Posts Tagged ‘anxiety’

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.

A Primer of Supportive Psychotherapy

A Primer of Supportive Psychotherapy

Pinsker H

Hillsdale (NJ): The Analytic Press; 1997. 278 pp. with index

ISBN 0-88163-274-0 (cloth)

Convincing evidence has accumulated that the supportive or nonspecific component, common to most forms of psychotherapy, is responsible for most of the change that results from psychotherapeutic interventions. This component appears to be both supportive — in that it is derived from the quality of the therapeutic relationship — and technical — in that it stems from the contract established with the patient and the use of nonspecific interventions. Specific interventions drawn from different schools of thought account for surprisingly little of the variance in outcome for most disorders, with the possible exceptions of panic and obsessive-compulsive disorders. The implications of these findings are clear. All mental health clinicians, regardless of their field, should be well versed in nonspecific interventions, and clinical training should emphasize integrated or so-called transtheoretical perspectives. Unfortunately, both practice and training tend to lag behind research. Many clinicians continue to rely on specific psychotherapeutic models, and training rarely gives nonspecific interventions the weight that they deserve, although there is some evidence that this is changing.

In this context, Dr. Pinsker’s very practical little volume is a useful addition to the growing number of texts on supportive therapy. Although one might disagree with some of the ideas and with the theoretical model that lies behind the volume, one must agree with the tone. This is the work of a sensitive and humane clinician who respects his patients. The approach emphasizes a conversational style and a responsive approach, rather than listening silently or interrogating the patient. The volume offers a model worth emulating. Anyone who adheres to the spirit of this work will not go far wrong, nor will his or her patients come to harm.

The value of this work lies in the large number of examples of the kinds of statements patients typically make and the clinician’s possible responses. The topics discussed include most of the key issues in therapy: increasing self-esteem, reducing and preventing anxiety, promoting adaptive skills, building a treatment alliance, and so on. These topics are explored through specific examples that include illustrations of helpful and less helpful responses that therapists may make. It is these examples that make this book especially helpful as an introductory text. Here is an experienced clinician talking in a common-sense way about the nuts and bolts of therapy. This makes for a style that is at times a little dull but replete with clinical wisdom. The simple practical examples will be helpful to a neophyte clinician who is learning how to conduct assessment and therapy interviews. They may also be worth a brief perusal by those who are much more experienced, who may be surprised to recognize bad habits unwittingly accumulated over the years.

The volume is not without limitations. Two issues are worthy of comment. First, some of the examples are a little sparse, and the discussion of alternative responses by the clinician is a little limited. Hence, the implications of the different possible therapist responses may not always be clear to the beginning therapist. More problematic is the theoretical perspective that runs through the volume. This is classically psychodynamic; hence, much is made of the distinction between supportive and expressive therapy. With increasing emphasis on integrated approaches, this distinction is less important. It may also be a little dated. The problem emerges on the first page when supportive therapy is differentiated from expressive therapy in terms of technical considerations. These are defined as using a conversational style, viewing the patient-therapist relationship as a real relationship that is not analysed, and supporting defences that are not maladaptive. Perhaps the important issue is not the distinction between supportive and exploratory therapy — which is important only to those who espouse the psychoanalytic tradition — but rather the degree of intrusiveness and the extent to which generic mechanisms are used to effect change. Dr. Pinsker describes these clearly, although in different terms. Consequently, it is easy to put theoretical issues to one side and concentrate on the practical component of the book. In this regard, the volume meets its goal of being a is a useful primer.

Handbook of Behavioral State Control

Handbook of Behavioral State Control: Cellular and Molecular Mechanisms

Lydic R, Baghdoyan HA, editors

Boca Raton (FL): CRC Press LLC; 1999. 700 pp. with index

ISBN 0-8493-3151-X (hard cover)

Although one may argue that any change in neuronal activity may ultimately lead to behavioural alterations, a closer relation between single cell function and behavioural consequences is needed. This relation is complex, and there are numerous and inter-related regulatory levels between cellular/molecular processes and behavioural outcome. It is therefore not surprising that there is a remarkable lack of exhaustive textbooks that explain cellular mechanisms underlying behavioural activity more globally. This book, edited by Lydic and Boghdoyan, both from Pennsylvania State University, partially fills this gap. It is a carefully planned handbook divided into 38 chapters organized in 8 sections, and written by 95 authors. The book’s major goal is to provide updated material on the cellular and molecular mechanisms generating diverse behavioural states. The authors do not explain cellular mechanisms of particular behaviours but rather provide information about the neural processes that regulate behavioural states, such as sleep, wakefulness, consciousness, arousal, etc. Different behavioural states, in turn, determine a subset of possible behavioural outcomes. The dominating theme of the book is sleep, wakefulness, arousal, and vigilance; this theme is compatible with the research interest and experience of the editors in the neurobiology of sleep mechanisms.

