognitive neuroscience [views from child psychiatry and medical genetics]).

The authors review a wealth of new evidence from disciplines hitherto separate, to form a new synthesis, linking molecular genetics and environmental variables with the development of the brain structures and function and with clinical phenotypes. The links are clear for some disorders, but are speculative for others. This novel synthesis provides a new paradigm and a new vocabulary toward a better understanding of neurodevelopmental disorders.

The clinician who has limited access to journals and can hardly keep up with the great advances made in fields such as molecular genetics, developmental neurobiology and neuroscience will find this volume illuminating. Although most chapters are compelling, there is some repetition in chapters that address related disorders (e.g., dyslexia and specific language impairment). It might, however, be argued that each chapter can stand on its own, forming a comprehensive entity. The limited use of graphs, figures and photos is one drawback. Because this book covers a dynamic field of inquiry, whereby new knowledge is constantly being acquired, it is likely a new edition will be needed every few years.

This is an excellent book, and I recommend it as essential reading for child psychiatrists and psychologists, speech-language pathologists and clinicians in other related disciplines.

Les troubles anxieux

Les troubles anxieux : approche cognitive et comportementale

Ladouceur R, Marchand A, Bois-vert J, editors

Montreal: Gaetan Morin Editeur; 1999. 213 pp

ISBN 2-89105-736-8 (paper)

This book addresses anxiety disorders and their treatment with cognitive-behaviour therapy. Each of the 6 chapters, coauthored by 1 of the 3 main authors, covers a different anxiety disorder The authors (Robert Ladouceur of Université Laval, André Marchand of Université du Québec a Montréal and Jean-Marie Boisvert of Université Laval) are renowned researchers and have considerable international reputations. Several chapter coauthors are also well-known in their areas of expertise (e.g., Michel Dugas in generalized anxiety disorders, and Mark Freeston in obsessive-compulsive disorders, among others).

The introduction details the theories, the difference between normal and abnormal anxiety, the different causes of anxiety and finally, the outline of the book. The content of each chapter follows somewhat the same format: a review of diagnostic criteria, a clinical description, prevalence and precipitating factors and comorbidity. Then, evaluation and rating scales for each specific disorder are reviewed. Finally, theoretical models of etiology and therapeutic strategies are discussed.

The authors review the current literature well, and research avenues to be pursued are also elicited. Several chapters have extended clinical examples of therapeutic techniques and detail the objectives and content of therapeutic sessions.

Some chapters — for example the one on generalized anxiety disorder — also propose some very innovative models of explanation of the disorder. Obviously, these proposals are in accordance with cognitive-behavioural therapy theory.

This book is manifestly meant for mental health professionals who do cognitive-behaviour therapy with patients suffering from anxiety disorders. Psychologists, psychiatrists, family physicians, social workers and others who feel a need to better understand cognitive-behaviour therapy will also find this book very helpful.

Because it is written in French with a North American flavour, it will be popular with French-speaking Canadians and in Europe where several of the coauthors are very well known. It should be of interest to all psychiatrists and clinicians who see patients with anxiety disorders in consultations and are aware from the literature of cognitive-behavioural therapy’s encouraging results.

This is an excellent multiauthored book which reviews the up-to-date theories and therapeutic approaches for the treatment of anxiety disorders within a cognitive-behavioural framework. It is clearly written and readable by all health professionals. The format and presentation make it an agreeable work to consult. Finally, because it is so well documented, it could well become a very useful work of reference in the French literature.

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Wheatley D, Smith D, editors

London: Chapman & Hall Medical; 1998. 228 pp. with index

ISBN 0-412-82470-1 (hardcover)

