Posts Tagged ‘mental disorders’

A Primer of Supportive Psychotherapy

A Primer of Supportive Psychotherapy

Pinsker H

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

ISBN 0-88163-274-0 (cloth)

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

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

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

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

Pharmacology of Anxiolytic Drugs

Pharmacology of Anxiolytic Drugs. WHO Expert Series on Neuroscience, vol. 3

Racagni G, Masotto C, Steardo L

Seattle (WA): Hogrefe and Huber; 1997. 132 pp. with index

ISBN 0-88937-088-5 (cloth)

This monograph forms part of the World Health Organization’s expert series in neuroscience, which is intended to help prevent or control mental neurological disorders and psychosocial problems, as well as to ensure broad use of mental health knowledge in general health care within WHO member states. It is indeed a textbook of pharmacology and should be viewed as such.

The authors must be world renowned in the field of pharmacology and its clinical application, although I could find only one citation by one of the authors (a publication in Nature in 1979) through MEDLINE. As well, the authors do not cite themselves in the book, indicating either that they are modest or that their publications are now aged. The University of Milan, however, has a reputation for expertise in pharmacology.

The book begins with a succinct history of the search for anxiolytics. The comprehensive contents of the book are then divided into 4 groups. Group 1, on benzodiazepines, is the most comprehensive of the chapters and includes a detailed description of each of the benzodiazepines, including their 2-dimensional chemical formulae. There is an extensive discussion of action, side effects, dependance and interactions. Group 2 discusses compounds with benzodiazepine-like activity, and details agonists, partial-agonists and antagonists. Group 3 reviews compounds that act on nonbenzodiazepine receptors and includes a large discussion of the role of serotonin in anxiety. Group 4 considers the role of antidepressants as anxiolytics and includes tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, α2-adrenergic blockers and β-blockers.

Only generic drug names are used throughout the book.

This book is a very comprehensive, well-organized and crisp discussion of anxiolytic drugs, and includes scientifically backed clinical use. Remember, the title is Pharmacology of Anxiolytic Drugs, and so the rather dry chemical formulae, pharmacokinetics and pharmacodynamics seem clinically sterile. The authors include substances that we prescribe routinely as well as medications that are not very commonly used in this country but may be in other parts of the world.

There are other texts, such as those by Goodman and Gilman or by Schatzberg and Nemeroff, that are more enjoyable to read, but they are not as complete as this book, and they cannot be held in one hand. This book is not a light read, but is a good, comprehensive reference.

My main criticism is that there is a lack of reference to the clinical situation, but then, this is a textbook of pharmacology.

The readership is meant to include nurse practitioners, social workers, family physicians, and others, but I believe they would use this book only as a reference text. Psychiatrists, residents in psychiatry and anesthetists would find this book quite valuable.

Neural Networks and Psychopathology

Neural Networks and Psychopathology: Connectionist Models in Practice and Research

Dan J. Stein, Jacques Ludik, editors

Cambridge (UK): Cambridge University Press; 1998. 371 pp. with index

ISBN 0-521-57163-4 (cloth)

Neural networks are mathematical models of how the mind processes information, just as mathematical equations can be seen to describe the universe. Neural networks can provide the theoretical framework that clinical science lacks for integrating psychological and neurobiological data. This theoretical framework is based on the idea that the brain functions by a process of pattern recognition. Each chapter in this collection, edited by Dan Stein and Jacques Ludik, looks at this process from a unique perspective and, taken as a whole, demonstrates the complexity of the mind arising from basic units and their interconnections.

This book is aimed at a very diverse audience including clinicians, researchers in psychopathology and those working in cognitive science and artificial intelligence. Its chapters are organized into 2 broad sections. The first part of the book presents general concepts. Each chapter demonstrates how neural network modelling can be used to understand clinical practice and research in areas such as diagnosis and psychotherapy. The second part of the book constructs neural network models of various clinical disorders and demonstrates their usefulness in helping improve one’s understanding of the pathologic process underlying these clinical disorders.

