Posts Tagged ‘mood disorders’

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.

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications. CD-ROM

Stahl SM. New York: Cambridge University Press; 1998

ISBN 0-521-62892-X

This CD-ROM is an introductory textbook to the extraordinary complexities of basic and clinical neurochemistry pertaining to psychopharmacology. To make this information lucid, engaging and accessible requires a gifted communicator; Stephen Stahl is such a teacher, whose credentials as a researcher give authority to the concepts, facts and speculations he conveys so clearly.

Since this “book” is in CD-ROM format, any review must consider both the content and the format. The text is structured into 12 chapters and relies heavily on figures and diagrams to illustrate key concepts. The first 4 chapters focus on basic science and provide the foundation for the remaining 8 chapters. Stahl begins with the principles of chemical neurotransmission, including signaling, receptor occupancy, second messengers and co-transmission. He then explains receptors and enzymes as targets of drug action and further explores special properties of receptors in terms of subtypes, agonists and antagonists. He concludes the basic science section with a chapter on the interaction between disease and chemical neurotransmission.

The second section is clinically focused and briefly summarizes the biological bases of mood disorders, anxiety disorders and psychoses as a prelude to explaining and rationalizing the actions and benefits of psychiatric medications — as well as speculating on interventions in the future. Stahl concludes by considering cognitive enhancers, neuroprotective agents and drugs of abuse.

Any one of these basic science concepts, clinical disorders and psycho-pharmacological treatments could easily be the subject of a separate book — one that Stahl himself could probably write. It is a remarkable talent to synthesize, integrate and communicate clearly this wealth of information as effectively as he does. The text is unencumbered by references or wordy explanations. Advanced experts in various areas may sneer at oversimplification (a similar phenomenon occurs when someone makes psychotherapy fundamentals obvious and accessible), but this text is clearly not intended for them.

The ideal readership for this CD-ROM includes medical students, residents in psychiatry and allied health professions, and psychiatrists whose training concluded more than 5 years ago.

This text existed as conventional “hard copy” (what we nostalgically refer to as a “book”) before its current incarnation as a CD-ROM. What is the advantage of the CD-ROM format? It could be an expensive proposition unless you already own an IBM-compatible computer with a 486 or faster processor, or a Macintosh computer with System 7 or 8, at least 16 mB of RAM, Quicktime software, a sound card and speakers or headphones, and a 2 x or faster CD-ROM drive. It is really designed for Macintosh computers, and the author acknowledges that there may be some limitations in using the CD-ROM in an IBM-PC environment. Reading the CD-ROM involves pressing keys and jumping backward and forward between text and figures. The advantages lie in the use of animated diagrams to illustrate neurotransmission concepts, often accompanied by audio narration featuring Stahl himself.

While the animation reflects the elegant synthesis characteristic of the author, it seems rather primitive compared with the sophisticated computer graphics on children’s games. The narration is the weakest of Stahl’s skills: it adds nothing and requires a separate keystroke to activate, when simply reading a caption would be preferable.

Other textbooks on CD-ROM provide more opportunity to print excerpts and take notes on the computer screen. This CD-ROM lacks flexibility. With a book version, I could have scribbled in the margin or photocopied a diagram. In summary, this textbook is superb in terms of content, but the technology of presentation does not facilitate access or understanding. Reading the CD-ROM made me want to buy the book.

Psychiatric Comorbidity in Epilepsy

Psychiatric Comorbidity in Epilepsy: Basic Mechanisms, Diagnosis, and Treatment

H. Mc-Connell, Peter J. Snyder, editors

Washington (DC): American Psychiatric Press; 1998

ISBN 0-88048-853-0 (hardcover)

There is a fascinating and complex interrelation between psychiatric pathology and epilepsy. Historically, epilepsy was known as the “sacred” disease because of its alleged association with astrology, with the divine, and with demoniacal possession. Despite Hippocrates’ assertion that epilepsy “is no more divine nor more sacred than other diseases, but has a natural cause like other diseases,” these misconceptions continued until well into the 19th century, when the neuropathologic origins of epilepsy were identified.

