Book reviews

Cries unheard: a new look at Attention Deficit Hyperactivity Disorder

George Halasz, Gil Anaf, Peter Elllingson, Anne Manneand Frances Thomson SaloAltona: Common Ground, 2002.ISBN 1 86335 497 2 pp.91 $25.00 (paperback);

$18.75 (electronic version)

This book arose out of a public seminar hosted by‘Like Minds’, a non-profit organization, whose aimsinclude raising awareness regarding patients’ rights totreatment. The editor, Dr Halasz, makes it clear that hehas an axe to grind, namely ‘to look behind the symptoms(of ADHD) at over-prescribing, and to re-conceptualizeADHD as an attachment-deficit-hyper-reactivity dis-order’. A consequent agenda is to advocate support for‘smartened up’ therapies, which address presumed fail-ings of maternal attachment in this condition.

It is important, however, that before engaging in criti-cism, one should get one’s facts right. For example, it isnow clear that ADHD is a problem of ‘hypo’ rather than‘hyper’ arousal. This does not mean that ADHD childrenmay not experience anxiety, but the core symptoms arenot due to over-arousal, as demonstrated by many neuro-psychological and brain imaging studies [1,2]. This doesnot diminish recent work on the biology of early trauma.Nevertheless, one should be cautious about uncriticalacceptance of what little is known about neural develop-ment, and the tendency to interpret it as the neural basisof behaviour.

Unfortunately, psychiatrists have often been very readyto preach to mothers about their deficiencies, Perhaps30 years on the coalface of working with mothers andfamilies, and attempting to research ADHD, has engen-dered some humility in this regard.

In terms of the ‘symptomatic’ approach to ADHD, itshould be pointed out that DSM-IV involves a multiaxialapproach to diagnosis and treatment. For Child Psychi-atry this includes particular attention to developmentalissues (including and beyond attachment, such as lan-guage and learning). It also includes an understanding ofthe nature of individual differences and their impact onthe mother-child relationship, as illustrated by the recentreport by Caspi

et al

. [3], showing that a functionalpolymorphism in the gene encoding the neurotransmitter-metabolizing enzyme monoamine oxidase was found tomoderate the effect of maltreatment. While applicationsare premature and need replication, the study provides awindow on the long-term effects of maltreatment.

The chapters in

Cries unheard

tend to repeat similarthemes, but the analysis by Anne Manne of the effects

of the New Capitalism on families is a useful reminderof the stresses faced by families and children in copingwith the demands of our society.

Dr Anaf argues against the separation of ‘reason’ from‘concern’ manifested in modern managerial policies.One can sympathize with this point of view, but thecriticism of lack of resources applies to all children’spsychological treatments rather than just meaning-basedtreatments.

The concern about a lack of attention to meaningis also manifested in Peter Ellingson’s critique of the‘Beyond Blue’ approach to the treatment of depression.The question of consciousness and mind–body relation-ships has occupied philosophers since Descartes, so itmay be somewhat unfair to blame the activities of drugcompanies for this problem. Nonetheless, the relation-ship between drug companies and psychiatry in a freemarket society is fraught on both sides. The text byDavid Healy

The creation of psychopharmacology

makesinteresting reading in this regard [4].

It should be pointed out that in the history of psychi-atry, whenever a physical treatment has become avail-able, it has been subsumed by medical doctors (e.g.syphilis, and epilepsy). The only exception to this hasbeen the antipsychotics, perhaps because others werewary of the mentally ill. As far as methylphenidate isconcerned, in Australia at least, it is now largely pre-scribed by paediatricians, who may not have time toattend to the issues described by Dr Anaf. Nonetheless,mothers are tending to vote with their feet.

I believe there is an important role for child psychi-atrists in helping to establish the parameters in whichmethylphenidate (and other medications) should beprescribed, as illustrated by the work of the StimulantCommittee of the New South Wales Health Department,which has painstakingly reviewed cases falling outsideprescribed parameters for 14 years [5]. While the processmay not be perfect, there has been a plateauing of theamount and dose levels of stimulants prescribed in NewSouth Wales (1.2% of 4–17 year-olds as at 1 December2000). I would thus recommend an integrative rolefor Child Psychiatrists, which should incorporate newknowledge as it develops.

Cries unheard

draws attention to some of the complex-ities involved, but I suspect that, like its own critique, itsuffers from oversimplification. It should perhaps beread by those not already believers in the cause.

References

1. Levy F, Swanson JM. Timing, space and ADHD. The dopamine theory revisited.

Australian and New Zealand Journal of Psychiatry

2001; 35:504–511.

BOOK REVIEWS 247

2. Levy F. Implications for Australia of the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder.

Australian and New Zealand Journal of Psychiatry

2001; 35:45–48.

3. Caspi A, McClay J, Moffitt TE

et al.

Role of genotype in the cycle of violence in maltreated children.

