Posts Tagged ‘psychiatrists’

Psychiatric Diagnosis

Psychiatric Diagnosis. 4th Edition

Donald W. Goodwin and Samuel B. Guze

New York, Oxford University Press, 1989. 332 pp.

In their preface to the fourth edition of Psychiatric Diagnosis, authors Goodwin and Guze are clear on the limitations of their work: there is little “theory” or “speculation” nor any unproved claims in this review of a dozen psychiatric diagnoses. While this approach leaves a straightforward and complete compendium of current knowledge, it also handicaps the work. Like other texts, it provides the most current diagnostic definitions and clinical approaches. Unlike more speculative works on psychiatric diagnosis, it offers nothing interesting or exciting. What is left is a complete, but not comprehensive, up-to-date, but dull text.

Psychiatric Diagnosis presents the basic definitions, history, DSM-III-R criteria, epidemiology, clinical findings, etiological research, and treatments for the following eleven psychiatric diagnoses: affective disorders, schizophrenia, panic disorders, hysteria, obsessive-compulsive disorder, phobic disorders, alcoholism, drug dependence, sociopathy, brain syndrome, and anorexia nervosa. A final chapter presents topics addressed in a psychiatric examination, but is neither complete nor systematic; while this chapter may be of some use to a medical student who has never conducted a psychiatric interview, it would be of little use to a clinician.

The chapters themselves provide complete definitions of each diagnosis, with an emphasis on DSM-III-R criteria (which are included verbatim). The historical accounts of the developing nosologies are perhaps the most interesting parts of the chapters. The epidemiological sections provide some substantive data but reflect the often conflicting accounts of prevalence. Several chapters augment this epidemiological data with descriptions of family studies. The sections on clinical data, etiology, and treatment are well written and complete and include transcripted examples. Additional sections on differential diagnosis are included but, in general, are very brief and offer little discussion on either psychometric measures or clinical data which would be of use in distinguishing one diagnosis from another. References at the end of each chapter are extensive and complement the evidence presented throughout the chapters. In particular, the chapters on hysterical disorders and sociopathy are excellent presentations.

Although Psychiatric Diagnosis presents solid accounts of eleven disorders, it offers nothing more — in fact, much less — than many other texts. In intentionally omitting their own opinions, the authors have also left out any clinical wisdom which may be critical in making a diagnosis. The text is certainly well written and well researched, but one gets the sense throughout that too much is missing, and that there is nothing unique about it. The book attempts to tackle such relevant topics as alcoholism and anorexia nervosa while eliminating much of the speculative and theoretical research which, although not “absolute proof” for etiology, clinical course, or treatment, has sparked so much of the creative thinking on these disorders. Much of psychiatry is “theory, speculation, and explanation,” and deliberately to leave this out ignores much of the credible phenomenological, psychological, and psychodynamic evidence which has provided the impetus for current research. Ironically, the authors frequently quote Karl Jaspers, perhaps one of the most systematic and yet speculative phenomenological psychiatrists.

The authors’ desire to provide the best objective guide to diagnosis is admirable and certainly consistent with current psychiatric approaches; however, they should have provided more current research, rather than such sketchy accounts, to flesh out what is currently known about each disorder. Not even the current psychobiological theories are presented in sufficient depth.

For a student or layperson who is unfamiliar with psychiatric diagnoses, Psychiatric Diagnosis would be a useful guide. It would also be useful to a clinician seeking a quick review of a particular diagnostic category. In general, however, there are many more comprehensive textbooks on diagnosis, and many smaller works on psychopathology which include more interesting clinical vignettes and theory. A less sterile approach, either with more personal clinical wisdom and theory, or with more objective data on each diagnosis, would have added much to this volume.

Comprehensive Neurology

Comprehensive Neurology

Edited by Roger N. Rosenberg

New York, Raven Press, 1991.920 pp.

