Posts Tagged ‘Psychotherapy’

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.

Biology of Personality Disorders

Biology of Personality Disorders

Annual Review of Psychiatry series

Silk KR. Washington: American Psychiatric Press; 1998. 156 pp

ISBN 0-8804-883-52

This book, part of the Annual Review of Psychiatry series, is a multi-authored text comprising 5 chapters by recognized authorities in the field. The topic is of interest because of the increased activity in the area of personality disorders over the past decade and a half with respect to typology, research and new treatment approaches. This book focuses on research into the biological aspects of personality disorders over the last 10 years or so. As Silk points out in the Foreword, earlier studies of biological correlates of personality disorders did not lead to clear conclusions because of lack of appropriate separation between personality disorders and Axis I disorders. The “second-generation” studies have focused on the core negative traits of personality disorders (e.g., impulsivity, aggression, cognitive disturbances and affective lability, which cut across most personality disorders) and sought to understand their biological underpinnings.

The first 2 chapters of the book review and discuss the biological research in the field, including research strategies employed, the results of some of the most important studies and the implications for further development.

The first chapter, by Coccaro, reviews studies of neurotransmitters that are significant for personality functioning. The most important of these are serotonin and the cate-cholamines, including dopamine and norepinephrine. The studies are reviewed under categorical headings including cerebrospinal fluid (CSF) metabolite studies, pharmacological challenge studies, platelet receptors and DNA in polymorphism studies, etc. The studies consistently find an inverse relation between CSF 5-HIAA levels and impulsive-aggressive behaviour.

There is a smaller body of research into the role of acetylcholine and vasopressin, which shows that acetycholine does contribute to affective lability.

The second chapter, entitled “New Biological Research Strategies for Personality Disorders” by Siever and colleagues, complements the first. It reviews studies using a variety of recently developed strategies to study core traits of impulsivity, affective instability and cognitive dysfunction. The strategies vary from neuroendo-crine and cognitive studies that look at the antecedents of neuroendocrine and cognitive abnormalities found in personality disorders, to the use of imaging (positron-emission tomography, single-photon emission computed tomography, magnetic resonance imaging [MRI] and functional MRI) to study neuroanatomical correlates of personality dysfunctional traits such as impulsivity and aggression. There are fewer studies using candidate gene strategies. The author comments on the implications of the findings to date from these areas of investigation.

A particularly creative strategy was the linking of the study of trauma to personality disorders. Trauma has its biological impact on the hypothalamic-pituitary-adrenal (HPA) axis, but trauma is also a major etiologic factor in many personality disorders, including borderline personality disorder (BPD). Studies of the HPA axis changes, such as dexamethasone suppression test (DST) in patients with post-traumatic stress disorder, have been extended to personality disorders as BPD, with the DST pattern more closely resembling that in PTSD than that in mood disorders.

The third chapter focuses on Cloninger’s proposed 7-f actor model of personality, comprising temperamental factors such as harm avoidance, novelty seeking, reward dependence and persistence, and 3 character elements: self-directedness, cooperativeness and self-transcendence. Cloninger makes the case for the neurobiological basis of learning abilities that underlie temperamental traits by summarizing studies of the psychobiological correlates of these traits. He then puts forward a psychobiological learning model based on his review of the neuropharmacological, neuroanatomical and biochemical studies, and on studies of the phylogeny of learning abilities. He concludes by making a strong argument in support of the 7-factor model as a basis for understanding the various dimensions of personality disorder and even the diagnostic clusters. Although much of the material is quite technical, the use of tables and other visual aids is helpful in summarizing and reinforcing the material presented in the text.

The last 2 chapters are more application-oriented. The fourth chapter, by Links, is interesting because of the proposal of an outcome-based approach to the pharmacotherapy of personality disorders. Outcome indicators would be reduction in certain characteristic behaviour patterns, such as repetitive self-injury, that have been shown to have a biological basis. Other outcome indicators include quality of life. The author notes the shortcomings of the current conceptual models of personality disorder as a basis for developing a treatment rationale. The outcome-based model proposes specifically desirable functional outcomes of treatment and more systematic approaches to assessment of the efficacy of medication. This proposal is very much in keeping with the current evidence-based approach to medical practice.

