Posts Tagged ‘depression’

Akathisia and Restless Legs

Akathisia and Restless Legs

P Sachdev

New York: Cambridge University Press; 1995. 425 p

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Natural History of Mania, Depression and Schizophrenia

The Natural History of Mania, Depression and Schizophrenia

G Winokur, MT Tsuang

Washington (DC): American Psychiatric Press; 1996. 372 p

The resident had just presented his formulation of a case. I posited that hysteria might be an important aspect. He seemed genuinely puzzled, even when I told him that terms like “hysteria” and “hypochondriasis” had been available for more than 2 millennia. “But,” he said, “for my boards, I only need to know DSM-IV.”

“Well,” I thought, “if you’re so keen on cookbook psychiatry, why did you not stay with cooking rather than spoiling psychiatry?”

So here is the rub. What are we to do with this charming, scholarly work full of medical science when the psychiatric world has moved as it were, from bookshelves to the Internet? Or is that being too generous? While I acknowledge that the American Psychiatric Association committees have slaved to obtain syndromes made up of a concatenation of symptoms, it might be an overstatement to suggest that these have the same historical significance as the stirrup, the Gothic arch, and the printing press. They might conceivably be compared with gunpowder, however, since it changed the overthrow of castles from sieges lasting several years to crumbling walls in a few days. So the biopsychosocial anamnesis that can take a considerable time to collect might well be thought in the modern era to be replaceable by a convenient American Psychiatric Association cluster analysis.

Nevertheless, the book The Natural History of Mania, Depression and Schizophrenia is based upon the approach recommended by Adolph Meyer at Johns Hopkins at the beginning of this century. What is now called the “biopsychosocial” model is really the same model with a new name and the same methodology by which psychiatric diagnoses and formulations are developed all over the world. Thus psychiatrists in Iowa, London, Sydney, and Bombay have for decades collected the history of the present illness, the family and personal history, and a mental state examination before proposing a formulation for a patient. Examples of these, in copperplate handwriting, lie in the archives of mental hospitals everywhere.

So what is different about Iowa? The answer is professors George Winokur and Ming T Tsuang. Winokur moved to Iowa from Washington University in St Louis a quarter of a century ago. That university, like several in North America and many in Western Europe, did not see psychoanalysis as the Second Coming and fastidiously kept psychiatry on the Meyerian track. In Iowa, Winokur was joined by Tsuang, who eventually became a professor of psychiatry at Harvard. In the best tradition of psychiatric nosology, generously referred to in the preface, they dug like archeologists into their archives and collected a fascinating cache of data hitherto known as the Iowa 500. Case material was available from 1920 and seemed to be comprehensive; thus, “the quality of material in terms of documenting symptomology was quite sufficient for making diagnoses according to modern diagnostic criteria that had been published for research purposes.”

Nevertheless, there is a caveat. Old data have to be updated and massaged as psychiatry goes through another convulsive spasm in terms of the lexicon and nosology. As seen in the Stirling County and Lundby studies, this can be done. So what did they find? A lot. The Iowa 500 was made up of admissions to the Iowa Psychopathic Hospital (later the Iowa Psychiatric Hospital) between 1934 and 1944 and consisted of 100 bipolar disorder, 225 unipolar disorder, and 200 schizophrenia patients (with a few subsequent changes in diagnosis). The study started in 1971 and completed a 27- to 30-y follow-up of a psychiatric population originally “treatment-naive” in modern terms.

The book itself is made up of 15 chapters, and each contains reams of facts. Each chapter requires careful scrutiny. Perhaps the most salutatory is number 15 entitled “The Contribution of the Iowa 500 to Diagnosis and Classification of the Affective Disorders and Chronic Non-affective Psychosis.” Using symptoms, demographic criteria, and admission criteria, the authors demonstrated that the original diagnoses were stable over time. Thus: “These data strongly suggest an unequivocal separation of the primary affective disorders from the chronic non-affective psychoses according to the factors involved in the medical model.”