Comprehensive Neurology proposes to review “all aspects of neurologic disease,” providing yet another addition to the ever-growing list of neurology references. Its editor, R.N. Rosenberg, claims substantial experience in neurology editorship with The Treatment of Neurological Diseases (1979), Neurology (1980), and the five-volume Clinical Neurosciences (1983); more recently, he has produced shorter studies, including Neurogenetics: Principles and Practice (1985) and Molecular Biology of Neurological Disease (1988). In contrast to other textbooks like Asbury, Mckhann, and McDonald’s Diseases of the Nervous System, which contain two cumbersome volumes of material, Rosenberg hopes with the present volume to produce a comprehensive neurological reference in a single volume, while providing a “detailed, scholarly account” of neurological diseases, synthesizing the basic and clinical neural sciences for clinicians and interested researchers.

Unfortunately, Rosenberg only partially accomplishes his goal, instead producing a book that conveys a fragmented view of neurology. Compared to other comprehensive textbooks, like Asbury et al.’s Diseases of the Nervous System, or even smaller works much as Rowland’s Merritt’s Textbook of Neurology, Rosenberg’s haphazard contribution simply pales. Comprehensive Neurology attempts to touch upon every aspect of neurological disease with chapters by various specialists, on topics from teratology to psychiatric disorders to coma; but the book fails to tackle an in-depth discussion of neurology. Indeed, most chapters do not consider all aspects of their respective topics, and the accounts tend to be either all-encompassing but superficial or else informative but specialized. For example, such chapters as “Diseases of the Autonomic Nervous System” or “Cerebellar Disorders” provide only brief descriptions of clinical phenomena, while “Headache Syndromes” and “The Comatose Patient” provide informative detail on pathogenesis, clinical presentation, and treatment, albeit limited to their specialized disease. The book treats more general topics rather lightly, though it offers excellent timely information on particular specialized subjects. The result is, by avoiding a thorough coverage of basic neurological concepts and disorders, its utility as a reference diminishes.

Comprehensive Neurology further suffers from a lack of focus or direction in editorship. The table of contents itself reflects a dense conglomeration of chapters without any obvious logical sequence. Many chapters overlap in coverage of several topics, including such conceptual issues as the principles of magnetic resonance imaging and computerized tomography, or such background issues as the neuroanatomy of the vestibular or ocular systems. As the most obvious example, even though Rosenberg generally devotes, at most, one chapter to individual sensory systems, the eighth nerve system alone receives two chapters of coverage, and the majority of their content reiterates information found in other chapters. Moreover, despite Rosenberg’s expressed desire to coordinate basic science with clinical disease and treatment, chapter formats vary tremendously, with some chapters presenting mostly background information, like G. Rosenberg and Wolfson’s chapter on brain fluid and electrolyte disorders, while other chapters present only clinical information, for example, Damasio and Tranel’s chapter on disorders of higher brain function. Some chapters even stray from their title topics: Hecox and Hogan’s chapter, “Diagnostic Principles in Neuro-otology,” for instance, scarcely even addresses diagnostics and instead focuses on neuroanatomy and physiology, while Richter and Corder’s “Neurotoxic Syndromes” chapter concentrates mostly on substance abuse, virtually skipping the role of biological toxins or metabolic toxicities. On the other hand, such chapters as Kase et al.’s on cardiovascular disease, Chad and Munsat’s on muscular disease, and Wray’s on neuro-ophthalmologic disorders clearly and concisely provide thorough, up-to-date information about their respective fields. Laudably, these chapters provide informative, thoughtful presentations. In my view, this volume contains a great diversity of writing quality and content, reflecting an editorship that allows the book’s contributors overmuch free rein to digress. The end product strays too far from the claim “comprehensive neurology.”

In light of other alternative neurology references, a clinician or any interested scientist might therefore find little of interest in Rosenberg’s Comprehensive Neurology, other than some specialized topics such as multiple sclerosis, metabolic encephalopathy, and the aforementioned cardiovascular, muscular, and ophthalmologic diseases. The book’s chapters generally offer unsatisfying whirlwind tours of neurological disorders, never providing a unique or novel presentation of the material. Other contemporary works provide identical information, presented in a more pragmatic, informative, and concise manner, such as Swash and Oxbury’s Clinical Neurology (1991) or, particularly, Asbury et al.’s thoughtfully organized and edited Diseases of the Nervous System (1992). Rosenberg’s present work fails to satisfy the requirements for a comprehensive neurological work in one volume because it rambles through neurological discourses. The editor and his contributors have unfortunately and disappointingly produced a weak overall contribution to the neurological library.

