General Psychiatry

Images in Psychiatry: Canada. Q Rae-Grant, editor. Washington (DC): American Psychiatric Press; 1996. 301 p.

Review by

Stanley P Kutcher, MD, FRCPC
Halifax, Nova Scotia

This book is a truly enjoyable compilation of brief vignettes, written by various distinguished Canadian psychiatrists. Each sketch stands alone, yet taken together, they provide a fascinating, albeit brief, review of the recent historical development of psychiatry in Canada.

This book can be read cover to cover, or it can be “dipped into” at the reader’s leisure. Each chapter is informative, and some provide a historical context.

As might be expected from such a multiauthored work, the results are not always even. Additionally, many areas are conspicuous by their absence; in particular, adolescent psychiatry, in which Canada has been an acknowledged leader. This is somewhat surprising as Dr Rae-Grant himself has made a significant contribution in this area.

Although this book is not a history, it nevertheless delivers messages to the reader while allowing the reader to develop his or her own interpretation. For example, the chapter on community psychiatry notes that the 1964 Royal Commission on Health Services Report recommended that provincial mental hospitals be replaced by general hospital psychiatric units. One cannot help but wonder at the slow pace of change for members of our specialty to move from the “alienist” position to a place equal to that of our medical and surgical colleagues.

In other parts of the book, authors have seized the opportunity to issue a wake-up call to Canadian psychiatry. For example, the chapter on prevention correctly identifies the excellent work done in the advancement of improving child outcomes and points out that our professional perspectives and training programs need to be encouraged to develop and critically evaluate prevention and early intervention programs.

All in all, this is a truly engaging book. It is a credit to its editor and to the many authors who participated in this project. In my opinion, it should be read by every psychiatrist and psychiatric trainee in Canada, because it not only provides information relevant to our discipline but serves to assist us in the development of a Canadian, professional identity.

That being said, there is a not too subtle irony that this excellent little book on Canadian psychiatry is published by the American Psychiatric Press.

Psychological Trauma: A Developmental Approach. D Black, M Newman, J Harris-Hendriks, G Mezey, editors. London: Gaskell; 1997. 412 p. £30.00.

Review by

Clare Pain MD, FRCPC
Toronto,Ontario

It may surprise the North American reader aware of the plethora of books on trauma published in the last few years that this book describes itself as the first British textbook on psychological trauma. In explanation, one of the contributors suggests that in the United Kingdom (UK), war neuroses associated with World War II stimulated the development of group analytical and therapeutic community theory. With fewer Holocaust victims and no Vietnam veterans, overall concern in the UK, until the Falklands and Gulf Wars, had focused on intrapsychic conflict. Anticipating many Gulf War casualties, the British Government requested that networks of experts be established to provide local services for the management of trauma in district hospitals. Ironically, although the influx of war casualties never materialized, there has been a string of civil disasters in the UK in the late 1980s and early 1990s, including the Zeebrugge ferry disaster, the Kings Cross fire, and the Piper Alpha oil platform disaster. Within the therapeutic community, these disasters have resulted in the development of an understanding of and experience in dealing with people suffering from the sequelae of psychological trauma. It is these experiences that influence the form, content, and character of this book on psychological trauma.

Dr Sims, a past president of the Royal College of Psychiatrists, writes in the forward that the book is a “comprehensive account of psychological trauma from a predominantly British perspective.” It is a 400-page edited collection of 48 short chapters, published by the Royal College of Psychiatrists. The 45 contributors are mostly psychiatrists, psychologists, and psychotherapists, but there are also a few contributions by lawyers, nurses, and social workers. All of the authors seem to be British, with the exception of Beverly Raphael from Australia and Daniel Siegel from California.

Apart from the facts that the disasters occurred in the UK and the contributors are mainly British, perhaps another aspect of the “British perspective” is a glimpse at how an understanding of trauma is integrated into UK current theory and practice. This is particularly evident in section 1, “Human Responses to Stress, Normal and Abnormal.” The 6 short chapters build on each other by laying out the territory of trauma. Chapters on the derivation of the diagnosis and classification according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) systems are followed by a focus on the difference and overlap between threat and loss, threat being associated with posttraumatic stress disorder (PTSD) and loss being associated with bereavement and grief. This interweaving of themes continues throughout the collection. The developmental aspect of the book is addressed by the chapters on children and the elderly as victims of traumatic experiences and on their particular responses and needs. Embedding an exploration of trauma in an understanding of attachment, stages of psychological development, and loss is unusual in equivalent North American compilations. Section 1 includes the only chapter in the book on the biology of trauma. It is a short but comprehensive chapter, but since research is moving ahead so quickly in this area, it will soon be out of date. The chapter by Siegel on memory and trauma is exceptionally good. Section 1 ends with an exploration of psychoanalytic and cognitive-behavioural models with reference to PTSD.

