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Approach to the Psychiatric Patient: Case-Based Essays
Am J Psychiatry 2009;166:939-939. doi:10.1176/appi.ajp.2009.09020156
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edited by John W. Barnhill, M.D. Washington, D.C., American Psychiatric Publishing, 2009, 565 pp., $62.00.

This is a fascinating textbook that attempts to approach the clinical and educational challenges of treating psychiatric patients from a truly multidisciplinary perspective using a case-based format. Other publications have used case-based presentations as a stimulus for thoughtful discussion, but none, to my knowledge, have approached this as Dr. Barnhill does.

The book is organized around 10 cases, which represent composite features drawn from clinical experience across the diagnostic spectrum. Each case includes a brief overview; personal, family, and medical histories; and a summary, which poses questions for the essays that follow. The cases are followed by eight to 14 essays in which the authors have been asked to comment on one aspect of the case in less than 1,500 words—quite a feat for most clinicians. Dr. Barnhill drew his guest commentators from all perspectives of psychiatry: psychoanalysis, neuroscience, clinical psychopharmacology, interpersonal psychotherapy, cognitive-behavioral psychotherapy, child psychiatry, substance abuse, violence, pain, and others. Nearly 120 clinicians and scientists contributed.

The cases cover a broad spectrum of psychiatric disorders, including double depression, schizophrenia, mood instability, anxiety, and hypomania. In addition, the vignettes include a discussion of issues that fall outside of the diagnostic nomenclature, such as adolescent bereavement, terminal illness, and “exam failure.” In the context of the essays, the text includes discussions of other significant psychiatric issues and disorders, such as the psychodynamic formulation, brain stimulation, eating disorders, various types of psychotherapy, violence, homelessness, substance abuse, genetic counseling, family therapy, suicide, homosexuality, complementary medicine, the impact of culture and ethnicity, and emergency evaluations, among others.

While the range of psychopathology and sophisticated commentary on psychiatric illness is exceptional, the book suffers from a degree of disorganization and lack of clarity. Dr. Barnhill faces the familiar editor’s dilemma of how to integrate disparate writing styles and approaches to patients in a coherent and logical way. For example, six of the cases are followed by a “part A” and a “part B” discussion. These appear to be divided into essays that focus on a didactic analysis of a disorder or syndrome (part A) versus essays that specifically focus on the patient in question (part B). The other four cases are not similarly focused or divided. In addition, the issues addressed by the discussants in each case are not systematically organized, and as a result, the content seems to reflect individual approaches to diagnosis and treatment rather than a consensus or scientifically based process. While this approach may accurately reflect the complexity of psychiatric disorders and how psychiatrists approach patients, such an overinclusive narrative detracts from how this text might be used effectively by students and trainees.

Nevertheless, this book is an appealing and intriguing way for the clinician to read about complex patients and diverse treatment approaches.

+The author reports no competing interests.

+Book review accepted for publication February 2009 (doi: 10.1176/appi.ajp.2009.09020156).




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