Posts Tagged ‘schizophrenia’

NMR Spectroscopy in Psychiatric Brain Disorders

NMR Spectroscopy in Psychiatric Brain Disorders

HA Nasrallah, JW Pettegrew, editors

Washington (DC): American Psychiatric Press; 1995. 260 p

Every year the American Psychiatric Press publishes several books in the Progress in Psychiatry series based on some of the best symposia presented at the American Psychiatric Association’s annual meeting. The symposia themselves are focused on a particular problem or emerging area of psychiatry and are specifically designed to bring experts together to share their understanding, insights, and directions for future research. The books in this series build on the process begun at the symposia. In publishing the distilled knowledge of leading researchers, the books help “nonexperts” to acquire quickly a sophisticated understanding of areas of psychiatry that are complex or new.

NMR Spectroscopy in Psychiatric Brain Disorders is volume 47 in the Progress in Psychiatry series, and it clearly fulfills the promise of the series to provide “innovative ideas” in a “timely” manner. Nuclear magnetic resonance spectroscopy (NMRS or MRS) is a technique that has been used for many years in basic sciences, but only in the past decade has it been applied to in vivo studies of the human brain. Depending on the technique used, different chemical moieties are “visible” as peaks on a spectrum. For example, N-acetyl-aspartate (a presumed neuronal marker), lactic acid, and glutamate all produce peaks on proton (1H) NMR spectra, while phospholipids and high-energy phosphates such as adenosine triphosphate (ATP) produce peaks that are best resolved using 31P MRS. If it is a “pure” peak, the area under a spectral peak is proportional to the concentration of the particular chemical. What makes MRS particularly enticing to clinician-researchers is that it is a noninvasive approach permitting in vivo biochemical studies without exposing patients to ionizing radiation and that much of the hardware required (for example, magnet, computer) is already available in clinical settings with magnetic resonance imaging.

Each of the 11 chapters of this book is authored by, and represents the work of, 1 of 9 groups currently involved in the application of NMRS to psychiatry. (Two groups have earned 2 chapters.) The 1st 6 chapters examine applications of MRS to the study of psychoses, predominantly schizophrenia. Many of the pilot studies described in these chapters compared concentrations of various metabolites in particular brain regions in different populations. For example, phospho-monoesters (phospholipid precursors) were found to be decreased and phosphodiesters (phospholipid breakdown products) were increased in the prefrontal cortex of 1st-episode, neuroleptic-naive patients. This is the only finding that has been replicated. Other results are conflicting or awaiting replication. Many findings are presented in terms of their consistency with other research in schizophrenia. For example, increased ATP and decreased inorganic phosphate (P1) in the prefrontal cortex is interpreted as being “consistent with” the hypothesis of hypofrontality in schizophrenia (p 65). Preliminary findings in other areas of psychiatry include increased brain lactate levels in patients with panic disorder; transiently increased “lipid” levels (which are believed to be free fatty acids) following electroconvulsive therapy; and whole-brain lithium concentrations that are 40% to 70% of serum levels. In addition to lithium, there are several fluorinated psychotropic medications that are “visible” to MRS and thus amenable to in vivo pharmacokinetic studies (including fluoxetine, haloperidol, fluphenazine, and flurazepam). Precise localization of these drugs in the brain has been limited by technical problems, but it is expected that current constraints will eventually be overcome.

In many respects, this book is like a collection of papers, with each chapter including its own background information on the MRS technique. Unfortunately, this resulted in unnecessary repetition of some basic principles of MRS in nearly every chapter, while other fundamental concepts were not addressed until quite late in the compilation, if at all. As well, more in-depth discussions of technical refinements are scattered throughout the book. This fragmented presentation of technical information was not easily assimilated. An introductory chapter dedicated to providing a comprehensive overview of the technical aspects, including limitations, of MRS would have been preferable. Such an introductory chapter would have been useful as a reference both for subsequent chapters (when concepts are revisited) and for future readings of the literature. Similarly, an early chapter with an overview of the biology of some of the compounds that are visible to MRS (such as phospholipids and high-energy phosphates) would also have been helpful as a reference.