Science

2002; 297:851–854.

4. Healy D.

The creation of psychopharmacology

. Cambridge, MA: Harvard University Press, 2002.

5. Salmelainen P.

Trends in the prescribing of stimulant medication for the treatment of Attention Deficit Hyperactivity Disorder in children and adolescents in NSW

. Sydney: NSW Department of Health, 2002.

Florence LevySydney, Australia

Implementing early intervention in psychosis: a guide to establishing early psychosis services

Jane Edwards and Partick D. McGorry (eds)London: Martin Dunitz, 2002

ISBN 1 84184 053 X pp.186 $19.95

This book is a milestone in the development of thetheory and practice of early psychosis intervention; Iunreservedly recommend it to clinicians of all back-grounds who treat psychotic disorders. This volumewill be seen as an essential training material, and everypsychiatrist and trainee should own a copy.

Its economy of style and gorgeous presentation shouldnot lead you to conclude that the contents are superficialor for novices. It covers, in incisive detail, all elementsof practice, presented in a phase-specific framework, andthen in depth, describes how these elements can becombined into a multicomponent service structure. Itis richly referenced and lets the reader know whereto resource early psychosis materials now available. Ittakes you well beyond principles and philosophy ontothe ‘nuts and bolts’ of practice and service implementa-tion. The authors deserve commendation for weldingtogether the many service-related issues raised by earlypsychosis intervention. It is clearly the product of amaturing field which continues to drive the service andpractice reform agenda across all mental health services.

There is currently a flood of publications hitchingthemselves to the ‘early psychosis’ bandwagon. Trustme, this book is not one of those. I believe this is the bestsummary of early psychosis intervention I have read, andan invaluable up-to-date resource.

Buy it!

Stanley V. CattsBrisbane, Australia

Neuropsychopharmacology: the fifth generation of progress, 5th edn

Kenneth L. David, Dennis Charney, Joseph T. Coyle andCharles Nemeroff (eds)Philadelphia, PA: Lippincott Williams and Wilkins, 2002

ISBN 0 78172 837 1 pp.2010 $478.50

In 1967 the American College of Neuropsycho-pharmacology published

Psychopharmacology: a reviewof progress 1957–1967

. This publication represented alandmark in the new discipline of psychopharmacology.

Each subsequent edition has represented an authorita-tive review of the advances in the neurosciences andtheir impact on psychiatry. Following this tradition,the fifth edition of ‘a generation of progress’ covers thedecade of the brain, a period that witnessed enormousprogress in the basic and clinical neurosciences.

The 2000 pages of text is divided into 13 sections.Each section is prefaced with a summary of the topicsto be covered by each of the contributing authors, and,in some, the highlighting of advances and significantchanges which have occurred since the previous edition.The standard of the contributions by its many authors,drawn mainly from universities and research institutes inthe USA, is uniformly high.

A brief review cannot do justice to the scope of thisbook. The following comments represent a personalsmorgasbord of the many contributions that are on offer.

The first three sections cover an overview of the basicneuroscience research in neurotransmitters, molecularbiology and genetics and imaging technologies. Theimpact of advances in genetics as a result of the humangenome project and the profound effects of the tech-niques of molecular biology on neuropharmacologicalresearch can hardly be overstated. Despite the technicalcomplexity of these disciplines as they are described inthe various chapters, the overviews provide an introduc-tion to the non-specialist to terms such as ‘gene chips’and ‘knockout mice’ and how these techniques in simpleorganisms can be used to understand the mechanisms ofactions of drugs, such as lithium.

The section on brain imaging is a critical review of thetechnologies and their limitations. The key to progress,however, may lie in the capabilities of imaging tech-niques, such as magnetic resonance imaging (MRI), tomap

in vivo

white matter pathways in a technique knownas diffusion tensor imaging providing a fundamental stepfor understanding cerebral structure and functional organ-ization and the effects of disease processes. Similarly,transcranial magnetic stimulation combined with func-tional brain imaging to address the causal relationshipbetween regional brain activity and behaviour is

248 BOOK REVIEWS

explored. Magnetic resonance imaging spectroscopy ofmajor neurotransmitters glutamate and gaba aminobutyric acid (GABA) and its linking to glucose oxidationand energy metabolism in the cortex may provide a newwindow on the GABA ergic system in neurological andpsychiatric illness.

A new section on drug discovery and evaluation istimely. It is a must-read as it provides a distillation ofinformed opinion concerning the processes and out-comes involved. These range from the need for pre-clinical testing of drugs, despite the limitations of animalbehaviour models, to regulatory and ethical aspects ofclinical research and clinical trial design. Drug inter-actions are an area of increasing concern as polypharmacybecomes more common and for the clinician there is anexcellent review of the principles of drug interactionsand their clinical importance.