In the final chapter, Paris assesses the significance of research for a biopsychosocial model of personality disorders. The author points out inconsistencies between theoretical assumptions underlying some research strategies and real-world observations, as well as the many confounding factors that complicate the search for one-to-one correlations between biological variables and particular personality traits. Taking a dimensional view of personality disorders as the pathological amplification of normal traits, the author discusses the complicated interaction of biological and environmental factors in producing personality disorders via the diathesis-stress model. He proposes 3 potential research directions: new drugs targeting personality traits, gene therapy, and new forms of psychotherapy based on better understanding of temperament.

Since much of the research on impulsivity and aggressiveness reviewed is common to conduct disorder and attention deficit hyper-activity disorder as well as anxiety disorders in children, one would have expected a discussion of the relation of these conditions to personality disorders in adults. Despite this lack, I found this book to contain more than anticipated. The material in the first 3 chapters was detailed and informative, and the last 2 chapters helped to make it practically relevant. One is left with a feeling that personality disorders are now more real, and that there is hope for more targeted treatment in the future. I certainly recommend it.

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications. CD-ROM

Stahl SM. New York: Cambridge University Press; 1998

ISBN 0-521-62892-X

This CD-ROM is an introductory textbook to the extraordinary complexities of basic and clinical neurochemistry pertaining to psychopharmacology. To make this information lucid, engaging and accessible requires a gifted communicator; Stephen Stahl is such a teacher, whose credentials as a researcher give authority to the concepts, facts and speculations he conveys so clearly.

Since this “book” is in CD-ROM format, any review must consider both the content and the format. The text is structured into 12 chapters and relies heavily on figures and diagrams to illustrate key concepts. The first 4 chapters focus on basic science and provide the foundation for the remaining 8 chapters. Stahl begins with the principles of chemical neurotransmission, including signaling, receptor occupancy, second messengers and co-transmission. He then explains receptors and enzymes as targets of drug action and further explores special properties of receptors in terms of subtypes, agonists and antagonists. He concludes the basic science section with a chapter on the interaction between disease and chemical neurotransmission.

The second section is clinically focused and briefly summarizes the biological bases of mood disorders, anxiety disorders and psychoses as a prelude to explaining and rationalizing the actions and benefits of psychiatric medications — as well as speculating on interventions in the future. Stahl concludes by considering cognitive enhancers, neuroprotective agents and drugs of abuse.

Any one of these basic science concepts, clinical disorders and psycho-pharmacological treatments could easily be the subject of a separate book — one that Stahl himself could probably write. It is a remarkable talent to synthesize, integrate and communicate clearly this wealth of information as effectively as he does. The text is unencumbered by references or wordy explanations. Advanced experts in various areas may sneer at oversimplification (a similar phenomenon occurs when someone makes psychotherapy fundamentals obvious and accessible), but this text is clearly not intended for them.

The ideal readership for this CD-ROM includes medical students, residents in psychiatry and allied health professions, and psychiatrists whose training concluded more than 5 years ago.

This text existed as conventional “hard copy” (what we nostalgically refer to as a “book”) before its current incarnation as a CD-ROM. What is the advantage of the CD-ROM format? It could be an expensive proposition unless you already own an IBM-compatible computer with a 486 or faster processor, or a Macintosh computer with System 7 or 8, at least 16 mB of RAM, Quicktime software, a sound card and speakers or headphones, and a 2 x or faster CD-ROM drive. It is really designed for Macintosh computers, and the author acknowledges that there may be some limitations in using the CD-ROM in an IBM-PC environment. Reading the CD-ROM involves pressing keys and jumping backward and forward between text and figures. The advantages lie in the use of animated diagrams to illustrate neurotransmission concepts, often accompanied by audio narration featuring Stahl himself.

