Posts Tagged ‘delirium’

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.

Synopsis of Neuropsychiatry

Synopsis of Neuropsychiatry

SC Yudofsky and RE Hales, editors

Washington DC: American Psychiatric Press; 1994. 641 p

This paperback is a synopsis of the American Psychiatric Press Textbook of Neuropsychiatry, which was first published in 1987 (a second edition has subsequently been published). The Synopsis of Neuropsychiatry is designed to condense most chapters from the second edition, and its content is aimed at medical students and residents in psychiatry and neurology.

The book is divided into 5 sections: the basic principles of neuroscience, neuropsychiatric assessment, neuropsychiatric symptomatologies, neuropsychiatric disorders, and neuropsychiatric treatments.

The section on basic principles of neuroscience includes chapters on cellular and molecular biology of the neuron, and on human electrophysiology. The chapter by Daniel Tranel on functional neuroanatomy from a neuropsychological perspective is particularly well done. These chapters are all well organized and plentiful diagrams add interest and clarity.

The neuropsychiatric assessment section includes chapters on bedside neuropsychiatry, neuropsychological evaluation, electrodiagnostic techniques, brain imaging, and epidemiology and genetics. The chapter on bedside neuropsychiatry by Fred Ovsiew is an excellent summary of the major symptoms and signs of neuropsychiatric disorders. The chapters on electrodiagnostic techniques and brain imaging are also good overviews. I found the chapter on epidemiology and genetics too technical when describing linkage analysis and molecular approaches to the investigation of various neuropsychiatric diseases such as Huntington’s Disease and schizophrenia.

The third section on neuropsychiatric symptomatologies includes chapters on differential diagnosis in neuropsychiatry, neuropsychiatric aspects of pain management, and delirium. Chapters on neuropsychiatric aspects of aphasia and related language impairments, and neuropsychiatric aspects of memory and amnesia are also part of this section. The chapter on differential diagnosis by Richard Strub and Michael Wise has an excellent algorithm on the approach to the patient with memory loss, as well as an informative and concise table on common focal behavioral syndromes and their localization. The chapter on pain management by William Brouse and David Spiegel focusses on neurological mechanisms of pain and neuropharmacology but could be more clinically oriented. Delirium is well covered by Michael Wise and George Brandt. Frank Benson provides a superb chapter on aphasia, which presents a complicated topic clearly and succinctly. The chapter on neuropsychiatric aspects of memory and amnesia by Arthur Shimamura and Felicia Gershberg describes the neural and biochemical mechanisms of memory very well, and outlines some clinical syndromes. However, it would benefit by a section on the differential diagnosis and investigation of the patient with memory disturbance.

The next section has 12 chapters on specific neuropsychiatric disorders: traumatic brain injury, epilepsy, sleep, cerebral vascular disorders, brain tumors, human immunodeficiency virus, endocrine disorders, poisonous and toxic disorders, alcohol-induced organic mental disorders, degenerative dementias associated with motor dysfunction, Alzheimer’s Disease and other dementias, and the neuropsychiatry of schizophrenia. There are particularly comprehensive and clinically focussed chapters on sleep (by Thomas Neylan, Charles Reynolds and David Kupfer), cerebral vascular disorders (by Sergio Starkstein and Robert Robinson), Alzheimer’s Disease (by Jeffrey Cummings), and the neuropsychiatry of schizophrenia by Henry Nasrallah. There is little, in any chapter, written on the neuropsychiatric aspects of multiple sclerosis despite its prevalence. Other missing topics include autistic disorders and mental retardation, neuropsychiatric aspects of street drug abuse, and chronic fatigue syndrome.

The final section on neuropsychiatric treatments includes chapters on psychopharmacological treatment in neuropsychiatry, psychotherapy for neuropsychiatric disorders, cognitive rehabilitation and behavior therapy, stress and coping in family caregivers, and ethical and legal issues in neuropsychiatry. The chapter on psychopharmacology by Steven Dubovsky is comprehensive and well organized. I found the chapter on psychotherapy too long and wordy, although the tables nicely summarize the lengthy discussion in the text. The chapter on cognitive rehabilitation and behavior therapy by Mark Lovell and Christopher Starratt is a well-written overview, and serves as a good introduction to this topic. Stress and coping in family caregivers is covered mostly by discussing theorical models with little attention to clinical issues. Ethical and legal issues in neuropsychiatry are well covered in the chapter by Robert Simon.

