Psychiatry

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.

Assessment Scales in Old Age Psychiatry

Assessment Scales in Old Age Psychiatry

Burns A, Lawlor B, Craig S, editors

Martin Dunitz Ltd.; 1999. 302 pp. (paper)

ISBN 1-85317-562-5

Being asked to review Assessment Scales in Old Age Psychiatry was like being let loose in a candy store: fun, filled with many new experiences and ultimately vaguely disappointing, although definitely worth the visit.

About 150 diverse instruments are described, including neuropsychological assessments, tests for activities of daily living and quality of life, and tools for assessing depression and delirium. But to keep with the candy analogy, not all of the goodies are what they seem. Sometimes there is only a list of test contents, at other times only a description, and often there is nothing to help digest a complex mouthful.

The layout of this book is appealing. Each scale is described on one page, and the facing page lays out test elements. There is space on every page for notes and annotations; to use this book effectively, cross-referencing and additional notes from one’s own experience are necessary. Each chapter has an introduction that outlines the purpose of that domain of test and reviews the history of old or modified tests. Some analysis is given about which tests might be more useful for certain circumstances and why. The book usually indicates how long a test should take to administer and who is best suited to give it, along with information on how to score tests and what different total scores mean.

Disappointments include the following. Some of the “additional references” are oriented principally towards researchers or those interested in developing new tools, rather than clinicians. There are too few up-to-date references. For example, references are to articles re-evaluating older tools versus newer techniques, information that is essential where tests are unknown or where a choice has to be made between a tried-and-true older tool and a more recent tool. A few of the tools referred to “updated guidelines,” which may score an old test on a new scale, but unfortunately, in at least one instance, the new guidelines are not referenced and there is no example of the newer scale (for example, see Bartel on pages 132-3). One test is described as a “visual analogue” scale, but lacks a visual presentation. Primary sources are missed in a few cases.

Some information is given on the reliability, validity and accuracy of different tools, but the editors have not done a consistent enough job here. As a result, it is difficult for anyone unfamiliar with a test to choose between tools.

The editors excuse some of their lapses in editing in the introduction. However, I cannot accept their excuses. The job of a technical editor should be an arduous one. The editors of this book have not met the many technical requirements of their task and therefore fail their readers.

Despite my many reservations about this book, if you have the time to do your own homework, and the $77.50, it might be a fun addition to your library.

Biology of Personality Disorders

Biology of Personality Disorders

Annual Review of Psychiatry series

Silk KR. Washington: American Psychiatric Press; 1998. 156 pp

ISBN 0-8804-883-52

This book, part of the Annual Review of Psychiatry series, is a multi-authored text comprising 5 chapters by recognized authorities in the field. The topic is of interest because of the increased activity in the area of personality disorders over the past decade and a half with respect to typology, research and new treatment approaches. This book focuses on research into the biological aspects of personality disorders over the last 10 years or so. As Silk points out in the Foreword, earlier studies of biological correlates of personality disorders did not lead to clear conclusions because of lack of appropriate separation between personality disorders and Axis I disorders. The “second-generation” studies have focused on the core negative traits of personality disorders (e.g., impulsivity, aggression, cognitive disturbances and affective lability, which cut across most personality disorders) and sought to understand their biological underpinnings.

The first 2 chapters of the book review and discuss the biological research in the field, including research strategies employed, the results of some of the most important studies and the implications for further development.

The first chapter, by Coccaro, reviews studies of neurotransmitters that are significant for personality functioning. The most important of these are serotonin and the cate-cholamines, including dopamine and norepinephrine. The studies are reviewed under categorical headings including cerebrospinal fluid (CSF) metabolite studies, pharmacological challenge studies, platelet receptors and DNA in polymorphism studies, etc. The studies consistently find an inverse relation between CSF 5-HIAA levels and impulsive-aggressive behaviour.

There is a smaller body of research into the role of acetylcholine and vasopressin, which shows that acetycholine does contribute to affective lability.