A number of important ideas are introduced in the first section. For example, neural network or connectionist models “rely on the idea that almost all knowledge is implicit in the structure of the device that carries out the task rather than explicit in the states of the units themselves.” This means that knowledge is stored in the strength of the connections between units or neurons and not in the units’ moment-by-moment activity. Nevertheless, this activity does affect the strength of synaptic connections through the process of learning. This leads to an important dilemma: How can the brain be plastic enough to learn new patterns as well as stable enough to remember old patterns? Knowledge is stored as patterns of activation of neurons, determined by synaptic connections. This leads to another important concept: the function of the brain is to recognize patterns; and the effectiveness of the brain is measured by how accurately it can match patterns and by how well it can generalize (find similar patterns). When the brain becomes faulty in its ability to correctly discriminate patterns, clinical symptoms such as delusions and hallucinations can arise. Delusional individuals interpret all inputs in the light of some false belief. Any bit of information is used to support this false belief no matter how ludicrous the connection. Conceptually, the delusional brain continually matches all inputs to a specific incorrectly matching pattern; or in other cases, one pattern becomes central in interpreting all inputs. With respect to hallucinations, perception involves the superposition of sensory input with higher cognitive expectations, but if the system is strongly focussed on expectations and ignores sensory input then the system will perceive objects that are not there. Again the brain is unable to correctly match incoming patterns (sensory information) with stored patterns (memory or expectations).

In the second half of the book, specific clinical disorders are modelled, based on the basic principles from the first half of the book. The success of this modelling is both thought-provoking, in demonstrating how underlying neuropathology can result in complex symptomatology, and fascinating, by forcing one to reexamine previous views of psychopathology. The models very nicely integrate neurobiology and psychological data, and because the computer models are working models one can see how the brain might process information. Dan Lloyd looks in depth at how a new memory can affect previously learned related memories and vice versa. This process is addressed in the specific context of traumatic memories. He constructs a computer simulation, called Lucynet, that models human learning based on the most basic neural network theoretical principles. The simulation is exposed to the traumas of Sigmund Freud’s patient, Lucy R. The results of this recreation address several aspects of memory. They support the cognitive research showing that recall is the construction of a memory rather than its extraction from a form of storage. The results also show that repression can result from the inherent process of memory formation rather than requiring the hypothesis of a novel mechanism of the ego as proposed by Freud.

In another chapter, Ira Cohen gives an elegant working model of autism. Working from the neurobiological data, which suggests that autistic people have a greater number of synaptic connections, a greater number of neurons or abnormal wiring patterns in various brain regions, combined with the recognition that autistic children are very poor at generalization, the computer model runs several scenarios of either too few, an optimal number or too many neurons faced with a learning task. “With too few neurons, the computer simulation shows that overall learning and generalization are weak and responses are inconsistent. With an optimal number of neurons, both learning and generalization are good and correct responding is consistent and predictable. With too many neurons, learning is good but generalization is poor and shows relatively little variation.” This inflexibility relates to the typically stereotyped and inflexible responses of autistic children. There is more depth and complexity to these models when presented in their respective chapters, but this brief summary may convey the ability of these simulations to recreate psychopathology while functioning with only the basic rules of learning in connectionist theory.

Although the term “neural network” or “neural net” is becoming popularized, at least in science fiction, it is not a well-understood concept. There are few, if any, psychiatry programs or even psychology programs that include it as part of their teaching curriculum. I believe that it will become increasingly advantageous to know something of this area. The scope of this book is wide and it is aimed at a diverse audience. Nevertheless, it is an important attempt to make this area more understandable. Each chapter is written by a different expert, and this format requires a strong introduction to pull the pieces together. The lack of this kind of introduction is the major deficiency of the book. This format also runs the risk of becoming disjointed. Luckily, this does not happen because the structure of the book itself allows for a significant amount of redundancy, and the concepts from the first half of the book are expanded on in the second half. There was only one chapter that I found quite incomprehensible because it was so poorly written. Generally, all authors focus more on concepts than on the details of how to construct and run a neural network model. This approach keeps the book accessible to the diverse audience to which it is aimed.

As a non-expert in the field of neural network modelling, I found the book absolutely fascinating because there are many concepts and reconceptualizations that do not require an intimate working knowledge of neural network theory. Still, some knowledge of neural network modelling is of benefit in appreciating the complexity of the issues. And I must point out that the subject matter is dense.

The editors open the first chapter with the following statement “The recent shift in psychiatry from a predominantly psychodynamic model towards a neurobiological paradigm has led to advances in our understanding and management of many mental disorders. At the same time this shift has been characterized as a move from a brainless psychiatry to a mindless one.” Neural network modelling has the capacity to reintroduce the mind even if not in all its complexity. This makes the final chapter by David Forrest on the challenges facing clinicians and researchers, as well as some of the potential limitations of neurocomputational modelling, an especially appropriate and thought-provoking conclusion to a book that challenges one to think.