Overall, this is a strong textbook which provides a solid overview of neuropsychiatry. The authors are all recognized neuropsychiatry experts. Every chapter is well referenced, which enables the reader to investigate any topic in more depth, if necessary. A strength of almost every chapter is the liberal use of tables, diagrams and figures. Unfortunately, several chapters contain diagrams and figures that require colour to be useful, such as figures of PET and SPECT scans. The reader is referred to The American Psychiatric Press Textbook of Neuropsychiatry, second edition, for full-color figures. This is extremely irritating, and it is unlikely that many readers will have ready access to the larger textbook when reading this chapter, thus losing the benefit of illustrations. I suggest that the publisher consider adding full-color figures even if it increases the cost of the Synopsis of Neuropsychiatry.

This book will be very useful for residents in psychiatry, particularly during a rotation in consultation-liaison psychiatry, and also for neurology residents and neuropsychology interns. Medical students will benefit from this book during their rotations in psychiatry and neurology. It will also be useful to clinical psychiatrists involved in inpatient and consultation-liaison psychiatry, although other textbooks will be necessary if an indepth look into a particular area is desired.

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.

Human Development and Homeostasis: The Science of Psychiatry

Human Development and Homeostasis: The Science of Psychiatry

W.E. Powles

Madison CT, International Universities Press, pp. 622, 1992

William E. Powles, M.D. F.R.C.P. (C) is Professor Emeritus at Queen’s University. He is a distinguished Canadian teacher and clinician. This book adresses an important gap in the literature by not only drawing together a rich and readable compendium of the basic science underlying psychiatry but, perhaps even more importantly, by providing us with a way of organizing, understanding and integrating that information in a way that is clinically useful. Whereas most texts classify both the underlying science and the pathological disorders into a series of discrete pigeonholes with a most uncertain (if any) relationship between them, this book is based on orderly developmental principles that draw together the elements of the biopsy chosocial model such that not only is the development of the normal personality made clearly understandable but psychopathology is also described as a comprehensible process emanating either from failures in the original developmental construction (fixations) or else from subsequent breakdowns in the operation of the emergent system (regressions).

Developmental not only in name and in content, this book is also developmental in the sense that it comprises one man’s attempt to integrate information into a coherent whole from an amazingly eclectic and broad range of subjects that have captured his interest throughout a long and distinguished career. In so doing, the author has made no claim to be complete. In my area of child psychiatry, for instance, there has been a strong emphasis upon Anna Freud, John Bowlby, Erik Erikson and Jean Piaget but no mention is made of Margaret Mahler (separation-individuation), Stella Chess (temperament) or such doughty thinkers and researchers as Michael Rutter or Jerome Kagan — and I presume that there have been similar arbitrary choices in other subject areas. Instead, the author has chosen to be selective and retain his personal perspective while taking care to offer a section called “Bibliographic notes: key readings” at the end of each chapter in which the reader who is interested in more complete knowledge is referred both to original seminal material as well as to extensive modern reviews of the areas.

The book is organized into two major parts. The first section on “Human Growth and Development” uses a developmental-structural model as an organizing concept and incorporates the principles of structuralism (the hierarchical set of relationships that provide organization and meaning to the data), epigenesis (the laying down of early foundations as a pre-requisite for the more sophisticated additions that are layered on top) and emergence (the whole is greater, unpredictable, and qualitatively different from the sum of its parts) to five main developmental streams: growth of the body and brain and sexual dimorphism, intelligence and cognitive development, the life cycle and developmental tasks, the object concept and human attachment and sequences in the development of moral judgement, including gender differences.

Having constructed his building, Powles then describes its function in the second section of the book entitled “Human Adaptation and Homeostasis”. In this section he uses a “homeostatic-dynamic model” as his organizing concept by which, after a preliminary chapter entitled “Information Processing, Memory, and Brain Damage”, he describes a sequence on psychiatric normality and four defensive homeostatic levels which form an entropic progression as each preceding one fails following an environmental challenge, each of which gives rise to a characteristic form of psychopathology such as fight-flight (the neuroses), conservation-withdrawal (depressive disorders), disintegration (the psychoses and delirium) and death. Recovery (when it occurs) proceeds in reverse order.