There is an excellent introduction to the basic principlesof pharmacoeconomics, and those who are unfamiliarwith this area are taken through concepts, such as costminimization, cost effectiveness and cost benefit analysis.These areas are further expanded in the sections on eachof the drug classes considered later in the book. Thisinitiative recognizes the increasing importance of cost andequity of access for new pharmaceuticals in a time oflimited resources. The need for demonstration of costeffectiveness is one criterion for listing on the Pharma-ceutical Benefits Scheme in Australia and is enshrined inthe National Health Act. The ‘Australian solution’ toequitable access to new drugs has been a model for othercountries grappling with similar rising drug costs.

The clinical chapters on schizophrenia, anxiety disordersand affective disorders, follow a similar format. Theinitial chapters are a reprise of the basic neurosciencethemes and how they have informed our understandingof these disorders. The dramatic changes in the therapeu-tic landscape that have occurred with the development ofnovel antipsychotics and their impact on the treatmentof schizophrenia, and the impact of new antidepressantsand mood stabilizers on the treatment and outcomes indepression and bipolar disorder are comprehensivelycovered. The overview of the therapeutics of depressioncontains a useful guideline for clinicians for manage-ment. Similar guidelines would have been helpful in theoverview of therapeutics for bipolar disorder. There areuseful chapter reviews on electroconvulsive therapy andthe current status of transcranial magnetic stimulation(TMS) at the time of printing. However, developmentsin the area of TMS are occurring at such a rapid rate thatany overview risks being out of date by the time it isprinted.

The section on Alzheimer’s and other dementiastraces advances in the basic sciences informing our

understanding of the structural and functional changes inthese disorders. The importance of tau, a microtubularprotein, and its central role in the formation of neurofi-brillary tangles observed in Alzheimer’s and otherneurodegenerative diseases, has led to an entire newterm for these conditions, Tauopathies. The developmentof a transgenic mouse model that has shownover-expression of Tau protein can cause neurodegener-ative Tauopathies. The recent decade has also seen therecognition of dementia with Lewy bodies, the secondmost common form of degenerative dementia account-ing for up to 20% of cases in the elderly. Recognition isclinically important in view of the high incidence ofadverse and life-threatening reactions to antipsychoticmedication and the differential response to cholinergictherapy.

The biology of substance use disorder has undergonemajor advances. A unifying hypothesis is that therewarding and reinforcing properties of virtually allmajor classes of addictive drugs are mediated throughthe mesocorticolimbic dopamine system. From the clin-ical perspective, treatment focus has shifted. It is statedthat there is a greater acceptance of the chronic diseasemodel, which focuses on functional impairment, as arealistic goal of treatment, rather than ‘cures’. Thecurrent edition is unique in including a section oncompulsive and impulsive disorders, focusing on coresymptom domains that link these clinical phenomena totheir fundamental neurobiology and psychopharmaco-logical treatment.

A section on neuropsychiatry considers advances inmovement and paroxysmal disorders. The significantfall in incidence and risk of iatrogenic movement dis-orders with the introduction of the second generationantipsychotic drugs has been one of the major advancesin the treatment of psychoses.

The final section describes advances in the field ofchrono biology and sleep disorders. It includes a usefulreview of circadian phase disorders and relationship toseasonal affective disorder and light therapy. The author,who is also a co-inventor on several melatonin use pat-ents, critically reviews the role of this agent. A concisereview of insomnia and its treatment contains clinicalguidelines for pharmacological and non-pharmacologicalmanagement.

If this book can be said to have a common thread it isthe emphasis on the links between the basic and clinicalneurosciences that are driving discovery and innovationand the promise of future advances in our understandingand treatment of psychiatric disorders. This is a book forresearchers and clinicians alike and should be on everylibrary shelf. The size of the book however, and its cost,may mean that many will pass it by. This would be their

BOOK REVIEWS 249

loss as it has no equal as a textbook on the neurosciencesand psychiatry.

Gordon JohnsonSydney, Australia

Essentials of clinical psychopharmacology

Alan F. Schatzberg and Charles B. Nemeroff (eds)Washington: American Psychiatric Press, 2001

ISBN 1 58562 017 3 pp.780 $198.00

This book represents yet another quality publicationfrom the American Psychiatric Press. The title capturesthe essence of the text which delivers exactly what itpurports to – the essentials of clinical psychopharma-cology. With 31 chapters authored by internationallyacclaimed experts in their respective clinical fields,

The essentials of clinical psychopharmacology

providesan up-to-date and comprehensive overview of psycho-pharmacology across the life cycle from childhood to oldage. Management beyond the pharmacological is alsoincluded in a number of chapters as appropriate, forexample those on anxiety disorders and insomnia.