While the animation reflects the elegant synthesis characteristic of the author, it seems rather primitive compared with the sophisticated computer graphics on children’s games. The narration is the weakest of Stahl’s skills: it adds nothing and requires a separate keystroke to activate, when simply reading a caption would be preferable.

Other textbooks on CD-ROM provide more opportunity to print excerpts and take notes on the computer screen. This CD-ROM lacks flexibility. With a book version, I could have scribbled in the margin or photocopied a diagram. In summary, this textbook is superb in terms of content, but the technology of presentation does not facilitate access or understanding. Reading the CD-ROM made me want to buy the book.

Neural Networks and Psychopathology

Neural Networks and Psychopathology: Connectionist Models in Practice and Research

Dan J. Stein, Jacques Ludik, editors

Cambridge (UK): Cambridge University Press; 1998. 371 pp. with index

ISBN 0-521-57163-4 (cloth)

Neural networks are mathematical models of how the mind processes information, just as mathematical equations can be seen to describe the universe. Neural networks can provide the theoretical framework that clinical science lacks for integrating psychological and neurobiological data. This theoretical framework is based on the idea that the brain functions by a process of pattern recognition. Each chapter in this collection, edited by Dan Stein and Jacques Ludik, looks at this process from a unique perspective and, taken as a whole, demonstrates the complexity of the mind arising from basic units and their interconnections.

This book is aimed at a very diverse audience including clinicians, researchers in psychopathology and those working in cognitive science and artificial intelligence. Its chapters are organized into 2 broad sections. The first part of the book presents general concepts. Each chapter demonstrates how neural network modelling can be used to understand clinical practice and research in areas such as diagnosis and psychotherapy. The second part of the book constructs neural network models of various clinical disorders and demonstrates their usefulness in helping improve one’s understanding of the pathologic process underlying these clinical disorders.

A number of important ideas are introduced in the first section. For example, neural network or connectionist models “rely on the idea that almost all knowledge is implicit in the structure of the device that carries out the task rather than explicit in the states of the units themselves.” This means that knowledge is stored in the strength of the connections between units or neurons and not in the units’ moment-by-moment activity. Nevertheless, this activity does affect the strength of synaptic connections through the process of learning. This leads to an important dilemma: How can the brain be plastic enough to learn new patterns as well as stable enough to remember old patterns? Knowledge is stored as patterns of activation of neurons, determined by synaptic connections. This leads to another important concept: the function of the brain is to recognize patterns; and the effectiveness of the brain is measured by how accurately it can match patterns and by how well it can generalize (find similar patterns). When the brain becomes faulty in its ability to correctly discriminate patterns, clinical symptoms such as delusions and hallucinations can arise. Delusional individuals interpret all inputs in the light of some false belief. Any bit of information is used to support this false belief no matter how ludicrous the connection. Conceptually, the delusional brain continually matches all inputs to a specific incorrectly matching pattern; or in other cases, one pattern becomes central in interpreting all inputs. With respect to hallucinations, perception involves the superposition of sensory input with higher cognitive expectations, but if the system is strongly focussed on expectations and ignores sensory input then the system will perceive objects that are not there. Again the brain is unable to correctly match incoming patterns (sensory information) with stored patterns (memory or expectations).

In the second half of the book, specific clinical disorders are modelled, based on the basic principles from the first half of the book. The success of this modelling is both thought-provoking, in demonstrating how underlying neuropathology can result in complex symptomatology, and fascinating, by forcing one to reexamine previous views of psychopathology. The models very nicely integrate neurobiology and psychological data, and because the computer models are working models one can see how the brain might process information. Dan Lloyd looks in depth at how a new memory can affect previously learned related memories and vice versa. This process is addressed in the specific context of traumatic memories. He constructs a computer simulation, called Lucynet, that models human learning based on the most basic neural network theoretical principles. The simulation is exposed to the traumas of Sigmund Freud’s patient, Lucy R. The results of this recreation address several aspects of memory. They support the cognitive research showing that recall is the construction of a memory rather than its extraction from a form of storage. The results also show that repression can result from the inherent process of memory formation rather than requiring the hypothesis of a novel mechanism of the ego as proposed by Freud.

