Posts Tagged ‘mental illnesses’

Psychopharmacology

Psychopharmacology: The Third Generation of Progress

Edited by Herbert Y. Meltzer

New York, Raven Press, 1987. 1,824 pp.

The utility and desirability of Psychopharmacology: The Third Generation of Progress is attested to by the fact that it was the first book to be stolen from our newly established psychiatry library. This book is the third in a series, updated every decade since 1967, from the preeminent biological psychiatry organization in the United States, the American College of Neuropsychopharmacology (ACNP). This comprehensive review of clinical neuroscience was “trimmed” to 184 chapters by 350 authors and amounts to more than 1,800 pages.

For a book that is so large and cumbersome, relevant information on most topics in neuroscience is surprisingly accessible. Topics are presented as clusters of individual reviews covering specific interest areas rather than as a single comprehensive review chapter. Thus, an experienced clinician or researcher seeking an update on a specific topic, such as maintenance pharmacotherapy for schizophrenia, is likely to find a brief, focused review. In contrast, readers with limited psychiatry or neuroscience backgrounds may find that the magnitude of the text and its somewhat fragmented presentation style make information more difficult to integrate. For example, in order to learn about schizophrenia, the novice neuropsychiatrist must read two introductory chapters, at least four preclinical chapters, and 24 clinical chapters from over thirty authors. Although this mountain of information would appear to be daunting, I have found that the chapters are quite popular as review materials among second-year psychiatry residents.

Despite the excitement and interest that a book such as this generates, it suffers from some flaws that are characteristic of multi-authored texts. Some parts of the book, such as the section on neuroanatomic and neurochemical mechanisms, contain several excellent chapters but lack a central focus or clearly apparent organization. The scope of reviewed materials also varies widely between chapters. As an illustration of this problem, “animal models in psychiatry” is included in the section on “Biology of Depression,” a review of animal models is absent from the section on “Biology of Schizophrenia,” and two of the four chapters in the “Biology of Anxiety” section review animal models. Also, the quality of the chapters varies noticeably in this book. In contrast to many chapters written with depth and clarity, others appear sketchy or even poorly written.

Although generally skeptical about the utility of purchasing expensive scientific books that rapidly become outdated, I wanted to own this text in order to insure continued access to the many useful reviews that it contains. In addition, it is one of very few books that I recommend to psychiatry residents interested in clinical neuroscience. Despite its flaws, Psychopharmacology: The Third Generation of Progress is clearly an important contribution to neuroscience and psychiatry.

Chronic Mental Illness in Children and Adolescents

Chronic Mental Illness in Children and Adolescents

Edited by John G. Looney

Washington, American Psychiatric Press, Inc., 1988. 267 pp.

For many, the notion of chronic mental illness in children is hard to accept. Children, even emotionally disturbed children, usually engender a sense of optimism and hope in the future. For those who work in the fields of child welfare and child psychiatry, however, it is well known that there exists a fraction of children and adolescents whose disturbance is both severe and enduring. This book focuses on severely disturbed youngsters, describes these children, and illuminates their needs.

The book, with fifteen contributors, is an outgrowth of a national conference held in 1985 aimed at this same population. There are four major sections in the book and a total of thirteen chapters; each of the major sections addresses a particular aspect of the larger picture of child mental health services. Although the volume evidences some repetition, it is well organized; each chapter builds on previous chapters.

The first section deals with the nature and scope of the problem and moves nicely from the case examples of Chapter 1 to Chapter 2’s discussion of these children in the aggregate. Some readers may find the methods used in Chapter 3 to estimate the prevalence of severely emotionally disturbed children and adolescents from existing data a bit facile, but, given the state of the art of child psychiatric epidemiology, the estimates offered may not be far out of line. Another chapter in this section, written by Jane Knitzer, provides a lucid review of recent policy concerning this population and offers some ideas regarding pressing policy questions. The major theme of this section is that, as a group, severely emotionally disturbed children have needs that require careful treatment and planning.

Section two considers the role of the public and private sectors in the treatment and programmatic planning for severely disturbed children and adolescents. Two of the chapters in this section point out the continuity of care problem, which is compounded by the fragmented service system and the multiple treatment needs of these youngsters. The problem is described in Chapter 5, and a model for solving the problem is outlined in the last chapter of this section. Included in this section is an essay on private inpatient care. Unfortunately, this chapter describes long-term treatment of children and adolescents in a private psychiatric hospital, in contrast to the current trend, driven to a great extent by economic pressures, which is clearly toward brief hospitalization.

