Posts Tagged ‘psychotherapists’

The American Psychiatric Press Textbook of Psychiatry

The American Psychiatric Press Textbook of Psychiatry, 3rd ed

Robert E. Hales, Stuart C. Yudofsky, John A. Talbott, editors

Washington (DC): American Psychiatric Press; 1999. 1762 pp. with index

ISBN 0-88048-819-0 (cloth)

As would be expected of both the American Psychiatric Press and the American Psychiatric Association as an organization, the latest edition of the Textbook of Psychiatry, edited by Hales, Yudofsky and Talbott, is an impressive book. Members of the editorial board, the international advisory board and the individual chapter authors, make up a Who’s Who of modern psychiatry, although with a strong American bias. As examples, the chapter entitled “Psychiatric education” is written by Jonathan Borus, “Clinical neuropsychiatry” by Jeffrey Cummings, contributions on hypnosis and dissociation are provided by David Spiegel, and “Group therapy” is by Irvin Yalom. Thus, in most cases, the chapters have been prepared by leading experts in a particular field.

But there is a problem. In many ways, it is one that is illustrated, in parallel fashion, by the inclusion of DSM-IV on CD-ROM in a kind of “book within a book.” The CD-ROM is fun — easy to load on the computer and browse through but, in the end, not particularly useful. It comes on a CD-ROM, so cannot be downloaded, which means I have to choose whether to leave it at home or at work. More important, apart from providing another way to look up something (and I still think picking up my well worn mini DSM, which opens automatically to the Global Assessment of Functioning Scale is quicker), it really doesn’t do much. You can search key words on it, and find out how many diagnoses include anhedonia in the description of symptoms, and you could cut and paste sections from the DSM into other documents, but apart from that relatively restricted use, it just doesn’t seem to have a role.

Similarly, the question arises: What is the purpose of a large textbook like this now? Is it to provide a quick reference source for the field of psychiatry, a state of the art presentation of the field or a study tool for residents preparing for their fellowship examinations? Should it provide sufficient depth of discussion of topics to allow clinicians to expand their practical skills and knowledge substantially, making the book a large one indeed, or is it designed to provide overviews of complex fields?

Clearly, a textbook, no matter how well produced, is not going to be a state of the art presentation for long, although this one does an admirable job. As a reference tool, the textbook varies in its ability to deliver. The depth of discussion is limited by size constraints so, for example, important advances such as Linehan’s work on dialectical behaviour therapy for personality disorder, are presented and described, but not in sufficient depth to do more than stimulate interest. Autistic disorders are discussed fairly thoroughly, but little useful discussion of autism in adults is provided, even though the section is clear and well written. Finally, the chapter on group therapy restricts most of its content to a focus on the interpersonal orientation of Yalom, without providing a broad overview of writing on psychodynamic groups, cognitive behavioural groups or psychoeducation groups and the roles of these in various illnesses.

This limits to some degree the value of the book as either a quick reference or a study tool for residents, and yet this limitation, with some minor exceptions, stems more from the restrictions of the art of the textbook in current medicine than from the limitations of the authors. The expansion of knowledge in any field may have pushed the limits beyond that which is practically encompassed in a comprehensive textbook. Despite my earlier comments, overall, this is a good textbook. Chapters are generally very well written and ideas presented clearly. In most cases, key, up-to-date references are included. Clearly, the editors have run a tight ship to ensure publication of a textbook as up-to-date as possible.

Organization is fairly standard, with chapters on the theoretical foundations of psychiatry, a section on assessment, a section focussing on the disorders of psychiatry (following the DSM system of classification) and one on treatments. The editors avoided the pitfall of excessive reliance on DSM by setting chapters in the final section on topics such as violence, an area not well classified in DSM.

There are some excellent sections. Despite the loss of prominence of psychoanalytic theory politically, there is an excellent chapter by Robert Ursano and Edward Silberman on psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy. It reviews important writings and research and includes an extremely useful section looking at a comparison of psychodynamic, interpersonal and cognitive therapies, and pointing out the similarities and common roots that are often forgotten or ignored in debates between proponents on the relative merits of each.

