Posts Tagged ‘mental disorders’

Multi-axial Classification of Child and Adolescent Psychiatric Disorders

Multi-axial Classification of Child and Adolescent Psychiatric Disorders: The ICD-10 Classification of Mental and Behavioral Disorders in Children and Adolescents

World Health Organization

New York: Cambridge University Press; 1996. 302 pp with index

ISBN 0-521-58133-8 (cloth)

For many decades, psychiatric epidemiology involving comparisons among countries has been handicapped by different classification systems. North Americans tend to use the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria, developed primarily by committees of the American Psychiatric Association, whereas western European countries use the International Classification of Diseases system, now in its 10th revision (ICD-10). This book is the ICD-10 equivalent of the big green DSM-IV manual that lists the multi-axial classification of psychiatric disorders, together with the brief description of signs and symptoms that make up the essence of the diagnoses.

The introduction, by the eminent child psychiatrist Michael Rutter, is first-rate. It indicates that there has been serious corroboration with DSM-IV. The similarities, including the use of a multi-axial description of each diagnosis and brief descriptions of signs and symptoms, are much more evident than any differences. As with DSM-IV, the diagnoses are based on clinical description and not on etiology, since precise causation in psychiatric disorders cannot be determined in most diagnostic categories.

As is often the case with British medical textbooks, the language is more succinct and the book is shorter than its North American counterpart.

A compare-and-contrast exercise does reveal some interesting, although relative minor, differences. Autism or pervasive development disorder and mental retardation are placed on axis II, instead of on axis I, in the ICD-10 system.

Under conduct disorders, always a problematic diagnostic category, there is an intriguing and possibly useful category called “conduct disorder confined to the family context.” In the section on affective disorders, the ICD-10 system does not include rapid cycling bipolar disorder.

The ICD-10 system has maintained a category of neurotic disorders, which are virtually identical to the personality disorders in DSM-IV. Among the neurotic disorders described by ICD-10 is “neurasthenia.” This concept, which feels outdated from a North American perspective, is related in a fairly modern way to postviral fatigue states and depression. “Neurasthenia” appears to have resurfaced in North America as chronic fatigue syndrome.

The section in ICD-10 on personality disorders suggests that these disorders can be diagnosed as early as 16 years of age, in contrast to the North American view that personality disorders begin only at age 18. The North American approach takes into account the flexibility of adolescent minds, which we hope will not settle into permanent personality structures prematurely. The use of the term “anankastic” for obsessive-compulsive disorders is another example of the way that traditional psychiatric phenomenology is maintained in the ICD-10.

Another example of a difference in terminology, which is illustrative of British brevity, is “clumsy child syndrome,” which is the same as “developmental coordination disorder,” described in DSM-IV.

In contrast with DSM-IV, ICD-10 does not set up lists of symptoms with the instruction that 3 or more must be present. There is usually a description of the general presentation of the problem. Instead of counting up symptoms, the clinician then forms personal impressions and makes his or her own judgements.

Axis V in ICD-10 refers to associated abnormal psychosocial situations. This is virtually the same as axis IV in DSM-IV, which refers to psychosocial and environmental problems. I found, however, that the ICD-10 axis V was more specific and clearer in describing the precise problems that children and families have. For instance, there is a specific category for lack of warmth in parent-child relationships, for scapegoating of a child, for disability in a sibling, for experiential privation and even for parental overprotection. Such clear categories allow family dysfunction to be introduced diagnostically in a clearer way.

The ICD-10 text on multi-axial classification of child and adolescent psychiatric disorders is a parallel but not identical effort to the DSM-IV currently in use in North America. Each system has something to teach the other. The continuing collaboration between the two evolving systems can only be of benefit. This book is not exactly a thriller to read, but for those interested in international collaboration in clarity of diagnostic categories, it is a very important sourcebook.