Dual Disorders: Essentials for Assessment and Treatment

Dual Disorders: Essentials for Assessment and Treatment

O’Connell DF

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

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

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

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

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

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

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

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

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Obsessive-Compulsive Disorder: Theory, Research and Treatment

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

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

ISBN 1-57230-335-2 (cloth)

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

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

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

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

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

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

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

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

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

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

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

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

Schizotypy: Implications for Illness and Health

Schizotypy: Implications for Illness and Health

Claridge G, editor

New York: Oxford University Press; 1997. 340 pp with index

ISBN 0-19-852353-X (cloth)

Psychiatrists and psychologists start from a different place. Given their medical background, psychiatrists tend to emphasize the dichotomy between health and illness. Moreover, classifications of mental disorders, such as the various editions of the Diagnostic and Statistical Manual of Mental Disorders, are taken to imply that psychiatric illnesses, like medical conditions, are distinct entities with unique etiologies.

Yet a great deal of evidence indicates that psychiatric diagnoses are very fuzzy indeed. In fact, the phenomenon of “comorbidity,” which is the focus of many research studies, may be nothing but a reflection of the failure of the categorical system to describe psychopathology adequately.

Psychologists, who study normality and variation from it, are much more inclined to see health and illness as continuous. Since the editor (a professor at Oxford University) and most of the contributing authors of this book are psychologists, it is not surprising that this volume takes a strongly dimensional view of psychopathology. “Schizotypy” — the focus of this book — can be conceptualized as a set of traits that form the basis of a variety of illnesses, ranging from schizophrenia to personality disorders, as well as of normal variations in personality that can produce eccentricity or creativity.

Two issues arising from this theory are of particular interest to psychiatrists. First, some evidence suggests that both forms of psychosis originally described by Kraepelin (i.e., schizophrenia and bipolar disorder) could lie on a single dimension, and may not be as separate as we often assume. Second, disorders not usually considered to reflect schizotypal traits, such as obsessive-compulsive disorder and dyslexia, may reflect the same psychopathologic dimension — at least in part.

Several chapters in the book raise questions of broader theoretical significance. There are excellent reviews of research on cognitive processes and cerebral lateralization in schizotypy. Other chapters concern the measurement of schizotypal traits. Finally, there is a whole section entitled “schizotypy in health subjects.”

This book has strengths and weaknesses. Since all chapters are written by Claridge and his collaborating colleagues, the text is much more coherent than many multi-author books. On the other hand, research conducted outside of Great Britain is not given enough weight. Although Claridge suggests that readers also consult a recent companion volume based on a conference on schizotypal personality, the contributions of investigators such as Holzman and Siever and Davis could have been given much more space.

Claridge’s strong editing leads to a relatively high standard of scientific writing throughout. Inevitably, however, some of the chapters are hard-going, while those written by the editor himself are the best. Claridge is a natural writer and communicates in an incisive and witty way that quickly engages the reader.

I was particularly stimulated by Claridge’s ideas about how to conceptualize psychopathology in a dimensional system. The point of view is refreshingly different from the perceived wisdom in North America. These principles are also developed in several of the chapters written by neuropsychologists.

Although I agree strongly with the general approach of this book, it lacks breadth. It fails to address some of the most crucial areas for theory, most particularly genetics and neurobiology. I also found myself less than sympathetic toward the chapters on normal schizotypy, some of which come dangerously close to reviving the Laingian romanticism of the 1960s.

A related objection concerns the emphasis in many chapters on the role of psychosocial factors in the etiology of schizophrenia and related disorders. I agree with Claridge that psychiatrists are often too busy prescribing medication to consider individual differences in the psychology of their patients, and that cognitive therapy may well have a role in the treatment of psychosis. However, his views on the role of the environment can be somewhat quirky, most particularly his somewhat dogmatic idea that trauma and bad parenting are the major factors that determine whether traits develop into disorders.

With these caveats, I found this book highly original and extremely thought-provoking. Researchers studying disorders related to schizotypy will find it a useful reference, and clinicians and clinician-teachers will benefit from reading the theoretical chapters. The main impediment to the wide use of this volume is the price, which, whatever the state of the Canadian dollar, is much higher than for books imported from our southern neighbour.