The authors worked, albeit inconclusively, on schizoaffective disorder (the border state) and on the types of affective disorder and chronic nonaffective psychoses. They concluded that “the Iowa 500 has presented new ways of investigating clinical entities and family illness… However it is clear that psychiatric illnesses or diseases are often composed of overlapping syndromes and . . . subsequent studies should be planned in a different fashion and less clear cut diagnostic groups should be included as index cases.”

Essentially, what we have here is a wonderful, though somewhat old-fashioned (especially the font), longitudinal study in the best psychopathological fashion. It is descriptive, as psychiatry has remained to this day, but many residents will likely, and regrettably, find it anachronistic. For those of us trained in the Meyerian sense in the best psychiatric institutions of Europe, North America, and Australasia, it validates what we have been doing all of these years. It is not about receptors and cookbooks, but it does provide a warm, fuzzy feeling. All who like a historical perspective to their work should read it.

Serotonin in the Central Nervous System and Periphery

Serotonin in the Central Nervous System and Periphery

A Takada, G Curzon, editors

Amsterdam: Elsevier Science BV; 1995. 260 p

This book is part of the International Congress Series and contains the proceedings of the Symposium on Serotonin in the Central Nervous System and Periphery held in Nagoya, Japan, on April 1 -2, 1995. It is comprised of papers presented at the symposium and contains up-to-date information on the area, written by some of its top researchers, who were selected to participate in the symposium based on their expertise. It has become necessary for clinicians and scientists to focus on the basic science and fundamental actions of the new serotonin-acting drugs in order to understand their functions. This book attempts to provide such information in a timely fashion.

There are 7 sections in the book: Regulatory Mechanisms, Relationship with Feeding, Amines and Stress, Depression and Anxiety, Other Central Aspects, Vascular System, and Lung. The most useful and important section is the first, which covers the regulation of serotonin release, genes, and the pathophysiology of affective disorders. Even with a minimum of prior knowledge of the area, the clinician, by reading this section, can gain an understanding of how serotonergic drugs work. The section on depression and anxiety is a must-read for psychiatrists, though the majority of information refers to animal models. The relationship of serotonin and feeding behavior, pre- and postnatal stress reactions, antipsychotic medications, the psychoprotective effect of estrogen, learning and memory, Alzheimer’s disease, and physical health are also covered in the book.

Although this book suffers stylistically because of the number of different authors, it is, overall, a succinct, well-written, and extremely informative text. It provides recent information in the field of serotonin research and could prove to be a valuable teaching and research reference. We highly recommend this book to clinicians, who could apply it in their use of psychopharmacology, to biological researchers, who will find it a useful reference, and to residents in psychiatry, who may appreciate it as a learning tool.

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

GJ Siegel, editor

New York: Raven Press; 1994. 1080 p

This multiauthor volume (80 contributors) is a 5th edition of the book published under the auspices of the American Society for Neurochemistry. The 4th edition was published in 1989 under the same editorship. The book is divided into 6 parts: neuronal membranes, synaptic function, molecular neurobiology, cellular neurochemistry, medical neurochemistry, and behavioral neurochemistry. Each part contains several (from 3 to 14) chapters; there are 50 chapters in total. Each chapter is further divided into sections and has a separate bibliography.

Rapid advances in the field of neurosciences and a virtual explosion of information in areas of molecular biology and genetics during the last several years have presented the editors with the enormous challenge of conveying the material in a comprehensive yet readable manner within a single volume. It appears that they have successfully met this challenge. They have expanded the book by only about 100 pages in adding new chapters on the molecular basis of olfaction and taste, neurotransmitter and growth factor receptor families and 2nd-messenger signaling systems, amino acid and purinergic neurotransmission, neurotransmitter uptake system, and molecular targets of drugs of abuse. Many other chapters have been revised or rewritten to include new information on amine transmitters, eicosanoids and neuronal function, developmental neurobiology, gene expression, aging, cytoskeletal development and plasticity, and cognitive functions. An important new feature of this edition is the introduction of color plates for figures and tables and color subheading summarizing key concepts. The cartoons illustrating important concepts and mechanisms are instructive, and some of them use witty symbols (turtles) to indicate various pathways. They are easy to follow and to read. It is, though, a pity that 2 chapters in the behavioral neurochemistry section do not have any illustrations. All of these features make this volume virtually a new book, more readable and appealing than the last edition.