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

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

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

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

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

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

Hyperactivity Disorders of Childhood

Hyperactivity Disorders of Childhood

S Sandberg, editor

New York: Cambridge University Press; 517 p

This book reveals some of the differences in the approach to diagnosis and treatment of attention-deficit hyperactivity disorders (ADHD) between the clinicians and researchers from Europe and those from the United States. The Australian and Canadian contributors seem to bridge these different approaches. The book is edited by a British psychiatrist from the Royal London Hospital. She has worked with E Taylor, who has spent some of his time in the United States.

The book has 13 chapters, of which 3 very good ones are written by the editor with some of her colleagues. One of these is on the historical development of the diagnosis, etiology, and treatment of ADHD, 1 on its clinical aspects, and another on the psychosocial contributions to the hyperactive child. Other chapters include the epidemiology, developmental aspects, sex differences, and cross-cultural aspects of hyperactive children and children with associated conditions such as conduct disorders and reading disability. There are 3 excellent chapters: 1 on the treatment of ADHD by the Canadians Schachar, Tannock, and Cunningham, 1 on outcomes by Swedish researchers Gilberg and Hellgren, and 1 on biological aspects by Tagade and Takagi. Overall, the book has a rich international flavor. Only 1 chapter (on the developmental aspects of ADHD) was rather densely written; its author did not indicate what she felt were the most important research findings on this subject, but rather gave a long list of findings. Further, a citation in this chapter (p 153) to Biederman, Newcord, and Sprich (1990) is not listed in the reference section, which is somewhat irksome. In addition, some of the developmental findings are covered in an earlier chapter on the clinical aspects of ADHD.

In contrast, the chapter on the biological aspects was clear and interesting, and that on gender differences by Heppinstrall and Taylor showed some fascinating results “which may well give clues to the etiology of the disorder” (p 344). They suggest that girls do not have an overrepresentation of hyperactivity in their families and that mild degrees of hyperactive behaviour in girls should not be “given undue weight as peer relationship impairment and educational failures may be more important targets for therapy.”

It was particularly useful to find all the epidemiological studies and the basic investigations on attention reviewed in 1 place. The book was equally comprehensive in its review of several other topics, which makes it an invaluable resource text.

In the preface, the editor states that this is the 2nd of a monograph series “aimed at practitioners in child and adolescent mental health services and researchers in development and clinical neuroscience” and that “it is intended that there should be detailed consideration of topics less commonly found in standard texts” (p xix). This book accomplishes these goals admirably. It is interesting, different, and well presented, and for the most part, the contributions are of an evenly high standard. I would strongly recommend it for clinicians and researchers who deal with children who have behavior disorders.

Biology of Schizophrenia and Affective Disease

Biology of Schizophrenia and Affective Disease

SJ Watson, editor

Washington (DC): American Psychiatric Press; 1996. 540 p

Over the past 30 y and particularly over this last decade — the decade of the brain — there has been marked acceleration of research efforts in the fields of neuroscience, molecular genetics, and biochemistry of mental disorders. Coupled with increasing sophistication in clinical observations, there has been an explosion of information about mechanisms of normal and pathological brain function. Although we are still far away from a clear understanding of the psychopathology behind 2 of the major psychiatric disorders, schizophrenia and affective disorders, substantial information already exists linking subcellular biological activities and the functioning of the neurons. The integration of information from molecular genetics, biochemistry, pharmacology, brain anatomy, and neuroimaging has advanced our knowledge about the impact of mental illness on specific brain neural circuits and their response to treatment. The recent and evolving knowledge about such specific brain circuits has inspired a new strategy of pharmacological targeting in the treatment of mental disorders. In this context, this book has its major strength focusing on the interface between several mental disorders and the genetics, pharmacology, neurochemistry, brain imaging, and postmortem studies reported by the researchers themselves, who are active in these fields.