Despite these limitations, the authors have clearly met the goals of the series by amassing an impressive body of knowledge in a new field. They are particularly careful to include as much background biology as necessary to ensure the reader fully understands the rationale for and implications of their studies. Where possible, the authors have indicated how their findings compare with other imaging, postmortem, animal, and in vitro studies. This book certainly provides more than enough background for readers who wish to follow this emerging literature. For those wanting to pursue studies using MRS, it is a point of departure only, providing an overview of all the current (as of 1995) applications of this technique to psychiatry, as well as important references. Because MRS is evolving as an in vivo technique, new researchers in this field will need to be as concerned with technical issues as the current group of authors have been. Let us hope that future developments will prove that MRS has truly opened a new “window” on the brain.

Handbook of Culture and Mental Illness: An International Perspective

Handbook of Culture and Mental Illness: An International Perspective

I Al-Issa, editor

Madison (CT): International Universities Press; 1995. 391 p

With the hectic pace of travel, migration, and social change of the modern world, psychiatrists, mental health professionals, and trainees can expect to see people from all continents and many cultures. Moreover, they are required to be knowledgeable about and sensitive to the different backgrounds of these people and to be able to make a diagnosis, understand the psychopathology, and conduct a treatment relevant to these cultures. This is a tall order. How can any single professional become acquainted with, let alone gain expertise about the predominant cultures in each continent? These are precisely the goals that the body of knowledge and practice called cultural psychiatry or transcultural or cross-cultural psychiatry has been pursuing over the past few decades. The burning question, then, is how far can Dr Al-Issa’s book advance the practitioners, teachers, or trainees in this field in their endeavors to understand and treat effectively people from all continents and main cultural groups with full awareness and systematic use of their background and experiences? The brief answer is that indeed this book advances the body of knowledge very significantly in this direction.

The volume has a simple and bold structure. Its main parts are dedicated to Africa, Asia, Australia, the South Pacific, Central and South America, and Eastern and Western Europe; within each part about 5 specific countries or cultures are presented in terms of historical background, epidemiology of illness, cultural context, psychopathology, and treatment practices. Ethnic groups and minorities, including immigrants and aboriginals, are dealt with in a special chapter at the end. The introductory chapter by Dr Al-Issa offers an international perspective on the main psychiatric syndromes, including somatization and alcohol abuse, and on ethnic and immigrant minorities. Dr Al-Issa shows both a command of the broad field of epidemiology, including the most recent studies of the World Health Organization and associate groups, and a critical focus on controversial issues, for example, somatization in Third World versus industrial societies, multiculturalism as potential neoracism, or the suggested incapacity of some “non-Indo-European languages to differentiate between some emotions” (p 21). It closes with about 150 well-selected references that would be extremely helpful to any trainee or researcher.

The chapters that follow are innovative and mark a new era in cultural psychiatry. All of the leading books on cultural psychiatry of the past 4 decades were wholly or partially written or edited by Western-trained and -rooted professionals such as Ari Kiev, Transcultural Psychiatry (1972); HBM Murphy, Comparative Psychiatry (1982); or even I Al-Issa’s previous book, Culture and Psychopathology (1982). By contrast, all 24 chapters of this volume are written singly or in coauthorship by professionals who, by all indications, practice or have roots in the culture on which they are reporting. Clearly, they are also highly trained in Western medicine and psychiatry and maintain ongoing contacts with Western ideas and practices. One or 2 exceptions might be the report on the Inuit in Greenland and possibly the Maoris from New Zealand. This knowledge of both worlds is manifest in the twin advantages of sophisticated Western epidemiological knowledge and intimate understanding of cultural dynamics, psychopathology, and native treatment modalities. In this respect, this volume is also politically correct: nobody could accuse the authors of “stealing a people’s voice,” since they are themselves of those peoples.

