Posts Tagged ‘obsessive-compulsive disorder’

Les troubles anxieux

Les troubles anxieux : approche cognitive et comportementale

Ladouceur R, Marchand A, Bois-vert J, editors

Montreal: Gaetan Morin Editeur; 1999. 213 pp

ISBN 2-89105-736-8 (paper)

This book addresses anxiety disorders and their treatment with cognitive-behaviour therapy. Each of the 6 chapters, coauthored by 1 of the 3 main authors, covers a different anxiety disorder The authors (Robert Ladouceur of Université Laval, André Marchand of Université du Québec a Montréal and Jean-Marie Boisvert of Université Laval) are renowned researchers and have considerable international reputations. Several chapter coauthors are also well-known in their areas of expertise (e.g., Michel Dugas in generalized anxiety disorders, and Mark Freeston in obsessive-compulsive disorders, among others).

The introduction details the theories, the difference between normal and abnormal anxiety, the different causes of anxiety and finally, the outline of the book. The content of each chapter follows somewhat the same format: a review of diagnostic criteria, a clinical description, prevalence and precipitating factors and comorbidity. Then, evaluation and rating scales for each specific disorder are reviewed. Finally, theoretical models of etiology and therapeutic strategies are discussed.

The authors review the current literature well, and research avenues to be pursued are also elicited. Several chapters have extended clinical examples of therapeutic techniques and detail the objectives and content of therapeutic sessions.

Some chapters — for example the one on generalized anxiety disorder — also propose some very innovative models of explanation of the disorder. Obviously, these proposals are in accordance with cognitive-behavioural therapy theory.

This book is manifestly meant for mental health professionals who do cognitive-behaviour therapy with patients suffering from anxiety disorders. Psychologists, psychiatrists, family physicians, social workers and others who feel a need to better understand cognitive-behaviour therapy will also find this book very helpful.

Because it is written in French with a North American flavour, it will be popular with French-speaking Canadians and in Europe where several of the coauthors are very well known. It should be of interest to all psychiatrists and clinicians who see patients with anxiety disorders in consultations and are aware from the literature of cognitive-behavioural therapy’s encouraging results.

This is an excellent multiauthored book which reviews the up-to-date theories and therapeutic approaches for the treatment of anxiety disorders within a cognitive-behavioural framework. It is clearly written and readable by all health professionals. The format and presentation make it an agreeable work to consult. Finally, because it is so well documented, it could well become a very useful work of reference in the French literature.

A Primer of Supportive Psychotherapy

A Primer of Supportive Psychotherapy

Pinsker H

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

ISBN 0-88163-274-0 (cloth)

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

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

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

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

OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual

OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual

March JS, Mulle K

New York: The Guilford Press; 1998. 298 pp with index

ISBN 1-57230-242-9 (cloth)

This text is a good example of how clinical demand can prompt the synthesis and organization of a body of work into a useful guide for the practitioner. John March and Karen Mulle have extensive experience in the assessment and treatment of child and adolescent anxiety disorders in general, and obsessive-compulsive disorder in particular. Dr. March is particularly qualified to prepare this text, given that he is a co-author of the Expert Consensus Treatment Guidelines for Obsessive-Compulsive Disorder. The authors have prepared a treatment manual that guides the practitioner step-by-step through the cognitive-behavioural treatment of obsessive-compulsive disorder in children and adolescents.

The book is organized into 3 sections. The first provides a review of the various symptomatic presentations of obsessive-compulsive disorder and a description of the assessment protocol that the authors use in their program. The second provides a session-by-session guide to the cognitive-behavioural treatment of pediatric obsessive-compulsive disorder, with emphasis on treatment goals and means of evaluating outcomes. The third deals with tricky issues in pediatric obsessive-compulsive disorder, including common therapeutic roadblocks and difficult obsessive-compulsive disorder subtypes. It also includes suggestions for working with families and schools. In their appendices, the authors include copies of useful assessment materials as well as educational materials for parents and families.