The 2 parts of the book with most extensive coverage of the subject are synaptic function and medical neurochemistry. I found the part on synaptic function well balanced and coordinated with excellent chapters on neuronal proteins and role of protein phosphorylation in regulation of neuronal function. The receptor classification is up to date (that is, to the book’s publication date). The readers will notice that some classifications have changed and new receptors have been identified since the book has appeared. An example at hand is the 5-HT1c receptor that is now classified as a member of the 5-HT2 receptor family (5-HT2C receptor). In addition, 5-HT2A and 5-HT2B receptors have been identified as distinct receptors. The part on medical neurochemistry includes chapters dealing with bio- and neurochemistry of some muscular disorders, vitamin and nutritional deficiencies, neuropathies, myelin diseases, metabolic disorders, drug abuse, ischemia, epilepsy, basal ganglia disorders, and Alzheimer’s disease. A chapter on brain imaging emphasizes the important role of positron emission tomography in studying brain function. Perhaps other techniques (magnetic resonance imaging [MRI], single photon emission computed tomography [SPECT]) could also have been described, at least briefly.

The behavioral neurochemistry part contains chapters on biological aspects of psychotic disorders, hypotheses of mood and anxiety disorders, as well as chapters on learning and memory. It was slightly disappointing to this reviewer that psychiatric disorders received much less prominent treatment than some neurologic disorders (for example, epilepsy). The chapter on mood disorders is actually confined to biochemical hypotheses without presenting some at least illustrative biochemical and clinical data. In this chapter, all hypotheses are given equal importance, although evidence would indicate otherwise (for example, importance of the serotonergic versus the cholinergic system). One of the important hypotheses of depression and mode of action of antidepressants involving adaptive changes of presynaptic 5-HT1A receptor is not even mentioned, though it is often quoted in other textbooks.

Considering that the volume has so many contributors, the chapters are, on the whole, well balanced, and the style of introducing concepts, supporting evidence, illustrations, and conclusions is remarkably uniform. Credit for this goes undoubtedly to the editors. The quality of print and reproductions is high. This is a book that should be a part of the personal library of any worker in the various fields of neuroscience, clinical medicine, and psychiatry who look not only for factual information but also for a feast of ideas.

Contemporary Issues in the Treatment of Schizophrenia

Contemporary Issues in the Treatment of Schizophrenia

CL Shriqui, HA Nasrallah, editors

Washington (DC): American Psychiatric Press; 1995. 863 p

It is heartwarming to see a first-rate text about schizophrenia that includes so many Canadian authors. Many of the breakthroughs in schizophrenia research in recent years have come from Canadian laboratories and clinics, but the average reader would not know it because most textbooks and widely read journals are published in the United States of America and the United Kingdom, and the impact analysis of cited papers is highest for American authors. This trend is understandable, but it presents the world with a lopsided view of where the action is in schizophrenia research. This book is coedited by a Canadian and an American editor who draw on the expertise of both nations and even include some (not many) European authors.

The first decision in attempting to write a book about schizophrenia is whether or not to adopt an atheoretical stance (as these editors have done) or whether to advance a particular point of view about the “true” nature of this mysterious malady. The first way is more democratic and allows input from many, sometimes conflicting, perspectives. It is also probably less subject to criticism. The second way is going out on a limb, and it severely limits the number of authors you invite to take part. Contributors need to be only those who can faithfully adhere to a unified theory. Though this approach is challenging for editors, it makes for easier and more interesting reading. I would hope that the talented, knowledgeable authors who have contributed to this book could next produce a smaller, integrated text which could offer a vista of how a general theory of brain function might embed a specific theory of schizophrenia impairment, which would lead to the crux of what needs to be researched and resolved.

