Book Forum

EDUCATION will find it helpful to review an editorial in the British Journal

of Psychiatry (3) and the January 1995 issue of Psychiatric
Annals, devoted largely to a description and discussion of
Diagnostic and Statistical Manual of Mental Disorders, 4th
DSM-IV.
ed. (DSM-IV), by the American Psychiatric Association.
Washington, D.C., APA, 1 994, 873 pp., $54.95; $42.95 (pa-
per). REFERENCES

Work on DSM-III began in 1975, and it was published in 1. Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G,
1980. DSM-III-R was published in 1987. Taken together, Munoz R: Diagnostic criteria for use in psychiatric research.
Arch Gen Psychiatry 1972; 26:57-63
these volumes and DSM-IV represent a major change in
2. Robins E, Guze SB: Establishment of diagnostic validity in psy-
American psychiatry. The emphasis and attention to psychi-
chiatric illness: its application to schizophrenia. Am J Psychiatry
atric diagnosis reflects a broad redirection toward the goal of 1970; 126:983-987
reintegrating psychiatry into medicine generally. Diagnosis 3. Cooper JE: On the publication of the Diagnostic and Statistical
has been the foundation of medicine for centuries, and its re- Manual of Mental Disorders: Fourth Edition (DSM-IV) (edito-
newed emphasis in psychiatry expresses the movement toward nial). BrJ Psychiatry 1995; 166:4-8
the medical model for psychiatric disorders. Those of us who
believed strongly in the need for this change in direction and SAMUEL B. GUZE, M.D.
who participated in the emphasis on psychiatric diagnosis can- St. Louis, Mo.
not help but feel gratified at the results of our efforts.
Many of us, however, as well as other colleagues, feel some
misgivings. We are impressed by and worried about the phe- The American Psychiatric Press Textbook of Psychopharma-
nomenal growth in the number of diagnoses now recom- cology, edited by Alan F. Schatzberg, M.D., and Charles B.
mended. Our original diagnostic criteria ( 1 ) proposed 12 di- Nemeroff, M.D. Washington, D. C., American Psychiatric
agnoses; DSM-IV deals with several hundred. Many who have Press, I 995, 896 pp., $100.00.
been outside the active effort to develop the new system may
be puzzled at this explosion in diagnoses. Those who are fa- This more-than-800-page volume has 41 chapters and 100
miliar with the process, however, understand how this has authors/coauthors. The textbook is divided into four sections:
come about. Colleagues interested in diagnosis and especially Principles of Psychopharmacology, Classes of Psychiatric
interested in any particular subgroup of patients were asked Drugs, Clinical Psychobiology and Psychiatric Syndromes,
to serve on committees charged with making sense of the di- and Psychopharmacological Treatment. Each section was ed-
agnostic issues associated with the particular disorders. It is ited by a very prominent contributor to current psychiatric
not surprising that such individuals put forth strong argu- research, and the list of authors and coauthors contains names
ments for recommending that these diagnoses achieve official of familiar, productive individuals. The references extend
status and that many of the categories be subdivided in one through 1993, and the index is extremely user friendly. I also
or more ways. In other words, DSM-IV is the natural outcome liked the referencing style, which included the titles of articles
of what is essentially a process of discussion and debate within as well as the relevant page numbers.
a sociopolitical context. In the absence of more powerful sci- The first section, Principles of Psychopharmacology, con-
entific foundations, this was and is inevitable. It also repre- sists of six chapters relating neurotransmitters and receptors,
sents a certain level of progress. molecular neurobiology, biochemical anatomy, electrophysi-
The time is surely ripe for thinking about how future edi- obogy, animal models of depression and schizophrenia, and
tions can be strengthened and put on a more dependable sci- principles of pharmacokinetics and pharmacodynamics. The
entific footing. In 1970, Eli Robins and I put forth a strategy chapters are very well illustrated and quite readable.
for establishing diagnostic validity in psychiatric illness (2). The second section consists of 15 chapters on animal and
We used schizophrenia as a model and reviewed some of the human pharmacology of psychiatric drugs. The topics in this
literature dealing with the diagnosis of schizophrenia to illus- section include anxiolytics and a ntidepressants, antipsy-
trate our thesis. We proposed five phases: clinical description, chotics, drugs for the treatment of bipolar disorder, and other
laboratory studies, delimitation from other disorders, follow- agents, such as cognitive enhancers, sedative-hypnotics, and
up study, and family study. We emphasized that without data stimulants. Chapters include discussions of the history of de-
from systematic and controlled studies concerning patho- velopment of these compounds, relationships between struc-
physiological changes, differential diagnosis, follow-up, out- ture and activity, pharmacological profiles, presumed mecha-
come, and family/genetic studies, diagnosis could never realize nisms of action, major and minor indications, side effects, and
its full potential in psychiatry as it has in medicine generally. drug interactions.
Most thoughtful reviewers of DSM-IV would have to agree The third section consists of seven chapters on the clinical
that very few of the hundreds of diagnostic categories have psychobiology of psychiatric syndromes such as mood disor-
been satisfactorily validated according to these criteria. Let us ders, schizophrenia, anxiety disorders, Alzheimer’s disease,
hope that much progress will be evident in this direction when substance abuse disorders, and eating disorders. This is actu-
we see DSM-V. At this time, however, the effort and devotion ably a very interesting and comprehensive section. Chapters in
of scores of colleagues deserve thoughtful recognition. Many this section summarize a good deal of current biological re-