The handbook represents a working reference for numerous topics relating to physiological, psychological and pathophysiological states, including information on epidemiology, diagnosis, and treatment of common state disorders. The chapters in the first section discuss mammalian circadian rhythms, structure and function of the suprachiasmatic nuclei, melatonin rhythm-generation systems, and genetic circadian clock mechanisms. The subsequent chapters of the second section describe daily alterations in the arousal state, REM sleep dreaming, NREM sleep mentation, and neurological disorders of sleep. Section 3 deals with the anatomical substrate, neurochemical coding, and functional organization of components of the ascending reticular activating system, which includes ascending cholinergic, monoaminergic, and glutamatergic pathways. Particular attention is paid to the mesopontine cholinergic system and its role in REM sleep, wakefulness and cortical activation, and the noradrenergic and serotonergic pathways and their role in sleep, wakefulness, regulation of motor output and sensory information processing. The same systems are further discussed in more detail in the next section. Successive chapters deal with intrinsic membrane properties, synaptic activity, membrane current characteristics and excitability of cholinergic, noradrenergic, and serotonergic neurons. Particular attention is focused on the state-dependent cellular oscillations in the corticothalamic system and on the rhythmic oscillations in the hippocampal formation.

Mechanisms of behavioural state control may be altered by centrally active drugs. Several chapters in the section entitled “Molecules modulating mental state” discuss this issue. Neuronal and neurochemical mediation of addictive behaviour, and alterations in behavioural state caused by benzodiazepines, barbiturates, ethanol, caffeine, nicotine, marijuana, and serotonin antagonists are discussed.

The following 2 sections of the handbook review the current knowledge regarding state-dependent processing in somatosensory pathways and the role of the rostral ventromedial medulla in regulating ascending sensory transmission. Several chapters of the last 2 sections of the handbook deal with pathophysiological states. There is a particular emphasis on pain sensation, anesthesia, pharmacological and surgical treatment of pain, and immunological alterations in the arousal state. The topics cover cytokines in sleep regulation, immune effects on neurotransmission, and finally, body temperature, fever and microbial modulations of arousal.

Although the textbook covers vast areas of behavioural neuroscience, there are several important areas that are not represented. Results of the vast research concerning emotional states, such as anxiety or fear, and relevant regulatory functions of the limbic structures are not included. Also, psychopathological states of panic, depression, or euphoria are not described, except in parts of one chapter about addictive behaviour and neural mechanisms of reward. This topical selection was probably necessary to keep the textbook at the manageable size.

The textbook is well illustrated and contains overall 3500 references, more than 90 references per chapter. The book may serve as an excellent resource for advanced undergraduate and graduate students, postdoctoral fellows and biomedical researchers working with animal models of neurological and neuropsychiatric disorders. It will also be highly useful for medical residents, lecturers in neuroscience courses, and other professionals interested in problems of behavioural neuroscience and general neural principles governing animal and human behaviour.

The Maudsley Handbook of Practical Psychiatry

The Maudsley Handbook of Practical Psychiatry, 3rd edition

D. Goldberg, editor

New York: Oxford University Press; 1997

ISBN 0192628534 (hard cover)

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

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

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

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

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

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

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

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

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

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

The Neuropsychiatry of Limbic and Subcortical Disorders

The Neuropsychiatry of Limbic and Subcortical Disorders

Salloway S, Malloy P, Cummings JL, editors

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

ISBN 0-88048-942-1 (cloth)

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

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

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

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

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

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

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

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

Akathisia and Restless Legs

Akathisia and Restless Legs

P Sachdev

New York: Cambridge University Press; 1995. 425 p

This book provides the most comprehensive review to date on akathisia, restless legs, and neuroleptic-induced dysphoria. The volume is divided into 4 distinct parts. Part 1 provides a historical review of akathisia and restlessness as well as a concise and excellent review of neuroleptic-induced dysphoria. Part 2 focuses extensively on drug-induced akathisia. The definition, epidemiology, differential diagnosis, and clinical characteristics of both acute and tardive akathisia are well presented. Assessment procedures are discussed, as are the etiology, pathogenesis, and treatment of the disorder. Part 3 reviews the clinical features, pathophysiology, and treatment of restless legs syndrome. Part 4 offers the reader a summary and recommendations for future research followed by appendices of 4 akathisia clinical rating scales.

