Posts Tagged ‘psychiatric 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.

Acute Stroke Treatment

Acute Stroke Treatment

Bogovsslavsky J, editor

London (UK): Martin Dunitz; 1997. 304 pp with index

ISBN 1-85317-413-0 (cloth)

Few fields in medicine are undergoing a greater shift from despair to hope than stroke therapy. As the editor points out, the title of the book itself — Acute Stroke Treatment — would have been taken as a bad joke even just a few years ago. So what has changed? First, there is converging evidence of a therapeutic window between the onset of the neurological deficit and intervention. Second, stroke units have been demonstrated to be effective in reducing mortality, morbidity and length of hospital stay. Third, a US National Institutes of Health study has demonstrated that, if tissue plasminogen activator is given within 3 hours of a stroke in selected patients, 12% of them will have minimal or no neurological deficits compared with control patients.

This book addresses all the relevant areas of acute stroke treatment. It begins with a thoughtful overview of acute stroke management from around the world by Stephen M. Davis and colleagues, and continues with practical chapters on clinical, imaging, ultrasonography and cardiac evaluations. Chapters by Kogure and associates, and by Dolkara and Moskowitz, identify the experimental evidence for therapeutic targets for clinical stroke. Separate chapters address intensive care treatment of ischemic stroke, thrombolysis neuroprotection, gene therapy and surgery. Lawrence M. Brass contributes a conceptually valuable chapter on “Ideal Trials for Acute Stroke/’ and the book concludes with chapters on the treatment of intracerebral hemorrhage, subarachnoid hemorrhage, prophylactic neuroprotection for pretreatment of brain infarction and prevention of early recurrent stroke.

All the senior contributors to the chapters are recognized experts in their fields, and the emphasis is on clarity and pragmatism, a compliment to the editor. An obvious objection to a book such as this is that the field is moving so rapidly that many items in this book are already obsolete. However, concepts, approaches and basic knowledge do not change as quickly. Moreover, if there is a major advance, you will be sure to read it, hear it, or see it on the news. Even if you miss it, your patients will tell you about it. As a practical, comprehensive, yet succinct book, it can be highly recommended to all those dealing with acute stroke.

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.

Electroconvulsive Therapy

Electroconvulsive Therapy, 3rd Edition

Richard Abrams

New York: Oxford University Press; 1997. 382 pp

ISBN 0-19-510944-9

The dust jacket describes this textbook on electroconvulsive therapy (ECT) as “indispensable.” I agree. Now in its third edition, this book is unique in the field. It is written entirely by the author — a practising clinician with expertise in ECT, a scholar (this book has 73 pages of references; about 125 references have been added since the second edition in 1992) and a researcher whose contribution to the scientific literature goes back more than 30 years. Written in an engaging style, this book reflects the author’s intimate knowledge of an indispensable psychiatric treatment.

The chapter headings are the same as those in the second edition, but new material has been incorporated throughout (sometimes with new subheadings). The result is a refined and up-to-date disquisition on a complex and multifaceted subject. I recommend it for psychiatrists — particularly those who prescribe or administer ECT, for residents, for clinical psychologists and for anyone else with clinical or research interests in ECT. Supplemented by some recent research papers, this book would provide an ideal structure on which to base a course on ECT for residents. With such a knowledge base complementing supervised experience in the administration of ECT, a trainee would quickly acquire the expertise needed to deliver ECT.

Despite the favourable overall impression the book makes, there are some minor points with which one might reasonably take issue. For example, the advice to use ECT before drugs to treat pregnant women (page 29) seems unbalanced, especially in view of recent studies showing the safety of a number of medications, even during the first trimester. Although there is certainly a place for the use of ECT during pregnancy, there is also a place for the judicious use of psychoactive medication. Another point of contention is the statement that “despite manufacturers’ claims, no significant progress in the pharmacological treatment of major depression has occurred since the introduction of imipramine in 1958″ (page 9), which is made to support the continued use of ECT. In fact, there has been considerable progress in this area, and indeed the author does go on to mention lithium augmentation of tricyclic antidepressants (page 16). This style of making strong, unequivocal statements at least lets the reader know where the author stands and should, in fact, make it easier for critical readers to draw their own conclusions.