The second chapter, entitled “New Biological Research Strategies for Personality Disorders” by Siever and colleagues, complements the first. It reviews studies using a variety of recently developed strategies to study core traits of impulsivity, affective instability and cognitive dysfunction. The strategies vary from neuroendo-crine and cognitive studies that look at the antecedents of neuroendocrine and cognitive abnormalities found in personality disorders, to the use of imaging (positron-emission tomography, single-photon emission computed tomography, magnetic resonance imaging [MRI] and functional MRI) to study neuroanatomical correlates of personality dysfunctional traits such as impulsivity and aggression. There are fewer studies using candidate gene strategies. The author comments on the implications of the findings to date from these areas of investigation.

A particularly creative strategy was the linking of the study of trauma to personality disorders. Trauma has its biological impact on the hypothalamic-pituitary-adrenal (HPA) axis, but trauma is also a major etiologic factor in many personality disorders, including borderline personality disorder (BPD). Studies of the HPA axis changes, such as dexamethasone suppression test (DST) in patients with post-traumatic stress disorder, have been extended to personality disorders as BPD, with the DST pattern more closely resembling that in PTSD than that in mood disorders.

The third chapter focuses on Cloninger’s proposed 7-f actor model of personality, comprising temperamental factors such as harm avoidance, novelty seeking, reward dependence and persistence, and 3 character elements: self-directedness, cooperativeness and self-transcendence. Cloninger makes the case for the neurobiological basis of learning abilities that underlie temperamental traits by summarizing studies of the psychobiological correlates of these traits. He then puts forward a psychobiological learning model based on his review of the neuropharmacological, neuroanatomical and biochemical studies, and on studies of the phylogeny of learning abilities. He concludes by making a strong argument in support of the 7-factor model as a basis for understanding the various dimensions of personality disorder and even the diagnostic clusters. Although much of the material is quite technical, the use of tables and other visual aids is helpful in summarizing and reinforcing the material presented in the text.

The last 2 chapters are more application-oriented. The fourth chapter, by Links, is interesting because of the proposal of an outcome-based approach to the pharmacotherapy of personality disorders. Outcome indicators would be reduction in certain characteristic behaviour patterns, such as repetitive self-injury, that have been shown to have a biological basis. Other outcome indicators include quality of life. The author notes the shortcomings of the current conceptual models of personality disorder as a basis for developing a treatment rationale. The outcome-based model proposes specifically desirable functional outcomes of treatment and more systematic approaches to assessment of the efficacy of medication. This proposal is very much in keeping with the current evidence-based approach to medical practice.

In the final chapter, Paris assesses the significance of research for a biopsychosocial model of personality disorders. The author points out inconsistencies between theoretical assumptions underlying some research strategies and real-world observations, as well as the many confounding factors that complicate the search for one-to-one correlations between biological variables and particular personality traits. Taking a dimensional view of personality disorders as the pathological amplification of normal traits, the author discusses the complicated interaction of biological and environmental factors in producing personality disorders via the diathesis-stress model. He proposes 3 potential research directions: new drugs targeting personality traits, gene therapy, and new forms of psychotherapy based on better understanding of temperament.

Since much of the research on impulsivity and aggressiveness reviewed is common to conduct disorder and attention deficit hyper-activity disorder as well as anxiety disorders in children, one would have expected a discussion of the relation of these conditions to personality disorders in adults. Despite this lack, I found this book to contain more than anticipated. The material in the first 3 chapters was detailed and informative, and the last 2 chapters helped to make it practically relevant. One is left with a feeling that personality disorders are now more real, and that there is hope for more targeted treatment in the future. I certainly recommend it.

