Asperger Syndrome

Declan G.M. Murphy

BJP 2001, 179:375.
Access the most recent version at DOI: 10.1192/bjp.179.4.375

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B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 1 ) , 1 7 9 , 3 7 2 ^ 3 7 7

Book reviews
EDITED BY SIDNEY CROWN and ALAN LEE

Violence, Crime and Mentally

Disordered Offenders: Concepts
and Methods for Effective
Treatment and Prevention
Edited by S. Hodgins & R. Mu
Muller-Isberner.
ller-Isberner.
Chichester: John Wiley & Sons. 20 0 0. 233 pp.
27.50
27.5 0 (pb). ISBN 0 471 97 72 6

Violence among the Mentally III:

EffectiveTreatment and
Management Strategies
Edited by Sheilagh Hodgins. Dordrecht:
Kluwer Academic. 20 0 0. 416 pp. 107.0 0
(hb). ISBN 0 7923 6437
6 437 6

It's a funny business, forensic psychiatry.

You wait years for a decent book on the
treatment of mentally disordered offenders,
and then along come two at once. This
phenomenon is well recognised in the
public transport industry, where researchers devote their lives to the problem of
`clustering'. I do not know why no. 12
buses hunt in packs, but I am confident that
it is not because they share a driver.
The simultaneous appearance of these
two books raises other issues, of more
direct relevance to the academic world.
Anthony Burgess expressed a belief that the
desire to write was inseparable from the
need to make money, but he was speaking
of a more innocent age, before the advent
of the Research Assessment Exercise. Burgess also reflected gloomily that he may
have achieved nothing more than to increase the number of words in the world. It
is a sobering thought that this is now the
definition of success, provided that the
words are published in the right place.
When playing by these rules, it is no
surprise that an academic publishes two
books where one would do. The more
difficult question concerns the rest of us.
Why should we read them or, more to the
point, buy them?
That question is easily answered for the
first book of the pair, Violence, Crime and
Mentally Disordered Offenders.
Offenders. It is an
excellent book, summarising current knowledge about a wide range of treatments.
Drugs, psychological and social treatments

372

are all covered. Each chapter is self-contained, so it is easy to find the topic you are
interested in, and each begins with a review
of background knowledge about the disorders concerned, before going on to deal
with research into treatment. The book is a
bargain and it will be useful to a wide range
of practitioners, whether they are planning
services, treating mentally disordered offenders, or thinking about a research project.
By contrast, Violence among the Mentally Ill is disposable. It is a book in disguise.
Although the cover makes no reference to it,
the introduction begins by talking about the
``NATO Advanced Study Institute on the
Prevention of Crime and Violence Among
the Mentally Ill'', held in Italy in May 1999.
Just as `collateral damage' means dead
civilians, so `Advanced Study Institute' is
NATO-speak for what the rest of us call a
conference. We are in the dreaded world of
conference proceedings, and the book has
all the faults of the genre.
At first sight, it seems surprising that the
book is such a disappointment. The contributors are eminent, many of them have
published widely and some have written
essential texts in the area. Several of the
chapters are well written. The problem lies in
the fundamental difference between good
conference presentations and good books. I
like presentations that are lively, spiced up
with a few anecdotes and not too dense. One
can imagine that some of the talks here,
presented on a hilltop in Tuscany, with a
Powerpoint backdrop, had the audience
crying out for more. In the cold light of the
printed page, they just do not work.
As an example of the problem, consider
one speaker/author's explanation of how
most of the problems in institutions are
caused by a small number of difficult
individuals. It is impossible to disagree
with the point. I have even seen ``The few
who spoil it for the rest'' stencilled on the
leather jackets of a gang of Hell's Angels,
suggesting that the notion is accepted even
among those who are not social scientists.
Here, the explanation takes more than a
page and it appears complicated and meandering. Other presentations have similar