In the third section, special issues such as the training needs of mental health professionals, the value of family treatment with this population, and the importance of evaluative research to assess the effectiveness of various treatment programs are considered. Although the chapters in this section are not as unified as those in other sections of the book, each of these chapters is particularly strong.

The last section considers the policy and funding issues that require resolution in order to confront the needs of these children and adolescents. The first of the two chapters reiterates the need for a high degree of cooperation between public and private agencies to build an integrated system of care. The author, Donald Gair, returns to the notion of chronicity and cautions against building a system of care for these children. He warns that the definition of chronicity may result in the exclusion of troubled children from services. Rather than being exclusionary, the service system should focus on the tasks of childhood and provide interventions that are commensurate with developmental needs. In such a child development model, public schools would form the foundation of the service system, and psychiatry would have to relinquish the medical model to some extent. The final chapter outlines a strategy for constructing an organized system of care for children; here, John Looney, also the book’s editor, carefully maps out the barriers to building such a system and provides an agenda for further discussion and planning. This chapter could stand as a summary of the entire book.

This volume was intended for mental health professionals, though others interested in child development and public policy for children will also find the book worth reading. It does not consider in any detail the effect of current economic pressures on child psychiatric services — especially on inpatient services, which is an unfortunate omission because as inpatient stays decrease, there may well be an increase in referrals of more acutely disturbed children to residential and public facilities. Hence there is an urgent need to achieve coordination between public and private service sectors. The book effectively describes the difficulties confronting severely emotionally disturbed children and their families in human terms. The magnitude of the problem is estimated, and possible solutions are described — perhaps the major contribution of the volume. It goes beyond mere complaining about the fragmented service system that currently exists and offers an agenda for further discussion of this problem and its solution.

Vision and the Brain

Vision and the Brain: Organization of the Central Nervous System

Edited by Bernard Cohen and Ivan Bodis-Wollner

New York, Raven Press, 1990. 364 pp.

While experimenting with retinal ganglion cells of cats in 1966, Enroth-Cugell and Robson made one of the major breakthroughs of the century in vision research. They showed that these cells, capable of firing action potentials, are organized in relation to simple receptive fields on the retina centralis. This work pioneered the ongoing effort to understand how light-induced signals are graded, distributed, and processed from the retina to the thalamus to the cortex (and within the cortex), making visual function possible. Vision and the Brain: Organization of the Central Nervous System, edited by Bernard Cohen and Ivan Bodis-Wollner, attempts to bring the reader up to date on the latest research in this fascinating and dynamic field.

Vision and the Brain is volume 67 in a series published by the Association for Research in Nervous and Mental Disease. The organization has been sponsoring a new volume about once a year since 1920. Vision and the Brain is the product of 37 authors, and contains 161 illustrations. It is drawn from the authors’ original works and compiled from eighteen papers, each complete with a set of references. The volume is supplemented with an extensive index.

Vision and the Brain reads more like a textbook than a collection of many authors’ writings. In general, each chapter provides a clear and concise overview of the topic under consideration that the non-expert can easily understand and appreciate. This overview is followed by descriptions of potential domains of research as well as a summary of the authors’ pioneering work in the field. The book begins with a thorough examination of the functional and pharmacological organization of retinal cells. Here, much attention is given to the horizontal cell and the role of dopamine as a modulator of lateral inhibition — a phenomenon that aids in the visual recognition of edges. Next, the authors discuss the different transmitters mediating systems within the lateral geniculate nucleus, thus summarizing the pre-cortical processing of visual input.

Most of the book is dedicated to describing the complex interpretation of images at the level of the cortex. A summary of the encoding of objects in their shapes, color, movement, and depth is provided in an enjoyable chapter which explains some of the rationale behind optical illusions. This material is followed by a detailed analysis of neural velocity field computation, recognition of facial expression, motion processing, and the coordination of eye movement. An interesting discussion of the use of positron emission tomography to help map visual cortex functioning is also included.

For the neurology student, this book can be an amusing and up-to-date summary of visual processing systems. For the clinician, it also sheds light on the visual disturbances associated with such conditions as Parkinson’s disease, Altzheimer’s disease, and multiple sclerosis. For the vision researcher, it serves as a convenient collection of some of the field’s pioneering work. In any case, it comes with a hefty price tag.