Treatment Compliance and the Therapeutic Alliance

Treatment Compliance and the Therapeutic Alliance

Barry Blackwell, editor

The Netherlands: Harwood Academic Publishers; 1997. 325 pp. with index

ISBN 90-5702-546-9 (cloth)

Many clinicians take the “compliance” of their patients for granted. They assume that medications are taken as ordered and rarely check pill boxes or take any action other than questioning the patient to ensure that instructions are being followed. Yet we know from well-designed studies that as many as 50% of patients do not take their medications as prescribed. Contrary to expectation, psychiatric patients are not notably less compliant than nonpsychiatric “medical” patients. Compliance also is impaired in older patients when medication requirements are complex, and in socially isolated people, and it is adversely affected by a poor doctor-patient relationship.

The philosophy of compliance is also changing, to keep up with changes taking place in the role of the physician in our society. The older paternalistic medical model of “the good doctor knows best” no longer holds. Patients are far better informed about their health problems and their treatment options and are encouraged, and rightly so, to take charge of their medical treatment. With some exceptions, the medical profession has come to terms with these changes, and most physicians have accepted their new role as health educators and advisers rather than treatment directors.

This book deals with many of these issues, in particular the doctor-patient relationship. Yet it is curiously uneven in content, philosophy and quality. It is divided into 3 sections: “Compliance research, theory and social context,” “Participants in the alliance” and “People with special needs.” The first section provides a useful and practical overview of the field. The chapters entitled “Models of the compliance process, “Medication noncompliance in schizophrenia,” “Insight and compliance” and “Compliance and decision making capacity” were of particular interest and value. The second section includes chapters on community mental health programs, the role of families, and the role of the physician in the therapeutic alliance. The final section has chapters on schizophrenia, manic depression, developmental disabilities, alcoholism and the elderly.

The quality of the book starts at a high level but rapidly deteriorates in the middle and later chapters. Many of the later chapters are written by “consumers” or health care professionals with antiestablishment axes to grind. Their tone tends to be adversarial, and they write as if nothing has changed since the days of the paternalistic medical model. There is much discussion of the individual’s right to refuse treatment but little or no discussion of a patient’s right to have effective treatment when such is available. The topical issue of community treatment orders is barely mentioned. Although the editor (who authored 2 of the chapters) commendably attempts to integrate compliance into the therapeutic alliance, the book nevertheless lacks philosophical coherence and consistency. One has the impression that no decision was reached on whom the book is addressed to, and too wide an audience has been targetted.

Despite the importance of the subject, this book is likely to be of value only to those with a special interest in compliance.

A Guide to Treatments That Work

A Guide to Treatments That Work

Peter E. Nathan and Jack M. Gorman, editors

New York, Oxford: Oxford University Press; 1998 . 594 pp. with index

ISBN 0-19-510227-4 (cloth)

This kind of book has to be written from time to time in any area of knowledge, in an attempt to establish benchmarks. In this case the aim is to highlight current “state of the art” aspects of the treatment of psychiatric disorders. It is a brave effort, tightly edited and with a large number of eminent and expert authors who are, in general, balanced and incisive in their viewpoints. They consist of a judicious mix of MD psychiatrists and PhD clinical psychologists, and there is a refreshing lack of inter-profession infighting in their writings.

The editors have insisted that the contributors’ approach should be evidence-based, and they have clearly delineated the relative degrees of investigative rigour present in the many studies under review. In their introduction, they say that, to be reputable, treatment studies must show that patients got “better” (acknowledging the difficulties in defining and measuring that concept). They also say that treatment simply as an exercise in promoting self-awareness is a more appropriate approach for religion than for a science-based medical specialty. Now there’s a brisk, no-nonsense send-off, so why is the last word (”Afterword — a plea”) given to a writer who makes a pitch for the supremely intuitive psychoanalytically based forms of psychotherapy? And why is that writer advocating impracticable methods of research that have never been effective in giving them a verifiable basis in the past? I can only assume that this is a manifestation of that aspect of the American psychiatric Zeitgeist that has never quite lost its awe of psychoanalysis even when knocking it, and which has to indulge in little propitiatory rituals to allay some possible ”Furor Sigmundicus.” That said, it should be emphasized that the psychological contributors adhere mostly to reviews of behavioural and cognitive therapies, with a strong emphasis on psychosocial intervention, and take a very objective view of what constitutes psychotherapy and how its outcomes may be assessed.