In another chapter, Ira Cohen gives an elegant working model of autism. Working from the neurobiological data, which suggests that autistic people have a greater number of synaptic connections, a greater number of neurons or abnormal wiring patterns in various brain regions, combined with the recognition that autistic children are very poor at generalization, the computer model runs several scenarios of either too few, an optimal number or too many neurons faced with a learning task. “With too few neurons, the computer simulation shows that overall learning and generalization are weak and responses are inconsistent. With an optimal number of neurons, both learning and generalization are good and correct responding is consistent and predictable. With too many neurons, learning is good but generalization is poor and shows relatively little variation.” This inflexibility relates to the typically stereotyped and inflexible responses of autistic children. There is more depth and complexity to these models when presented in their respective chapters, but this brief summary may convey the ability of these simulations to recreate psychopathology while functioning with only the basic rules of learning in connectionist theory.

Although the term “neural network” or “neural net” is becoming popularized, at least in science fiction, it is not a well-understood concept. There are few, if any, psychiatry programs or even psychology programs that include it as part of their teaching curriculum. I believe that it will become increasingly advantageous to know something of this area. The scope of this book is wide and it is aimed at a diverse audience. Nevertheless, it is an important attempt to make this area more understandable. Each chapter is written by a different expert, and this format requires a strong introduction to pull the pieces together. The lack of this kind of introduction is the major deficiency of the book. This format also runs the risk of becoming disjointed. Luckily, this does not happen because the structure of the book itself allows for a significant amount of redundancy, and the concepts from the first half of the book are expanded on in the second half. There was only one chapter that I found quite incomprehensible because it was so poorly written. Generally, all authors focus more on concepts than on the details of how to construct and run a neural network model. This approach keeps the book accessible to the diverse audience to which it is aimed.

As a non-expert in the field of neural network modelling, I found the book absolutely fascinating because there are many concepts and reconceptualizations that do not require an intimate working knowledge of neural network theory. Still, some knowledge of neural network modelling is of benefit in appreciating the complexity of the issues. And I must point out that the subject matter is dense.

The editors open the first chapter with the following statement “The recent shift in psychiatry from a predominantly psychodynamic model towards a neurobiological paradigm has led to advances in our understanding and management of many mental disorders. At the same time this shift has been characterized as a move from a brainless psychiatry to a mindless one.” Neural network modelling has the capacity to reintroduce the mind even if not in all its complexity. This makes the final chapter by David Forrest on the challenges facing clinicians and researchers, as well as some of the potential limitations of neurocomputational modelling, an especially appropriate and thought-provoking conclusion to a book that challenges one to think.

A Guide to Treatments That Work

A Guide to Treatments That Work

Peter E. Nathan and Jack M. Gorman, editors

New York, Oxford: Oxford University Press; 1998 . 594 pp. with index

ISBN 0-19-510227-4 (cloth)

This kind of book has to be written from time to time in any area of knowledge, in an attempt to establish benchmarks. In this case the aim is to highlight current “state of the art” aspects of the treatment of psychiatric disorders. It is a brave effort, tightly edited and with a large number of eminent and expert authors who are, in general, balanced and incisive in their viewpoints. They consist of a judicious mix of MD psychiatrists and PhD clinical psychologists, and there is a refreshing lack of inter-profession infighting in their writings.

The editors have insisted that the contributors’ approach should be evidence-based, and they have clearly delineated the relative degrees of investigative rigour present in the many studies under review. In their introduction, they say that, to be reputable, treatment studies must show that patients got “better” (acknowledging the difficulties in defining and measuring that concept). They also say that treatment simply as an exercise in promoting self-awareness is a more appropriate approach for religion than for a science-based medical specialty. Now there’s a brisk, no-nonsense send-off, so why is the last word (”Afterword — a plea”) given to a writer who makes a pitch for the supremely intuitive psychoanalytically based forms of psychotherapy? And why is that writer advocating impracticable methods of research that have never been effective in giving them a verifiable basis in the past? I can only assume that this is a manifestation of that aspect of the American psychiatric Zeitgeist that has never quite lost its awe of psychoanalysis even when knocking it, and which has to indulge in little propitiatory rituals to allay some possible ”Furor Sigmundicus.” That said, it should be emphasized that the psychological contributors adhere mostly to reviews of behavioural and cognitive therapies, with a strong emphasis on psychosocial intervention, and take a very objective view of what constitutes psychotherapy and how its outcomes may be assessed.

