Psychiatry is under siege.  The past president of the NIMH, Dr Steve Hyman, has documented the difficulties in a recent invited article, "Can neuroscience be integrated into the DSM-V?," Nature Reviews Neuroscience 8, 725-732 (September 2007). In this editorial, Hyman documents the difficulties and pondered whether neuroscience has the capacity yet to inform on biological markers that can support a DSM V version.

In the meantime, psychiatry continues with a flawed signs and symptoms manual as its bible, a useful but much critiqued body of knowledge. People who present with signs and symptoms related to their psychosocial functioning are categorized by shoehorning them into one size fits all categories which in turn inform on what broad medication selection might be efficacious. This is largely trial and error, current attempts at personalized medicine as championed by Ed Abraham's Personalized Medicine Coalition, have focused on genes.  No one can criticize Hyman's article, some have tried, but it was an invited article. No one can fault attempts to isolate biological markers, but these are likely to succeed in providing ant-viral therapies that protect against cervical cancer rather than in Schizophrenia.

By page 5, Gill has acknowledged there are problems with the signs and symptoms approach despite the money that has gone into their elucidation. Consequently Gill proceeds with caution and colors his comments with guarded statements about the complicating comorbidities, 'causes and need for prevention', only a recent addition to the literature. He therefore introduces neurochemistry, neuroradiology and epidemiology under the headings above, as well as the individual life experience.  Together with comments on prevention, this is a brief flirtation with the tenets of personalized medicine.

Chapter three concerns itself with the examination, briefly touching on the physical examination, as well as other more standardized techniques of assessment.

Part two now addresses the clinical conditions themselves, beginning with schizophrenia,  This is not an in depth book, so the outline skims vital issues, but covers what one would expect from such a primer.

There are no prizes for guessing the content of the next chapter, it's of course mood, meaning depression and mania.  Early on there is a caveat of accepting at face value the serotonin or other hypotheses, which deny or simplify the complex feedback regulating mechanism of such complex systems.  Particularly useful are the NICE guidelines on page 88, in keeping with the British approach. It is also interesting, as an aside, that the NICE guidelines on some medications in general medicine, indicate that payers will only release funds for drugs that work, in proven outcomes.  So if a cancer drug works only in 30% for instance, then payers will only pay for that 30%. So far this has not been applied to mental health, but with the cost of the spend for instance in Schizophrenia at $21billion p.a. this could make a huge financial difference.

Anxiety and stress related disorders follow in the next chapter. Little detail is offered, but this is only an introductory tome, so discussions are limited, especially in PTSD for instance.

Similarly, the chapter on the personality disorders is brief, and together with the last one, probably don't do justice to the commonality of the former, and the difficulty in engaging with the other. For those who are DSM centric, it is important to notice the difference with using the ICD, which for instance do not have a Borderline category. I doubt many American psychiatrists could comment on a Haltlose presentation, immature or psychoneurotic styles or treatments. They might manage anankastic when they realize its an OCD presentation.  Paranoid states follow, dealt with in three pages.

The physical problems chapter is the most interesting, of course including somatoform-type illnesses, with controversy boiling, such as Munchasen by Proxy and other contentious conditions, often not in the ICD 10, and neurasthenia amongst others such as malingering and exaggeration.

'Organic' brain syndromes is next.  Delirium and dementia dominate immediately, moving on to focal lesions. Its another short chapter with very little attention to the frontal or executive areas.

The insertion of a brief chapter on liaison psychiatry is unusual, but useful.  These are the psychiatrists that work with other doctors in general medical or specialist wards.

One of the longer chapters is devoted to drug misuse, and then an entire separate chapter on Alcohol abuse. Not many references are used, one only in this latter case, so the student is not really assisted in that regard.

Another unusual chapter is the next one, on self harm. This includes DSH but with little or much more than a passing reference to sexual abuse and other issues in childhood that are so common, as reviewed over the years by Glaser, Parry and others.

No such book would be complete without eating disorders, and very few would include the next, namely disorders related to the female reproductive cycle.  These are focused on perinatal events more than perimenstrual.

Sex-related disorders are canvassed, and even homosexuality gets almost a page, apologized for on the basis of the high rates of mental illness, not the entity as a disease or disorder.

Chapters are devoted to child and adolescent psychiatry as well as learning disorders.  No real discussion is presented on the current controversy related to medication in this group, but Gill seems to rely on non-medication therapies anyway.  A few pages are devoted to the elderly, which seems a bit too little considering the complexity of this group. Forensics follows, with about double the coverage in page count anyway.

The third section covers treatment specifics.  The first chapter is a reasonably extensive one, but devoted more to CBT rather than the host of other therapies available. A similarly thorough chapter is devoted to psychopharmacotherapy, as well as ECT and even psychosurgery, follow.  A United Kingdom focused chapter on mental health services and another on the mental health act of 1983 are a useful reference for those in the rest of the world, and for those naïve on such matters in the UK, needing frequent revision as things change rapidly in that industry there.

There is a glossary, as befits a primer, and this is the only truly thorough feature of the book.  The index is small, as there are few references for each chapter, Gill takes the view that a mere outline needs little referencing.  I take the opposite view, students and neophytes need a lot of referencing or at least a reading list to inform on who might be the best to read in each subject, or what other opinions there might be.

Otherwise, the book outlines psychiatry well, with caveats that are necessary, and with clarity where it needs to, for the most part, but with weaknesses, such as in the elderly.

It will I am sure remain a popular textbook, now in its fifth revision. It surely does this by relying on its clarity, and its brevity, without losing much detail.

© 2007 Roy Sugarman

Roy Sugarman, Ph.D., Director of Clinical and Neuropsychological Services, Brain Resource Company, Ultimo, Australia

Categories: MentalHealth, Psychology