This is a solid tome, with 28 dense, closely-argued chapters on 18 wide-ranging areas of psychiatric disorder, mostly grouped in complementary pairs of presentations reviewing pharmacologic and psychosocial approaches. Despite this diversity and apparent depth, however, there is an introductory section entitled “Summary of treatments that work,” which occupies only 13 pages. It seems extraordinarily sad that in 1998 all our verifiable knowledge of psychiatric treatment can seemingly be encapsulated in 13 pages of text (reading time approximately 30 minutes).

But to some extent this brevity is misleading, since we are considering a highly-selected filtrate of the best-attested results available. The editors have been further selective in appearing to concentrate on disorders that seem more treatable than others, and there is a sense that some of the choice is influenced by what the psychology contributors consider “sexy” these days. The result is a number of notable omissions, including, for example, delusional disorder, schizoaffective disorder and dysthymic disorder.

Although the book is entitled A Guide to Treatments that Work, relatively little attention is given to the question, Work on what? The authors have meticulously culled their literatures, and most of the references are impressively recent. Nevertheless, we have to be aware how crude our nosologic system remains and what a moving target it is. DSM and ICD have become very intent on narrowing their diagnostic criteria to exclude false-positive findings. A result of this is an over-refinement of case identification in formal investigations and the provision of a number of residual diagnostic categories to which “atypical” cases may be consigned. The latter are so heterogeneous that they virtually deny investigation. Also, small but significant differences in diagnostic criteria between DSM and ICD, or between successive editions of these authorities, are sometimes enough to make superficially similar treatment studies incompatible with each other. So, when the editors use refinement of technique in the measurement of quality of treatment studies as their major criterion of credibility they narrow the scope of their work very considerably. They may be, in effect, investigating Jello with techniques appropriate to the testing of properties of high-tensile titanium. This feeling, in my mind at least, is accentuated when so many dramatic results are reported for behavioural cognitive treatment methods. I know how effective they can be, but when I read of their apparent success as primary intervention in what are reputed to be severe psychotic disorders, I just know that we are not talking about the unselected cases the front-line psychiatrist meets in everyday practice.

I do not intend to belittle this book because I think it serves a very useful purpose in hammering home the need for much more science in our clinical and research activities. The editors are at pains to point out that it is neither a comprehensive textbook nor a therapeutic vade mecum. But read uncritically, it could give an unbalanced message. Like it or not, “state-of-the-art” treatment in psychiatry still has a great deal of art in it, and the more difficult the patient, the greater is the need for that very art.

If we regard this book as a starting point from which we can move on and begin to validate the much bigger, much messier and much more demanding world of non-academic psychiatry, then we need not be discouraged by these mere 13 pages of summary. It is good to see a psychiatric work aim high, and it is a trenchant reminder of how far we have to go in psychiatry before we can be regarded as a scientifically-based discipline. I would suggest that every psychiatric library have a copy of this text.

Bipolar Disorders

Bipolar Disorders: Clinical Course and Outcome

Goldberg JF, Harrow M, editors

Washington (DC): American Psychiatric Press; 1999. 315 pp. with index

ISBN 0-88048-768-2 (cloth)

This volume is based on a symposium held at the annual meeting of the American Psychiatric Association in 1995. Various authors have contributed data on the course and outcome of bipolar disorder. Almost without exception, these data are from their own research programs, supplemented with a limited literature review. The topics covered are broad, including naturalistic outcome studies, the impact of a broad range of treatments — both pharmacotherapies and psychotherapies — on outcome, as well as the impact of comorbidity on the long-term prognosis of bipolar disorder. Other topics include clinical subtypes, such as rapid cycling and bipolar II disorder, and hypomania.