Africa is represented by Egypt, Nigeria, Tanzania, South Africa, and French West Africa. All are most interesting and well-documented chapters. Especially rich is the chapter on West Africa. To the pioneer work of Henri Collomb in Dakar and the psychoanalytical work of E and M-C Ortigues on the African oedipus is added a review of the work of Andras Zempleni on the transformation of persecutory ideas and agents into modes of control of individual anger and the development of inner self as a psychological space. Self psychologists would find these ideas of special interest.

The chapter on India is also exceptional. VR Varma, based on his own work in the Indian continent, addresses 2 frontline issues in the development of or controversy about cultural psychiatry: cultural formulation and basic or ethnic “modal” personality. The issues, of course, are not resolved but are considerably elucidated.

The chapter on Jamaica, or rather Jamaicans at home and abroad, deals with the perennial theme of culture and personality and attempts to explain the high rates of schizophrenia diagnosed in Western mental hospitals. It is a matter of some curiosity that this phenomenon has been well researched in Great Britain, but not in Canada, where, since the 1970s, some 100 000 West Indians have arrived. The chapter on immigrants and minorities in Great Britain shows excellent documentation on the Irish, Jewish, and West Indians, but a similar vacuum is left in the book with respect to minorities in Canada.

Mexico, Uruguay, and the Iberian Peninsula (primarily focused on Spain) are dealt with in terms of epidemiology and, rather weakly, cultural dynamics. Important in Spain are the high rates of alcoholism, migrant adaptation, and the burden on families of the “new chronic” mentally ill population after the poorly coordinated mental health reform of 1986.

The critical, often refreshing approach of the book is shown once more in the chapter on Germany where, applying to this industrial society the same standards as one would use on any Third World country, we discover that about half to one-third of the clergy believes in demonic possession and exorcism. Of course, the sad legacy of Nazism is briefly examined, revealing that much denial and avoidance apparently still persists among the medical profession.

The chapter on Hungary is a masterpiece on the epidemiology and dynamics of suicide, topics on which the authors, Buda and Furedi, are experts. The chapter on multicultural Australia, which reviews adequately the work of Krupinski and colleagues, should be of great interest to Canadians as we share the same British traditions and institutions, a recent multicultural immigrant community, and a native population.

The chapters on Egypt include references to the seminal contributions of Ahmed Okasha to the epidemiology and dynamic understanding of suicide, somatization, and the rituals of Zar. Including a chapter on Turkey, the book provides a good report on Islamic societies, never adequately treated in this type of volume until now. The chapter on Israel deals extensively with the issue of religion, intragroup variations, and posttraumatic stress disorder, referring to the comprehensive work of Dasberg on holocaust survivors and more recent civilian and military populations exposed to the trauma of war and armed conflict. South Korea, Singapore, and Bali (Indonesia) are Asiatic countries with epidemiological information limited to key issues: suicide, substance abuse, and culture-bound syndromes such as epidemic koro and hysteria, somatization, and illness behavior in various groups. In South Korea, a traditional country in the process of rapid modernization, the majority of people tend to use both traditional and modern therapies and remedies.

There are necessarily deficits or limitations to be found in a book of such ambitious scope. Russia or any country of the former Soviet Union, China, the United States of America, and Canada are not included. On various issues, however, the references to North America and China are plentiful, and one gets some idea of sociocultural variations in these regions. Dissociation is not listed in the subject index, although frequent references exist throughout the text when it deals with possession states and hysterical psychosis. Posttraumatic stress disorder, a major issue in refugee populations at present, has only a few references. There is not a single reference on psychopharmacology or biological studies among the various ethnic groups.

I would recommend this book to practitioners and trainees in psychiatry, psychology, and social work because the advances reported in the dynamic understanding of cultural groups will be helpful in clinical practice.