Although this is a text on cognitive-behavioural treatment for obsessive-compulsive disorder, there are small nuggets of useful information on the pharmacological management of this disorder as well. The authors emphasize the importance of framing obsessive-compulsive disorder within a neurobehavioural framework from the outset. Another major strength of this text is that it reminds the clinician to consider the whole child or adolescent in the management of obsessive-compulsive disorder, recognizing that this disorder occurs in a context (home, school) that requires the coordinated efforts of many individuals (parents, teachers, therapist, patient). It views cognitive-behavioural treatment as one component of treatment that is often multi-modal.

Two minor shortcomings of this book are the limited presentation of empirical support for cognitive-behavioural treatment of obsessive-compulsive disorder in children and adolescents, and the generally child-oriented approach in describing techniques. Compared with the literature on adult obsessive-compulsive disorder, the controlled research on cognitive-behavioural treatment with children and adolescents is weak. Although the principal author is currently collaborating on a major trial comparing cognitive-behavioural treatment, medication, and combination treatment, results were not yet available for inclusion in this text. The authors do make a significant effort to include throughout the text comments on developmental considerations for the adaptation of their techniques to treating adolescents. Unfortunately, the majority of the scenarios and techniques presented target children.

Overall, this is a useful text for clinicians who are likely to see children with obsessive-compulsive disorder in their practice. It should not replace more comprehensive training in cognitive-behavioural treatment, but rather represents a focused application of these skills to a specific problem.

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Obsessive-Compulsive Disorder: Theory, Research and Treatment

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

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

ISBN 1-57230-335-2 (cloth)

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

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

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

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

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

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

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

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

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

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

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

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

Obsessive-Compulsive Disorder: The Facts

Obsessive-Compulsive Disorder: The Facts, 2nd edition

de Silva P, Rachman S

New York: Oxford University Press; 1998.141 pp with index

ISBN 0-19-262860-7 (paper)

This is a small book — only 141 pages in its second edition — and part of a series on a number of medical topics entitled “The Facts.” Other topics in this series include alcoholism, asthma, cancer, eating disorders, and kidney failure.

The authors are both psychologists who are well known to psychiatry and have extensive experience in the area of anxiety disorders, including obsessive-compulsive disorder.

The book is intended as an information source for patients who have obsessive-compulsive disorder and their families and friends, but it would also be very useful for workers in health care who need to have an overview of this disorder but are not directly involved in assessment and treatment. It would also be useful for family practitioners as a quick read.

The first chapter describes the classification of anxiety disorders and the diagnostic criteria used for obsessive-compulsive disorder. Unfortunately, the authors use the terms “neurotic disorder” and “neuroses,” which have many negative connotations and have not been used in the Diagnostic and Statistical Manual of Mental Disorders for many years. Beyond this initial bad start, the chapter goes on to include an excellent description of obsessions and compulsions with great attention to detail — explaining covert compulsions, resistance, distress and interference. Obsessions and compulsions of everyday life are also discussed. The detail reflects the authors’ behaviouristic background and would be extremely helpful for a patient and family when first engaging in cognitive behavioural therapy.

Subsequent chapters continue with a good description of clinical phenomena, including the relation of obsessive-compulsive disorder to other psychiatric disorders and the various ways obsessive-compulsive disorder can present, illustrated with several clinical vignettes. The impact on family, prevalence rates and cultural factors are also included.

Even considering the main purpose of the book, the section on etiology is very brief and superficial. The description of the psychoanalytic view of obsessive-compulsive disorder could have been deleted, as this is only of historical interest and could be confusing to a lay reader. More detail regarding the biological aspects of obsessive-compulsive disorder should have been included, as well as some information on how obsessive-compulsive disorder can be seen from an evolutionary perspective. This would have been helpful in easing the guilt that patients and family often have about the role they feel they may have played in the development of the illness.

The chapter on treatment heavily emphasizes behavioural therapy, reflecting the clinical background of the authors. Although this provides patients and families with information on an aspect of treatment that will require their active involvement, the brief discussion of drug treatments does not provide enough information and also implies that pharmacotherapy is a secondary aspect of treatment.

The penultimate chapter on assessment only briefly mentions the Yale Brown Obsessive Compulsive Scale, which is the one most commonly used in Canada, whereas it includes the complete Maudsley Obsessional Compulsive Inventory, which is useful but is not widely used. The Leyton Obsessional Inventory, also mentioned, is never used. All of this may serve to confuse patients who may see the book as authoritative and then wonder why these scales are absent from their assessment and treatment.