Although this book does not accomplish that, it is, nevertheless, an extremely useful compilation of what is known. Section 1 covers biochemistry, postmortem abnormalities, and the new genetics. This is the traditional way to start, but it begs the question of which “schizophrenia” is being talked about in the various studies cited. This illness continues to defy understanding. Is it the tail end of a continuum of subtly increasing brain abnormality and, as such, not likely to yield homogeneous results structurally, biochemically, or genetically? Is it a group of genetically separable diseases, and if so, what strategy best disentangles these discrete illnesses so that clues to the etiology of each can be better pursued?

Since the heyday of the discovery of‘ Treponema pallidum as a direct cause of a subgroup of the schizophrenias, there has been no similar breakthrough, although prion disease may eventually account for more human psychoses than only Jakob-Creutzfeldt disease: the expansion potential of trinu-cleotide repeats has already explained several neurologic diseases among whose manifestations psychotic thinking is prominent.

Section 2 addresses the issue of subgrouping but does it indirectly by discussing the incompatibilities among diagnostic systems, the epidemiology of “negative” and “positive” syndromes, the near ubiquity of depression in schizophrenia (what does this imply with respect to the dichotomy between schizophrenic and affective psychosis?), the category of late-onset schizophrenia, the possibility that neurocognitive findings could lead to natural subdivisions (the chapter by Anne Hoff is excellent), and the possibility of subgrouping by brain structure, antipsychotic response, or sex-related phenomena such as premorbid strengths, onset age, and longitudinal illness course. I would have preferred that, rather than the authors discussing these topics simply as a means of reiterating the empirical evidence about difference and overlap, they instead consider each category as a possible filter through which a search for genetic or other causes could be conducted.

For instance, male-female differences in schizophrenia are striking and reproducible. We also know that male and female deoxyribonucleic acid (DNA) is dimorphic not only because women have 2 X chromosomes instead of an XY pair, but also because recombination rates and lengths of autosomes differ, and maternally and paternally inherited DNA conserve somewhat different characteristics. Integrating that knowledge into new genetic strategies might yield important results. Similarly, something is known about male-female brain differences. Can this knowledge help to explain male-female differences in schizophrenia? An example of such integration is Tim Crow’s notion of lateralized language development as an evolutionary force that is specifically impaired in schizophrenia and accounts for many of the differences found between men and women with schizophrenia. Crow is probably the most theory-driven contemporary schizophrenia researcher: it is too bad that his concepts are not represented here.

Sections 3, 4, and 5 are about treatments and treatment side effects, and it is these sections that are best reflected in the book’s title. The concept of novel antipsychotics is somewhat premature, I think, because the newer, so-called atypical drugs are very closely modeled on the old and are an improvement only insofar as they tend to produce fewer extrapyramidal side effects. They can, however, introduce other side effects no less difficult for patients to tolerate. I would have wanted to see a discussion on the ethics of drug trials, especially the use of placebos in situations where standard treatment does not always work, is sometimes unnecessary, and sometimes produces more adverse than beneficial effects. The difficulty, of course, is that we still cannot predict into which of these categories any given patient will fit. I would also have wanted to see a discussion of treatment sequencing—should we be thinking of stages of illness, with the best treatment of an initial stage followed by a subsequent optimal treatment focus on a second neurochemical system or a consequent social impairment? This is the standard approach to the treatment of other chronic illnesses (for example, rheumatoid arthritis, chemotherapy for cancer, and HIV treatment), but it has not been tried seriously in schizophrenia. There have been some attempts at logical sequencing of cognitive remediation techniques in schizophrenia rehabilitation, but these are not mentioned in this book.