Biology of Personality Disorders

Biology of Personality Disorders

Annual Review of Psychiatry series

Silk KR. Washington: American Psychiatric Press; 1998. 156 pp

ISBN 0-8804-883-52

This book, part of the Annual Review of Psychiatry series, is a multi-authored text comprising 5 chapters by recognized authorities in the field. The topic is of interest because of the increased activity in the area of personality disorders over the past decade and a half with respect to typology, research and new treatment approaches. This book focuses on research into the biological aspects of personality disorders over the last 10 years or so. As Silk points out in the Foreword, earlier studies of biological correlates of personality disorders did not lead to clear conclusions because of lack of appropriate separation between personality disorders and Axis I disorders. The “second-generation” studies have focused on the core negative traits of personality disorders (e.g., impulsivity, aggression, cognitive disturbances and affective lability, which cut across most personality disorders) and sought to understand their biological underpinnings.

The first 2 chapters of the book review and discuss the biological research in the field, including research strategies employed, the results of some of the most important studies and the implications for further development.

The first chapter, by Coccaro, reviews studies of neurotransmitters that are significant for personality functioning. The most important of these are serotonin and the cate-cholamines, including dopamine and norepinephrine. The studies are reviewed under categorical headings including cerebrospinal fluid (CSF) metabolite studies, pharmacological challenge studies, platelet receptors and DNA in polymorphism studies, etc. The studies consistently find an inverse relation between CSF 5-HIAA levels and impulsive-aggressive behaviour.

There is a smaller body of research into the role of acetylcholine and vasopressin, which shows that acetycholine does contribute to affective lability.

The second chapter, entitled “New Biological Research Strategies for Personality Disorders” by Siever and colleagues, complements the first. It reviews studies using a variety of recently developed strategies to study core traits of impulsivity, affective instability and cognitive dysfunction. The strategies vary from neuroendo-crine and cognitive studies that look at the antecedents of neuroendocrine and cognitive abnormalities found in personality disorders, to the use of imaging (positron-emission tomography, single-photon emission computed tomography, magnetic resonance imaging [MRI] and functional MRI) to study neuroanatomical correlates of personality dysfunctional traits such as impulsivity and aggression. There are fewer studies using candidate gene strategies. The author comments on the implications of the findings to date from these areas of investigation.

A particularly creative strategy was the linking of the study of trauma to personality disorders. Trauma has its biological impact on the hypothalamic-pituitary-adrenal (HPA) axis, but trauma is also a major etiologic factor in many personality disorders, including borderline personality disorder (BPD). Studies of the HPA axis changes, such as dexamethasone suppression test (DST) in patients with post-traumatic stress disorder, have been extended to personality disorders as BPD, with the DST pattern more closely resembling that in PTSD than that in mood disorders.

The third chapter focuses on Cloninger’s proposed 7-f actor model of personality, comprising temperamental factors such as harm avoidance, novelty seeking, reward dependence and persistence, and 3 character elements: self-directedness, cooperativeness and self-transcendence. Cloninger makes the case for the neurobiological basis of learning abilities that underlie temperamental traits by summarizing studies of the psychobiological correlates of these traits. He then puts forward a psychobiological learning model based on his review of the neuropharmacological, neuroanatomical and biochemical studies, and on studies of the phylogeny of learning abilities. He concludes by making a strong argument in support of the 7-factor model as a basis for understanding the various dimensions of personality disorder and even the diagnostic clusters. Although much of the material is quite technical, the use of tables and other visual aids is helpful in summarizing and reinforcing the material presented in the text.

The last 2 chapters are more application-oriented. The fourth chapter, by Links, is interesting because of the proposal of an outcome-based approach to the pharmacotherapy of personality disorders. Outcome indicators would be reduction in certain characteristic behaviour patterns, such as repetitive self-injury, that have been shown to have a biological basis. Other outcome indicators include quality of life. The author notes the shortcomings of the current conceptual models of personality disorder as a basis for developing a treatment rationale. The outcome-based model proposes specifically desirable functional outcomes of treatment and more systematic approaches to assessment of the efficacy of medication. This proposal is very much in keeping with the current evidence-based approach to medical practice.

