Psychiatry

Psychiatric Diagnosis

Psychiatric Diagnosis. 4th Edition

Donald W. Goodwin and Samuel B. Guze

New York, Oxford University Press, 1989. 332 pp.

In their preface to the fourth edition of Psychiatric Diagnosis, authors Goodwin and Guze are clear on the limitations of their work: there is little “theory” or “speculation” nor any unproved claims in this review of a dozen psychiatric diagnoses. While this approach leaves a straightforward and complete compendium of current knowledge, it also handicaps the work. Like other texts, it provides the most current diagnostic definitions and clinical approaches. Unlike more speculative works on psychiatric diagnosis, it offers nothing interesting or exciting. What is left is a complete, but not comprehensive, up-to-date, but dull text.

Psychiatric Diagnosis presents the basic definitions, history, DSM-III-R criteria, epidemiology, clinical findings, etiological research, and treatments for the following eleven psychiatric diagnoses: affective disorders, schizophrenia, panic disorders, hysteria, obsessive-compulsive disorder, phobic disorders, alcoholism, drug dependence, sociopathy, brain syndrome, and anorexia nervosa. A final chapter presents topics addressed in a psychiatric examination, but is neither complete nor systematic; while this chapter may be of some use to a medical student who has never conducted a psychiatric interview, it would be of little use to a clinician.

The chapters themselves provide complete definitions of each diagnosis, with an emphasis on DSM-III-R criteria (which are included verbatim). The historical accounts of the developing nosologies are perhaps the most interesting parts of the chapters. The epidemiological sections provide some substantive data but reflect the often conflicting accounts of prevalence. Several chapters augment this epidemiological data with descriptions of family studies. The sections on clinical data, etiology, and treatment are well written and complete and include transcripted examples. Additional sections on differential diagnosis are included but, in general, are very brief and offer little discussion on either psychometric measures or clinical data which would be of use in distinguishing one diagnosis from another. References at the end of each chapter are extensive and complement the evidence presented throughout the chapters. In particular, the chapters on hysterical disorders and sociopathy are excellent presentations.

Although Psychiatric Diagnosis presents solid accounts of eleven disorders, it offers nothing more — in fact, much less — than many other texts. In intentionally omitting their own opinions, the authors have also left out any clinical wisdom which may be critical in making a diagnosis. The text is certainly well written and well researched, but one gets the sense throughout that too much is missing, and that there is nothing unique about it. The book attempts to tackle such relevant topics as alcoholism and anorexia nervosa while eliminating much of the speculative and theoretical research which, although not “absolute proof” for etiology, clinical course, or treatment, has sparked so much of the creative thinking on these disorders. Much of psychiatry is “theory, speculation, and explanation,” and deliberately to leave this out ignores much of the credible phenomenological, psychological, and psychodynamic evidence which has provided the impetus for current research. Ironically, the authors frequently quote Karl Jaspers, perhaps one of the most systematic and yet speculative phenomenological psychiatrists.

The authors’ desire to provide the best objective guide to diagnosis is admirable and certainly consistent with current psychiatric approaches; however, they should have provided more current research, rather than such sketchy accounts, to flesh out what is currently known about each disorder. Not even the current psychobiological theories are presented in sufficient depth.

For a student or layperson who is unfamiliar with psychiatric diagnoses, Psychiatric Diagnosis would be a useful guide. It would also be useful to a clinician seeking a quick review of a particular diagnostic category. In general, however, there are many more comprehensive textbooks on diagnosis, and many smaller works on psychopathology which include more interesting clinical vignettes and theory. A less sterile approach, either with more personal clinical wisdom and theory, or with more objective data on each diagnosis, would have added much to this volume.

Chronic Mental Illness in Children and Adolescents

Chronic Mental Illness in Children and Adolescents

Edited by John G. Looney

Washington, American Psychiatric Press, Inc., 1988. 267 pp.

For many, the notion of chronic mental illness in children is hard to accept. Children, even emotionally disturbed children, usually engender a sense of optimism and hope in the future. For those who work in the fields of child welfare and child psychiatry, however, it is well known that there exists a fraction of children and adolescents whose disturbance is both severe and enduring. This book focuses on severely disturbed youngsters, describes these children, and illuminates their needs.

The book, with fifteen contributors, is an outgrowth of a national conference held in 1985 aimed at this same population. There are four major sections in the book and a total of thirteen chapters; each of the major sections addresses a particular aspect of the larger picture of child mental health services. Although the volume evidences some repetition, it is well organized; each chapter builds on previous chapters.