The Dementias: Crossroads between Neurology and Psychiatry

The Dementias: Crossroads between Neurology and Psychiatry

M. Girgis and K. Harris

St. Louis, Warren H. Green, Inc., 1992, 187 pp.

“The average human life expectancy has increased markedly since the turn of this century … unmasking a new epidemic: dementia.” This epidemic, dementia, is the focus of the book The Dementias: Crossroads between Neurology and Psychiatry, by Girgis and Harris, both of the University of Sydney, Australia. This book provides a fairly technical look at the role of neurotransmitters in degenerative neurologic disease. Glutamate is one major focus. The authors discuss extensively its chemical structure, synthesis, metabolism, and its many known and theorized pathways in the brain, arguing for a role of glutamate in dementia. The authors include data from their own current research, and extensively reference the work of others in the field. In addition they continually suggest new directions for research.

Additional chapters are devoted to such topics as “Neurotoxic Amino Acids in Human Degenerative Disorders” and there is a chapter providing an excellent overview of research in “Neurotransmitter Imbalance in Psychiatric Disorders”. This chapter relates the neurotransmitters discussed previously in reference to dementia to their theorized roles in depression, and in the action of antidepressant medications. The final chapter moves away from discussion of glutamate and deals with another neurotransmitter, acetylcholine, and studies of its role in Alzheimer’s disease.

The middle section of the book contains three chapters which deal with neurotransmitters in limbic epilepsy. As the authors explain in the preface, their own research focus is mediation of excitation in brain tissue in relation to limbic epilepsy. It was neurotransmitters in limbic epilepsy they were studying when data suggested to them a connection between these neurotransmitters and dementia. This specific research interest seems to be the only link between the information presented in the three chapters on limbic epilepsy and the rest of the book. These chapters do, however, present at thorough and up to date discussion of kindling in limbic epilepsy.

In summary, The Dementias: Crossroads between Neurology and Psychiatry presents a good technical discussion of research on the role of neurotransmitters, and especially glutamate, in human degenerative disorders. Although some background information is given, some prior knowledge of biochemistry and neurophysiology is helpful in understanding this text.

Biological Psychology

Biological Psychology: An Introduction to Behavioral, Cognitive and Clinical Neuroscience (Book and CD-ROM), Third Edition

Mark R. Rosenzweig, S. Marc Breedlove, and Arnold L. Leiman

Sunderland, Massachusetts: Sinauer Associates, 2001. 651 pp.

Biological Psychology by the trio of Rosenzweig, Breedlove, and Leiman explains the biological foundations of evolution, development of the nervous system, regulation of behavior, emotions and mental disorders on a student-oriented textbook. Throughout the entire book lies a strong emphasis in the biological processes that produce and govern behavior and cognition with respect to the environment. The level of the text is geared to the beginning student in the discipline. With a colorful format, icons, key terms, boxes, and a CD-ROM, which contains quizzes and Sylvius, a module to learn neuroanatomy, a new student should consider purchasing or buying Biological Psychology.

The writing is clear and the illustrations that accompany it are not only attractive but illustrative as well. With CD-ROM links to several key illustrations, the book is undoubtedly tightly integrated and cross-referenced among its various modes of presenting information to the student. Because the text is geared for the beginner that would consider specializing in the discipline, it was general, yet technical enough that as a medical student I found it helpful in relearning some neuroanatomy structures such as the circle of Willis. Therefore, certain parts of the text can also be used by students who wish to become clinicians in addition to those who want to become specialized researchers. All chapters contain up-to-date research that would prove useful to both kinds of students. As an aside, the book actually contains photographs of current researchers such as Nancy Wexler, which connects a face with hot-off-the press research.

Usually, I devote the second or third paragraphs in the review to criticisms of the book. The terseness of this paragraph indicates how I feel this textbook is as close to a paragon for excellence for biological psychology textbooks that I have read.

Biological Psychology was clearly designed with the student in mind. I give it the highest recommendation and it should be welcome addition to your library.