In the final chapter, Paris assesses the significance of research for a biopsychosocial model of personality disorders. The author points out inconsistencies between theoretical assumptions underlying some research strategies and real-world observations, as well as the many confounding factors that complicate the search for one-to-one correlations between biological variables and particular personality traits. Taking a dimensional view of personality disorders as the pathological amplification of normal traits, the author discusses the complicated interaction of biological and environmental factors in producing personality disorders via the diathesis-stress model. He proposes 3 potential research directions: new drugs targeting personality traits, gene therapy, and new forms of psychotherapy based on better understanding of temperament.

Since much of the research on impulsivity and aggressiveness reviewed is common to conduct disorder and attention deficit hyper-activity disorder as well as anxiety disorders in children, one would have expected a discussion of the relation of these conditions to personality disorders in adults. Despite this lack, I found this book to contain more than anticipated. The material in the first 3 chapters was detailed and informative, and the last 2 chapters helped to make it practically relevant. One is left with a feeling that personality disorders are now more real, and that there is hope for more targeted treatment in the future. I certainly recommend it.

Problem Drinking

Problem Drinking, 3rd edition

Heather N, Robertson I

New York: Oxford University Press; 1997. 226 pages

ISBN 0-19-262861-5 (paper)

This book was somewhat of a challenge to review. Increasingly, recent empirical literature on substance-related cravings and relapses transcends the ideological boundaries and rivalries among 2 schools of thought: one characterizing addiction as a disease and one characterizing it as a learned behaviour. Recently, there has been increased recognition of the complementary nature of these approaches and a promise of improved patient outcome; Problem Drinking is a setback from this position. The authors, Nick Heather and Ian Robertson, are well-known exponents of a social-learning theory in the United Kingdom, although, surprisingly, their credentials are not mentioned in the book. They present a sustained argument that problem drinking is best regarded as a learned behavioural disorder rather than a disease.

The book is divided into 2 parts: the first is “unapologetically destructive” and reviews the current evidence countering the position that problem drinking is a disease. This is accomplished in 4 chapters, which account for 60% of the book. The first chapter reviews the changes in alcohol consumption in Britain and the influence of the temperance and prohibition movements on the disease concept. The second chapter presents a critical overview of selected literature in which alcoholism is looked upon as a physical shortcoming, a mental illness or psychopathology, or an acquired addiction or dependence. The possibility that recovering alcoholics can drink normally is addressed in the third chapter, and evidence derived from epidemiological surveys and laboratory investigations is presented. The fourth chapter outlines the potential detrimental effects of considering problem drinking a disease, including the licence to abrogate responsibility, the labelling of problem drinkers and the requirement for abstinence, and discusses the legal and preventive implications.

This literature review is a selective one. Of note is the limited reference to the neuroscientific research supporting the disease concept. Much work has been conducted on the notion of acquired addiction or dependence since the publication of works by E.M. Jellinek and G. Edwards. The findings of the current systematic research program, backed by neuroimaging and largely funded by National Institute on Drug Abuse, are not mentioned. Regarding the presence of a possible physical marker of vulnerability, the work of investigators such as Begleiter and Schuckit are omitted. Of particular interest to psychiatrists, the review of the evidence of alcoholism as a psychopathology is limited to the conclusions of Freud, Adler and Menninger. Has anybody made a more recent contribution? This portion of the book does not shy away from statements against phenomena such as “12 step hysteria” and “medical imperialism.” The perception of a conspiracy theory emerges from this book, where holders of the truth are ignored by the field at large, if not victimized.

Feeling somewhat chastised, one looks forward to the book’s briefer second part where the new paradigm is described: the social-learning theory. After a brief historical introduction, the applications of several types of learning theory to alcohol use are described. In classical conditioning, for example, new stimuli or “cues” evoke the desire to consume alcohol. Problem drinking arises when people interpret manifestations of withdrawal as cues to drink. Tolerance arises because of the homeostatic processes produced by the body to counter the action of drinking. Cue-exposure treatments owe their effectiveness in part to the extinction of conditional tolerance and withdrawal. Alcohol, by acting as either a positive or negative rein-forcer, also exposes a person to instrument learning. Community-reinforcement programs and aversive treatment harness this form of learning to promote abstinence. Higher forms of learning include modelling after, say, a parent’s behaviour, and self-regulation, lack of which prevents the person from stopping drinking. Higher cognitive processes, such as expectations, learned helplessness and the reasons for helplessness, also determine how alcohol is abused. Popular therapeutic approaches such as Marlatt’s relapse prevention and Beck’s cognitivenbehavioural therapy have focused on countering these effects.