Contemporary Issues in the Treatment of Schizophrenia

Contemporary Issues in the Treatment of Schizophrenia

CL Shriqui, HA Nasrallah, editors

Washington (DC): American Psychiatric Press; 1995. 863 p

It is heartwarming to see a first-rate text about schizophrenia that includes so many Canadian authors. Many of the breakthroughs in schizophrenia research in recent years have come from Canadian laboratories and clinics, but the average reader would not know it because most textbooks and widely read journals are published in the United States of America and the United Kingdom, and the impact analysis of cited papers is highest for American authors. This trend is understandable, but it presents the world with a lopsided view of where the action is in schizophrenia research. This book is coedited by a Canadian and an American editor who draw on the expertise of both nations and even include some (not many) European authors.

The first decision in attempting to write a book about schizophrenia is whether or not to adopt an atheoretical stance (as these editors have done) or whether to advance a particular point of view about the “true” nature of this mysterious malady. The first way is more democratic and allows input from many, sometimes conflicting, perspectives. It is also probably less subject to criticism. The second way is going out on a limb, and it severely limits the number of authors you invite to take part. Contributors need to be only those who can faithfully adhere to a unified theory. Though this approach is challenging for editors, it makes for easier and more interesting reading. I would hope that the talented, knowledgeable authors who have contributed to this book could next produce a smaller, integrated text which could offer a vista of how a general theory of brain function might embed a specific theory of schizophrenia impairment, which would lead to the crux of what needs to be researched and resolved.

Although this book does not accomplish that, it is, nevertheless, an extremely useful compilation of what is known. Section 1 covers biochemistry, postmortem abnormalities, and the new genetics. This is the traditional way to start, but it begs the question of which “schizophrenia” is being talked about in the various studies cited. This illness continues to defy understanding. Is it the tail end of a continuum of subtly increasing brain abnormality and, as such, not likely to yield homogeneous results structurally, biochemically, or genetically? Is it a group of genetically separable diseases, and if so, what strategy best disentangles these discrete illnesses so that clues to the etiology of each can be better pursued?

Since the heyday of the discovery of‘ Treponema pallidum as a direct cause of a subgroup of the schizophrenias, there has been no similar breakthrough, although prion disease may eventually account for more human psychoses than only Jakob-Creutzfeldt disease: the expansion potential of trinu-cleotide repeats has already explained several neurologic diseases among whose manifestations psychotic thinking is prominent.

Section 2 addresses the issue of subgrouping but does it indirectly by discussing the incompatibilities among diagnostic systems, the epidemiology of “negative” and “positive” syndromes, the near ubiquity of depression in schizophrenia (what does this imply with respect to the dichotomy between schizophrenic and affective psychosis?), the category of late-onset schizophrenia, the possibility that neurocognitive findings could lead to natural subdivisions (the chapter by Anne Hoff is excellent), and the possibility of subgrouping by brain structure, antipsychotic response, or sex-related phenomena such as premorbid strengths, onset age, and longitudinal illness course. I would have preferred that, rather than the authors discussing these topics simply as a means of reiterating the empirical evidence about difference and overlap, they instead consider each category as a possible filter through which a search for genetic or other causes could be conducted.

For instance, male-female differences in schizophrenia are striking and reproducible. We also know that male and female deoxyribonucleic acid (DNA) is dimorphic not only because women have 2 X chromosomes instead of an XY pair, but also because recombination rates and lengths of autosomes differ, and maternally and paternally inherited DNA conserve somewhat different characteristics. Integrating that knowledge into new genetic strategies might yield important results. Similarly, something is known about male-female brain differences. Can this knowledge help to explain male-female differences in schizophrenia? An example of such integration is Tim Crow’s notion of lateralized language development as an evolutionary force that is specifically impaired in schizophrenia and accounts for many of the differences found between men and women with schizophrenia. Crow is probably the most theory-driven contemporary schizophrenia researcher: it is too bad that his concepts are not represented here.

