Posts Tagged ‘psychiatric illnesses’

Treating the Elderly with Psychotherapy

Treating the Elderly with Psychotherapy: The Scope for Change in Later Life

Edited by Joel Sadavoy and Molyn Leszcz

Madison, CT, International Universities Press, Inc., 1987. 366 pp.

As emphasized early in this book, the elderly will represent nearly 20 percent of the U.S. population in the twenty-first century. This fact underscores the importance of a work for physicians, therapists, and health workers which focuses on issues specific to clients who are 65 and older. Editors Sadavoy and Leszcz have put together a series of essays by some of the pioneers in geriatric psychiatry (e.g., George Pollack, Jerome Grunes, Martin Berezin, Ralph Kahana, and others), each of whom has brought an expertise to different aspects of psychotherapeutic care. The essays are well-written, interesting, and full of eye-opening clinical vignettes, and the book as a whole has met its challenge of encouraging “hopefulness” in geriatric care. One problem, however, is that in presenting essays largely from a psychodynamic perspective, it lacks coherent underlying theories. Several essays, moreover, fail to distinguish the elderly patient from any other client. The overall collection, however, is pioneering and should encourage more specific studies.

The book is divided into three parts. Part I, entitled “General Psychodynamic Perspectives,” comprises essays by Pollack, Grunes, and Berezin, respectively. Each focuses on a general theme: Pollack emphasizes the wealth of psychodynamic material in therapy with the elderly and presents his own notion of a mourning-liberation process in bereavement. Grunes writes about the unique features of transference between an older client and a younger therapist and provides the concept of reverse empathy to account for the elder’s regard for the therapist. Berezin presents a wonderful introduction to clinical work, stressing the depth and vitality of the elderly. Taken together, these three essays break many stereotypes of the older client and provide a much deeper sense of age-specific therapeutic needs.

Part II, entitled “Manifestations of Psychopathology,” is the most theoretical section of the book and, as a result, the weakest. Its essays, which cover such topics as paranoia in the aged, the impact of massive psychic trauma, and character disorders, are well-organized and yet tangential to the stated goals of the general collection. The flaw seems to lie in the dearth of relevant psychodynamic theories; each essay provides concise theoretical introductions, yet never adequately adapts them for a geriatric population. In addition, no essay attempts to define the elderly. Are clients in their 60s similar to others in their 80-s and 90-s? One is left with little regard for the life cycle as a viable force past adulthood. Several of the cases presented raise interesting issues but, again, do not place them within a meaningful context. One exception in Part II is an essay by Lawrence Breslau on the Exaggerated Helplessness Syndrome. This syndrome, in which elderly patients become maladjusted to their disabilities, highlights their passivity and serves to maintain the support of primary caregivers. The psychodynamic issues here are ripe for intervention, and Breslau provides good clinical examples.

Part III, entitled “Specific Psychotherapeutic Modalities,” picks up many issues from Part I and ends with a real gem: an essay entitled “The Whole Grandfather: An Intergenerational Approach to Family Therapy” by Etta Ginsberg McEwan. The other essays focus on crisis management and short-term and group geriatric psychotherapy, and the information provided here is perhaps the most practical for readers, since it addresses the appropriate structure of therapeutic intervention. For example, Kahana’s chapter on crisis management presents a crucial skill for the intake of elderly clients. He provides a working definition for geriatric crisis, along with many useful clinical pieces. Ginsberg McEwan’s essay, coming second to last, is poignant and informative, presenting an entire case study within the context of family and intergenerational therapy. It speaks to the very intent of the book in tying together the therapeutic goals of the elderly with those of children and grandchildren. By juxtaposing these issues, Ginsberg McEwan illustrates points of common interest as well as age-specific ones.

Sadavoy and Leszcz’s collection of essays will, it is hoped, serve to encourage study along the lines of its distinguished contributors. Although several essays are a bit incongruous with the book’s focus on treating the elderly, one should not be discouraged. There has simply not been enough longitudinal work on the elderly, and the very concept, both before and after reading the book, remains a diffuse notion of “people 65 years and older.” What emerges from the book, then, is not a specific definition, but a well-rounded appreciation for the complex issues facing the elderly and the enormous potential for therapeutic intervention.