The one main drawback for an international audience, is that this text is ultimately an American one. The chapters on psychiatric education, and law and psychiatry are about medicolegal psychiatry and education in the United States. “Public psychiatry,” “Managed care and psychiatry” and “Psychiatry and primary care” are written about US models and experiences of these fields; therefore, for example, the work by Kates and others on a shared care model for psychiatry and primary care is not included. This is unfortunate because the discussion on any of these areas could, with relatively little expansion of content, be greatly enriched by the inclusion of the experience in other countries. Including differing perspectives on the legal handling of dangerousness in the psychiatrically ill, or different models of postgraduate education in psychiatry, would not only benefit readers from other countries but could expand the dialogue on these issues through contrast and comparison. After all, many of these systems evolve in a particular way for historical reasons that may not always reflect the only or the best solution. Given the inclusion of an expert international advisory panel, it is unfortunate that the textbook falls short in this way.

Textbook of Psychiatry from the American Psychiatric Press is ultimately a pretty good textbook. It is comprehensive, well written and up-to-date. It is limited by its very nature, but if one feels that one does need such a book, then this book is competitive with any other in the field. It is unfortunate that it is limited by being essentially an American textbook. Relatively minor changes could have made it a truly international one, of use to both an American and an international audience.

The Insider’s Guide to Mental Health Resources Online

The Insider’s Guide to Mental Health Resources Online

Grohol JM

New York: The Guilford Press; 1997. 326 pp with index

ISBN 1-57230-262-3 (cloth)

ISBN 1-57230-229-1 (paper)

This book is the sixth in the “Clinician’s Toolbox” series. The author, John M. Grohol, is a psychologist whose credentials and training are not specified but who has developed a reputation as an expert in psychological informatics. At his Web site (grohol.com), he informs consumers and answers simple questions about mental disorders and treatment. He apparently has a broad, in-depth knowledge of mental health resources on the Internet.

The author’s objective is to initiate the busy clinician to the World Wide Web; he guides the reader to what’s available and where to find it online so as to avoid surfing aimlessly. He critically evaluates numerous Web sites, making our journey into cyberspace easier.

The book is well organized and is divided into 4 parts: the first contains basic maps and tools for finding mental health information online; the second involves getting answers to your professional questions; the third is on patient education resources; and the fourth contains appendices and a useful glossary. For the novice Web-surfer, the first part is a very helpful introduction to the major resources online and the way search engines work. (Formulating a search question properly is essential to obtaining relevant information, whether it is a MEDLINE literature search or a search for a specific self-help group.) The second and main part of the book has specific chapters on finding information about disorders, treatments, employment opportunities and continuing education as well as on researching, networking and finding useful books, journals and software online. In one chapter, the author discusses psychotherapy and counselling online, and he clearly states the ethical issues involved. The third part contains 3 chapters listing patient-education resources and includes consumer mailing lists and news-group discussion and support groups. The fourth part has 4 appendices, one of which is a brief introduction to creating your own Web site.

I found the book to be free of errors (except for 2 minor ones) and easy to read. As a psychiatrist, though, I take exception with the author’s bias against electroconvulsive therapy. On page 195 he writes, “radical treatments such as electroconvulsive therapy (ECT)” and, on the next page, “About the only useful thing this site does offer is information on the pitfalls of ECT.” Elsewhere, he states his own biases clearly and reasonably.

One of the redeeming qualities of the book is the frequent reference to the “Insider’s Guide” online update page, which at the time of writing contained 3 pages of updates — mainly changes to uniform resource locators (URLs) and notices of “bad” links. Without such an update, this book would become outdated very quickly.

In conclusion, this book can help allay a middle-aged novice’s fears of the Internet and add another dimension to the communication of information, both among doctors and between doctors and patients. Although the book is targeted to a larger readership than the subscribers of this journal, it contains enough relevant material for me to recommend it to psychiatrists as well as allied health professionals interested in “psych” online.

The Clarke and Its Founders: The Thirtieth Anniversary

The Clarke and Its Founders: The Thirtieth Anniversary. A Retrospective Look at the Impossible Dream

D Frayn, editor

Toronto: Coach House Press; 1996.181 p

This is a book about the Clarke Institute of Psychiatry. Essentially, it presents a series of interviews of past and present luminaries, with Doug Frayn acting as interviewer and editor. Frayn, as a distinguished psychoanalyst, allows himself a piece of puffery regarding the title. Noticeably, all the comments in the book, and more so in the references, are idiosyncratic. Each of us trained, matured, and gilded at the Clarke will cherish different memories. That they may matter to others is a nice thought, but not critical. As Frayn would endorse, our memories are our delight as well as torment.