Sections 3, 4, and 5 are about treatments and treatment side effects, and it is these sections that are best reflected in the book’s title. The concept of novel antipsychotics is somewhat premature, I think, because the newer, so-called atypical drugs are very closely modeled on the old and are an improvement only insofar as they tend to produce fewer extrapyramidal side effects. They can, however, introduce other side effects no less difficult for patients to tolerate. I would have wanted to see a discussion on the ethics of drug trials, especially the use of placebos in situations where standard treatment does not always work, is sometimes unnecessary, and sometimes produces more adverse than beneficial effects. The difficulty, of course, is that we still cannot predict into which of these categories any given patient will fit. I would also have wanted to see a discussion of treatment sequencing—should we be thinking of stages of illness, with the best treatment of an initial stage followed by a subsequent optimal treatment focus on a second neurochemical system or a consequent social impairment? This is the standard approach to the treatment of other chronic illnesses (for example, rheumatoid arthritis, chemotherapy for cancer, and HIV treatment), but it has not been tried seriously in schizophrenia. There have been some attempts at logical sequencing of cognitive remediation techniques in schizophrenia rehabilitation, but these are not mentioned in this book.

These are minor quibbles, however. The book is thorough, easy to read, relatively comprehensive, and has some wonderful chapters by Canadian authors. I would recommend it to medical students, residents, and practitioners.

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.

The Schedules for Clinical Assessment in Neuropsychiatry

The Schedules for Clinical Assessment in Neuropsychiatry. Version 2

Wing JK, chief editor

Geneva: World Health Organization—Division of Mental Health; 1994.331 p.

The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a manual published by the World Health Organization designed to assess, measure, and classify the psycho-pathology and behavior associated with the major psychiatric syndromes of adult life. SCAN had its origins in the 9th edition of the Present State Examination (PSE 9). SCAN consists of 4 components: the 10th edition of the “Present State Examination” (PSE 10), the “Item Group Check List,” the “Clinical History Schedule,” and the “Glossary of Differential Definitions.” Only the first 3 were reviewed. The PSE 10, which forms the greater part of SCAN, covers phenomenology. The “Item Group Check List” is a method of obtaining information from case records and informants other than the patient himself or herself. The “Clinical History Schedule” is a method of checking or entering data relevant to the broader clinical and social history.

The PSE itemizes various domains and categories of psychopathology. For each phenomenological category an appropriate probe question is provided. The PSE does not give detailed definitions. These are contained in the “Glossary of Differential Definitions” which was unfortunately not available for review. This is regrettable since the SCAN can only be fully appreciated in the context of the glossary.

The SCAN is designed for epidemiological research rather than day-to-day clinical care. Data from the schedules are intended to be entered into a computer algorithm (C ATEGO-5) which processes the data. The output is a series of options including a range of profiles of symptoms, an index of definitions and ICD-10, and DSM-III-R diagnostic categories.

Interviewers who use SCAN must first address those factors that would interfere with access to psychopathology or indicate a need to adopt specific interview strategies. These include severe language disorders, cognitive impairment, severe behavioral disturbance, uncooperativeness, or the likelihood of a premature termination. The PSE 10 rating scales address various domains and categories of psychopathology. The domains contain overlapping phenomenological categories that can be confusing. For example, depersonalization and derealization, which are rightfully disturbances of perception, are also included in the domain of nervous tension. While this may be useful for research purposes and computerized programs, overlapping phenomenological categories muddy the analysis of the mental state. This is akin to describing motor weakness in a neurological patient within the domain of sensory changes. It is preferable to keep phenomenological categories within their rightful domains. Elicited psychopathology can then be extracted and linked together within the context of a biopsychosocial framework to reach a diagnosis.

The domains of the mental state identified by the PSE include: somatic symptoms, nervous tension, panic, anxiety and phobia, obsessional symptoms, depressed mood and ideation, thinking, concentration, energy and interests, body functions, eating disorders, expansive mood and ideation, alcohol and substance abuse, language difficulties, perceptual disorders other than hallucinations, hallucinations, subjectively described thought disorder and experience of replacement of will, delusions, cognitive impairment and/or decline, motor and behavioral phenomenology, observed affect, speech abnormalities, and social impairment.