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 BOOK FORUM

search. Topics focus on clinical neurobiology in contrast to and alcohol, family issues, ethnicity, and gender issues. Dis-
the second section, which presents animal studies and phar- cussions of public drinking and social problems are well han-
macological data. dled, and the inclusion of the subject of alcoholism in the
The last section summarizes treatments of psychiatric dis- workplace is a very good idea. My only criticism of the social
orders and contains chapters on the treatment of mood disor- and cultural portions of the book would be that this section
dens, bipolar disorders, schizophrenia, Alzheimer’s disease, does not go into enough detail. The individual chapters should
childhood disorders, psychiatric emergencies, medically ill pa- be expanded. For example, only 10 pages each are given to
tients, geriatric patients, pregnant patients, and lactating pa- gender issues and cultural variations. These important areas
tients. The appendix discusses psychopharmacological agents could easily be described in much greater detail, but it is a
available in Europe. good sign that these contributions were made at all, and they
What is clear from the recent psychopharmacology text- provide a reasonable basis for further independent study.
books is that psychopharmacology is not just the process of The biological portions of the work are divided into exten-
prescribing medications for people with emotional disorders sive chapters on physiology and biochemistry. There is an ex-
but merits a discussion of the basic neurobiology of these con- celbent section on neuronal ion channels. The segment on clini-
ditions. Treatments of psychiatric disorders require up-to- cab pathology has a powerful review of current knowledge
date knowledge of their psychobiology as well as how drugs regarding genetic transmission, molecular biology, and appro-
work and which ones to choose. Furthermore, these textbooks priate receptor sites.
are not meant to be read in their entirety as much as to serve The table of contents and the index are well organized and
as reference books and as guides for clinicians who want to allow for a quick review when needed. The general organi-
know something about a patient’s disorder and treatment. zation of the book is also quite good, making for logical,
Thus, the index of such books is probably one of the most enjoyable enlightenment. The choice of Marc Galanter as edi-
telling ways of indicating the utility of a text. With this in tom for this series is a good one. He is experienced at such
mind, I first turned to the index to determine whether I could writing and sifts through the material quite masterfully. As
find things I would be interested in. Indeed, the index worked both a psychiatrist and an addictionologist, I found Recent
for me for whatever topic I chose. The index is useful, and Developments in Alcoholism, vol. 1 1, to be well worth read-
major sections are highlighted. ing. I recommend it.
What I particularly liked about this volume was its utility
as a reference The text.
information contained here would be JAMES ALLEN WILCOX, D.O., MS.
of considerable benefit to residents who are new to the field El Paso, Tex.
of psychiatry and want to grasp basic mechanisms and have
an overview of psychiatric syndromes and approaches to
treatment. If one were studying for board examinations, this Network Therapy for Alcohol and Drug Abuse: A New Ap-
book would be quite useful and probably could be easily read proach in Practice, by Marc Galanter, M.D. New York, Basic
from cover to cover as a study guide. For the practicing clini- Books, 1993, 216 pp., $32.00.
cian, this book is an excellent reference text. It has up-to-date
material written in a thorough yet readable manner. The book A recent thaw in the relations between the traditional ad-
is well illustrated, the bibliographies are up-to-date and thor- diction treatment community and those who come from psy-
ough, and the chapters are written by people who are expert chiatric, social, and biological orientations has been occurring.
and well-known in their fields. The index is easy to use and Dr. Galanter describes the lack of sophistication regarding ad-
comprehensive. dictions and poor treatment results in his early years in the
field. Many addiction counselors, Alcoholics Anonymous
DAVID L. DUNNER, M.D. (AA) advocates, and others have, likewise, been slow to accept
Seattle, Wash. the reality of the dual-diagnosis patient and the need of many
patients for some form of psychotherapy. Dr. Galanter is
uniquely qualified to take advantage of this change because
SUBSTANCE ABUSE he has a long track record in addictions treatment from all
perspectives.
Network therapy, as he describes it, takes complete sobriety
Recent Developments in Alcoholism, vol. 1 1: Ten Years of as its aim, as recommended by AA. He gives a clear direction
Progress, edited by Marc Galanter, M.D. New York, Plenum, for therapy, involving a behavioral focus on maintaining ab-
1993, 518 pp., $85.00. stinence. A group of people-a network-consisting of family
or friends is assembled to focus on this one goal. No attempts
This work is a computation of 10 years of progress in the at group therapy or processing of individual issues are made.
field of alcoholism. It is very comprehensive and well organ- The network provides support, confrontation, and an outside
ized. Although concentrating primarily on recent develop- monitor on the patient’s progress toward sobriety. Galanter
ments, the contributors also provide an excellent review of has found this approach much more effective than individual
older, relevant material. therapy in achieving abstinence. Individual therapy, AA meet-
The book contains an unusually rich collection of ideas ad- ings, and any other forms of therapy are not precluded.
dressing social and cultural perspectives on alcoholism. The The network therapy approach is meant for patients with
sections on physiology and biochemistry of alcohol abuse are a moderate degree of dependency; patients with severe de-
up-to-date and instructive. The latter part of the text is de- pendency requiring hospitalization and those with psychoses
voted to observations in clinical pathology and trends in treat- would usually be unsuitable. To qualify, patients need family
ment. The authors of the chapters are all experts in their me- members or friends who are very committed to them but not
spective fields. overly involved in a pathological relationship with them. The
I was especially pleased with the way the editor and authors model involves the use of accepted behavioral techniques to
handled sociological issues. Included are chapters on children reduce the likelihood of drinking. With total abstinence as a