faults. Few have the breadth that is implied

in the book's title, tending to concentrate
on a particular area of interest, rather than
a comprehensive review.
If these comments seem unduly harsh, it
is important to remember the context. I
would not complain if this book were given
to me by the representative of a pharmaceutical company, to be placed on a shelf
alongside my other volumes of conference
proceedings (especially if a couple of pens
and some sticky labels were thrown in with
it). But when I am asked to pay over 100
for the privilege of owning it, I feel entitled
to voice some reservations.
It is unfortunate that the book as a whole
cannot be recommended, because there are
some gems within it. For example, there is an
account of some of the findings of the
MacArthur Study, followed by a reasoned
and effective critique of that study's methods. This makes for great reading, but it sits
uncomfortably in a book that is supposed to
describe ``effective treatments and management strategies'', as the debate revolves
around issues far removed from the clinic.
Several other chapters have only distant
relevance to the treatment theme. The overall impression is of a mixed bag of papers on
mentally disordered offenders, squeezed to
fit in under a catchy title.
In a rational world, the appearance of
two books on the same topic begs the
question, why was the second one necessary? Important material about treatment
should have been included in the first book,
which feels like a comprehensive account. If
the material is not sufficiently important,
then why bother to publish at all under a
similar title? One of these books is good,
the other is not so good. They could have
been combined into an excellent text,
leaving the world a little less crowded.
Anthony Maden Professor of Forensic
Psychiatry, Imperial College of Science,Technology
and Medicine, Academic Centre,Trust
Centre, Trust
Headquarters, EHF NHS Trust,Uxbridge Road,
Southall, Middlesex UB7 3EU,UK

Essential Psychopharmacology of
Depression and Bipolar Disorder
By Stephen M. Stahl.Cambridge: Cambridge
University Press. 20 0 0.
0.187
187 pp. 16.95 (pb).
ISBN 0 521 786 45 2

This is an impressive book by an author who

clearly knows how to communicate his
subject in a clear and interesting way. Drawn

B OOK R E V I E W S

from Stahl's longer publication, Essential

Psychopharmacology (2000), it has the feel
of a programmed learning text, a pedagogic
style popular in American student texts but
relatively unusual in British textbooks of
psychiatry. It is beautifully illustrated in
colour throughout.
The author states clearly at the outset
that his aim is to give the reader a conceptual understanding of the subject. He
begins with a gallop through the basics of
depression and bipolar disorder, with an
emphasis on fundamental neuroscience.
This material forms the basis of discussion
in the remaining two chapters.
Chapter 2 gives a methodical description of the mechanisms of action of the
major classes of antidepressant in current
use, augmented by easy-to-follow colour
diagrams. The role of the cytochrome P450
enzyme system is clearly and simply illustrated in a review of the pharmacokinetics
of antidepressants.
The final chapter, which will probably be
the most interesting for advanced readers,
deals with the mechanisms of action of newer
antidepressants and mood stabilisers. The
concept of antidepressants with dual modes
of action is illustrated using examples including venlafaxine, mirtazapine and nefazodone.
Mention is also made of antidepressants still
undergoing development, for example, substance P antagonists. Stahl concludes with a
survey of possible drug-combination strategies for treatment-resistant patients.
This readable and attractive volume
should be required reading for all those
interested in acquiring a comprehensive understanding of the neuroscience of mood
disorders and a working knowledge of the
basic pharmacology of antidepressants and
mood stabilisers at a neurochemical level. Its
clear and simple explanations and illustrations
are particularly suited to readers new to the
subject, although advanced readers will also
find it useful in consolidating their knowledge.
For those with clinical responsibility for
prescribing antidepressants and mood
stabilisers there is no other book quite like
this to stimulate, inform and direct further
enquiry. There is a list of further reading,
but no source references are provided.
Multiple choice questions allow the reader
to test retention of the material.
Stahl, S. M. (2000) Essential Psychopharmacology (2nd
edn). Cambridge: Cambridge University Press.

M. Bodani Locum Consultant Psychiatrist, St

Nicholas Hospital,Collingwood Court, Jubilee Road,
Gosforth, Newcastle uponTyne NE3 3XT,UK

Dangerous Sex Offenders: A Task

Force Report of the American
Psychiatric Association
By H. Zonana,G. Abel, J. Bradford, S.K. Hoge,
J. Metzner, J. Becker, R. Bonnie & L. Fitch.
Washington, DC: American Psychiatric Press.
1999. 181 pp. 29.95 (pb).
ISBN 0 89042 28 0 X