SCAN contains a separate section for evaluating stress-causing acute reactions and posttraumatic stress disorders, the course of schizophrenia as described by either DSM-III-R or ICD-10, acute psychosis, induced psychotic disorder, schizotypal disorder, simple schizophrenia (an ICD-10 but not a DSM-III-R diagnosis), and the negative syndrome of schizophrenia. The latter has been included in SCAN for research purposes.

The section on cognitive impairment and/or decline includes the well-known Mini-Mental State Examination (MMSE) as well as the less well-known Verbal Trails Test. This section also contains probes to assess language, calculation, praxis, abstraction, fiind-of-knowledge, frontal-sub-cortical function, and level of consciousness. The section on dementia includes specific etiologies such as Alzheimer disease and Parkinson disease.

SCAN was developed by an international panel of researchers. Various groups of collaborators were responsible for the design and field trials of particular sections of SCAN. This presumably accounts for the lack of integration and the overlap of phenomenological categories across various psychopathological domains. In addition SCAN, unlike PSE 9, shifts out of the context of the mental state examination and includes sections that rate specific psychiatric disorders and disease course as well as identifies specific etiologies. SCAN is, therefore, much more than a rating scale for the mental state examination. Users of the SCAN may find this confusing and would be wise to look elsewhere for a clear and integrated conceptual understanding of the various domains and categories of the abnormal mental state. Nonetheless SCAN does list much of the psychopathology of mental disorders and can be used as a reference by clinicians to enrich and polish their own mental state evaluations.

Review of Psychiatry

Review of Psychiatry. Volume 14

JM Oldham and MB Riba, editors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Synopsis of Neuropsychiatry

Synopsis of Neuropsychiatry

SC Yudofsky and RE Hales, editors

Washington DC: American Psychiatric Press; 1994. 641 p

This paperback is a synopsis of the American Psychiatric Press Textbook of Neuropsychiatry, which was first published in 1987 (a second edition has subsequently been published). The Synopsis of Neuropsychiatry is designed to condense most chapters from the second edition, and its content is aimed at medical students and residents in psychiatry and neurology.

The book is divided into 5 sections: the basic principles of neuroscience, neuropsychiatric assessment, neuropsychiatric symptomatologies, neuropsychiatric disorders, and neuropsychiatric treatments.

The section on basic principles of neuroscience includes chapters on cellular and molecular biology of the neuron, and on human electrophysiology. The chapter by Daniel Tranel on functional neuroanatomy from a neuropsychological perspective is particularly well done. These chapters are all well organized and plentiful diagrams add interest and clarity.

The neuropsychiatric assessment section includes chapters on bedside neuropsychiatry, neuropsychological evaluation, electrodiagnostic techniques, brain imaging, and epidemiology and genetics. The chapter on bedside neuropsychiatry by Fred Ovsiew is an excellent summary of the major symptoms and signs of neuropsychiatric disorders. The chapters on electrodiagnostic techniques and brain imaging are also good overviews. I found the chapter on epidemiology and genetics too technical when describing linkage analysis and molecular approaches to the investigation of various neuropsychiatric diseases such as Huntington’s Disease and schizophrenia.

The third section on neuropsychiatric symptomatologies includes chapters on differential diagnosis in neuropsychiatry, neuropsychiatric aspects of pain management, and delirium. Chapters on neuropsychiatric aspects of aphasia and related language impairments, and neuropsychiatric aspects of memory and amnesia are also part of this section. The chapter on differential diagnosis by Richard Strub and Michael Wise has an excellent algorithm on the approach to the patient with memory loss, as well as an informative and concise table on common focal behavioral syndromes and their localization. The chapter on pain management by William Brouse and David Spiegel focusses on neurological mechanisms of pain and neuropharmacology but could be more clinically oriented. Delirium is well covered by Michael Wise and George Brandt. Frank Benson provides a superb chapter on aphasia, which presents a complicated topic clearly and succinctly. The chapter on neuropsychiatric aspects of memory and amnesia by Arthur Shimamura and Felicia Gershberg describes the neural and biochemical mechanisms of memory very well, and outlines some clinical syndromes. However, it would benefit by a section on the differential diagnosis and investigation of the patient with memory disturbance.