The final chapter on practical advice is good. However, the list of helpful organizations at the back of the book is very incomplete with respect to Canada; only 3 addresses from 3 provinces in eastern Canada are listed!

In conclusion, the book has some of the facts on obsessive-compulsive disorder, but not all. The description of clinical phenomena is excellent. The inclusion of a discussion of obsessive-compulsive disorder and pregnancy would have been useful, as would a treatment flow chart with more emphasis on biological treatment. Also, since the majority of cases of obsessive-compulsive disorder begin in childhood or early adolescence, a separate section on this area would have been useful. Such a section should include some comments on the known association between group A P-hemolytic streptococcal throat infections and the acute onset of obsessive-compulsive disorder in some cases.

This book is not the best self-help book for patients in Canada. There are others available that have more complete lists of helpful addresses and are more compatible with the clinical approach a Canadian psychiatrist would most likely take with respect to treatment. The suggested price of $28.50 also makes the book quite expensive, considering the small size and soft-cover format.

The strengths of the book are that it is well written, well organized and easy to read.

Schizotypy: Implications for Illness and Health

Schizotypy: Implications for Illness and Health

Claridge G, editor

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

ISBN 0-19-852353-X (cloth)

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

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

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

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

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

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

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

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

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

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

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

Dreaming and Other Involuntary Mentation

Dreaming and Other Involuntary Mentation: An Essay in Neuropsychiatry

Arthur W. Epstein. Madison (CT): International University Press; 1995

The author of this essay, Dr. Arthur Epstein, is emeritus professor of psychiatry and neurology at Tulane University of Louisiana in New Orleans, and director of the Tulane Psychoanalytic Program since 1977; he is also a past president of the Society of Biological Psychiatry and of the American Academy of Psychoanalysis. He has a major interest in neuropsychiatry and has paid attention in his research and practice to the biological basis, as well as the psychodynamic meaning, of dreaming and other involuntary (unconscious) mentation.

In this interesting short book, written in a sharp, direct, minimalistic literary style, he presents with great simplicity, clarity and brevity many complex, fundamental aspects of the brain and mind, and particularly the associative areas of the brain.

He makes the fundamental point that the mind works in “connectivity” — the sets of neuronal and dendritic connections permitting the associative areas of the brain to function and to act as the organic substratum for the many brain functions, including involuntary mentation such as dreaming. He elaborates on this point in sections on associative processes, showing their normal as well as pathological patterns, with clinical and laboratory examples from nominal aphasia and epileptic states, in which neuronal excessive discharge during dreaming presents the involuntary (i.e., unconscious, that could in part become conscious) mentation in the recurrent dream-epilepsy equivalence. Here again, he uses both laboratory and clinical examples of all-night sleep studies. He deals with many aspects of sleeping and dreaming, including REM sleep behaviour disorders, impaired modulation and narcolepsy. He goes on to consider dominant networks that produce imperative fetishistic and phobic ideas. In one chapter he deals with dominant networks in relation to the imperative ideas of obsessive-compulsive disorders, and in another he concentrates on the origin and transmission of imperative ideas. He ends with his thoughts on implications for psychodynamic science.

I enjoyed reading this book. Its content is very clearly and simply presented. In fact, by presenting in an interesting and instructive way complex phenomena that bridge brain, mind and several neuroscientific disciplines (neurology, psychodynamic psychiatry, and many aspects of neuroscience, including sleep research), with clinical and research examples, he has accomplished a major tour de force. This is a useful and instructive book for all who are involved in our disciplines. I thoroughly recommend it.

Multi-axial Classification of Child and Adolescent Psychiatric Disorders

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

World Health Organization

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

ISBN 0-521-58133-8 (cloth)

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

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

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

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

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

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

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

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

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

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

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

Clinical Child Neuropsychiatry

Clinical Child Neuropsychiatry

C Gillberg

New York: Cambridge University Press; 1995. 368 p

This reviewer was privileged to hear a remarkable presentation by Dr Christopher Gillberg, a Swedish child psychiatrist, in Australia in 1992. He was one of the invited plenary speakers at the International Association for the Scientific Study of Mental Deficiency at the Gold Coast Conference in 1992. He spoke clearly and precisely as he related a wealth of personal research about the underlying medical conditions leading to the autistic disorders. During the past 10 years, Dr Gillberg has become a preeminent world authority in the field of mental retardation and psychiatric disorder. This textbook confirms that his writing matches his memorable presentation in Australia. It is an encyclopedic distillation of not only the psychiatric aspects of mental retardation but also the organic factors involved in obsessional disorders, attentional disorders, language disorders, sleep and elimination disorders, and more. Even more surprising is his compilation of the existing knowledge on behavioral and physical phenotypes, which he correlates with genetic findings, a task not previously attempted to this reviewer’s knowledge.