In part 1, the book offers a detailed introduction to the development of the concept of akathisia, which was 1st reported by Thomas Willis (1621-1675). The term “akathisia” translated from its Greek root, however, means “not to sit” and was 1st used by Lad Haskovec in 1902. Ekbom introduced the term “restless legs syndrome (RLS)” in 1945 and described the most characteristic symptom of this disorder as “creeping or crawling sensations most frequently localized to the lower leg.” By the 1960s, RLS was firmly established as a neurological disorder, albeit of unknown etiology. After antipsychotic drugs became widely available, a number of reports of akathisia appeared in the literature, with descriptions of patients being restless, being unable to sit, or marching like soldiers. In spite of the few interesting papers examining the psychological and psychodynamic meaning of the akathisic reaction, consensus emerged in the early 1960s that akathisia was an extrapyramidal side effect (EPS) of neuroleptic medication.

Acute akathisia (AA) refers to akathisia that develops soon after the introduction of neuroleptic drugs; by contrast, tardive akathisia develops as a delayed side effect of long-term neuroleptic medication.

Akathisia is often used synonymously with neuroleptic-induced restlessness, yet the term was introduced well before neuroleptic drugs became available. In the clinical setting, restlessness can be caused by psychological factors, organic disorders (drug-induced disorders, drug withdrawal reactions, delirium, dementia, head injury, hypoglycemia, and RLS), and nonorganic psychiatric disorders (affective disorders, psychotic disorders, anxiety disorders, and childhood disorders like attention-deficit hyperactivity disorder).

The author distinguishes 2 aspects of restlessness — a motor (objective) component and a mental (subjective) component — and suggests a comprehensive operational definition.

The motor component of restlessness is typically considered to be under voluntary control; there is, however, a compelling need to move, and suppression of movement results in mounting distress. Sachdev reminds us that the functional neuroanatomy and the neurochemical basis of restlessness remain poorly understood. In many cases, restlessness must be treated because of its negative impact on the patient and caregivers. It is important, however, to identify and, if possible, to rectify the various psychological, social, and environmental determinants of restlessness. Drug therapy may be required to reduce motor activity and subjective distress. The choice of a particular drug is guided by the setting and the possible etiology. Neuroleptics are probably the drugs most commonly used for the management of agitation in dementia and delirium. Benzodiazepines are used quite extensively in the treatment of agitation, and a number of studies attest to their efficacy in some patients.

Neuroleptic drugs induce unpleasant subjective effects among healthy controls and in many psychiatric patients. A dysphoric response is often a predictor of neuroleptic non-compliance. The manifestations of neuroleptic-induced dysphoria (NID) are varied and range from complaints like “the drug disagrees with me” and “I feel emotionally unresponsive” to neuroleptic noncompliance, anxiety and dere-alization, school and work avoidance, painful sensory symptoms, and even depression. The question of whether or not NID can also manifest as a cause of or contributor to depression is a controversial issue that remains to be resolved.

NID may result in a poor outcome, but while many NID patients become noncompliant, others benefit from dysphoria by negotiating with their psychiatrists for lower yet effective doses of neuroleptics, resulting in less severe EPS. The neurobiological basis of NID remains poorly understood.

While the importance of akathisia is now well recognized, there is no consensus on its essential characteristics and hence its diagnostic criteria. The essential features of drug-induced akathisia (DIA) are: 1) exposure to neuroleptic drugs; 2) subjective component: feelings of restlessness, constant urge to move the legs, difficulty or inability to maintain a posture for several minutes; 3) objective component: movements while sitting, standing, or lying. The assessment scale Sachdev uses is the Prince Henry Hospital Akathisia Scale, which includes 3 subjective items, 7 objective items, and a global akathisia score. Sachdev also proposes detailed criteria to diagnose akathisia. It is appropriate to consider onset of symptoms after 3 mo of continuous use of the drug without change in dose or type as tardive akathisia. Onset within 6 weeks of stopping or significantly reducing the dosage of a neuroleptic drug should be considered a withdrawal akathisia, and if the diagnosis of akathisia persists beyond 3 mo after drug cessation or reduction, tardive akathisia should be diagnosed. Akathisia that continues for 3 mo or longer is considered to be chronic.

The published rates of AA with conventional neuroleptics vary from 8% to 76%. A conservative estimate of the incidence of akathisia with classical neuroleptics at clinical dosage levels is about 20% to 30%, but this rate is significantly affected by treatment-related and other variables (parenteral administration and drug potency, for example). Akathisia can also be induced by novel or atypical neuroleptic drugs. Current evidence suggests a reduced rate of AA with these novel agents, and further systematic work is necessary. Nonneuroleptic drugs that can also induce AA include serotonin reuptake inhibitors, serotonin antagonists, heterocyclic antidepressants, anticonvulsants, calcium channel antagonists, and lithium carbonate.