Public opinion on both sides of the Atlantic

currently seems to show `zero tolerance' to
sex offenders. Meanwhile, behind both
determinate and indeterminate sentencing
can lie a pretence that treatment is the
purpose of confinement.
The American Psychiatric Association
task force has endeavoured to question the
`policing' role given to psychiatrists, while
at the same time educating them about sex
offenders and their needs. It also examines
the effectiveness of classification and treatment and the impact (or lack of impact) of
the latter on recidivism.
Many statistics attempting to determine
the prevalence of the different paraphilias
are provided. As is often the case in such
studies, the descriptions of the different
diagnoses far outweigh any attempts to
understand why such behaviours occur.
Treatment is discussed in chapters on
cognitivebehavioural and pharmacological method. Psychodynamic treatments
are mentioned only in the chapter on
recidivism (with its implication that no
treatment cures these problems), which
contains a brief reference to the lack of
psychodynamic research findings. The task
force concludes that psychodynamic treatments are not reported because they are not
successful.
This seems to me a simplistic review of
a complicated field. There is a substantial
international psychoanalytic literature that
offers much in the way of understanding
sexually deviant behaviour, an understanding that has arisen out of careful treatment.
Perhaps it is not accredited because it often
describes single cases in detail and does not
set out to count successes. The failure to
acknowledge this literature is particularly
apparent in the same chapter on recidivism,
in the section on theoretical explanations. It
makes no sense to me for the task force to
state that there have been very few recent
attempts to conceptualise the theoretical
causes of sexual offending. Again, the
developmental aspects so important to
psychoanalysis are completely missed out.
The psychological entity is overlooked in

the tendency to create ever-growing descriptive lists.

The final two chapters offer some useful questions and information to encourage
the reader to think about the issues
involved. For example, various scenarios
involving a fictitious John Doe examine
what to do when he is accused of abusing
his 5-year-old daughter, a 13-year-old boy
and a 23-year-old woman. The statement in
the section on policy recommendations that
``sexual predator commitment laws represent a serious assault on the integrity of
psychiatry'' is certainly thought-provoking.
With reservations, the report serves as a
review of the current struggle with a very
real and complex problem for which there
is no simple answer.
Anne Zachary Consultant Psychiatrist in
Psychotherapy,
Psychotherapy,The
The Portman Clinic, 8 Fitzjohn's
Avenue, London NW3 5NA,UK

Male Victims of Sexual Assault

(2nd edn)
Edited by Gillian C. Mezey & Michael B.King.
Oxford: Oxford Medical Publications. 20 0 0.
161 pp. 37.50
37.5 0 (hb). ISBN 0 19 262932 8

``Male rape is a taboo subject'' is the first

sentence of the first edition of this volume,
published in 1992. It is partly a tribute to
the editors that times have changed, with
the subject now being more openly

373

B OOK R E V I E W S

discussed, and this new edition, with its

updated research, is welcome.
I find it paradoxical that male rape has
long been a cultural reality, for example, in
prison dramas such as Pasolini's film, Salo
(1975). Based on de Sade's 120 Days of
Sodom and set in fascist Italy, the film
recounts the story of a group of young
women and men imprisoned in a chateau
and abused by four male `libertines' with
the help of female accomplices. Thus,
Pasolini combines sexual and political
aspects of assault, both of which are
addressed in this volume (e.g. in Turner's
chapter `Surviving sexual assault and sexual
torture' and Coxell & King's `The sexual
assault of men in custodial environments').
Among the other issues that are highlighted, relevant to both female and male
sexual abuse, is the question of what is
meant when an attack is described as sexual
or political. The authors conclude that the
definitions depend on context, either in
particular, such as in a prison, or in a wider
sociocultural environment, such as a culture
of homophobia.
Of particular interest is the chapter on
sexual assault in prisons: research describes
apparently low incidence and prevalence
levels, and the discussion here addresses
whether or not this is actual or a result of
underreporting. What seems clear is that
the threat of rape is in itself very important
and the authors ask whether rape in prison
is an institutional myth whose function is to
control inmates. This is a topic I would like
to see explored more fully.
The volume is impressive in its collation
of the current literature on male victims of
sexual abuse in a variety of contexts, but I
thought there to be some thinness of
discussion around understanding why
men, in particular, sexually attack other
men. There is a difficulty in divorcing this
entirely from homosexuality, which this
book does at several points, as if sexual
desire plays no part at all. It is important to
emphasise, as some chapters do, that
homosexuality in itself does not make
someone more likely to commit a sexual
crime, but that sexuality plays some part in
what occurs. This topic is always difficult,
and of help was West's chapter on homophobia; this explores men's fear of homosexuality (an explanation for some attacks),
which appears to be more powerful than
women's fear of it. From an anecdotal
point of view, working in a secure unit, I
have noticed that men who suffer from
schizophrenia often have delusions about