The book emanates from contributions by a number of well-known and accomplished researchers in neuroscience to the 73rd meeting of the Association for Research in Nervous and Mental Disease, which took place in New York in 1993. One major feature of that meeting was that speakers were asked not only to present an overview of their field and their own work but also to provide their views on future developments. The book includes 17 chapters that deal with topics related to schizophrenia, affective disorders, infantile autism, an introductory chapter by the editor himself, and an overview chapter with discussions at the end. The introductory chapter by Watson presents an overview of mood disorders, autism, and schizophrenia from a clinical perspective and sets the stage for the basic science chapters that follow. The chapter written by Akil, “Biology of Stress from Periphery to the Brain,” explores the concept of “stress” as a trigger for psychiatric illnesses. The contributor documents her extensive work on the regulation of the limbic-hypothalamic pituitary-adrenal access and makes clear the well-known point that “the stressful nature of any given stimulus resides less in its objective characteristics and more in the organism’s ability to cope with it” (p 15).

The 5 chapters that relate to affective disorders include a contribution by Blakely about norepinephrine and serotonin transporters that highlights the progress on the molecular targeting of antidepressant effects. Another chapter, by Owens and others, deals with peptides and affective disorders and concludes with an account of future directions in the area based on the development of such new approaches as the application of ribonuclease (RNASE) protection assay, the expanding knowledge of the peptidergic brain circuits, and the ability to image central nervous system tissue with magnetic resonance imaging and positron emission tomography technology. The chapter about the mechanism of action of antidepressants by Berman and others elegantly reviews information, both basic and clinical, about well-known monoamines that have been explored in terms of their mechanism of action: serotonin, norepinephrine, dopamine, and neuropeptides. The chapter delves beyond the monoamines theory, however, by exploring postreceptors signal transduc-tion and neuroanatomy of antidepressant action and their relevance for the development of novel treatment approaches to depressive disorders. The chapter by Raichle and Drevets maps brain circuits relative to brain function and explores its implication for psychiatric illnesses. Another excellent chapter, by Mann and others, presents an up-to-date review of available information spanning more than 2 decades about postmortem studies of suicide victims.

The book includes 8 chapters related to schizophrenia. The chapter by Benes entitled “Excitotoxicity in the Development of Cortico Limbic Alterations in Schizophrenia” examines both the proposition that schizophrenia is a neurodegenerative disorder and the evidence for glutamatergeric dysfunction in schizophrenia. Goldman-Rakic, in her chapter, “Dissolution of Cerebral Cortical Mechanisms in Schizophrenia,” advances the argument from a neurocognitive perspective about the importance of frontal cortex and the role of working memory in the disordered thinking of patients with schizophrenia. Using postmortem studies, Kleinman and Nawroz provide evidence for the involvement of dorsal lateral prefrontal cortex, the hippocampus, and the entrorhinal cortex in the pathology of schizophrenia. An up-to-date review of the “Epidemiology and Behavioral Genetics of Schizophrenia” is provided by Tsuang and Faraone. Khan and her colleagues, in their excellent chapter, “Revisiting the Dopamine Hypothesis in Schizophrenia,” advance the argument for schizophrenia as both a hyper- and hypodopamine state, thus linking such diverse elements of the broad spectrum of symptomatology as positive and negative symptoms as well as neurocognitive deficits. The contributions of neuroimaging to the understanding of the psychopathology of schizophrenia is well presented in a chapter by Van Horn and colleagues. “Abnormal Frontotemporal Interactions in Patients with Schizophrenia,” by Friston and others, provides results of their extensive work using neuroimaging in examining functional connectivity by studying corticocortical interactions in patients with schizophrenia. The last contribution related to schizophrenia is the excellent chapter by Meltzer and others, “Exploring the Mechanism of Atypical Anti-psychotic Medications,” which provides evidence for Meltzer’s recent argument for a major role for serotonergic mechanics in the improved therapeutic effects of atypical antipsychotics, particularly their tendency to produce significantly fewer extrapyramidal side effects.

The chapter devoted to “Linkage and Molecular Genetics of Infantile Autism” by Ciaranello reports the results of extensive linkage studies of 1 of the least understood disorders: infantile autism. This chapter, coming after the recent sudden and untimely death of its author, serves as a memorial to a distinguished scientist.