This is a solid tome, with 28 dense, closely-argued chapters on 18 wide-ranging areas of psychiatric disorder, mostly grouped in complementary pairs of presentations reviewing pharmacologic and psychosocial approaches. Despite this diversity and apparent depth, however, there is an introductory section entitled “Summary of treatments that work,” which occupies only 13 pages. It seems extraordinarily sad that in 1998 all our verifiable knowledge of psychiatric treatment can seemingly be encapsulated in 13 pages of text (reading time approximately 30 minutes).

But to some extent this brevity is misleading, since we are considering a highly-selected filtrate of the best-attested results available. The editors have been further selective in appearing to concentrate on disorders that seem more treatable than others, and there is a sense that some of the choice is influenced by what the psychology contributors consider “sexy” these days. The result is a number of notable omissions, including, for example, delusional disorder, schizoaffective disorder and dysthymic disorder.

Although the book is entitled A Guide to Treatments that Work, relatively little attention is given to the question, Work on what? The authors have meticulously culled their literatures, and most of the references are impressively recent. Nevertheless, we have to be aware how crude our nosologic system remains and what a moving target it is. DSM and ICD have become very intent on narrowing their diagnostic criteria to exclude false-positive findings. A result of this is an over-refinement of case identification in formal investigations and the provision of a number of residual diagnostic categories to which “atypical” cases may be consigned. The latter are so heterogeneous that they virtually deny investigation. Also, small but significant differences in diagnostic criteria between DSM and ICD, or between successive editions of these authorities, are sometimes enough to make superficially similar treatment studies incompatible with each other. So, when the editors use refinement of technique in the measurement of quality of treatment studies as their major criterion of credibility they narrow the scope of their work very considerably. They may be, in effect, investigating Jello with techniques appropriate to the testing of properties of high-tensile titanium. This feeling, in my mind at least, is accentuated when so many dramatic results are reported for behavioural cognitive treatment methods. I know how effective they can be, but when I read of their apparent success as primary intervention in what are reputed to be severe psychotic disorders, I just know that we are not talking about the unselected cases the front-line psychiatrist meets in everyday practice.

I do not intend to belittle this book because I think it serves a very useful purpose in hammering home the need for much more science in our clinical and research activities. The editors are at pains to point out that it is neither a comprehensive textbook nor a therapeutic vade mecum. But read uncritically, it could give an unbalanced message. Like it or not, “state-of-the-art” treatment in psychiatry still has a great deal of art in it, and the more difficult the patient, the greater is the need for that very art.

If we regard this book as a starting point from which we can move on and begin to validate the much bigger, much messier and much more demanding world of non-academic psychiatry, then we need not be discouraged by these mere 13 pages of summary. It is good to see a psychiatric work aim high, and it is a trenchant reminder of how far we have to go in psychiatry before we can be regarded as a scientifically-based discipline. I would suggest that every psychiatric library have a copy of this text.

Thérapie brève et intervention de réseau

Thérapie brève et intervention de réseau: une approche intégrée

Jérôme Guay

Montréal : Les Presses de l’Université de Montréal; 1992. 189 pp

ISBN 2-7606-1556-1 (papier)

L’auteur de ce livre de base souligne l’importance de la multidisci-plinarité pour traiter les personnes souffrant de troubles psychiques en pointant les interventions psychosociales comme composante indispensable des soins aux malades.

