Book reviews

The mental health consequences of torture: plenum series on stress and coping

E Gerrity, TM Keane, F Tuma (eds)New York: Kluwer Academic, 2001

ISBN 0 30646 422 5 pp.374 $111.54

I am writing this review in the aftermath of the Tampa‘crisis’ and the apparent evaporation of empathy withinour country for asylum seekers who have survivedtorture and trauma. In such a climate it has been adifficult task to read and review this book. The bookcontains all the evidence and much clinical and humanwisdom to inform a logical and humane response to themental health needs of refugees who have survivedtorture and related forms of trauma. The material alsoindirectly illustrates how our current social policies arecreating serious morbidity among the most vulnerableindividuals in our community. There has been sufficientrecent concern about this for the RANZCP to develop anurgent response and link with the other Colleges toadvocate with the Government on behalf of asylumseekers.

The book is the result of a 1997 conference convenedby the National Institute of Mental Health (NIMH),which led to the establishment of the ‘Working Group onthe Mental Health Consequences of Torture and RelatedViolence and Trauma’, comprising 24 experts who pro-vided a report to the South African Truth and Reconcili-ation Commission. Typically, only 3 contributors fromoutside the USA were involved, one of whom wasDerrick Silove, the leading Australian psychiatrist in thisfield. There are chapters on every aspect of the field. Anearly chapter written from the perspective of the survi-vors by Diana Ortiz is superb. As well as clearly articu-lating the psychological experiences and responses ofthe individual, she emphasizes the destructive effects ofhuman rights abuses on society itself. This is a legacythat Australia is actively creating for itself through itsserious abuse of asylum seekers, most of whom aresurvivors of torture and trauma. Other excellent contri-butions include the chapter on research by Basoglu

et al

., on neurobiological models by Southwick andFriedman, and on survivors of war trauma, mass vio-lence and civilian terror by Silove and Kinzie. Thesecontributions detail the evidence base for assessment,treatment and advocacy. A key mechanism for inappro-priate rejection of genuine asylum claims in the Aus-tralian system is the discrediting of the applicants’ stories.This is made more plausible in the context of a relentlesscampaign of public disinformation. The research evi-dence regarding the impact of trauma on memory is

almost never considered in these legal determinations,yet is a crucial factor in understanding how the person’saccount emerges during the process. A chapter on theeconomic impact of torture and trauma has relevance forthe Australian context as well. In addition to focusing onthe massive direct costs of current policies, we can usesuch methodologies to assess the long-term costs of themorbidity being created by the system of remote deten-tion in refugees who are eventually accepted.

In later chapters, the issues of recovery, the needs ofchildren and the effects on clinicians and care-givers arecovered. Jaranson

et al

. describe the three elements ofthe South African reconciliation model, namely ack-nowledgement, apology and reparation. These essentialfeatures of recovery from any mass abuse situation notonly have obvious relevance to Australia in relation toour indigenous population, but also in relation to ourcurrent treatment of asylum seekers and detainees. Even-tually an apology is going to be required for what isoccurring in the detention centres even as you read thisreview. Only a relatively small number of Australianpsychiatrists are directly involved in the assessment andtreatment of detainees. All are deeply distressed aboutwhat is occurring. Very few psychiatrists are involved intreating community-based asylum seekers, who aredenied Medicare access, or even torture survivors whoare permanent residents. There is a much greater role forpsychiatric involvement here since a substantial propor-tion suffer from complex psychiatric problems. Theimpact on clinicians of treating severely traumatizedpeople especially in the current policy environment iscomplex and potentially harmful. This is covered tosome extent in a brief chapter by Kinzie and Engdahl,though the ethical aspects as they apply currentlywithin the Australian context are much more complexthan addressed here. The effects of torture, trauma andthe refugee experience on children are covered in achapter by Pynoos

et al

. There are currently 633 chil-dren in detention centres in Australia, including 73unaccompanied minors. This chapter highlights howthis experience, which has included forced separationby Australian authorities of children from their fami-lies, exacerbates pre-existing trauma and creates newmorbidity.

The monograph is a rich resource for clinicians andresearchers working with torture and trauma survivors.More skilled clinicians are needed in Australia toenhance our response to these marginalized and abusedgroups of people. This book is an important weapon inmobilizing and underpinning such a response.

Patrick D. McGorryMelbourne, Australia

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Psychodynamic psychiatry in clinical practice, 3rd edn.