Overall, the book is a significant contribution, providing valuable information for understanding the mechanisms of normal and pathological brain function and its relevance to schizophrenia and affective disorders. The book makes a good attempt to integrate information at the level of functional neurocircuits. It should be of interest not only to neuroscientists but also to psychiatrists, neurologists, and psychologists. Although the book is about basic neuroscience, its relevance to clinicians is obvious because it explores the basic biological brain functions in relation to mental

illness. The book reads well, which reflects the skills of its editor, Stanley Watson. The only regret I have is that it took 3 y to publish the proceedings of that 73rd meeting of the Association for Research in Nervous and Mental Disease, which is rather a relatively long time in terms of the rapidly evolving neuroscience research. Nevertheless, the book is a valuable contribution and continues to be equally relevant today.

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.

Handbook of Culture and Mental Illness: An International Perspective

Handbook of Culture and Mental Illness: An International Perspective

I Al-Issa, editor

Madison (CT): International Universities Press; 1995. 391 p

With the hectic pace of travel, migration, and social change of the modern world, psychiatrists, mental health professionals, and trainees can expect to see people from all continents and many cultures. Moreover, they are required to be knowledgeable about and sensitive to the different backgrounds of these people and to be able to make a diagnosis, understand the psychopathology, and conduct a treatment relevant to these cultures. This is a tall order. How can any single professional become acquainted with, let alone gain expertise about the predominant cultures in each continent? These are precisely the goals that the body of knowledge and practice called cultural psychiatry or transcultural or cross-cultural psychiatry has been pursuing over the past few decades. The burning question, then, is how far can Dr Al-Issa’s book advance the practitioners, teachers, or trainees in this field in their endeavors to understand and treat effectively people from all continents and main cultural groups with full awareness and systematic use of their background and experiences? The brief answer is that indeed this book advances the body of knowledge very significantly in this direction.

The volume has a simple and bold structure. Its main parts are dedicated to Africa, Asia, Australia, the South Pacific, Central and South America, and Eastern and Western Europe; within each part about 5 specific countries or cultures are presented in terms of historical background, epidemiology of illness, cultural context, psychopathology, and treatment practices. Ethnic groups and minorities, including immigrants and aboriginals, are dealt with in a special chapter at the end. The introductory chapter by Dr Al-Issa offers an international perspective on the main psychiatric syndromes, including somatization and alcohol abuse, and on ethnic and immigrant minorities. Dr Al-Issa shows both a command of the broad field of epidemiology, including the most recent studies of the World Health Organization and associate groups, and a critical focus on controversial issues, for example, somatization in Third World versus industrial societies, multiculturalism as potential neoracism, or the suggested incapacity of some “non-Indo-European languages to differentiate between some emotions” (p 21). It closes with about 150 well-selected references that would be extremely helpful to any trainee or researcher.

The chapters that follow are innovative and mark a new era in cultural psychiatry. All of the leading books on cultural psychiatry of the past 4 decades were wholly or partially written or edited by Western-trained and -rooted professionals such as Ari Kiev, Transcultural Psychiatry (1972); HBM Murphy, Comparative Psychiatry (1982); or even I Al-Issa’s previous book, Culture and Psychopathology (1982). By contrast, all 24 chapters of this volume are written singly or in coauthorship by professionals who, by all indications, practice or have roots in the culture on which they are reporting. Clearly, they are also highly trained in Western medicine and psychiatry and maintain ongoing contacts with Western ideas and practices. One or 2 exceptions might be the report on the Inuit in Greenland and possibly the Maoris from New Zealand. This knowledge of both worlds is manifest in the twin advantages of sophisticated Western epidemiological knowledge and intimate understanding of cultural dynamics, psychopathology, and native treatment modalities. In this respect, this volume is also politically correct: nobody could accuse the authors of “stealing a people’s voice,” since they are themselves of those peoples.