These are minor quibbles, however. The book is thorough, easy to read, relatively comprehensive, and has some wonderful chapters by Canadian authors. I would recommend it to medical students, residents, and practitioners.

Aiding Older Adults with Memory Complaints

Aiding Older Adults with Memory Complaints

F. Scogin and M. Prohaska

Sarasota: Professional Resource Press, 66 pp, 1993

The need to develop and provide novel specialized services to the elderly increases with the rise of an aging population. This fact is underscored by the authors of Aiding Older Adults with Memory Complaints. Dr. F. Scogin, Associate Professor of Psychology at the University of Alabama, has pursued the field of geropsychology from both clinical and research perspectives, whereas M. Prohaska, M.S., a doctoral student and graduate research assistant to Dr. Scogin, has trained study participants in memory enhancing techniques. The book is intended for professionals involved in front line work who may lack formal training in geriatrics or gerontology and promotes an exhaustive and multisensory approach to treatment. It introduces the “non-gerontologically trained professional” to the most prominent complaint voiced by the older adult, that of impoverished and declining memory, and provides adaptive coping strategies.

In the first third of the book, memory changes associated with normal aging are described using the information-processing model of memory (i.e. sensory, primary, secondary, and tertiary memory stores). Then follows a review of the gamut and frequency of memory complaints, the impact of depression on these and the threefold focus of their memory assessment (i.e. objective performance, subjective complaints, and affective status). The topic of cognitive training in brain injury and rehabilitation programs is alluded to only briefly in order to raise the issue of using complex novel mnemonics techniques on a system which has already proven to be less than optimal. Such a concern can readily be applied to the older adult. The position of the authors regarding this issue is obvious. Nonetheless, they argue that more research is necessary before we can truly determine whether memory training learned in an artificial situation generalizes to everyday living, and whether such techniques serve to enhance memory functioning.

The memory training program detailed in the second third of the manuscript provides a description of three intervention strategies to enhance acquisition and retention of new information: 1. organizational techniques (categorization & chunking); 2. imagery techniques (method of loci & novel interacting images); and 3. physical reminders (writing things down, placing reminder objects in a prominent place and use of established locations). The latter third of the book details how to integrate memory training when providing intervention to older adults. It also reviews the findings of empirical studies on memory training programs and highlights the limitations of such training. Finally, the book closes with suggestions for future investigations.

On the whole, the authors have provided a concise and relatively encompassing exposé of a most important issue. Indeed, it is not sufficient to merely substantiate or disconfirm memory complaints experienced by the older person. One should also provide the means to compensate for such limitations. To do so, the clinician can readily refer to this resource work for a review of useful strategic techniques. The brevity of the book will make it a favorite of professionals constricted by time limitations as it may be more readily consulted than lengthy and comprehensive handbooks on the topic. Another positive aspect of this exposé pertains to its emphasis on educating the older adult about the various aspects of memory and the expected changes associated with aging. In that regard, it may help alter inaccurate perceptions or beliefs regarding memory.

Clinicians often encounter unrealistic expectations about memory performance in their elderly patients. Too often, these expectations are inappropriately elevated, particularly with the more educated individual. Unfortunately, this manuscript has failed to address the impact of education and/or high premorbid abilities on memory complaints, two most important contributing factors. Although reactions from participants of such training programs may well be summarized as positive overall, they constitute a selective subsample and may not be representative of the population of people who complain of memory disturbances. Another area which lacked adequate critical examination pertains to a general statement that memory changes on the whole are only mild in the aging population and that “the picture is not as grim as most believe” (p. 3). Reviews of normative data on frequently used standardized measures of memory functioning (e.g. WMS-R or CVLT) indicate a significant decline in the amount of information retained with increasing decades.

Despite these minor shortcomings, the manuscript provides the clinician with a workable tool by which to instill practical methods of compensation to those who present with memory complaints. The clinician sensitive to the needs of the individual patient may consult this book to find practical coping strategies that may be proposed and for which they are less likely to encounter resistance. Finally, the book can easily be read by highly functioning individuals.