The book is broadly divided into two sections. Thefirst section is a series of 16 chapters covering the manydifferent classes of psychotropic medication, includingcognitive enhancers and psychostimulants as well asthe various subclasses of antidepressants, antipsychotics,anxiolytics and mood stabilisers that you would expectto find in such a text. Broadly speaking, the pharma-cological profile, mechanism(s) of action, relevantpharmacodynamic/pharmacokinetic considerations, clin-ical indications, side-effects, toxicity and important inter-actions with other agents are noted for each class ofpsychotropic medication. This first section finishes withan excellent, informative and practical chapter on electro-convulsive therapy.

Fifteen chapters comprise the second section of thebook, which covers the treatment of various mentaldisorders and related clinical problems. Again, this sectiongoes beyond the expected treatment of depression, schizo-phrenia, bipolar and anxiety disorders and so forth toinclude separate chapters on the psychopharmalogicaltreatment of psychiatric emergencies, medically ill andgeriatric patients, pregnant and lactating women pluschildhood and adolescent disorders.

Although overall an excellent clinical resource, thereis some variability in the standard of individual chaptersof the book. The majority are very good while somestand out as being of particularly high quality. Fortu-nately, only a minority are mediocre.

Notable chapters include that on the treatment ofdepression, which provides a splendid, comprehensiveoverview including the management of treatment resis-tance. The chapter on childhood and adolescent dis-orders is another excellent, practical chapter covering thepharmacological management of the wide range of mentaldisorders seen in this age group, including intellectualdisability. Attention Deficit Hyperactivity Disorder andthe mood disorders were particularly well covered. Itwas great to find such a well-written and comprehensivechapter in a general text of psychopharmacology.

The management of disorders occurring at the otherend of the age range was addressed in a separate chapteron geriatric psychopharmacology, which looked at theeffects of ageing on pharmacodynamics and pharmaco-kinetics, as well as the common issue of polypharmacyin this age group. Although the pharmacological treat-ment of psychosis, depression, mania, anxiety and sleepdisorders were discussed, there was disappointinglylimited coverage of the management of dementia. How-ever, this was perhaps compensated for by earlierseparate chapters on the cognitive enhancers and thetreatment of the non-cognitive symptoms of dementia.

Two other chapters warrant special mention as excel-lent chapters which add to the practicality of this book asa resource for psychiatric clinicians. The chapter on themanagement of agitation and aggression goes well beyondthe pharmacological management of these commonproblems, while that on the treatment of the medically illpatient comprehensively covers medical considerationsrelevant to the different classes of psychotropic medica-tion and electroconvulsive therapy.

In contrast to the high standard of the above chapters,that written on the treatment of bipolar disorder wasrather disappointing and somewhat underdeveloped.The antipsychotics, including depot preparations andthe atypicals, were entirely overlooked despite theircommon use in clinical practice. Perhaps the chapter’semphasis on the use of mood stabilizers for acute maniaand maintenance was a reflection of the Americanauthorship and prescribing bias. The chapter on eatingdisorders also appeared under-developed but perhapsrelated more to the limited role of medication in thesedisorders.

No modern psychopharmacological text would becomplete without a chapter on the use of psychotropicmedication in pregnancy and lactation and indeed a goodreview on the subject is included. The chapter on psychi-atric emergencies was also very good and again practical,dealing with the different levels of need for pharmaco-logical intervention for a range of acute clinical situationsfrom adjustment disorder to acute psychosis to the homi-cidal and suicidal patient.

250 BOOK REVIEWS

As an overall textbook of clinical psychopharma-cology across the life cycle and across diagnostic andclinical problems this text would be hard to beat. Itsmain limitation for the Australasian reader would be theAmerican focus with the expected differences in avail-ability or licensing of specific drugs and some variationin prescribing practices especially for mood disorders.

Heather McPhersonDunedin, New Zealand

Assertive outreach in mental health: a manual for practitioners

Tom Burns and Mike FirnOxford: Oxford University Press, 2002

ISBN 0 19851 615 0 pp.317 $US39.95

This manual for practitioners will become a usefulbook for any mental health worker who is interested inworking in the community in an outreach setting. Everypage demonstrates the long and valuable experience ofthe two authors, particularly in the UK setting. ForAustralian and New Zealand readers the assertive out-reach teams as described in this book would most closelyresemble the Mobile Support/Treatment Teams. Thebook is divided into 3 parts, Conceptual Issues, Healthand Social Care Practice, and Structural Issues.

Part 1, Conceptual Issues, provides a good historicaloverview of assertive outreach followed by a discussionof which patients/clients are and are not suitable for asser-tive outreach. The vexed issue of 24-hour teams versusextended hours teams is explored. The importance ofestablishing an agreed model for the team is emphasized.This consists of small caseloads, 10 patients (at times upto 15 patients) per full-time key worker (case manager).The team must offer flexible and frequent contact, visitingonce or twice a week, and be able to offer a crisis responseif this is required. In the Australasian setting the crisisresponse may be provided by workers either within anintegrated outreach team or by a separate crisis responseteam. Assertive outreach teams are multidisciplinary, con-sisting of medical, nursing and allied health members. Therole of compulsory (involuntary) treatment in the commu-nity is described, particularly in the context of the currentmental health legislation in the UK, which is expected tochange in the near future. Conversely, for mental healthworkers in an Australasian setting the use of CommunityTreatment Orders is an established procedure. The chapteron cultural sensitivity is fascinating and shows the enor-mous development of this approach which has taken placein the UK in recent years and provides useful guidance foroutreach services that may wish to follow this path in thefuture.