Africa is represented by Egypt, Nigeria, Tanzania, South Africa, and French West Africa. All are most interesting and well-documented chapters. Especially rich is the chapter on West Africa. To the pioneer work of Henri Collomb in Dakar and the psychoanalytical work of E and M-C Ortigues on the African oedipus is added a review of the work of Andras Zempleni on the transformation of persecutory ideas and agents into modes of control of individual anger and the development of inner self as a psychological space. Self psychologists would find these ideas of special interest.

The chapter on India is also exceptional. VR Varma, based on his own work in the Indian continent, addresses 2 frontline issues in the development of or controversy about cultural psychiatry: cultural formulation and basic or ethnic “modal” personality. The issues, of course, are not resolved but are considerably elucidated.

The chapter on Jamaica, or rather Jamaicans at home and abroad, deals with the perennial theme of culture and personality and attempts to explain the high rates of schizophrenia diagnosed in Western mental hospitals. It is a matter of some curiosity that this phenomenon has been well researched in Great Britain, but not in Canada, where, since the 1970s, some 100 000 West Indians have arrived. The chapter on immigrants and minorities in Great Britain shows excellent documentation on the Irish, Jewish, and West Indians, but a similar vacuum is left in the book with respect to minorities in Canada.

Mexico, Uruguay, and the Iberian Peninsula (primarily focused on Spain) are dealt with in terms of epidemiology and, rather weakly, cultural dynamics. Important in Spain are the high rates of alcoholism, migrant adaptation, and the burden on families of the “new chronic” mentally ill population after the poorly coordinated mental health reform of 1986.

The critical, often refreshing approach of the book is shown once more in the chapter on Germany where, applying to this industrial society the same standards as one would use on any Third World country, we discover that about half to one-third of the clergy believes in demonic possession and exorcism. Of course, the sad legacy of Nazism is briefly examined, revealing that much denial and avoidance apparently still persists among the medical profession.

The chapter on Hungary is a masterpiece on the epidemiology and dynamics of suicide, topics on which the authors, Buda and Furedi, are experts. The chapter on multicultural Australia, which reviews adequately the work of Krupinski and colleagues, should be of great interest to Canadians as we share the same British traditions and institutions, a recent multicultural immigrant community, and a native population.

The chapters on Egypt include references to the seminal contributions of Ahmed Okasha to the epidemiology and dynamic understanding of suicide, somatization, and the rituals of Zar. Including a chapter on Turkey, the book provides a good report on Islamic societies, never adequately treated in this type of volume until now. The chapter on Israel deals extensively with the issue of religion, intragroup variations, and posttraumatic stress disorder, referring to the comprehensive work of Dasberg on holocaust survivors and more recent civilian and military populations exposed to the trauma of war and armed conflict. South Korea, Singapore, and Bali (Indonesia) are Asiatic countries with epidemiological information limited to key issues: suicide, substance abuse, and culture-bound syndromes such as epidemic koro and hysteria, somatization, and illness behavior in various groups. In South Korea, a traditional country in the process of rapid modernization, the majority of people tend to use both traditional and modern therapies and remedies.

There are necessarily deficits or limitations to be found in a book of such ambitious scope. Russia or any country of the former Soviet Union, China, the United States of America, and Canada are not included. On various issues, however, the references to North America and China are plentiful, and one gets some idea of sociocultural variations in these regions. Dissociation is not listed in the subject index, although frequent references exist throughout the text when it deals with possession states and hysterical psychosis. Posttraumatic stress disorder, a major issue in refugee populations at present, has only a few references. There is not a single reference on psychopharmacology or biological studies among the various ethnic groups.

I would recommend this book to practitioners and trainees in psychiatry, psychology, and social work because the advances reported in the dynamic understanding of cultural groups will be helpful in clinical practice.

The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders

The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV Guidebook

Washington DC: American Psychiatric Press Inc; 1995. 501 p

When a book is described as “Essential,” the 1 st questions are “To whom?” and “For what?”. The answers to “for what” are right there in the preface, which states that the guidebook is a road map for DSM-IV, that it will annotate the DSM-IV diagnostic criteria so as to clarify them, that it will facilitate differential diagnosis, refer to historical context and controversies in the DSM system, and indicate some possible future directions for psychiatric classification. The authors add, “This guidebook contains just about everything we know about psychiatric diagnosis,” a statement that could be regarded as somewhat naive and, in the context in which it occurs, leading to the potential criticism that all they know is psychiatric diagnosis according to DSM-IV.