Psychiatric Emergencies

John Chapman Urbaitis

Norwalk, Apple-ton-Century-Crofts

1983. x + 166 pp.

This small volume dealing with psychiatric emergencies is one of many such compilations, but has its own particular merits. One of these is its brevity. Emergency management requires the clear grasping of specific principles, unencumbered by more or less remotely related data which may safely be left for less immediate attention. The language of this treatise is what it should be considering the nature of its subject matter. Concision, pithiness, and solid substance are its meritorious attributes.

The orderly presentation of topics to be considered characterizes this book. It contains what it should and omits the nonessential.

Anyone who has worked in a psychiatric admitting office or emergency room will appreciate the author’s directives for procedure. Some pathologic conditions have been omitted or alluded to only in generalizations, but the book is not intended to be encyclopedic.

One appreciates the author’s emphasis on general medical procedures and neurologic diagnostic problems. Such conditions are always prominent in psychiatric emergencies, and their accurate diagnosis may make the difference between life and death.

The volume is to be recommended to all medical personnel required to deal with these disorders. It reminds us to bear in mind the admonition of Sir William Osier as to the necessity of equanimity for every physician.

Assessment Scales in Old Age Psychiatry

Assessment Scales in Old Age Psychiatry

Burns A, Lawlor B, Craig S, editors

Martin Dunitz Ltd.; 1999. 302 pp. (paper)

ISBN 1-85317-562-5

Being asked to review Assessment Scales in Old Age Psychiatry was like being let loose in a candy store: fun, filled with many new experiences and ultimately vaguely disappointing, although definitely worth the visit.

About 150 diverse instruments are described, including neuropsychological assessments, tests for activities of daily living and quality of life, and tools for assessing depression and delirium. But to keep with the candy analogy, not all of the goodies are what they seem. Sometimes there is only a list of test contents, at other times only a description, and often there is nothing to help digest a complex mouthful.

The layout of this book is appealing. Each scale is described on one page, and the facing page lays out test elements. There is space on every page for notes and annotations; to use this book effectively, cross-referencing and additional notes from one’s own experience are necessary. Each chapter has an introduction that outlines the purpose of that domain of test and reviews the history of old or modified tests. Some analysis is given about which tests might be more useful for certain circumstances and why. The book usually indicates how long a test should take to administer and who is best suited to give it, along with information on how to score tests and what different total scores mean.

Disappointments include the following. Some of the “additional references” are oriented principally towards researchers or those interested in developing new tools, rather than clinicians. There are too few up-to-date references. For example, references are to articles re-evaluating older tools versus newer techniques, information that is essential where tests are unknown or where a choice has to be made between a tried-and-true older tool and a more recent tool. A few of the tools referred to “updated guidelines,” which may score an old test on a new scale, but unfortunately, in at least one instance, the new guidelines are not referenced and there is no example of the newer scale (for example, see Bartel on pages 132-3). One test is described as a “visual analogue” scale, but lacks a visual presentation. Primary sources are missed in a few cases.

Some information is given on the reliability, validity and accuracy of different tools, but the editors have not done a consistent enough job here. As a result, it is difficult for anyone unfamiliar with a test to choose between tools.

The editors excuse some of their lapses in editing in the introduction. However, I cannot accept their excuses. The job of a technical editor should be an arduous one. The editors of this book have not met the many technical requirements of their task and therefore fail their readers.

Despite my many reservations about this book, if you have the time to do your own homework, and the $77.50, it might be a fun addition to your library.

Thyroid Diseases of Infancy and Childhood

Thyroid Diseases of Infancy and Childhood: Effects on Behavior and Intellectual Development

Hauser P, Rovet J, editors

Washington: American Psychiatric Press; 1999. 312 pp. with index

ISBN 0-88048-767-4 (cloth)

This book, by a group of distinguished authors, presents the neurobehavioural science underlying and a clinical overview of thyroid deficiency and excess in the growing human organism.

The current knowledge of thyroid physiology and molecular genetics is reviewed in detail and is well referenced. Hence, this book is more than enough for the busy clinician.

A historical review of newborn screening programs over the past 25 years includes the complete history of thyroid screening in North America, from the Quebec experience starting in the mid-1970s to the present. The problem of false-positive results in term as well as premature infants is elucidated.