However, the association between epilepsy and psychiatric illness did not cease when it was identified as a neurologic condition. People with epilepsy have an increased prevalence of both affective and schizophreniform disorders. Personality and adjustment disorders are common and seizures may be simulated by conversion states. Epilepsy also has profound socioeconomic implications for the sufferer. It is perhaps therefore the “psychosomatic” illness par excellence.

This book is a compendium of the psychiatric conditions associated with epilepsy. Its 12 chapters cover the historic, physiologic, pathologic, clinical and social aspects of epilepsy. There is an excellent chapter on the changing systems of classification of the epilepsies; the current international classification bears little resemblance to the systems used even 50 years ago. The advent of sophisticated investigative techniques for studying neuronal activity, such as EEG recordings and neuroimaging, has given this system a firm neuroanatomical basis, and has helped to integrate the neuroanatomical changes with the clinical seizure pattern.

There are excellent chapters on the neuropsychological assessment of patients with seizures, and on the mood disorders and psychoses associated with epilepsy. The latter chapter is of particular interest because recent developments have shown that there are lesions in the medial temporal structures of the brain in both epilepsy and schizophrenia. This etiologic overlap may explain not only the increased prevalence of schizophreniform psychoses in patients with epilepsy, but also suggests that there may be a neurophysiologic overlap at the neurotransmitter level between these seemingly disparate conditions.

Perhaps the 2 most useful chapters in the book are those on pharmacology. One reviews the behavioural effects of antiepileptic drugs, the other discusses the treatment of psychiatric disorders in patients with epilepsy. They provide an excellent state-of-the-art summary of the pharmacology of epilepsy and give many practical suggestions about the use of psychotropic agents and their effects on seizure threshold.

The book ends with 2 chapters on the “social” part of biopsychosocial aspect of epilepsy: one on family systems theory and the other, written by a man with epilepsy, entitled “Living with Epilepsy.” The latter is of special interest because the experiences he describes and the problems he raises are not dealt with elsewhere in the book. For example, he describes memory dysfunction, post ictal pain, social rejection and communication difficulties with his neurologists — experiences that are surely not unique to people with epilepsy. It would have rounded out the book if these consumer-driven issues had been dealt with in the clinical sections.

There are weaknesses in the book. The history of epilepsy is long and colourful and it is unfortunate that it is described here in a trite and cliche-ridden way. The chapter on diagnosis and treatment of nonepileptic seizures was superficial and unhelpful. It is puzzling why such seizures should be described in negative language when acceptable terms such as “conversion” or even “hysterical” seizures are available.

On the whole, however, this is a comprehensive, well structured and well referenced book. Each chapter ends with a conclusion that summarizes the main points in that chapter. I was very glad also to see

a uniform and consistent use of the term “people with epilepsy” rather than “epileptic” throughout the book. The word “epileptic” brands the sufferer in a pejorative manner and reinforces the very stigma we try to avoid. If only psychiatrists would similarly use the term “people with schizophrenia” rather than “schizophrenics”!

This book is highly recommended to psychiatrists, neurologists, neuropsychologists and others who see people with epilepsy in their practice.

Handbook of child psychiatry for primary care

Handbook of child psychiatry for primary care

B. Robertson

New York: Oxford University Press; 1997. 368 pp

ISBN 0-19-571372-9 (paper)

This is a well written, concise book about psychiatric disorders of children and adolescents. It is written for the primary care physician, but it would be useful to medical students and psychiatric residents. The author is a child psychiatrist and head of the department of psychiatry at the University of Cape Town Medical School in Cape Town, South Africa. His many research interests and extensive travel experience make him very well qualified to write this book.

Not only are the various disorders and their management described, but there is also a chapter on assessment and the management of psychosocial problems in general. Parent education and education about illness are emphasized and expensive management approaches (e.g., individual psychotherapy) are mentioned, even though these apply to only a small number of patients. The disorders covered included attention deficit disorder, mood disorders, anxiety disorders, eating and somatoform disorders, dissociative disorders and culture-bound disorders. The latter are specific to South Africa and the chapter is very short but interesting. The substance-related disorders are especially well presented. All chapters are up to date, which is a remarkable achievement for a book with a single author.