Psychopharmacology is a rapidly growing field. The elderly population is also expanding, especially the oldest of the population, who are major consumers of pharmaceutical drugs. However, elderly patients are under-represented in clinical studies because of difficulties in recruitment, greater interindividual variability and the lack of consistent changes in pharmacokinetics associated with the aging process. They also have increased susceptibility to adverse effects for various reasons, including multiple chronic or degenerative physical illnesses, multiple pharmacotherapies, difficulties with compliance, lack of reporting of side effects and lack of recognition of adverse drugs effects that may be attributed to other causes. For all of these reasons, the astute clinician working with the elderly must have a good understanding of the aging process, of the pharmacokinetic and pharmacodynamic changes of psychotropic drugs and potential adverse drug reactions. This international contribution attempts to critically review the vast field of psychopharmacotherapy in a concise, clinically useful and well-written monograph. The book is divided into 3 parts: basic concepts, cognitive disorders and psychiatric disorders. Like most textbooks, it has the drawback of not being up-to-date with the most recent advances in pharmaceutical drugs available to the clinician, especially as there is a dearth of information concerning elderly patients. Its major contribution is in providing guiding principles that will help the clinician choose a proper drug and monitor its effects on patients. Most authors are recognized experts in their respective fields of pharmacology or clinical pharmacology, but, as is the case of multi-authored books, there is an unevenness in the chapters. The editors succeeded in avoiding duplication within the book, however. The chapters on neurochemical substrates, neuropathology and drug therapy for Alzheimer’s disease were well integrated. Only one chapter, on measuring memory, lost my interest. Although the discussion on the different types of memories was insightful, examples or diagrams would have been helpful. It listed several assessment and screening tests of cognitive functions which are, for the most part, more suited for research purposes and have little use in the clinical setting.

The major psychiatric syndromes are covered in part 3 of the book; however, a discussion on bipolar illness, which often presents as a major clinical challenge in the elderly, is lacking. Newer anticonvulsants used in psychiatry, such as lamotrigine and gabapentin, are not discussed. There is no mention of the use of bupropion (antidepressant) or quetiapine (atypical antipsychotic) in the elderly. Other newer treatments, such as risperidone, olanzapine and venlafaxine are only briefly discussed, yet they are used commonly in clinical practice and are rapidly becoming a first treatment choice because of their favourable adverse effects profile.

Of the many textbooks of psychopharmacology, few are dedicated specifically to the elderly. Overall, this is a comprehensive, yet concise, well-written and clinically applicable monograph which does what it proposed to do — review the nature of the aging process, the pharmacokinetics and pharmacodynamics, and the side effects of the various drugs used to treat elderly patients. It would be of interest to all clinicians seeing elderly patients and to residents in psychiatry, geriatric medicine and family medicine.

The Neurology of Eye Movements

The Neurology of Eye Movements, 3rd ed. CD-ROM

Leigh RJ, Zee DS. New York: Oxford University Press; 1999

CD-ROM – ISBN 0-19-512974-1

656 pp. with index – ISBN 0-19-512972-5

The neurology of eye movements sometimes seems to be an esoteric concern to many in the neurosciences. However, the analysis of eye movements often turns out to be extremely valuable in clinical practice. Eye movements are examples of other motor phenomena and, because they are more simple than limb movements, they often give greater insight into problems of paresis, fatigue or coordination. They particularly lend themselves to quantitative evaluation. The knowledge of specific types of eye movement deficiencies is an important tool for localizing disease and diagnosing neurological disorders.

Drs. John Leigh and David Zee have issued the third edition of their highly praised book, The Neurology of Eye Movements. In addition to the classic text, they have also produced, for the first time, a CD-ROM version. Both text and CD versions follow a similar outline, with an initial survey of the basic forms of eye motions. There follows an analysis of the vestibular-ocular system and the classical saccadic and pursuit systems, conjugate gaze, gaze holding, eye-head movements and vergence movements. These are superb chapters and give up-to-date information on the anatomical and physiological basis of these movements. The text is accompanied by excellent tables and figures.

Part II provides 2 sections on diagnosis, the first is on the diagnosis of peripheral ocular motor palsy and strabismus. Many would think of this as the “classical section” of a text on ocular motor problems. It details clinical testing of diplopia and, for neurologists, a must read description on how to diagnose strabismus (which is often left out of the classical neurological education). This is followed by a superb section on central disorders of motility, with enlightening dissections of the various forms of nystagmus and saccadic intrusions, as well as a useful discussion of vertigo and its treatment. Specific disease entities are treated in this latter section. There are discussions on eye movements and psychiatric disorders, stupor and coma, multiple sclerosis and metabolic deficiencies, all of which are excellent.

The CD-ROM version allows easy movement between chapters. It provides excellent access to the often-cited tables and figures that one has to find again when they are referred to in subsequent chapters. This is a more difficult task when reading the book because page headings do not indicate chapter numbers, which would help one locate the tables and figures more easily. The CD version has something that the hard cover version does not have — video clips. The videos, 60 in number, include virtually every sort of eye movement disorder one could want to view. These videos alone are worth the price of the CD; although they are relatively short, each shows the eye movement clearly. My one problem with the CD version is that the key word search feature often failed to reveal all of the important references; I found it much easier to use the index in the back of the book for this endeavour.