The book begins with the history of ECT and then reviews studies on efficacy, including those employing a sham ECT control group. The third chapter deals with predictors of successful outcome, and the fourth reviews the physiology of ECT. A later chapter on the high-risk patient will be very useful to practitioners considering ECT for severely depressed patients who have had a recent stroke, myocardial infarction or other serious medical problem, and who may also be on more than one medication. This chapter, supplemented by a MEDLINE search, will help the clinician make the best treatment decision in such cases.

There is a chapter devoted to the ECT stimulus, a critical variable affecting the response to treatment. Another chapter reviews the issue of unilateral treatment. The author concludes that high-dose (i.e., several times seizure threshold) right unilateral ECT should generally be the method of choice, at least initially. This recommendation may indeed improve the general standard of ECT, but the practitioner should also consider alternative electrode placements and levels of stimulation. Some patients may receive excessive doses with the high-dose unilateral approach. Of course this is an evolving area, and clinicians administering ECT must be aware of the issues regarding electrode placement and stimulus level when they make treatment decisions. They must also take into account side effects and clinical response as the series of ECT progresses.

Two chapters comprehensively cover the technique of ECT, and another covers the issue of memory and cognitive functioning after ECT (and contains descriptions of the important studies in the area). In the chapter on neurochemical correlates, Dr. Abrams concludes that “modern ECT researchers, regardless of their species of predilection, do not have any more of a clue about the relation between brain biological events and treatment response in ECT than they did when the first edition of this book was published — which is to say, none at all. Moreover, modern theories of the action of ECT — even as formulated by sophisticated investigators with impeccable credentials — have not surpassed in conceptual elegance the 18th century claim that things burned because they contained phlogiston; “ECT awaits its Lavoisier” (page 268). Thus there is plenty of scope for further research, but new researchers would be wise to understand the history of basic research in this field, particularly animal-based research, before embarking on their own.

The last chapter is on patients’ attitudes, legal-regulatory issues and informed consent. It is of interest that the history of ECT regulation in the US includes a 1982 ordinance, approved in a referendum by the citizens of Berkeley, California, that made the administration of ECT in city hospitals a crime punishable by a fine, 6 months in prison, or both! (The regulation was later reversed by a court decision on a technical point of law.) ECT continues to be a controversial treatment, despite its safety and proven efficacy. Perhaps because of its safety, ECT is surprisingly unlikely to result in malpractice claims. The best protection against the minimal risk of complaints or litigation is good clinical practice and fully informed consent. A sample consent form is presented in the appendix.

Much refined over the years, ECT will continue to be an important part of our therapeutic armamentarium in the foreseeable future. Apart from the mechanism of action of ECT, which remains an intriguing mystery, other promising areas for research include magneto-convulsive therapy (with induction of electrical currents by magnetic fields), new approaches to the control of ECT-induced increases in pulse and blood pressure, effects of bifrontal ECT on autobiographical memory, maintenance ECT (which appears to be increasingly prescribed) and stimulus variables.

This comprehensive review of a complex and sometimes controversial topic by one of the leading researchers in the field is highly recommended for both the clinician and researcher.

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.

The Maudsley Handbook of Practical Psychiatry

The Maudsley Handbook of Practical Psychiatry, 3rd edition

D. Goldberg, editor

New York: Oxford University Press; 1997

ISBN 0192628534 (hard cover)

Often when residents begin training in psychiatry there is a great deal of anxiety, particularly related to the first on-call experience. Most training in medical school focuses on the skills used to take patient histories and conduct medical examinations; these need to be modified when dealing with psychiatric patients.

Residents who have been comfortable with the medical model are frequently unsure about how to elicit information from patients with psychiatric difficulties. And most introductory psychiatry textbooks contain a great deal of factual information but do not provide practical advice. The widely used Synopsis of the Comprehensive Textbook of Psychiatry by Kaplan and Saddock is an example of a work that began as a condensed version of a larger textbook but has grown to such a size that there will soon be a need for a synopsis of the Synopsis of the Comprehensive Textbook.