With Gillberg’s inclusion of the psychiatric sequelae of traumatic brain injury in children, epilepsy, cerebral palsy, and brain tumors, along with their neurodevelopmental, neuropsychological, and laboratory workups, directors of child and adolescent psychiatry education, after reading this textbook, will likely have to insist on the inclusion of 6 months to a year of developmental pediatric and pediatric neurology in child psychiatry training in order to allow themselves to be called “Complete Child Psychiatrists”!

Although the Ontario Health Study indicates that the percentage prevalence of emotional and behavioral disorders in children and adolescents is in the double figures, Gillberg, in his chapter on epidemiology, states that up to 10% of children have neuropsychiatric disorders(the bulk of which manifest as attention deficit disorders). The importance of workup and diagnosis by trained clinical child psychiatrists is emphasized by such figures.

In this textbook, we are brought up to date with molecular genetics in diagnosing such conditions as fragile X syndrome, Prader-Willi syndrome, Angelman’s syndrome, neuroflbromatoses, Duchenne muscular dystrophy, and possibly Williams syndrome. Other background factors, such as temperament, prenatal, sociocultural, and familial factors are noted, and an excellent bibliography is provided for more detailed reviews.

A brief but significant chapter on normal development includes not only a practical table of milestones (useful for clinical inventory) but also a clear exposition of Baron-Cohen’s “Theory of Mind” and subsequent development of complex social interaction and empathy.

As would be expected from one of Gillberg’s primary areas of interest, the chapter on autism and “autism spectrum” disorders is excellent. It not only brings us up to date with DSM-IV definitions, but also it supports Lorna Wing’s thesis that there is doubtful specificity of “pure” Kanner autism. Instead, Gillberg proposes that there are a number of conditions that result in disorders of “empathy.” He makes a compelling argument against the current classification of pervasive developmental disorders. This is particularly supported when he lists 17 organic conditions that have been confirmed as producing the autism spectrum. The standardized neuropsychiatric assessment and relevant laboratory workups to detect these 17 conditions are outlined. Of particular importance and interest to child psychiatrists is his detailed review of the current state of knowledge of Asperger’s syndrome, including an outline of the controversy over classification and the long-term outcome for those suffering from this condition.

There is a surprising inclusion of anorexia nervosa in the chapter, which also links obsessive-compulsive disorders with tic disorders and Tourette’s syndrome. He outlines the hypothesis that anorexia nervosa is a final common pathway disorder including psychosocial, neurochemical, and local gastric factors with a minimal relationship to family dysfunction.

Gillberg makes a significant contribution to clinical diagnosis and treatment as well as future research potential by introducing the term “DAMP” disorders. This new umbrella term covering “Deficits in Attention, Motor Control and Perception” is much clearer than the alternative phrase, “Minimal Brain Dysfunction.” It was coined by Gillberg in 1983 and is now accepted by the Nordic consortium of child psychiatry. Given that attentional disorders, motor control disorders, hyperkinetic disorders, perceptual (reading and writing) disorders, and speech and language disorders overlap, this is a much-needed classification that is worthy of considerable scrutiny by the American Psychiatric Association and World Health Organization.

Another new term for this reviewer is “Jactatio capitis.” No, it is not a new paraphilia, but it has implications for those clinicians working with tic disorders and other repetitive rhythmic disorders. (To find out more, the reader is referred to Chapter 9.)