The appendices list DSM-IV diagnoses and the Global Assessment of Functioning for children, which are useful, and the bibliography is selective but recent.

There are, however, some contentious statements. For example, I do not think that family therapy needs 2 highly skilled therapists; many programs only have 1 therapist per family. And the assertion that group therapy is “not commonly being offered,” may apply in South Africa, where primary care physicians are not be trained in this modality, but does not apply in North America.

This book is attractively presented and can fit into a jacket pocket (11 cm X 18 cm). Overall, I would strongly recommend this book; it is germane to countries other than the author’s home of South Africa and it is competitively priced.

Concise Guide to Geriatric Psychiatry

Concise Guide to Geriatric Psychiatry, 2nd edition

Spar JE, La Rue A

Washington (DC): American Psychiatric Press; 1997. 326 pp with index

ISBN 0-88048-796-8 (paper)

Geriatric psychiatry is becoming an important psychiatric sub-specialty. The authors, James Spar, MD, and Asenath LaRue, PhD, from the University of California, Los Angeles and the University of Mexico, respectively, are experts in this burgeoning field. The first edition of their book, based on the DSM-III-R and published in 1990, provided a delightful, well-written, pocket-book-sized summary of practical information for psychiatrists, psychiatry residents and medical students working in a variety of treatment settings. It included information on mental health issues in old age, on normal aging and on the diagnosis and management of geropsychiatric disorders.

The second edition (based on the DSM-IV) is even better. It is 50% longer than the original and includes necessarily expanded sections on the differential diagnosis and psychopharmacology of mood disorders, an additional section on Alzheimer’s disease, and a thoughtful 30-page appendix of instruments (e.g., Mini Mental State Examination, Geriatric Depression Scale) commonly used for clinical assessment. Particularly useful are the numerous clinical vignettes throughout the text and the many tables and figures that summarize information.

Despite the strengths of this little book, it does have limitations. It is not evidence-based. It does not define the frontiers of knowledge or encourage critical thinking. Some statements or recommendations appear to be just opinions; for example, some readers might not agree that selective serotonin reuptake inhibitors (SSRIs) are first-line drugs for the treatment of depression. Finally, the lists of references and additional readings include articles published almost exclusively in US journals.

Limitations notwithstanding, this pithy paperback is the book of choice for psychiatry residents completing a mandatory rotation in geriatric psychiatry. It may also be of interest to general psychiatrists, geriatricians or family physicians who want a clear summary of the psychiatry of old age.

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.

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

GJ Siegel, editor

New York: Raven Press; 1994. 1080 p

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

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

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

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

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

Psychopharmacology: The Fourth Generation of Progress

Psychopharmacology: The Fourth Generation of Progress

FE Bloom, DJ Kupfer, editors

New York: Robin Press; 1995. 2002 p

This 2002-page monumental publication is the 4th in the series that started in 1968 with the book, Psychopharmacology: A Review of Progress 1957-1967. The 2 subsequent publications appeared at 10-year intervals and extensively reviewed progress in the decade before. This book, published less than 7 years after the last publication, reflects the highly accelerated pace of neuropsychopharmacology. As this volume is an official publication of the American College of Neuropsychopharmacology, its purpose (as for its 3 predecessors) is to redefine the scientific field for the College and to map the recent progress in neuropsychopharmacology.