Hughlings Jackson on Psychiatry

Kenneth Dewhurst

Oxford, Sanford Publications, 1982. pp. xi + 169

The clinical researches in neurology of John Hughlings Jackson (1834 –  1911) are well known, but his contributions to the field of psychiatry are not; nevertheless, they are considerable, as Kenneth Dewhurst notes in this fine small book. Jackson’s education at the medical school at York provided him with more experience in the field of psychiatry than most of his contemporary medical students. This was made possible by two exceptional professors on the faculty, Daniel Hack Tuke and Thomas Laycock, both of whom became leaders of British psychiatry during their era. Tuke probably had a greater impact on the clinical side while Laycock’s studies on brain reflexology and on the mind-brain problem had an enduring influence on neurophysiology.

Jackson also attended the St. Bartholomew Hospital Medical School in London for a year. He settled in London finally in 1859, where he spent the rest of his life in private practice and was associated with the London Hospital and the National Hospital for the Paralyzed and Epileptic. During his career, he wrote well over 300 articles using a careful observational and philosophical approach, but never put his findings and thoughts together in a coordinated whole in spite of the urgings of his professional friends. Nevertheless, he was “acclaimed as the greatest British scientific clinician of the 19th century.”

Jackson’s greatest contribution to the understanding of psychiatric issues arose from his careful studies of epilepsy and its phenomena. As he slowly collected material from 1866 on, he became interested in selected patients who experienced odors undetectable to others present (a form of olfactory hallucination). These subjects also revealed episodes of losses of consciousness, automatic movements and thoughts, and the appearance of certain dream-like states. Jackson also explored the amnesia that was associated with these states and finally named them “uncinate fits.” Over the years the terminology changed to epileptic equivalents, psychomotor epilepsy, and currently to temporal lobe epilepsy. Dewhurst also discusses a famous case of Jackson’s known as “Quaerens or Dr. Z.”, who has recently been identified by the studies of D. C. Taylor and S. M. Marsh as Dr. Arthur Thomas Myers, a distinguished sportsman and physician whose major contribution to medical history was his careful reportage of his own case, albeit anonymously. He became a patient of Jackson’s who published Myers’ case and included Myers’ autobiographical study. Both in his own right and through the efforts of his brother, Frederick W. H. Myers, Arthur contributed to the movement for the study of parapsychological phenomena and those of the subconscious. Arthur wrote articles on both hypnotism and telepathy. It was his brother Frederick, however, who helped to found the Society for Psychical Research and wrote extensively on subliminal matters. Both went to LeHavre, France, in 1886 to watch a then unknown professor of philosophy named Pierre Janet do experiments on hypnosis at a distance.

Arthur died in January 1894 from an overdose of chloral hydrate. His illness plus his medical focus thereup had made possible a greater clinical understanding of temporal lobe epilepsy. Exploration of the connections of the temporal lobes to psychiatry has experienced a resurgence during the past two decades. That religious and parapsychological behavior could be connected to this area of the brain was pointed out in a 1970 article by Drs. Dewhurst and Beard. They reported six cases of epilepsy with investigative evidence suggesting a temporal lobe focus. All of these patients reported experiences of religious conversion. Approaching the question from the other side, the authors also found support for their thesis from the history of conversions in a number of saints and religious figures who also had a history of convulsive-like episodes. A more recent study brought further confirmation to this view as well as demonstrating a high incident of dissociation and multiple personality in these patients.

Other topics explored by Dewhurst in Jackson’s writings are: the mind-body problem, consciousness, delirium, coma, psychosis, hysteria, dreams, Gilles de la Tourette Syndrome, obsessions, jokes, etc. Dewhurst concludes his book with a two-chapter review of Jackson’s impact on continental psychiatry as well as on British and North American psychiatry. Among the familiar names that emerge are: Freud, Pick, Charcot, Ribot, Henri Ey, S. Weir Mitchell, J. J. Putnam, Adolf Meyer, and Bernard Sachs.

We are highly indebted to Dr. Dewhurst for surveying John Hughlings Jackson’s voluminous writings and culling those comments of psychiatric import and placing them in their historical context. An excellent index makes the various topics easily accessible. Dewhurst has continued to make valuable contributions to the history of medicine. His range is impressive. He is famous for his 17th century book-length studies on Sydenham, Willis, and Locke. He recently wrote a book on Fredrich Schiller (19th century), and he now has an excellent book on Jackson.