The longest chapter (70 pages) and the one filled with the most “meat” is entitled “Specific Syndromes Not Otherwise Referred To.” Here, Gillberg is at his most-knowledgeable best, compiling the prevalence, sex ratios, behavioral phenotypes, pathogenesis, diagnosis, workup, treatment, and outcome of congenital developmental syndromes. My only criticism of this chapter, and it is rather muted, is that the chapter could have included more pictures of the dysmorphic features of some of the syndromes. I suppose, however, that the knowledgeable reader should have a companion volume such as the Nyhan and Sakatis textbook, Diagnostic Recognition of Genetic Disease, on the shelf.

The psychopharmacology of child neuropsychiatric syndromes is complete, succinct, and up to date and draws heavily on the author’s former working relationship with Magda Campbell.

For his next edition (hopefully because of the importance of this textbook there will be many future editions), this reviewer would like to see expansion in the size of the specific syndrome chapter as well as an expansion on the psychiatric sequelae of and psychosocial intervention with traumatic brain injury, cerebral palsy, and epilepsy.

The textbook gains tremendous consistency from its single authorship. It is a major textbook, more comprehensive, detailed, and current than any other on developmental psychiatry. It, along with Levine and others’ 1983 textbook, Developmental-Behavioural Pediatrics, should be on the shelf of every child psychiatry resident, notwithstanding its price. It has fulfilled Gillberg’s goal of being “the first such compilation on clinical child neuropsychiatry, in which all the infancy, childhood or adolescent onset disorders in which mental, emotional and behavioural problems predominate . . . and for which biological factors . . . play a major . . . role are included.” Congratulations, Dr Gillberg!

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals

G Andrews, R Crino, C Hunt, L Lampe, and A Page

New York: Cambridge University Press; 1995.423 p

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals begins with a section entitled “How To Use This Unusual Book”. The warning is useful because this book is presented differently from most. It consists of 3 sections that are repeated for each anxiety disorder: first, a collection of relatively brief reviews of the presentation, aetiology and treatment of anxiety disorders; second, a series of brief therapists’ manuals; and third, a set of more extensive patient manuals. The authors and publishers generously give the reader permission to photocopy the patient manuals for repeated use. The authors are well-known clinician researchers working in Australia. The senior author, Gavin Andrews, has contributed widely to the anxiety disorder field for many years, particularly in issues of neurotic defense styles and the use of behavioral treatments for anxiety.

The brief reviews are adequate and represent a fairly succinct way of obtaining current information on anxiety disorders, largely from a cognitive-behavioral perspective. Despite this general perspective, issues relating to biological and aetiological theories, genetics, and drug treatments are expertly handled. The clinician guide to general treatment issues focusses on cognitive and behavioral approaches which may disappoint those with other therapeutic orientations, but help those looking for advice on how to deliver behavioral treatments in their own practices.

The book addresses each of the major anxiety disorder syndromes in turn, and provides the clinician with 5 structured manuals for the treatment of panic disorder and agoraphobia, social phobia, specific phobias, obsessive-compulsive disorder, and generalized anxiety disorder. Adjustment disorder and secondary anxiety are dealt with briefly without the manuals. The clinician manuals are useful guides to the step-wise treatments used in cognitive-behavioral therapy. The manual for panic and agoraphobia gives details of therapeutic tasks to be undertaken in each of 19 treatment sessions, and relates these steps to the patient manual consisting of 50 pages of information and exercises. Each of the other disorders is dealt with in similar fashion.

The patient manuals are rather repetitive and focus considerable attention on hyperventilation control and the use of relaxation. Appropriate attention is paid to the use of exposure methods and cognitive techniques. The patient manual for the treatment of obsessive-compulsive disorder is surprisingly short given the usual complexity of clinical cases of this disorder. One potential difficulty with the patient manuals is the level of reading skills necessary to understand them. With therapist help this will probably not be a problem, but the writing style of the 3 different sections varies less than expected.

This 423-page book sets out to tackle 3 large areas and it does so reasonably well. It cannot be all things to all anxiety sufferers, and there are other self-help manuals available that are more reader friendly. There are few sources for the clinician that combine, quite so conveniently, current information about the various anxiety disorders and their treatment. Andrews’ book can be recommended to clinicians looking for guidance on how to conduct cognitive-behavioral treatment. It is also a useful book for training junior colleagues, and I will use it in that setting. I expect that most clinicians who use this particular book and set of manuals will be reasonably satisfied, but they will probably want to add to their information base by turning to more comprehensive texts about the individual disorders.