avoiding gratuitous repetition and achieving stylis- tic consistency despite their having enlisted so many participants. In addition, chapters of partic- ular interest can be selected out and appreciated individually, or the book can be read and enjoyed cover-to-cover. The use of numerous subheadings enhances readability, and each chapter cites rele- vant material to be found elsewhere in the book. The chapters are brief, cogent, well-referenced, and sometimes, as in the case of Professor Roy Porter’s review of historical perspectives, quite entertaining. The majority of the contributors practice in the U.K., but just as the problem of functional symp- toms is international, the applicability of the mate- rial is as well. Epidemiologic and other studies from outside the U.K. are cited liberally, and there is attention to both DSM and ICD nomenclature and to systems of healthcare outside Britain.

The book is not without its foibles, however. The distinction made in a few places between “physi- cians” and “psychiatrists” is bound to be troubling to those of us who are psychiatrist-physicians. Fac- titious disorder is erroneously classified as a so- matoform disorder. The multidimensional diagnos- tic approach the editors propose as a replacement for the DSM and ICD systems is cumbersome. It would have been valuable to have had more dis- cussion of the reactions of those who work with somatizing patients, and to have been offered a listing of specific resources (print, audio, video, or cyber) recommended as aides in patient education. I would have liked the authors’ counsel regarding the standardized questionnaires and other tools that they have found most useful.

Finally, copyediting should have been better. Ty- pographical or grammatical problems (well beyond the linguistic differences between the U.S. and U.K.) are distracting at times. I was amused by the substitution of “an geography” for “angiography,” an error that probably occurred during transcrip- tion. Mistakes such as the term “orthostatic ‘hyper- take”’ rather than “hypotension” are less under- standable. Even harder to forgive are errors such as the repeated substitution of “somalization” for “so- matization” in a book on the subject. No doubt these problems will be corrected in subsequent edi- tions.

Throughout the book, the authors highlight the need for large-scale, controlled clinical trials in this area while acknowledging the sober reality that there are unlikely ever to be any quick fixes. As a result, our goal in cases involving functional symp- toms must typically be “damage control” rather

than cure. For far too many patients, despite our best efforts, the preoccupation with symptoms be- comes a way of life-a cuddly blanket to which they cling resolutely. This excellent book equips clinicians remarkably well, if not to loosen the grip, at least to soften it through application of a consis- tent, knowledgeable, and eminently reasonable ap- proach. Despite its hefty price, it is recommended to clinicians, particularly physicians, at all levels.

MARC: D. FELDMAN, M.D.

Birmingham Alabama

PI1 SO163-8343(97)1)1102(1-O

The Spectrum of Factitious Disorders. Edited by Mark D. Feldman, M.D. and Stuart J. Eisendrath, M.D., Washington DC., American Psychiatric Press, Inc., 1996, ($36.00), 229 pp.

As a part of the Clinical Practice Series, this volume on factitious disorders strives to provide “current, factual, and theoretical material of interest; a prac- tical clinical approach; up-to-date literature re- views; and the most recent treatment methods.” The Spectrum ofFactitious Disorders succtvds in nearly all of these goals, and is probably the best book for clinicians on the subject. This is no small feat, since factitious disorders are among the most difficult of all mental illnesses to study. The surreptitious be- havior of the patients and the chaotic nature of their lives have led to a paucity of systematic data, so that conceptualization can only be guided by sparsely substantiated assertions.

The first few chapters provide a good represen- tation of the available literature. In Chapter 1, ‘The- odore Nadelson reviews his own and other contrib- utors’ use of the spectrum concept to place factitious disorders in context. Since these disorders usually involve faking a medical illness, consider- able efforts have been made to understand facti- tious disorders not only among psychiatric ill- nesses, but also in terms of illness behavior in general. Dr. Nadelson’s “common sense” synthesis of features of somatic presentations of illness makes considerable sense. Difficult issues such as motiva- tion for factitious illness behavior, comorbidity, the relationship between factitious disorder and Mun- chausen’s syndrome, and differentiation from ma- lingering are raised here. Many of these issues are also elaborated on in Chapter 2, in -rvhich Stuart Eisendrath reviews epidemiology and clinical fea-

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tures of factitious disorders. Dr. Eisendrath’s clini- cal experience is evident in the clinical pearls he relates. The practical and theoretical pros and cons of trying to separate factitious physical disorders from factitious psychological disorders are adeptly discussed by Pamela Parker in Chapter 3. These chapters use both individual case vignettes as well as pooled information from case reports to illustrate the phenomenology of factitious disorders.

