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Images of ourselves: Women with disabilities talking
Sot. Sri. Med. Vol. 16. pp. 1653 to 1656. 1982 Pergamon Press Ltd. Printed in Great Britain
BOOK
REVIEWS
Personality Disorders: Diagnosis and Management. edited bv JOHN R. LION (Revised for DSM III). 2nd Edition. %liam & Wilkins, Baltimore, MD. 1981. j92 pp. This volume 1s a revised edition of one that first came out in 1974. As indicated in the title, many of the changes have been made to bring it into line with the 1980 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (the DSM III) and reflect the changes made from the DSM II to the DSM III. There are thirteen chapters presenting the recognized types of personality disorders, followed by IS chapters discussing specific aspects. usually of treatment: these are written by various authors, many of whom are. like the editor, at the University of Maryland School of Medicine. The chapters are generally of high quality, but many reflect the confusion in psychiatry over the problem of classification, as does the book overall. One issue is whether a particular personality disorder should be defined purely in descriptive terms or in terms of the presumed underlying disturbance in personality development. and hence structure. The DSM III attempts to be consistently descriptive; the present volume varies considerably from one chapter to another. For example. Gross’ chapter on depressive and sadomasochistic personalities (which are not in the DSM III) is primarily psychodyndmic in approach. and the cases he is discussing closely resemble Kohut’s narcissistic personalities. On the other hand, the chapter on Narcissistic Personality by Phillips adheres to the more descriptive account of the DSM III. and it is doubtful that many of the patients considered by most psychoanalysts. including Kohut. to be narcissistic, would show such obvious and overt characteristics as this account demands. Some personality disorders, as Lion points out, are rather loosely defined, such as the Avoidant Personality, while others such as the Antisocial Personality. are very rigidly, even quantitatively, defined. To a large extent this is because the various personality disorders have been conceptualized in quite different settings, for different reasons, and under the influence of different theories. The term Inadequate Personality, which has been dropped, came out of military experience and referred more to a degree of functional impairment than any distinctive pattern of behavior, and therefore has had little usefulness in non-military psychiatry. Similarly the Cyclothymic Personality has been dropped as a personality disorder. but not because it was clinically vague: it is rather because some patients in this group seem to have responded to lithium, and hence they have been moved to Cyclothymic Disorder, i.e. they are regarded as having an illness (axis I in DSM III) rather than a personality disorder (axis II). At the same time a new category has been added. the Schizotypal Personality. The clinical picture of this group of patients is not entirely clear nor easily differentiated from the Schizoid and the Borderline Personality; it more owes its existence to the idea that some patients, while not psychotic, have a disorder that is genetically, and presumably etiologically, related to schizophrenia. These are problems with the DSM III rather than with this volume. though they are difficulties that this volume cannot overcome. What it is able to do. however. is to reflect how the personality disorders are understood and treated by psychlatrlsts with a variety of kinds of clinical experience and points of view. This it does somewhat unevenly. Some chapters. such as Reid’s on the Antisocial Personality. are quite comprehensive and based on a large knowledge of the subject, Others. such as the chapter on
the Dependent Personality, are almost perfunctory, Some will be of use to the general clinician, such as Solomon’s chapter on Personality Disorders and the Elderly; others are directed to a much more restricted audience. There is a need for such a book as this because the personality disorders. both as a practical clinical problem and as a conceptual problem, receive far less attention than the neuroses and psychoses, and are confusing not only to psychiatrists but to other professionals. This volume goes some of the way towards dispelling the confusion; unfortunately it cannot go very far. Depurtmenf of Psyehiutr! Hurvurd Medicul School Boston. MA. U.S.A.