The last chapter outlines other potential applications of social-learning theory: treatment programs, non-medical staffing, counselling and social policies. Even the results of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), which showed no difference between 12-step facilitation, cognitivenbehavioural coping skills and motivational enhancement therapy are interpreted in support of a more cost-effective social-learning theory. In fact, the media in North America have opted to perceive the results as a vindication of Alcoholics Anonymous!

My overall concern about this book is the deliberate effort to present evidence against the disease model and in support of the social-learning theory. In effect, most of the clinical programs I know have incorporated quite successfully therapeutic approaches from both schools of thought. Currently, moderate problem drinkers are likely to be advised by their physicians to set a “sensible drinking” goal, whereas heavy drinkers will be counselled to abstain. The spectrum of alcohol-related disorders is well recognized. Most therapists will not exclusively use 12-step facilitation, cognitivenbehavioural coping skills or motivational enhancement therapy, but will use each of these approaches at different phases of treatment. The case for polarization may not be as excessive as the authors purport, and the complementary nature of these approaches is not addressed.

In 1993, the Sobells published a book entitled Problem Drinkers. In the first 30 pages they discussed the lack of differentiation between problem drinkers and chronic alcoholics and for the rest of the book described useful treatment approaches for problem drinkers. I found this publication much more clinically relevant, but would recommend Heather and Robertson’s Problem Drinking to students who are eager to steep themselves in one of our field’s controversies. The price is appropriate for a library.

Neurobiology of Violence

Neurobiology of Violence

Volavka J

Washington (DC): American Psychiatric Press; 1995. 397 pp with index

ISBN 0-88048-343-4 (cloth)

Human behaviours are extremely complex; human aggression and violence toward other human beings are the most complex of them all. Neurobiology of Violence by Jan Volavka is an important contribution to the understanding of this most complex of human behaviours. If you are a practising clinician (psychiatrist, physician, psychologist or other mental health professional), I recommend that you order this book immediately. If you are a psychiatric resident preparing for the specialist examination, I recommend that you beg, borrow, steal or preferably buy a copy of this book, as it should be an essential part of your reading list.

In the preface the author talks about her imprisonment in a Nazi prison at the age of 10, an experience that inspired her to study and understand the roots of violence. In the introductory chapter she discusses the concepts of biological and environmental reductionism and the 3 models of the nature-versus-nurture debate: the either/or model, the combined model and the transactional model.

The first chapter deals with semantics: definitions of aggression, violence and destructive behaviour, and the difficulties with these definitions. The author goes on to define crime and criminality and points out the flaws in the studies of crime rates, incidence and prevalence; she also discusses instruments for assessing aggression and hostility. Thus, in chapter 1 the author primes the reader for a critical review of various research studies on violence. Chapters 2 and 3 review studies of aggression in animals and human beings, especially the role of neurotransmitters and hormones. Chapter 4 deals with neurological, neuropsychological and electro-physiological correlates of violence. Chapter 5 covers congenital and demographic factors in the causation of violence. Chapter 6 deals with developmental antecedents of violent behaviour, including early childhood factors such as inappropriate parenting, attention deficit with hyperactivity disorder and physiological traits that interfere with the child’s ability to learn the inhibition of antisocial and aggressive behaviour. Chapter 7 moves on to the clinical area of personality disorders and impulse control. Specific types of impulse control disorders, such as intermittent explosive disorder and pyromania, are explained. Relevant research on the serotonergic system, glucose metabolism and electrical brain activity are reviewed. Chapter 8 deals with the important area of violence and psychoactive substance abuse. The effects of both acute and chronic use of alcohol and cocaine and other drugs — alone and in combination with alcohol — are discussed. The review of research on the effects of cannabis is topical, as there is renewed discussion of the decriminalization of the use of marijuana, especially for medical purposes.

