Book Review
General Psychiatry
The New Oxford Textbook of Psychiatry. Michael
Gelder, Juan J Lopez-Ibor, Nancy Andresen, editors. Oxford (UK):
Oxford: Oxford University Press; 2000. 2938 p. CAN$565.50.
Reviewer
rating*: Excellent
Review by Mostafa Showraki, MD, FRCPC
Toronto, Ontario
Finally, we have a new, unconventional textbook of psychiatry that
meets the needs of psychiatrists in this millennium. Oxford University
Press has published this volume as the final section of a trilogy.
The first 2 texts are Psychiatry (An Oxford Core Text), designed
for medical students, and Oxford Textbook of Psychiatry, targeted
at psychiatric residents. This new and comprehensive textbook is
specifically written for practising psychiatrists. Edited by Michael
Gelder from Oxford University, Juan J Lopez-Ibor from Spain, and
Nancy Andresean from the University of Iowa, who is also the editor-in-chief
of the American Journal of Psychiatry, the book has been compiled
by a group of world-famous experts and does indeed fulfil the needs
of psychiatrists around the globe.
In 2 volumes, 11 major parts, and 2938 pages, this beautifully
crafted text focuses on 3 themes that dominate psychiatry in our
era. These are the growing unity of the subject, the pace of scientific
advance, and the growth of practice in the community. The book attends
not only to the treatment of mental ailments but also to their prevention,
not only to academic psychiatry but also to community-based psychiatry,
and not only to domestic psychiatry but also to international psychiatry
and the challenges facing the discipline worldwide.
The first part deals with the subject matter of, and approach to,
psychiatry. It is a rarity in many conventional psychiatry textbooks.
This part starts with the tender subject of what it means to be
a patient! “It is difficult to be a psychiatric patient, but
a good doctor makes it less so . . . Patients, when first given
a psychiatric diagnosis, are commonly both relieved and frightened”
(page 3) While reading this section, I pictured a client of mine
who had been terrified and shocked by the diagnosis of dysthymic
disorder that her previous psychiatrist disclosed to her without
any consideration of her feelings and the tenderness of the matter.
To the last day of our treatment, I had to work to clean up his
mess. “The specifics of what a doctor says, and the manner
in which he or she says it, are critically important” (page
3).
This interesting opening section discusses the stigma of mental
illness and the public attitude toward it and provides good references
for further studies. In this section, the reader will become familiar
with the differing ways in which mental illness is perceived. To
treat psychiatric illnesses effectively, competent psychiatrists
need to be able, with the help of the sufferers, to defeat stigma.
This means having a good knowledge of all the facets of ignorance
expressed as stigma in their society. They must enlighten both their
patients and the public alike to the fact that psychiatric illness
does not equate to being “dangerous, contaminating, weak or
culpable,” (page 5) that these are true and not feigned illnesses,
and that psychiatric patients are not complainers or individuals
avoiding responsibilities. This book reminds us that stigma is as
dangerous as any other prejudice and that it is especially important
to battle it now that psychiatrically ill persons are not locked
up in mental institutions but treated in general hospitals and community
clinics.
If the cardinal contributory factors to stigmatization are ignorance,
fear, and hostility, then the antidotes are information, reassurance,
and a vigorous anti-discriminatory campaign on the part of policy
makers and opinion-formers (page 7)
Here, the important role of media in destigmatization is also emphasized.
In this cutting-edge and comprehensive text, psychiatric illness
is recognized as a worldwide public health problem—a burden
to all humans, regardless of origin. We learn that depression currently
ranks fourth on the list of leading causes of disability worldwide
and that it will soon rank second, after ischemic heart disease.
Among the suggested key initiatives in the book are
better mental health services for children and adolescents including
early detection and prevention, co-ordinated efforts to improve
gender policies, to interdict violence toward women and to empower
women (page 10–11)
Regarding the history of psychiatry, we are warned about the “crisis
in psychiatry.” At this time, the crisis is not caused by the
conflict of one school of thought with another, but by the rising
practice of psychiatry among nonpsychiatrists.
In Germany a medical psychotherapeutic specialty distinct from
psychiatry has been created. . . . In France 60% of antidepressants
are now prescribed by general practitioners. . . . There is undoubtedly
a movement towards a limitation of psychiatry specialty to the
care of the most severe cases (page 26)
But while the text warns us about the new threat that psychiatry—or
at least the psychosocial part of it—may be eliminated, it
ends with the ray of hope that the current crisis is “another
transitory episode” in psychiatry’s tumultuous history.
The section discussing the education of psychiatrists emphasizes
4 major perspectives. These are “the disease perspective, the
dimensional perspective, the behavioral perspective, and the life
story perspective” (page 42) The authors cite the Johns Hopkins
psychiatric residency program as a well-known example of such an
educational approach. Psychiatrists are becoming more and more involved,
not only in the treatment of mental illnesses but also in managing
and providing psychiatric programs in the community, and a section
has been dedicated to this subject, as well.