Powles is a very thorough and logical thinker who either provides historical and systematic evidence for his hypotheses and concepts as he goes, or else points out that there is as yet no data, but indicates how his views can be researched and challenged. He writes clearly, and uses language well and in a personal style such that even the driest passages are readable and retain their interest.

In summary, this book constitutes the view of a very experienced and knowledgeable man about the important science that lies behind psychiatry and offers a schema for how it might be integrated into a coherent whole. In my view, Powles succeeds admirably in his mission even though another author might have chosen a different perspective and different sources to review and cite.

Although the dust jacket indicates that the book is suitable for medical students, it will likely prove to be insufficiently didactic and too comprehensive for all but the most thoughtful readers. It is a wonderful book that psychiatric residents, their teachers, and all those in clinical practice who either feel a need for a guidebook to help them update their knowledge of basic science or who are looking for organizing principles with which to make sense of their experience will find to be a rich and rewarding resource.

Principles of Geriatric Neurology

Principles of Geriatric Neurology (Contemporary Neurology Series, 38)

Robert Katzman, John W. Rowe

Philadelphia, PA: F.A. Davis Company/Publishers, 368 pp, 1992

“There is a tendency to underestimate the energies of old age, which are considerable. You won’t do what you could do, but yet you find that you need to do far more than society allows you to do” (Biythe 1979). Comments such as these are sprinkled throughout this new text on geriatric neurology and place the material presented within the spectrum of everyday life. The authors have brought together neurology and geriatrics to cover the material of this new discipline. The first part of the book places the problems in perspective by first discussing the evolving demographics of our society, with growing numbers of “old” old and the changes in neurological functioning with normal aging. This is supplemented by useful information on the neuropsychopharmacology of aging, imaging of the aging brain and neuropsychological assessment of the elderly. The approach to the neurological evaluation of the aged is discussed, in particular how it contrasts with that of younger patients.

The last section of the book deals with specific medical problems as they apply to the elderly. The first three chapters deal with disturbance in cognitive functioning, dementia, Alzheimer’s disease and delirium. Following these are briefer sections on falls and gait, syncope and urinary dysfunction. One chapter covers everything else, including sleep disorders, seizures, strokes, tumors and spinal cord problems. A brief chapter on ethical issues related to medical problems of the elderly completes the book.

On the whole, this is an excellent book that will be useful for clinical neurologists, geriatricians and other medical professionals who deal with the elderly. My only criticism is that perhaps too much space is devoted to the discussion of dementia. However, the authors qualify this in their introduction. After all, this text does not purport to completely cover the disciplines of neurology and geriatrics, but attempts to highlight the areas where they meet.

Melancholia and Depression: From Hippocratic Times to Modern Times

Melancholia and Depression: From Hippocratic Times to Modern Times

Stanley W. Jackson

New Haven, CT: Yale University Press, 441 pp., 1990

“Melancholia is one of the great words of psychiatry. Suffering many mutations, at one time the tenacious guardian of outworn schemes or errant theories; presently misused, cavilled at, dispossessed, it has endured into our own times, a part of medical terminology no less than of common speech.” With such magisterial prose did Sir Aubrey Lewis start his historical review of the subject. Now, over half a century later, Dr. Jackson gives us a splendid volume to flesh out the skeleton which Sir Aubrey provided. And one of the excellent features of this book is the ample use of quotations from the various authors thus enabling the reader to form his or her own opinion on the clinical entity being described.

In his first chapter Jackson makes it clear that he is concerned with the disease or syndrome, not the symptom. But equally, consideration of the developing concepts of disease, knowledge of “the passions,” explanatory systems in medicine and, at times, the relevance of contemporary “belief-action systems other than medicine” receive attention to elucidate the main subject.

Greeks, Arabs and Others

Like Sir Aubrey, Jackson begins with Hippocrates and Greek medicine. This is of necessity as ‘melancholia‘ is formed from the Greek words for black bile an excess of which was supposed to account for the condition. This is not to say that earlier peoples had no notion of this enduring aberration of the human condition. The skulls of many neolithic men showed trephine holes made, it is conjectured, to let out spirits supposedly inserted to cause disease. (As Ackerknecht points out thought insertion may be a legitimate explanation of disease in some primitives and not a sign of illness.) Nonetheless, there is little recognizable reference to affective disorders in either primitive medicine or the ancient civilizations of Egypt, Sumeria, Mexico or Peru. The concept of disease as retribution for offending the gods, however, was prevalent in all cultures and the equating of disease with sin was particularly characteristic of the Babylonians.