In the Maudsley Handbook of Practical Psychiatry, David Goldberg, director of medical education at the Bethlehem Maudsley NHS Trust in London, has attempted to provide a comprehensive yet accessible introductory textbook for residents as they begin training. The book was developed in consultation with staff psychiatrists and house officers from the Maudsley to ensure that the book meets the needs of house officers and residents. It attempts to provide a comprehensive guide to psychiatric and neuropsychiatric examinations and guidelines for the clinical management of common psychiatric presentations in the emergency setting and in the early phases of treatment. It is meant to be a guide for doctors beginning their training in psychiatry and for those preparing for professional examinations, and although written in the United Kingdom, is intended to be used elsewhere.

The structure of the book reflects these objectives. There is a section on the psychiatric interview and assessment, which includes the mental status examination as well as some aspects of neuropsychiatric assessment. The section on early treatment is less extensive and focuses primarily on the initial stages of management. There are also sections on referring patients to specialists and on the medicolegal issues related to psychiatry in the UK.

The most valuable section of the book is on interview and assessment; it provides practical guidelines for the assessment of children, adults and geriatric patients. Although written for the beginning trainee, a review of this section would be valuable for residents preparing for their oral examinations. There are well-written discussions of difficult situations in the interview setting, and of issues such as gifts, disinhibited patients, violence and sexual involvement with patients.

The issue of false memory and repressed memory is certainly a controversial one in the field of psychiatry. This handbook provides one of the better overviews of this area, discussing the evidence for repressed memory and for concerns about false memory. Practical discussions about the impact of these issues on the psychiatric interview are clear, as are discussions of cross-cultural issues and their impact on the psychiatric assessment.

Unfortunately, other sections of the book are not as helpful. The sections on medico-legal issues are relevant largely to the UK. Although there is some interesting discussion of such things as consent and hospitalization, these are presented within the context of UK laws rather than in terms of general principles. The section on referral is largely unhelpful in the Canadian context; many of the suggested indications for specialist referral are in fact issues that residents are directly involved with.

Because drug therapy evolves so rapidly, by the time a book is in print, aspects of it are already out of date. This fact has limited the usefulness of the section on early treatment. For example, haloperidol is recommended for patients who present with acute psychosis, and for patients who are unresponsive, treatment with chlorpromazine and clozapine is recommended. Obviously, this does not take into account the impact of newer atypical antipsychotic agents on the management of patients in the acute treatment setting or in first-episode psychoses. There is even less discussion of medication use, probably because the goal of the book is to focus on early management, the assumption being that residents will discuss the initiation of such treatments as antidepressant medication with a staff psychiatrist. In many cases the treatment plans outlined are general, probably insufficient to allay the anxiety of a beginning resident, and lack sufficient complexity to be of use to a senior resident.

The final difficulty I had with this book is related to one of its strengths. As noted above, there is an unfortunate tendency in the medical field for handbooks and synopses to rapidly balloon into tomes large enough that no hand could easily encircle their girth. The Maudsley Handbook is in fact a book that could slip quite comfortably into the pocket of a lab coat. Because of that, however, the layout is very tight and the margins are small. This makes it difficult to find things quickly when leafing through it. Breaks are not obvious and sections blend together.

The Maudsley Handbook is, I believe, a valuable introductory handbook in terms of its discussion of the psychiatric interview and assessment. For this reason alone I would recommend it for beginning residents and those preparing for their oral examinations. It does not, however, live up to its billing as a provider of extensive and practical management guidelines for a variety of psychiatric conditions, and is limited by the fact that it is written primarily for the UK audience, despite its claim to do otherwise.