The book is organized in 3 major sections: Preclinical, Clinical, and Special Topics. Part 1 (Preclinical) includes an introduction to preclinical neuropsychopharmacology by Floyd E Bloom, 5 chapters about critical analysis of methods, and 49 chapters detailing aspects of transmitter systems: amino acids, amines, peptides, and new neurotransmitters. Part 1 concludes with 9 chapters dealing with integrative concepts. Part 2 (Clinical) is similarly organized and starts with an introductory chapter to clinical neuropsychopharmacology by David J Kupfer, followed by 8 chapters about the critical analysis of methods. Psychiatric and age-related disorders are covered syndromally. The section includes mood disorders (19 chapters), schizophrenia (11 chapters), anxiety disorders (6 chapters), geriatric disorders (11 chapters), neurologic disorders (9 chapters), personality disorders (1 chapter), eating disorders (3 chapters), sleep disorders (1 chapter), childhood disorders (5 chapters), and substance abuse disorders (10 chapters). Part 2 concludes with 3 chapters about integrative concepts dealing with genetic strategies for multimodality research and methodological and statistical research. Part 3 (Special Topics) includes 6 chapters on diverse topics, namely, new drug design in psychopharmacology, ethical issues in genetic screening, the economics of psychotropic drug development, economic evaluations of drug treatment, ethnicity and culture in psychopharmacology, and psychopharmacology of violence and aggression.

This book is somewhat of a departure from previous volumes, not only by the expanded content and the long list of contributors (over 21 pages) but also by the way it is organized. The introductory chapter for every part provides an excellent and succinct overview that prepares the reader for the detailed and extensive information provided in the chapters that follow. The concluding integrative concepts of every major part provide excellent information, moving from individual systems as receptors and neurotransmitters to a more integrated brain functioning. The critical analysis of methods included in the preclinical and clinical sections provides useful information about the most current tools employed in the research approaches of the particular area.

The book provides extensive cross-referencing between preclinical and clinical topics, which allows readers at various levels of expertise to gain appreciation of the depth and complexity of the field. The extremely detailed preclinical section relates the rapid and extensive development in basic research that had been brought about by the major technological advances in recent years. The reader with less expertise in the field may find the complexities of basic research data difficult to follow at times, but this struggle can serve as a reminder for clinicians that brain behavior is an extremely complex subject. Nevertheless, it is important for clinicians and neuroscientists to appreciate such complexities. It is also equally important for researchers as well as educators in the field to attempt to bridge the gap between the new and exciting information overload and clinical practice. Though some of the major developments in the field are carried forward by basic scientists, it is encouraging to note the increased contributions from clinical researchers. This volume certainly makes an effort to connect the preclinical and clinical material in a way that makes it easier for the clinician to grasp the complex mechanisms and principles underlying drug actions.

Though the book contains 163 chapters written by a long list of contributors, the editors are to be complimented for assembling this vast amount of information by various contributors with different writing styles, maintaining general conformity with style, and allowing the information to flow easily. Obviously, this monumental work is not intended for the casual reader or the reader who needs a quick-fix on “how to,” but certainly it is a valuable tool for basic and clinician scientists. It is necessary reading for graduate students in neuropsychopharmacology. The book covers an extensive list of important topics, all of them relevant. The book would have benefitted, however, from more attention to a number of topics that can be grouped under the rubric of the social psychology of medication taking. After all, the development of the best medication is of little impact if our patients do not take it or if we lack the knowledge to make them take it. In addition, because a good base of knowledge about the interface of neuropsychopharmacology and other approaches, such as psychosocial contributions, is evolving, this textbook could have touched more specifically on this area of interest.

In conclusion, this book is valuable in the field of neuropharmacology and provides up-to-date information on the breadth and depth of the topic. In the practice of psychiatry, pharmacotherapy is only 1 part of the total management. In that sense, some emphasis on conceptual integrative approaches toward the treatment of psychiatric patients would have added value in the clinical section. Obviously, a major contribution of such magnitude cannot conceivably cover all the nuances of the field. I highly recommend this book, which represents a major and important endeavor; its editors are to be complimented. Given the current pace of neuroscience research developments, the next volume will likely be needed in the next few years. This raises the issue of the phenomenal demands on energy and time to publish such books and whether it is more practical between decades to rely on selected updates of certain topics that made significant progress in a short time.

Review of Psychiatry

Review of Psychiatry. Volume 14

JM Oldham and MB Riba, editors

Washington DC: American Psychiatric Press Inc; 1995. 846 p

This book is the latest in what is becoming an extended series of reviews of psychiatry published by the American Psychiatric Association. I imagine most readers are aware of this series. It continues in the tradition of producing comprehensive yet fairly succinct summaries in 5 areas of special importance. These are: “Substance Abuse,” “Psychiatric Disorders in Women and Women’s Health Care,” “Psychiatric Genetics,” “Cross-Cultural Psychiatry,” and “Sexual Disorders.”

