Psychiatry, 2nd ed.

Reading a book of the monumental (both literally and metaphorically) depth and breadth of the second edition of Psychiatry is a veritable journey into the dazzling realities of our discipline today. In turn, the review of a textbook like this must pay attention to its overall philosophy; its structure; the substance, actuality, and validity of its content; and the quality of its editorial presentation and style. It is my pleasure to say that in all of these areas, the book lives up to its promise, improves its record, inspires the reader, and makes us all wonder at how far psychiatry has come and how much work remains to be done.

The three editors, one senior associate editor, and eight associate editors of this second edition have assembled 252 contributors, 20 of them from 10 foreign countries, giving it the most international stamp of any other American textbook of psychiatry in history. Whether this is a tribute to globalization, a confirmation of the fact that psychiatry pervades every angle of human activity everywhere in the world, or simply the recognition of scholars from academic centers or institutions of international scope, this is certainly a lofty landmark. Twenty new chapters have been added, and references have been updated to as recently as 1 year before the publication of the volumes.

The editors summarize the philosophy of the book as going along with the “march of science” while reaffirming the essential value of the biopsychosocial perspective, the recognition of the cultural aspects of all psychiatric work, and, most important, the central role of the doctor-patient relationship. This is, indeed, a “total approach”—public health blending with bench knowledge, sociocultural views side by side with purely clinical considerations, science and humanism in a constructive dialogue—a most cogent response to the daunting challenges that psychiatry faces 5 years into the 21st century.

Seven sections and 117 chapters constitute the heart and meat of these volumes. Whenever pertinent, clinical vignettes are introduced in an attractive design. Diagrams, illustrations, tables, algorithms, photographs, and imaging pictures provide the necessary visual variety that keeps the reader’s attention, clarifies issues, and illustrates points. Even if a point is hammered at in different sections, through different chapters, with perhaps different emphases based on different perspectives, the text always retains transparency and usefulness, two of its most outstanding trademarks.

Section 1, Approaches to the Patient, emphasizes “active listening” skills, cross-cultural consistency and diversity of emotional experiences, the usefulness of cognitive templates, and the overriding ingredient of empathy. Section 2, A Developmental Perspective on Normal Domains of Mental and Behavioral Function, offers, among other gems, a chapter on developmental perspectives with an excellent critical approach, as well as a chapter providing a solid historical perspective of adolescent development. In section 3, Scientific Foundations of Psychiatry, one finds a scholarly and colorful chapter on the history of psychiatry, the notion of “molecular insight” in the chapter on neural development, a nice introductory chapter on neurotransmitters, a “progress report” on pathophysiology research, concepts such as chronicity in cognitive processes, and a chapter on the emerging field of “social neuroscience.”

Section 4, Manifestations and Assessments of Psychiatric Illness, initiates the clinical component of the textbook with a chapter on psychopathology across the life cycle, and it also includes a comprehensive review of comorbidity. Section 5, succinctly called Disorders, has excellent chapters on learning and motor conditions, disruptive behaviors, and delirium and dementia, among others. The chapter on alcohol use disorders presents an elegant report on the vicissitudes of typology and a good review on international patterns of drinking. And the list goes on.

The reader can walk through comprehensive descriptions of different perspectives on each of the major and minor psychiatric conditions. An ever-present feature is the effort to make clear the comparability of DSM-IV-TR and ICD-10 criteria. One of the chapters I liked most, “Bipolar Disorders,” offers an extraordinary historical account, a solid review of genetics, a fascinating approach to conditions such as dysphoria, concepts of clinical and functional outcomes, and different views on lithium and mood stabilizers. I further enjoyed the “fear network” concept and the intriguing association between phobias and panic disorders in the chapter on anxiety disorders. Obsessive-compulsive disorder, impulsivity, and their relationship to addictions are some of the many complex clinical realities and dilemmas examined with authoritative clarity. Updated concepts of etiology and pathogenic mechanisms are provided for polemical categories such as somatoform disorders. The value of the chapters on psychological factors affecting medical conditions and on medication use in movement disorders is evident. The multidisciplinary nature of our daily work is well explored in the chapter on relational problems.