I was at the Clarke Institute for almost a quarter of a century, and I savor some memories, laugh at others, and see poignancy in yet others. I remember Robin Hunter, on my coming from Australia in 1971, looking astounded at the cost of removal and declaring he never had such an expensive relocation. Shortly after my arrival, I recall having been honored with an invitation to the monthly Friday-night poker game at his house and being mortified at being jejune, not having played for many years. In the end, however, by 06:00 on Saturday, I’d only lost $100! As I reflect on the decency of Robin Hunter, who always ate at noon at the same table on the 12th floor and was patient about and receptive to anxious questions, crass remarks, and timid jokes, I bear in mind his concerns expressed at the same table before his exploratory surgery, which led to his premature death.

Other events have become a kaleidoscope. Harvey Stancer ran the research ward and was a great chief. He always had his staff back to his house for parties and genuinely cared for them: he was the quintessential chief of service. I remember antivivisectionists bombing the research wing with a very serious risk to life and limb there; Ben, the barber, who cut our hair and would look pained if we went elsewhere; Molly, who presided over the cafeteria; and Siebert, who delivered the mail while singing hymns. I recall the ongoing obsession with rebuilding — the Clarke must have been built and rebuilt many times from within, producing many rooms with no soundproofing so that the secretaries had to play their radios to avoid hearing their bosses’ psychotherapy interpretations. There were also the maintenance staffs Christmas parties in the basement; the Christmas shows; the transsexuals with skirts and large boots waiting on the 4th floor for treatment; the patients with schizophrenia who used the place as a hotel; and the staff and patients who smoked outside the building together when the no-smoking legislation was passed.

Now we are somewhat at a nadir. The Clarke as I knew it has changed and is due to merge with Queen Street Mental Health Centre. The scenario will change, and things may never be the same again. Nevertheless, the same thing must have been said many times in the past 30 y. Change has been inevitable at the Institute, without necessarily being beneficial. Ironically, Charlie Roberts, the Clarke Institute midwife, recently died at about the time the Clarke was told it would lose its free-standing, unique place in Canadian psychiatry. Although he was not seen much at the Clarke during its 3 decades of existence, he surely would be 1 of the only people who could have said what the original dream was.

Those wanting to see how the work tallies with their own dreams and memories should read the book.

Clinical Guide to Alcohol Treatment

Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach

RJ Meyers, JE Smith

New York: Guilford Press; 1995. 215 p

Robert Meyers from the Centre on Alcoholism, Substance Abuse and Addictions (CASAA) and Jane Smith from the Department of Psychology, both from the University of New Mexico, have authored a pragmatic “how-to” instruction book on the Community Reinforcement Approach (CRA) to alcohol treatment. CRA is listed in the US Institute of Medicine’s report on alcohol problems as a contingency management approach designed to provide focused behavioral training to persons with chronic alcohol problems (Institute of Medicine 1990). This approach remains unfamiliar to many clinicians in the field although several grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse have been provided to enrich its research basis.

The 1 st chapter outlines the approach’s empirical pedigree dating back to the work of NH Azrin and his group in 1973. The reinforcers used were access to family, to jobs, and to friends, which were contingent on sobriety. In a series of trials, CRA procedures improved the outcome of traditional 12-step programs, monitored disulfiram compliance, and enhanced an alcohol-free recreational environment as well as the involvement of concerned others. These procedures have also been applied to the management of cocaine and heroin abusers and, more recently, to an alcohol-abusing homeless population.

The book’s main contribution lies in the next 10 chapters. Five chapters provide detailed instruction in the CRA assessment procedure, an intriguing approach to facilitating a client’s acceptance of the need for sobriety through a contractual “time-limited sampling” period, the optimal use of disulfiram, and the planning of a treatment protocol using a quality of life scale and identification of counselling goals. The remaining chapters describe procedures to be used for behavioral skills training as well as coping strategies at work, in one’s social interactions and significant relationships, and in relapse prevention.