Brain Biochemistry and Brain Disorders

Brain Biochemistry and Brain Disorders

Philip G. Strange

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

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

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

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

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

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

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.

Environment and Psychopathology

Environment and Psychopathology

A.-M. Ghadirian and E.H. Lehmann

New York, NY: Springer Publishing Company, 188 pp, 1993

When I initially browsed through this book, I wondered how topics as diverse as seasonal affective disorder, taijin kyofu sho, the homeless, and terrorism could be tied together in a cohesive mental health theme. After completing it, I believe the editors deserve credit for doing just that. Drs. Ghadirian and Lehmann are well-known and respected clinician researchers from McGill who are eminently qualified to examine the interaction between our environment and the expression of mental illness. As they point out in the introduction, this interaction is complex and difficult to study, but is essential for understanding stress and coping. Their book is divided into three sections: physical factors and psychopathology; social and cultural forces; and catastrophic forces. The first section includes chapters on how light, noise, pollution, and nutrition may contribute to psychopathology. The second section looks at the relationship between mental illness and culture-bound syndromes (taijin kyofu sho is a form of Japanese social phobia), the “postwar generation”, homelessness, and substance abuse. The psychological effects of natural disasters, terrorism and torture, and concentration camps are addressed in the final section.

Overall, the writing and editing are good, the quality of the book is excellent, and the price is very reasonable. The usual problem with multi-authored books (that of overlap between chapters) is a non-issue because of the diversity of topics. My one criticism of the technical aspects is that the references in the text include all the authors’ names. While I very much prefer text references in this author/year style instead of numbers, I find it annoying to have to wade through five or six author names for a single reference, especially when several references are cited.

The chapters are succinct and well-written by authorities in each field. As expected in a book with this theme, the authors range from psychobiologists, to sociologists, to epidemiologists. Sometimes the chapters are a bit too sparse. Gerald Klerman has a chapter on the fascinating epidemiologic data showing increasing depression rates in younger age cohorts in the 20th century. He describes the methodology in detail, but does not elaborate on possible explanations for these findings. Unfortunately Dr. Klerman died last year, but his ideas and speculations on the matter would have been very interesting. Other topics such as environmental illness, or “20th century disease” seem conspicuous by their absence. Dr. Lehmann has not contributed a chapter, but Dr. Ghadirian penned the chapter on psychoactive substance abuse and psychopathology, a nice summary of the available literature. The chapter on homelessness and psychopathology by Wallace, Streuning and Susser offers a well-thought out treatise that limited effective social networks leading to spiralling feedback loops that result in homelessness. The final chapter by John Sigal on concentration camps points out that all of the literature on survivors of concentration camps is based on people from Western industrialized nations, and that we have very little understanding of the psychological effects of atrocities on Third World people. He pointedly suggests that this may be merciful, but I wonder about this restricted focus that we have in the “First World”.

One small omission from the book’s introduction is a clear statement of the target audience, i.e. who should read the book. This is important, because I think of books as meals. Choosing a meal depends on your appetite and interest. For example, reference books are like smorgasbords — there is lots of variety and everything is available in vast quantities. Researchers prefer gourmet fare, like nouvelle cuisine — small portions, but carefully and exquisitely prepared with only quality ingredients. Residents tend to favour health food — lean and spare, with all the vital nutrients but no frills. Medical students like easily digestible food that has been strained of birdseed. In this analogy, I would classify this book as an appetizer course — small, varied, tasty nibbles that whet your appetite for more. When thinking about environmental effects on mental illness, one tends to forget broader issues like culture or disasters, and ubiquitous factors like light or noise. I would therefore recommend this book to readers interested in brief essays on the way selected environmental factors can affect psychopathology and mental illness.

Headache and Depression: Serotonin Pathways as a Common Clue

Headache and Depression: Serotonin Pathways as a Common Clue

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

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

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

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

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

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

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

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

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

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