3 74

being sodomised by other men, when

particularly paranoid.
The authors do not explore the nature of
gender and of male (v.
(v. female) sexuality, and
their relation to violence, as extensively as I
would have liked. It is noted that far fewer
girls than boys become sexual abusers after
having been sexually abused themselves in
childhood, and that research suggests that
males report feeling less damaged by their
experience of abuse than do females. However, the paradox is not examined in depth. I
am either being unfair to the authors and
editors or paying them a tribute by saying
that they left me wishing for more.
Cleo Van Velsen Consultant Psychiatrist in
Forensic Psychotherapy, Maudsley Hospital,
Denmark Hill, London SE5 8AZ,UK

Core Psychiatry
By Padraig Wright, Julian Stern & Michael
Phelan. London: W. B. Saunders. 20 0 0.
652 pp. 49.95 (pb). ISBN 0 7020 2490 2

Although an obituary has been written for

textbooks more than once, they have
proven to be a hardy breed which has
survived despite being frequently criticised
and even at times unloved. Indeed, rather
than dying out new textbooks continue to
appear and this is true in psychiatry no less
than in other branches of medicine.
Core Psychiatry is one such volume. In
the preface the authors tell us that, like
many other textbooks, it has arisen from a
teaching course, in this case one oriented
towards individuals sitting Parts 1 and 2 of
the MRCPsych examination. In line with
this, the book is divided into three parts:
Part 1 concentrates on the foundations of
psychiatry, Part 2 on clinical psychiatry and
Part 3 on diagnosis, investigation and
treatment. The curriculum for the membership examination is wide-ranging, to say
the least, and to attempt to cover the full
range of knowledge in a single volume is
ambitious. The authors do not claim to
have produced a textbook for psychiatry
per se;
se; rather, they offer one specifically for
exam candidates. They do, however, claim
that it will be a reference volume for those
who have passed the MRCPsych and others
in medicine and related professions.
By and large, the authors have succeeded in their aim of producing a core
textbook that is particularly useful to those
who are required to absorb large amounts
of information over a short period of time

for the purpose of passing examinations.

Nevertheless, there are deficiencies. The
foundations of psychiatry are inadequately
covered (although this must be almost
inevitable given that psychiatry draws from
so many different disciplines). However, I
would think that no trainee psychiatrist,
even one cramming for exams, would go
through psychiatric training without reading about fundamental issues such as
diagnosis and classification, adumbrated
so well by Robert Kendell in the Companion to Psychiatric Studies (Kendell &
Zealley, 1993). Other parts of the book
are perhaps weaker than rival volumes such
as the Oxford Textbook of Psychiatry
(Gelder et al,
al, 1996), and I found the
coverage of neuropharmacology particularly disappointing, as was the coverage of
affective disorders and psychopharmacology. It is notable that the other textbooks
mentioned above deal with these particular
areas much more completely.
Upon taking a straw poll of the few local
trainees who have attended the course and
used the textbook, I found that the direct
consumers were very positive about both the
course and the textbook. Nevertheless, any
potential purchaser will have to consider very
seriously whether they will spend their limited
amount of cash on this or would prefer one
of the more established textbooks.
Gelder, M., Gath, D., Mayou, R., et al (1996) Oxford

Textbook of Psychiatry (3rd edn). Oxford: Oxford

University Press.

Kendell, R. & Zeally, A. K. (1993) Companion to Psychi-

atric Studies (5th edn). Edinburgh: Churchill Livingstone.

AllanYoung Professor of Psychiatry, Department

of Psychiatry, Royal Victoria Infirmary,Queen
Infirmary, Queen
Victoria Road, Newcastle uponTyne NE1 4LP,UK

B OOK R E V I E W S

Asperger Syndrome
Edited by Ami Klin, Fred R.Volkmar & Sara S.
Sparrow. New York: Guilford Press. 20 0 0.
489 pp. 32.50 (hb). ISBN1 57230 534 7

