Posts Tagged ‘anxiety disorders’

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.

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications. CD-ROM

Stahl SM. New York: Cambridge University Press; 1998

ISBN 0-521-62892-X

This CD-ROM is an introductory textbook to the extraordinary complexities of basic and clinical neurochemistry pertaining to psychopharmacology. To make this information lucid, engaging and accessible requires a gifted communicator; Stephen Stahl is such a teacher, whose credentials as a researcher give authority to the concepts, facts and speculations he conveys so clearly.

Since this “book” is in CD-ROM format, any review must consider both the content and the format. The text is structured into 12 chapters and relies heavily on figures and diagrams to illustrate key concepts. The first 4 chapters focus on basic science and provide the foundation for the remaining 8 chapters. Stahl begins with the principles of chemical neurotransmission, including signaling, receptor occupancy, second messengers and co-transmission. He then explains receptors and enzymes as targets of drug action and further explores special properties of receptors in terms of subtypes, agonists and antagonists. He concludes the basic science section with a chapter on the interaction between disease and chemical neurotransmission.

The second section is clinically focused and briefly summarizes the biological bases of mood disorders, anxiety disorders and psychoses as a prelude to explaining and rationalizing the actions and benefits of psychiatric medications — as well as speculating on interventions in the future. Stahl concludes by considering cognitive enhancers, neuroprotective agents and drugs of abuse.

Any one of these basic science concepts, clinical disorders and psycho-pharmacological treatments could easily be the subject of a separate book — one that Stahl himself could probably write. It is a remarkable talent to synthesize, integrate and communicate clearly this wealth of information as effectively as he does. The text is unencumbered by references or wordy explanations. Advanced experts in various areas may sneer at oversimplification (a similar phenomenon occurs when someone makes psychotherapy fundamentals obvious and accessible), but this text is clearly not intended for them.

The ideal readership for this CD-ROM includes medical students, residents in psychiatry and allied health professions, and psychiatrists whose training concluded more than 5 years ago.

This text existed as conventional “hard copy” (what we nostalgically refer to as a “book”) before its current incarnation as a CD-ROM. What is the advantage of the CD-ROM format? It could be an expensive proposition unless you already own an IBM-compatible computer with a 486 or faster processor, or a Macintosh computer with System 7 or 8, at least 16 mB of RAM, Quicktime software, a sound card and speakers or headphones, and a 2 x or faster CD-ROM drive. It is really designed for Macintosh computers, and the author acknowledges that there may be some limitations in using the CD-ROM in an IBM-PC environment. Reading the CD-ROM involves pressing keys and jumping backward and forward between text and figures. The advantages lie in the use of animated diagrams to illustrate neurotransmission concepts, often accompanied by audio narration featuring Stahl himself.

While the animation reflects the elegant synthesis characteristic of the author, it seems rather primitive compared with the sophisticated computer graphics on children’s games. The narration is the weakest of Stahl’s skills: it adds nothing and requires a separate keystroke to activate, when simply reading a caption would be preferable.

Other textbooks on CD-ROM provide more opportunity to print excerpts and take notes on the computer screen. This CD-ROM lacks flexibility. With a book version, I could have scribbled in the margin or photocopied a diagram. In summary, this textbook is superb in terms of content, but the technology of presentation does not facilitate access or understanding. Reading the CD-ROM made me want to buy the book.

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.

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.

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Swinson RP, Antony MM, Rachman S, Richter MA, editors

New York: The Guilford Press; 1998. 478 pp with index

ISBN 1-57230-335-2 (cloth)

This book, as its subtitle indicates, sets out to review all aspects of obsessive-compulsive disorder. It is comprehensive, consisting of 18 chapters by 41 contributors, and is divided into 3 major sections. The first is on psycho-pathology and theoretical perspectives, the second on assessment and treatment, and the third on obsessive-compulsive spectrum disorders.

