Brain, Vol. 122, No. 4, 786-788,
April 1999
© 1999 Oxford University Press
Book Reviews |
DISORDERS OF BRAIN AND MIND
Edited by Maria Ron and Anthony S. David. 1998. Pp. 373. Cambridge: Cambridge University Press. Price £55.00. ISBN 0-521-47306-3..
Gabalfa Clinic, Cardiff, UK
The concept that common psychiatric disorders such as schizophrenia may have an organic basis has been far from fully accepted during the twentieth century. The work of pioneers such as Kraepelin at the turn of the century was largely forgotten or ignored by an influential body of opinion who appeared to reject an organic explanation for psychiatric disorder. The extreme position on this was to view schizophrenia as an understandable escape from pressures in life. The non-organic viewpoint was probably most prevalent in the USA, where psychiatry was dominated by psychoanalytically orientated psychiatrists. In the United Kingdom psychiatry has traditionally been considered as more organic and the prevalence of this view has increased over the last two decades.
Disorders of Brain and Mind highlights the advances that have been made concerning the physical basis of psychiatric disorder in recent years. It is dedicated to the recently retired Professor Alwyn Lishman, a major, if not the, protagonist, of neuropsychiatry in the United Kingdom; Lishman's Organic Psychiatry has long been established as the bible of neuropsychiatry to many psychiatrists.
Neuropsychiatry is given a broad definition by the editors. Basic biological, chemical, pharmacological and anatomical investigations, genetics and clinical studies are all considered key components. More recently, brain imagery has been added to this list and investigations such as computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), single photon emission computed tomography (SPECT) and electroencephalography (EEG) are now considered fundamental tools in neuropsychiatry.
The book is divided into seven sections each of two chapters. The idea of combining quite detailed chapters on basic science and neuropsychology along with more clinically orientated chapters is a good one. Unfortunately there is some repetition between chapters, in particular those on neuroimaging, which seems almost inevitable in multiple authorship books. The first section considers the frontal lobes: the cognitive–behavioural function of the frontal lobes is described, as are the frontal–subcortical circuits and the cognitive behavioural changes that result if damage occurs to structures participating in the circuits or to the circuits themselves. Indeed, the fact that lesions in the circuits have been implicated in psychiatric disorders such as affective disorders and obsessive compulsive disorder is mentioned. The excellent resumé of the common tests employed to measure frontal function will be welcomed by many clinically orientated readers, as will the brief consideration of the key frontal functions of language, attention, concentration, memory, visuospatial skills, executive function and motor function. There is also a good description of the types of emotional disturbance commonly encountered with frontal lobe damage, for example personality change.
Evidence from neuroimaging for frontal lobe structural abnormalities in schizophrenia is considered in some detail. Neuropathology is briefly discussed and then CT studies and MRI studies are critically reviewed. Third ventricle and lateral ventricle enlargement in schizophrenia have been confirmed by CT and MRI studies, lending strong support to the notion that schizophrenia has an organic basis. The findings of mesial temporal lobe volume loss have usually been replicated but studies of frontal lobe structures reveal less consistent findings, although it is concluded that more recent and technologically advanced studies suggest that the critical frontal lobe abnormality in schizophrenia is a reduction in grey matter.
The basal ganglia are considered in the second section of the book. Several studies of basal ganglia function following damage are considered and suggest that the deficits resemble the executive deficits that follow frontal lobe damage. Behavioural pharmacology of the brain dopamine system is also considered. The problematic dopamine hypothesis for schizophrenia is discussed and, not surprisingly, found to be untenable in its current form. Dopamine receptors are discussed, as are animal models derived from learning theory and considered relevant to schizophrenia. The evidence from research extends the role of dopamine in controlling behaviour from the subcortical regulation of motor acts to the cortical regulation of behaviour guided by internal representation. The somewhat confused literature on the original atypical antipsychotic, clozapine, is reviewed and the authors believe that the question of whether antipsychotic drugs can improve neuropsychological function in relation to improvement in symptoms of schizophrenia will not be answered until more rigorous and sophisticated studies are performed. They conclude that dopamine neurotransmission plays a significant role in cognitive functioning but the relevance of this to schizophrenia remains unclear. Schizophrenia is a complex condition and the authors emphasize this by arguing that the distorted neuronal cytoarchitecture in the temporal and frontal cortex underlies schizophrenia and presumably involves many neurotransmitter systems, representing powerful evidence against a single neurotransmitter defect in the illness.