The first section deals with the nature and scope of the problem and moves nicely from the case examples of Chapter 1 to Chapter 2’s discussion of these children in the aggregate. Some readers may find the methods used in Chapter 3 to estimate the prevalence of severely emotionally disturbed children and adolescents from existing data a bit facile, but, given the state of the art of child psychiatric epidemiology, the estimates offered may not be far out of line. Another chapter in this section, written by Jane Knitzer, provides a lucid review of recent policy concerning this population and offers some ideas regarding pressing policy questions. The major theme of this section is that, as a group, severely emotionally disturbed children have needs that require careful treatment and planning.

Section two considers the role of the public and private sectors in the treatment and programmatic planning for severely disturbed children and adolescents. Two of the chapters in this section point out the continuity of care problem, which is compounded by the fragmented service system and the multiple treatment needs of these youngsters. The problem is described in Chapter 5, and a model for solving the problem is outlined in the last chapter of this section. Included in this section is an essay on private inpatient care. Unfortunately, this chapter describes long-term treatment of children and adolescents in a private psychiatric hospital, in contrast to the current trend, driven to a great extent by economic pressures, which is clearly toward brief hospitalization.

In the third section, special issues such as the training needs of mental health professionals, the value of family treatment with this population, and the importance of evaluative research to assess the effectiveness of various treatment programs are considered. Although the chapters in this section are not as unified as those in other sections of the book, each of these chapters is particularly strong.

The last section considers the policy and funding issues that require resolution in order to confront the needs of these children and adolescents. The first of the two chapters reiterates the need for a high degree of cooperation between public and private agencies to build an integrated system of care. The author, Donald Gair, returns to the notion of chronicity and cautions against building a system of care for these children. He warns that the definition of chronicity may result in the exclusion of troubled children from services. Rather than being exclusionary, the service system should focus on the tasks of childhood and provide interventions that are commensurate with developmental needs. In such a child development model, public schools would form the foundation of the service system, and psychiatry would have to relinquish the medical model to some extent. The final chapter outlines a strategy for constructing an organized system of care for children; here, John Looney, also the book’s editor, carefully maps out the barriers to building such a system and provides an agenda for further discussion and planning. This chapter could stand as a summary of the entire book.

This volume was intended for mental health professionals, though others interested in child development and public policy for children will also find the book worth reading. It does not consider in any detail the effect of current economic pressures on child psychiatric services — especially on inpatient services, which is an unfortunate omission because as inpatient stays decrease, there may well be an increase in referrals of more acutely disturbed children to residential and public facilities. Hence there is an urgent need to achieve coordination between public and private service sectors. The book effectively describes the difficulties confronting severely emotionally disturbed children and their families in human terms. The magnitude of the problem is estimated, and possible solutions are described — perhaps the major contribution of the volume. It goes beyond mere complaining about the fragmented service system that currently exists and offers an agenda for further discussion of this problem and its solution.

Psychosomatic Medicine and Contemporary Psychoanalysis

Psychosomatic Medicine and Contemporary Psychoanalysis

Graeme J. Taylor

Madison, CT, International Universities Press, Inc., 1987. 391 pp.

Psychoanalysis is often criticized for not keeping up with advances in modern medicine. In an attempt to expand one area for development, Graeme Taylor has shown how contemporary thought in psychoanalysis can provide a new disease model for psychosomatic illness. Taylor’s review is meticulously researched and presented and provides a logical and relevant basis for further work. Most notable is his clear presentation of a psychobiological perspective, integrating behavioral and neurobiological research with object relations theory.

Taylor begins with a historical review of psychoanalytic approaches to psychosomatic illness, suggesting that the latter grew out of the former. Early studies tried to discern a personality type which correlated with classic psychosomatic illnesses, such as asthma and hypertension. Franz Alexander regarded conflict and dependency as correlates of illness. In the 1950-s and 60s, disillusionment with psychoanalytic approaches led to studies which looked at stress and bereavement in generating a susceptibility to illness. Work along the lines of Hans Seyle’s general adaptation syndrome largely replaced psychoanalytic research during this period. To counter this perception, Taylor refocuses discussion on the more recent notion of “alexithymia,” a clinically derived concept which he defines as “a specific disturbance in affective and symbolic functions which renders [the] communicative style sterile and colorless.” According to Taylor, this term has reintroduced discussion of the role of psychoanalytic therapy for psychosomatic illness. In his opening chapters, Taylor clearly presents the successes and failures of each of these developments along with numerous illuminating cases.