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BOOK FORUM

goal, patients are instructed to recognize behavioral cues that sensibility for analyzing pictures in which pain is a feature,
may lead to substance use and to modify their behavior to sometimes a surprising one.
avoid these situations. The network of family and friends is All in all, then, this book is magisterial. Every clinician in-
used to help maintain the behavioral program. terested in patients with pain should own it. It has already
A useful aspect of Galanter’s approach is that he applies a become a standard part of the canon in the medical humani-
behavioral model that consists of both conditioning and op- ties. Who knows, perhaps it will help address the one thing
erant principles. that unites patients with pain, their family members, and their
A good bit of time is spent in network sessions looking for doctors-namely, deep frustration over the limits of lay as
cues to relapse and their avoidance. The section on Under- well as clinical language and praxis.
standing Addiction is so lucid that this part of the book alone
would be a useful addition to a medical student or resident ARTHUR KLEINMAN, M.D.
course in substance abuse. Boston, Mass.
The book contains many helpful suggestions on choosing
network members, scheduling sessions, setting goals, and
other practical matters. Case examples are liberally used to Torture and Its Consequences: Current Treatment Approaches,
illustrate successes and pitfalls in the approach. edited by Metin BatogVu. New York, Cambridge University
We highly recommend this book to psychiatrists and resi- Press, 1992, 519 pp., $99.95.
dents at all levels of experience.
This book is dedicated to sufferers of torture with a survi-
WALTER F. FARR, M.D. vor’s quote: “I didn’t mind the pain so much. It was the cries
JAMES ALLEN WILCOX, D.O., M.S. next door I couldn’t bear.” These introductory words speak
El Paso, Tex. to a shade of torture that psychiatrists should find interesting.
Recurring observations throughout the text echo that survi-
vors recall the sounds of the horror as far more enduring and
PAIN
agonizing than any physical sufferings. These remembered
pains have many faces, seen and unseen, embodying distant
outcries, the screams of nearby prisoners, and the demeaning
The Culture of Pain, by David B. Morris. Berkeley, University accusations and humiliations of persecutors. Some tortuous
ofCalifornia Press, 1991, 336 pp., $30.00; $14.00 (paper). tongue-lashings cut piercingly deep, causing scars that often
inexorably resist exorcism, forging images so hurtful that they
David Morris has written a masterly account of how mean- punish long after all tormentors vanish. Survivors sense these
ings and practices associated with pain grow out ofa deep and intrusive recollections as hands reaching from the grave.
changing nexus of historical and cultural processes. Voice, The editor recognizes that a clear-cut definition of torture
genre, speech community, aesthetic style-all affect pain com- is problematic, especially when one considers the sweep of
plaints and experiences. Morris writes beautifully and con- situations involving purposeful physical and psychological
vincingly about the thorny and controverted questions-theo- torment. He has chosen to adopt the World Medical Associa-