Part 2, Health and Social Care Practice, deals with arange of approaches to the delivery of services. Theessential topic of medication compliance is well bal-anced and provides a 3-phase model for compliancetherapy, which all workers should find useful. Riskassessment and management is covered with interestingexamples of the documentation that is used by the team.There are chapters on all the major diagnostic groupsplus a helpful chapter on the broad topic of self-neglect.Substance abuse receives appropriate attention includinga guide to motivational interviewing. The need to provideassistance to patients in managing their finances isrecognized and is dealt with in the context of the UKlegislation. The authors note the importance of employ-ment to patients and applaud the models, which havebeen established in the USA. My favourite chapter is onpsychosocial interventions and work with families. Thiscovers psychoeducation, behavioural family manage-ment and cognitive behaviour therapy. There are sometips on different strategies which all outreach workerscould consider. The need for workers to receive addi-tional training in some of these skills is noted as well asthe substantial benefits that can flow on to both patientsand their families. Although first episode psychotic ill-nesses are mentioned early in the book it is disappointingto note the lack of a specific approach to this criticalgroup of patients.

Part 3 deals with Structural Issues. The roles of theteam leader and the consultant psychiatrist are described.There is even a suggested weekly format for meetingssuch as handovers, community review meetings andbusiness meetings. Issues of accountability and respons-ibility are covered. Both management supervision andclinical supervision are also explored. There is a chapterdealing with training, which covers both basic com-petencies and those additional competencies, which pro-fessionally trained key workers (case managers) shouldpossess. The chapter on service planning issues is clearlyset in the UK context although many of the issues, suchas risk assessment and the concept of an integratedmodel will have relevance for Australasian workers. Thefinal chapter is on research and development and coversthe important topics of service evaluation and some ofthe basic principles of setting up a research project.

In summary, very experienced clinicians have writtenthis manual for clinicians and managers in the work-place. It is comprehensive and practically focused andwill especially appeal to those professional staff who areconsidering taking up a position in a service that offersan assertive outreach programme.

Cristea MileshkinMelbourne, Victoria

BOOK REVIEWS 251

Specific learning disabilities and difficulties in children and adolescents: psychological assessment and evaluation

A.S. Kaufman and N.L. Kaufman (eds)Cambridge: Cambridge University Press, 2001

ISBN 0 52165 840 3 pp.467 $125.00

This book takes a refreshingly objective approach toexamining the role of psychologists, and their psycho-metric tools, in unravelling the mysteries of develop-mental learning disabilities (LD).

The quest for a definitive explanation of LD beganmore than a century ago, and some will argue that littleprogress has been made since that time. However, thisdisorder has generated tremendous scientific interest,across a number of fields including neuroscience, psy-chology and education. The importance of the conditionis based on its incidence (up to 10% of school-agedchildren) and the need to develop efficacious interven-tion strategies.

In this text, Kaufman and Kaufman address recentcriticisms from some workers in the field with respect tothe use and abuse of intellectual tests and ‘IQ’ scores inthe diagnosis of LD. Traditionally, presence of a sig-nificant discrepancy between IQ and achievement scoreshas been used to identify LD. While it is generallyagreed that this method has its limitations, no bettermodels are available at present. Some of this argument isspecifically targeted to a North American readership,where specific diagnostic approaches are directly linkedto the provision of funds and access to intervention.However, the problem of determining accurate diag-nostic tools is of broader relevance.

This book takes the position that the study of LDinvolves the integration of both educational and neuro-logical approaches. A discussion of the history of LDfrom both of these perspectives is included in the text.The authors take a strong stance on assessment practicesmoving away from the more common summary score(e.g. IQ) approaches, to a more comprehensive model,which can describe a number of relevant cognitive andneuropsychological domains. In particular, the authorsargue that the range of skills required for reading – forexample, language, attention, memory, visuospatial skills,executive function – should be covered in any assess-ment of LD. Based on the data obtained from such anevaluation, the nature of the LD, and the possibleapproaches to treatment, can be identified.