The highlights of the book for me were the tables appended at the end of each chapter that could be readily adapted by therapists to their own practice. The book is a good primer for those interested in developing their cognitive-behavioral skills with substance abusers. Some procedures may be more controversial or dated than others. For example, recent studies have provided mixed evidence regarding the usefulness of disulfiram (Institute of Medicine 1990). Will the use of naltrexone replace disulfiram as a preferred pharmacotherapy?

As highlighted by the Director of the Research Division at CASAA, Dr WR Miller, many of the procedures included in the original CRA trials, such as motivational preparation and early relapse prevention strategies, have become important elements in today’s treatment programs and have gained more recognition than their predecessors. Elements of the CRA have been incorporated as part of the cognitive-behavioral intervention to be tested in Project MATCH (1994), the current NIAAA-funded multisite clinical trial of patient-treatment matching.

This book’s content is suitable for a multidisciplinary team dedicated to the field of addiction and for the psychiatric resident or psychiatrist searching for ways to enhance his or her skills with this challenging population. The cost of the book is reasonable.

Medical-Psychiatric Practice

Medical-Psychiatric Practice. Volume 3

A Stoudemire, BS Fogel, editors

Washington (DC): American Psychiatric Press; 1995. 625 p.

Medical-psychiatry (alias consultation-liaison psychiatry, alias psychosomatic medicine) continues to have an identity problem. This is exemplified by its continued search for a name and also by continued uncertainty about its defined area of knowledge. In the United States of America, perhaps more so than in Canada, it is also being affected by economic factors involving health insurance coverage.

In their preface to this the 3rd volume of their series covering the field of medical-psychiatric practice, the editors review the crisis taking place in American psychiatry. They focus on 3 factors: the economics of health care, which discourages referrals to consultants and other specialists; pressure and competition from nonmedical professionals; and the difficulties of recruitment of medical graduates into psychiatry. These difficulties, ironically, are occurring at a time when psychiatric therapies are not only clinically effective but also economically efficient. The editors recommend that the most effective way for psychiatry to counter these pressures is to maintain its close connection to the medical model but to emphasize also its base in the social sciences and humanities. There is no other professional discipline that bridges these spheres of knowledge to an equivalent degree, and the subspecialty of medical-psychiatry is at a leading edge of this development.

The 10 chapters in this volume deal with psychopharmacokinetics and psychopharmacology in medical patients, psychosis in Parkinson’s disease, psychiatric aspects of systemic lupus, HIV infection, bone marrow transplantation, and mild traumatic brain injury. The book also includes chapters on “chemical sensitivity” syndromes and on vulvodynia.

All the chapters are well referenced and have a comparable structure suggesting good editorial control. I particularly appreciated the scholarly and sensitive way that the complex topics of brain trauma and chemical sensitivities were discussed. Chemical sensitivity is a politically explosive area that, whether we like it or not, is assuming increasing importance in the clinical practice of many psychiatrists.

The 3 volumes of this series as a whole can be criticized for the apparent lack of an overall plan. Some topics are dealt with intensively and comprehensively, for example, psychopharmacology, HIV, and the neurological aspects of psychiatry; others are dealt with poorly or not at all, for example, respiratory, gastrointestinal, musculoskeletal, and conversion disorders. This suggests that the editors themselves are not certain which areas should be covered in a compendium of medical psychiatry. These shortcomings make it difficult to recommend this series as the “Bible” of medical-psychiatry. They are likely best used as reference books for residents and psychiatrists requiring updated reviews on particular topics. For this purpose, these volumes can be highly recommended.

The cost of this book was not available in the book reviewed.