retical, pragmatic, policy-oriented, and ethical-that make tion’s definition of torture in its I 975 Tokyo declaration:
pain such a perennial conundrum. His words about the lan-
guages of pain provide as clearheaded a statement about what deliberate, systematic or wanton infliction of physical
is and is not expressible as one can read. His handling of mind- or mental suffering by one or more persons acting alone
body issues is deft. Clinicians, even experienced ones, will or on the orders of any authority, to force another per-
learn from the wise things he writes about the collective, in- son to yield information, to make a confession, or for
tersubjective, and interior meanings of pain. any other reason. (p. 1)
What makes this book really special is what Morris-a lit-
erary scholar-has to say about the place of pain in litera- The different authors in this book recognize that all forms
ture-virtually the entire canon of Western writing. The chap- of torture target a victim’s vulnerabilities-physical, sexual,
ten on “Tragic Pain” probably should become part of the and mental. They also recognize that the actual purpose of
reading of all medical students and house officers. Tragedy is torturing the body is to destroy the mind. Torture is attempted
after all the literary mode for engaging suffering, and pain is “soul-murder” (1), and what happens verges on the unspeak-
as quintessential a source of suffering as medicine routinely able. Victims of sexual torture feel shamed and often remain
engages. There are other things in this book as well that will silent for years about their sufferings for fear of losing the love
educate a student of pain, such as the chapters on pain and and respect of friends and family. Torture survivors remember
the sublime and “Sex, Pain, and the Marquis de Sade. “ Mor- and live a horror that quakes and also transcends the rhythm
ris’ handling of postmodernist authors-Lyotard, Blanchot- of ordinary human existence. An Auschwitz survivor, many
whose work seems so apposite to the embodied ironies of years afterward, when surrounded by beauty, sighed, “This
chronic pain is especially noteworthy. Blanchot’s idea of world is not this world” (2).
“learning to think with pain” offers an intriguing and desta- In preparing this review, I recalled a chapter in another
bilizing vision of what medicine might do for patients with book about the sequelae of prolonged and repeated trauma
chronic pain to make caregivers, in Philip Larkin’s telling (3). Regarding torture survivors, each of these texts discusses
phrase, “find words at once true and kind, or not untrue and the shortcomings of the diagnosis of posttraumatic stress dis-
not unkind. “ Drawing on the French ethicist Emmanuel Levi- order (PTSD), and each recognizes a more complex and in-
nas’ conviction that suffering is useless for the sufferer but the transigent variant of PTSD existing in victims of prolonged,
opening to moral experience for the friend or family member, repetitive violence and victimization. Broadly, three areas of
Morris tells the reader something quite extraordinary about disturbance intensify the clinical picture. First, there is ampli-
listening to (or “reading”) and affirming the experience of fication of physiological symptoms and somatization. Second,
pain of chronically ill patients. Morris also draws on a subtle pathologic personality changes emerge, distorting identity and

