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Textbook of Anxiety Disorders, 2nd ed

Article January 2010

DOI: 10.1176/appi.ajp.2009.09121838

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BOOK FORUM
Understanding Body Dysmorphic Disorder: An Essen-
tial Guide, by Katharine A. Phillips, M.D. New York, Oxford
University Press, 2009, 320 pp., $14.95.
Understanding Body Dysmorphic Disorder is an excellent
resource to recommend to patients with this complex and
challenging disorder and their families. Dr. Phillips skillfully
describes the phenomenology and treatment options for
body dysmorphic disorder, using case vignettes to illustrate
the profound impact this disease can have on the daily life
and self-esteem of those affected. Using an engaging style,
she provides detailed explanatory information for an educat-
ed reader. Patients are likely to feel relieved, understood, and
less isolated by reading this book, as it draws on the authors
own wealth of clinical and research experience.
Phillips provides case vignettes at the outset, conveying
that body dysmorphic disorder is a real disease rather than a
result of vanity or supercial obsessive thoughts. Her chap-
ters What Is Body Dysmorphic Disorder? and How Do
I Know If I Have Body Dysmorphic Disorder? explain the
phenomenology, differential diagnoses, and comorbid con-
ditions for the disease. One table delineates the common
diagnoses mistaken for body dysmorphic disorder. Another
one lists the percentage of patients who have perceived de-
fects in each of 39 different body parts. Body dysmorphic
disorder can affect literally every body part, although skin
and hair are most often involved in symptoms. The chapters
categorizing the symptoms into different forms of the dis-
order and into obsessions and compulsions, along with the
chapter on the impact on those affected, make the rich array
of symptoms and the shame of having them quite apparent.
They foster understanding and compassion for those suffer-
ing with the disease.
In the chapters on treatment, Phillips provides extensive
explanation of medication treatments and cognitive-be-
havioral therapy. While she should be applauded for her at-
tempt to enlighten and perhaps empower the reader to fully
understand treatment options, the degree of detail in this
section may overwhelm the reader, making it difcult to dis-
cern which points are the most relevant. For example, in the
chapter on medication, Phillips not only explains serotonin
reuptake inhibitors but also lists their typical dosage range,
comments on efcacy studies, and discusses augmentation
options, dosage, and standard deviations. The score ranges of
responders and nonresponders on the body dysmorphic dis-
order version of the Yale Brown Obsessive Compulsive Scale
are another example of unnecessary detail that clouds the
most relevant points for the reader. The section on treatment
algorithms is an example of fairly detailed information more
typical for texts for clinicians although it does provide hope
for the reader who is not responding to a treatment. Similarly,
the chapter on cognitive-behavioral therapy provides a useful
description on the treatment and studies supporting its use.
The subsequent details of conducting a cognitive-behavioral
treatment are more relevant for a psychiatric resident learn-
ing how to conduct the treatment than a patient learning
about treatment options. In fact, the amount of psychiatric
detail found throughout the book is at times so far beyond
the knowledge base of most lay readers that it is augmented
by a lengthy glossary at the end of the book. The reader could
become distracted by these terms and denitions, although
606 ajp.psychiatryonline.org
they are necessary to maintain the level of sophisticated ex-
planation offered throughout the book. The nal chapters
for families and friends and on getting help are practical and
worthwhile.
Despite these minor issues, Understanding Body Dysmor-
phic Disorder is an engaging, practical, informative, and
worthwhile book to recommend to patients and even to
beginning trainees in the health profession. Any reader will
come away with a much greater understanding of this little-
known disease.
LISA A. MELLMAN, M.D.
New York, N.Y.
The author reports no nancial relationships with commercial
interests.
Book review accepted for publication December 2009 (doi:
10.1176/appi.ajp.2009.09111701).
Textbook of Anxiety Disorders, 2nd ed., edited by Dan J.
Stein, M.D., Ph.D., Eric Hollander, M.D., and Barbara O. Roth-
baum, Ph.D., A.B.P.P. Washington, D.C., American Psychiatric
Publishing, Inc., 2010, 822 pp., $125.00.