The Neurology of Eye Movements

The Neurology of Eye Movements, 3rd ed. CD-ROM

Leigh RJ, Zee DS. New York: Oxford University Press; 1999

CD-ROM – ISBN 0-19-512974-1

656 pp. with index – ISBN 0-19-512972-5

The neurology of eye movements sometimes seems to be an esoteric concern to many in the neurosciences. However, the analysis of eye movements often turns out to be extremely valuable in clinical practice. Eye movements are examples of other motor phenomena and, because they are more simple than limb movements, they often give greater insight into problems of paresis, fatigue or coordination. They particularly lend themselves to quantitative evaluation. The knowledge of specific types of eye movement deficiencies is an important tool for localizing disease and diagnosing neurological disorders.

Drs. John Leigh and David Zee have issued the third edition of their highly praised book, The Neurology of Eye Movements. In addition to the classic text, they have also produced, for the first time, a CD-ROM version. Both text and CD versions follow a similar outline, with an initial survey of the basic forms of eye motions. There follows an analysis of the vestibular-ocular system and the classical saccadic and pursuit systems, conjugate gaze, gaze holding, eye-head movements and vergence movements. These are superb chapters and give up-to-date information on the anatomical and physiological basis of these movements. The text is accompanied by excellent tables and figures.

Part II provides 2 sections on diagnosis, the first is on the diagnosis of peripheral ocular motor palsy and strabismus. Many would think of this as the “classical section” of a text on ocular motor problems. It details clinical testing of diplopia and, for neurologists, a must read description on how to diagnose strabismus (which is often left out of the classical neurological education). This is followed by a superb section on central disorders of motility, with enlightening dissections of the various forms of nystagmus and saccadic intrusions, as well as a useful discussion of vertigo and its treatment. Specific disease entities are treated in this latter section. There are discussions on eye movements and psychiatric disorders, stupor and coma, multiple sclerosis and metabolic deficiencies, all of which are excellent.

The CD-ROM version allows easy movement between chapters. It provides excellent access to the often-cited tables and figures that one has to find again when they are referred to in subsequent chapters. This is a more difficult task when reading the book because page headings do not indicate chapter numbers, which would help one locate the tables and figures more easily. The CD version has something that the hard cover version does not have — video clips. The videos, 60 in number, include virtually every sort of eye movement disorder one could want to view. These videos alone are worth the price of the CD; although they are relatively short, each shows the eye movement clearly. My one problem with the CD version is that the key word search feature often failed to reveal all of the important references; I found it much easier to use the index in the back of the book for this endeavour.

The authors suggest that this book is for neurologists, ophthalmologists, otolaryngologists, optometrists, neurosurgeons, psychiatrists and basic researchers. I suspect neurologists and ophthalmologists would enjoy it the most. Otolaryngologists who have a specific interest in vertigo would certainly find this text useful, though the vestibular systems are probably dealt with in more detail in other works. There are likely few neurosurgeons and psychiatrists who will purchase this, which is a shame because I think everyone could learn from this text.

I think everyone in neurology should own a copy of this text. The major question is which version to buy, the hard cover or the CD. I would guess that a neurology resident on a restricted income might want to buy the CD version for the videos alone. However, if you have seen these eye movements many times and just want a review of the neurological basis of eye movements, perhaps the book, which offers a better index, would be easier to read. Whichever one you decide to purchase, the price is quite reasonable for the information enclosed. I would suggest both versions.

The Hippocampal and Parietal Foundations of Spatial Cognition

The Hippocampal and Parietal Foundations of Spatial Cognition

Burgess N, Jeffery KJ, O’Keefe J, editors

Oxford: Oxford University Press; 1999. 490 pp. with index

ISBN 0-19-852452-8 (paper)

This well-organized volume has much of interest to basic researchers. The 3 roughly equal sections discuss, first, the parietal cortex, then the hippocampal formation and, finally, the interaction of the two in spatial learning and memory. Studies of rats, monkeys and humans are included. Among the techniques reviewed are behavioural, neuropsychological, electrophysiological, brain imaging and neural net computational modeling. Reading this book from cover to cover reveals a lot of repetition of similar material, such as anatomical details. It is often surprising to read about the same ideas in different chapters that do not cross-reference each other. However, for the reader who uses this book as a source of specific information about cortical regional specialization of function, the chapters provide independent and complete reviews of the latest relevant work.