But it is entirely appropriate for Jackson to start with Greek medicine because, in the words of Ackernecht, it “is incomparably closer to modern medicine than any other historical form of medicine.” “Disease was no longer regarded as a supernatural phenomenon; it was approached from a rational, naturalistic and scientific point of view” and he wonders why “a small group of people in the eastern Mediterranean took this important and radical step in human thought.”

As Jackson recounts, the Hippocratic writings of the fifth century B.C. describe melancholia as an “aversion to food, despondency, sleeplessness, irritability, restlessness” and “fear or depression that is prolonged.” The cause was located squarely in the body due to an excess of black bile. (The latter, together with yellow bile, blood and phlegm, formed the explanatory system of four humors which was to last for another two millennia. Had the subject started in our present day one wonders if ‘indolia’ or ‘catecholia’ would be equally durable). Subsequently Aristotle speculated why those who became “eminent in philosophy or politics or poetry or the arts” were apparently prone. The disease was distinguished from both the temperament and the despondency “which occurs in everyday life.” Yet supernatural or dualist views still persisted in that some forms of melancholia were believed to be a “divine madness” associated with gifts of prophecy. Aristotle also noted sexual intercourse as a cause. Subsequent writers elaborating on these ideas included Celsus, Soranus and Rufus of Ephesus who, in contrast to Aristotle, regarded coitus as “the most helpful remedy of all against melancholia.” These views were later extended by Aretaeus, (c. 150 A.D.) and in particular by Galen (A.D. 131-201).

This teaching was preserved and nurtured in translation during the “Golden Age” of Arabic medicine and the names of Constantine, Oribasus, Alexander of Tralle and Paul of Aegina deserve honor. Throughout the clinical descriptions remained remarkably consistent from Soranus’ account at the beginning of the second century A.D. to that of Bartholomaeus Anglicus in the thirteenth century (summarizing Greco-Arabic views) and which, hardly changed, persisted to the seventeenth century.

The Early Church

Powerful religious views, on the other hand, took a different direction. Whilst the humoral theory obviously anchored symptoms to changes in the body, many were of a dualist persuasion (from Plato to Descartes), and the spiritual side was emphasized by the early Christian church through the notion of “acedia.” This condition was first described in Egyptian desert monks near Alexandria in the fourth century A.D., and the symptoms included dejection, sorrow, lassitude, weariness, carelessness and neglect. This result of cenobitic life was considered a sin and hence the cure lay in religion. An important part of Jackson’s work is the separation of the concept of acedia (which was blameworthy) from melancholia (for which the sufferer was to be pitied). It is one of the banes of sufferers from depressive illness that the milder manifestations are often categorized as sloth, a fate which those suffering from many mild forms of physical illness escape. (If one has a mild rash one simply has fewer or less ostentatious spots). In contemporary terms, it is illustrated by the debate about the “chronic fatigue syndrome.” But certainly the idea of “accidie” as a cardinal sin had great influence and, together with the often proffered guilt of the sufferers themselves and theological notions of demonic possession, not infrequently led to burning of many depressed women as witches. It is to Dr. Jackson’s great credit that he teases out from the very confusing and conflicting notions of medieval writers these two concepts of sin and illness.

Renaissance to the Eighteenth Century

The early years of the Renaissance saw little change in the humoral theories of Hippocrates and Galen. There were, however, comprehensive accounts including Burton’s well-known “Anatomy of Melancholy” and also, as Jackson points out, the lesser-known but equally deserving notebooks of Richard Napier, which contained records of more than 2000 mentally disturbed patients and which have been analyzed by MacDonald. An exception was the fiery Paracelsus. He objected to the system of Galen but had to replace it with an equally speculative “chymistrie.” (He also disagreed with the clergy who espoused supernatural causes.) And Thomas Willis in the later seventeenth century tried to shift explanatory schemes for the first time in two thousand years from humors to chemistry. For Willis, melancholia was “a complicated Distemper of the Brain and Heart: for as Melancholick people talk idly, it proceeds from the vice or fault of the Brain, and the inordination of the Animal Spirits dwelling in it.” The latter, which were normally transparent, became thick and dark, “Acetous and Corrosive, like those liquors drawn out of Vinegar,” and were instilled into the brain. Iatro-chemistry, however, was short-lived and replaced by iatro-mechanics, reflecting both the advances in physics pioneered by Newton and in physiology by Harvey. Thus melancholia for Pitcairn was due to a defect of the normal “vivid motions” of the blood, part of which became sluggish. Similar views were espoused by Hoffman and Boerhaave, the black bile being transmuted into a sort of dark sludge from the blood. In turn, mechanistic views were criticized or often held pari passu with electrical and vitalist theories.