Call me sad, but when I was asked to review

Asperger Syndrome my heart skipped a
beat. The reasons: increasing numbers of
people are being referred to mental health
services for advice on `Asperger's', yet little
is known about the disorder; the editors of
this book are pre-eminent in their field; and
the people contributing chapters include
outstanding researchers and affected individuals. So, what do we know already, and
what was I hoping to learn?
We know that autistic disorder (comprising the genetically related subtypes of
classic autism, high-functioning autism and
Asperger syndrome) is a developmental
neuropsychiatric condition and that it is
associated with a significant increase in
social exclusion and mental health problems. Core symptoms include impaired
development of reciprocal social skills and
communication, ritualistic/compulsive behaviour. Individuals with classical autism
also have delayed language development
and most have learning disability. However, around 25% are classified as highfunctioning, because they have normal or
superior general intellectual ability, in spite
of having a history of early language delay.
Individuals with Asperger syndrome have
no history of language delay and have
normal or superior intellectual abilities,
but also show the characteristic impairments in reciprocal social interaction (Wing,

1997; Gillberg, 1998). Thus, in both highfunctioning autism and Asperger syndrome
there is a significant dissociation between
cognitive and social skills.
There are also many things we do not
know about Asperger syndrome. These
include its genetic and neurobiological
determinants, comorbidity with other mental health disorders, response to treatment,
long-term outcome and the health and
social costs to the person and their family.
Does this book help illuminate these
issues and would I recommend it to
researchers, clinicians and people affected
by Asperger syndrome? My answers are
``Well, sort of'' and (respectively) ``Yes'',
``No'' and ``No''. The chapters on historical
aspects, differential diagnosis, neuropsychology, brain imaging, language disorders
and non-verbal learning disabilities are
illuminating, and the contributions by
affected people are valuable. However,
there is little new information on issues of
assessment, treatment or outcome. Also,
some chapters seemed to be based mainly
on work in classical or high-functioning
autism. This is almost inevitable because
our knowledge about Asperger syndrome is
relatively limited. None the less, I could not
help feeling that the book, while well
intentioned and responding to our demand
for more information, is slightly premature,
given the current level of knowledge.
Gillberg, C. (1998) Asperger syndrome and highfunctioning autism. British Journal of Psychiatry,
Psychiatry, 172,
172,
200^209.
Wing, L. (1997) The autistic spectrum. Lancet,
Lancet, 350,
350,

1761^1766.

Declan G. M. Murphy Professor of Psychiatry

and Brain Maturation, Division of Psychological
Medicine, Institute of Psychiatry, De Crespigny Park,
Denmark Hill, London SE5 8AF,UK, and Honorary
Consultant Psychiatrist, South London and Maudsley
NHS Trust

Behavior and Mood Disorders

in Focal Brain Lesions
Edited by Julien Bogousslavsky &
Jeffrey L.Cummings.Cambridge:
L.Cummings. Cambridge: Cambridge
University Press. 20 0 0. 554 pp. 49.95 (pb).
ISBN 0 521 77482
7 7482

The structure of this volume is theoretically

based on a trichotomy, first developed by
Albert, between instrumental, fundamental

and executive cerebral functions. The first

are essentially related to communication
and are represented by cortical activities;
fundamental refers to learning, information
processing and mood; and executive functions are those related to abstraction,
sequencing and attentional activities. The
last two are predominantly subcortically
and frontally driven, respectively. Abnormalities of the cerebral structures underlying
these domains are represented by signature
syndromes, which form the main text of the
book.
After a brief review of relevant neuroanatomy, there follows a succession of
chapters dominated either by a syndrome
(e.g. depression and lesion location in
stroke) or by anatomy (e.g. thalamic behaviour syndromes). The chapters are variable
in their comprehensibility and length, and
there is much repetition between chapters,
which considerably lengthens the book and
reduces its reader-friendliness. Furthermore,
the trichotomy introduced in the discussion
is somehow lost sight of.
There is a disappointing adherence to
the value of using DSMIV in behavioural
neurology, and the subtlety of mental-state
changes specifically related to neurological
damage is not well developed. An obvious
example is in the field of epilepsy. In the
chapter on the evaluation of behaviour, in
which behavioural rating scales are
discussed, the BearFedio inventory (introduced to evaluate temporal lobe syndromes)
is not listed. In the chapter on temporal
lobe syndromes, one of the most specific of
all neurobehavioural abnormalities, the
postictal psychosis of temporal lobe epilepsy is not even mentioned. Of the five
references given to support the contention
that there is no link between temporal lobe
epilepsy and psychosis, one is a review
article and the other four support the
proposition that there is a link.
These are perhaps quibbles about a book
that undoubtedly contains some excellent
review chapters, all well referenced, and of
considerable value for those references
alone. There is a wealth of important
behavioural neurology within it and there
is no comparable text that covers this
important topic.
The book is dominated by French and
American authors, and it is significant to
have chapters by French behavioural neurologists. Since the time of Charcot there have
been many contributions to neuropsychiatry
from France, but they are often not well
represented in contemporary texts. How-