The book is comprehensive in its broad range of topics covered. Unfortunately, however, this comprehensiveness is achieved at the expense of a more in-depth and critical analysis of each topic. With a few notable exceptions, each chapter is quite cursory in its approach to the topic under consideration. Furthermore, as with many multi-authored books derived from symposia, the individual contributions are neither direct reports of particular studies nor a comprehensive and up-to-date literature review of the topic. Rather, one gets something in between, with the author’s individual studies supplemented by a relevant, but unnecessary, comprehensive literature review.

There are some very good chapters. For example, the chapter on psychotherapies by Miklowitz and Frank manages to achieve a succinct literature review and present some very tantalizing data on new psychotherapeutic approaches. Maj presents some very interesting findings on lithium prophylaxis of bipolar disorder, although frankly it is much more satisfying to read his original research reports. A chapter by Bowden compares and contrasts findings from open clinical studies and randomized controlled trials. This is particularly relevant to the literature on bipolar disorder, in which a vast amount of findings are from open clinical observation. This is an interesting attempt by Bowden but, because of the presumed constraints of a relatively brief chapter, the topic is not thoroughly dealt with in a way that the importance of the topic and the expertise of the author would justify. I thought that the chapters on comorbidity with alcoholism, substance abuse and anxiety disorders were an important addition to the book as these are very rarely broached in books on bipolar illness.

This book would have some interest for community psychiatrists and residents looking for a relatively brief review of the course and outcome of bipolar disorder. One cannot term this book an “update,” as much of the data has been superseded by the recent explosion of information on bipolar disorder. Furthermore, it adds very little to such important, seminal texts as Manic-Depressive Illness by Goodwin and Jamieson.

Essentials of Clinical Psychiatry

Essentials of Clinical Psychiatry

Robert E. Hales, Stuart C. Yudofsky, editors

Washington (DC): American Psychiatric Press; 1999. 1070 pp. with index

ISBN 0-88048-848-1 (paper)

A recent publishing phenomenon in psychiatry, particularly in the United States, is the creation of textbooks that are comprehensive, authoritative and expensive. These textbooks are usually multi-authored, and the contributing authors are selected for their well-established expertise in a particular area. In recognition of the needs of medical students and junior residents, more affordable synopses are then created out of these large textbooks. A well-known example of such a synopsis is the one edited by H. Kaplan and B. Sadock entitled Synopsis of Psychiatry that is based on the comprehensive textbook of psychiatry. That synopsis has gone through many editions and remains a popular reference for residents and medical students.

A recent addition to this trend is Essentials of Clinical Psychiatry, based on the 3rd edition of The American Psychiatric Press Textbook of Psychiatry. It is intended for medical students to use during their 3rd year of clerkship or in 4th-year psychiatry electives and for junior psychiatry residents who want a comprehensive overview.

The editors reviewed the 50 chapters in the parent textbook and selected the 25 chapters they felt were “most important and relevant for clinical practice in a variety of settings.” The authors of these chapters were asked to prune their text by 50%, selecting the most important material for their target audience. The resulting text contains 2 sections, “Theoretical foundations and assessment” and “Psychiatric disorders,” and 2 appendices, “Diagnostic criteria from DSM-IV” and “Excerpts from the American psychiatric glossary.”

Compared with its competitors, the major advantage this synopsis has is its discussion of current controversies in the field. An example is the rediscovery of trauma: “The most exciting development for theory of the mind and psychopathology in the 1980s and 1990s has been the rediscovery of the role trauma plays in shaping personality and creating symptoms.” This ambitious claim is well developed in the section on theories of the mind and psychopathology, which includes a discussion on repressed memory.

How should a medical student decide on the appropriate textbook? The following criteria should be used.

• Comprehensiveness. This book can make a strong claim for comprehensiveness. However, there are notable omissions, such as separate sections on Geriatric Psychiatry and Emergency Room Psychiatry.

• Relevance. The book is relevant to the theory and practice of psychiatry and will remain so for the next few years. However, another consideration for relevance is its value as a quick reference text, specifically in emergency situations. Apart from a few sentences in the section on interviewing skills, this book does not provide quick references.