More important, Jackson suggests, was the clinical separation of hypochondriasis from depression, the former consisting of “a syndrome of physical complaints and a non-psychotic depressed state…. It seems likely that the logic of separating nonmad dejected states from mad dejected states was more compelling to clinical observers than any effect of mechanical explanations.” The notion of melancholia had also penetrated the literary world and was ascribed to Addison, Thomas Gray and Cowper. Jackson considers in detail the autobiographical accounts of two other supposed sufferers, namely Timothy Rogers and Samuel Johnson. The latter defined Melancholy in his dictionary as “a kind of madness, in which the mind is always fixed on one object.” (Shakespeare, incidentally, was also considered afflicted by the careful and critical Sir Aubrey Lewis on the basis of the sonnets. A “heartfelt utterance of shame and self-disgust” was thought to be expressed in sonnets 110 and 111 to be distinguished from the “contrived woe” of sonnet 66).

The Nineteenth Century to the Present

In the nineteenth and twentieth centuries we reach more familiar ground. The fresh insights which Jackson’s work provides show that Rush departed from his contemporaries in both terminology and concepts. He advocated a theory of an excited cardiovascular system which he derived from Cullen who had previously abandoned it. Jackson reaffirms the central place of Pinel, whose 1801 scheme of mental disorders comprised the quartet of mania, melancholia, dementia and idiotism. Pinel’s use of the term “mania” reflected the understood meaning of his time but must not obscure the fact that he obviously recognized the manic component (in present-day terminology) commenting: “sometimes it is distinguished by an exulted sentiment of self-importance, associated with chimerical pretensions to unbounded power or inexhaustible riches.” Esquirol, the pupil of Pinel, introduced the term monomania to denote any form of insanity “in which the delirium is partial, permanent, gay or sad.” It is to Griesinger that we owe both the use of the word depression in a technical psychiatric sense and the concept of the unitary psychosis (Einheitspsychose) currently being resuscitated by British workers. His views on an organic pathology were far more sophisticated and less dogmatic than many think. Others receiving mention include Tuke, Bucknill, Maudsley, Krafft-Ebing, Mercier and Savage.

Kraepelin’s name is given primacy at the start of the chapter on the twentieth century which is just since his views have continued to hold influence to the present day. Adolf Meyer, Freud and others take us up to DSM-III and our current preoccupations.

The book’s concluding sections comprise a thoughtful discussion of the relationships of melancholia to mania, hypochondriasis, grief and religion; accounts of three variants of the syndrome, namely, lycanthropy, love and nostalgia, (none of which have yet appeared in DSM formulations); and an overview and afterthoughts.

The Value of History

Many, preoccupied with the minutiae of advancing technology, will be impatient with an exploration of the ideas of bygone years; some may even be suspicious — remarking that whilst God cannot change the past historians can. But this book clearly exemplifies the values of an historical approach.

First, the volume shows, through quotations of the various authors across two millennia, that melancholia or depression is an enduring and recognizable clinical entity surviving all translations and known as far back as recorded history will take us. It is a biological phenomenon capable of description, and remarkably consistent in its main features. To regard it as a professional construct or a mode of behavior imposed by society or physicians, as some of the more outre* and otiose sociological and Marxist theories profess, is to adopt a viewpoint of marginal and tangential significance.

Second, not only has the notion survived down the centuries but it is equally evident that it has occurred in all cultures where there are adequate records. It has affected ancient Greeks, monks in Egyptian monasteries, medieval Englishmen and modern Americans.

A third value of chronicling the past is, one hopes, the encouragement of humility in those who espouse particular causes and/or treatments.

Fourth, the story of melancholia displays beautifully the four perspectives of psychiatry enunciated by McHugh and Slavney. It can be a disease, a temperament, a learned form of behavior, and, in all cases, an individual’s life story.