Psychopharmacology: The Fourth Generation of Progress

Psychopharmacology: The Fourth Generation of Progress

FE Bloom, DJ Kupfer, editors

New York: Robin Press; 1995. 2002 p

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

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

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

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

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

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

Behavior Therapy in Psychiatric Hospitals

Behavior Therapy in Psychiatric Hospitals

PW Corrigan and RP Liberman, editors

New York NY: Springer Publishing Company; 1994.244 p

Corrigan and Liberman have pulled together an assorted collection of clinical reports on the application of behavior therapy techniques to patients in psychiatric hospitals and a few other settings. These settings include Liberman’s research unit at Camarillo, a forensic unit at Fulton State Hospital in Missouri, a unit at the Albuquerque VA Medical Center, a psychiatric hospital in Munich, Germany, an adolescent ward at a private California hospital, a behavioral medicine unit at the University Health Sciences Center in St Louis, the Therapeutic Contracting Program from McLean Hospital Harvard Medical School, a ward in a state hospital in New York City, and a unit at Tinley Park Mental Health Center in suburban Chicago.

There are also chapters, more general in focus, on implementing and maintaining programs and on selling them in the “Health Care Marketplace”. Most of the programs are token economics or variants thereof.

This book is well on the way toward anachronism. Focusing as it does on the impersonal and manipulative aspects of rewarding people for desired behaviors, it is very much out of step with the current increasing value being placed on patients’ rights and on patients’ active participation in their own treatment programs.

The accounts of programs tend to be anecdotal or didactic rather than research-oriented or scientific and, in that respect, there is really nothing here that supersedes Paul and Lentz’s (1977) definitive study of almost 20 years ago. However, the book can provide at least some food for thought for those working with long-hospitalized, chronic patients. These patients are now a highly selected group, since bed closures and fiscal restraints, and mental health reform have led us to discharge, and try to maintain outside the hospital, all but the very sickest patients. This group of patients provides an interesting challenge to those few remaining professionals

who work with them. Thus, besides making us aware that there is still a group of die-hards doing behavior therapy and even running token economies, albeit with increasing difficulty, Corrigan and Liberman’s book can make us aware of a few methods that can supplement the meagre, available therapy armamentarium for such patients. We must remember to use them in a more collaborative and less high-handed way, however.

Concise Guide to Neuropsychiatry and Behavioral Neurology

Concise Guide to Neuropsychiatry and Behavioral Neurology

JL Cummings and MR Trimble

Washington DC: American Psychiatry Press Inc; 1995.275 p

Psychiatry is heading, willy-nilly, down the subspecialty route. Child, geriatric and forensic psychiatry are already recognized as subspecialties, and others such as psychotherapy and consultation-liaison psychiatry are following closely. Unfortunately, subspecialization is progressing in a disorganized manner, and this leads related subdisciplines such as neuropsychiatry and consultation-liaison psychiatry to evolve in parallel. Often, little effort is made to cohere or even to collaborate.

The authors of this small volume define neuropsychiatry and behavioral neurology as “clinical disciplines devoted to understanding and treating behavioral disturbances associated with brain dysfunction” (p 1). This definition seems restrictive and appears to rule out, by definition, the psychosocial aspects of neurological practice. Therefore, neuropsychiatry, according to these authors, does not follow the biopsychosocial model. The first author is a professor of psychiatry and neurology at the University of California at Los Angeles (UCLA) School of Medicine, and the second is a professor of behavioral neurology at the Institute of Neurology, London, England.

Initial chapters are devoted to assessment, neurobiology and psychiatric syndromes. The rest of the book is devoted to neurological syndromes such as epilepsy, dementia, stroke and head injury. Each chapter is concise, and frequent tables list and summarize relevant points. The text is clear, readable and nonrepetitive. No references are given in the text, but there is a useful reading list at the end of each chapter.

Despite the authors’ restrictive definition, I was surprised by the total absence of any reference to somatoform disorders or to the psychosocial aspects of neurology. Somatoform disorders form at least 14% of a neurologist’s practice (Mai 1995). One would have thought that any clinical textbook that included the word “behavior” in its title would also cover the field of illness behavior. However, one looks in vain in this book for any recognition of the existence of illness behavior, conversion or somatization. Even the brief description of pseudoseizures fails to mention that they may have a conversion basis. The authors do not explain the reasons for this omission, but it is likely the result of their chosen focus on neurological disease.

This approach reminds me of the old story about the drunk who returns home late at night to find he has lost the key to his front door. He then confines his search to the area around the street light, because “that’s where the light is”. The authors of this volume have similarly chosen to ignore the darker areas of neurology which, inspite of themselves, affect the clinical practice of this discipline.