There are no accurate estimates available as to the prevalence or incidence of tardive akathisia, and data on the epidemiology of withdrawal akathisia are extremely limited. In children and adolescents, drug-induced movement disorders have been poorly documented, and akathisia has been relatively neglected. In individuals with developmental disabilities on long-term neuroleptic medication, akathisia appears to be common, but the overall data are too few to make comparisons with nondisabled populations. In the geriatric population, reports of akathisia have been few.

The main feature of AA is subjective distress. In its milder form, it is experienced as a vague feeling of apprehension, irritability, dysphoria, impatience, or general unease. While the restlessness of akathisia may be felt in the mind or body or both, the characteristic that distinguishes it from restlessness of other etiology is its reference to the lower limbs. The movements are described as a response to an irresistible urge to move, but the movement alleviates the urge and the distress only temporarily. Akathisia has been associated with psychotic exacerbation, violence, and suicide. Fidgetiness is perhaps the most common motor sign of akathisia and is usually manifest as semipurposive or purposeless movements of legs, feet, and toes. While the emphasis is on leg and postural movements, semipurposeful or purposeless arm and hand movements may occur. Upper limb movements are less prominent and virtually never occur in isolation. Activating maneuvers in the case of akathisia tend to diminish or suppress movements.

Tardive akathisia has not been universally accepted as a distinct syndrome. The phenomenological examination of patients on long-term neuroleptic medication suggests that tardive akathisia is distinct from tardive dyskinesia, with overlap between the 2. “Chronic,” in terms of describing akathisia, refers to the duration of the disorder, irrespective of the nature of onset, whereas “tardive” denotes a delayed onset.

The most popular method of measuring akathisia is with the multiitem rating scales such as the Barnes Akathisia Rating Scale, the Hillside Akathisia Scale, and the Prince Henry Hospital Akathisia Scale. The measurement of akathisia presents a number of difficulties owing to the complex manifestations of the disorder, the lack of a well-accepted definition, and its variability. No instrumental method is totally satisfactory, but a combination of strain-gauge measurements and actigraphy can provide an accurate measurement of the motor component of akathisia.

The etiology of akathisia must be understood in terms of the drugs that are directly causative and in view of a number of background variables that are likely to increase the risk of its development. Its pathogenesis is incompletely understood, and many competing hypotheses exist. tardive akathisia and withdrawal akathisia have not been reported with nonneuroleptic drugs, suggesting that, unlike AA, they may be purely neuroleptic-related syndromes.

Treatments for AA include modification of the offending drug (cessation, dosage reduction, change to another type, reduction in rate of increment); modification of risk factors; and introduction of benzodiazepines, anticholinergic, antiadrenergic (β-antagonists, α2-agonists), or other agents (ristanserin, amantadine, piracetam, tricyclic antidepressants, and sodium valproate). The treatment of tardive akathisia is, in general, unsatisfactory and the main emphasis should be on its prevention.

There is still no consensus on the incidence and prevalence of RLS. Like akathisia, it is characterized by sensory and motor features. The restlessness in RLS is different from the movements seen in DIA. The other main motor feature in RLS is myoclonic jerks. RLS often leads to sleep disruption. The course of idiopathic RLS is variable — starting in childhood, adulthood, or old age, being progressive or staying the same or even getting better. Table 12.5 (p 317-318) contrasts the DIA and RLS disorders clearly. In RLS treatment, clonazepam remains the drug of 1st choice. Although evidence supports the use of 1-dopa, problems with the long-term use of this drug make clonazepam a better initial agent. If 1-dopa is not tolerated, bromocriptine can be used.

In summary, this is a timely, well-written, and well-researched volume. Dr Sachdev is to be congratulated for offering readers the 1st book-length review of akathisia and related syndromes. Undoubtedly, this book will be a welcome reference for psychiatrists and neurologists.

The Schedules for Clinical Assessment in Neuropsychiatry

The Schedules for Clinical Assessment in Neuropsychiatry. Version 2

Wing JK, chief editor

Geneva: World Health Organization—Division of Mental Health; 1994.331 p.

The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a manual published by the World Health Organization designed to assess, measure, and classify the psycho-pathology and behavior associated with the major psychiatric syndromes of adult life. SCAN had its origins in the 9th edition of the Present State Examination (PSE 9). SCAN consists of 4 components: the 10th edition of the “Present State Examination” (PSE 10), the “Item Group Check List,” the “Clinical History Schedule,” and the “Glossary of Differential Definitions.” Only the first 3 were reviewed. The PSE 10, which forms the greater part of SCAN, covers phenomenology. The “Item Group Check List” is a method of obtaining information from case records and informants other than the patient himself or herself. The “Clinical History Schedule” is a method of checking or entering data relevant to the broader clinical and social history.

The PSE itemizes various domains and categories of psychopathology. For each phenomenological category an appropriate probe question is provided. The PSE does not give detailed definitions. These are contained in the “Glossary of Differential Definitions” which was unfortunately not available for review. This is regrettable since the SCAN can only be fully appreciated in the context of the glossary.