Fifth, it directs us to look carefully at our current approach to nosology. The strength of the Kraepelinian view was to base disease distinctions on carefully observed natural histories. The psychoanalytical approach on the other hand introduced interpretation which influenced DSM-I and -II to be replaced by the operational criteria provided in DSM-III. Now that we have improved reliability surely the next step in nosology is empirical biological validation rather than committee reviews of the literature. Science should proceed from individual studies which can be replicated rather than consensus and democratic opinion. One has a rising anxiety, not yet of DSM-III proportions, that we are currently in danger of allotting vast amounts of money and human effort to an enterprise where the shifting sands of categorization are determined by political process (cf. the pre-menstmal syndrome) and not by scientific method. Further whilst DSM-III and III-R gave us a more reliable vocabulary, frequent repetition of the undertaking may be self-defeating. The case has been well argued by Zimmerman. In fact committee confusion and conflation of conflicting concepts are evident in the DSM-IH-R definition of delusions — the veritable keystone of psychopathology — a matter lucidly exposed by Manfred Spitzer. It would logically follow, as cogently argued by Costello, that such careful examination of symptoms may be more fruitful than constantly changing the syndromes.

At the end, an exemplary volume such as Jackson’s reminds all of us engaged in day-to-day practice or research that from time to time it is imperative to stand back and look at the subject from afar. This is the final message of the historical approach. It should ensure that our broader objectives are sensible and worthwhile, and that our energies are channelled in the most appropriate way to the elucidation and alleviation of suffering in our patients. Dr. Jackson’s excellent exegesis provides a scholarly and even-tempered survey for our future guidance.

Delirium: Acute Confusional States

Delirium: Acute Confusional States

Zbigniew J. Lipowski

New York: Oxford University Press, 568 pp., 1990

Returning from abroad, ready to tackle this review, I happened to glance at two pieces. One, a subtitle in a London newspaper, said Continental Drifts: Paula Burnett finds Delirium and Dissent at the International Writers’ Conference in Dublin; the other, a description of the present book, under the neurology section. So medicine, particularly psychiatry, has to contend with its symptoms and syndromes being described by common or garden words which the lay public uses any old how, thereby producing mass confusion. Then, when a psychiatrist writes a book to sort it all out credit is given to another speciality.

These chance observations seem suitable points from which to start thinking about delirium. Is it a well-defined clinical entity, is it well taught and which group of physicians has taken it upon themselves to manage it? Given the rate at which it occurs, it certainly seems worth looking at and yet it has not received much attention. Psychiatrists, who often seem to believe that it belongs to them, have not given it anywhere near the attention that they have given to depression and dementia. (Perhaps things have been better since the advent of consultation liaison psychiatry.) In all likelihood delirium has fallen between the cracks of psychiatry, neurology and internal medicine. If quiet, the delirious patient runs the risk of being ignored and, if excitable and repeatedly heading for the fire escape, then the psychiatrist may be called in. All of which does not sound particularly efficient or effective.

However, to put it all into perspective, Dr. Zbigniew Lipowski has written another book on delirium entitled Delirium: Acute Confusional States. It is a successor to Delirium: Acute Brain Failure in Man published in 1980. As the author states “The present version has been completely rewritten and brought up-to-date. While no major advances in the understanding of delirium have occurred in the past decade and the syndrome has continued to be neglected by researchers, progress in the neurosciences and in many other areas relevant to it necessitated a thorough revision of the original text.” Furthermore, “apart from a treatise by Frings that appeared in 1746, not a single book devoted solely to this syndrome had been published before the first version of this book appeared. As far as I could ascertain, it remains the only monograph in English on this subject today. Hopefully, it will stimulate research on delirium and help clinicians treat it.”

An Oxford English Dictionary definition of the word “encyclopedia” is “an elaborate and exhaustive repertory of information on all the branches of some particular art or department of knowledge.” If this definition is acceptable, then the author of this book on delirium can be described as an encyclopedist. Dr. Lipowski, now retired from the University of Toronto, has spent nearly three decades collecting material on different kinds of brain syndrome. Psychiatry is indebted to him for his efforts in this regard and particularly those dealing with the nosology of DSM-III, DSM-IIIR and DSM-IV. This work, completed during his final academic years, must be seen as his magnum opus. As such it is worth describing in some detail.