Chapter 9 is probably the most clinically relevant chapter in this book. It deals with the violent behaviour of persons with mental disorders outside the hospital setting. The relation between major mental disorders, arrest rates (criminal behaviour) and violence is discussed. The author reviews various studies and evaluates the strengths and weaknesses of their methodologies and, consequently, of their findings. The author also discusses the concepts of criminalization of mental illness and “psychiatricization” of criminal behaviour. Prediction of violence and risk assessment are examined with findings from relevant studies. The author compares and contrasts the concepts of prediction of violence using clinical methods and actuarial methods. (There is an appendix on “Statistical explanation of the actuarial method: Bayes decision.”) The author goes on to analyze critically the limited number of studies and points out the “failure of psychiatric prediction of dangerousness.” Clinicians face the task of predicting violence in individual patients daily, in hospitals, emergency department and other clinical settings. This chapter describes the strengths and weaknesses in this task. The author’s willingness to state her opinion on controversial and complex issues is very evident in her review and analysis of findings from various studies of the prediction of violence.

Chapter 10 deals with the violent behaviour of psychiatric patients in the hospital setting. Chapter 11 discusses the pharmacological treatment of violence and problems in conducting research in this area. The use of drugs — including antipsychotics, benzodiazepines, 6-adrenergic blockers, lithium, antidepressants and anxiolytics — is adequately covered. Chapter 12 is a summary of the subjects dealt with in the previous 11 chapters. There are also 60 pages of references of all the studies referred to in the main text. This is followed by an 28-page index that helps the reader to locate information readily.

The author’s writing style is very enjoyable, and her ability to synthesize information from a large number of studies and arrange them in a clinically relevant sequence is very evident. The author has made an excellent contribution through this important book on the study and understanding of violence.

This book deals only with the biological aspects of violence. Any reader who wishes to understand the other facets of violence must rely on books dealing with nonbiological factors.

I hope that every clinician will get a copy of this book, since dealing with and predicting violence in psychiatric patients is an unavoidable task and this book helps immensely in fulfilling that task as an informed and erudite practitioner.

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.

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.

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.

Effective Use of Group Therapy in Managed Care

Effective Use of Group Therapy in Managed Care

K. Roy MacKenzie

Washington DC: American Psychiatric Press, 182 pp., 1994.

Managed care is clearly an area of current and growing concern for psychiatrists. Even in jurisdictions where managed care itself is not currently part of the practice climate, the containment of cost and measurement of efficacy of treatments are central to health care planning. In some ways it is surprising that a book like this has not appeared earlier, as the face validity of group therapy as a cost containment measure seems obvious.

This book is one of the American Psychiatric Press’ Clinical Practice Series and, hence, is a relatively succinct outline of both the potential role of group therapy in managed care systems, and some of the possible forms that such treatment systems may take. Thus, the book includes chapters on the rationale for group psychotherapy in managed care and an overview of managed care and competition. It also includes several chapters on various forms of group therapy systems that have been devised for such varying clinical populations as the seriously mentally ill, personality disordered patients, depressed patients and individuals who have experienced loss. There is, however, nothing dealing specifically with patients at either end of the age spectrum — children and adolescents, or the elderly.

The book draws on contributions from an impressive group of authors, and is, therefore, able to reflect in many ways the state of the art in group therapy systems. The editor, Dr. Roy MacKenzie, is an experienced and well-known group therapist who has worked in both Canada and the United States, giving him a useful perspective on managed care. The other authors include such highly respected names as Dr. William Piper, Dr. Howard Kibel and Dr. Walter Stone.

The strength of the book and its greatest value lies in its ability to challenge the reader to think creatively about service delivery in psychiatry and psychotherapy. Anyone who is looking at the issue of providing effective and efficient psychotherapeutic interventions for a patient population would be well-advised to consult this book, both for its usefulness in presenting what has been done and, hence, stimulating one to think creatively about service delivery, and for the ways that several of the authors have attempted to measure the effectiveness of their work. If one is thinking of setting up a new treatment system or trying to assess the effectiveness of an ongoing psychotherapy service, the chapters in this book provide useful models.

Despite its claim on the cover to “provide a solid understanding of how group programs work,” this book is not a textbook of group therapy. It will not help someone learn how to provide effective group therapy. It will instead help an experienced therapist expand his or her horizons. It is not an extensive examination of the technique, but rather an excellent overview of the possibilities of group therapy.

Group psychotherapy is frequently treated as the poor cousin of individual psychotherapy. MacKenzie’s book goes some way to show that group therapy may, in fact, have an extremely important role to play in the future, as we are increasingly forced to examine the efficiency and effectiveness of our treatments in psychiatry.