The authors employ a simple formula to provide thereader with an overview of a range of tests, which theyconsider useful in diagnosing, treating and understand-ing the cognitive profiles of children with LD. They

begin with well known intellectual batteries includingthe Wechsler scales, Kaumnan tests, Cognitive Assess-ment System, and Differential Ability Scales. They thengo on to cover more contemporary standardized neuro-psychological tests, which focus on language, memory,attention and executive function. For each test, the authorsprovide a discussion of theoretical underpinnings, psycho-metric properties, test description and applications forthe assessment and diagnosis of LD. In each case, theemphasis is on moving beyond summary IQ scores tothe more detailed understanding of patterns of cognitiveability provided by the test. Finally, case illustrations areincluded to give the reader a sense of how the test maybe helpful in the clinical context.

This text represents a useful addition to the clinicalliterature in the area of LD. While it includes sufficientdepth to attract the experienced professional working inthis field, it also provides a useful tool for those trainingin the fields of psychology, education, paediatrics anddevelopmental neuroscience.

Vicki A. AndersonMelbourne, Australia

Psychotherapy with children and adolescents

H. Remschmidt (ed). Revised and translated from Germanby Peter Matthias and Helen CrimliskCambridge: Cambridge University Press, 2001

ISBN 0 52177 558 2 pp.588 $150.00

The dual tension between first, the various ‘brands’ ofcompeting psychotherapies and second, between psycho-therapy and cost-driven mental health policies withdemands of ‘quality assurance’ for contractors andaccountability to insurance companies, in many casestaking precedence over adequate patient care, means thatany current psychotherapy text book must address theseissues. Professor Helmut Remschmidt’s translated 1997edition achieves this and more. Most chapters haveeither very useful figures or case studies.

Eleven German and two British contributors provide34 chapters which cover in four sections basic principlesof psychotherapy; outlines of the methods of psycho-dynamic, behavioural, cognitive behavioural, inter-personal play, as well as group and family therapy andpsychodrama; application of psychotherapy techniquesto a wide spectrum of conditions including a range ofemotional disorders to psychosis, substance abuse tostuttering; and finally, addresses the demands on psycho-therapy of various settings such as inpatient, day-patientand home treatment.

252 BOOK REVIEWS

Despite achieving ambitious aims, to provide such abroad coverage of the field of psychotherapy with chil-dren, adolescence and their families, based on the Euro-pean ICD-10 classification for specific disorders andtheir treatment, a number of issues troubled me as I readthe book. First, the English translation appears over fouryears after the original German text. In the rapidlyadvancing area of developmental psychology and psycho-pathology finding most references dated before 1997 is aserious drawback.

Second, given that attachment theory, research andclinical applications in child, adolescent and infant mentalhealth underpins emerging areas of psychotherapy think-ing [1], the absence of any serious discussion devoted toattachment or even mention of the term ‘attachment’ inthe index is troubling. This omission may, in part, reflectdifferent cultural attitudes to the importance of attach-ment research held by European, North American andUK academics and clinicians. Third, while there arereadable chapters dealing with physical abuse and neglect,and sexual abuse and maltreatment, the lack of discus-sion on ‘trauma’ or posttraumatic stress disorder inchildhood is of further concern in a modern psycho-therapy text.

While I have been impressed with the other publica-tions in the Cambridge Child and Adolescent Psychiatryseries dealing with specific disorders, and the field ofchild and adolescent psychotherapy is in urgent needof a major publication, I find it hard to recommend this1997 translation as an essential addition to a currentlibrary.

Reference

1. Cassidy J, Shaver PR, eds.

Handbook of attachment. Theory, research and clinical application.

New York: Guilford Press, 1999.

George HalaszMelbourne, Australia

DSM-IV-TR case studies: a clinical guide to differential diagnosis

Allen Frances and Ruth Ross (eds)Washington: American Psychiatric Press, 2001.

ISBN 1 58562 055 6 pp.386 $105.60

This book is primarily a reference text, produced bythe same people who brought us the DSM-IV-TR. Itis at its most useful when called on to flesh-out aDSM-IV-TR category, but is a difficult cover-to-coverread, partly because it follows the format and chapterorder of the DSM-IV-TR. Despite the didactic nature of

the parent text, cautious statements in the introductionwarn against premature diagnostic closure and empha-size the overriding importance of clinical judgementrather than any external set of criteria.

The case studies themselves are interesting andwell-chosen in general. Each is followed by a multiaxialdiagnosis and the DSM-IV-TR diagnostic criteria for theprimary diagnosis illustrated, some dry but useful guide-lines for differential diagnosis, concise guidelines ontreatment planning and a brief summary. Generally, themore common diagnoses in any diagnostic category areillustrated.

The text is at its most interesting and valuable whendiscussing controversial and rare diagnoses. The sectionon Dissociative Identity Disorder [p.220–223] is veryreadable and the discussion of iatrogenic risks in thisarea and the concept of ‘fad diagnoses’ was brief, butbalanced and informative. The Sexual and Gender Iden-tity Disorders section gave priority to regarding normal-ity as the first differential diagnosis to consider, gave anoverview of the CBT and psychodynamic considerationsin treatment, and added an important rider that a diag-nosis of paraphilia in no way absolves a person of criminalresponsibility – all common sense, but clearly presentedand easy to read.