Glen GabbardWashington: American Psychiatric Press, 2000

ISBN 1 58562 002 5 pp.616 $US147.95

This text is a welcome update given the escalatingdevelopments in the fields of neuroscience, and psy-chodynamic research and thinking. It is an extremelycomplex task to marry descriptive diagnosis based onDSM-IV criteria with psychodynamic diagnosis ‘basedon an understanding of the patient and the illness’ (p.79).The former involves ‘assignment of a correct label’(p.79) and is based on what is directly observable, whilethe latter is concerned with what, by definition, includesthe patient’s inner world, and is not so directly observ-able. In short, these are fundamentally different approachesto understanding, and this becomes obvious in thesecond and third sections of the text which deal withdynamic approaches to Axis 1 and Axis 11 Disorders.For example, in chapter 16, Cluster B Personality Dis-orders: Narcissistic, we find this label applies ‘equallywell to patients with quite different clinical pictures’(p.466). To those used to thinking along descriptivediagnostic lines (DSM-IV), it might seem that psycho-dynamic understanding has little coherence or consistence.

The preface to this third edition, states that it has been‘rewritten, not [as was the second edition] in response toa nomenclature change [the publication of DSM-IV] butrather “to reflect changes in the science and art of psycho-dynamic psychiatry”. Further stated aims include – the‘integration of neuroscience and psychodynamics’, thehighlighting of theoretical trends and the implications ofthese for clinical practice, and the inclusion of researchfindings ‘to bolster the case for a psychodynamicapproach’. All of these have been admirably achieved.

Section 1, on Basic Principles and Treatment Approachesin Dynamic Psychiatry is written in a clear and informa-tive manner, carefully placing psychotherapy in contextwith many examples to aid understanding. Yet, on someoccasions, the examples given are surprising. When cat-egorizing the types of intervention under Advice andPraise, we read under Advice: ‘I think you should stopgoing out with that man immediately', under Praise: ‘Iam very pleased you were able to tell him you will notsee him again’(p.98). Gabbard goes on to state that ‘thevast majority of psychotherapeutic processes contain allthese interventions (including advice and praise) at sometime during the course of treatment’ (p.98). This iscertainly not my understanding, and both interventionsseem to leave no room for the patient’s autonomy. Icannot think of a situation in which they would be likelyto be therapeutic.

In the introduction to chapter 2, Gabbard states‘psychoanalytic theory is the foundation of dynamicpsychiatry’ (p.27). I think it is worth adding it is thetheory and the method (which inform each other) thatprovide this foundation. In chapter 4, he makes thepoint:

‘Historically, insight and understanding were alwaysconsidered the ultimate goals of psychoanalysis andpsychotherapy . . . In the last 40 years, however,there has been considerable acceptance of the notionthat the therapeutic relationship itself is healing inde-pendently of its role as delivering insight. Loewald(1957/1980) noted that the process of change is “setin motion not simply by the technical skill of theanalyst, but by the fact that the analyst makes himselfavailable for the development of a new

object rela-tionship

between the patient and the analyst’ (p.91).

A text such as this is highly relevant to alert psychia-trists to the danger of over-emphasizing either a bio-logical or a psychodynamic (psychosocial) approach atthe expense of the other. It is most suited to those whoare in psychiatric training, and those who need convinc-ing that a psychodynamic understanding is an integralpart of the assessment and management. This third editionis an important reference for the latest in research find-ings, together with theoretical and clinical developments.

Bill BettsMelbourne, Australia

International handbook of alcohol dependence and problems

Nick Heather, Timothy J Peters, Tim Stockwell (eds)London: Wiley, 2000

ISBN 0 47198 375 6 pp.900 £95.00

Let’s not beat about the bush; this is a terrific book.While there are several large texts on the general topic ofaddiction, this book addresses only alcohol related prob-lems and in doing so is able to go into a depth ofcoverage seldom achieved in such texts. The 42 chaptersdivided into six parts, each by leaders in their particularfield on almost all of the important topics related toproblematic alcohol use, establish it as

the

authoritativereference on the topic. It has the clarity to encouragenonspecialists in the alcohol and drug field to delve intoit, and the depth to teach the most knowledgeable ofspecialists something new. Ultimately during the reviewperiod I went back to this book frequently, not to checkout various sections for review but rather to enjoybrowsing and learning something new. It’s that rare kind

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of book of textbook; not just an excellent reference butalso a good read.