The authors suggest that this book is for neurologists, ophthalmologists, otolaryngologists, optometrists, neurosurgeons, psychiatrists and basic researchers. I suspect neurologists and ophthalmologists would enjoy it the most. Otolaryngologists who have a specific interest in vertigo would certainly find this text useful, though the vestibular systems are probably dealt with in more detail in other works. There are likely few neurosurgeons and psychiatrists who will purchase this, which is a shame because I think everyone could learn from this text.

I think everyone in neurology should own a copy of this text. The major question is which version to buy, the hard cover or the CD. I would guess that a neurology resident on a restricted income might want to buy the CD version for the videos alone. However, if you have seen these eye movements many times and just want a review of the neurological basis of eye movements, perhaps the book, which offers a better index, would be easier to read. Whichever one you decide to purchase, the price is quite reasonable for the information enclosed. I would suggest both versions.

The Hippocampal and Parietal Foundations of Spatial Cognition

The Hippocampal and Parietal Foundations of Spatial Cognition

Burgess N, Jeffery KJ, O’Keefe J, editors

Oxford: Oxford University Press; 1999. 490 pp. with index

ISBN 0-19-852452-8 (paper)

This well-organized volume has much of interest to basic researchers. The 3 roughly equal sections discuss, first, the parietal cortex, then the hippocampal formation and, finally, the interaction of the two in spatial learning and memory. Studies of rats, monkeys and humans are included. Among the techniques reviewed are behavioural, neuropsychological, electrophysiological, brain imaging and neural net computational modeling. Reading this book from cover to cover reveals a lot of repetition of similar material, such as anatomical details. It is often surprising to read about the same ideas in different chapters that do not cross-reference each other. However, for the reader who uses this book as a source of specific information about cortical regional specialization of function, the chapters provide independent and complete reviews of the latest relevant work.

The sophisticated studies of Milner and Goodale, identifying 2 streams of visual information processing with different functions, provide a useful basis for integrating much of the work presented in the first section on the parietal cortex and some of the studies presented in the third section on integration of parietal and hippocampal function. Goodale et al have argued that the dorsal stream of visual processing into the superior parietal lobe is concerned with the use of that information for the generation of motor actions; damage to this area leads to optic ataxia. The ventral stream projecting into the inferior parietal lobe and dorsal temporal cortex is concerned with what is being seen; damage here leads to spatial neglect. The chapter by Karnath, for example, presents results of studies showing that patients with damage to the right parietal cortex made exploratory eye movements consistent with an ipsilesional deviation of egocentric space representation. The same patients showed no deficit in goal-directed arm movements to targets around them. These findings are consistent with the idea that there are 2 streams of processing and that the damage in the patients studied affected the ventral but not the dorsal stream.

Colby presents fascinating electrophysiological data recorded in the ventral intraparietal area in monkeys. Cells were found to be responsive to both visual and so-matosensory stimuli; neurons with foveal visual receptive fields had somatosensory receptive fields on or around the muzzle. It was as if the mouth was the “fovea” of the facial somatosensory system! Furthermore, visual receptive fields moved across the retina in order to maintain spatial correspondence with somatosensory fields, suggesting that stimuli are coded in a head-centred reference frame. Patients with parietal cortical damage can be seen to suffer from a deficit in updating spatial representations for use by the motor system. Colby suggests that the remapping of visual fields observed in parietal cortical neurons provides the substrate for this updating.

In coaching students preparing for comprehensive examinations, one of my colleagues often counsels them to identify landmark papers that open whole new areas of investigation. Two such works in Spatial Cognition are Scoville and Milner’s paper and O’Keefe and Nadal’s 1978 book The Hippocampus as a Cognitive Map. The former is the first report of a role for the hippocampus in recent memory, and the latter identifies the place specificity of hippocampal cells. Juxtaposition of the ideas from these 2 classic works influences much of the thinking in Spatial Cognition. Some interesting ideas linking recent memory and place specificity can be found.