For the basic scientist, pediatrician or pediatric endocrinologist seeing newborns with positive thyroid screening tests, the later chapters on screening and long-term results of L-thyroxine therapy heighten awareness of the potential behaviour, intellectual and hearing problems faced by these children due to an otherwise treatable disorder. The association between thyroid hormone resistance syndrome and attentional disorders is intriguing. The neurobehavioural aspects of acquired thyroid disorders in children has been adequately highlighted for the clinician.

Finally, the chapters on neurodevelopmental change with thyroid-disrupting contaminants is thought-provoking for the environmentally conscious reader.

The book as a whole presents a balanced perspective on the neurobehavioural consequences of thyroid disease in infants and children and should be on the bookshelf of every pediatric library for current and future basic scientists and clinicians involved with children. It is a “must read” for every pediatric endocrinologist and child psychologist.

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.

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.

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

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

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

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

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

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

The Natural History of Mania, Depression and Schizophrenia

The Natural History of Mania, Depression and Schizophrenia

G Winokur, MT Tsuang

Washington (DC): American Psychiatric Press; 1996. 372 p

The resident had just presented his formulation of a case. I posited that hysteria might be an important aspect. He seemed genuinely puzzled, even when I told him that terms like “hysteria” and “hypochondriasis” had been available for more than 2 millennia. “But,” he said, “for my boards, I only need to know DSM-IV.”

“Well,” I thought, “if you’re so keen on cookbook psychiatry, why did you not stay with cooking rather than spoiling psychiatry?”

So here is the rub. What are we to do with this charming, scholarly work full of medical science when the psychiatric world has moved as it were, from bookshelves to the Internet? Or is that being too generous? While I acknowledge that the American Psychiatric Association committees have slaved to obtain syndromes made up of a concatenation of symptoms, it might be an overstatement to suggest that these have the same historical significance as the stirrup, the Gothic arch, and the printing press. They might conceivably be compared with gunpowder, however, since it changed the overthrow of castles from sieges lasting several years to crumbling walls in a few days. So the biopsychosocial anamnesis that can take a considerable time to collect might well be thought in the modern era to be replaceable by a convenient American Psychiatric Association cluster analysis.

Nevertheless, the book The Natural History of Mania, Depression and Schizophrenia is based upon the approach recommended by Adolph Meyer at Johns Hopkins at the beginning of this century. What is now called the “biopsychosocial” model is really the same model with a new name and the same methodology by which psychiatric diagnoses and formulations are developed all over the world. Thus psychiatrists in Iowa, London, Sydney, and Bombay have for decades collected the history of the present illness, the family and personal history, and a mental state examination before proposing a formulation for a patient. Examples of these, in copperplate handwriting, lie in the archives of mental hospitals everywhere.

So what is different about Iowa? The answer is professors George Winokur and Ming T Tsuang. Winokur moved to Iowa from Washington University in St Louis a quarter of a century ago. That university, like several in North America and many in Western Europe, did not see psychoanalysis as the Second Coming and fastidiously kept psychiatry on the Meyerian track. In Iowa, Winokur was joined by Tsuang, who eventually became a professor of psychiatry at Harvard. In the best tradition of psychiatric nosology, generously referred to in the preface, they dug like archeologists into their archives and collected a fascinating cache of data hitherto known as the Iowa 500. Case material was available from 1920 and seemed to be comprehensive; thus, “the quality of material in terms of documenting symptomology was quite sufficient for making diagnoses according to modern diagnostic criteria that had been published for research purposes.”

Nevertheless, there is a caveat. Old data have to be updated and massaged as psychiatry goes through another convulsive spasm in terms of the lexicon and nosology. As seen in the Stirling County and Lundby studies, this can be done. So what did they find? A lot. The Iowa 500 was made up of admissions to the Iowa Psychopathic Hospital (later the Iowa Psychiatric Hospital) between 1934 and 1944 and consisted of 100 bipolar disorder, 225 unipolar disorder, and 200 schizophrenia patients (with a few subsequent changes in diagnosis). The study started in 1971 and completed a 27- to 30-y follow-up of a psychiatric population originally “treatment-naive” in modern terms.