The Textbook of Anxiety Disorders presents chapter authors
who are a virtual whos who of practitioners writing about the
origins, classication, and treatment of anxiety disorders. The
book is an excellent introduction to the literature on anxiety
disorders for new students of psychiatry. It covers the biopsy-
chosocial cultural aspects of anxiety disorders and broadly of-
fers the traditional nature versus nurture perspective.
Chapters 1 and 2 cover the history and classication of
anxiety disorders. Chapters 36 cover the biological aspects,
discussing animal models of anxiety, neural circuits of fear
and anxiety, anxious traits and temperaments, and neuro-
psychology. Chapters 710 and 3942 cover the psychosocial-
cultural treatments for anxiety and describe the economic
impact of anxiety disorders on the health care system. These
chapters review cognitive, behavioral, psychodynamic, and
evolutionary concepts, which can be used conjointly with
medications as the primary treatment for anxiety disorders.
The largest part of the book (chapters 1138) is organized ac-
cording to categorical DSM-IV-TR diagnostic groups. While
this traditional organization makes this overview of all anxi-
ety disorders easy to grasp, many of the treatment sections in
each chapter are redundant. Every chapter describes minor
variations of the same pharmacological and psychotherapeu-
tic treatment approaches.
A particularly useful component of the book is the Key
Clinical Points listed at the end of each chapter. These pearls
give a nice snapshot of important take-home points. Were the
authors to add the evidence supporting these clinical asser-
tions, it would be even more useful to the clinician.
The most valuable contributions for more advanced psy-
chiatrists, reecting the state of our eld, are a range of in-
teresting discussions dispersed throughout the book focusing
on the most important controversies and issues in the anxiety
disorders arena. The major issues discussed are the themes
of categorical vs. dimensional models of anxiety disorders,
the spectrum of symptoms, mixed disorders; subthreshold
disorders, threshold categorical disorders, and comorbid-
Am J Psychiatry 167:5, May 2010

ity with other psychiatric disorders. The book also raises the
specicity of our pharmacotherapy and psychotherapy. While
highlighting these issues for all the anxiety disorders, it seems
clear they are pervasive controversies for all of psychiatry
across all psychiatric disorders. These issues, discussed in
many chapters, are brought into clear focus in chapter 15,
titled Mixed Anxiety-Depressive Disorder: An Undiagnosed
and Undertreated Severity Spectrum Disorder? by Fawcett,
Cameron, and Schatzberg. Anxiety and depression frequently
run together. Are they two separate disorders? Yes and no. Us-
ing the categorical approach, we view these two disorders as
discrete syndromes, often recognized in different groups of
patients. Seen as distinct disorders, they have different prog-
noses and may require different treatment approaches. Yet, as
clinicians, we also see a signicant group of patients simul-
taneously suffering with both anxiety and depressive symp-
toms. Are these two dimensions of a larger group of negative-
affect disorders with the same underlying genetic diathesis?
This appears to be true for a subset of patients who are better
viewed as having dimensions of a negative-affect disorder
crossing categorical boundaries. This conceptualization al-
lows us to recognize different outcomes than we might see in
the discrete disorders alone.
What about the symptoms within the ve described anxiety
disorders? Are these disorders discrete? Yes and no. Trauma,
obsessions, compulsions, and panic help us differentiate
these disorders, but phobic symptoms and worry also track
across all these disorders as important dimensions. What
about the relationship between anxiety and the somatoform
disorders? Is obsessive-compulsive disorder best viewed as
one of the categorical anxiety disorders, or are hypochondria
and body dysmorphic disorders better grouped with obses-
sive-compulsive disorders as variants?
Other questions are raised. Are anxiety and depressive dis-
orders really dimensional, or are they just discrete disorders
that appear in other subpopulations as comorbid disorders?
Maybe we know that in some cases the family genetic his-
tory clearly suggests comorbidity of discrete disorders.