Mishkin et al, for example, discuss episodic and semantic memory. When a new item, association or fact is being encoded into memory, the relevant sensory information arrives as an episode that includes spatial information, as well as temporal cues and information about emotional and mental states. The amount of contextual information that is retained determines the nature of the stored memory: con-textually rich memories include spatial and other information and are, therefore, episodic; contextually poor memories record only the facts, and therefore constitute semantic memory. From this point of view, semantic memory is lower in a hierarchy of mnemonic sophistication than episodic memory. Mishkin et al argue that the hippocampus is necessary for episodic but not for semantic memory. Spatial information would be intrinsic to episodic memory. Rolls, Gaffan and Hornak make similar arguments in later chapters.

One distinction that guides some of the discussion of the interactions between parietal and hippocampal systems in space and memory is that between allocentric and egocentric frames of reference. Egocentric reference is putatively mediated by parietal circuits, and allocentric reference by hippocam-pal circuits. Rolls reported that 46% of the spatial cells of the hippocampus represented space in allocentric coordinates, versus 10% that, by comparison, were egocentric. Maguire reported that positron-emission tomographic (PET) images of people who walked mentally along a recently learned spatial route showed right hippocampal activation, suggesting that this region provides an allocentric representation of space. Parietal cortical regions seemed to play a role in egocentric movements through environments.

Another work that strongly influences many authors writing in Spatial Cognition and could be added to the comprehensive reading list that I mentioned earlier is The Visual Brain in Action by Milner and Goodale. This is the source of the idea, mentioned above, that the dorsal stream guides visuomotor actions and the ventral stream identification of what is seen. In the final chapter, Milner et al suggest that, if a participant was required to perform a delayed motor act, accurate performance would depend on the ventral stream because the egocentric coordinates that are tracked by the dorsal stream will have changed during the delay (assuming the participant moves). Thus, visually guided motor acts like pointing should be impaired after a delay in people with damage to the ventral stream. Results supported this conclusion.

One interesting contrast that I found in Spatial Cognition was between Rolls’ and Maguire’s view of imaging studies. Rolls reported the results of electrophysiological studies in rats and monkeys showing that hippocampal cells in rats were place cells, responding when the rat was in that place; in monkeys, hippocampal cells fired when the monkey looked to a particular place, even if it didn’t go there. Rolls argues that imaging studies could not make this distinction; they did not provide a full description of what was being represented in the brain. Maguire reports differences in regional activation assessed by PET imaging, as described above, and concludes that PET offers a means to pursue many outstanding questions in understanding neuronal control of spatial cognition. I suspect that they are both right. The breadth of techniques reported in this book and the emerging clarity of the knowledge about the cognitive functions of these brain regions attests to the power of multiple empirical approaches to the study of the brain for discovering the mechanisms underlying the amazing abilities of this structure.

Handbook of Neurodevelopmental and Genetic Disorders in Children

Handbook of Neurodevelopmental and Genetic Disorders in Children

Goldstein S, Reynolds CR, editors

New York: The Guilford Press; 1999. 602 pp. with index

ISBN 1-57230-448-0 (cloth)

I found this book very interesting to read and extremely informative. It consists of 3 sections, which are authored by individual professionals well known in their fields. The book’s presentation, as well as the specific information in each section, are very attractive to the reader and easy to follow.

The first section addresses the basic principles and applications relevant to neurodevelopmental and genetic disorders in children. The principal editors and contributing authors address rather difficult and, in some way, controversial areas of specific neurodevelopmental disorders, their origin and the basic interplay of “nature versus nurture.” The section also contains various ways of assessing these disorders and various interventions that are helpful for each subcategory.

In the second section the authors contribute a great deal of knowledge in the areas of specific disorders that primarily affect learning and behaviour. They shed new light in the exploration of such disorders such as learning disabilities, attention-deficit/hyperactivity disorder, Tourette’s disorder, anxiety disorders, and autism and other pervasive developmental disorders.

This section of the book is particularly interesting, as the various contributing authors offer general, updated information on the definition and genetics of each disorder, as well as the associated phenomenology, assessment methods and available interventions. The state-of-the-art knowledge presented is linked to relevant research and clinical data, offering a wealth of references as the literature has evolved during the past 3 decades. As a professional child psychiatrist, specialized in neurodevelopmental and genetic disorders of childhood and dealing daily with these issues, I found this section very useful, not only for its knowledge base, but also for its clinical implications and suggested services related to these disorders.