The sophisticated studies of Milner and Goodale, identifying 2 streams of visual information processing with different functions, provide a useful basis for integrating much of the work presented in the first section on the parietal cortex and some of the studies presented in the third section on integration of parietal and hippocampal function. Goodale et al have argued that the dorsal stream of visual processing into the superior parietal lobe is concerned with the use of that information for the generation of motor actions; damage to this area leads to optic ataxia. The ventral stream projecting into the inferior parietal lobe and dorsal temporal cortex is concerned with what is being seen; damage here leads to spatial neglect. The chapter by Karnath, for example, presents results of studies showing that patients with damage to the right parietal cortex made exploratory eye movements consistent with an ipsilesional deviation of egocentric space representation. The same patients showed no deficit in goal-directed arm movements to targets around them. These findings are consistent with the idea that there are 2 streams of processing and that the damage in the patients studied affected the ventral but not the dorsal stream.

Colby presents fascinating electrophysiological data recorded in the ventral intraparietal area in monkeys. Cells were found to be responsive to both visual and so-matosensory stimuli; neurons with foveal visual receptive fields had somatosensory receptive fields on or around the muzzle. It was as if the mouth was the “fovea” of the facial somatosensory system! Furthermore, visual receptive fields moved across the retina in order to maintain spatial correspondence with somatosensory fields, suggesting that stimuli are coded in a head-centred reference frame. Patients with parietal cortical damage can be seen to suffer from a deficit in updating spatial representations for use by the motor system. Colby suggests that the remapping of visual fields observed in parietal cortical neurons provides the substrate for this updating.

In coaching students preparing for comprehensive examinations, one of my colleagues often counsels them to identify landmark papers that open whole new areas of investigation. Two such works in Spatial Cognition are Scoville and Milner’s paper and O’Keefe and Nadal’s 1978 book The Hippocampus as a Cognitive Map. The former is the first report of a role for the hippocampus in recent memory, and the latter identifies the place specificity of hippocampal cells. Juxtaposition of the ideas from these 2 classic works influences much of the thinking in Spatial Cognition. Some interesting ideas linking recent memory and place specificity can be found.

Mishkin et al, for example, discuss episodic and semantic memory. When a new item, association or fact is being encoded into memory, the relevant sensory information arrives as an episode that includes spatial information, as well as temporal cues and information about emotional and mental states. The amount of contextual information that is retained determines the nature of the stored memory: con-textually rich memories include spatial and other information and are, therefore, episodic; contextually poor memories record only the facts, and therefore constitute semantic memory. From this point of view, semantic memory is lower in a hierarchy of mnemonic sophistication than episodic memory. Mishkin et al argue that the hippocampus is necessary for episodic but not for semantic memory. Spatial information would be intrinsic to episodic memory. Rolls, Gaffan and Hornak make similar arguments in later chapters.

One distinction that guides some of the discussion of the interactions between parietal and hippocampal systems in space and memory is that between allocentric and egocentric frames of reference. Egocentric reference is putatively mediated by parietal circuits, and allocentric reference by hippocam-pal circuits. Rolls reported that 46% of the spatial cells of the hippocampus represented space in allocentric coordinates, versus 10% that, by comparison, were egocentric. Maguire reported that positron-emission tomographic (PET) images of people who walked mentally along a recently learned spatial route showed right hippocampal activation, suggesting that this region provides an allocentric representation of space. Parietal cortical regions seemed to play a role in egocentric movements through environments.

Another work that strongly influences many authors writing in Spatial Cognition and could be added to the comprehensive reading list that I mentioned earlier is The Visual Brain in Action by Milner and Goodale. This is the source of the idea, mentioned above, that the dorsal stream guides visuomotor actions and the ventral stream identification of what is seen. In the final chapter, Milner et al suggest that, if a participant was required to perform a delayed motor act, accurate performance would depend on the ventral stream because the egocentric coordinates that are tracked by the dorsal stream will have changed during the delay (assuming the participant moves). Thus, visually guided motor acts like pointing should be impaired after a delay in people with damage to the ventral stream. Results supported this conclusion.