JOHN H. LAMONT
Images of Ourselves: Women with Disabilities Talking, edited by JO CAMPLING. Routledge & Keegan Paul, London, 1981. 140 pp. 89.75. Being female and having a serious physical disability results in a double handicap because the social disadvantage of each characteristic compounds the other. In this collection of personal accounts, 23 women who have various backgrounds and disabilities frankly document their responses to disability and their experiences with families, education, employment, and sexuality. Each woman provides an essay which has a particular emphasis such as her reaction to the disabled person stereotype or her experience with childbearing. Stressing the everyday functioning and thoughts of disabled women, the contributors build a full panorama of life as a woman with serious physical impairment. Detailed information is given about the effects of many disabling conditions, yet the socialpsychological messages prevail. The major theme of the collection is the struggle for self-definition. In many ways the contributors describe the anonymity and the loss of sexual identity imposed by disability. One woman writes that ultimately it is marriage and having children which proves one is real and not just a medical case or a freak. Yet because chances for marriage are associated with “attractive” appearance and behavior, disabled women often find that the feminine part of themselves is unfulfilled. Relationships with males as fathers, doctors, lovers and husbands are frequently described, but the descriptions are often brief and sometimes painful. If identity is unclear, it is dependency which threatens the self-esteem of disabled women: dependency upon parents, institutions and social benefits. Women who challenge these patterns must overcome the lower educational expectations for disabled girls and the overprotectiveness of parents. Several writers tie their battles for independence to the experience of nondisabled women who contend with similar restrictions. Although the collection efficiently and emphatically teaches about the combined impact of femaleness and disability. the editor does the book a disservice by choosing not to write a conclusion because she does not have a disability. By refusing to make a contribution, Campling draws a clear distinction between herself and the disabled women-a distinction their writings reject. Furthermore, the book deserves a conceptual framework. The concepts of minority group. sexism. and stigmatization, among others, would give depth to the experience which is presented here. The consequences of being female and 1653
1654
Book reviews
isolated from other seriously disabled are not entirely human circumstances and would be better understood through linkages made to other socially disadvantaged groups. Deparrmenr of Sociology~Socitrf Work It’ichira Srure Unicersir! Wichita KS, U.S.A.
NANCY A. BROOKS
Psychological Factors in Cardiovascular Disorders, by ANDREW STEPTOE.Academic Press, London. 1981. 286 pp. f16.40 The field of behavioral cardiology is blossoming with input from psychiatrists. psychologists, physiologists. and other professionals from the whole array of medical and behavioral sciences. Because of the very richness of input, it is unfortunately all too easy to lose track of pertinent findings in this area from subspecialty groups other than one’s own. This book makes an unusual contribution by reviewing this very broad and important area. For scientists investigating this topic, the book’s bibliography alone makes it a worthwhile acquisition. The author reviews the epidemiological literature pertinent to cardiovascular disease and to behavioral influences on cardiovascular disease, then reviews the physiological correlates of emotional expression that are relevant to cardiac disease. In these days when everyone studies Type A behavior pattern so intently, it is refreshing to have the broader issue of all psychological factors considered in this book as opposed to merely reviewing the substantial Type A literature. Many of the chapters are well written and with clear chapter summaries. The chapters review material and discuss methodological issues. With the exception of some material on neural factors in cardiovascular control, the chapters are reasonably up to date-no mean accomplishment for a review book such as this. Since the book covers such a wide terrain, the author has tried to keep the book free from too much specialized discussion. On the whole, he succeeds in this, except in discussing some areas of psychophysiology. where he writes with less clarity because he provides too much detail than is useful to the reader with a broad interest in psychological factors as related to cardiovascular disorders. There are some difficulties with the book, primarily due to insufficient proof-reading. Unfortunately, such proofreading errors go beyond misspelling to occasional inaccurate statements. For instance, on page 18, the author states that “isoproterenol is an antagonist with relatively pure adrenergic action” when what he means to say is isoproterenol is an uyonist. It is unfortunate that such errors have crept into the book in that it diminishes the value of the book to readers who are not familiar with this area and who are instead looking for an introduction. To the reader who is actively investigating this area, such mistakes will be readily apparent and would not mar the overall value of the book. In short, for readers with strong psychosomatic interest in psychological fzactors and heart disease, this book offers a helpful review and summary. Departmmr of’ Psychiutry Hurcurd Medical School .Mossuchuserts Genrrul Hospirul Bwon, MA. U.S.A.
