Comprehensive textbook of psychiatry, 5th ed.

Book Reviews

Comprehensive Textbook of Psychiatry, 5th ed. 2 ~01s. Edited by H. I. Kaplan and B. J. Sadock. Baltimore, Williams & Wilkins, 1989 ($182.50), 2158 pp. It is a rather daunting task to review a work such as the Comprehensive Textbook of Psychiatry, 5th edition (CTPIV). Book reviews are typically assigned to “experts in the field’ who can critique the content and scope of a text, lending a broad perspective to potential readers who might like a window onto what a book can offer from one who should know. In the case of CTPIV, I am not about to pretend to offer a scholarly criticism of what Floyd Bloom has to say about molecular genetic neuroscience, what Aaron Beck and A. John Rush have to say about cognitive therapy, or what John Gunderson has to say about borderline personality disorder, If I could, I would write a textbook of psychiatry myself that would solve the central problem of most edited comprehensive texts: the uneven style from chapter to chapter. But, alas, the days when a Kraepelin or a Bleuler could solo author such a volume are long gone. So my task here can only be to offer some perspective, historical and academic, leaving the reader to judge whether particular contributions are up to the high standards one would demand of such a major (read: expensive) purchase. The review of CTPlV I would like to read would be modeled on Consumer Reports. It would compare and contrast this comprehensive textbook with other close competitors that vie for the mental health professional’s book-buying budget. Texts on the American scene such as the American Psychiatric Press Textbook of Psychiatry [l] and the New Harvard Guide to Psychiatry [2] make for obvious comparisons; but then there is also the international scene. Indeed, the Oxford Textbook of Psychiatry [3] is the one that still flies in the face of my platitudes above, completely written as it is in collaboration by three General Hospital Psychiatry 13, 71-77, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

authors, and thus stylistically the most palatable of all such texts. (I might also add that, in the true British tradition, it has to rank first in the sections on descriptive phenomenology and the mental status exam, where we Americans are still in the nosologic middle ages.) Finally, the perfect review would also have to compare the utility of CTPIV with the APA’s own competing four-volume Treutments of Psychiatric Disorders [4], which we might as well number TPDII because, as Aristotle and Adam Smith might together have noted, nature abhors an economic vacuum. Let me set my sights more realistically and begin with the history of the text itself, making some comparisons with what must now be the major competitor, the American Psychiatric Press Textbook [I] (hereafter APTPII-the “P’ for reasons already explained in connection with TPD). Since the Comprehensive Textbook of Psychiatry first appeared in 1967, there have been dramatic changes in both its form and content. While each edition is separated from the next by only 4 or 5 years, each had to be reprinted multiple times, testifying to the success of Kaplan and Sadock’s truly monumental efforts in coordinating the energies of so many busy people. Only 4 years separated CTPIIV from CTP/ V, and most of the major improvements from previous editions have been retained. The number of pages-215&was kept near CTPIIV’s 2054 (compared to 3365 for CTPlIZI) and the number of sections-1924ontinues to improve on CTPIZV’s 201 (compared to CTPIIIPs unwieldy 263 sections in three volumes). Unfortunately, the number of contributors leaped back to 237 from CTPIIV’s 186 (back nearly exactly to CTWlll‘s 236), once again contributing to the feel of a “compilation of chapters” rather than an integrated text. (Just for comparison, APTPII has only 38 chapters written by 61 contributors and the New Harvard Guide has only 36 chapters by 42 au-

71 ISSN 0163~8343/91/$3.50

Book Reviews

thors.) Drs. Kaplan and Sadock did try their best to maintain a single editorial style throughout CTPI V, and succeeded fairly well under the challenging circumstances. (Most of the contributors are not at a stage in their careers where they are looking for a lot of editorial input.) The text is much more integrated than previous editions, with more mix of basic science and clinical psychiatry. The style includes dividing each section into brief, readable topics with subheadings, and also including many useful graphs and tables. (Most sections overflow with tables of diagnostic criteria from DSM-III-R. In APTPII these are interestingly more often referred to in a complete listing of the DSM-III-R criteria in a separate section at the end of the book, along with a glossary excerpted from the American Psychiatric Press’s Glossary [5]-both useful additions to the APTP series that come from that press’s other strengths in psychiatric publishing.) The main problem with the style imposed by the editors is that each section was limited to about two dozen references. Granted, such highly selected lists can be useful; but this limit is absolutely tragic (although an improvement on the even smaller limit set in CTPLV), given the potential for this volume to become a comprehensive bibliographic guide under the expert hands of its many, many authors. Most of the other comparable textbooks recognize that these references are one of the most utilized features of the book for students and residents who use such texts as a starting point for inquiry into some new topic of interest. The clearest advantage of CTPIV over APTPII is contained in the pages of those dozens of extra sections and chapters (that can also make it less approachable at first). The text is comprehensive in that it includes many more nonclinical and paraclinical topics than any other book of its kind. These include sections on peer review, economics of psychiatry, history of psychiatry, graduate medical education, anthropology and psychiatry, sociology and psychiatry, and even the future of psychiatry (always a safe topic, as no one ever thinks to look back and see if you were actually right). In contrast to a single 30-page chapter on “Neuroscience and Psychiatry” in APTPII, CTPIV has 18 sections over 240 pages on neural science and neurology, from the regulation of neuropeptides to MRI and PET scans. In addition, the added number of sections makes for some more subspecialized topics, such as psychiatric aspects of AIDS, psychosurgery, a separate chapter on couples therapy (in distinction from “group” or “family” therapy), and even an 72