The next section has 12 chapters on specific neuropsychiatric disorders: traumatic brain injury, epilepsy, sleep, cerebral vascular disorders, brain tumors, human immunodeficiency virus, endocrine disorders, poisonous and toxic disorders, alcohol-induced organic mental disorders, degenerative dementias associated with motor dysfunction, Alzheimer’s Disease and other dementias, and the neuropsychiatry of schizophrenia. There are particularly comprehensive and clinically focussed chapters on sleep (by Thomas Neylan, Charles Reynolds and David Kupfer), cerebral vascular disorders (by Sergio Starkstein and Robert Robinson), Alzheimer’s Disease (by Jeffrey Cummings), and the neuropsychiatry of schizophrenia by Henry Nasrallah. There is little, in any chapter, written on the neuropsychiatric aspects of multiple sclerosis despite its prevalence. Other missing topics include autistic disorders and mental retardation, neuropsychiatric aspects of street drug abuse, and chronic fatigue syndrome.

The final section on neuropsychiatric treatments includes chapters on psychopharmacological treatment in neuropsychiatry, psychotherapy for neuropsychiatric disorders, cognitive rehabilitation and behavior therapy, stress and coping in family caregivers, and ethical and legal issues in neuropsychiatry. The chapter on psychopharmacology by Steven Dubovsky is comprehensive and well organized. I found the chapter on psychotherapy too long and wordy, although the tables nicely summarize the lengthy discussion in the text. The chapter on cognitive rehabilitation and behavior therapy by Mark Lovell and Christopher Starratt is a well-written overview, and serves as a good introduction to this topic. Stress and coping in family caregivers is covered mostly by discussing theorical models with little attention to clinical issues. Ethical and legal issues in neuropsychiatry are well covered in the chapter by Robert Simon.

Overall, this is a strong textbook which provides a solid overview of neuropsychiatry. The authors are all recognized neuropsychiatry experts. Every chapter is well referenced, which enables the reader to investigate any topic in more depth, if necessary. A strength of almost every chapter is the liberal use of tables, diagrams and figures. Unfortunately, several chapters contain diagrams and figures that require colour to be useful, such as figures of PET and SPECT scans. The reader is referred to The American Psychiatric Press Textbook of Neuropsychiatry, second edition, for full-color figures. This is extremely irritating, and it is unlikely that many readers will have ready access to the larger textbook when reading this chapter, thus losing the benefit of illustrations. I suggest that the publisher consider adding full-color figures even if it increases the cost of the Synopsis of Neuropsychiatry.

This book will be very useful for residents in psychiatry, particularly during a rotation in consultation-liaison psychiatry, and also for neurology residents and neuropsychology interns. Medical students will benefit from this book during their rotations in psychiatry and neurology. It will also be useful to clinical psychiatrists involved in inpatient and consultation-liaison psychiatry, although other textbooks will be necessary if an indepth look into a particular area is desired.

Neurobiology and Psychiatry

Neurobiology and Psychiatry: Volume 2

Robert Kerwin

Cambridge: Cambridge University Press, 223 pp., 1993.

How often have you talked to a patient with schizophrenia and wondered what is going wrong in this person’s brain to cause such extraordinary symptoms? This second volume from Cambridge Medical Reviews traces how far we have come in our understanding of schizophrenia and other neuropsychiatric disorders such as manic depressive illness, mental retardation and Alzheimer’s disease.

As with most areas of science, knowledge is based on technology. Some of the technologies are familiar to all, but the majority are likely to be new to most readers. However, even the familiar approaches are given a new twist. The best example of this is a chapter on neuroendocrinology by Beam and Raven which examines the effects of hormones on neurotransmitters and brain development. Another excellent chapter by Falkai and Bogerts discusses the post mortem neuropathology of schizophrenia. Their carefully crafted review slowly accumulates evidence for the hypothesis that the major locus of pathology in schizophrenia has to be in the temporal lobe and that this damage likely occurs during early brain development.