Its broad sweep covers topics such as the history andclassification of alcohol problems (Part I; Alcohol andPeople), the medical complications of alcohol use (PartII; Clinical Pathology), the aetiological processes involvedin the development of alcohol problems (Part III; Ante-cedents of Drinking, Alcohol Problems and Dependenceand Part IV; Drinking Patterns and Types of AlcoholProblem), treatments, their effectiveness and the processof natural recovery (Part V; Treatment and Recovery)and public health and prevention issues (Part VI; Preven-tion of Alcohol Problems).

Each part starts with an editor’s introduction. Eachchapter begins with a synopsis of about a page in length;an excellent device for orientating the reader and pro-viding a context within which to place the informationthat follows. The synopses are invariably concise and, inthemselves, could produce a short and useful entry leveltext. Within each chapter, a wealth of information issupported not just by references to key research findingsbut by descriptions of the key findings and their implica-tions. This layout means that while the content hassufficient depth for alcohol and drug specialists to learnsomething new each time they dip into the book, it is notso esoteric that nonspecialists can’t also benefit from it.

What parts of the book did I value the most? Given therelative evenness in the contributions it is difficult tohighlight any one area over another. Following my ownparticular area of interest therefore, the chapter ‘Treatingcomorbidity of alcohol problems and psychiatric dis-order’ by Kim Mueser and David Kavanagh reviewedthe area of coexisting substance use and mental healthdisorders succinctly. But perhaps the sections I enjoyedthe most were those I knew the least about; those dealingwith public health issues and a more social perspectiveon alcohol use.

However, despite the authors’ claims that all the topicsof clinical importance are adequately covered, there aresome deficiencies. As useful as the chapter on coexistingsubstance use and mental health disorders is, giving only42 pages to the topic is woeful. I admit my biases in thisarea. I acknowledge that few other generalist addictiontextbooks deal with the topic as well as this one. But Iremain unable to see how the significant interactionsbetween alcohol and some of the most common anddisabling disorders known warrants less space than adiscussion on the effects of alcohol on, for example,muscle, skin and bone. There is little attention given tothe problem of polysubstance use and the difficulties ofhelping people who use other drugs in addition to alco-hol. While alcohol use by adolescents crops up in discus-sion in a number of places there is no section dedicated

to the nature and treatment of alcohol and drug problemsin young people and as such, no coherent discussion ofthis area. Related to this latter point, I could find little onthe role of family interventions in alcohol and drugtreatment.

In the end, the main benefactors of any textbook needto be our patients. This book will help encourage clini-cians to learn and to provide them with easy access tohigh quality and relevant information. As such the bookis a great success. But it also maintains the separation ofalcohol disorders from drug use problems, and moreimportantly of alcohol and drug disorders from othermental health disorders. Perhaps the mark of the book isthat I had hoped it wouldn’t do this – and that is anunreasonable expectation; certainly not one I wouldplace on many other textbooks in the alcohol and drugarea.

Fraser ToddChristchurch, New Zealand

Brain calipers: descriptive psychopathology and the psychiatric mental status examination

David J RobinsonMichigan: Rapid Psychler

ISBN 1 89432 802 7 pp.428 US$34.95

In the vast profusion of books that are available,very few stand out as unique or indispensable.

Braincalipers

. . . is one of those rare exceptions. The out-standing characteristic of the book is that it effectivelyaddresses a critical and often neglected aspect of psychi-atric training, the mental state examination and associatedpsychopathology. The book is an excellent referencesource of definitions and clinical examples of a range ofpsychopathology. Furthermore it manages to look atwhat could be a dry and dusty topic with a combinationof thoroughness and depth, tempered by humour, anec-dotes and Rapid Psychler Press in-house cartoons andgraphics. The humour is carefully judged, and neverrisks being derogatory or offensive. Mnemonics, tablesand illustrations are effectively used, and it is well refer-enced. There is a strong clinical and practical focus. Thestyle is light enough, so that despite the substantial list oftopics and definitions it covers, it remains eminentlyreadable.

Brain calipers

. . . covers a wide range of areas. Chap-ters include the principles of the mental status examina-tion, appearance, behaviour, cooperation and reliability,speech, thought process, and content, suicide, affect andmood, perception, insight, sensorium and cognitivefunction. Additional sections cover bedside screening

282 BOOK REVIEWS

instruments and psychopathology in the elderly andchildhood.

This book would serve as a most valuable resource forany student of clinical psychiatry, particularly at reg-istrar and medical student level. It deserves to be read,and merits a place in any psychiatric library.