In other respects, the book provides a useful and concise description of the field within die confines set by the authors. It could be of value to residents, psychiatrists and neurologists with an interest in this field. It is expensive for a soft-cover book.

Effective Use of Group Therapy in Managed Care

Effective Use of Group Therapy in Managed Care

K. Roy MacKenzie

Washington DC: American Psychiatric Press, 182 pp., 1994.

Managed care is clearly an area of current and growing concern for psychiatrists. Even in jurisdictions where managed care itself is not currently part of the practice climate, the containment of cost and measurement of efficacy of treatments are central to health care planning. In some ways it is surprising that a book like this has not appeared earlier, as the face validity of group therapy as a cost containment measure seems obvious.

This book is one of the American Psychiatric Press’ Clinical Practice Series and, hence, is a relatively succinct outline of both the potential role of group therapy in managed care systems, and some of the possible forms that such treatment systems may take. Thus, the book includes chapters on the rationale for group psychotherapy in managed care and an overview of managed care and competition. It also includes several chapters on various forms of group therapy systems that have been devised for such varying clinical populations as the seriously mentally ill, personality disordered patients, depressed patients and individuals who have experienced loss. There is, however, nothing dealing specifically with patients at either end of the age spectrum — children and adolescents, or the elderly.

The book draws on contributions from an impressive group of authors, and is, therefore, able to reflect in many ways the state of the art in group therapy systems. The editor, Dr. Roy MacKenzie, is an experienced and well-known group therapist who has worked in both Canada and the United States, giving him a useful perspective on managed care. The other authors include such highly respected names as Dr. William Piper, Dr. Howard Kibel and Dr. Walter Stone.

The strength of the book and its greatest value lies in its ability to challenge the reader to think creatively about service delivery in psychiatry and psychotherapy. Anyone who is looking at the issue of providing effective and efficient psychotherapeutic interventions for a patient population would be well-advised to consult this book, both for its usefulness in presenting what has been done and, hence, stimulating one to think creatively about service delivery, and for the ways that several of the authors have attempted to measure the effectiveness of their work. If one is thinking of setting up a new treatment system or trying to assess the effectiveness of an ongoing psychotherapy service, the chapters in this book provide useful models.

Despite its claim on the cover to “provide a solid understanding of how group programs work,” this book is not a textbook of group therapy. It will not help someone learn how to provide effective group therapy. It will instead help an experienced therapist expand his or her horizons. It is not an extensive examination of the technique, but rather an excellent overview of the possibilities of group therapy.

Group psychotherapy is frequently treated as the poor cousin of individual psychotherapy. MacKenzie’s book goes some way to show that group therapy may, in fact, have an extremely important role to play in the future, as we are increasingly forced to examine the efficiency and effectiveness of our treatments in psychiatry.

Seminars in Basic Neurosciences

Seminars in Basic Neurosciences

Gethin Morgan and Stuart Butler

College Seminars Series (Royal College of Psychiatrists), London: Gaskell, 328 p., 1993.

The following remarks fall into two parts: first, a review of the book listed above; second, some comments on the place of the neurosciences in current psychiatry.

The title (with “Basic Neurosciences” placed in a prominent box on the cover) might suggest that this book is a rival to such a text as that by Kandel et al (1991) on “Principles of Neural Sciences”. This small volume, however, has a different purpose, namely, that of instructing clinical trainees in psychiatry to those aspects of neuroscience which may be of value to the practising clinician (and in meeting examination demands). In fact, it incorporates far more than the basic neurosciences as conventionally understood for it includes, in addition, a concise course in clinical neurology. Perhaps a future addition might reflect this in the title. Two important features should be noted at the outset. First, it is written by “contributors…experienced as teachers of clinical trainees.” Second, “there are many figures, diagrams, tables and boxes to make the information accessible and more easily absorbed”.

The contents of the book fall into nine chapters with short reference lists. They will now be considered seriatim; (the figures in parentheses indicate the page lengths of each).

“Functional neuroanatomy” (41) Butler: This chapter provides, in brief form, a standard account of relevant neuroanatomy. It includes an excellent diagram (Figure 1.14) on the limbic system and its connections.