The Neuropsychiatry of Limbic and Subcortical Disorders

The Neuropsychiatry of Limbic and Subcortical Disorders

Salloway S, Malloy P, Cummings JL, editors

Washington (DC): American Psychiatric Press; 1997. 217 pp with index

ISBN 0-88048-942-1 (cloth)

The limbic system is a topic of considerable interest to both psychiatrists and neurologists. For biologically oriented clinicians, one can barely go a week without encountering some reference to a limbic disorder. The explosion of information about the interconnectedness of various brain regions is forcing both practising clinicians and neuroscientists to grapple with all brain regions, not just a favorite few. Inevitably, one is confronted with the need to understand the function of the limbic system. The definition of the limbic system has steadily broadened over time to include not just the medial circuit of Papez, but structures that are functionally associated with it. In common usage then, the term “limbic system” speaks to a set of cognitive functions; these functions are subserved by a network of cortical and subcortical structures.

In this spirit, The Neuropsychiatry of Limbic and Subcortical Disorders represents a snapshot of the state of knowledge of the limbic system. This book expands on the summer 1997 special issue of The journal of Neuropsychiatry and Clinical Neurosciences on the same topic. Published by the American Psychiatric Press, it is a high-quality book at a reasonable price, with many colour figures and photomicrographs.

This book is not an easy introduction to the anatomy and function of the limbic system. As the editors state in their introduction, “The essays in the volume cover a broad range of basic and clinical material at various levels of difficulty. … Some of the chapters present complex material requiring careful study and perhaps a second reading.” This is not an understatement. The book is divided into 2 sections: Anatomy and Neurochemistry, and Clinical Syndromes. It is the first, more technical section that presents the most difficult material. For neuroscientists familiar with the terminology, these chapters represent an excellent resource. They are good summaries of the anatomical literature with extensive references. Most chapters have 50 to 100 well-selected references, though a few contain up to 300. There is an abundance of photomicrographs, many of which have been previously published and retain an alphabet soup of anatomical abbreviations. This may present a problem, primarily to the student of behaviour wanting to learn more about the neural substrates.

If the anatomy section suffers from over-inclusion of information, then the clinical section suffers from a lack of rigour, and must be taken as hypothetical in many cases. There are interesting ideas here, and the authors have put forth several theories regarding the pathology of syndromes including temporal lobe epilepsy, emotional experience, recovered memory and religious experience.

While many of the chapters focus purely on the anatomical or clinical aspects of the limbic system, a few successfully link anatomy and function. The chapter entitled “Neurobiology of Fear Responses,” by Michael Davis, is a particularly cogent exposition of the role of the amygdala in fear. This chapter, appropriately positioned between the 2 major sections, introduces concepts such as classical conditioning, and outlines the evidence from lesion and excitation studies for the amgydala’s function. It is accessible to both anatomists and behaviourists. The chapter entitled “The Neurobiology of Emotional Experience,” by Kenneth Heilman, lucidly outlines several theories of emotion, ultimately arriving at the modular theory. One version of the modular theory states that emotions are mediated by anatomically distributed modular networks, and it is the relative activation of these modules that gives rise to the variety of human emotion. The location of the modules, of course, overlaps with the limbic system. The chapter entitled “Limbic-Cortical Dysregulation,” by Helen Mayberg, is an excellent exposition of a theory of the functional organization of medial cortical and limbic structures. This theory, based largely on human functional imaging (positron emission tomography and functional magnetic resonance imaging), is quite successful in unifying often contradictory studies regarding cingulate function. Finally, the chapter by Koob and Nestler entitled “The Neurobiology of Drug Addiction” is a good summary of the neural substrates that underlie reward behaviour, and how drugs of abuse affect them.

All of the authors in this book have published extensively in their fields. Consequently, most of the material has appeared in other review articles. Nevertheless, it is convenient to have the information all in one place, together with the colour reproductions.