The book is organized into 4 sections; section 2 describes 9 recent UK civil disasters. These chapters provide the unique heart of this book, and it is not possible to read them without being deeply moved. Although each of the descriptions is short and anecdotal, each takes a particular aspect of a disaster that illustrates a specific difficulty confronting the victims, workers, and/or community. The disruptions in communication within the affected communities and between the aid personnel demonstrate the difficulty of adequate on-site and follow-up help for the individuals and communities involved; let alone the near impossibility of conducting any research at the time of the disaster to help evaluate interventions. Section 2 also includes a chapter each on other types of trauma, such as the effects of conflict on combatants and on civilian populations, civil violence, population displacement, interpersonal violence, and torture. This section tends to emphasize the predispositions in the victim to develop PTSD and to de-emphasize the role of the severity of the trauma as a factor in subsequent psychiatric morbidity.

Section 3 is called “Diagnosis, Intervention and Treatment.” Included are chapters on crisis intervention; bereavement counselling; and behavioural, cognitive, and psychodynamic approaches to treatment for both adults and children; and a 1-paragraph chapter on Eye Movement Desensitization Reprocessing (EMDR). The chapters address psychopharmacology treatment and service provision where the roles of the police, social workers, schools, volunteers, and employers are addressed. The effects of disasters on helpers is the subject of the final chapter. This section and the book in general focus mainly on PTSD and the effects and treatment of bereavement. This collection is weakened by the fact that no attention is paid to the most frequent accompanying symptoms such as somatoform symptoms, other anxiety disorders, substance abuse, or personality symptoms. Although the last chapter in the book acknowledges the exclusion of dissociative disorders, it is surprising that the phenomenon of dissociation is insufficiently addressed. Dissociation at the time of the traumatic event is common and probably has prognostic significance, and dissociation as a sequelae to trauma usually requires attention in the treatment plan; it is frequently a stumbling block for inexperienced clinicians and helpers, to whom the book is largely addressed.

The fourth and final section is titled “Legal Aspects: Victims as Witnesses and Claimants.” Although interesting, this section is perhaps less relevant to a Canadian readership because it relates to British civil and criminal law. However, the section includes a chapter on ethical issues in disasters, which is easily generalizable to the Canadian experience. The final chapter, “Overview and Comment,” is very helpful but would have been more useful earlier in the book to orient and direct the reader through the sections and elaborate on the purposes of the collection.

The book as a whole is well written, thoughtful, and easy to read. Each chapter presents a brief summary of its topic and synthesizes the research around trauma. It is extremely well referenced and would be useful for that reason alone to anyone wanting to explore specific issues in depth. It is neither a how-to manual nor a collection of results of randomized, controlled trials on trauma. It is largely a psychosocial orientation to various large-scale traumatic circumstances, addressing responses to disaster and the effects of disasters on the individual, the community, and helpers from various disciplines. The diagnosis of PTSD; grief and bereavement issues; treatment approaches; legal, ethical, and organizational responses to mass disaster are well addressed. The subjects of childhood physical and sexual abuse, adult sexual assault, and domestic violence are alluded to briefly but not elaborated on; the authors note that there are now many specialized texts on these subjects. The book is ambitious, unusual, and for the most part successful in its description of so many different types of trauma and in its multidisciplined focus. The book’s readership should include not only psychiatrists and psychologists but especially accident and emergency specialists and other associated health professionals. Lawyers, employers, and those involved in strategic planning of health care would find it a useful and comprehensive overview. The problem with a book of this nature is that, despite the fact that it is interesting and informed, it is expensive. The majority of trauma patients who are seen by clinical psychiatrists are suffering from the sequelae of domestic trauma, which the book does not address in depth. Consequently, this collection may not be relevant for clinicians in their daily practice, although it certainly provides an interesting background to and broad perspective on the consequences of large-scale disasters.

Child Psychiatry

Assessment of Childhood Disorders. Third Edition. EJ Mash, LG Terdal, editors. New York: Guilford Press; 1997. 800 p. US$75.00

Review by

Margaret M Steele, MD, FRCPC
London, Ontario

In the third edition of this book, the editors, Eric J Mash, University of Calgary, and Leif G Terdal, Oregon Health Sciences University, provide comprehensive, current knowledge about the assessment of child and adolescent mental health problems. Since the first edition of the book a few decades ago, the importance of recognizing and assessing mental health problems has grown substantially, as has the amount of research in this area.