• Examinations. In my experience, the great value of Kaplan and Sadock’s Synopsis of Psychiatry is that it lends itself more easily than this book to the setting of examination questions (and as a result is of greater benefit to residents when studying for these examinations).

• Integration. Because of the rapid developments in psychiatry, particularly in neurobiology, there is an increasing need to integrate the information in a meaningful way for medical students and residents. Essentials of Clinical Psychiatry is weak in this area, and, particularly in the theories of the mind and psychopathology, a student may be left with the sense that these theories hang loosely, separate from each other.

• Authoritativeness. This book reads as an authoritative text that incorporates the latest information. However, medical students may still need to read other texts for some areas. I recommend the chapter on the alcohol-dependent and drug-dependent person, by George E. Vaillant, in New Harvard Guide to Psychiatry. Also, this book does not contain a chapter on the history of psychiatry. Students should be well informed on this subject, therefore I refer them to Synopsis of Psychiatry. The book contains a number of superb chapters: “Neuroscientific foundations of psychiatry,” “Theories of the mind and psychopathology and the psychiatric interviews” and “Psychiatric history and mental status examination.” “Laboratory and other diagnostic tests in psychiatry” also provides important information, and the section on psychiatric disorders is extremely well done, providing comprehensive information on most of the major diagnostic groups. “Anxiety disorders” stands out as an excellent rendering of this important diagnostic area. • Cost. Choice of a text may depend entirely on cost. Now that the 3rd edition of The American Psychiatric Press Textbook of Psychiatry is available in synoptic form as Essentials of Clinical Psychiatry, it should be an important option for libraries, medical students and psychiatric residents.

The American Psychiatric Press Textbook of Psychiatry

The American Psychiatric Press Textbook of Psychiatry, 3rd ed

Robert E. Hales, Stuart C. Yudofsky, John A. Talbott, editors

Washington (DC): American Psychiatric Press; 1999. 1762 pp. with index

ISBN 0-88048-819-0 (cloth)

As would be expected of both the American Psychiatric Press and the American Psychiatric Association as an organization, the latest edition of the Textbook of Psychiatry, edited by Hales, Yudofsky and Talbott, is an impressive book. Members of the editorial board, the international advisory board and the individual chapter authors, make up a Who’s Who of modern psychiatry, although with a strong American bias. As examples, the chapter entitled “Psychiatric education” is written by Jonathan Borus, “Clinical neuropsychiatry” by Jeffrey Cummings, contributions on hypnosis and dissociation are provided by David Spiegel, and “Group therapy” is by Irvin Yalom. Thus, in most cases, the chapters have been prepared by leading experts in a particular field.

But there is a problem. In many ways, it is one that is illustrated, in parallel fashion, by the inclusion of DSM-IV on CD-ROM in a kind of “book within a book.” The CD-ROM is fun — easy to load on the computer and browse through but, in the end, not particularly useful. It comes on a CD-ROM, so cannot be downloaded, which means I have to choose whether to leave it at home or at work. More important, apart from providing another way to look up something (and I still think picking up my well worn mini DSM, which opens automatically to the Global Assessment of Functioning Scale is quicker), it really doesn’t do much. You can search key words on it, and find out how many diagnoses include anhedonia in the description of symptoms, and you could cut and paste sections from the DSM into other documents, but apart from that relatively restricted use, it just doesn’t seem to have a role.

Similarly, the question arises: What is the purpose of a large textbook like this now? Is it to provide a quick reference source for the field of psychiatry, a state of the art presentation of the field or a study tool for residents preparing for their fellowship examinations? Should it provide sufficient depth of discussion of topics to allow clinicians to expand their practical skills and knowledge substantially, making the book a large one indeed, or is it designed to provide overviews of complex fields?