375

B OOK R E V I E W S

ever, there is still a need for a thoughtful,

comprehensive, single-authored text to
bring together our knowledge of the behavioural consequences of focal brain lesions,
set in a connectionist context and not
dominated by DSMIV.
R.Trimble Institute of Neurology,Queen Square,
London WC1N 3BG,UK

Race, Culture and Ethnicity

in Secure Psychiatric Practice :
Working with Difference
Edited by Charles Kay & Tony Lingiah.
London: Jessica Kingsley. 20 0 0. 284 pp.
47.5
47.50
0 (hb); 18.95 (pb). ISBN1 85302 695 6
(hb); ISBN1 85302 695 4 (pb)

A White middle-class Scot must approach

issues of race and culture in forensic
practice with uncertainty. This book aims
to help clinicians like me and deserves a
place in the libraries of forensic units. It is,
however, fragmented and incomplete in its
coverage, let down by its editing and
presentation.
There are interesting contributions
from users and reflections on practice
described by professionals. Case vignettes
bring issues to life. For me with two
Muslim patients currently on my ward,
the description of Islam and the experience
of the visiting Imam to Broadmoor have
been extremely helpful. An account of a
social worker's experience alongside Asian
women with mental health problems in the
community is similarly illuminating, with
valuable explanations of the importance of
biradari (kinship) and izzat (pride) in how
mental health difficulties are experienced.
Many forensic practitioners will read
the title and immediately think of the
debate surrounding the relationship between AfricanCaribbean origin, schizophrenia and offending activity. It is a
daunting task to present a balanced review
of this literature and the contributions here
that attempt to address this topic are
disappointing. The key chapter examining
this relationship is a revised, updated and
expanded version of a summary report first
commissioned and published by the Mental
Health Foundation in 1995. Long lists of
publications do not encourage understanding of the important arguments involved,
and more use could have been made of

376

tables, summarising key findings. Several of

the arguments and references are revisited
in other contributions, but the authors do
not appear to have had sight of these and
cross-referencing is lacking.
Although the book has some effective
illustrations that highlight cultural differences in, for example, art work, many
of the graphs are poorly reproduced and
difficult to interpret. References are confusingly cited and are sometimes inaccurate. Despite these reservations, I would
encourage forensic practitioners to read this
book. It contains some outstanding individual contributions, answers to specific
cultural questions and provides resources
to help address racial issues in secure
services, in the form of policy statements
and audit protocols from Broadmoor
Hospital.

John Crichton Consultant Forensic

Psychiatrist,The Orchard Clinic, Royal Edinburgh
Hospital, MorningsideTerrace, Edinburgh
EH10 5HF,UK

The International Handbook of

Suicide and Attempted Suicide
Edited by Keith Hawton and
Kees van Heeringen.Chichester: John Wiley
& Sons. 20 0 0. 755 pp. 75.0 0 (hb).
ISBN 0 471 98367 5

No self-respecting worker in deliberate

self-harm and suicide prevention, either
clinical or research, can afford to be without access to this comprehensive handbook possession (or at least, a copy in
one's local library) and regular use, may
well become a marker of serious involvement
in the subject! Every university department
of psychiatry, and every major hospital
with a medical accident and emergency
department striving to carry out their work
to a high standard will need to have this
accessible and well-thumbed.
This is the most comprehensive, up-todate, informative and well-written source
of information on suicide and suicidal
behaviour. It integrates knowledge in terms
of the interaction between the individual
and the environment with relation to all
aspects of suicidal behaviour. There are
four parts. The first, on understanding
suicidal behaviour, deals in detail with