Chapters devoted to newer technologies are not nearly so straightforward. To make it easier for the general reader, the editor has attempted to provide some background information. This is particularly helpful in the case of molecular genetic studies. Gill and Walsh provide a very useful discussion of such things as candidate gene analysis compared to linkage analysis, which makes it much easier to understand more complex chapters such as the one by Honer and Kennedy. These Canadian investigators have taken a novel approach to the molecular genetics of schizophrenia by using antibodies as clues. Keshavan and Pettegrew also provide a superb review of magnetic resonance spectroscopy which provides the reader with a clear understanding of how brain chemistry can be examined in living patients with this technique.

It is interesting how often new knowledge in neurophysiology can be applied to many neuropsychiatric disorders. It is now known that nerve growth factors (NGF) play a critical role in the development and maintenance of the neuron. This fact has stimulated researchers to examine the role of NGF in Alzheimer’s disease, mental handicap and even the psychoses. Likewise, it has been recognized that neuronal growth and migration are controlled to some degree by membrane proteins called integrins. Genetic abnormalities in these proteins may cause developmental abnormalities which could result in mental handicap or psychosis. Most clinicians will probably find these discussions a little difficult to follow. However, it seems likely that neurophysiology is going to become increasingly important in psychiatry in the coming years. These preliminary investigators should provide a good introduction to the work to follow.

In spite of the sophistication of this volume, one still might ask whether we really know more about what is wrong with the brains of these patients. I believe that the honest answer is that we still don’t know much about causality. However, we seem to have rediscovered our organ – the brain. With the rapid acquisition of knowledge about how the brain works, the future can only appear bright.

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.

Brain Biochemistry and Brain Disorders

Brain Biochemistry and Brain Disorders

Philip G. Strange

Oxford, New York, Tokyo: Oxford University Press, 342 pp, 1992

I read and re-read this book several times — it is easy to read. On my first survey, I noted numerous excusable and many unforgiveable omissions (for example, only a brief mention of the dopamine D-3 receptors on page 239 and not even a word on the D-4 receptors that had been described by then). But I came to the realization that one cannot be an excessively critical judge. Any book of this size that comprises biochemistry, structure, research methodology and a wide range of pathologies of the brain can only be somewhat of a smorgasbord. There is nothing wrong with a neuroscience buffet, however, provided it is nutritious and served with style. And this must be recognized about this book, including the extremley well chosen cover illustration of Edward Munch’s “The Dance of Life”.

The first seven chapters provide sufficient amounts of basic information and neuroscience facts that are required for the grasp of the second part of the book, which focuses on six different disorders.

The author discusses artfully and, for purposes of psychiatric residents and practitioners, sufficiently the cellular aspects of the brain tissue, the chemical and electrical signalling, the neurotransmitter and receptor systems as well as some research technologies, although the description of the restriction-fragment length polymorphism (RFLP) could have been made clearer.

The author chose six diverse pathologies that are connected along the mesostriatal, mesolimbic and mesofrontal tracts. The totality of these six pathologies, and some others mentioned en passant, provides a base not only for the understanding of these illnesses but also for the comprehension of these brain parts. The discussion of Parkinson’s disease, including the MPTP, genetic aspects, rationale of tissue transplant, etc. is fairly complete, as is the chapter on Huntington’s disease and Alzheimer’s disease. The chapter on schizophrenia, as a brain disease, competently deals with the subject, although the contribution of Weinberger (mentioned briefly on page 256) could have been more extensive. The chapter on depression, although thorough and interesting, is too speculative in relation to the septohippocampal system. The last chapter, on anxiety, is probably the weakest.

The illustrations, including the CT scans, are of good quality. There are aspects of the quotations of original contributors where one could disagree with the author. Considering that books rapidly become outdated, this book has a certain philosophy and appeal — not to mention a modest price — that will assure a measure of longevity.