In the chapter on classifying psychiatric disorders the book, unlike
many American psychiatric texts, does not limit itself solely to
the DSM-IV but familiarizes the readers with the international classification
of diseases (ICD-10) as well. North American psychiatrists are obliged
to follow the DSM system, and it has helped us over the past 2 decades
to have a consensus, at least. However, now may be the right time
to reach beyond the DSM—as Nancy Andreasen recommends in her
new book, Brave New Brain: Conquering Mental Illness in the Era
of Genome:
The scientific basis of DSM is credible. But it is not infallible.
Because DSM has become institutionalized in training programs,
it’s revered too much and doubted too little. . . . DSM criteria
may limit creativity and flexibility in thinking, which may inhibit
progress in understanding the underlying mechanisms of mental
illnesses (1).
“From Science to Practice” is a chapter that may help
practising psychiatrists to keep up-to-date with knowledge that
is expanding rapidly in the wake of evidence-based medicine. This
section will even teach readers how to perform a single-case study
on their clients and how to improve patients’ clinical conditions.
It explains how to gather evidence from different resources and
provides good practice guidelines. Busy clinicians will learn how
to gather the most reliable information from the seas of data surrounding
them in many journals and the Internet. Readers are also shown how
to appraise the articles they read.
Unlike other psychiatric textbooks, the section on “The Scientific
Basis of Psychiatric Aetiology” places major emphasis on the
historical development of etiology in psychiatry, on developmental
psychology, and on the current theoretical trends in regard to causality.
It asserts that medical, psychological, and social models of mental
diseases with no link and interaction with each other “fragment
the causality process and render themselves sterile.” The authors
believe that “views on causality are historical events—the
result of ideology and social expediency . . . and they are not
empirical in any real sense” (page 152) While endorsing the
view that the history of psychiatric etiology has been influenced
by the dominant trends of time, I personally believe that the truth
of the matter is not a unitary vision of one model or the other,
but an interaction of all. In this era of “the mind meets the
brain,” even the interactive-integrative model should not be
a dogma but amenable to modification as the need arises over time.
This is not an era of “left” vs ‘right” or of
psychopharmacology vs psychotherapy. As Kandel accurately points
out, “Insofar as our words produce changes in our patient’s
mind, it is likely that these psychotherapeutic interventions produce
changes in the patient’s brain” (2).
Throughout this prolific work, readers are entertained and introduced
to many rare, interesting, and important subjects and concepts that
may not be found in other texts, including recovered and false memories;
obesity as a psychiatric issue; psychiatric problem gambling; adjustments
to physical illnesses, handicaps, and bereavement; health screening
and prevention programs in psychiatry (with compelling evidences
of the efficiency of such strategies); and health psychology. This
last subject area targets the wide range of psychological processes
in health, illness, and health care; the interrelation of patients’
health and illness behaviour; lifestyle and health; and practitioner
aspects of health psychology. For those who find it difficult to
understand journal articles and scientific trials that employ the
sophisticated language of biostatistics, there is a comprehensive
review of clinical trials that includes such hard-to-digest methododology
as metaanalysis, analysis of group trials, the effects of placebo
and nonspecific factors on the outcome of trials, and the significance
of their inclusion. There is a good discussion of the general principles
of drug therapy—a subject that it is most important for practising
psychiatrists to consider before deciding on what medication to
prescribe for their clients.
The section entitled “Psychotherapy” offers a scholarly
explication of cognitive-behavioural therapy (CBT) in 4 subchapters.
This is an invaluable section, because other textbooks do not offer
much on CBT, despite the increasing number of promising outcomes
from different studies and trials of this effective and scientific
psychotherapy. CBT could well be combined with pharmacotherapy to
treat many psychiatric illnesses.
Chapters such as “Rehabilitation Techniques,” “Psychiatric
Nursing,” “Social Work Approaches to Mental Health,”
“Traditional Non-Western Folk Healing Methods,” and “Alternative
Treatments” will familiarize practising psychiatrists with
the reality of what is happening around them—a reality not
taught in medical school! Not many psychiatric textbooks cover areas
like public policy and environmental issues; service needs assessment
of individuals and populations; planning and providing mental health
services for a community; cultural differences in pathways to care,
service use, and outcome; evaluation and economic analyses of psychiatric
services; the role of advocacy; self-help; care groups and voluntary
organizations; the special psychiatric problems of refugees, homeless
people, and ethnic minorities; the influence of family, school,
and the environment on mental health of children; prevention of
mental disorders in childhood; child abuse and neglect; the effects
of adoption and foster care on child mental health; and the effects
of parental psychiatric and physical illnesses and bereavement on
child psychological development.
Special forensic issues discussed include juvenile delinquency,
the child as a witness, offending; dangerousness, risk, the prediction
of probability, the impact of victimization, the psychiatrist in
court, the legal use of psychiatry and law as an instrument of psychiatric
practice, and organization of services. All these subjects are discussed
with distilled wisdom, lucidity, and richness in this now gold standard
text.
References
1. Andreasen NC. Brave New Brain: Conquering Mental
Illness in the Era of the Genome. New York, Oxford University Press,
2001.
2. Kandel ER. A New Intellectual Framework for Psychiatry.
Am J Psychiatry 1998; 155:457–69.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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