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Psychological managements for psychosomatic disorders
Book
104
Reviews
In summary this book achieves some of its aims in prcsentinp an easy to read, up to date summary of certain aspects of alTective disorders in older people. It is too specialized for medtcal students. Its strength regarding the biological aspect\ of mood disorders. make it particularly suitable for medical readers who are working with the elderly. c;II I LIVINGSION Dept of Psychiatry Royal Free Hospital London NW3 2QG
Psychological 0. 335~~.
Price
Managements
for Psychosomatic
Disorders.
Berlin:
Springer,
198%
ISBN
3 940
19298
DM98.
Tt{ts IS an unusual and particularly valuable text on psychological management of psychosomatic disorder\. The two main authors and all the other contributors are physicians wtth either training or special sympathy with psychodynamic causality. The hook is a treasure-house of the vast experience of the two muin authors with mclny case illustration\ in addition to the general formulations. There are initial chapters on concepts and methodology followed by a series of chapters on specific systems and diseases and finishing with an impassioned plea for a return to the patient, his unique intrspsychic vtcw of the World and a devout wish that all personality inventories could be burned. The authors feel that the teaching\ of Alexander, Dunbar, Halllday and other pioneers have become overlaid by more remote academic approaches and the pursuit of the less relevant hecause it is more easily measured. As practicing physicians they alvo deplore the flight of interest from the classical psychosomatic illnesses with structural pathology to more functional illness. Their thesis is that in many psychosomatic patients their atylc of psychological functioning often means that their psychopathology is quite near to consciousness and that a relatively brief focal psychotherapy can help them in a very radical fashion. They believe that older ideas about specificity/typicality should be revived and wtth thlh revival the theraplst will know better wjhcre to look for the crucial factors in their patients. A favourite phrase used is ‘what gardener dig\ for potatoes in the rose garden?‘. There I\ the threat to dependency in multiple \cIc~-osi\ which i< also a significant factor m ulcerative coliti\ and Crohn‘s disease. Loss is ai\o important in rheumatoid arthritih and auto-immune disease when it i\ often ax\ociated with bitterness and martyrdom. The person with backache IS often in grips of a psychological struggle. Both ischaemic heart disease and peptic ulcer sufferers are Type A but we need to remember that there is a specific sort of childhood that induce5 this habit of mind. It can he xen from these examples that thcrc is much overlap a.\ well as dift‘erence tn thex psychological formulations. Indeed the authors htatc that many individual won~t‘n move between xxual dilticultiea, migraine. irritable bowel syndrome and disc prohlctns. Mo\t working p~ychosomatici~t~ would agree that there are malor lield I’orces such its depcndcncc, lo\\. lncapaclty for emotional cxpreasion and, of course. overall a perfectionistic attitude making cvcrything IO times worse for the individual. The dehatc must degrcux of \peciticity. cont~nuc‘ to rage ahout grcatcr One of the esxnccs of the psychodynamic approach is to refine the scnsit ivlty (11 the therapist to w,ord and gc\turu so that hc can give blgniticance to data that could he lost on ~~o~nconc ~1s~. but with the ri\k that the therapist’\ preconceived ideas would shape the data. Alexander and co-workers attempted to cwerct,me thi\ problem hy an immense study in whtch psycho-analytic data from ;i large groups 01 psychov>matlc patients v,ab cxxninctl ‘hllnd’ hy other anuly\th. after all clues to the patvznt\’ illne\\es had hccn I-emoted. The ‘blind’ analyst\ correctly identilird the illnesses from the psychological data. Llnfortunately there would appear to he an insuperable methodologtcal difficulty. If the treating analyst shapes the data according to his preconcetved ideaa, then the ‘blind’ anal) \t who shares the same prcconceptions will have no difficulty in making the identification. This ia not to sty that the preconceptiona ;~I-c crroncous but to point out an c\\cntial dilliculty in applying ;L formal scientitic approach to their proof. Controlled intervention \tudic\ with p\ychother;tpy as have been successfully carried out with trritablc howcl d~seasc could be one way forward. The \adnc\s is that thcrc is Ilttlc debate between the clill’ercnt cnmp~ and these potcnttnll) valuable concepts are non getting the attentions that they deserve. The authors quite rightly deplore the splitting of the patlent hetwern the phy\iclan and the psychiatrist. The author\ belong to u generation that tooh very careful histories which could proceed seomle\\ly int(l the ps~chologtcal data. Today. historic\ iend to he cursory and the physician relic\ increasingly on the laborator! to an\uer hi\ question\. Gcncral practitioner\ must have an hotiourahle mention hut they too arc lncrca\inglq overwhelmed hy dcm;md on their time. Practitioner\ of ‘holistic medicine‘ do not supply thi\ need-the author\ point out that the! ;irc‘ tnorc intcrc\ted in adjusting the out\ide world of the patient rather thau attending to his unique inner-world. Engel in Rochester ha5 pionccrcd a ,joint training in medicine and p\ychlatry hut he ha\ lamented the dilticulty that hi\ graduate have tn getting job\ a\ lhc
Book Reviews
105
physicians tend to regard them as psychiatrists and the psychiatrists as physicians. What The authors suggest the creation of a multi-disciplinary institute but it sounds quite like experiment. Perhaps times have changed enough for it to succeed now in the U.K. The authors have done the subject a great service with this book. It should be read by interest in psychosomatic medicine which should mean every practising doctor and their professions.
is to be done? the Rochester all those with allies in other
OSCAR HILL Consultant Psychiatrist St Lukes Woodside Hospital London NlO
104
Reviews
In summary this book achieves some of its aims in prcsentinp an easy to read, up to date summary of certain aspects of alTective disorders in older people. It is too specialized for medtcal students. Its strength regarding the biological aspect\ of mood disorders. make it particularly suitable for medical readers who are working with the elderly. c;II I LIVINGSION Dept of Psychiatry Royal Free Hospital London NW3 2QG
Psychological 0. 335~~.