Women’s Health: Hormones, Emotions and Behavior

Women’s Health: Hormones, Emotions and Behavior

Regina C. Casper, editor

Cambridge (UK): Cambridge University Press; 1998. 328 pp

ISBN: 0-52156-341-0 (hardcover)

Cambridge University Press has initiated a very useful series of clinical texts in the area of psychiatry and medicine. The editorial board of this series is to be congratulated for its selection of books and for its uniformly high standard of publication. This book is no exception. It is a “must read” for all mental health professionals, both women and men.

Women’s Health: Hormones, Emotions and Behavior is well written and informative, but not overly detailed. It covers the important areas and keeps the reader’s attention throughout. Women’s health has become a popular topic and there has been a recent spate of books in this area. This is the best one. Although it is multi-authored, the editor has kept a strict rein on the contributors, has participated actively in each of the chapters and has ensured a high level of readability, comprehensiveness and up-to-date thinking on a common theme.

She has done what is very difficult to do — she has interwoven highly sophisticated neuroendocrine and neuropharmacological information and recent thinking about the impact of roles, functions, supports and losses in women’s lives so seamlessly that perspectives from many different fields are integrated into a complex framework. The readership will emerge not only with knowledge but also with wisdom.

The field of women’s health is evolving so quickly that the book is already a little out of date. The discovery of a second estrogen receptor and of several ways in which selective estrogen receptor antagonists affect and protect different body tissues all promise new insights and new therapies. The role of estrogens in Alzheimer’s disease is attracting new attention. Our increasing awareness of autosomal differences between the sexes, and of immune differences, will incrementally contribute to this field. As all this happens, women’s (and men’s) roles will change and diversify, and will no doubt induce hormonal and neurotransmitter changes, which perhaps will stand all the old findings on their heads. As we have recently learned, the expansion of the universe we inhabit is accelerating. So is knowledge in this field of study. This is a book we should all read to try to keep up.

Thérapie brève et intervention de réseau

Thérapie brève et intervention de réseau: une approche intégrée

Jérôme Guay

Montréal : Les Presses de l’Université de Montréal; 1992. 189 pp

ISBN 2-7606-1556-1 (papier)

L’auteur de ce livre de base souligne l’importance de la multidisci-plinarité pour traiter les personnes souffrant de troubles psychiques en pointant les interventions psychosociales comme composante indispensable des soins aux malades.

Dans le premier chapitre, il affirme que la psychothérapie est seulement efficace pour régler des problèmes mineurs. Malheureusement, ses références sont limitées et datent de plus de 10 ans. Au cours de la dernière décennie, de nombreuses études de recherche ont prouvé l’efficacité de la psychothérapie brève (thérapie cogni-tive du comportement, psychothérapie interpersonnelle et dynamique) pour des troubles mentaux sérieux.1 La psychothérapie à long terme, la psychothérapie de groupe et l’hospitalisation à temps partiel sont essentielles pour les patients souffrant de troubles psychopathologiques plus sévères qui manquent de soutien social.

L’auteur identifie les compétences essentielles du thérapeute pour améliorer l’alliance thérapeutique, p.ex., se montrer sincèrement intéressé, écouter et avoir de l’empathie envers les patients. Les principes de base de la psychothérapie sont abordés. Cependant, l’auteur a omis de définir clairement des concepts principaux, comme la résistance, le transfert et le contre-transfert. L’importance de garder des «limites» à l’intérieur de la relation thérapeutique est décrite brièvement mais elle n’est pas expliquée. Cela est inquiétant, compte tenu que la violation des limites est plus souvent initiée par le thérapeute et qu’elle cause des dommages psychologiques aux patients.

Le deuxième chapitre renferme un guide d’évaluation avec des questions utiles pour évaluer le degré de motivation du patient, le type de crise, la stratégie d’adaptation, les aspirations et le réseau de soutien. L’auteur, qui mène un rôle actif dans la promotion des programmes communautaires, souligne l’utilité de rencontrer les membres de la famille et les amis qui constituent le réseau de soutien social du patient. Cinq types de thérapie sont résumés. Parmi les faiblesses dans ce chapitre, je remarque l’absence d’une évaluation de la force du Moi, qui est un outil utile pour déterminer les contre-indications pour des psychothérapies brèves. De plus, à l’intérieur du guide d’évaluation, on ne fait pas mention du besoin d’éliminer les troubles médicaux qui peuvent simuler et (ou) compliquer des symptômes psychologiques. L’auteur n’a également pas abordé l’importance d’un renvoi à un psychiatre pour les patients qui ont besoin de phar-macothérapie pour traiter des symptômes graves.