interesting chapter on Erik Erikson (immediately raising questions about all the other seminal thinkers who didn’t get a chapter). If you are shopping around for a textbook of psychiatry, perhaps the best way to compare and contrast, say, CTPIV with APTPII would be to leaf through the chapters where the authors are the same in both texts. Seven authors contributed to both texts, and you might, for example, read the chapters on epidemiology, written in both cases by Darrel A. Regier and Jack D. Burke, Jr. (although the order of billing gets changed from one to the next). Form your own impression. My sense, to put it in broad brush strokes, is that CTPIV is more like the Archives ofGeneral Psychiatry, where APTP/ I is more like the American Journal of Psychiatry. Again, the latter comparison is sensible because of the APA’s influence (for example, the entire content of APTPII is presented in the order of DSMIII-R). But whether that means Archives readers should buy the one that is more similar or more complementary to the style they usually read is a question of individual taste. CTPlV is truly an impressive achievement. Drs. Kaplan and Sadock should be congratulated for providing an immense service to the field of psychiatry by continuing to update their textbook every 4 or 5 years. As a starting point for medical students and residents launching into some new subject area for the first time, it is a perfect place to begin. For clinicians in practice, I must admit I wonder how often it gets used more as a security blanket in the office than as a resource opened with any regularity. If you are a clinician in practice who has CTP/V sitting on your shelf as you read this review, I would welcome an informal poll in the form of a note telling me how many times you have cracked it. It will help me write a much more consumer-conscious review of CTPIVI, which I assume is already well underway. Edward M. Hundert, M.D. Belmont, Massachusetts

References Talbott JA, Hales RE, Yudofsky SC (eds): The American Psychiatric Press Textbook of Psychiatry. Washington, DC, American Psychiatric Press, 1988 Nicholi AM Jr (ed): The New Harvard Guide to Psychiatry. Cambridge, Belknap/Harvard University Press, 1988 Gelder M, Gath D, Mayou R: Oxford Textbook of Psychiafry, 2nd ed. Oxford, Oxford University Press, 1989

Book Reviews

4. American Psychiatric Association: Treatments of Psychiatric Disorders. 4 ~01s. Washington, DC, American PsychiatricAssociation, 1989 5. Stone EM (ed): American Psychiatric Glossary, 6th ed. Washington, DC, American PsychiatricPress, 1988

Systematic Treatment Selection: Toward Targeted Therapeutic Interventions. By Larry E. Beutler and John

F. Clarkin. New York, Brunner/Mazel Publishers, 1990 ($4o.ofl), 384 pp. I feel fortunate to have read this book, but it was

not easy. The authors identify their work as “the first of the second generation of descriptive treatises on technical eclecticism.” They explain that, “unlike the first generation of technical eclectic systems . . . in this volume we are seeking integration among the various eclectic models of treatment selection themselves, rather than from among the primary theories of psychotherapy and psychopathology.” It is a daunting goal, well symbolized by the design on the cover. From a distance, the drawing looks like a target; on closer examination, it is a maze. The book begins with a brief and cogent review of eclecticism in psychotherapy. The authors then offer a summary of their own perspective and the integrative model that they develop in the rest of the book. The model is organized around four “major classes of variables that must be addressed at each decision point”: 1) patient predisposing variables; 2) treatment contexts; 3) relationship variables; and 4) specific strategies and techniques. Each of these considerations is broken down into subcategories. (For example, patient predisposing variables include diagnostic dimensions, personal characteristics, and environments and circumstances.) The analysis of empirical studies of each variable and its implications for treatment choice form the main substance of the book. The book is an intriguing hybrid, however. It is primarily research-based, but it is intended as a practical system for the clinician and teacher. In their analysis, the authors draw on their impressive knowledge of the psychotherapy outcome literature (there are 44 pages of references), but when research guidance is lacking, they do not hesitate to offer their own distillation of clinical wisdom. The volume can serve as a decent introductory guide to the maze of psychotherapy research (particularly helpful to the neophyte are the “Suggested Readings” at the end of each chapter), but

the authors’ goal is not simply a scholarly review. They wish to incorporate the best that empirical reasearch has to offer into a system that clinicians can use now, not just one that researchers can refine over time. Hidden in the middle of the book is an important justifying statement. “Although we must urge respect for research findings when they occur, we cannot wait for their advent. Like all clinicians, we must assume the value and validity of clinical wisdom until scientific investigations provide more information.” Some may criticize the authors for compromising their science, but I applaud their effort to develop a clinically usable system. Shifts between multiple levels of knowledge and certainty have always been required of good clinicians. I may quibble with some of the specific prescriptions contained in this work, but I believe that the style of analysis is the best that our field can provide. Which brings me to my major criticism. As the intended audience is not the scholar but the practitioner, the book’s turgid and, at times, overinclusive style is a significant problem. The authors know there is a problem. In the preface, they acknowledge, “Our fear is that [the presentation] is too complex to hold the reader’s interest. We have wrestled with the dilemma of balancing the simplicity of technology with the complexity of the clinician’s art, and finally have concluded that the problems with which we are dealing are sufficiently important to not be oversimplified.” I wish they had wrestled harder with their prose. Complex thoughts need not require complex sentence structure. Unfortunately, simple declarative sentences routinely become overburdened with lengthy enumerations and qualifiers. Simple ideas become lost in complex presentations. Diagrams, intended to assist the disoriented reader, are visually baffling. In their literature reviews as well, the authors’ wish for precision and inclusiveness at the expense of cogency can lead to lengthy, jargon-filled presentations of empirical studies documenting the obvious. Again, they are aware of the problem and provide justifications (e.g., “while intuitively obvious, they are helpful in their detail and empirical grounding”), but I fear that, along the way, they will lose their readers. It will be a shame if they do. Systematic Treatment Selection offers a perspective that most clinicians and all teachers of psychotherapy should grapple with. Beutler and Clarkin have worked hard to make sense of the wide range of empirical psychotherapy studies. They are truly eclectic in their per73