Michael BerkGeelong, Australia

The psychiatric interview: a guide to history taking and the mental state examination

Saxby PridmoreAmsterdam: Harwood Academic, 2000

ISBN 9 05823 106 2 pp.146 $US22.00

How refreshing to see yet another book on the psychi-atric interview, that much neglected aspect of the craft ofpsychiatry. Does this herald a renewed interest in theinterview and the data that is generated therein and amove away from standardized interview schedules, whichare creeping into psychiatric practice, and psychiatricreport writing? It is almost routine now to see reports ofthe depth of depression on mental state examinationbeing assessed on the Beck rather than on observationsand empathic connectedness at the interview.

On closer inspection the book turns out to be a bit of adisappointment. It is actually not about the psychiatricinterview but rather a ‘guide to history taking and themental state examination’ which is its appropriate sub-title. There is very little in this book about the process ofinterviewing and the dynamics of the interview althoughthe general approach and how one questions in an openmanner as against a closed approach is discussed. ThusPridmore disappoints but this is not to say that it is not auseful book, particularly for psychiatric trainees strug-gling to come to terms with the complexity of the psy-chiatric examination and what the data means.

In the eliciting of the psychiatric history, Pridmoredraws attention to personality and the much neglectedconcept of alexithymia. He assumes however, that alex-ithymia arises in the patient. What about the alexithymicdoctor? Could not alexithymia in the patient be a reflec-tion of the interaction between doctor and patientwherein the doctor is uncomfortable with feelings andmoreover finds it difficult to listen to feelings. There ispresumably a Greek word to describe this, if not some-body who knows Greek should invent a neologism andbecome famous.

The strong point of this book is the mental state exam-ination. The various aspects of examination are des-cribed succinctly and with fine examples from real life.

The author seems to have an excellent collection ofwritings and drawings by real patients.

Pridmore also gives sufficient space to the assessmentof cognitive function and the neuropsychiatric examina-tion and in particular the assessment of higher functions.This is another neglected area in psychiatric trainingwhere patients are referred for neuropsychological testingoften before assessment of higher cognitive functions atthe clinical level. There is also a nice discussion of‘insight’ and what this term means.

If there is one quarrel I have with Pridmore’s approach,it is that the symptoms in the mental state examinationsection are not described phenomenologically. Delu-sions are defined in terms of the falseness of content andclassified by their content. There is no discussion of the‘form’ of the idea and how this distinguishes patho-logical from nonpathological erroneous ideas. It is asif Jaspers and Schneider never existed. Moreover, dis-orders of the experience of thought as in thought broad-casting, thought insertion and thought alienation andalso passivity symptoms are assumed to be delusions(i.e. disorders of belief) rather than disorders of experi-ence of self. It seems to me that there may or may not bedelusional elaboration of these primary experiences.Also disappointing is the discussion of mood congruenceand incongruence and its diagnostic significance. What-ever happened to understandability?

It is of interest that while Pridmore discusses ‘dissoci-ative hallucinations’, there is no mention of ‘flashbacks’.Hence my search for a definition of this much used andabused term continues and indeed I search in vain for agood definition of ‘dissociation’. Perhaps ‘flashbacks’would not have existed if the movie camera and tele-vision had not been invented?

Pridmore writes in a clear and engaging manner and Iwould recommend this book to anyone starting trainingin psychiatry. It would serve a first year trainee well inthe examinations. However, they will need to know a lotmore about phenomenology and the process of psychi-atric interview in the later years.

Frank VargheseBrisbane, Australia

A pocket reference for psychiatrists, 3rd edn.

SC Jenkins, JA Tinsley, JA Van Loon (eds)Washington: American Psychiatric Press, 2001

ISBN 1 58562 008 4 pp.332 US$30.95

Another brief guide is hatched (in its third edition) outof Minnesota, eager to join the throng of condensationsof psychiatric practice. Despite competition, this has

BOOK REVIEWS 283

proved successful enough to warrant three publishings,which instils hope in the cautious reviewer. As with mostsuch guides, the reader is at first disarmed by the oblig-atory disclaimer, warning those seeking both more andless detail than is presented.

Useful areas of the book include a brief run throughneuropsychological and psychological tests, with a firmemphasis on the MMPI (hardly surprising given theprovenance of the book).

Tables I found interesting included AntipsychoticDrug Receptor Affinities (p.83), Temporal Onset ofAdverse Events (p.87), Opiate Receptor Types andActions (p.248) and Herbals (pp.139–146), althoughguarana is not mentioned. Curiously, despite ‘black cohosh’being listed as used for promotion of lactation, it is alsocautioned/contraindicated in lactation (p.140). I alsonoted that Seroquel apparently causes cataracts in beagles(p.96). Do we instigate eye exams on a 6 monthly basison all our Seroquel patients as suggested?