Les troisième et quatrième chapitres sont intéressants et ils atteignent vraiment les objectifs fixés par l’auteur. Il encourage les praticiens à développer une confiance dans la pratique d’interventions psychosociales. Il élabore sur les jumelages entraidants, les groupes d’entraide, les groupes communautaires et d’autres ressources précieuses. L’annexe comprend des tableaux détaillés, des diagrammes et des questions qui sont pratiques et bien organisés.

Ce livre facile à lire est une bonne introduction pour les professionnels de la santé qui sont intéressés à connaître les évaluations et les interventions psychosociales. Les lacunes principales de ce livre sont l’absence de concepts essentiels de psychothérapie et le manque d’explication sur le moment opportun pour envoyer un patient recevoir des consultations médicales et (ou) psychiatriques.

J’apprécie le commentaire de l’auteur affirmant que la pratique de la psychothérapie requiert une formation clinique. Toutefois, en tant que psychiatre spécialisé en psychothérapie psychodynamique, je crois que nous devons maintenir les normes sociales et morales, chercher à obtenir la supervision d’experts qualifiés et obtenir beaucoup plus que deux ans d’expérience clinique. La compétence clinique est essentielle et fondamentale à la pratique de la psychothérapie.

Impulsivity: Theory, Assessment, and Treatment

Impulsivity: Theory, Assessment, and Treatment

CD Webster and MA Jackson, editors

New York: Guilford Press; 1997. 462 pp. with index

ISBN 1-57230-225-9

Webster and Jackson have made a bold attempt at editing a multi-disciplinary book on the construct of impulsivity. The book focuses on impulsive individuals and their speed of judgement. It approaches the construct of impulsivity by covering a broad range of problematic behaviours that have impulsive components. The editors seem to take the view that, if several blindfolded individuals feel different body parts of a large animal such as an elephant, each will describe the respective body part, and the reader will then have a collection of descriptions that can be combined to form a holistic concept of the construct.

The first section of the book deals with the diverse theoretical perspectives on the construct of impulsivity. There are chapters on the clinical, social, sociological, legal and “cybonautical” (computer technologies involving cyberspace, virtual reality and information technology) perspectives on impulsivity. I singled out the chapter on “social perspectives,” in which the content, in my view, is incongruent with the focus of the book. The author seems to have an axe to grind about psychiatrists and the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for intermittent explosive disorder. He mistakenly takes the view that “psychiatrists” see “wife batterers” as individuals who have an intermittent explosive disorder. He then attempts to apply this psychiatric concept to 2 of his case studies of wife batterers. My concern lies in the author’s ludicrous view that the psychiatric explanation of all spousal assault lies in interpreting that these individuals fall within the boundaries of the DSM-IV diagnostic criteria for intermittent explosive disorder. The author also appears to be misinformed about such psychiatric terminology as the difference between a delusion and an overvalued idea.

The second section, on the foundations of impulsivity, provides 2 well-written chapters on the biology of impulsivity. The first chapter focuses on serotonin mediation of various neurophysiological processes. It traces the complex relations between the neurochemical substrates in the brain and impulsivity. The second chapter looks at the role of organic brain syndrome in impulsive violence. Researchers attempting to understand the nature of the connection between neurochemical factors and brain damage have concluded that these elements are mere components of a complex whole, rather than adequate explanations for certain types of behaviour. There is also a comprehensive and informative chapter on the measurement approaches used by researchers studying impulsivity. Unfortunately, the lack of definitional constructs has led to multiple self-reports and behavioural measures with poor and inconsistent inter-correlations. Unless we can overcome our definitional problems, we are unable to construct reliable and valid measurement instruments. The following 3 chapters look at major mental disorders, impulse-control disorders, and psychopathology. The relation of these 3 diagnostic groups provides the reader with insight into the complex interrelation between impulsivity and other psychopathology. The final chapter looks at a conceptual model for the study of violence and aggression. This author proposes the use of facet analysis to clarify the poor definitional issues that have plagued the study of risk research. A facet is defined as the basic unit of an enquiry into a specific phenomenon of interest. Facet analysis involves mapping the conceptually independant facets into a “mapping sentence/’ thereby enabling researchers to engage in a evolving dialogue on risk research.