This is an amiable, easy-to-read publication, written clearly, and set out systematically. And yes, it does offer a helpful hand in negotiating DSM-land, it does flesh out DSM-IV s necessarily bald clinical criteria, and it does very briefly look at past trends and future possibilities. Yet, while it stresses the importance of differential diagnosis throughout, it frequently departs from a methodical approach and appeals to the physician’s clinical judgment as final arbitrator. While the intent is praiseworthy, at times this seems like a put-down of the DSM’s insistence on the value of systems and a rather weak-kneed concession to the “art” of psychiatry. Unfortunately, this air of faint-heartedness tends to crop up rather frequently.

Chapter 2 deals rather specifically with conceptual issues in psychiatric diagnosis. It begins by discussing the epistemology of the diagnostic endeavor and kindly reminds the reader that epistemology is the study of the nature of knowledge. Deep stuff, it seems, but what follows is a quick whisk through the philosophical concepts, historical and current, underlying the definition of mental disorders and the range of psychiatric nosology. Despite its superficiality, this chapter is a useful reminder to the practicing clinician that diagnosis should be a thoughtful process, uncluttered by preconception and informed by modern and relevant knowledge. The chapter also allows DSM-IV to preen itself by claiming that it never goes to conceptual extremes, and justifies the DSM process by emphasizing its preoccupation with classification.

No doubt classification is important, but it is not an end in itself. The authors do acknowledge that the increasingly refined definition of mental disorders more and more allows us to distinguish one illness from the other. Classification is simply the hat rack on which we hang our definitions of illness and is a convenience rather than a reality. If disorder A and disorder B are currently placed in the same classificatory niche, that is a mnemonic device and not usually a statement of shared pathology. One is left with the suspicion at times that the heavy emphasis on classification in DSM is not unallied to the importance of illness categories for fee-remuneration in the US medical system.

Chapter 3 describes how DSM-IV came into being, and this should be intriguing at least, enlightening (and perhaps reassuring) at best. What emerges is a bloodless account of the step-by-step progress to publication, with 1 or 2 nods on the side to links with ICD-10. Occasional hints emerge of the passions that must have been aroused around some of the more controversial issues, but mostly the authors are at pains to tell us (modestly) how much more methodical and scientific they were compared with those who worked on previous DSMs.

There is an apologia for getting rid of the term “organic” (as in organic mental disorders) and the authors’ argument about the increasing artificiality of differentiating organic and nonorganic mental disorders is a fair one. But, at this point, a distinct impression develops that they become uncomfortable when they begin to approach the rest of medicine. Some pride is expressed that DSM-IV has a representative list of medical diagnoses to which one can refer when making a diagnosis of mental disorders due to a general medical condition. But why, given that list, do we still have vascular dementia, dementia due to HIV disease, and dementia due to head trauma separately listed under “Delirium, Dementia and Amnesic and Other Cognitive Disorders”? The authors, avowed nondualists all (in the Cartesian sense), do not explain this dichotomy, which is not only of diagnostic habit, but of attitude on the part of psychiatry toward medicine. This is particularly disappointing since, on page 475, they look forward eagerly to the increasing influence of sophisticated research tools (shared with medicine), which will revolutionize psychiatric diagnosis.

Dr Frances and his coauthors say the book is a personal statement reflecting their own perspectives, but actually there is very little of the personal in it. Fairly rapidly it becomes another gloss on the use of DSM-IV, without any real perceptible novelty. Where the personal aspect does come in is in the index, which has only a meagre 45 references, 40 of which have at least one of the book’s authors as coauthor. The other 5 are by close associates of the authors. Does one detect a trace of inbreeding here?