There is a reasoned though defensive attitude to ECT,and a useful listing of drugs and medical conditionscausing psychiatric syndromes, expanded in the geriatricsection.

An intriguing breakdown of premenstrual dysphoricdisorder (pure-pure, pure, premenstrual magnificationand PMS) is given (p.198). A risk of perimenopausaloestrogen triggering rapid cycling in bipolar patients ismentioned (p.200), although the evidence I have beenable to find for this is sketchy at best.

Guidelines for reporting on the child patient areconcise and thorough (p.205), and the suggested sleepdisorders interview (p.218) appears a useful reminder.

Much of the rest of the book is not overwhelminglyuseful to the Australian market. Medication listings arehampered by availability (moclobemide is still not avail-able in the USA) and trade name variability, although thepaediatric dose guides are clear, with weight expressedin kilograms. Prior authorization guidelines (p.260) areapplicable only to managed care.

The sedative withdrawal conversion (p.242) is almostuseless, employing chlordiazepoxide or phenobarbitalequivalents. I obtained quite worrying results with thephenobarbitone challenge test (p.241) – definite toler-ance results in a daily phenobarb dose equivalent ontheir conversion to 167–200 mg diazepam/day, markedtolerance to a dose of 267 mg diazepam, and extremetolerance to a dose of 333–400 mg of diazepam or more.I think few practitioners would be prepared to risk pre-scribing these quantities routinely, even on an acutewithdrawal basis.

Long-term adverse effects of lithium on the renalsystem are omitted in the otherwise exhaustive list ofside-effects (p.122).

Several typographical errors escaped the editors’ eye(pp. 24, 147) and there are some confusing remarks suchas ‘widest girth more than 55cm’ as a relative contrain-dication for MRI (p.13). I also noted a quaint but dis-turbing phraseology with regard to tardive dyskinesiaincidence; ‘Blacks are at greater risk than whites’(p.91)– surely the USA has more to say about distinct racialgroups than this dichotomous view.

All things considered, my favourite section of themanual was on pages 231–33. This lists techniques toinduce a false negative on urine drug screen for par-ticular substances by interfering with the immunoassayreagents, and how to detect the likely use of theseadulterants. I think most substance use populations inAustralia are relatively naïve in the use of these adulter-ants, but with availability of information on the Internetit is certainly worth being aware of the possibilities.Monitored sampling may be the only answer wheredoubt exists.

Despite covering many issues well, this manual is lessthan ideal as a primary rapid resource in Australia. Moreextensive footnoting would assist greatly in weighing theevidence for much of the information given. Some sec-tions are intriguing due to altered perspectives in a verydifferent practice environment, and it would make auseful augmentation to a well-stocked bookshelf.

Angela HarteMelbourne, Australia

The executive brain: frontal lobes and the civilized mind

Elkhonon GoldbergNew York: Oxford University Press, 2001

ISBN 0 19514 022 2 pp.270 $75.00

The frontal lobes have long fascinated neuropsycholo-gists, and many have attempted to conceptualize frontallobe function with varying degrees of success. ElkhononGoldberg was fortunate enough to study with a manwhose contribution to our understanding of the frontallobes (and neuropsychology in general) was monumen-tal and paradigm shifting, Alexandr Romanovich Luria.

Chapter 2 ‘An End and a Beginning: A Dedication’tells the story of Goldberg’s separation from his greatmentor, a story which unfolds against the backdrop ofthe repressive regime under which the two men lived,were educated, and pursued their deep interest in psy-chology. We know little of Luria’s personal style or theway in which he related to his students. Goldberg paintsa portrait of the Lurias as ‘warm and generous’, with ahabit of ‘drawing their associates into their family life’,himself becoming ‘the object of their semi parental

284 BOOK REVIEWS

supervision’. But he also felt a ‘nagging ambivalence’towards Alexandr Romanovich. In order to preserve hisinternal (intellectual) freedom, Luria had made an exter-nal compromise (he joined the Party), and he tried topersuade his protégé to do the same. Goldberg found thisunpalatable, and his refusal led, in effect, to the loss ofLuria’s patronage (‘there is nothing more I can do foryou’), and to a covert plan to leave Russia.