There is also a 6-page appendix of information on national organizations concerned with obsessive-compulsive disorder, anxiety disorders, and obsessive-compulsive spectrum disorders, both in and outside North America, as well as supplementary material intended for both the public and professionals.

The writing is consistent and clear, a tribute to the authors and the 4 editors — 2 of whom are psychiatrists and 2 psychologists. Each chapter is followed by a list of references that includes both those of historical interest and those that are refreshingly current, published as recently as 1998.

The first part, on psychopathology and theoretical perspectives, both psychological and biological, constitutes about half the book.

The presentations in this section are balanced and critical. The evidence in support of prevailing hypotheses is mainly from controlled studies, with suggestive evidence from case reports and clinical experience. Areas of uncertainty in theorizing about obsessive-compulsive disorder are clearly indicated, and arguments favouring or opposing prevailing theoretical positions are clearly set out.

Chapter 4 contains an intriguing discussion of the comorbidity of obsessive-compulsive disorder with various personality disorders and a preliminary consideration of possible subtypes of obsessive-compulsive disorder. The effect on the patient’s family is dealt with as well.

Chapter 9 mentions that resistance to obsessive thoughts and compulsive acts is not always found. To my knowledge, a paper by British psychiatrist Valerie Walker1 was the first to report this in the literature, but she is not given credit.

Discussion of the relation between obsessive-compulsive disorder and generalized anxiety disorder includes a description of worry, but does not include worries about possible but highly improbably occurrences (as one patient termed it, “the what ifs”).

Chapters 10 to 15 include a critical review of the instruments useful in establishing the diagnosis and a helpful section, in chapter 10, on clinical considerations. Both psychosocial and biological treatments are discussed thoroughly. The sections on clinical applications of treatment will be especially helpful to practitioners.

Chapter 16 covers comprehensively the subject of obsessive-compulsive disorder in children and adolescents, and chapters 17 and 18 deal with the subject of obsessive-compulsive spectrum disorders, including screening questions for patients and useful assessment instruments.

This is an excellent book. It contains a critical discussion of controversial issues, a challenge to our current classification of obsessive-compulsive disorder as an anxiety disorder, and evidence that obsessive-compulsive disorder is not a homogeneous disease entity — which should lead to more effective treatments.

I recommend it highly to all personnel who care for patients with mental disorders.

Obsessive-Compulsive Disorder: The Facts

Obsessive-Compulsive Disorder: The Facts, 2nd edition

de Silva P, Rachman S

New York: Oxford University Press; 1998.141 pp with index

ISBN 0-19-262860-7 (paper)

This is a small book — only 141 pages in its second edition — and part of a series on a number of medical topics entitled “The Facts.” Other topics in this series include alcoholism, asthma, cancer, eating disorders, and kidney failure.

The authors are both psychologists who are well known to psychiatry and have extensive experience in the area of anxiety disorders, including obsessive-compulsive disorder.

The book is intended as an information source for patients who have obsessive-compulsive disorder and their families and friends, but it would also be very useful for workers in health care who need to have an overview of this disorder but are not directly involved in assessment and treatment. It would also be useful for family practitioners as a quick read.

The first chapter describes the classification of anxiety disorders and the diagnostic criteria used for obsessive-compulsive disorder. Unfortunately, the authors use the terms “neurotic disorder” and “neuroses,” which have many negative connotations and have not been used in the Diagnostic and Statistical Manual of Mental Disorders for many years. Beyond this initial bad start, the chapter goes on to include an excellent description of obsessions and compulsions with great attention to detail — explaining covert compulsions, resistance, distress and interference. Obsessions and compulsions of everyday life are also discussed. The detail reflects the authors’ behaviouristic background and would be extremely helpful for a patient and family when first engaging in cognitive behavioural therapy.