The SCAN is designed for epidemiological research rather than day-to-day clinical care. Data from the schedules are intended to be entered into a computer algorithm (C ATEGO-5) which processes the data. The output is a series of options including a range of profiles of symptoms, an index of definitions and ICD-10, and DSM-III-R diagnostic categories.

Interviewers who use SCAN must first address those factors that would interfere with access to psychopathology or indicate a need to adopt specific interview strategies. These include severe language disorders, cognitive impairment, severe behavioral disturbance, uncooperativeness, or the likelihood of a premature termination. The PSE 10 rating scales address various domains and categories of psychopathology. The domains contain overlapping phenomenological categories that can be confusing. For example, depersonalization and derealization, which are rightfully disturbances of perception, are also included in the domain of nervous tension. While this may be useful for research purposes and computerized programs, overlapping phenomenological categories muddy the analysis of the mental state. This is akin to describing motor weakness in a neurological patient within the domain of sensory changes. It is preferable to keep phenomenological categories within their rightful domains. Elicited psychopathology can then be extracted and linked together within the context of a biopsychosocial framework to reach a diagnosis.

The domains of the mental state identified by the PSE include: somatic symptoms, nervous tension, panic, anxiety and phobia, obsessional symptoms, depressed mood and ideation, thinking, concentration, energy and interests, body functions, eating disorders, expansive mood and ideation, alcohol and substance abuse, language difficulties, perceptual disorders other than hallucinations, hallucinations, subjectively described thought disorder and experience of replacement of will, delusions, cognitive impairment and/or decline, motor and behavioral phenomenology, observed affect, speech abnormalities, and social impairment.

SCAN contains a separate section for evaluating stress-causing acute reactions and posttraumatic stress disorders, the course of schizophrenia as described by either DSM-III-R or ICD-10, acute psychosis, induced psychotic disorder, schizotypal disorder, simple schizophrenia (an ICD-10 but not a DSM-III-R diagnosis), and the negative syndrome of schizophrenia. The latter has been included in SCAN for research purposes.

The section on cognitive impairment and/or decline includes the well-known Mini-Mental State Examination (MMSE) as well as the less well-known Verbal Trails Test. This section also contains probes to assess language, calculation, praxis, abstraction, fiind-of-knowledge, frontal-sub-cortical function, and level of consciousness. The section on dementia includes specific etiologies such as Alzheimer disease and Parkinson disease.

SCAN was developed by an international panel of researchers. Various groups of collaborators were responsible for the design and field trials of particular sections of SCAN. This presumably accounts for the lack of integration and the overlap of phenomenological categories across various psychopathological domains. In addition SCAN, unlike PSE 9, shifts out of the context of the mental state examination and includes sections that rate specific psychiatric disorders and disease course as well as identifies specific etiologies. SCAN is, therefore, much more than a rating scale for the mental state examination. Users of the SCAN may find this confusing and would be wise to look elsewhere for a clear and integrated conceptual understanding of the various domains and categories of the abnormal mental state. Nonetheless SCAN does list much of the psychopathology of mental disorders and can be used as a reference by clinicians to enrich and polish their own mental state evaluations.

Seminars in Basic Neurosciences

Seminars in Basic Neurosciences

Gethin Morgan and Stuart Butler

College Seminars Series (Royal College of Psychiatrists), London: Gaskell, 328 p., 1993.

The following remarks fall into two parts: first, a review of the book listed above; second, some comments on the place of the neurosciences in current psychiatry.

The title (with “Basic Neurosciences” placed in a prominent box on the cover) might suggest that this book is a rival to such a text as that by Kandel et al (1991) on “Principles of Neural Sciences”. This small volume, however, has a different purpose, namely, that of instructing clinical trainees in psychiatry to those aspects of neuroscience which may be of value to the practising clinician (and in meeting examination demands). In fact, it incorporates far more than the basic neurosciences as conventionally understood for it includes, in addition, a concise course in clinical neurology. Perhaps a future addition might reflect this in the title. Two important features should be noted at the outset. First, it is written by “contributors…experienced as teachers of clinical trainees.” Second, “there are many figures, diagrams, tables and boxes to make the information accessible and more easily absorbed”.

The contents of the book fall into nine chapters with short reference lists. They will now be considered seriatim; (the figures in parentheses indicate the page lengths of each).

“Functional neuroanatomy” (41) Butler: This chapter provides, in brief form, a standard account of relevant neuroanatomy. It includes an excellent diagram (Figure 1.14) on the limbic system and its connections.