But there was also a surprising intellectual rift betweenthe two neuropsychologists: when Goldberg revealed his‘gradiential’ theory of brain organization to the master,probably with a mixture of youthful pride and trepida-tion, it was received with ‘benign indifference’. Forthose with an interest in the history of neuropsychologi-cal thought, gradiential theory is a natural extension ofthe Jackson–Freud–Luria tradition. Goldberg knew that,and while he brushes off Luria’s lack of enthusiasm, Iwonder if he does not retain a sense of perplexity.

Gradiential theory emphasizes continuity in the corti-cal representation of cognitive function, as opposed tothe discontinuities that characterize modular or location-ist views. In this book, Goldberg emphasizes the massiveinterconnectedness that exists between the frontal lobesand the rest of the brain, not as a static anatomicalcharacteristic, but as continually shifting patterns offunctional interconnection or ‘dynamic topology’.

The rest of the book is a tour through the frontal lobes,under the guidance of a very knowledgeable exponent.Exactly how to conduct the tour, however, was anothersource of ambivalence for Goldberg. The book wasintended for a general audience, but in Goldberg’s wordsit turned out to be ‘something of a hybrid, the product ofa conflict between Goldberg as “professional” and Gold-berg as “populariser”’. The final product is remarkablysuccessful. Goldberg’s device is social metaphor. Heportrays the brain as a microcosm of society, and thefrontal lobes as conductor of the orchestra, corporateexecutive, military leader. and like all executives, thefrontal lobes are specialized to regulate internal mentallife in the interests of embedding the individual in awider social context. It preserves the individual froma slavish responsiveness to external demand or internalperturbation. When it is damaged, the effects are pro-foundly societal, but paradoxically continue to fall ona ‘public blindspot’ because they are difficult to con-ceptualize.

The executive metaphor is now commonplace inneuropsychological discussions of the frontal lobes, butits origins in the thinking of Freud and Luria are notunderstood, and the concept has been simplifiedbeyond any genuine usefulness. Paradoxically, Gold-berg’s book intended for a general audience may helpto re-introduce some depth.

The Executive Brain

is

likely to be a fascinating read for those who are familiarwith frontal lobe neuropsychology, and Goldberg’sapproach in particular, and an inspiring educationalexperience for the general reader interested in the mind–brain interface.

Michael M. SalingMelbourne, Australia

Assessing forensic mental health need; policy, theory and research

Andrea Cohen, Nigel EastmanLondon: Gaskell, 2000

ISBN 1 90124 242 0 pp.228 $115.00

This is a sobering book. It endeavours to explain theplace of ‘needs assessment’ in current mental healthpolicy in the United Kingdom. The authors provide thecontext of such assessment by describing developmentsin health policy over recent decades, including the innu-merable reports and working documents (one notes allthe ‘ing’ titles – so much potential activity for all con-cerned!) and apparent shifts in direction, no doubt to theconfusion and befuddlement of the hapless clinician.The authors express caution regarding the meaning anduse of a term that seems to imply appropriate and bene-ficial results, yet must always be read within a politicaland economic context. It is difficult not to approachthe area with a degree of cynical realism, in which the‘needs assessment’ must lead to the answer that is withinthe government’s means and acceptable to the com-munity. This is especially so when it is the needs ofmentally disordered offenders (MDO) that are beingconsidered.

Having set the scene of changing health policy in theUK in the last decade, the authors move to attempt to tiedown a definition of need – no easy task given the manyinfluences brought to bear. The bulk of the book thengoes on to describe the approaches to needs assessment:(1) survey methods which consistently demonstrate ahigh level of need and the limited impact of efforts toaddress this to date; (2) a rates-under-treatment methodwhich illustrates who does access services, but provideslittle information on unmet need; (3) the social indicatorapproach which assesses need indirectly; and (4) the keyinformant and community opinion approach which ratesneed on what community groups with differing levels ofexpertise think is needed. The authors then examineattempts to evaluate services for the MDO – a task socomplex and with so many competing interests that theauthors rightly conclude that in this area outcome

BOOK REVIEWS 285

measurement is simply inadequate. The book concludesby highlighting the potential dangers of needs assess-ment in this area. The recent push towards a separatepolicy approach to the dangerous severe personality dis-ordered (DSPD) in the UK is a cogent reminder that theneeds assessed are not always those of the patient.

The book is clearly written, well researched and is notonly relevant to MDO service development, but also tothe wider health sphere. It is not easy to read, and is verymuch UK-centred, but will be of interest to those whowonder how it is that we get the services we do, and howgovernment attempts to respond to multiple conflictinginterests in times of limited resources.