In Parts II and III, Taylor discusses current research in object relations theory and neurobiology, respectively. The mother-infant relationship, which he describes as a regulatory factor in the child’s homeostasis, is shown to be highly relevant for research purposes. Animal studies have linked separation from the mother to variations in heart rate, sleep, growth, and thermoregulation. Recent attempts to create bridges of thought between neurobiology and psychoanalysis are discussed with respect to dream theory, and here the author seems to stray. He provides an extensive review of neurobiological studies on sleep and dreaming and ties in early psychoanalytic theory, but he does not pursue the issues sufficiently. Little is said about how sleep research — which has become the most popular area of mind-brain discussion — can bridge enormous epistemological dilemmas between psychoanalysis and neurobiology. Moreover, how is this research relevant to psychosomatic illness? Taylor’s point here is elusive and leaves too much extrapolation to the reader.

Gathering together a rich history of research and theorizing on psychosomatic illness, Taylor approaches the last chapters stressing the potential contribution of object relations theory. As stated above, an understanding of the mother-infant bond, taken here as the most original interpersonal relationship, is crucial for studying predispositions to illness. A truly biopsychosocial approach to psychosomatic illness can only gain from such an understanding, and psychoanalysis is one logical tool of study. Although the author’s overall work is successful in defining a role here for psychoanalysis, he falls short — despite a gallant effort — in establishing a clearly “new” model for disease. He has merely pointed in one direction and provided numerous signposts.

The groundwork for any psychobiological or biopsychosocial model is difficult to construct, because there are endless considerations from each direction. Despite this fact, Taylor has done a masterful job in bringing together many diverse threads of research, thought, and theory. Consequently, he has defined a unique and viable role for psychoanalysis in the study of psychosomatic medicine.

Therapy of Parkinson’s Disease

Therapy of Parkinson’s Disease

Edited by William C. Koller and George Paulson

New York, Marcel Dekker, Inc., 1990. 583 pp.

Therapy of Parkinson’s Disease represents volume five in a series written on neurologic disease and therapy. It focuses on the therapeutic approaches to Parkinson’s disease (the second in this series dealing with that disorder). In addition to treatment issues, other areas are covered, including clinical evaluation, imaging, pathophysiology, neurochemical systems, and behavioral aspects. A clear strength of this text is that it covers a range of very specific treatment approaches in depth, which in sum provide a broad review of the clinical and research aspects of Parkinson’s disease therapeutics.

The volume is divided into five parts, composed of chapters on specific topics. Part 1 is cfevoted to the assessment and measurement of symptoms and signs and provides a review of clinical assessment via rating scales, videotape analysis, measures of motor disability, neurochemical evaluations, and various neuroimaging techniques. Part 2, an extensive review of pharmacological interventions, addresses traditional agents, novel agents, various routes of administration, preventive therapy, and treatment of secondary disorders. Part 3 discusses surgical interventions such as stereotaxic thalamotomies and neurotransplantation. Part 4 is concerned with the dietary issues related to Parkinson’s disease treatment, and part 5 addresses the behavioral and psychiatric issues, along with physical therapy issues, in Parkinson’s disease.

As indicated, each chapter provides a condensed, in-depth account of a highly specific topic and cites numerous references. The reference list is both comprehensive and timely (through 1990) and provides a good base from which to search for further literature on a specific topic. Most chapters are succinct and well organized. Tables, graphs, photographs, diagrams, and photomicrographs are used extensively throughout the volume. The contributors to the text (numbering 69) represent the mainstream of basic and clinical research and practice in the area of Parkinson’s disease, from academic centers in the U.S. and abroad. Errors are present in the arrangement of some material (for example, a section on dopamine receptor blocking drugs describes both agonists and antagonists). The chapter on neuroimaging could be difficult to get through without knowledge of various imaging techniques. The chapter on the management of behavioral symptoms reviews depression, drug-induced psychosis, and cognitive impairment, but does not discuss other (less common) neuropsychiatric issues, such as non-iatrogenic psychosis, the therapy of which is a timely issue in the psychiatric literature.

Therapy of Parkinson’s Disease is an expensive book, and not appropriate for everyone. Those who are involved in the clinical or research aspects of Parkinson’s disease and the related neuroscience, or who have an interest in that area, will find this text a valuable resource.

Hughlings Jackson on Psychiatry

Kenneth Dewhurst

Oxford, Sanford Publications, 1982. pp. xi + 169

The clinical researches in neurology of John Hughlings Jackson (1834 –  1911) are well known, but his contributions to the field of psychiatry are not; nevertheless, they are considerable, as Kenneth Dewhurst notes in this fine small book. Jackson’s education at the medical school at York provided him with more experience in the field of psychiatry than most of his contemporary medical students. This was made possible by two exceptional professors on the faculty, Daniel Hack Tuke and Thomas Laycock, both of whom became leaders of British psychiatry during their era. Tuke probably had a greater impact on the clinical side while Laycock’s studies on brain reflexology and on the mind-brain problem had an enduring influence on neurophysiology.