“Neurophysiology” (28) Logan: This chapter is a concise account of synaptic transmission and, thereafter, reflex phenomena in the sensory and motor sphere. Diagrams are less plentiful but usually useful (for example, Figure 2.5 as opposed to Figure 2.4) (One wonders if the busy clinician will ever have recourse to the complex connections of the cerebellum portrayed in Figure 2.4 – unless it is a particularly slow day).

“Neurochemistry and neuropharmacology” (40) Nutt: This chapter is one of the best chapters in the book. Written by the Director of the Psychopharmacology Unit in the School of Medical Sciences at Bristol University, it deals succinctly with receptors and the mechanisms by which the ever-increasing numbers of psychotropic drugs are presumed to work. While the diagrams are excellent, the tables are outstanding. Figures 3.6 and 3.8 together with Tables 3.1,3.2 and 3.6 are superb summaries of current knowledge and Dr. Nutt deserves our gratitude and congratulations. The book is worth buying for these alone.

“Neurological examination and neurological syndromes” (38) Barrett: This chapter gives a remarkably complete account of clinical neurology as well as the neurological examination. Here summarized information given in “boxes” varies in utility from good 4.3 (classification of epileptic seizures), 4.5 (causes of dementia) to poor 4.4 (causes of epilepsy), 4.6 (causes of delirium). Simply listing seventeen or thirteen items in a “box” without any attempt at organization is daunting, not helpful. Nonetheless, to cover so well a wide area in such a small space does credit to the author.

“Neuropsychology” (34) Hallett: This is another excellent chapter. In Hallett’s own words, “neuropsychology offers a robust system for the measurement and quantification of cognitive function, emotional state and behavioural repertoire…” and is a “complementary system of analysis to psychiatry.” The chapter goes on to detail what psychology can and cannot do in this area. As an even-handed exposition in a small space I doubt if this chapter could be bettered. The appendices are admirable summaries of relevant tests.

“Neuropathology” (34) Luthert: This chapter provides the pathological complement to Barrett’s chapter. After discussing techniques and basic pathological processes, the writer then surveys most of the common neurological diseases. Most relevant to psychiatry is the excellent and concise account (in six paragraphs and one table) of the changes in Alzheimer’s disease. The “boxes” in this chapter are outstandingly good, for example, 6.2 (time course of events following focal occlusion of a cerebral vessel) and 6.3 (routes of infection.)

“Neuroendocrinology” (25) Gilbey and Macrae: This chapter provides a good survey of the field and here excellent diagrams are a feature (Figures 7.1, 7.3, 7.4 and 7.7). This section is particularly valuable since it collects together in one place information which is much less accessible to most of us than the content of many other chapters of this volume. Table 7.4 and 7.5 (psychiatric manifestations of endocrine disorder and endocrine manifestations of psychiatric disorders) are very helpful.

“Clinical neurophysiology” (SS) Hilary Morgan: This chapter deals successively with techniques of recording the EEG, its normal appearance and the changes occurring in metabolic and toxic states and following treatment (including ECT). After an account of changes in the various neurological disorders, there is then a special section devoted to epilepsy. The facts are encapsulated in the “mother of all tables” 8.1 which runs over four pages. Pages 281 to 283 contain important summaries on violence, epilepsy and the EEG; the EEG and episodic behavioural changes and schizophrenia and affective disorders. There is a short account of sleep and the EEG (now a subspecialty of psychiatry with its own testing examination) and the chapter concludes with mapping (including power spectral analysis) event-related potentials and evoked potentials. Instead of boxes there are numerous illustrations of the EEG in various conditions.

“Neuroradiology” (12) Bradshaw and Lewis: After discussing the various techniques in this chapter (plain radiography, angiography, CT, MRI, PET and SPECT), the authors survey successively the spine, congenital lesions, vascular disease, trauma, neoplasia and finally degenerative, metabolic and toxic disorders. There is an introductory and minatory warning against the temptation to scan large numbers of psychiatric patients in the hope of “finding something”. But there are replicable findings, for example, the ventricular changes in schizophrenia and changes in rCBF and glucose metabolism in dementia which deserve discussion. This could with profit replace the account of radiology of the spine. And the use of PET and SPECT to study a wide variety of neuroreceptors is surely of interest (Daniel et al). There are missed opportunities here.