Ruth VineMelbourne, Victoria

Anxiety disorders in children and adolescents: research, assessment and intervention

Wendy Silverman, Philip Treffers (eds)Cambridge: Cambridge University Press, 2000

ISBN 0 52178 966 4 pp.256 $135

Anxiety is a ubiquitous human experience and anxietydisorders are among the most common psychiatric dis-orders noted in children and adolescents. Therefore, itis concerning that relatively little systematic clinicalresearch has focused on anxiety and anxiety disorders.

The 1997 international research conference on anxietydisorders in children and adolescents has led to thispublication of various aspects of anxiety disorders inchildren and adolescents. Sixteen chapters are includedwith an historical overview leading to a comprehensivereview of the field and synthesis of the majority ofavailable clinical research on of anxiety disorders. Suc-cinct presentation of the data is a positive feature ofthis publication. The only disadvantages, if any, are thebrevity of the discussion about some comorbidity issuesraised by the data presented, and the occasional lack offocus on particular issues relevant for adolescents withanxiety disorders.

Nevertheless, this publication will be of considerableinterest to child and adolescent psychiatrists and paedia-tricians in clinical practice and clinical researchers in thefield of anxiety disorders and comorbid psychiatric dis-orders. It is a fine and scholarly text.

Alasdair VanceMelbourne, Australia

Management of psychiatric disorders during pregnancy

Kimberly Yonkers, Bertis Little (eds)Illinois: Arnold, 2000

ISBN 0 34076 126 1 pp.320 $158.13

The authors present a thorough review covering issuesof management across a broad range of psychiatric dis-orders in pregnancy; depression and psychosis the mostcomprehensively covered. This is an important area, andone that while some psychiatrists specialize in, manymore will need to deal with either through the normalcourse of referral, or when their own patient wishes to,or becomes pregnant.

There is a strong leaning towards the issues associatedwith psychotropic medication use in pregnancy, which isan area of clear concern in the medico-legal orientatedmilieu of the USA, and certainly is the basis of manyreferrals and phone calls to me for opinion. This iscovered comprehensively, and gives guidance of whenmedication is justified, but stops short of giving a ‘pre-scription’ for this. It provides a very useful guide andthis is the clear strength of the book.

The book also contains a chapter on ‘Obstetrics for thenonobstetrician’ which covers a number of important andoften neglected areas, from differentiating between preg-nancy and psychiatry symptoms to issues of genetic coun-selling and teenage pregnancies. Because of the breadth ofcover, however, there is limited depth. This limits theusefulness to someone well entrenched in the area, but ofvalue to those with an interest but limited experience.

The psychological aspects of pregnancy and manage-ment are also covered, though not as comprehensively, andthere is a disappointing lack of reference to the mother-foetus and by inference mother-infant relationship. Thisperhaps deserves another book on its own, so with theexception of this oversight, this work offers a valuableresource for general practitioners and psychiatrists. Thestyle is somewhat dry, so it is probably a book to delvein and out of rather than reading from cover to cover.

Anne BuistMelbourne, Australia

From neurons to neighbourhoods: the science of early child development

Jack P Shonkoff, Deborah A Phillips (eds)Washington, DC: National Academy Press

ISBN 0 30906 988 2 pp.588 $US40.00

This text is the report of the Committee on Integratingthe Science of Early Childhood Development. The

286 BOOK REVIEWS

committee was established by the National ResearchCouncil, itself established in 1916 by the US NationalAcademy of Sciences, to advise the US government onissues associating science and technology. Input was alsoreceived from the Institute of Medicine, anotherAcademy of Sciences body asked to advise governmenton public health policy. The mandate of the committeewas to update knowledge of early child development,‘disentangle such knowledge from erroneous popularbelief’ (p.3) and to discuss the policy, practice andresearch implications of such knowledge.

The project was funded from government, nongovern-ment and philanthropic sources allowing the 17 individ-uals of the ‘eminent persons’ committee to examine indetail the scientific literature. The activities of the corecommittee were augmented by direct input from leadersin the field and workshops with stakeholders. The latterincluded a workshop on the Science of DevelopmentalPromotion and Early Childhood Intervention (June 1999),on Home Visiting Interventions and The Precursors ofAntisocial Behaviour. Other input included consultantsand invited presenters to committee meetings, writtensubmissions and interviews with individuals involved inearly childhood practice, research and policy.