Clearly, a textbook, no matter how well produced, is not going to be a state of the art presentation for long, although this one does an admirable job. As a reference tool, the textbook varies in its ability to deliver. The depth of discussion is limited by size constraints so, for example, important advances such as Linehan’s work on dialectical behaviour therapy for personality disorder, are presented and described, but not in sufficient depth to do more than stimulate interest. Autistic disorders are discussed fairly thoroughly, but little useful discussion of autism in adults is provided, even though the section is clear and well written. Finally, the chapter on group therapy restricts most of its content to a focus on the interpersonal orientation of Yalom, without providing a broad overview of writing on psychodynamic groups, cognitive behavioural groups or psychoeducation groups and the roles of these in various illnesses.

This limits to some degree the value of the book as either a quick reference or a study tool for residents, and yet this limitation, with some minor exceptions, stems more from the restrictions of the art of the textbook in current medicine than from the limitations of the authors. The expansion of knowledge in any field may have pushed the limits beyond that which is practically encompassed in a comprehensive textbook. Despite my earlier comments, overall, this is a good textbook. Chapters are generally very well written and ideas presented clearly. In most cases, key, up-to-date references are included. Clearly, the editors have run a tight ship to ensure publication of a textbook as up-to-date as possible.

Organization is fairly standard, with chapters on the theoretical foundations of psychiatry, a section on assessment, a section focussing on the disorders of psychiatry (following the DSM system of classification) and one on treatments. The editors avoided the pitfall of excessive reliance on DSM by setting chapters in the final section on topics such as violence, an area not well classified in DSM.

There are some excellent sections. Despite the loss of prominence of psychoanalytic theory politically, there is an excellent chapter by Robert Ursano and Edward Silberman on psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy. It reviews important writings and research and includes an extremely useful section looking at a comparison of psychodynamic, interpersonal and cognitive therapies, and pointing out the similarities and common roots that are often forgotten or ignored in debates between proponents on the relative merits of each.

The one main drawback for an international audience, is that this text is ultimately an American one. The chapters on psychiatric education, and law and psychiatry are about medicolegal psychiatry and education in the United States. “Public psychiatry,” “Managed care and psychiatry” and “Psychiatry and primary care” are written about US models and experiences of these fields; therefore, for example, the work by Kates and others on a shared care model for psychiatry and primary care is not included. This is unfortunate because the discussion on any of these areas could, with relatively little expansion of content, be greatly enriched by the inclusion of the experience in other countries. Including differing perspectives on the legal handling of dangerousness in the psychiatrically ill, or different models of postgraduate education in psychiatry, would not only benefit readers from other countries but could expand the dialogue on these issues through contrast and comparison. After all, many of these systems evolve in a particular way for historical reasons that may not always reflect the only or the best solution. Given the inclusion of an expert international advisory panel, it is unfortunate that the textbook falls short in this way.

Textbook of Psychiatry from the American Psychiatric Press is ultimately a pretty good textbook. It is comprehensive, well written and up-to-date. It is limited by its very nature, but if one feels that one does need such a book, then this book is competitive with any other in the field. It is unfortunate that it is limited by being essentially an American textbook. Relatively minor changes could have made it a truly international one, of use to both an American and an international audience.

Dual Disorders: Essentials for Assessment and Treatment

Dual Disorders: Essentials for Assessment and Treatment

O’Connell DF

New York: The Haworth Press; 1998. 250 pp. with index

ISBN 0-7890-0401-1 (paper).

This 250-page book gives an overview of the psychiatric problems that often accompany substance use disorders. The book targets health care workers who have been trained specifically to work in the addictions field, but who have not had psychiatric training. The obvious readership would be addiction counsellors and behaviour therapists, but the book would be useful for anyone beginning to work in this area — medical students, psychologists or social workers.

Essentially, this is an expansion and explanation of the disorders in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) that tend to be found with substance use disorders. It is comprehensive and clearly written in plain language. Each chapter gives an overview of a group of disorders and then moves to more detailed descriptions of the specific disorders in the group. The author supplements the factual material with excellent practical management advice and succinct case examples. He succeeds in balancing this formula throughout the book, making this not only a readable book but also one that can be used for reference.