In a book that juxtaposes both anatomical and syndromic chapters, it becomes painfully obvious that our knowledge of brain wiring is fast outpacing our ability to describe behaviour. A great deal is known about connectivity, neurotransmitters and gene expression, but how can these be related to only a crude description of human experience? Saver and Rabin, in their chapter on religious experience, offer several convincing descriptions that would suggest that the mystical quality of a religious experience is a manifestation of limbic activity, if not outright seizure activity. While quite reductionist, it may even be true, but something is lost in the characterization of the experience. It is no coincidence that virtually every work of fiction is fundamentally concerned with “limbic function.” The conclusions of all classical tragedies are known — it is the human experience that captures our interest. When speaking about the function of the limbic system, one quickly realizes that the putative functions, emotion, memory and motivation, are difficult to describe, let alone quantify — hence, an unlimited supply of literature. Unlike other cognitive functions such as perception, language and motor behaviour, these limbic processes do not lend themselves easily to experimentation.

Are these processes unquantifiable? Perhaps the language is wrong. For example, anxiety is an emotion variously localized to the limbic system. One can go to great lengths using different rating scales to quantify the severity of anxiety, but ultimately one relies upon individual interpretation of crude descriptions. What if an emotion like anxiety were compacted to a measure of probability? For example, “I feel like I’m going to die,” represents the assignment of a non-zero probability to the outcome of death. While the individual may know death is unlikely, it nevertheless creates a situation of uncertainty: “I know I won’t die, but then again, what if I do?” Measures of uncertainty, while not in the usual parlance of emotion, do lend themselves to quantification, and ultimately correlation with neural activity. Perhaps it is time for a shift in the description of limbic behaviour. Only when these phenomena are accurately described will we be able to relate them to brain function and dysfunction.

Brain Repair

Brain Repair

Donald G. Stein, Simon Brailowsky, Bruno Will

New York: Oxford University Press; 1995. 156 pp. with index

ISBN 0-19-511918-5

In the 16th century, Theofrastus Bombastus Paracelsus openly burned the works of Galen because they had become church dogma and thus had a paralyzing effect upon progress. By approximation, this is what Stein, Brailowsky and Will have done to the neurophysiological concepts we all learned in medical schools: that, once damaged, the neurons in the brain and spinal cord do not regenerate. In 10 chapters and an enlightening epilogue, these 3 prominent neuroscientists have marshalled a vast accumulation of knowledge, starting with Ramon y Cajal’s pessimism on the issue at the turn of the centure and continuing to the sophisticated research strategies of our times. This book should be on the “must-have” list of anyone interested in biological psychiatry.

The 140 pages of text, plus notes, references and indices, are printed in fairly small, uncomfortable-to-read type and densely packed pages, void of any illustrations or graphics. However, the visual style, reminiscent of that in Scientific American, is eminently clear and simple.

Brain injury is justly portrayed as a major public health problem. The term takes in not only traumatic brain lesions but also Parkinson’s and Alzheimer’s diseases and all other conditions that damage a sizeable number of nerve cells. The authors emphasize neural plasticity, its intricacies and, in the past, its poorly understood peculiarities. This is the epicentre of the book. Stein, Brailowsky and Will confidently get the reader to walk through the bridge of the successive epoches, as the idea has bounced from one research group to another. The authors highlight that, following the description of the Wallerian degeneration and chromatolysis, the first observation hinting at possible neuronal regeneration has been the discovery of the collateral sprouting: a spontaneous, seemingly purposeless propagation of axonal tangles. These cellular proliferations, called “neurites,” were regarded in the past by many neurologists as a mere nuisance. But further research found them potentially useful. Rita Levi-Montalcini was able to enhance or inhibit the development of these cellular proliferations by various neurotrophic factors. Franz Hefti’s discovery with regard to Alzheimer’s disease — the remarkable neuronal descruction occurring in the nucleus basalis Meynert, diagonal band of Broca and medial septum — is captioned, indicating that different brain parts do require diverse types of growth factors. The work of Anders Bjorklund, Fred Gage and Donald Stein is discussed, and the exploration of the specificity of trophic factors in the work of Carl Cotman is summarized. The now-classic research of J.R. McWilliams and Gary Lynch on hippocampal lesions and memory is mentioned, and the outcome of the serial lesion studies is abridged.