“Neurophysiology” (28) Logan: This chapter is a concise account of synaptic transmission and, thereafter, reflex phenomena in the sensory and motor sphere. Diagrams are less plentiful but usually useful (for example, Figure 2.5 as opposed to Figure 2.4) (One wonders if the busy clinician will ever have recourse to the complex connections of the cerebellum portrayed in Figure 2.4 – unless it is a particularly slow day).

“Neurochemistry and neuropharmacology” (40) Nutt: This chapter is one of the best chapters in the book. Written by the Director of the Psychopharmacology Unit in the School of Medical Sciences at Bristol University, it deals succinctly with receptors and the mechanisms by which the ever-increasing numbers of psychotropic drugs are presumed to work. While the diagrams are excellent, the tables are outstanding. Figures 3.6 and 3.8 together with Tables 3.1,3.2 and 3.6 are superb summaries of current knowledge and Dr. Nutt deserves our gratitude and congratulations. The book is worth buying for these alone.

“Neurological examination and neurological syndromes” (38) Barrett: This chapter gives a remarkably complete account of clinical neurology as well as the neurological examination. Here summarized information given in “boxes” varies in utility from good 4.3 (classification of epileptic seizures), 4.5 (causes of dementia) to poor 4.4 (causes of epilepsy), 4.6 (causes of delirium). Simply listing seventeen or thirteen items in a “box” without any attempt at organization is daunting, not helpful. Nonetheless, to cover so well a wide area in such a small space does credit to the author.

“Neuropsychology” (34) Hallett: This is another excellent chapter. In Hallett’s own words, “neuropsychology offers a robust system for the measurement and quantification of cognitive function, emotional state and behavioural repertoire…” and is a “complementary system of analysis to psychiatry.” The chapter goes on to detail what psychology can and cannot do in this area. As an even-handed exposition in a small space I doubt if this chapter could be bettered. The appendices are admirable summaries of relevant tests.

“Neuropathology” (34) Luthert: This chapter provides the pathological complement to Barrett’s chapter. After discussing techniques and basic pathological processes, the writer then surveys most of the common neurological diseases. Most relevant to psychiatry is the excellent and concise account (in six paragraphs and one table) of the changes in Alzheimer’s disease. The “boxes” in this chapter are outstandingly good, for example, 6.2 (time course of events following focal occlusion of a cerebral vessel) and 6.3 (routes of infection.)

“Neuroendocrinology” (25) Gilbey and Macrae: This chapter provides a good survey of the field and here excellent diagrams are a feature (Figures 7.1, 7.3, 7.4 and 7.7). This section is particularly valuable since it collects together in one place information which is much less accessible to most of us than the content of many other chapters of this volume. Table 7.4 and 7.5 (psychiatric manifestations of endocrine disorder and endocrine manifestations of psychiatric disorders) are very helpful.

“Clinical neurophysiology” (SS) Hilary Morgan: This chapter deals successively with techniques of recording the EEG, its normal appearance and the changes occurring in metabolic and toxic states and following treatment (including ECT). After an account of changes in the various neurological disorders, there is then a special section devoted to epilepsy. The facts are encapsulated in the “mother of all tables” 8.1 which runs over four pages. Pages 281 to 283 contain important summaries on violence, epilepsy and the EEG; the EEG and episodic behavioural changes and schizophrenia and affective disorders. There is a short account of sleep and the EEG (now a subspecialty of psychiatry with its own testing examination) and the chapter concludes with mapping (including power spectral analysis) event-related potentials and evoked potentials. Instead of boxes there are numerous illustrations of the EEG in various conditions.

“Neuroradiology” (12) Bradshaw and Lewis: After discussing the various techniques in this chapter (plain radiography, angiography, CT, MRI, PET and SPECT), the authors survey successively the spine, congenital lesions, vascular disease, trauma, neoplasia and finally degenerative, metabolic and toxic disorders. There is an introductory and minatory warning against the temptation to scan large numbers of psychiatric patients in the hope of “finding something”. But there are replicable findings, for example, the ventricular changes in schizophrenia and changes in rCBF and glucose metabolism in dementia which deserve discussion. This could with profit replace the account of radiology of the spine. And the use of PET and SPECT to study a wide variety of neuroreceptors is surely of interest (Daniel et al). There are missed opportunities here.

“Appendix and index” The former contains a map of cutaneous innervation and a table of reflexes. There is an excellent index compiled by Linda English.

At first sight, the chapters appear uneven but to a degree this reflects the subject matter. It is easier to be enthusiastic about the latest findings in the brains of patients suffering from Alzheimer’s disease than to get excited over the corticothalamic tracts which haven’t changed much in the last few centuries. But this would be a very unfair reflection on the authors who have produced remarkably good summaries of their areas which, despite brevity, are readable, thanks in large part to the lavish use of boxes and diagrams which contribute to the success of this enterprise.