Jackson also attended the St. Bartholomew Hospital Medical School in London for a year. He settled in London finally in 1859, where he spent the rest of his life in private practice and was associated with the London Hospital and the National Hospital for the Paralyzed and Epileptic. During his career, he wrote well over 300 articles using a careful observational and philosophical approach, but never put his findings and thoughts together in a coordinated whole in spite of the urgings of his professional friends. Nevertheless, he was “acclaimed as the greatest British scientific clinician of the 19th century.”

Jackson’s greatest contribution to the understanding of psychiatric issues arose from his careful studies of epilepsy and its phenomena. As he slowly collected material from 1866 on, he became interested in selected patients who experienced odors undetectable to others present (a form of olfactory hallucination). These subjects also revealed episodes of losses of consciousness, automatic movements and thoughts, and the appearance of certain dream-like states. Jackson also explored the amnesia that was associated with these states and finally named them “uncinate fits.” Over the years the terminology changed to epileptic equivalents, psychomotor epilepsy, and currently to temporal lobe epilepsy. Dewhurst also discusses a famous case of Jackson’s known as “Quaerens or Dr. Z.”, who has recently been identified by the studies of D. C. Taylor and S. M. Marsh as Dr. Arthur Thomas Myers, a distinguished sportsman and physician whose major contribution to medical history was his careful reportage of his own case, albeit anonymously. He became a patient of Jackson’s who published Myers’ case and included Myers’ autobiographical study. Both in his own right and through the efforts of his brother, Frederick W. H. Myers, Arthur contributed to the movement for the study of parapsychological phenomena and those of the subconscious. Arthur wrote articles on both hypnotism and telepathy. It was his brother Frederick, however, who helped to found the Society for Psychical Research and wrote extensively on subliminal matters. Both went to LeHavre, France, in 1886 to watch a then unknown professor of philosophy named Pierre Janet do experiments on hypnosis at a distance.

Arthur died in January 1894 from an overdose of chloral hydrate. His illness plus his medical focus thereup had made possible a greater clinical understanding of temporal lobe epilepsy. Exploration of the connections of the temporal lobes to psychiatry has experienced a resurgence during the past two decades. That religious and parapsychological behavior could be connected to this area of the brain was pointed out in a 1970 article by Drs. Dewhurst and Beard. They reported six cases of epilepsy with investigative evidence suggesting a temporal lobe focus. All of these patients reported experiences of religious conversion. Approaching the question from the other side, the authors also found support for their thesis from the history of conversions in a number of saints and religious figures who also had a history of convulsive-like episodes. A more recent study brought further confirmation to this view as well as demonstrating a high incident of dissociation and multiple personality in these patients.

Other topics explored by Dewhurst in Jackson’s writings are: the mind-body problem, consciousness, delirium, coma, psychosis, hysteria, dreams, Gilles de la Tourette Syndrome, obsessions, jokes, etc. Dewhurst concludes his book with a two-chapter review of Jackson’s impact on continental psychiatry as well as on British and North American psychiatry. Among the familiar names that emerge are: Freud, Pick, Charcot, Ribot, Henri Ey, S. Weir Mitchell, J. J. Putnam, Adolf Meyer, and Bernard Sachs.

We are highly indebted to Dr. Dewhurst for surveying John Hughlings Jackson’s voluminous writings and culling those comments of psychiatric import and placing them in their historical context. An excellent index makes the various topics easily accessible. Dewhurst has continued to make valuable contributions to the history of medicine. His range is impressive. He is famous for his 17th century book-length studies on Sydenham, Willis, and Locke. He recently wrote a book on Fredrich Schiller (19th century), and he now has an excellent book on Jackson.

Psychiatric Emergencies

John Chapman Urbaitis

Norwalk, Apple-ton-Century-Crofts

1983. x + 166 pp.

This small volume dealing with psychiatric emergencies is one of many such compilations, but has its own particular merits. One of these is its brevity. Emergency management requires the clear grasping of specific principles, unencumbered by more or less remotely related data which may safely be left for less immediate attention. The language of this treatise is what it should be considering the nature of its subject matter. Concision, pithiness, and solid substance are its meritorious attributes.

The orderly presentation of topics to be considered characterizes this book. It contains what it should and omits the nonessential.

Anyone who has worked in a psychiatric admitting office or emergency room will appreciate the author’s directives for procedure. Some pathologic conditions have been omitted or alluded to only in generalizations, but the book is not intended to be encyclopedic.

One appreciates the author’s emphasis on general medical procedures and neurologic diagnostic problems. Such conditions are always prominent in psychiatric emergencies, and their accurate diagnosis may make the difference between life and death.

The volume is to be recommended to all medical personnel required to deal with these disorders. It reminds us to bear in mind the admonition of Sir William Osier as to the necessity of equanimity for every physician.

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.

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.

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.

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.