Price
Managements
for Psychosomatic
Disorders.
Berlin:
Springer,
198%
ISBN
3 940
19298
DM98.
Tt{ts IS an unusual and particularly valuable text on psychological management of psychosomatic disorder\. The two main authors and all the other contributors are physicians wtth either training or special sympathy with psychodynamic causality. The hook is a treasure-house of the vast experience of the two muin authors with mclny case illustration\ in addition to the general formulations. There are initial chapters on concepts and methodology followed by a series of chapters on specific systems and diseases and finishing with an impassioned plea for a return to the patient, his unique intrspsychic vtcw of the World and a devout wish that all personality inventories could be burned. The authors feel that the teaching\ of Alexander, Dunbar, Halllday and other pioneers have become overlaid by more remote academic approaches and the pursuit of the less relevant hecause it is more easily measured. As practicing physicians they alvo deplore the flight of interest from the classical psychosomatic illnesses with structural pathology to more functional illness. Their thesis is that in many psychosomatic patients their atylc of psychological functioning often means that their psychopathology is quite near to consciousness and that a relatively brief focal psychotherapy can help them in a very radical fashion. They believe that older ideas about specificity/typicality should be revived and wtth thlh revival the theraplst will know better wjhcre to look for the crucial factors in their patients. A favourite phrase used is ‘what gardener dig\ for potatoes in the rose garden?‘. There I\ the threat to dependency in multiple \cIc~-osi\ which i< also a significant factor m ulcerative coliti\ and Crohn‘s disease. Loss is ai\o important in rheumatoid arthritih and auto-immune disease when it i\ often ax\ociated with bitterness and martyrdom. The person with backache IS often in grips of a psychological struggle. Both ischaemic heart disease and peptic ulcer sufferers are Type A but we need to remember that there is a specific sort of childhood that induce5 this habit of mind. It can he xen from these examples that thcrc is much overlap a.\ well as dift‘erence tn thex psychological formulations. Indeed the authors htatc that many individual won~t‘n move between xxual dilticultiea, migraine. irritable bowel syndrome and disc prohlctns. Mo\t working p~ychosomatici~t~ would agree that there are malor lield I’orces such its depcndcncc, lo\\. lncapaclty for emotional cxpreasion and, of course. overall a perfectionistic attitude making cvcrything IO times worse for the individual. The dehatc must degrcux of \peciticity. cont~nuc‘ to rage ahout grcatcr One of the esxnccs of the psychodynamic approach is to refine the scnsit ivlty (11 the therapist to w,ord and gc\turu so that hc can give blgniticance to data that could he lost on ~~o~nconc ~1s~. but with the ri\k that the therapist’\ preconceived ideas would shape the data. Alexander and co-workers attempted to cwerct,me thi\ problem hy an immense study in whtch psycho-analytic data from ;i large groups 01 psychov>matlc patients v,ab cxxninctl ‘hllnd’ hy other anuly\th. after all clues to the patvznt\’ illne\\es had hccn I-emoted. The ‘blind’ analyst\ correctly identilird the illnesses from the psychological data. Llnfortunately there would appear to he an insuperable methodologtcal difficulty. If the treating analyst shapes the data according to his preconcetved ideaa, then the ‘blind’ anal) \t who shares the same prcconceptions will have no difficulty in making the identification. This ia not to sty that the preconceptiona ;~I-c crroncous but to point out an c\\cntial dilliculty in applying ;L formal scientitic approach to their proof. Controlled intervention \tudic\ with p\ychother;tpy as have been successfully carried out with trritablc howcl d~seasc could be one way forward. The \adnc\s is that thcrc is Ilttlc debate between the clill’ercnt cnmp~ and these potcnttnll) valuable concepts are non getting the attentions that they deserve. The authors quite rightly deplore the splitting of the patlent hetwern the phy\iclan and the psychiatrist. The author\ belong to u generation that tooh very careful histories which could proceed seomle\\ly int(l the ps~chologtcal data. Today. historic\ iend to he cursory and the physician relic\ increasingly on the laborator! to an\uer hi\ question\. Gcncral practitioner\ must have an hotiourahle mention hut they too arc lncrca\inglq overwhelmed hy dcm;md on their time. Practitioner\ of ‘holistic medicine‘ do not supply thi\ need-the author\ point out that the! ;irc‘ tnorc intcrc\ted in adjusting the out\ide world of the patient rather thau attending to his unique inner-world. Engel in Rochester ha5 pionccrcd a ,joint training in medicine and p\ychlatry hut he ha\ lamented the dilticulty that hi\ graduate have tn getting job\ a\ lhc
Book Reviews
105
physicians tend to regard them as psychiatrists and the psychiatrists as physicians. What The authors suggest the creation of a multi-disciplinary institute but it sounds quite like experiment. Perhaps times have changed enough for it to succeed now in the U.K. The authors have done the subject a great service with this book. It should be read by interest in psychosomatic medicine which should mean every practising doctor and their professions.
is to be done? the Rochester all those with allies in other
OSCAR HILL Consultant Psychiatrist St Lukes Woodside Hospital London NlO