Following an executive summary, the text is structuredinto preliminary chapters that overview the current stateof the nature-nurture debate, the importance of integrat-ing culture and the science of deriving causal con-nections. Section 2 considers three domains of masteryessential for the infant to progress towards mentalhealth: self-regulation, the capabilities that underpincommunication and learning, and the ability to relate toothers and make friends. A fourth domain, research onthe developing brain, highlights the explosion of researchin this area and the desire to integrate behavioural andneuroscience research. Issues include the move fromparents as ‘extensions of their (the child’s) internal reg-ulatory systems’, points of biobehavioural shifts indevelopment, the development of regulation of sleep,crying and self-soothing, emotion and attention.

Section 3 reviews the context of early development.While the focus is more on nurture and environmentrather than nature, consistent with contemporary behav-ioural genetics a dichotomous nature-nurture divide is nolonger sustainable as a useful construct. The section onnurturing relationships examines research on what isgained from early relationships, security, self-efficacy,self-esteem, cooperative endeavour and social reciproc-ity. Attachment and the effect of attachment type on laterlife are discussed. The family resource section discussesincome inequity, poverty, single parent families, parentemployment patterns and parent psychological distress.The section neighbourhood and community considers

the community ecology in more depth; growing up inimpoverished neighbourhoods, minority group member-ship, and community hazards such as violence, crimeand environmental health hazards. A separate sectionreviews the literature on out of home childcare. The textconcludes with 11 recommendations relating to policyand practice, early environments, the needs of childrenduring societal change and the interaction of early child-hood science, policy, and practice.

It is with some pleasure that I highly recommend thistext. It is unusual for a text to so thoroughly coverinformation from such a diverse group of areas. The textachieves this without the style changes seen in manymulti-author texts and with a clarity and ease of readingoften not seen in committee reports. The most contempo-rary research is cited and the recommendations shouldprovide direction to the field over the next decade. Thistext should be prescribed reading for those in the childand adolescent mental health field. Many practitioners inthe adult field will appreciate

Neurones to Neighbour-hoods

as an excellent update and reference.

Brett McDermottPerth, Australia

Bedlam on the streets

Caroline KnowlesNew York: Routledge, 2000

ISBN 0 41523 2996 pp.208 $51.15

Bedlam on the Streets

is an excellent book thatdemands reading by anyone concerned with mentalhealth care, social policy and planning and methodolog-ical and theoretical aspects of sociology, ethnographyand qualitative research.

The author sets out to distinguish the rhetoric fromreality for community mental health care in Montreal.Race and ethnicity are viewed in context and throughinteractions. In doing so we are taken on a journeythrough city landscapes, via the precarious existence of‘mad’ people who occupy and transit urban spaces/places.

The use of the term ‘mad’, often viewed as stigmatiz-ing in today’s formal world of mental health care andconsumer advocacy, is reappropriated by the author toclearly reflect the reality of mental distress. It is alsoused subjectively by the characters in the text to refer tothemselves and their peers.

The life world of the mad is theoretically informed byBourdieu, Foucault, Nietzsche and importantly, Lefebve’s‘concept of space as a domain of social relationships andpolitical priorities’ (p.70).

BOOK REVIEWS 287

The reader journeys or voyeurs the public and privatespaces and relationships of the real and imagined worldof mad people through the richness of voice, photo-graphic images and text. Privacy occurs where the onlythings ‘that occur

outside

of the gaze of others happen

inside

you’ (p.157).We see asylums without walls as the mad are released

from incarceration. The revolving door of psychiatricinstitutions creates a situation where the mad are con-stantly mobile as ‘system nomads’ (p.36). Living arrange-ments are described in terms of degrees of autonomy andfreedom contrasted with control, surveillance and com-pliance. These include supported accommodation withcommunity mental health care support (this is the elite ofthe system), the foster home model (or the cottage indus-try of asylum where the public welfare system is trans-ferred to the private system), supervised apartments orrooming houses, and lastly the human warehousing ofhomeless shelters, where the old spaces of religion andindustry are redefined.

The fine detail and texture of the spaces and socialproblems associated with madness and social disadvan-tage is revealed in stories of schizophrenia and its mul-tiple meanings (to self/system), where the mad live a lifeof ‘walking exile’ (p.99).

Urban myths of dangerousness are explored revealingfears that mad people are a risk to society. Many of thesemyths are exposed showing that these people are avulnerable and endangered group. Indeed, ‘we fear themad and we fear

becoming

them’ (p.161).Community mental health care when properly planned

and resourced, can have positive results. However, theauthor clearly demonstrates that in Montreal this systemis only for a minority of those in need, resulting in alarger system of neglect.

Lesley NewtonSydney, Australia