The section on memory and its disorders is interesting. The neuropsychology of memory and amnesia is discussed, as is the neuroanatomy of amnesia, focusing on the medial temporal lobes, midline diencephalon and the basal forebrain. Kopelman's chapter complements this by offering a more clinical perspective. Brief descriptions of the common amnesic states including Korsakoff's psychosis, global dementia, transient amnesias and psychogenic amnesia are discussed. Key issues regarding differential diagnosis are usefully considered, as are the specific memory deficits in amnesic disorders including storage and encoding.
Using examples such as cerebrovascular accident and multiple sclerosis, Ron discusses the research that conclusively points to the association between certain organic pathologies and particular psychiatric presentations. She compares the psychiatric manifestations of established brain disease with symptoms and pathophysiological mechanisms of primary psychiatric illness. Affective symptoms, schizophreniform symptoms and obsessive compulsive symptoms are all discussed as manifestations of established brain disease and primary psychiatric illness. She concludes that a wide range of psychiatric symptoms found in individuals with brain disease are similar to those observed in primary psychiatric illness. The similarities of the psychiatric presentations appear greater than the differences and it therefore seems likely that the dysfunction of the same cortical–subcortical circuits is central in the causation of symptoms in both groups. She also highlights the important point that the presence of psychiatric symptoms in patients with neurological disease plays an important role in the survival, overall disability and outcome of rehabilitation. This justifies the need to develop neuropsychiatric and liaison psychiatry services to enhance detection and improve the treatment of psychiatric symptoms.
The section on epilepsy represents a detailed introduction and highlights the frequency of behavioural/psychiatric symptoms/signs in patients with epilepsy. This should come as no surprise to the individuals likely to be reading this book, but serves as a good reminder that such presentations can be understood from an organic perspective and that there has been considerable research undertaken to consider this. The first chapter considers a variety of animal models that simulate epilepsy and discusses the behavioural consequences of the epilepsy. This is, of course, used to suggest that such symptoms can have a common biological basis with the epilepsy, rather than being secondary to anticonvulsant medication or non-organic causes as is commonly suggested. The following chapter considers the possible underlying anatomical similarities between psychosis and epilepsy, in particular mesial temporal sclerosis. This is discussed and a similar point to Ron's is made concerning the similarity in clinical presentation of psychoses associated with temporal lobe epilepsy and paranoid states and schizophrenia in the absence of epilepsy. It is concluded that temporal lobe epilepsy provides a `privileged inroad to the inner emotional world of the human mind, and its exploration from a neuroanatomical perspective'.
The psychiatric disorder that dominates the book is schizophrenia, the choice of which, given the amount of relevant research into it, can be justified but makes the book most interesting to those specifically interested in schizophrenia. By focusing on schizophrenia the book provides a different viewpoint on neuropsychiatry than has been commonly taken in recent years. If readers were in any doubt before reading this book that schizophrenia is a neuropsychiatric disorder they should not be afterwards, although it is important to acknowledge that this does not necessarily result in us being able to comprehensively manage this condition from a purely organic perspective. Indeed several non-organic interventions including cognitive therapy and family therapy have been shown to improve symptoms and functioning.
The penultimate section of the book focuses on schizophrenia to consider perspectives of neurodevelopment. This attractive explanation for the complex condition of schizophrenia is discussed considering several diverse sources of support. Birth trauma, obstetric complications, genetic factors, foetal abnormalities, seasonality, viral infections, immigration, postnatal brain damage, post-mortem findings including cellular migration, volume and cellular density, gliosis and neural processing and neuroimaging are all discussed. The concept that schizophrenia is the consequence of a single specific developmental abnormality is felt not to be implausible or incompatible with the wide range of developmental outcomes seen in those at risk of schizophrenia. This is supported by discussion of the fact that abnormalities of neuropsychological development are common and mediated through complex pathways with the resilience of the developing brain usually modifying the effects.
The final section of the book focuses on new approaches. In particular magnetic resonance spectroscopy (MRS) is considered with a rather bullish prediction of its usefulness in the future. Throughout the book the various forms of imaging that have become available to us in recent times are discussed. It is difficult to determine the actual clinical usefulness of these techniques in conditions such as schizophrenia at present, although their research value is undoubted. Perhaps more advanced functional imaging will provide more appropriate clinical tools in the future. The final chapter of the book focuses on its title by considering the hallucination as a disorder of brain and mind.
This book is not always an easy read, but for anyone contemplating studying neuropsychiatry in more depth, and in particular applying an organic approach to schizophrenia, it represents an interesting and worthwhile read. Essentially it is a collection of papers with a common thread but is certainly not a comprehensive account of neuropsychiatry.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||