One interesting contrast that I found in Spatial Cognition was between Rolls’ and Maguire’s view of imaging studies. Rolls reported the results of electrophysiological studies in rats and monkeys showing that hippocampal cells in rats were place cells, responding when the rat was in that place; in monkeys, hippocampal cells fired when the monkey looked to a particular place, even if it didn’t go there. Rolls argues that imaging studies could not make this distinction; they did not provide a full description of what was being represented in the brain. Maguire reports differences in regional activation assessed by PET imaging, as described above, and concludes that PET offers a means to pursue many outstanding questions in understanding neuronal control of spatial cognition. I suspect that they are both right. The breadth of techniques reported in this book and the emerging clarity of the knowledge about the cognitive functions of these brain regions attests to the power of multiple empirical approaches to the study of the brain for discovering the mechanisms underlying the amazing abilities of this structure.

Diagnosis and Management of Dementia

Diagnosis and Management of Dementia: A Manual for Memory Disorders Teams. Wilcock GK, Bucks RS, Rockwood K, editors. Oxford: Oxford University Press; 1999.402 pp. with index (paper). ISBN 0-19-262822-4. Can$86.95.

Dementia — and Alzheimer’s disease in particular — has become a major public health problem, and the expected prevalence of this class of illness is expected to double by the middle of the next century. Health delivery systems have been generally slow to keep up with the need for services to affected individuals. One trend that has appeared in the past 20 to 30 years has been multidisciplinary memory disorder clinics. This model of diagnosis and provision of treatment seems to work very well in a number of centres, but these specialty units are still not widely available, particularly outside of tertiary care centres. Setting up and running such a clinic is a topic of this new book. Many recent publications address either the pathophysiology or the medical treatment of dementia; however, a more practically oriented book such as this one has not previously appeared.

The book is divided into 3 major sections. The first is on establishing and organizing a clinic, the second is on the diagnostic process and the final section is on management. The book has a multidisciplinary and multinational authorship, and the authors have experience in working with patients in multidisciplinary clinics.

The first section on establishing and organizing a clinic covers all aspects — from administrative and logistical concepts, to information management, medical, psychiatric, neuropsychological, speech, occupational and community assessments. In addition there is a brief chapter on the research potential of such clinics. They are all covered well, although some rather briefly.

There is a small section on the diagnostic process for dementia. This stresses the differential diagnosis and indicates how one differentiates between age-related memory and cognitive decline and pathological conditions.

The final section of the book is concerned with treatment, and this covers topics that have not previously been covered well in publications. This includes support for caregivers and nonpharmacological approaches to treatments, such as behavioural modification and management of associated problems. There is a chapter on medical management, which reviews the current state-of -the-art in therapy and gives a glimpse of some of the therapies that may appear in the future. There is also a final chapter on the role and perspective of the primary care physician.

There is an appendix, which I found to be one of the more useful parts of the book. It is a paper that surveyed the memory disorder teams represented by the contributors to this book. This survey covers clinics in North America, the United Kingdom, Europe and Australasia. Anyone already running such a memory clinic or anticipating setting up one would find the information conveyed in this section quite useful as a benchmark. The survey asked such information as how many clinics are held per week, how long the first visit or appointment takes and how long the waiting lists are.

I think this book is potentially very useful for those already running clinics, those anticipating setting up clinics and those involved in rationalizing health care services for older individuals with cognitive impairment.

Psychiatry

Psychiatry. Second edition. Oxford Core Texts series

Gelder M, Mayou R, Geddes J

New York: Oxford University Press; 1999

ISBN 0-19262-888-7

The first edition of this book was called The Concise Oxford Text of Psychiatry, and the title change implies that the authors and publishers are attempting to broaden the book’s appeal. The 3 authors are senior academic psychiatrists from the University of Oxford.

Before reviewing the book, I made a list of the key requirements of a textbook for medical students: clarity, comprehensiveness, conciseness, cost, practicality and pertinence. This book scores high on all these items with the exception of cost and pertinence. It emphasizes strongly the integration between psychiatry and general medicine, yet the psychosocial aspects of medicine and psychiatry are also underlined. An appropriate balance between comprehensiveness and overinclusive detail is maintained, and liberal use is made of tables, diagrams lists and summaries. Many chapters also include “screening questions” — a list of questions that can be asked of a patient to rule out a specific diagnosis. The chapters on suicide, pharmacotherapy and “psychological” treatment (as the psychotherapies are called in the quaint British tradition) are particularly well written.