Dans le premier chapitre, il affirme que la psychothérapie est seulement efficace pour régler des problèmes mineurs. Malheureusement, ses références sont limitées et datent de plus de 10 ans. Au cours de la dernière décennie, de nombreuses études de recherche ont prouvé l’efficacité de la psychothérapie brève (thérapie cogni-tive du comportement, psychothérapie interpersonnelle et dynamique) pour des troubles mentaux sérieux.1 La psychothérapie à long terme, la psychothérapie de groupe et l’hospitalisation à temps partiel sont essentielles pour les patients souffrant de troubles psychopathologiques plus sévères qui manquent de soutien social.

L’auteur identifie les compétences essentielles du thérapeute pour améliorer l’alliance thérapeutique, p.ex., se montrer sincèrement intéressé, écouter et avoir de l’empathie envers les patients. Les principes de base de la psychothérapie sont abordés. Cependant, l’auteur a omis de définir clairement des concepts principaux, comme la résistance, le transfert et le contre-transfert. L’importance de garder des «limites» à l’intérieur de la relation thérapeutique est décrite brièvement mais elle n’est pas expliquée. Cela est inquiétant, compte tenu que la violation des limites est plus souvent initiée par le thérapeute et qu’elle cause des dommages psychologiques aux patients.

Le deuxième chapitre renferme un guide d’évaluation avec des questions utiles pour évaluer le degré de motivation du patient, le type de crise, la stratégie d’adaptation, les aspirations et le réseau de soutien. L’auteur, qui mène un rôle actif dans la promotion des programmes communautaires, souligne l’utilité de rencontrer les membres de la famille et les amis qui constituent le réseau de soutien social du patient. Cinq types de thérapie sont résumés. Parmi les faiblesses dans ce chapitre, je remarque l’absence d’une évaluation de la force du Moi, qui est un outil utile pour déterminer les contre-indications pour des psychothérapies brèves. De plus, à l’intérieur du guide d’évaluation, on ne fait pas mention du besoin d’éliminer les troubles médicaux qui peuvent simuler et (ou) compliquer des symptômes psychologiques. L’auteur n’a également pas abordé l’importance d’un renvoi à un psychiatre pour les patients qui ont besoin de phar-macothérapie pour traiter des symptômes graves.

Les troisième et quatrième chapitres sont intéressants et ils atteignent vraiment les objectifs fixés par l’auteur. Il encourage les praticiens à développer une confiance dans la pratique d’interventions psychosociales. Il élabore sur les jumelages entraidants, les groupes d’entraide, les groupes communautaires et d’autres ressources précieuses. L’annexe comprend des tableaux détaillés, des diagrammes et des questions qui sont pratiques et bien organisés.

Ce livre facile à lire est une bonne introduction pour les professionnels de la santé qui sont intéressés à connaître les évaluations et les interventions psychosociales. Les lacunes principales de ce livre sont l’absence de concepts essentiels de psychothérapie et le manque d’explication sur le moment opportun pour envoyer un patient recevoir des consultations médicales et (ou) psychiatriques.

J’apprécie le commentaire de l’auteur affirmant que la pratique de la psychothérapie requiert une formation clinique. Toutefois, en tant que psychiatre spécialisé en psychothérapie psychodynamique, je crois que nous devons maintenir les normes sociales et morales, chercher à obtenir la supervision d’experts qualifiés et obtenir beaucoup plus que deux ans d’expérience clinique. La compétence clinique est essentielle et fondamentale à la pratique de la psychothérapie.

Handbook of child psychiatry for primary care

Handbook of child psychiatry for primary care

B. Robertson

New York: Oxford University Press; 1997. 368 pp

ISBN 0-19-571372-9 (paper)

This is a well written, concise book about psychiatric disorders of children and adolescents. It is written for the primary care physician, but it would be useful to medical students and psychiatric residents. The author is a child psychiatrist and head of the department of psychiatry at the University of Cape Town Medical School in Cape Town, South Africa. His many research interests and extensive travel experience make him very well qualified to write this book.