In no way do I downplay the importance or influence of the DSM series in reforming and rationalizing psychiatric diagnosis. It wields enormous power in psychiatry in many parts of the world and increasingly overshadows the ICD series. Of course the DSM structure is very imperfect, nationalistic (even chauvinistic), a series of uncomfortable compromises, and an arena for psychiatric politicking. But I would rather have it than not because of its impetus toward more accurate, verifiable diagnosis, and its provision of a common language in which to carry this out.

However, the sheer mass of publications which emerge with each new DSM is increasingly overwhelming. Books official and unofficial submerge us, and now it seems that it is mandatory for every textbook to time a new edition to coincide with the latest DSM. The amount of repetition becomes mind-numbing, and I am sorry to say that The Essential Companion is much more repetitive than innovative. This is a pity when the authors have clearly been so close to the DSM-IV action.

So, to return to the question “To whom” is The Essential Companion essential? I cannot come up with a good answer except to say that if there are some psychiatrists out there whose training and clinical experience have been out of sync with modern diagnostic practice, this book might be a stress-free introduction and guide to the world of DSM-IV. Otherwise I have to say that you have read virtually all of it before.

The Schedules for Clinical Assessment in Neuropsychiatry

The Schedules for Clinical Assessment in Neuropsychiatry. Version 2

Wing JK, chief editor

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

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

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

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

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

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

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

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

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

Behavior Therapy in Psychiatric Hospitals

Behavior Therapy in Psychiatric Hospitals

PW Corrigan and RP Liberman, editors

New York NY: Springer Publishing Company; 1994.244 p

Corrigan and Liberman have pulled together an assorted collection of clinical reports on the application of behavior therapy techniques to patients in psychiatric hospitals and a few other settings. These settings include Liberman’s research unit at Camarillo, a forensic unit at Fulton State Hospital in Missouri, a unit at the Albuquerque VA Medical Center, a psychiatric hospital in Munich, Germany, an adolescent ward at a private California hospital, a behavioral medicine unit at the University Health Sciences Center in St Louis, the Therapeutic Contracting Program from McLean Hospital Harvard Medical School, a ward in a state hospital in New York City, and a unit at Tinley Park Mental Health Center in suburban Chicago.

There are also chapters, more general in focus, on implementing and maintaining programs and on selling them in the “Health Care Marketplace”. Most of the programs are token economics or variants thereof.

This book is well on the way toward anachronism. Focusing as it does on the impersonal and manipulative aspects of rewarding people for desired behaviors, it is very much out of step with the current increasing value being placed on patients’ rights and on patients’ active participation in their own treatment programs.

The accounts of programs tend to be anecdotal or didactic rather than research-oriented or scientific and, in that respect, there is really nothing here that supersedes Paul and Lentz’s (1977) definitive study of almost 20 years ago. However, the book can provide at least some food for thought for those working with long-hospitalized, chronic patients. These patients are now a highly selected group, since bed closures and fiscal restraints, and mental health reform have led us to discharge, and try to maintain outside the hospital, all but the very sickest patients. This group of patients provides an interesting challenge to those few remaining professionals

who work with them. Thus, besides making us aware that there is still a group of die-hards doing behavior therapy and even running token economies, albeit with increasing difficulty, Corrigan and Liberman’s book can make us aware of a few methods that can supplement the meagre, available therapy armamentarium for such patients. We must remember to use them in a more collaborative and less high-handed way, however.

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines

RF Prien and DS Robinson, editors

New York: Raven Press; 1994, 669 pages

This book reflects several decades of active development in psychotropic drug evaluation. The first modern, randomized, double-blind controlled trial of a psychotropic drug was conducted in the early 1950s (Schou’s evaluation of anti-manic lithium). Since the first methodological book on evaluation, edited by Cole and Gerrard (1959), several international statements of expectations have been published describing how psychotropic drug evaluations should take place. The present volume represents a culmination of the US national effort to establish guidelines for clinical evaluation of psychotropic drugs. Academic, clinical, pharmaceutical, regulatory and public health sectors, as well as several other disciplines contributed to this unfolding over the years.