One could always argue with the editors about allocation of space to the different subjects. Thus, in considering diagnosis, many would put neuropsychology first followed by radiology, endocrinology and the EEG last; yet the pages allotted are 34, 12, 25 and 55 respectively. But the editors are presumably tuned to local needs and the requirements of examinations. (And the pages on the EEG are inflated by numberous multichannel illustrations).

In sum, this excellent volume provides in one place an extremely useful, concise and up-to-date compendium of clinical neuroscience and neurology. If the trainees absorb the contents then they will be well-equipped to deal with the increasing pace of change due to new research findings which, judiciously and selectively, they may wish to incorporate into their clinical practice.

If we accept the view that mental activity is based on brain activity then a knowledge of the basic neurosciences becomes essential. It is true that a few still hold to the dualist view, notably Sir John Eccles and the late Sir Karl Poppers, but most in the field are less defeatist and believe that eventually most mental activity will correlate with neuronal events. There are indeed notable successes to date which are recounted in the volume by Kandel et al (1991) already cited. Kandel’s work on anxiety and the synapse is a classical example of the progress being made.

Nonetheless, to the practising clinician the different neurosciences have varying relevance. Can we not, then, leave some to the specialist? While it is customary to defer to individual experts in, say, radiology or endocrinology, it is still essential, in this reviewer’s opinion, that the clinician have enough general knowledge not only to know what the different disciplines can provide but also to be able to interpret oneself in relation to any individual patient and at times overide the expert.

Some would even go further and deny the need for medical training. Thus, psychologists in the US have sought admission privileges and the right to prescribe drugs. Without full medical training including the neurosciences such a course is fraught with hazard. But if clinicians themselves do not use their medical skills then it becomes more difficult to answer the pressures of competitive professions. However, there is an increasing shift from consultation-liaison psychiatry to medical psychiatry defined by Stoudemire and Fogel (1987) as “a medical specialist who assumes primary responsibility for the diagnosis and treatment of psychiatric disorders within the medically ill population.” They go on to list the reasons for its growing importance as follows: “(1) the increasing prevalence of chronic disease and the aging of the population, (2) advances in neurodiagnostic techniques and psychopharmacology, permitting more rational biological therapy of psychiatric disorders in the medically ill, (3) the development and implementation of brief, focused dynamic psychotherapy techniques appropriate for the medical setting, (4) the development of specialized medical-psychiatric inpatient units, (5) increasing time pressures on other medical specialists, leaving the psychiatrist as the only medical specialist with the time, knowledge, and skills to develop a comprehensive understanding of the emotional dimensions of medical patients’ illnesses, and (6) increased competitive pressures from non-medical psychotherapists, causing psychiatrists to emphasize their medical training and skills.” The role of the basic neurosciences in the above needs no emphasis.

If, indeed, psychiatrists do not pay attention to these areas then psychiatry as a discipline will diminish and may vanish. Our patients will be the big losers. That dire consequences are already upon us is exemplified in a recent editorial by Robin Eastwood (1994). He notes that both by competition from other specialties and by default psychiatry is losing its place in dementia research in Canada. This displacement is occurring elsewhere too and he quotes a Lancet editorial which “says that dementia, especially basic research, is now indeed the domain of neurologists and that even schizophrenia is not exclusive to psychiatry anymore.” If, in fact, psychiatry has decided to concentrate on the “functional” psychoses, he concludes “how sad that the magnificent start given by Kraepelin and Alzheimer at the beginning of the century, at the Ludwig-Maximilians-Universitat in Munich, has come to this in Canada.”

This reviewer hopes the volume edited by Morgan and Butler will help stop the rot.

Brain Biochemistry and Brain Disorders

Brain Biochemistry and Brain Disorders

Philip G. Strange

Oxford, New York, Tokyo: Oxford University Press, 342 pp, 1992

I read and re-read this book several times — it is easy to read. On my first survey, I noted numerous excusable and many unforgiveable omissions (for example, only a brief mention of the dopamine D-3 receptors on page 239 and not even a word on the D-4 receptors that had been described by then). But I came to the realization that one cannot be an excessively critical judge. Any book of this size that comprises biochemistry, structure, research methodology and a wide range of pathologies of the brain can only be somewhat of a smorgasbord. There is nothing wrong with a neuroscience buffet, however, provided it is nutritious and served with style. And this must be recognized about this book, including the extremley well chosen cover illustration of Edward Munch’s “The Dance of Life”.

The first seven chapters provide sufficient amounts of basic information and neuroscience facts that are required for the grasp of the second part of the book, which focuses on six different disorders.

The author discusses artfully and, for purposes of psychiatric residents and practitioners, sufficiently the cellular aspects of the brain tissue, the chemical and electrical signalling, the neurotransmitter and receptor systems as well as some research technologies, although the description of the restriction-fragment length polymorphism (RFLP) could have been made clearer.