The third section is entitled “Practise: Assessment” and focuses on assessment of violence. Empirically, we know that there is a link between impulsivity and violence. There is, however, a lack of clarity on the exact nature of this association and the operational definitions of the respective elements. There are 4 chapters addressing assessment of risk of violence to self, others and wives (spouses), as well as the risk of the patient committing sexual assault. These chapters are devoted mainly to descriptions of the respective authors’ assessment instruments or checklists. There is also a chapter giving some useful suggestions on how not to conduct a risk assessment.

The final section focuses on the treatment of patients with impulsive behaviour. The diverse chapters discuss effective services for offenders with mental disorders, pharmaco-logic approaches to impulsive and aggressive behaviour, and a case management system to approach people with “multiproblems” and “impulsive driven” people. In the final chapter, Webster ends on an upbeat note, remarking that, although the concept of impulsivity has not yet been adequately defined, researchers have accumulated enough information about impulsivity and disorders that involve impulsive elements to lead to better solutions than are now available. He provides a guide for professionals who are interested in creating treatment programs for people with problems related to impulsivity.

The lack of consensus on the definition of this construct is apparent from the diversity of chapters in this book. The authors address topics such as spousal abuse, violence and aggression, offenders with mental disorders, psychopathology, suicide and sexual violence. It is uncertain whether impulsivity is a behaviour, a symptom of a broad range of psychiatric disorders, or a component of many functional and dysfunctional behaviours. This book is therefore as much about these other topics as about impulsivity per se. Readers who are looking for a book focused on impulsivity will likely find this book a disappointment. This is not a criticism, but rather a reflection of the poor definitional and operational concepts when approaching such a task. For readers who want a good overview of the current state of knowledge of the concept, this book is an interesting read.

The Insider’s Guide to Mental Health Resources Online

The Insider’s Guide to Mental Health Resources Online

Grohol JM

New York: The Guilford Press; 1997. 326 pp with index

ISBN 1-57230-262-3 (cloth)

ISBN 1-57230-229-1 (paper)

This book is the sixth in the “Clinician’s Toolbox” series. The author, John M. Grohol, is a psychologist whose credentials and training are not specified but who has developed a reputation as an expert in psychological informatics. At his Web site (grohol.com), he informs consumers and answers simple questions about mental disorders and treatment. He apparently has a broad, in-depth knowledge of mental health resources on the Internet.

The author’s objective is to initiate the busy clinician to the World Wide Web; he guides the reader to what’s available and where to find it online so as to avoid surfing aimlessly. He critically evaluates numerous Web sites, making our journey into cyberspace easier.

The book is well organized and is divided into 4 parts: the first contains basic maps and tools for finding mental health information online; the second involves getting answers to your professional questions; the third is on patient education resources; and the fourth contains appendices and a useful glossary. For the novice Web-surfer, the first part is a very helpful introduction to the major resources online and the way search engines work. (Formulating a search question properly is essential to obtaining relevant information, whether it is a MEDLINE literature search or a search for a specific self-help group.) The second and main part of the book has specific chapters on finding information about disorders, treatments, employment opportunities and continuing education as well as on researching, networking and finding useful books, journals and software online. In one chapter, the author discusses psychotherapy and counselling online, and he clearly states the ethical issues involved. The third part contains 3 chapters listing patient-education resources and includes consumer mailing lists and news-group discussion and support groups. The fourth part has 4 appendices, one of which is a brief introduction to creating your own Web site.

I found the book to be free of errors (except for 2 minor ones) and easy to read. As a psychiatrist, though, I take exception with the author’s bias against electroconvulsive therapy. On page 195 he writes, “radical treatments such as electroconvulsive therapy (ECT)” and, on the next page, “About the only useful thing this site does offer is information on the pitfalls of ECT.” Elsewhere, he states his own biases clearly and reasonably.

One of the redeeming qualities of the book is the frequent reference to the “Insider’s Guide” online update page, which at the time of writing contained 3 pages of updates — mainly changes to uniform resource locators (URLs) and notices of “bad” links. Without such an update, this book would become outdated very quickly.

In conclusion, this book can help allay a middle-aged novice’s fears of the Internet and add another dimension to the communication of information, both among doctors and between doctors and patients. Although the book is targeted to a larger readership than the subscribers of this journal, it contains enough relevant material for me to recommend it to psychiatrists as well as allied health professionals interested in “psych” online.