Legal and ethical aspects of factitious disorders are discussed in Chapter 4 by Charles Ford and Chapter 5 by Stuart Eisendrath, Deirdre Conway Rand and Marc Feldman. Dr. Ford’s chapter is par- ticularly clear, and includes references to relevant case law. Chapter 5 offers useful practical clues for reviewing cases in a forensic context. The necessity of a detailed review of all medical history in eval- uating any possible diagnosis of factitious disorder is described here, a point I think cannot be empha- sized enough. In any setting, historical review is likely to be essential to making the diagnosis. Also in Chapter 5, the concept of “secondary cost” is described, and its utility in distinguishing factitious disorders from malingering is clearly shown.

The second half of the book deals mostly with factitious disorder by proxy. These chapters are clearer and tighter than the earlier chapters on fac- titious disorder proper. Again, this stems from the clinical situations at hand. In factitious disorder by proxy there is usually greater opportunity to ob- serve and follow cases. Adults who fake or induce illness in themselves often flee when discovered, but child protection laws require that children who are victims of factitious behavior by adults be eval- uated and protected. Few caregivers who fake or induce illness in their children disappear while the child is in protective custody, and some such care- givers are required to be in treatment. Thus, the system allows for greater contact in factitious dis- order by proxy cases, and this seems to translate into better clinical information.

In DSM-4, factitious disorders by proxy is diag- nosed as “factitious disorder not otherwise speci- fied,” and the diagnosis accrues to the “perpetra- tor” of the incident, not to the victim. These issues are taken up in Chapter 6 in which Barbara Ostman and Marc Feldman provide a good overview of factitious disorder by proxy. The discussion of making and documenting the diagnosis is particu- larly good, and two lists of helpful tips are in- cluded. The disbelief that a caregiver could harm a child in this way-disbelief by family members, physicians, the courts-is also discussed.

The abusive essence of factitious disorder by proxy is compellingly described in Chapter 7, enti- tled “Comprehensive Psychosocial Assessment in Factitious Disorder by Proxy,” by Deidre Conway Rand. I consider this chapter to be the best in the book, and a significant contribution to the litera- ture. Writing with obvious clinical wisdom, Dr. Rand is both sensitive to and respectful of the com- plex natures of individual and interpersonal dy- namics hidden in this syndrome. She is able to illuminate important dimensions of emotional abuse and mother-child interactions without being simplistic. She offers insightful and balanced strat- egies for evaluating fictitious disorder by proxy (FDP) cases, and for treatment planning. Especially useful is an informed discussion of indications and contraindications for treatment of the abusive care- giver. This sort of consideration is all too rare in discussions of psychiatric treatment (for any disor- ders).

Beatrice Crofts Yorker, trained both as a lawyer and a medical professional, makes another out- standing contribution about legal issues in Chapter 8. Critical issues of criminal procedure and rules of evidence are clearly discussed here, with an excel- lent discussion of relevant legal cases. In Chapter 9, also by Ms. Yorker, several bizarre cases of epidem- ics of FDP, occurring at the hands of health profes- sionals, are documented.

Returning to factitious disorders in general, Chapter 10, by Marc Feldman and Roxenne Smith, chronicles the emotional tolls on both the patients and those who care about them. In an extended series of case examples, the pain experienced by significant others, family members, and health pro- fessionals can be appreciated. “Support groups” and “inservices” for those involved with factitious disorder patients are advocated.

In Chapter 11, the final chapter, Stuart Eisendrath and Adriana Feder survey management issues, in- cluding limited pharmacotherapeutic options, psy- chotherapeutic issues, and systems approaches. The chapter’s emphasis on “nonconfrontational” thera- peutic strategies reflects Dr. Eisendrath’s belief that “face saving is critical to psycho-therapeutic suc- cess.” Some of the limitations to such approaches are also discussed.