The third section of this volume deals with disorders with broader-spectrum effects. This is very relevant and important for professionals in this sphere, as well as for parents and other interested readers. I believe that each group can profit from the richness of the contributions offered in the areas of specific genetically transmitted disorders with associated neurodevelopmental deficits. The conditions explored in this section are Turner’s syndrome, fragile X syndrome, mucopolysaccaridoses, Noonan’s syndrome, neurofibromatosis, sickle cell disease, Down’s syndrome, Klinefelter’s syndrome, phenylketonuria, Rett’s syndrome, Lesch-Nyhan syndrome, seizure disorder, Prader-Willi syndrome and Williams’ syndrome.

This section has a presentation similar to the previous 2 sections. It is well written, with up-to-date information in the areas of genetics and neurodevelopment, classification assessment and clinical presentation, as well as interventions for these disorders. I found each chapter in this section to be very informative and well researched, with extensive references.

In summary, this book presents extremely interesting, important and relevant information for specialists in child psychiatry, neurology, psychology and allied sciences such as social work and speech or occupational therapy. It also offers good insights and general information for families with children with such disorders and suggests relevant interventions, which are so important for these families. I believe that this book is a “must-read” for all concerned with the specific topics that are covered.

Diagnosis and Management of Dementia

Diagnosis and Management of Dementia: A Manual for Memory Disorders Teams. Wilcock GK, Bucks RS, Rockwood K, editors. Oxford: Oxford University Press; 1999.402 pp. with index (paper). ISBN 0-19-262822-4. Can$86.95.

Dementia — and Alzheimer’s disease in particular — has become a major public health problem, and the expected prevalence of this class of illness is expected to double by the middle of the next century. Health delivery systems have been generally slow to keep up with the need for services to affected individuals. One trend that has appeared in the past 20 to 30 years has been multidisciplinary memory disorder clinics. This model of diagnosis and provision of treatment seems to work very well in a number of centres, but these specialty units are still not widely available, particularly outside of tertiary care centres. Setting up and running such a clinic is a topic of this new book. Many recent publications address either the pathophysiology or the medical treatment of dementia; however, a more practically oriented book such as this one has not previously appeared.

The book is divided into 3 major sections. The first is on establishing and organizing a clinic, the second is on the diagnostic process and the final section is on management. The book has a multidisciplinary and multinational authorship, and the authors have experience in working with patients in multidisciplinary clinics.

The first section on establishing and organizing a clinic covers all aspects — from administrative and logistical concepts, to information management, medical, psychiatric, neuropsychological, speech, occupational and community assessments. In addition there is a brief chapter on the research potential of such clinics. They are all covered well, although some rather briefly.

There is a small section on the diagnostic process for dementia. This stresses the differential diagnosis and indicates how one differentiates between age-related memory and cognitive decline and pathological conditions.

The final section of the book is concerned with treatment, and this covers topics that have not previously been covered well in publications. This includes support for caregivers and nonpharmacological approaches to treatments, such as behavioural modification and management of associated problems. There is a chapter on medical management, which reviews the current state-of -the-art in therapy and gives a glimpse of some of the therapies that may appear in the future. There is also a final chapter on the role and perspective of the primary care physician.

There is an appendix, which I found to be one of the more useful parts of the book. It is a paper that surveyed the memory disorder teams represented by the contributors to this book. This survey covers clinics in North America, the United Kingdom, Europe and Australasia. Anyone already running such a memory clinic or anticipating setting up one would find the information conveyed in this section quite useful as a benchmark. The survey asked such information as how many clinics are held per week, how long the first visit or appointment takes and how long the waiting lists are.

I think this book is potentially very useful for those already running clinics, those anticipating setting up clinics and those involved in rationalizing health care services for older individuals with cognitive impairment.

Atlas of Psychiatric Pharmacotherapy

Atlas of Psychiatric Pharmacotherapy

Shiloh R, Nutt D, Weizman A

London (UK): Martin Dunitz; 1000. 235 pp. with bibliography

ISBN 1-85317-630-3

For the psychiatric clinician for whom chemotherapy is the mainstay of his or her practice, this is a really, really good book! The text is easy to read (the entire book can be read in a few hours), and the unique format actually makes it fun.

The Atlas of Psychiatric Pharmacotherapy is, indeed, an atlas — a book of tables, charts and illustrations. There are approximately 100 of these figures on the left-hand pages, with corresponding text on the right-hand pages. And what charts and tables they are: glossy, coloured, well codified, elegant and easy to follow.