1230 Am] Psychiatry 152:8, August 1995

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relatedness. Third, survivors of such victimization demon- areas discussed to be able to evaluate these chapters. In ad-
strate vulnerability to further trauma at the hands of others dition, the information is difficult for a reader or researcher
or at their own hands. The inferno of torture undoubtedly interested in the particular topic to find because it appears in
extends beyond the calendar of imprisonment. a book rather than a journal. For example, the chapter enti-
Torture and Its Consequences is a well-researched text in tied “Correlation of Body Weight and Body Mass Index in
which international authorities discuss torture, shedding light Twins” by S. Bo and colleagues is an interesting study of the
on its long, haunting shadow. As with many multiauthored heritability of body weight in monozygotic and dizygotic
texts, some repetition occurs. Still, the book accomplishes its twins. However, even though this is a topic in which I am
goal, bridging a gap in the scientific literature regarding tor- interested, I would never have seen this report had I not been
tune and the treatment of survivors. Although primarily in- reviewing this book. Another problem is that the chapters are
tended for mental health professionals, it is of particular im- so short that some of the questions raised by the research are
portance to those with a special interest in patients who have not addressed.
suffered prolonged, purposefully sadistic victimization. The Several chapters are outstanding reviews by researchers
physical and psychological consequences of torture are dis- with a longstanding interest in the particular area reviewed.
cussed with detailed treatment recommendations. Further, the For example, “Eating Disorders in Males: Sociocultural
text covers medical and sociopolitical aspects of torture, pro- Norms, Clinical Course, Biomedical Factors, and Outcome”
viding important material for clinicians and researchers in- by A.E. Andersen and “The Robe of Corticotropin-Releasing
volved in international human rights issues. The sphere of the Factor in the Pathophysiobogy of Depression and Eating Dis-
book is global; systematic torture is specifically discussed in orders: Basic and Clinical Studies” by Y. Ohkubo and cob-
Africa, Asia, and South America. leagues both present “state of the art” reviews of the topics
The text is organized in several sections and encompasses discussed.
torture’s complex themes and emotionally traumatic after- One problem with the book is that the print size varies
math in detail. Different sections deal with psychobiological throughout the book, and although the editors explain that
and psychological theory; assessment, diagnosis, and classifi- this was done to facilitate quick access to the information, it
cation; rehabilitation; psychotherapeutic approaches ranging is quite distracting. Also, since many of the papers were not
from psychodynamic to behavioral and cognitive; torture in originally written in English, the translations introduce some
particular countries; and modern ethics and international law. errors. However, these relatively minor considerations aside,
Specific chapters examine physical and sexual torture as re- this is a very interesting book. It would have been helpful if
bated to prisoners of war and Holocaust survivors. the review articles had been grouped together and the new
research highlighted, because then it would be easier to use as
a reference for a particular topic.
REFERENCES

1. Shengold L: Child abuse and deprivation: soul murder. J Am PAULINE S. POWERS, M.D.
Psychoanal Assoc 1979; 27:533-559 Tampa, Fla.
2. Lifton RJ: The Nazi Doctors. New York, Basic Books, 1986
3. Davidson JR. Foa EB (eds): Posttraumatic Stress Disorder: DSM-
IV and Beyond. Washington, DC, American Psychiatric Press, From Fasting Saints to Anorexic Girls: The History of Self-
1993 Starvation, by Walter Vandereycken and Ron Van Deth. New
York, New York University Press, 1 994, 280 pp., $42.50;
CAPT. JOHN R. CUSACK, MC, USN $1795 (paper).
Charleston, S. C.