This book is lengthy, to which Dr. Lipowski attests in the introduction, and like Gaul, has three parts. These are “Delirium: an Organic Mental Syndrome,” “Organic Causes of Delirium,” and “Delirium in Special Patient Populations.” The book reads well and gains from summaries interspersed through the text. The initial historical section covers 2,500 years in 37 pages and is the most entertaining in the book. The author spends some time on the etymology of the term “delirium” which “stems from the Latin word delirare which literally means to go out of the furrow . . . but whose vernacular meaning is to be deranged, crazy, out of one’s wits.” First used in English in the sixteen century it has meant “A mental disorder due to disturbance of brain function and featuring incoherent speech, hallucinations, frenzied excitement and restlessness,” and also “uncontrollable excitement or emotion, ‘frenzied rapture’ or ‘wildly absurd thought or speech’.” While given medical usage in the first century A.D., its meaning was ambiguous, until the end of the eighteenth century, since it could mean insanity or a transient mental disorder, commonly due to fever. Thereafter, the author describes the thinking on the topic as it has occurred since Hippoccrates two and a half millennia ago. This was a demanding task, apparently without precedent, and meant the author often had to go to primary sources for information. While the terminology proved to be inchoate, the author tells of the intellectual excitement of discovering how the concept of the condition grew, albeit still poorly understood, and how it reflects on medical thinking at different periods of history. As such it would be read to advantage by staff and trainee psychiatrists everywhere. Too often these days people believe that psychiatry started with DSM-III and those practising beforehand were flat earthers. So the reader is taken from the ancients, whose term phrenitis can be largely equated with that of delirium, such as Hippocrates, Celsus, Aretaeus, Soranus and Galen, quickly through the “Dark Ages” and into the Renaissance. Thereafter, the medical contributions are given by century, including the first use of the term in England (1592). Many familiar and often surprising names such as Pare, Willis, Quincy, Cheyne, Cullen, Darwin, Hunter, Rush, Dupuytren, Hughlings Jackson, Tuke, Bonhoeffer, Adolf Meyer, Romano and Engel have been in the delirium Hall ofFame. However, the greatest plaudit goes to a relative unknown person, F.C. Greiner, who wrote on the topic in 1817.

In the second chapter Dr. Lipowski is at his best in dealing with the definition of terms. He dismisses previous efforts as “semantic muddle” and by page 41 he is able to offer a definition. “Delirium is a transient, organic mental syndrome of acute onset, characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity and a disordered sleep-wake cycle.” At the same time the book title is clarified. Thus, “the terms “confusion” and “acute confusional states” should be considered a synonym for delirium, albeit a clumsy and cumbersome one. Once the newly adopted psychiatric nomenclature becomes generally known and accepted, this term may be relegated to the annals of history.” Other terms disposed of are “acute brain syndrome,” “toxic psychosis,” “infective-exhaustive psychosis,” and “encephalopathy.”

Next Dr. Lipowski deals with incidence and prevalence. While he rightly draws our attention to how common delirium is in hospital, 10 to 15 percent of medical and surgical inpatients, and even more in those over 60, there is no mention of nosocomial effects and the extent of acute or subacute delirium in the community. This is of critical importance and it is worthwhile noting that surveys of dementia in the community are confounded by effects due to medication and systemic illness. The population is aging and, as hospital beds further decrease, the elderly will be weathering the effects of illness and treatment at home.

He then proceeds to clinical features, course, treatment and outcome. These are described in detail on pages 55 and 56 and summarized on page 68. The intricacies of the psychopathology in delirium are then spelled out. The etiology of this syndrome is tabled on page 133. The favored mechanisms of this disorder are variable cerebral blood flow, cholinergic blockade and disturbed sleep-wake cycle. Diagnosis is made essentially on clinical features, and identified etiology. Curiously, the MMSE (the most commonly used screening test for cognitive dysfunction in the world) is dismissed as being “of little value in patients over 60 years and older, as well as those with an 8th grade education. Moreover the MMSE has been criticized for its substantial false-negative rate, notably in patients with focal brain lesions and those with mild diffused cognitive dysfunction.” Interestingly, the EEG is not thought to be a specific tool for diagnosis. Differential diagnosis is, of course, between dementia, amnestic syndromes and other organic states and the functional psychiatric disorders. Dr. Lipowski argues that delirium is intelligible by its uniqueness — acute onset, fluctuating and transient course. Treatment is symptomatic: First, ridding the patient of the cause and, second, affording relief with adequate sleep, quiet, hydration and electrolyte balance, sound nursing and supportive psychotherapy. Oddities recommended are electroconvulsive therapy and rapid tranquillization. Who would give elderly patients large doses of haloperidol these days?