The text and corresponding tables start with basic principles of psychopharmacology. Tables and text include not only clinically well-known information on control and modulation of neurotransmitter release, specific biogenic amines, the P450 system, etc., but also relatively up-to-date (references through 1997) information and tables on signal transduction (3 different tables), vesicular mono-amine transporter (VMAT2), etc. The first section also includes tables on mood stabilizers, antidepressants, antipsychotics and their supposed mechanism of action, focusing on their specific action(s) at different receptor sites. There is a specific section on abused substances, their acute effects, withdrawal symptoms and specific profiles, with colour tables on each drug of abuse (opioids, cocaine, amphetamines, alcohol, cannabis, etc.), their supposed mechanism of dependence, adverse effects and treatment options. My only criticism of this section is that there could have been more detail on treatment options for alcohol abuse, by far the most common drug of abuse.

The third section is on drug interactions, arranged by class of medication. We have seen this information before, but not displayed in this manner — where the graph indicates where and why the specific side effect/drug interaction occurs (e.g., direct neurotransmitter effect, gastrointestinal absorption, first-pass effect, etc.).

The final section, on treatment strategies — is a gem. Thirty-five colour algorithms on the left-hand pages and text explanations on the right-hand pages explain the treatment for each syndrome — from major depression (non-resistant or treatment-resistant), acute exacerbation of schizophrenia, bulimia, anorexia, etc., including the 7 personality disorders. (Pharmacotherapy is not the treatment of choice for personality disorders, according to this atlas.) While the algorithms may not fit perfectly with some of the recent Canadian guidelines, they are pretty close to Canadian standards. Furthermore, the 35 algorithms for 35 specific DSM-IV diagnostic syndromes, with a corresponding text explanation is, in my opinion, a unique resource for the busy practising clinician.

My criticisms of this book are minor. The detailed references at the end of the manuscript are not footnoted in the text, so one cannot easily find a specific reference for a statement. I would have liked to review specific references in cases where a few text comments puzzled me (e.g., akathisia occurs in 90% of patients on antipsychotics in the first 10 weeks; the purported efficacy of amoxapine in psychotic depression). A second edition should include footnoted references and a cross-referenced index.

There is a little too much on sexual functioning, and, in particular, the mechanism of retrograde ejaculation with thioridazine. This topic is covered in 14 pages (7 tables/ graphs; 7 pages of text), whereas topics such as electroconvulsive therapy, Alzheimer’s disease and alcohol each get one table and one page of text.

The price is steep, but worth it. Where else can a clinician find “everything you really wanted to know but were too overwhelmed to ask” in a few pages? There is enough basic science detail for the clinician, but in a format that is easy to comprehend. The treatment and side-effects tables and text are excellent. (I found the tables on which specific drugs to use for specific extrapyramidal symptoms and the illustrated graph on side effects of antipsychotics particularly helpful.) As stated, the outstanding treatment algorithms are clear, organized, and would be an asset for any psychiatric clinician.

Psychiatry

Psychiatry. Second edition. Oxford Core Texts series

Gelder M, Mayou R, Geddes J

New York: Oxford University Press; 1999

ISBN 0-19262-888-7

The first edition of this book was called The Concise Oxford Text of Psychiatry, and the title change implies that the authors and publishers are attempting to broaden the book’s appeal. The 3 authors are senior academic psychiatrists from the University of Oxford.

Before reviewing the book, I made a list of the key requirements of a textbook for medical students: clarity, comprehensiveness, conciseness, cost, practicality and pertinence. This book scores high on all these items with the exception of cost and pertinence. It emphasizes strongly the integration between psychiatry and general medicine, yet the psychosocial aspects of medicine and psychiatry are also underlined. An appropriate balance between comprehensiveness and overinclusive detail is maintained, and liberal use is made of tables, diagrams lists and summaries. Many chapters also include “screening questions” — a list of questions that can be asked of a patient to rule out a specific diagnosis. The chapters on suicide, pharmacotherapy and “psychological” treatment (as the psychotherapies are called in the quaint British tradition) are particularly well written.

The book has its limitations. The chapter on psychiatry and the law is written for British readers and has limited relevance to other jurisdictions. For a soft cover, this book is not cheap. Finally, there are few references, although each chapter concludes with a recommended reading list.

With these provisos, the book can be highly recommended to medical students and to non-psychiatric residents who are interested in a readable and practical introduction to psychiatry.