“Appendix and index” The former contains a map of cutaneous innervation and a table of reflexes. There is an excellent index compiled by Linda English.

At first sight, the chapters appear uneven but to a degree this reflects the subject matter. It is easier to be enthusiastic about the latest findings in the brains of patients suffering from Alzheimer’s disease than to get excited over the corticothalamic tracts which haven’t changed much in the last few centuries. But this would be a very unfair reflection on the authors who have produced remarkably good summaries of their areas which, despite brevity, are readable, thanks in large part to the lavish use of boxes and diagrams which contribute to the success of this enterprise.

One could always argue with the editors about allocation of space to the different subjects. Thus, in considering diagnosis, many would put neuropsychology first followed by radiology, endocrinology and the EEG last; yet the pages allotted are 34, 12, 25 and 55 respectively. But the editors are presumably tuned to local needs and the requirements of examinations. (And the pages on the EEG are inflated by numberous multichannel illustrations).

In sum, this excellent volume provides in one place an extremely useful, concise and up-to-date compendium of clinical neuroscience and neurology. If the trainees absorb the contents then they will be well-equipped to deal with the increasing pace of change due to new research findings which, judiciously and selectively, they may wish to incorporate into their clinical practice.

If we accept the view that mental activity is based on brain activity then a knowledge of the basic neurosciences becomes essential. It is true that a few still hold to the dualist view, notably Sir John Eccles and the late Sir Karl Poppers, but most in the field are less defeatist and believe that eventually most mental activity will correlate with neuronal events. There are indeed notable successes to date which are recounted in the volume by Kandel et al (1991) already cited. Kandel’s work on anxiety and the synapse is a classical example of the progress being made.

Nonetheless, to the practising clinician the different neurosciences have varying relevance. Can we not, then, leave some to the specialist? While it is customary to defer to individual experts in, say, radiology or endocrinology, it is still essential, in this reviewer’s opinion, that the clinician have enough general knowledge not only to know what the different disciplines can provide but also to be able to interpret oneself in relation to any individual patient and at times overide the expert.

Some would even go further and deny the need for medical training. Thus, psychologists in the US have sought admission privileges and the right to prescribe drugs. Without full medical training including the neurosciences such a course is fraught with hazard. But if clinicians themselves do not use their medical skills then it becomes more difficult to answer the pressures of competitive professions. However, there is an increasing shift from consultation-liaison psychiatry to medical psychiatry defined by Stoudemire and Fogel (1987) as “a medical specialist who assumes primary responsibility for the diagnosis and treatment of psychiatric disorders within the medically ill population.” They go on to list the reasons for its growing importance as follows: “(1) the increasing prevalence of chronic disease and the aging of the population, (2) advances in neurodiagnostic techniques and psychopharmacology, permitting more rational biological therapy of psychiatric disorders in the medically ill, (3) the development and implementation of brief, focused dynamic psychotherapy techniques appropriate for the medical setting, (4) the development of specialized medical-psychiatric inpatient units, (5) increasing time pressures on other medical specialists, leaving the psychiatrist as the only medical specialist with the time, knowledge, and skills to develop a comprehensive understanding of the emotional dimensions of medical patients’ illnesses, and (6) increased competitive pressures from non-medical psychotherapists, causing psychiatrists to emphasize their medical training and skills.” The role of the basic neurosciences in the above needs no emphasis.

If, indeed, psychiatrists do not pay attention to these areas then psychiatry as a discipline will diminish and may vanish. Our patients will be the big losers. That dire consequences are already upon us is exemplified in a recent editorial by Robin Eastwood (1994). He notes that both by competition from other specialties and by default psychiatry is losing its place in dementia research in Canada. This displacement is occurring elsewhere too and he quotes a Lancet editorial which “says that dementia, especially basic research, is now indeed the domain of neurologists and that even schizophrenia is not exclusive to psychiatry anymore.” If, in fact, psychiatry has decided to concentrate on the “functional” psychoses, he concludes “how sad that the magnificent start given by Kraepelin and Alzheimer at the beginning of the century, at the Ludwig-Maximilians-Universitat in Munich, has come to this in Canada.”

This reviewer hopes the volume edited by Morgan and Butler will help stop the rot.