The editors state that “this is a book about assessment and diagnosis, clinical decision making, child and family development, developmental psychopathology, clinical child psychology, measurement and psychometrics, social values, ethics and cognitive behavioural therapy.” The book covers the most recent advances in the principles and procedures for assessing disturbed children and their families and focuses on the behavioural systems perspective of assessment. The editors emphasize that assessment practices can be used to inform clinical interventions. The book is intended as a reference for professionals working with children and their families and for students planning to work in this area.

The book is divided into 5 parts: Behavior Disorders, Emotional and Social Disorders, Developmental and Health Related Disorders, Children at Risk, and Problems of Adolescence. Each part contains several chapters written by Canadian and American psychology experts. Each chapter provides information on classification (ususally using the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]), symptomatology, epidemiology, and etiology of the various mental health problems as a foundation for proposing the behavioural assessments. The book is extensively referenced and has an author and subject index.

The introductory chapter, “Assessment of Child and Family Disturbance: A Behavioral-Systems Approach,” provides an extensive overview of the recent developments in behavioural assessments, pointing out that the distinction between behavioural and traditional approaches to assessment is not as clear as once considered. The purposes of assessment and the various types of classification are effectively described. The challenge of assessing children, who undergo rapid and uneven developmental changes and in whom age, gender, and culture are also factors, is well detailed. The importance of multiple informants (for example, child, parent, and teacher) and multiple forms of behavioural assessment measures (such as self-ratings, structured interviews, and direct observation) is emphasized.

Most chapters are extremely thorough and are clearly written. Chapter 11, “Child Physical Abuse and Neglect,” by Wolfe and McEachran, is, in my view, one of the best chapters in the book. The authors begin by defining child physical abuse and neglect. They discuss the incidence and profile of abuse and neglect, comparing statistics in the United States (US) and Canada and offering possible reasons for why abuse occurs less frequently in Canada. Very few chapters in the book address the differences between Canada and the US. Many chapters discuss legislation, such as The Education Act, but they refer exclusively to US law. The authors proceed to describe the characteristics of the abused child and the perpetrators and provide a developmental picture of how maltreatment affects children from infancy through adulthood.

A conceptual model for the assessment of the physically abused and neglected child is proposed, and the common assessment purposes are summarized. This chapter stresses that the psychologist’s role be coordinated with the role of the child protective services agency to promote an interdisciplinary approach to working with multiproblem families. They also provide an excellent case study to demonstrate the steps taken in assessment. The use of the case example helps the clinician apply the behavioural measures to clinical practice. Throughout the book, clinical examples would have been useful to bring the assessment measures to life for the clinician.

This book is definitely a valuable resource for psychiatrists. The behavioural measures are well described, and the rationale for their use is explained. Psychiatrists actively involved in research would find this book especially useful. For clinical psychiatrists the book could be used as a resource for interpreting psychologists’ reports. In many chapters, the etiology of the disorders are addressed from the biological, psychological, and social perspectives. However, the descriptions of the biological aspects of mental health problems are often minimal and/or do not address the current theories. For example, in chapter 4, “Depression in Children and Adolescents,” the author focuses on neuroendocrine dysfunction and biological rhythm disruptions but does not discuss neurotransmitters such as serotonin. It may have been helpful for the author to refer the reader to an up-to-date review article.

The role of the physician is also not fully appreciated. For example, in chapter 2, “Attention-Deficit/Hyperactivity Disorder,” Barkley describes the reasons for referring a child with attention-deficit/hyperactivity disorder for a medication trial. One such reason is “the absence of a personal or family history of tics or Tourette syndrome.” This statement is not accurate, since such an individual may benefit from a tricyclic antidepressant. It may have been helpful for Dr Barkley to have referenced his reasons or conferred with a physician.

Overall, the book is an excellent resource, especially for understanding the reasons for behavioural assessment, the steps taken in such an assessment, and the types of behavioural measures that can be used. To enhance its content and to be applicable to all professionals working with children, including medical professionals such as nurses and physicians, the authors could have commented on current biological theories of the various disorders and provided more case studies to make it more applicable to clinical practice. The book is attractive in its’ layout and is relatively free from production errors. It is a valuable reference at a reasonable price.