This leads the authors to the section on therapy, in which they outline the lack of immune reactions and thus the absence of tissue rejection in the cerebrum. The idea of embryonic brain-tissue transplantation to relieve symptoms is considered. The first cell transplants in cases of human Parkinson’s disease were performed in Mexico and Sweden. Eric-Olaf Backhand’s work — transplanting dopamine-producing cells from the patientis own adrenal glands — circumvented the objections of anti-abortion groups. Monkey-to-human tissue transplant results are also elaborated. A great deal of space is spent discussing the fascinating issue of how sex-specific hormones influence brain plasticity and the transplantation process. The higher efficacy of brain tissue from female donors is emphasized, a finding which, as Brian Kolb pointed out, may well be a mixed benefit because it may result in excess tissue production. Recent results of Patricia Goldman-Rakic’s work investigating prefrontal lesions in infant animals are presented in an interesting way. Different treatment strategies, the adverse role of the free radicals (unbound hydrogen, oxygen and iron molecules), lipid peroxidation and the beneficial effects of antioxidants are contrasted with the deleterious influence of sedation and the extensive use of benzodiazepines in brain-injury cases.

Preventive measures are also elaborated. Some of these reach far back, all the way to Donald Hebb’s environmental-deprivation experiments, conducted in the 1950s, and the venerable, classic research of Mark Rosenzweig and Bruno Will on the “enriched milieu,” with its beneficial effects on nerve-growth factor and other parameters of brain development. Similarly, the book discusses Michael Gazzaninga and Joseph Zihl’s findings on the positive effects of mental training and study sessions on animals with brain injuries.

It is impossible to ferret out all of the details of this useful little book in a brief review. There are no final answers in this work, but no such answers are expected in any scientific writing. At the price of $19.50, as a summation of major research work in the last 50 years, this book is a bargain.

The only misgiving I have is the inelegant title, Brain Repair. Somehow it reminds me of those utilitarian books that discuss the finesse of mending ruptured bicycle tires. Never mind; buy it.

Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

Philadelphia: WB Saunders; 1997. 509 pp. with index

ISBN 0-7216-5749-4

This book represents the state of the art in childhood psychopharmacology. Well written and capturing the highest level of existing evidence in the field, it serves as a reference text as well as an instructive how-to manual for those practising childhood psychopharmacology.

The text is organized into five sections. Section 1 is very brief and introduces the book by outlining the move toward empiricism in child and adolescent psychopharmacology, specifically, and childhood psychiatric disorders, generally. A broad clinical model is emphasized, to bring the science of the controlled experimental study into the realm of the clinical environment by combining medication with other empirical interventions.

Section 2 deals with baseline assessment before beginning psychopharmacological treatment. The section begins with general issues and then moves to more specific assessment, both in terms of rating scales for different disorders as well as more specialized ancillary assessments such as family, social and interpersonal, academic, speech and language and institutional assessments. The fourth chapter of the section covers baseline medical assessment for psychopharmacological treatment. Useful pointers in the medical history, exclusion of medical illness, baseline investigations and monitoring (including principles of therapeutic drug monitoring) are covered extensively.

Highlighted summaries allow quick rereading of a chapter. In addition, chapter 3, which deals with individual baseline psychiatric assessment for psychopharmacological treatment, has several useful tables with pointers to the psychiatric diagnosis. The reader is referred to relevant rating scales contained in the appendices. Of great use to the busy clinician is the visual analog scale, which allows for baseline rating and monitoring of specific target symptoms. Chapter 3 uses case examples and commentaries to illustrate points made in the text. These cases are relevant and reminiscent of my own day-to-day practice. Each raises important clinical examples and dilemmas. Rather than distracting from the text, in most cases they reinforce the text and make the book more readable. This excellent technique continues through the rest of the book.

Section 3 covers the planning, initiation and provision of psycho-pharmacological treatment. Although superficially this section seems to repeat some of the content of the previous section, it does in fact offer additional wisdom and deals with important practical issues in the treatment of children and adolescents generally and psychopharmacology more specifically. The principles of patient and family education are clearly articulated, as are the standards of informed consent. While legislation may vary in different jurisdictions, a useful set of guidelines is provided for obtaining informed consent from both the child and family, taking into account the developmental and cognitive status of the child. Throughout, the book adopts a respectful client-centred philosophy. This attitude is well reflected in the clinical case examples.