This book offers a rich examination of self-starvation and

the theories about it throughout history. The text teems with
EATING DISORDERS historical vignettes that bring fasting people and their treat-
ment to life in a sometimes painfully thorough tour of self-
Primary and Secondary Eating Disorders: A Psychoneuroen- starvation, a tour I have space only to hint at here. This tour
docrine and Metabolic Approach, edited by E. Ferrari, F. demonstrates that fasting in different sociocultural contexts
Brambilla, and S.B. Solerte. New York, Pergamon Press, has meant vastly different things.
1993, SIOpp., $145.00. For instance, self-starvation has been viewed as both re-
vered religious sacrifice and as amusing spectacle. In ancient
The goal of this edited volume, which represents the pro- Western cultures, holy fasts were used to express grief about
ceedings of the second international symposium on disorders and to share in Christ’s suffering. Some religious fanatics
of eating behavior held in Pavia, Italy, in September 1992, is fasted so rigorously that they would eat only the weekly Sac-
to present the latest research from a broad spectrum of view- rament.
points by groups of international researchers in the area of The spectacle of fasting saints attracted visitors from afar.
eating disorders. One of the underlying premises of the vol- Royalty hired watchmen to assure that these fasters were not
ume is that eating disorders lie along a continuum “from the actually cheating and eating on the sly. Fasting became a pro-
extreme emaciation of anorexia nervosa to the overweight of fessional spectacle, as immortalized in Franz Kafka’s “A Hun-
obesity” (p. v). The editors also include several chapters on ger Artist.” Such performers would starve themselves for
the so-called secondary eating disorders-abnormalities in weeks on end, locked in cages at circuses or on display in
eating behavior or weight attributable to stress, chronic ill- restaurants for the spectators’ amusement.
ness, aging, and other factors. This broad approach to the The authors hypothesize that fasting as a deadly mental
problems of eating disorders has merit but makes the book illness-anorexia nervosa-did not exist until this century and
difficult to read and understand. This is a problem of most that the rigid Victorian male-privileged society ofthe late nine-
books comprising proceedings of conferences. It would be an teenth century led naturally to anorexia nervosa. They theo-
unusual reader with sufficient expertise and interest in all the rize that thinness became a symbol of success as Victorian

Am ] Psychiatry 152:8, August 1995 I 231

BOOK FORUM

women worked to cast aside theirpowerless roles. The book the fascinating concept of psychiatric illness as inherently the
explains that “twentieth-century women progressively ideal- product of a historical milieu.
ized the lean, almost ‘tubular’ body type, deprived of the sym- This book suggests even more than what the authors overtly
bolic emphasis of fertility and motherhood. The thinness of conclude. In its examination of self-starvation, it is replete
the ‘new woman’ expressed her sexual liberation and rejection with references to ancient theories of illness ranging from the
of the traditional female role” (p. 213). four humours to demonic possession to the wandering uterus,
The authors conclude that although self-starvation has ex- subjects that I do not have room to explore here but the ab-
isted in multiple forms across the centuries, anorexia nervosa surdity of which offered me a valuable reminder to reflect on
as we know it has not, that anorexia nervosa is a time- and history and to question today’s established theories because
culture-bound disease. The deadly illness of the extreme pur- they, too, are the product of a given time and culture.
suit of a thin body, they say, is essentially different from the
deadly pursuit of suffering with Christ or the deadly parading JENNIFER BREMER, M.D.
of skeletal physiques in circuses, for example, thus supporting Boston, Mass.

Reprints of Book Forum reviews are not available.

1232 Am] Psychiatry 152:8, August 1995