Subsequent chapters continue with a good description of clinical phenomena, including the relation of obsessive-compulsive disorder to other psychiatric disorders and the various ways obsessive-compulsive disorder can present, illustrated with several clinical vignettes. The impact on family, prevalence rates and cultural factors are also included.

Even considering the main purpose of the book, the section on etiology is very brief and superficial. The description of the psychoanalytic view of obsessive-compulsive disorder could have been deleted, as this is only of historical interest and could be confusing to a lay reader. More detail regarding the biological aspects of obsessive-compulsive disorder should have been included, as well as some information on how obsessive-compulsive disorder can be seen from an evolutionary perspective. This would have been helpful in easing the guilt that patients and family often have about the role they feel they may have played in the development of the illness.

The chapter on treatment heavily emphasizes behavioural therapy, reflecting the clinical background of the authors. Although this provides patients and families with information on an aspect of treatment that will require their active involvement, the brief discussion of drug treatments does not provide enough information and also implies that pharmacotherapy is a secondary aspect of treatment.

The penultimate chapter on assessment only briefly mentions the Yale Brown Obsessive Compulsive Scale, which is the one most commonly used in Canada, whereas it includes the complete Maudsley Obsessional Compulsive Inventory, which is useful but is not widely used. The Leyton Obsessional Inventory, also mentioned, is never used. All of this may serve to confuse patients who may see the book as authoritative and then wonder why these scales are absent from their assessment and treatment.

The final chapter on practical advice is good. However, the list of helpful organizations at the back of the book is very incomplete with respect to Canada; only 3 addresses from 3 provinces in eastern Canada are listed!

In conclusion, the book has some of the facts on obsessive-compulsive disorder, but not all. The description of clinical phenomena is excellent. The inclusion of a discussion of obsessive-compulsive disorder and pregnancy would have been useful, as would a treatment flow chart with more emphasis on biological treatment. Also, since the majority of cases of obsessive-compulsive disorder begin in childhood or early adolescence, a separate section on this area would have been useful. Such a section should include some comments on the known association between group A P-hemolytic streptococcal throat infections and the acute onset of obsessive-compulsive disorder in some cases.

This book is not the best self-help book for patients in Canada. There are others available that have more complete lists of helpful addresses and are more compatible with the clinical approach a Canadian psychiatrist would most likely take with respect to treatment. The suggested price of $28.50 also makes the book quite expensive, considering the small size and soft-cover format.

The strengths of the book are that it is well written, well organized and easy to read.

Handbook of child psychiatry for primary care

Handbook of child psychiatry for primary care

B. Robertson

New York: Oxford University Press; 1997. 368 pp

ISBN 0-19-571372-9 (paper)

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

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

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

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

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

Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

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

ISBN 0-7216-5749-4

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

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

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

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

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

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

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

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

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

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

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

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

This book describes the role of primary care physicians in the prevention of mental disorders. The literature consistently reports that 25% to 30% of patients presenting in primary care have significant psychological problems. The book is divided into 3 sections dealing with the major types of illness prevention: primary (risk factors), secondary (early identification and intervention), and tertiary (decreasing complications and recurrence). These distinctions are not consistently followed, but overlap between sections is avoided. Each chapter is well referenced, and most chapters cover the subject adequately. A preventive model of conceptualizing problems is employed, but the flaw in this approach to primary prevention is acknowledged. Many known risk factors, such as social, economic, and societal conditions and attitudes, cannot be modified by primary care professionals. Effort must be directed primarily at high-risk patients. The authors recognize that some physicians lack sufficient interest and ability to diagnose and manage psychiatric illness and throughout the book suggest ways to address this problem.