The book has its limitations. The chapter on psychiatry and the law is written for British readers and has limited relevance to other jurisdictions. For a soft cover, this book is not cheap. Finally, there are few references, although each chapter concludes with a recommended reading list.

With these provisos, the book can be highly recommended to medical students and to non-psychiatric residents who are interested in a readable and practical introduction to psychiatry.

Psychosocial Factors in Pain

Psychosocial Factors in Pain: Critical Perspectives

Gatchel RJ, Turk DC, editors

New York: The Guilford Press; 1999. 510 pp. with index

ISGN 1-57230-285-2

The preface to this book stakes out its claim. We are told that 4 main developments, each involving psychologists, served as the impetus for a revolution in thinking about pain. This revolution consists in the rejection of a “medical model” in favour of a “bio-psychosocial approach.”

The volume comprises 30 chapters. Of these, the first 9 make up Part I, on biopsychosocial context. In Part II 11 chapters deal with special topics and populations, and Part III provides 10 more on issues in prevention and management. The book finishes with an overview on resolution and evolution. Three out of the 43 authors of the 30 chapters are physicians dealing with pain and AIDS (a magnificent review), the epidemiology of low-back pain, and work style and work-related upper extremity disorders. There is an epidemiologist or two, a dentist with qualifications in psychology, and almost all the rest are psychologists dealing with pain. These include 3 Canadians (Gagliese, Katz and Melzack), Flor from Germany, and Main (from Glasgow and now Manchester).

The great bulk of the material reflects the work and views of US psychologists and their special psychosocial context.

This is a long volume, well produced and full of information, often very well worked out. The text itself is easy to read and very solidly written for the most part. Some chapters are excellent in whole or in part, while others seem to exist only to disappoint.

It is an irritating pity that what could have been a superb volume is marred by 2 faults of emphasis. One is needless special pleading and the other is an ill-founded, albeit highly sophisticated, tendency to revise the understanding of what it means to favour a back-pain disability model.

The special pleading begins with the listing of 10 contributors to the psychological approach. Three of these were actually physicians but not identified as such. More important, and tellingly, there is a lack of understanding or recognition that psychosocial factors have always been strong in medicine. Psychologists now dwell in a field long inhabited and not relinquished by internists, family doctors, neurologists, psychiatrists and a host of others.

Psychologists are much more numerous than psychiatrists in the field of pain and have made great contributions, starting with Hebb and Melzack. But some of their contributions (e.g., behavioural therapy of pain) remain controversial, and the field in which they have gained most recognition and added most to the subject appears to be cognitive treatment, which, incidentally, was applied to pain by a psychiatrist, A.T. Beck. Thus, what should have been a friendly and sociable claim to have made a large contribution has been spoiled by exaggeration.

More important, the way in which the biopsychosocial construct is now treated serves to reduce the biological element and to suggest that pain is largely due to psychological causes. I partly made that mistake myself and can sympathize, but the fact is that we have very few genuine indications that pain for which physical explanations are lacking is due to psychological causes except when it occurs with or after the onset of an obvious affective disorder. In other cases, and especially with musculoskeletal pain that arises with questionable indications of psychological difficulty, there is insufficient evidence to support the view that pain is due to vaguely alleged “behavioural factors,” but there is growing evidence from systematic controlled investigations that the determining factor is the state of the facet joints or degeneration (not prolapse) of intervertebral disks.

One of the most insidious practices connected with rejecting the patient’s pain consists in describing correlated information as “predictive.” Every psychologist knows that correlations do not demonstrate a causal link, except when there is a serial position, and should not be thought of as a causal consequence. Yet the insinuating word “prediction” is used repeatedly to corroborate some argument for psychological causation.

I do not want to leave the impression that Gatchel and Turk, as editors, make no attempt to acknowledge evidence that complicates their message. They recognize much of it. However, overall the book states the problems softly when they relate to weaknesses in psychological achievement, and overstates the failures of the organic approach. This is the more distressing because the authors and editors have all made significant contributions in the past, and continue to do so. Unfortunately, as one of my colleagues puts it, those who state their adherence to the biopsychosocial approach most loudly do not appear to be as serious about the “bio-” element.