The author chose six diverse pathologies that are connected along the mesostriatal, mesolimbic and mesofrontal tracts. The totality of these six pathologies, and some others mentioned en passant, provides a base not only for the understanding of these illnesses but also for the comprehension of these brain parts. The discussion of Parkinson’s disease, including the MPTP, genetic aspects, rationale of tissue transplant, etc. is fairly complete, as is the chapter on Huntington’s disease and Alzheimer’s disease. The chapter on schizophrenia, as a brain disease, competently deals with the subject, although the contribution of Weinberger (mentioned briefly on page 256) could have been more extensive. The chapter on depression, although thorough and interesting, is too speculative in relation to the septohippocampal system. The last chapter, on anxiety, is probably the weakest.

The illustrations, including the CT scans, are of good quality. There are aspects of the quotations of original contributors where one could disagree with the author. Considering that books rapidly become outdated, this book has a certain philosophy and appeal — not to mention a modest price — that will assure a measure of longevity.

Headache and Depression: Serotonin Pathways as a Common Clue

Headache and Depression: Serotonin Pathways as a Common Clue

G. Nappi, G. Bono, G. Sandrini, G. Micieli

New York, NY: Raven Press, 345 pp., 1991

Serotonin (5-HT) is an ubiquitous substance, found throughout the body, which has become a common focus of interest for psychiatrists, neurologists and neuroscientists. Although originally discovered in the 1930s and isolated in 1948, only in the past decade has it caught the imagination of clinicians and basic scientists, particularly those exploring the basis of behaviour, mood, pain and headaches. The secret of how such a simple chemical substance could have such a variety of different physiological effects resides in the various kinds of serotonin receptors which are found in different tissues and organs.

This book examines the role of serotonin in depression, headaches and related conditions. The editors are all from Italy, where much research into serotonin has been conducted, but they have enlisted authorities from around the world to add chapters on their own fields.

The chapters vary in quality, but some contain excellent reviews and new material to which I will refer frequently. Feniuk and Humphrey give a nearly up-to-date account of 5-HT receptors. Since this book was published, they have added to the research on receptors, which is advancing at a furious pace. Edvinson describes the particular receptors involved in the cranial circulation. Sicuteri has written an excellent review of the role of serotonin pathways in headaches, and Cassano and Marazitti, its role in depression. The subject of chronic daily headaches is presented by Mathew. The possible role of serotonin and neuroendocrine factors in this condition and in cluster headaches are explored by several authors.

The role of serotonin in migraines is extremely complex. IV 5-HT can both precipitate and relieve migraine headaches. Blockage of serotonin synthesis can cause a panalgesia syndrome. While reserpine-induced serotonin depletion in platelets is associated with the precipitation of acute headaches, there is a reduction in migraine attacks during the subsequent month while serotonin is slowly restored. Certain 5-HT receptor agonists precipitate headaches in people who suffer from migraines, while most relieve acute attacks. The answer may be found in receptor specificity, with 5-HT-ID agonists generally relieving migraines. 5-HT-2 antagonists are used as prophylactic agents for migraines. Clearly, there is still much to be learned in this field.

In the case of mood disorders, the situation is even less clear. Both high and low levels of serotonin activity have been found in patients with depression. Again, the receptors may hold the key. 5-HT-2 receptors seem to be important in depression, while anxiety is related to 5-HT-l receptor activity. Up and down regulation of receptors are likely responsible for depression and the effects of antidepressive medications.

In trying to untangle this complex scheme, one may be forgiven for concluding that the only common factor in headaches, depression and serotonin perturbation is the nervous system itself.

I found many of the chapters on topics that were somewhat outside the main theme of the book to be very interesting. Chazot, from Lyon, reports on their experience with pinealectomized patients who have headaches and depression, presumably as a result of the loss of melotonin, which is metabolized to serotonin. Melotonin may also play a role in some features of cluster headaches. Studies in chronobiology may give new insights into the basis of mood disorders, cluster headaches and perhaps even migraines. Serotonin is undoubtedly involved as well in these cyclic conditions. It is less clear whether or not it is involved in menstrual syndromes, but headaches and depression are often part of premenstrual syndrome. There are several chapters in the book on this subject.

The book would have been of greater value to the casual reader had the editor added a concluding chapter summarizing the information. Nevertheless, this book provides a wealth of information on serotonin, depression and headaches, but only those who are specifically interested in the topics covered will find it worth the price of $130.00. However, I recommend it to psychiatrists who wish to have up-to-date information on some of the biochemical bases and the mechanisms of current therapeutic agents for treating depression. Headache specialists and behavioral neurologists may also find it useful. It will be of less interest to others in the profession.