Chapters 1, 9, and 15 deal with primary, secondary, and tertiary prevention of childhood psychiatric disorders. Risk factors in the child, parenting, and environment, as well as protective factors, are very well described. Most children are seen regularly in primary care, which gives these practitioners a unique opportunity to employ all 3 types of prevention. When disorders are detected, care must be taken to avoid inappropriate reassurance and unnecessary pharmacotherapy. The role of the family in the management of chronically ill and disabled children is emphasized, along with the need to provide support to the parents. Chapter 3, on the relevance of life events in mental illness, relies mainly on the work of George Brown and his colleagues. A practical guide for intervention strategies is also included. Prevention of postnatal depression, a distinct diagnosis in British psychiatry, is discussed in Chapter 4. The unique opportunity for primary care physicians to detect this disabling condition is emphasized, but the suggested role for health care visitors is generally unavailable in this country. Chapter 5, on bereavement, has a good description of normal grief and an excellent discussion of risk factors for abnormal grief reactions. Practical suggestions for the appropriate use of counseling and medication are included.

Chapter 6, on prevention in ethnic minorities, is quite specific to British society, although the principles of how physicians perceive, interpret, and treat psychiatric problems in ethnic patients are universally applicable. The chapter on “learning disability” is initially confusing because in Britain, unlike North America, the term refers to developmental delay. The references suggest that 33% to 66% of children with “learning disability” have significant psychopathology. The important role of primary care practitioners in secondary prevention is discussed, but the use of a team for management is seldom feasible for Canadian family doctors. Chapter 8 contains a general discussion of the importance of good counseling skills but again assumes the existence of a primary care “team” of professionals.

Chapters 10, 16, and 17 describe secondary and tertiary prevention of depression. This common and treatable disorder is frequently unrecognized in general practice both because of the symptoms presented (often somatic) and the knowledge, skills, and attitudes of physicians. Ways to improve the detection rate are described, and an excellent section on long-term drug management is presented. The particularly important role of general practitioners in encouraging compliance is acknowledged. Discussion of psycho-therapeutic interventions in the management of depression is limited to a good description of cognitive therapy. Primary and secondary prevention of anxiety disorders is addressed in Chapter 11, which includes a discussion of the physical, behavioral, and environmental factors that maintain anxiety symptoms. The author recommends and briefly describes nonpharmacological management techniques, although the use of a team approach is again assumed. Chapter 12, on eating disorders, addresses the well-recognized problems in primary prevention that deeply ingrained societal attitudes are impossible to change and that prevention programs sometimes increase unwanted behaviors (for example, binging and purging). The physical consequences of these disorders are well outlined, but little reference is made to the psychological and social sequelae. Detection of eating disorders is a major responsibility of general practitioners but requires a high level of awareness of risk factors and signs and symptoms — these patients are often very secretive. Not discussed is the role of physicians in monitoring physical health or supportive counseling as an adjunct for their patients who attend specialized treatment programs. Chapter 13, on alcohol and drugs, describes the detection and management of alcohol abuse, as well as the primary prevention of medication abuse by judicious prescribing practices. Because drug seeking from multiple physicians is uncommon under the British system, the problem is not mentioned in this book. Psychosis, primarily schizophrenia, is discussed in Chapters 14, 18, 19, and 20. As in Canada, general practitioners are now expected to detect and treat 1st-episode psychosis, and the importance of early pharmacological treatment is emphasized. Increasingly, patients are managed for the long term in primary care, and physicians must be aware of the special physical, psychological, and social needs of this vulnerable group and be cognizant of the high suicide risk. Social management of patients with schizophrenia is well described, with emphasis on the role of families. In Canada, the functions proposed for primary caregivers are provided, if at all, by specialized mental health services. Finally, Chapter 21 briefly discusses suicide prevention in primary care. The major roles are to recognize patients at risk, provide treatment and/or referral, and offer support for staff and families when suicide occurs.

The authors of this book are academics from general practice and psychiatry backgrounds. The intended audience is primary care physicians and their teams, but the book should also be read by psychiatrists and mental health professionals who treat patients also seen by family doctors and who teach medical students and residents. In conclusion, this is a very readable volume which is well researched and which provides good recommendations, although some are not applicable to the Canadian system.

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.