This concludes the first section and thereafter he proceeds to “Organic Causes of Delirium” and “Delirium in Special Patient Populations.” So whereas Section 1 is meant to educate and instruct the clinician, the other two sections become quasi-reference books. As such they would be appropriate for reference in acute medical settings.

This is a book of astonishing detail. It deals with a subject which has been known throughout medical history but oddly, despite observations by many famous physicians, has not received much medical attention. Perhaps because the subject is so multidimensional and multifactorial, whereas physicians prefer to deal with specificity.

A key question which psychiatrists should ask themselves is how do CNS disorders, like delirium and dementia, fit into psychiatry. Two recent pieces, Who Owns the Brain? (Eastwood 1990) and Who Owns Research? (Eastwood 1991) provide the basis for an answer.

The plain facts seem to be that psychiatrists are mostly bright, nice people who largely eschew research. They tend to be in the vanguard of being nice to patients. This is no bad thing given the hi-tech and rapid turnover of patients in medicine. However, psychiatry has what a recent article (Trent 1991) called an image problem; and, indeed, a relevance problem. It has been said that a good psychiatrist is someone who can live with ambiguity. While this might imply thoughtfulness and tolerance, conversely it could mean blissful ignorance. So the present day psychiatrist has to be seen to be solving problems. This has started in the academic centers where excellence and accountability have become key words. Research endeavor and academic standing will be rewarded financially. This may be a fillip to academic psychiatry. So may Bill C-22 which will encourage more drug trials. However, will there be better basic and clinical research? Currently, in the postgraduate schools there are more Ph.D’s than M.D.’s doing research in psychiatry. Amongst the M.D.’s doing brain research, neurologists seem to be foremost. There are 18 centers in the Canadian Study of Health and Aging (an epidemiological study of dementia) and only two of the principal investigators are psychiatrists. The rest are neurologists, geriatric physicians and Ph.D’s. Again looking at a multi-center trial of a cognitive enhancer” there are three psychiatrists amongst the 20 principal investigators. These are two of presumably a number of current dementia studies but they are mentioned because they are national studies. While there must be ongoing studies of delirium in Canada, I have no knowledge of these or the contribution of the different specialities. It would be nice to know and those involved should write to the editor of the Journal.

When it comes to clinical practice, there appears to be a distinct move amongst younger psychiatrists towards consultation liaison work, which obviously includes delirium. At the same time there is less interest in inpatient work. With about 3,000 psychiatrists in the country this need not be. Would it be mischievous to suggest consultation liaison pays better than inpatient work? (Physicians, psychiatrist included, used to see inpatient beds as being valuable for rich clinical, teaching and research material. This no longer appears to hold) So delirium is in the hands of a new breed of younger doctors. How many peer-reviewed grants in the area of delirium do these young doctors hold?

Dementia and delirium are twin problems. They both involve major disruption of the brain with the first being permanent and the second, potentially, temporary. Dementia has attracted more interest from psychiatry, although delirium may be as large a clinical problem. Dementia seems to have an attraction for psychiatrists, neurologists, neuropsychologists and neuropathologists, but it is not clear that delirium is equally engaging. Delirium, in fact, seems to be a “Cinderella.” It is an area that apparently does not excite those in physiology, epidemiology and pathology, so who will take on this topic? Is the subject too generic? Is the area too medical for most psychiatrists? Is there too much basic science there for psychiatrist? All possibly yes. However, since there is going to be so much delirium around, since its presentation is so frequently behavioral and since there is a considerable differential diagnosis, including a number of psychiatric disorders, it is imperative that psychiatry shapes up and sees the patients and does sound clinical investigation.

This book will charm many academic psychiatrists and may lead consultation-liaison psychiatrists to sharpen their measuring tools. Some will be left wondering why depression and dementia have attracted more research time than delirium and why this is only the third book written on this topic in English in 250 years. Hopefully, it will engender more interest in the field but at $97.50 it may only appeal to a specialized audience.