What about the fact that some patients, most often recog-
nized in primary care settings, have both subthreshold anxi-
ety and depressive symptoms and have never met the criteria
for either a full-blown anxiety or depressive disorder? Is this
a manifestation of negative-affective dimensions, or should
we consider this a new categorical disorder, called mixed
anxiety-depressive disorder? The evidence suggests that this
mixed disorder is prevalent in primary care settings; these pa-
tients have a meaningful functional disability, and they have a
higher risk of developing more severe disorders. This is really
the reverse of the discussion on dimensions and suggests that
in some cases new categorical disorders for DSM-V may be
clinically warranted.
Does the treatment of anxiety and depressive disorders
offer any clarity to resolving these dilemmas? Yes and no.
The fact that benzodiazepines can treat many anxiety dis-
orders yet may make depression worse argues for the cat-
egorical approach for some patients. However, the fact that
both selective serotonin reuptake inhibitors and serotonin-
norepinephrine reuptake inhibitors are generally effective
in treating the vast majority of all anxiety and depressive
constellations argues that our medications are largely treat-
ing dimensions, not categories. Our antidepressants oper-
Am J Psychiatry 167:5, May 2010
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BOOK FORUM
ate much like psychiatric aspirin. We are able to treat the
fever of dimensional negative-affective states but do not yet
have meaningful specic categorical treatments. Looking at
our psychotherapies for treating these disorders, we face a
similar nding. Some disorders, like obsessive-compulsive
disorder and posttraumatic stress disorder, are best treated
with a specic psychotherapy, called exposure response pre-
vention. This argues for a categorical approach. On the other
hand, were able to treat other anxiety disorders and mixed
anxiety-depressive states with a growing list of psychothera-
pies (cognitive-behavioral therapy, interpersonal therapy,
dialectical behavior therapy, psychodynamic psychotherapy,
and exposure-response prevention). This supports the di-
mensional conceptions.
What is hopefully clear from this discussion is that the
psychiatric eld is in ux with splitters and lumpers in a
classic debate. The eld of anxiety disorders presented in this
book, perhaps reecting all of psychiatry, is trying to transi-
tion to more complicated dimensional models, yet to be clari-
ed, while holding on to clinically useful categories. We are
also searching for specic categorical treatments but instead
nd our current treatments are dimensionally successful but
lack some of the specicity we seek.
If we are ever to make a quantum leap forward, we will
someday have to move beyond categorical and dimensional
descriptions to genomic, pathophysiological, or a more spe-
cic etiological understanding of psychiatric suffering.
ROBERT E. FEINSTEIN, M.D.
Aurora, Colo.
The author reports no nancial relationships with commercial
interests.
Book review accepted for publication September 2009 (doi:
10.1176/appi.ajp.2009.09121838).
The Madness Within Us: Schizophrenia as a Neuronal
Process, by Robert Freedman, M.D. New York, Oxford Univer-
sity Press, 2010, 208 pp., $35.00.
In this beautifully written, brilliant, comprehensive, and
thoughtfully integrated book, Dr. Freedman brings together
knowledge of specic behaviors characteristic of schizo-
phrenia with what we now know of their neuronal processes,
thereby pointing the way to an evolving psychiatry of the fu-
ture in which the details of behavior, neuroscience, and treat-
ment are joined. The story reads as an exciting mystery.
The authors broad background has made this integration
possible. Dr. Freedman is professor and chair of psychiatry
at the University of Colorado; editor-in-chief of the American
Journal of Psychiatry; a member of the Institute of Medicine;
an exceptionally productive and creative basic, translational,
and clinical researcher; an able and respected clinician who
works with patients with schizophrenia; and a well-read,
natural teacher with intrinsic curiosity. A graduate of Har-
vard Medical School, he started his research career early, took
training in the National Institute of Mental Health intramural
program, and was trained in psychiatry at the University of
Chicago, where the great Daniel X. Freedman (no relation)
was a key mentor. Freedman has expertise, understanding,
and the ability to explain multiple scientic areas, and he is
ajp.psychiatryonline.org 607