Psychiatry, vols. 1 and 2
Creating a textbook is always an ambitious undertaking. So imagine what it must have been like to create a textbook with the deceptively simple title Psychiatry. Think about it for a minute. Not Principles of Psychiatry. Not Textbook of Psychiatry. Just Psychiatry. The implication for you and me, dear reader, is that all aspects of our amazingly rich and complex field will be contained between the covers of these two books.
As I sat and looked at the two handsome and impressive volumes (dark burgundy cover, gold lettering), I found myself wondering how I might have approached such a task. What would you include in a textbook that is meant to encompass all of psychiatry? How would you organize the immense amount of material? How much of a historical overview would you include? How much from the psychological and social sciences? How much from neurobiology and cognitive neurosciences? How would you make sure that your own theoretical interests and biases did not unduly influence the overall content? Finally—the eternal question for anyone trying to teach material in the medical sciences—how would you strike a balance between presentation of evidence-based findings and acknowledgment of the unique human beings, our patients, who come to us in their suffering and look to us for help?
I opened the cover of the first volume and turned to the preface, curious to see how the three editors had conceptualized their work. To my interest and delight, for these are men whose credentials reach high into the academic and research stratosphere, the editors begin by stating the single most fundamental principle of psychiatry—the one that applies equally well to all of us, from the researcher to the clinician, from the trainee to the experienced practitioner, from the academic specialist in the urban setting to the general psychiatrist in a small town. Here it is, the fourth sentence of a textbook that goes on to nearly 2,000 pages and covers (among many, many other topics) genetics, epidemiology, neuronal plasticity, the trauma theory of neurosis, Melanie Klein, experimental therapeutics, ethics and law, and statistical techniques: “The physician-patient relationship provides the framework for quality psychiatric practice.”
Indeed, as I turned from the preface to look at the table of contents, I saw that the very first section of the textbook is titled Approaches to the Patient. Chapter 1 is called “Listening to the Patient.” This principle—that the framework of clinical psychiatry is defined by the physician-patient relationship—infuses many of the chapters. Clinical vignettes are used liberally throughout the textbook to illustrate important principles of theory and practice. In this day and age (mandated six-session treatment plans, telephone follow-up visits, Web-based health care), I found it refreshing—if not downright seditious—to see a major textbook use as one of its organizing principles the notion that the real-time relationship between two human beings is a critical element in the healing process.
Starting, then, from this basic premise, here is how the editors have organized the vast amount of material that makes up our field. First, they move from the physician-patient relationship (section 1, Approaches to the Patient), to an overview of normal behavioral development in the human being (section 2, A Developmental Perspective on Normal Domains of Mental and Behavioral Function). This link seems prescient to me, for as we learn more and more about the self-organizing and plastic capacities of the human brain, principles of neurodevelopment will certainly become the basic science of psychiatry.
Next, the textbook covers the evaluation and empirical foundations of abnormal behavior (more basic science in section 3, Scientific Foundations of Psychiatry), followed by the clinical sciences of psychiatry, which are the assessment of abnormal findings (section 4, Manifestations of Psychiatric Illness) and the classification and diagnosis of psychiatric disorders (section 5, Disorders). The editors conclude with topics that contribute to the art of psychiatry: how to treat psychiatric disorders (section 6, Therapeutics) and how to approach specialized situations (section 7, Special Clinical Settings and Problems). There are also three highly interesting appendixes: one on a brief history of psychiatry, one on research methodology, and one on continued professional development. All in all, more than 200 extremely well-known and highly regarded experts, many of them luminaries in the field, have contributed chapters to this endeavor.
Lest you feel overwhelmed by the sheer volume and breadth of the material covered in this textbook, let me hasten to assure you that the editors and authors have made a deliberate point of keeping it all extremely user-friendly. Despite the fact that we are talking about two large and heavy volumes of almost 1,000 pages in length each, there are plenty of tables, charts, illustrations, and clinical vignettes set off with clear and well-marked graphics. The effect is both pleasing and stimulating.
Textbooks are often aimed at people early in their career, but this one clearly is also meant to be useful to the experienced practitioner. The clinical vignettes are often complex and lengthy, and they present sophisticated longitudinal case material. Topics are covered in a very up-to-date and reasonably in-depth and well-referenced manner. The special section on novel or extreme therapeutic strategies—treatment approaches to consider when standard treatment fails—will be reassuring to the clinician trying to manage a treatment-resistant patient with an unusual combination of antidepressants, for example. The appendixes on research methods and on continued professional development speak to the established practitioner who has developed clinical self-confidence but who wants to be able to evaluate new findings continually and critically in the field.
I found myself browsing though the chapters with real interest and curiosity, catching up on topics I hadn’t thought about in a long time (the therapeutic frame, somatoform disorders) as well as delving into areas I’d always wanted to know a little more about (social psychology, intersubjectivity). While perusing the two volumes, in fact, I hit upon what I have decided is an easy, reliable, and valid three-step method for evaluating textbooks in psychiatry, one that should be immediately adopted by reviewers everywhere. Step 1: I read a chapter on a topic with which I am very familiar and have some research expertise (schizophrenia). Step 2: I read a chapter on a topic where I do not have any expertise, but where I have had a recent complex clinical encounter that has left me thinking about or reading about a particular problem (body dysmorphic disorder). Step 3: I let the book fall open at random and read about a subject on which I am completely ignorant (childhood disorders). My ratings are, in order, 1) masterful and thorough, 2) intelligent review, excellent case vignette, and 3) clear, precise, and balanced.
In sum, Psychiatry is a wonderfully conceived and beautifully executed textbook. Each time I open it, I am more impressed by the quality of work of the authors and editors. They have given us the gift of a gold standard for our field.