Despite the many strengths of The Spectrum of Factitious Disorders, further discussion would clarify some issues. First, though clinical factitious behav- ior is heterogeneous, and relatively few factitious disorder patients seem to exhibit the eponymic Munchausen syndrome, the concept of a spectrum

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may be overapplied here, in the service of normal- izing clinical factitious behavior. When Dr. Eisend- rath tells us that the spectrum “ranges from normal adaptive behavior to severe disability,” we need to keep in mind that factitious disorders, by defini- tion, involve pathological, maladaptive behavior. Dr. Eisendrath’s example of a child’s elaboration of somatic symptoms when faced with a developmen- tal or situational stress, and Dr. Don Lipsitt’s exam- ple of “the doctor game of childhood,” may appear phenomenologically similar to clinical factitious be- havior, but I suggest that such transient regressions and games serve much different developmental and dynamic functions than the adult behavior at issue here.

Second, one of the goals of the book is to separate fact from fiction, particularly the “touch of fable” that has accompanied case reports, ever since the term Munchausen’s syndrome was coined by Asher in 1951. It is puzzling then to hear factitious disor- der patients depicted here as “magicians” and “high-wire acrobats.” This sort of sensational and romanticized characterization of these patients re- curs in the many references to the patients’ “imag- ination” and “creativity.”

Third, this book seems to view factitious disorder patients primarily as victims of “various kinds of trauma, hospitalizations, and family dysfunction,” and sees factitious disorder behavior as “cultivated in this etiologic soil.” It is well to remember that no data are available to support this assumption, and as Dr. Lips& points out, “the potential for virtually every pathological entity is said to be heightened by early deprivation and emotional trauma” (empha- sis mine). Despite the many interesting and plausi- ble dynamic formulations offered by Dr. Lipsitt and his colleagues, the fact remains that most of these are “based entirely upon conjecture.” Still, there seems to be agreement that sadomasochism plays an important role in these patients. The authors tend to emphasize the patients’ masochism over their sadism and Chapter 10 reminds us of the agony caused to others by these patients. It is also important to remember that there are many types of masochism, and that masochism itself can serve various functions and have various meanings [1,2].

1 cannot think of any other psychiatric or psycho- logical syndrome in which experts have struggled so hard to emphasize the positive aspects of pa- tients and their psychopathology. Other recent pub- lications by some of these same authors have also taken this position. Such efforts to portray these patients positively seem to be designed to counter

common negative reactions to the patients and their behavior.

Contributors to The Spectrum of Faclitious Visor- ders point out that these patients can evoke feelings of “helplessness and frustration,” “anger and be- trayal,” and wishes for “revenge” in health care staff. The authors urge therapists to use such coun- tertransference feelings to better understand these patients. This is excellent advice, but the book would be made even better if the authors had ex- plained further, or even given examples of such therapeutic skill. Unfortunately, very iittle of such detailed clinical treatment data appears in the ex- isting literature. It seems only fair to point out, as has been described elsewhere, that countertransfer- ence reactions in factitious disorder cases can also include identification with the patient as victim, failure to address patients’ destructile behavior, and rescue fantasies; these responses cdn be just as countertherapeutic as overtly hostile responses to patients [3]. This principle is also acknowledged in psychotherapeutic treatment of severely ill patients and victims of abuse. Thus, balancing negative re- sponses by emphasizing positive aspects of patients is an understandable and potentially worthwhile effort, but is ultimately a complicated task.

One final suggestion for further discussion. The authors of The Spectrum of Factitious I>kvdr:rs coi- lectively report three cases in which il patient’s medical costs exceeded $l,OOO,OOO. There are prob- ably many more instances. The economic impact of factitious disorders, and the practical and ethical consequences of factitious disorders in the current health care market could, and should be discussed. Since factitious disorders are so extraordinarily dif- ficult to diagnose and treat, it seemb i-o me that mental health clinicians can make a critical contri- bution to appropriate conservation of rtsources and cost controls.

In summary, this is a useful and important book by some of the leading authorities in the field. It represents the existing literature well. ‘The sections of the book on legal and ethical aspects of factitious disorders, and the chapter on comprehensive as- sessment in factitious disorder by proxy are espe- cially noteworthy contributions to the literature. Hopefully, future work will clarify some of the other conceptually difficult and complicated areas in the field of factitious disorders, and make us less reliant on series of case reports. I have used The Spectrum of Factitious Disorders as a reference on a number of occasions already, and 1 dssurne this

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volume will remain a primary resource for clini- cians for some time.