This book was initiated in 1990 by the establishment of a task force on guidelines for clinical evaluation of psychotropic drugs; the American College of Neuropsychopharmacology (ACNP) and the National Institute of Mental Health (NIMH) collaborated. While the recent international volume (Grof et al 1993) focuses on education, the Prien and Robinson book appears more appropriate for experienced investigators. It often deals with issues and problems that would confound the novice looking for guidance in a maze of clinical trials.

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines is a resource that reflects the knowledge and experience of a wide group of US experts. The contributing authors number exactly 100, and the list reads almost like a “Who is Who” in US psychopharmacology. The book is as multi-authored as one could possibly imagine. An editorial group provided overall leadership. The ACNP taskforce advised on content and authorship of the book, and reviewed initial chapter drafts. Subsequent drafts were circulated to outside reviewers specializing in particular fields. Those of us foolish enough to engage in multi-authored writings will appreciate the challenges and the extensive nature of this process.

The book is divided into three main sections of increasing length. The first section, “Historical Perspectives”, describes the context of the book by providing a historical overview of clinical psychopharmacological research and guidelines. It also describes the decision-making process of establishing the efficacy and safety of psychotropics. The second section, “General Principles in the Evaluation of Psychotropic Drugs”, contains a broad outline of developments and issues of clinical methodology, and provides direction in research principles, study design and implementation, presentation of study findings, and ethical considerations involving drug evaluations. The third and most extensive section,”Specific Patient Groups: Application of General Methodologic Principles”, addresses methodologic developments and recommends clinical evaluation of specific diagnostic and age populations. This section builds on the ideas expounded in the preceding sections. A predecessor of this book, entitled Principles and Problems in Establishing the Efficacy of Psychotropic Agents and edited by Jerome, Levin, Burtrum, Schiele, Lorraine and Bouthelet, was published in 1971. The present book can be seen as an extensive revised and updated version of that first comprehensive volume, and it documents the advancement in the clinical trial methodology of psychopharmacology over the past 25 years.

This outstanding book will be essential for anyone actively involved in psychotropic drug trials. I found three parts particularly intriguing. First, the sections on ethical and legal considerations, which have become particularly heated during this time of political correctness, are of great interest. Second, the sections on maintenance (prophylactic) trials in general and in specific patient groups are also fascinating. If recent developments are indicators, there will be a major expansion in die area of testing, in particular because of the clinical need, and the widespread use of long-term treatments. Third, some of the innovative ideas that may improve and hasten the evaluation of new drugs are of interest. The desire for innovative approaches is driven by a new emphasis on cost containment as well as by the increasing importance awarded to treatment effectiveness, rather than relying solely on randomized, controlled trials for proof of efficacy.

It is clear that we are going through a stage of developing new methodology, and are questioning older ideas. It seems likely that in the future we will view the traditional, randomized, clinical trial as a necessary but insufficient technique in providing comprehensive evaluation. The Bayesian approach is becoming more common in clinical trials, with a de-emphasis on the frequentist approach. Increased attention is being paid to the problems of statistical analysis of longitudinal data, and the techniques of integrating information through meta-analysis. Researchers have become increasingly concerned about the limitations of generalized clinical trials in clinical practice. New strategies, envisaged in the World Health Organization (WHO) guidelines, are being proposed, ranging from the value of vigorously-collected observational data to the use of clinical databases and new strategies of cross design synthesis.

In a book of this size, with several contributing authors, it is to be expected that everything will not emerge perfectly, and that one will encounter allusions to the same issues a number of times (e.g., the complex placebo issue). It is also inevitable that, when a book is in preparation for several years, certain issues are dated by the time of publication. This is the case with the incorrect statement that the regulatory agencies in Europe do not require proof of prophylactic efficacy for new antidepressants. It is also of interest that the authors, although referring to the traditional phases of evaluation, have not structured the book following the four classical phases, as in previous books on clinical trials. Although this excellent book could not be useful to a psychopharmacological novice, it will be of much value to experienced investigators for years to come.