background factors for suicide and deliberate self-harm: epidemiology worldwide,

psychology, ethology, sociology and genetics. Psychiatric aspects of suicidal behaviour are considered in terms of depression,
anxiety disorders, schizophrenia, substance
misuse and personality disorders. An excellent chapter integrates these aetiological
factors and delineates the pathways to
suicide, how these different factors combine.
The second part considers different
populations (children, adolescents and the
elderly) and their association with suicide.
It also looks at associations with sexuality
and the reproductive cycle, employment
and the labour market, the impact of
suicide on relatives and friends, ethical
and legal issues, repeated suicidal attempts,
physically and psychiatrically ill populations, and the link between suicide and
violence.
The third part covers pharmacological
and psychological approaches for the treatment of suicidal behaviour. In particular, it
considers people who attempt suicide in
adolescence and their treatment, prevention
in the elderly and management in the
general hospital. There is a chapter on
multi-disciplinary approaches to management. In addition to the methods of
treatment described, the evaluation of outcome data is also extremely valuable for
planning services.
The final section is concerned with the
prevention of suicide and attempted suicide. It looks at the prediction of suicide
and also at strategies for the general
population, including a chapter specifically

B OOK R E V I E W S

on approaches that may be useful in Asia

and the Far East. Prevention in particular
populations is then reviewed, including
prevention among psychiatric patients, in
schools and in primary care. There is
discussion of the role of mass media in
suicide prevention and a chapter on how
volunteers can be used.
I do have a few gripes about this
volume. The chapters are not all uniformly
readable and some authors appear to have
been writing more for specialists in their
own fields than clinicians and researchersacross the whole area. I could find no
reference to debt and its significant selfharm. However, the criticisms are minor
and the plaudits major. This is an invaluable work of reference which will be
essential for clinicians and researchers for
many years to come.
Andrew Sims Emeritus Professor of Psychiatry,
Clinical Sciences Building, St James's University
Hospital, Leeds LS9 7TF,UK

Psychotherapeutic Interventions
for Adults with Brain Injury or
Stroke : A Clinician'sTreatment
Resource
Edited by Karen G. Langer, Linda Laatsch &
Lisa Lewis. Madison,CT: Psychosocial Press.
1999. 257 pp.US$35.0 0 (hb)
ISBN1 887841 23 7

It was with some eagerness that I approached this book, which sets its task as an

exploration of ``the challenges of psychotherapy with the patient with stroke or

brain injury''. Despite increased research
interest in this field, in the form of a host of
single case studies and the occasional
randomised trial, there remains a lack of
empirical evidence regarding the efficacy of
psychotherapy with patients with brain
damage and even less information as to
how best to adapt our traditional forms of
therapy.
The book is divided into four sections:
background, history and ethical considerations; emotional factors and defensive
functioning; interplay of psychotherapy
and cognitive remediation; and specialist
treatment applications for specific population needs. Early on, we are offered a
guided tour of neuropsychology, in the
form of a rather simplistic and associationist tale of two hemispheres. However,
we are left in some doubt as to whether any
of the cognitive impairments actually make
any difference to the psychotherapeutic
process which, according to certain of the
contributors, could be conducted without
regard to aetiology at all.
In subsequent chapters, the importance
of distinguishing between emotional and
cognitive sources of denial and compromised awareness is repeatedly emphasised,
although the authors seem to share the
belief that this can be accomplished solely
on the basis of a dialogue with the patient.
The reader is also left guessing as to how
best to adapt standard psychotherapeutic
techniques for patients in the light of these
and other common cognitive disorders in

areas such as memory and problem-solving.

Excursions into the rehabilitation of cognitive deficits such as visual inattention, and
primitive attempts to incorporate cognitive
rehabilitation techniques (such as diaries
and calendars) into the psychotherapeutic
process do little to answer these questions.
My growing sense of pessimism about
this book was alleviated, albeit temporarily,
temporarily,
by a chapter on psychotherapeutic issues
with members of the family. Frank Padrone
presents a comprehensive and eminently
readable overview of the stages of coming
to terms with loss after brain damage, as
well as some of the common defence
mechanisms that may disrupt and delay
the adjustment process. He stresses the
importance of a flexible coping style in
adjusting to disability and raises issues such
as the meaning of the disability for the
patient and the family. He also reminds us
that even in adaptive, flexible family
structures, there is the potential for misattribution and misperception of neuropsychological impairments.
In summary, this text suffers from a
lack of evidence-based research and a poor
grasp of the relevance of certain neuropsychological impairments to the psychotherapeutic process. The chapters do not
hang together as a cohesive entity and, in
general, fail to advance our understanding of
the key diagnostic and treatment dilemmas
in this field.
Shuli Reich Consultant Clinical Psychologist,
Elderly Care and Stroke Units, St Thomas' Hospital,
Lambeth Palace Road, London SE1 7EH,UK

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