References

1. Kernberg 0: Clinical Dimensions of Masochism. In Glick RA, Meyers DI (eds), Masochism: Current Psy- choanalytic Perspectives. Hillsdale, NJ, Analytic Press, 1988, pp 61-80

2. Meyers H: A Consideration of Treatment Techniques in Relation to the Functions of Masochism. In Glick RA, Meyers DI (eds), Masochism: Current Psychoan- alytic Perspectives, Hillsdale, NJ, Analytic Press, 1988, pp 175-88

3. Willenberg H: Countertransference in factitious dis- order. Psychother Psychosom 62:129-34, 1994

STUART TAYLOR, MD

New York, NY

PI1 SOl63-8343(97)00024-S

Outcomes Assessment in Clinical Practice. Edited by Lloyd I. Sederer and Barbara Dickey. Baltimore, Williams and Wilkins, 1996, ($45.00) 301 pp.

Health care professionals have always been inter- ested in treatment outcomes. Traditionally, though most clinicians practiced the very basic approach of “Primum Non Nocere” and learned about better treatments in conferences, researchers got involved with more complex endeavors such as large multi- center studies assessing the efficacy of a particular therapy. The current health care environment is forcing clinicians to take a much more pro-active role in the field of outcomes, as managed care com- panies are increasingly selecting members for pan- els based on efficacy of treatments provided. Clini- cians are thus asked to demonstrate that what they do results in patient improvement but few have acquired any knowledge in the emerging specialty of outcome measurement. Furthermore, since mea- suring outcomes has become a pressing need, sev- eral for-profit companies have developed propri- etary and very expensive “tools,” currently marketed to the inexperienced and worried clini- cian as the panacea for the outcome problem. In addition, controversies in the outcome arena abound. What is to be measured? By whom? For what length of time? Using which instruments? Will results be used to deny care or to “de-panel” otherwise excellent professionals?

Reading the book edited by Drs. Sederer and Dickey is a good start in the attempt to shed some

light on the issues mentioned above. The editors put together a collection of papers authored not only by seminal contributors to the field but also by managed care executives and public health schol- ars. For instance, the book contains chapters by Thomas Achenbach, Aaron Beck, Susan Eisen, Ronald Geraty, Howard Goldman, Thomas McLel- lan, Harold Pincus, G. Richard Smith, and Robert Spitzer, among many other distinguished writers.

The text is divided into four sections: Section I: “Integrating Outcomes Assessment Into Clinical Practice”, Section II: “Instruments of Outcome As- sessment”, Section III: “Future Directions”, and Sec- tion IV: “Appendices”. The first section has seven chapters that focus on various basic issues such as domains of clinical assessment, variables affecting outcome, choosing instruments, outpatient vs inpa- tient settings, design, implementation, and proce- dures for outcome evaluations, and health status evaluation. This section can be finished in under two hours and, once completed, the reader will be able to understand most terminology used to de- scribe outcome programs.

Section II contains 16 chapters, each reviewing a well known rating scale. In turn, each of these scales could be part of a comprehensive outcomes measuring system. Each of the chapters follows the same helpful structure, with the following head- ings: introduction, domain and number of items, target population, collection procedures, psycho- metric properties, scoring manual, automation, per- mission to use, description of where used, sum- mary of strengths and limitations, and list of references. This section contains descriptions of gold standards such as the SF-36, BASIS-32, GAF, BPRS, SCL-90-R, ASI, and CBCL among other ven- erable scales. With the exception of two scales, all other instruments are presented by their authors. This part of the text alone, which is a sort of who’s who in outcomes measuring, well justifies acquir- ing the book.

Section III has five chapters dealing with institu- tional and global issues. One chapter describes the American Psychiatric Association’s Practice Re- search Network, an effort in regaining leadership in the topic; other chapters focus on the role of prac- tice guidelines, report cards and the HEDIS system, and validity of instruments. There is also a chapter offering the views of an executive of a large man- aged care company. Finally, the appendix section contains copies of most scales reviewed, so readers have an example of what the instrument actually looks like.

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