Personality Disorders are covered very well in descrip-tive terms. Attention is drawn to sexual stereotyping,using the characters of Blanche Dubois and StanleyKowalski from

A Streetcar Named Desire

, who couldboth meet criteria for Histrionic Personality Disorder.The treatment-planning sections are generally brieferand slightly baffled in tone, with the exception of therather authoritarian section on Borderline PersonalityDisorder. The coverage of Antisocial Personality Dis-order ends with the candid statement ‘If this discussionof the treatment of Antisocial Personality Disordersounds pessimistic, it is meant to.’

Most of the case study titles verge on the banal, how-ever, some have an edge of humour, ranging from thepossibly unintended (‘An Old Bird with an Empty Nest’– Adjustment Disorder with Depressed Mood) to anunexpected reference either to

The Caine Mutiny

or to

Red Dwarf

(Principal ‘Queeg’ – Paranoid PersonalityDisorder).

The Test Yourself section (Chapter 17) provides aselection of more complicated cases, with the diagnosisfollowed by a discussion that is at times not uncritical ofthe DSM-IV and DSM-IV-TR.

The most frustrating aspect of this book was its failureto satisfy my curiosity about how these well-describedand easily visualized patients responded to treatment.Only briefly does one get a glimpse of this (the phobicdoctor who learned to overcome his dread of fingernails,

BOOK REVIEWS 253

and the avoidant man who surprised his treating doctorby going to the YMCA) and after reading several casesin a row it can get annoying. However, having said that,it is a good reference text to have on hand, is readableand chatty in a way the DSM could never be, and reallyprovides a sense of the person in the vignettes. It wouldmake a useful addition to the bookshelf and would be agood reference for preclinical trainees.

Angela HarteMelbourne, Australia

The burden of sympathy: how families cope with mental illness

David A KarpNew York: Oxford University Press, 2001

ISBN 0 19512 315 8 pp.319 $32

Every survey of families of patients with psychosisreports the huge emotional burden they have to carry. Asa trainee I was taught that their stress can reach levelsseen in the front line of battle . . . consequent ‘compas-sion fatigue’ can develop, just as for aid workers in battlezones.

David Karp, a professor of sociology, supplies thedetail. Most of his informants belonged to a weeklylong-term relatives’ support group at McLean Hospital,Boston. Through 60 lengthy, unstructured interviews,Karp explored ‘how love and obligation play out as aprocess over time’. Moving and useful quotes are pro-vided from his tape recordings, from which he inductedcertain recurring themes.

In my own experience with these families, as a psychi-atrist and family therapist, three themes stand out.

Fearof suicide

makes relatives feel ‘over a barrel’ to beinvolved, and Karp reports that too often health profes-sionals lack understanding of their dilemma.

Guilt

fornot caring enough, for genetic harm etc., is felt particu-larly by mothers; Karp believes that because women arebetter at empathising they suffer their feelings more.Strangely,

grieving

is hardly discussed, though it alwaysrequires our clinical attention. The loss of the future thatwas imagined for the patient is one of many losses to beexplored.

I found the testimonies of a child, a sibling and aspouse particularly valuable. Children and siblings havethe problem of how and when to reveal the psychosis totheir friends. Karp notes that no blame is incurred, whena sibling or child chooses to separate completely fromthe family. The son of a woman with schizophrenia tellshow he had to dissociate as a child: ‘It is terrifying to achild to have your parent helpless.’

Two-thirds of Karp’s informants were women, mostlymothers. Karp states that because men tend to besolution-oriented, they sometimes burn out quickly ascare givers. You wonder if this distinction may apply topsychiatrists as well . . .

The emotion Karp heard about most was frustration. Itpervades every phase of family members’ experiences.The first frustration, before diagnosis, is the inability toempathize with the sufferer. In this phase bewildermentrules. (Karp notes relatives’ tendency to deny mentalillness as an explanation, but he can’t throw any light onthis striking phenomenon.)

Diagnosis is a relief, sometimes even experienced withjoy – for at this point expectations of cure can be high.At last positive feelings of hope, love and compassionare expressed to the patient. However, the patient maynot express gratitude in return, as one with physicalillness might . . .

As initial expectations are revised downwards, fami-lies realize that their lives have been hijacked, with noend to the journey in sight. Anger and resentment areoften first voiced directly to the patient if they refusemedical treatment. ‘The hardest part of caregiving is notknowing if what you are doing is right or wrong.’ AtMcLean parents are taught to blame the illness and notthe person; and find support in a mantra called The FourC’s: ‘I didn’t cause it, I can’t control it, I can’t cure it –I can only cope with it’. Many remain guilt-ridden,nevertheless.