The book itself is made up of 15 chapters, and each contains reams of facts. Each chapter requires careful scrutiny. Perhaps the most salutatory is number 15 entitled “The Contribution of the Iowa 500 to Diagnosis and Classification of the Affective Disorders and Chronic Non-affective Psychosis.” Using symptoms, demographic criteria, and admission criteria, the authors demonstrated that the original diagnoses were stable over time. Thus: “These data strongly suggest an unequivocal separation of the primary affective disorders from the chronic non-affective psychoses according to the factors involved in the medical model.”

The authors worked, albeit inconclusively, on schizoaffective disorder (the border state) and on the types of affective disorder and chronic nonaffective psychoses. They concluded that “the Iowa 500 has presented new ways of investigating clinical entities and family illness… However it is clear that psychiatric illnesses or diseases are often composed of overlapping syndromes and . . . subsequent studies should be planned in a different fashion and less clear cut diagnostic groups should be included as index cases.”

Essentially, what we have here is a wonderful, though somewhat old-fashioned (especially the font), longitudinal study in the best psychopathological fashion. It is descriptive, as psychiatry has remained to this day, but many residents will likely, and regrettably, find it anachronistic. For those of us trained in the Meyerian sense in the best psychiatric institutions of Europe, North America, and Australasia, it validates what we have been doing all of these years. It is not about receptors and cookbooks, but it does provide a warm, fuzzy feeling. All who like a historical perspective to their work should read it.

Review of Psychiatry

Review of Psychiatry. Volume 14

JM Oldham and MB Riba, editors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe. Volume 66

HH Jasper, S Riggio, PS Goldman-Rakic, editors

New York NY: Raven Press; 1995. 400 p

Frontal lobe epilepsy has proven to be much more difficult to diagnose and treat, both pharmacologically and surgically, than the more common temporal lobe epilepsy. This volume represents the proceedings of a multidisciplinary symposium designed to bring together clinicians and basic scientists to elaborate current concepts in frontal lobe function and pathology, especially as they pertain to frontal lobe epilepsy. The book complements a previous work by the same publisher, entitled Frontal Lobe Seizures and Epilepsies. The editors state that the present volume is intended to emphasize “recent experimental work on the developing functional neuroanatomy of the prefrontal cortex in relation to working memory, cognitive behavior, and the physiopathology of frontal lobe seizures and their neurosurgical treatment.”

The first 7 chapters provide a comprehensive overview of animal and human studies which have contributed to our insight into developmental, anatomical, functional, cognitive, and neuropsychological aspects of the frontal lobes. A chapter on “Frontal Degenerative Dementia and Neuroimaging” is somewhat removed from the main emphasis of this collection but nevertheless offers an up-to-date synthesis of the clinical and radiological features of this form of increasingly recognized dementia. One of the highlights of this section is the chapter by Brenda Milner summarizing the ground-breaking work, largely under her direction, on the neuropsychology of the frontal lobes, carried out at the Montreal Neurological Institute over half a century. Herbert Jasper, who also worked in Montreal, provides a historical survey of prefrontal lobotomy, a chapter which should be of interest to psychiatrists.

Frontal lobe complex partial seizures have been notoriously difficult to diagnose and treat. Because they often manifest bizarre motor and vocal features, their seizures are relatively short-lived, and they have minimal surface EEG manifestations both ictally and interictally, patients who present with these types of seizures are often incorrectly labelled as having psychogenic pseudoseizures. The rest of this book is devoted to clinical phenomenology, EEG features, neuroimaging studies, and surgical therapy of frontal lobe seizures. A variety of techniques for localization of foci or investigation of function such as computerized-evoked potential analysis, PET scanning, MRI, depth electrode recordings, and electrical stimulation is covered. Several centres from the US, Canada, and Europe have contributed their experience and expertise to this volume. One of the most useful features of this book is the inclusion of the often revealing and less formal discussions that followed each presentation.

This is a well-organized, up-to-date account of all aspects of frontal lobe function and their relevance to frontal lobe epilepsy. Because of the importance of the frontal lobe in human behavior, cognitive ftinction and memory, and also because of the overlap between epilepsy and psychiatric illness, psychiatrists should find this work useful. It will also serve as a reference for neurologists and neurosurgeons, especially those working in the field of epilepsy.