Not only are the various disorders and their management described, but there is also a chapter on assessment and the management of psychosocial problems in general. Parent education and education about illness are emphasized and expensive management approaches (e.g., individual psychotherapy) are mentioned, even though these apply to only a small number of patients. The disorders covered included attention deficit disorder, mood disorders, anxiety disorders, eating and somatoform disorders, dissociative disorders and culture-bound disorders. The latter are specific to South Africa and the chapter is very short but interesting. The substance-related disorders are especially well presented. All chapters are up to date, which is a remarkable achievement for a book with a single author.

The appendices list DSM-IV diagnoses and the Global Assessment of Functioning for children, which are useful, and the bibliography is selective but recent.

There are, however, some contentious statements. For example, I do not think that family therapy needs 2 highly skilled therapists; many programs only have 1 therapist per family. And the assertion that group therapy is “not commonly being offered,” may apply in South Africa, where primary care physicians are not be trained in this modality, but does not apply in North America.

This book is attractively presented and can fit into a jacket pocket (11 cm X 18 cm). Overall, I would strongly recommend this book; it is germane to countries other than the author’s home of South Africa and it is competitively priced.

The 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.

Assessment and Diagnosis of Personality Disorders

Assessment and Diagnosis of Personality Disorders: The ICD-10 International Personality Disorder Examination (IPDE)

Loranger AW, Janca A, Sartorius N (editors)

New York: Cambridge University Press; 1997. 226 pp with index

ISBN 0-521-58043-9 (cloth)

Personality disorders are a controversial construct in psychiatry. There is no clear separation between normal traits and disorders. In spite of the diagnostic requirement that personality disorders continue over time, they are not always stable. Patients with other disorders, particularly depression, undergo distortions of their normal personality. As well, the categories of disorders described in the present classification system suffer from validity problems.

Nonetheless, there are several reasons why the construct of personality disorder is essential to psychiatry. Clinicians — particularly those interested in psychotherapy — find these diagnoses useful in describing patients who are unusually resistant to treatment. Failure to consider an Axis II diagnosis can lead to many clinical errors, since patients with these diagnoses respond relatively poorly to antidepressants and since their condition cannot be accounted for by an Axis I diagnosis alone.

A substantial group of researchers who have become interested in this subject have formed an international society that publishes its own journal. Granting agencies have often supported personality research and, in light of the possibility that personality pathology could eventually be treated pharmacologically, even drug companies have financed some research endeavours in this area.

Establishing the cross-cultural reliability and validity of these disorders would therefore be an important step in increasing the use of personality diagnosis by clinicians and researchers. This book offers a coherent method of addressing these problems, through a diagnostic instrument, the International Personality Disorder Examination (IPDE), that has been pilot-tested in many countries: Canada, the United States, Great Britain, Austria, Germany, Italy, Luxembourg, the Netherlands, Norway, Switzerland, Kenya, India and Japan.

Armand Loranger was the driving force behind this project. The interview described in this book is adapted from an earlier one that he developed for use in North America. The first part of the book contains several well-written and useful chapters by personality disorder researchers: Dahl from Norway, Andreoli from Switzerland and Reich from the United States. Most of the text consists of a detailed description of the IPDE, which is part of the International Classification of Diseases, 10th revision (ICD-10). The instrument can also be used to generate diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R), but describing this procedure would have required a longer book.

The research findings in this volume are of some general interest. Patients who met the criteria for the ICD-10 personality disorder categories (as well as those for the DSM-III-R categories) were found at all sites where the instrument was tested. The 2 disorders that were common in most countries were emotionally unstable (or “borderline” in the DSM-III-R system) personality disorder and anxious (or “avoidant” in DSM-III-R) personality disorder.

Since the IDPE is designed for research use, this book will be of interest primarily to investigators. The interview described here is extensive, in fact too extensive for wide application in practice. The authors caution that is not intended as a substitute for clinical diagnoses. Ultimately, the most important use for the IDPE is in community surveys to measure the cross-cultural prevalence of personality disorders. Such surveys could provide support for the cross-cultural validity of these disorders and examine the important question of whether there are cross-cultural differences in their prevalence. If we can identify such differences, social factors may play an important role in etiology of these puzzling conditions.