The topics chosen reflect the burgeoning interests of the day. For instance, substance abuse has had a major impact on the mental health of psychiatric patients, to the extent that the “typical” psychiatric patient of the 1990s is a rather different person from his or her counterpart of the 1950s. There are many reasons for this, but the abuse of substances is a major one. Substance use affects the course of major disorders, and the appearance of major disorders predicts the use of many substances.

Yet until recently, relatively little was known about substance abuse, and that which was known was not widely disseminated. There is probably still a series of connected prejudices on the issue, comprising such myths as “substance abusers are all low-class, unbeatable individuals” and “nothing can be done in any case.” In fact, a great deal of useful information is known, and patients can be successfully treated, using combinations of pharmacotherapy and psychosocial therapies.

To be sure, the “war on drugs” is still being won by the drugs. And the issue of substance abuse raises large and important questions that go well beyond the treatment of the individual patient—how should the nation’s wealth be apportioned to individual treatment, prevention, research, or criminal investigation, for example.

But the 6 chapters on substance abuse in this volume will be of immeasurable practical help to clinicians. And practical help is readily available in most of the other chapters in this book. I point particularly to the chapters on “Trans-Cultural Psychiatry.” This is a field on which one often finds superficial writings and meaningless conceptual articles that seem to forget that the individual doctor-patient interaction is still central to the game. The 3 leading articles in this section on assessment, psychotherapy, and drug therapy in the transcultural context are replete with (I thought they had disappeared forever!) case examples of what the author is talking about. This is a welcome regression.

The section on psychiatric genetics is the only one that contains information which this reviewer finds increasingly difficult to follow—the details of chromosome structure and gene chemistry. However, once you wade through a few pages of technobabble, you come to some excellent pragmatic articles on schizophrenia, agoraphobia, and bipolar illness, and a most sensitive and instructive article on genetic counselling.

The section on sexual disorders comprises 2 areas that those of us with overly linear minds probably separate too often: the areas of normal sexuality and the paraphilias. If I had to choose one must-read article from this section, it would be Seagraves’ essay on how drugs affect sexual behavior. I select this one, because its contents will bear on almost half of the patients seen by any psychiatrist in practice.

Finally, the section on women’s mental health issues is broad, useful, and relatively nonpolitical. The article on psychotropic medication is again one of the most useful for just about anyone, while the article on new reproductive technologies will appeal to the needs of those specializing in this area.

To be sure, there are a couple of articles in this American collection that are relatively less relevant for Canadian readers, such as the description of the US federal government’s response to women’s issues, and what seems to me to be the excessive overconcern about an infinitesimal number of transracial adoptions in the United States. But the bulk of this book contains information that will be needed by most psychiatrists.

One must be warned that this is not a book one simply sits down and reads from cover to cover; only the reviewer has that chore. Rather, the way to use this book is as an encyclopedia, turning to the areas of interest and need when necessary.

I have been reading this series for many years, and have become accustomed to the high quality of the content and style of presentation by all its authors. What I particularly admire is that the editors have succeeded in almost eliminating duplication from this multiauthored collection, a feat that I would have guessed to be impossible.

This book, and its 13 predecessors, should be readily accessible to every psychiatrist in practice. Its material is minimally dated—some reference is made to articles published as late as 1993, and I have found from experience that this book tends to remain relevant even when it gets a bit out of date. To cite only one specific example, if you look back at Robert Post’s summary of the treatment of refractory mood disorders in 1990, you will still have an excellent approach to the subject, although several new drugs have been introduced since then.

To some extent, books are going out of style in North America. The Review of Psychiatry remains a stubborn example of a medium that refuses to die. It should be on the shelf of every psychiatrist, but shouldn’t stay on that shelf for too long at a time.

Headache and Depression: Serotonin Pathways as a Common Clue

Headache and Depression: Serotonin Pathways as a Common Clue

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

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

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

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

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

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

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

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

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

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