Often the family becomes isolated. Some distancingoccurs as family members realize, with a wrench, thatthey could lose

themselves

in the illness. In time somerelatives come to respect and even admire the patient, forshowing courage with unimaginable pain.

Rightly or wrongly, doctors get a caning from thefamilies in this book. Often the first shock for relativesis to discover that the patient isn’t sick enough for treat-ment, because compulsory admission requires danger toself or others. When hospitalisation comes, they aredismayed to find that psychiatrists play only a small partin treatment. Relatives feel marginalised, and commentthat the therapeutic model appears to be one of doctor–patient alone. They feel blamed by psychiatrists, anddescribe snap judgements and unrealistic advice giving.

Karp’s book gives warning of what we can expect,if Managed Care crosses the Pacific. Even the bestAmerican teaching hospital discharges a patient, as soonas insurance runs out. Financial uncertainty is now oneof the great stresses for American families.

Governmental family support has eroded in Americasince 1970, and Karp states that over one quarter ofAmerican children are now going to bed hungry. Wehear of a Boston woman whose living comes from

254 BOOK REVIEWS

clients whom she helps to negotiate the Kafkaesquebureaucratic maze, to attain disability support. Appar-ently, initial denial of benefits is the rule – ‘theunschooled often take this at face value’ – and to have tofill out 30 pages of government forms is not unusual.

This book usefully complements Jules Henry’s ‘thicker’account, based on hundreds of hours with four families[1]. Karp sets out clearly what family members canexpect to experience, and offers useful advice. Thenotes and bibliography are excellent. Recommended forpatients’ families and for libraries serving mental healthstaff.

Reference

1. Henry J.

Pathways to madness.

New York: Random House, 1973.

Andrew FirestoneMelbourne, Australia

A city possessed: the Christchurch civic crèche case

Linley HoodDunedin: Longacre, 2001

ISBN 1 87713 562 3 pp.672 $59.95

I found this to be a very interesting book. At times itfelt like reading a ‘whodunit’ novel, but because of thelength of the book (672 pages) and the exhaustive detailprovided by the author, at other times the tempo of thebook did drag.

Having conducted research in the long-term sequelaeof child sexual abuse, I was interested to discover whetherthe book would change any of my current perspectives.In focusing on the investigation of New Zealand’slargest and most controversial case of allegations ofsexual abuse occurring in a Christchurch crèche, in theearly 1990s, author Linley Hood offers a fascinatinginsight into the case. Describing herself as a researchassociate with an interest in child care, the authordeclares her position at the outset, writing that her inves-tigation into the crèche sexual abuse allegations led herto believe that eccentric and flamboyant male childcareworker, Peter Ellis, and a number of other female child-care workers were victims of a modern ‘witch hunt’.

Hood suggests that the allegations developed atthe height of the ‘believe the children’ movement inthe child sexual abuse field developing in the 1980s,mixed with the risks of overly directive interviewing,the misuse of psychiatric testimony and over zealous

policing and prosecuting. These all lead to what shedescribes as a modern form of mass hysteria. There is aninteresting early chapter discussing the witch hunts ofvarious ages, the phenomenon of mass hysteria andurban legends.

The book, in sometimes excessive detail, looks at thehistorical background, the subculture of Christchurchand the very well respected crèche, which became thecentre of major allegations of child sexual abuse ofmultiple victims and of a ritual abuse type. Hood avoidsthe trap of obvious bias or zealotry in either direction.There is also an interesting touch when the authorbecomes caught up in the court appeals process and isfaced with the dilemma of whether to reveal confidentialinformation gained in her many interviews with thoseinvolved.

The main protagonist, Peter Ellis, serves a number ofyears in prison for the offences, but has continued tostrenuously claim his innocence, even when severalattempts at appeal did not clear his name. There is alsothe interesting sideline of a College of Psychiatry memberwho provided expert witness testimony at the trial. As astrong ‘believer’ of the potential damage of child sexualabuse for children, the book certainly raised a great dealof thought in my mind, in particular whether the widelytouted prevalence figures for abuse are in fact correctand whether the pendulum has swung ‘too far’ in termsof lack of scientific objectivity in investigating abuseallegations.

The book would be of interest to any psychiatristworking with child sexual abuse victims, either directlyor indirectly, and possibly also to adult psychiatrists whotreat those who suffer the long-term effects of childhoodsexual abuse. However, I think the book has an evenbroader appeal, with its emphasis on the difficulties ofpsychiatric testimony and looking at the broader socialissues of mass hysteria. The book is long and at timesarduous to read, but there are plenty of fascinatingchunks within it and I came away having a sense of anew perspective on the issues involved.

Whether or not you agree with author Linley Hood’sviews on the falseness of the allegations is not the pointof reading this book; the book effectively raises ques-tions that anyone in the area of child sexual abuse willfind interesting and challenging.

Lisa BrownSydney, Australia