Section 6, Therapeutics, starts with individual psychoanalytic psychotherapy and continues with chapters on group, family, time-limited, and cognitive techniques. Issues of practical importance are presented, such as termination of therapy, combined approaches, limitations of response, ethical implications of treatment, and ethnic and cultural perspectives on psychopharmacology (a key to dispelling the “color-blind approach”). The chapter on antipsychotic drugs, another of the many excellent chapters in volume 2, provides a balanced discussion about the “clinical superiority” of some psychotropic agents over others, and it describes the concept of treatment resistance. There are excellent reviews on pharmacogenomics, and the last paragraph of the chapter on mood stabilizers is an inspiring call for comprehensiveness. Throughout these chapters, the clinician in search of practical advice has to wonder whether to go to the chapters on clinical entities or to those specifically devoted to pharmacological treatments, such is the richness of the material in both. I was also impressed by the comprehensiveness and thoroughness of the chapter on therapeutic management of the suicidal patient, appropriately complemented by those on treatment of violent behavior and on compliance, among others.

Finally, Section 7, Special Clinical Settings and Challenges, has thought-provoking chapters on the social context of psychiatric practice, organization and financing of mental health care, the role of case managers, advocacy, and the interactions of law and ethics with psychiatry, as well as an outstanding review of global perspectives on mental health services.

Many authors do not shy away from presenting polemical views or from generating tough questions; this makes the two volumes an arena of scholarly debate. How could federal bureaucracies enhance compliance with constructive regulations without removing clinicians from their patients to write hyperdetailed documentation? Is the combination of psychotherapy and pharmacotherapy applicable to all, some, or none of the psychiatric conditions? Is the current, even fashionable, “split treatment” appropriate and valid? Is there still a place for psychoanalysis or its current version of psychoanalytically oriented psychotherapy, at a time when cognitive behavior therapies appear to be running the field? Is a neurodevelopmentalist a new sort of specialist? Is cognitive neuroscience a single discipline or a necessary amalgam of knowledge at this point in history? What is the status of schizoaffective disorder, or borderline personality for that matter, in the ever-changing scene of psychiatric nosology and diagnosis? How do we handle so-called comorbid conditions that might be part of the same pathogenic entity? Are decision trees thorough and ultimately valuable? When will antidepressants and antipsychotics generated by research beyond neurotransmitters become a reality? How much of a target is insomnia for sedatives and hypnotics, and what is the real role of “cognitive enhancers” in dementia patients? These are among the many questions emerging out of an engaging reading.

The book could have dealt with some areas differently. The chapter on dual diagnoses could have been placed earlier than volume 2. Realities in Latin American countries are not included in the chapter on global perspectives on mental health services. I missed an unequivocal recognition of Karl Jaspers’ contribution to phenomenology and diagnoses, as well as an unequivocal recognition of Jerome D. Frank’s seminal research on the therapeutic ingredients of psychotherapy. There are excellent presentations on dialectical behavior therapy and interpersonal psychotherapy, but those on areas such as culture-specific therapies, multidimensional culture/psychopathology connections, psychoses other than schizophrenia, and treatment flowcharting of factitious disorders are not as excellent. The presentations of the topics of the cultural framework of psychiatric diagnosis, psychiatric classification, and personality disorders are enjoyable but improvable. These are, indeed, minor observations. The two volumes of Psychiatry fulfill their mission with the highest of marks.

There is no question in my mind that Psychiatry is the definitive textbook that the United States can proudly offer to the world at this critical point in the history of our discipline. The authors obviously like what they do, and like to share the knowledge, uncertainties, expectations, triumphs, and failures—the full reality of our daily lives as psychiatrists trying to help others. Firmly planted on clinical and pragmatic terrain, the book is also an intellectual adventure, a station in the endless search for elusive truths, a journey of pleasure and excitement. It is like Paul Valéry’s vision (1):

And that is the essence of a classic.