Unfortunately, this book also has shortcomings. Chapter 1, the overview, fails to capture the complexity of treating dual disorders. I think the novice reader would be left without any sense of the role played by the relative severities of the comorbid disorders, of the idea of sequential versus simultaneous treatment of comorbid disorders, or even of the types of addiction treatment that can be used with patients suffering from psychotic disorders or severe post-traumatic stress disorder. Unfortunately, this simplistic view of dual disorders treatment is carried through the excellent chapters on the disorder groups.

The chapter on assessment includes an excellent description of the mental status examination as well as a less successful discussion of tests and questionnaires. Since the disorders are consistent with DSM-IV, it was surprising that this chapter did not include even a brief discussion of the 5-axis DSM diagnostic system.

The book also has appendices on cognitive therapy, medication, and sample treatment plan activities. These had the feel of having been added as an afterthought, which I suppose is inherent in the idea of an appendix. It would be more useful if they had been integrated into the discussions of the specific disorders. The information in the appendix on medication was outdated and did not convey the idea that medication can sometimes facilitate the treatment of addiction. The appendix on cognitive therapy is good, but, given the author’s credentials and experience, could have been more comprehensive.

Despite some shortcomings, I would recommend this book to addiction counsellors, psychologists, physicians and social workers who are beginning to work with patients with dual diagnoses.

OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual

OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual

March JS, Mulle K

New York: The Guilford Press; 1998. 298 pp with index

ISBN 1-57230-242-9 (cloth)

This text is a good example of how clinical demand can prompt the synthesis and organization of a body of work into a useful guide for the practitioner. John March and Karen Mulle have extensive experience in the assessment and treatment of child and adolescent anxiety disorders in general, and obsessive-compulsive disorder in particular. Dr. March is particularly qualified to prepare this text, given that he is a co-author of the Expert Consensus Treatment Guidelines for Obsessive-Compulsive Disorder. The authors have prepared a treatment manual that guides the practitioner step-by-step through the cognitive-behavioural treatment of obsessive-compulsive disorder in children and adolescents.

The book is organized into 3 sections. The first provides a review of the various symptomatic presentations of obsessive-compulsive disorder and a description of the assessment protocol that the authors use in their program. The second provides a session-by-session guide to the cognitive-behavioural treatment of pediatric obsessive-compulsive disorder, with emphasis on treatment goals and means of evaluating outcomes. The third deals with tricky issues in pediatric obsessive-compulsive disorder, including common therapeutic roadblocks and difficult obsessive-compulsive disorder subtypes. It also includes suggestions for working with families and schools. In their appendices, the authors include copies of useful assessment materials as well as educational materials for parents and families.

Although this is a text on cognitive-behavioural treatment for obsessive-compulsive disorder, there are small nuggets of useful information on the pharmacological management of this disorder as well. The authors emphasize the importance of framing obsessive-compulsive disorder within a neurobehavioural framework from the outset. Another major strength of this text is that it reminds the clinician to consider the whole child or adolescent in the management of obsessive-compulsive disorder, recognizing that this disorder occurs in a context (home, school) that requires the coordinated efforts of many individuals (parents, teachers, therapist, patient). It views cognitive-behavioural treatment as one component of treatment that is often multi-modal.

Two minor shortcomings of this book are the limited presentation of empirical support for cognitive-behavioural treatment of obsessive-compulsive disorder in children and adolescents, and the generally child-oriented approach in describing techniques. Compared with the literature on adult obsessive-compulsive disorder, the controlled research on cognitive-behavioural treatment with children and adolescents is weak. Although the principal author is currently collaborating on a major trial comparing cognitive-behavioural treatment, medication, and combination treatment, results were not yet available for inclusion in this text. The authors do make a significant effort to include throughout the text comments on developmental considerations for the adaptation of their techniques to treating adolescents. Unfortunately, the majority of the scenarios and techniques presented target children.

Overall, this is a useful text for clinicians who are likely to see children with obsessive-compulsive disorder in their practice. It should not replace more comprehensive training in cognitive-behavioural treatment, but rather represents a focused application of these skills to a specific problem.