Section 4, appropriately the most dense segment of the book with 10 chapters, deals with the clinical practice of child and adolescent psychopharmacology. Each chapter outlines the treatment of a particular disorder, with 3 chapters devoted to the anxiety disorders; the first of these very briefly describes the general issues in the psychopharmacological treatment of the anxiety disorders, followed by a chapter devoted to the treatment of panic disorder and the third to other anxiety disorders. The author emphasizes the high morbidity of anxiety disorders beginning in childhood and suggests that evidence supporting the principle of least intrusive intervention first is lacking. Combined interventions (pharmacological and psychological) applied aggressively, especially when symptoms and functional impairment are significant, may lead to better outcomes. This principle is applied in the subsequent 2 chapters. In keeping with the format of the book, these 2 chapters guide the clinician — with the use of case material — through the management of these disorders, providing a framework for assessment and measurement of outcome, as well as the specifics of drug choice, augmentation techniques, dosage ranges and some principles for treatment duration.

Other chapters that are highly recommended are those on the treatment of depressive disorders and bipolar disorder. In chapter 11, the author takes the reader through the standard management of depressive disorders in childhood and adolescence using 2 case examples and commentaries, which highlight treatment issues. The text is written like an expanded step-wise treatment manual but remains interesting and readable. The chapter focus is on the use of selective serotonin reuptake inhibitors (SSRIs). While the author clearly outlines alternative and augmentative treatment strategies, he completely dismisses the use of tricyclic antidepressants (TCAs) as alternatives, although there may still be a role for these drugs — for example, the use of desipramine or nortriptyline to treat dysthymia in adolescents with comorbid attention deficit hyperactivity disorder. There is only a single line devoted to the newer-generation antidepressant venlafaxine, and this appears odd and out of context. Nefazodone is not mentioned at all, perhaps because of its novelty.

Chapter 12 is thorough in its review of the thymoleptics and ancillary treatments for bipolar disorder. A subsequent edition will likely review the use of the novel antipsychotics, especially risperidone and olanzapine in the treatment of bipolar disorder with psychosis. These drugs are not mentioned, perhaps as a result of the author’s use of the highest available level of evidence in outlining psychopharmacological treatment of children.

If this book has any drawbacks, it is a tendency to be long-winded and repetitive. For example, the last paragraphs of the 2 case commentaries in the chapter on acute schizophrenia (chapter 13) are almost identical. While each of these paragraphs (page 224 and page 225) “emphasize[s] the importance of using proper pharmacological treatment within the context of optimal and comprehensive care” “and keeping in mind the expected paradigm of chronic care with the goal of controlling acute symptoms, preventing relapse, and optimizing patient function,” a single statement would suffice. Occasionally, terminology is used loosely; for example, neuroleptic malignant syndrome is referred to as a “true psychiatric emergency” when it is better defined as a true medical emergency. The section describing “initiating and optimizing methylphenidate treatment” (on page 279 of chapter 15, “Psychopharmacologic Treatment of Attention-Deficit Hyper-activity Disorder”) is quite unclear: 2 potential strategies are outlined (1 and 2) and then strategy 3 (which appears to be strategy 1) is referred to in the case example. Furthermore, it is difficult to determine any real difference between strategies land 2.

There are 7 appendices, which provide an inclusive array of potential rating scales available for the use of psychopharmacologists treating children. The book is well indexed, and a useful reference list can be found at the conclusion of each chapter.

Overall, this book is a very useful addition to the growing library of texts on child and adolescent psychopharmacology. I strongly recommend it as a useful and practical guide for practitioners prescribing psychopharmacologic agents to children and adolescents. I look forward to an updated and perhaps more streamlined edition in a few years’ time.

Impulsivity: Theory, Assessment, and Treatment

Impulsivity: Theory, Assessment, and Treatment

CD Webster and MA Jackson, editors

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

ISBN 1-57230-225-9

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

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

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

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

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

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