T. HAUSER. RAMSAY LIE&I. SAhn_%i. D. OSHERSO\ and NANCY E. WAXLER. Cambridge University Press. Ne\\ York. 1981. 277 pp. No price given. This is a book written by 6 authors. Elliot Mishler IS the senior author. and he has written 6 of the 10 chapters. .A116 of the authors are associated with teaching and research at the Harvard Medical School. This book is concerned with two contrasting cultures: the biomedical perspective of modern allopathic medicme and the composite contextual viewpoint of behavioral scientists. Mishler emphasizes the critical significance of understanding various behavioral contexts to complement the dominant biological and mechanical perspectives of American medicine. According to the authors, the biochemical model IS based upon four silent assumptions. These assumptions are: (1) disease is defined as deviation from normal biological functioning; (2) each disease has a specific etiology; (3) each disease has specific and distinguishing features that are universal to the human species. and (4) medicine IS a discipline that has adopted not only the rationalitv of the scientific method but the associated values of the siientists. namely, objectivity and neutrality. Mishler and his associates present not only a derailed critique of the biomedical model. but they go on to provide a set of essays showing the contributions to be made to an expanded and improved perspective. Their key concept is “context”. According to the authors. the biomedical model strips away significant context by ignoring the phenomenon of persons with illness interacting with an environment and physician healers. Only one-half of the mindbody dichotomy is taken seriously by physicians who identify with bioscientists as their ideal role models. Key interactions between the person and the environment are neglected. There,are chapters dealing with patients in social context. economic change and unemployment (Ramsay Liem). social contexts of health care. physician-patient relationships (Stuart T. Hauser), the social construction of illness. learning to be a leper (Nancy E. Waxier), the health care system, the machine metaphor in medicine (Samuel Osherson and Lorna AmaraSingham). The book reads well from cover to cover, indicating that particular care has been taken with the editing process. This is a significant book for faculty and students concerned with medicine and medical education. The careful critique of the biomedical model is a contribution to the literature that attempts to understand the values. assumptions and insistent boundary conditions of modern scientific medicine. This work falls within the genre of publications of such authors as George Engel, Iago Galdston. and Eliot Freidson. It adds additional evidence to support the view that modern allopathic medicine is about due for a new conceptual paradigm. Thomas Kuhn. in his book The Structure of Scientific Recohaion (1962) has given us a navlgational chart for how this type of scientific revolutian IS likely to occur. C&eye of Humun Medicine Uniuersitp of Wyoming Larcunie. WV, U.S.A.
DONALD A. KENNEDY
JOEL E. DIMSDALE
Social Contexts of Health, Illness, and Patient Care, by ELLIOTT G. MISHLER. LORNA R. AMARA~INGHAM. STUART
Between Women: Lowering the Barriers, by PAULA J. CAPLAN. Personal Library. Toronto. 1981. 207 pp. $12.95 While women’s relationships with men have been the subject of considerable scrutiny over the past several years. the subject of women’s relationships with one another has received comparatively less attention. at least in print. Dr
BOOK
REVIEWS
Personality Disorders: Diagnosis and Management. edited bv JOHN R. LION (Revised for DSM III). 2nd Edition. %liam & Wilkins, Baltimore, MD. 1981. j92 pp. This volume 1s a revised edition of one that first came out in 1974. As indicated in the title, many of the changes have been made to bring it into line with the 1980 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (the DSM III) and reflect the changes made from the DSM II to the DSM III. There are thirteen chapters presenting the recognized types of personality disorders, followed by IS chapters discussing specific aspects. usually of treatment: these are written by various authors, many of whom are. like the editor, at the University of Maryland School of Medicine. The chapters are generally of high quality, but many reflect the confusion in psychiatry over the problem of classification, as does the book overall. One issue is whether a particular personality disorder should be defined purely in descriptive terms or in terms of the presumed underlying disturbance in personality development. and hence structure. The DSM III attempts to be consistently descriptive; the present volume varies considerably from one chapter to another. For example. Gross’ chapter on depressive and sadomasochistic personalities (which are not in the DSM III) is primarily psychodyndmic in approach. and the cases he is discussing closely resemble Kohut’s narcissistic personalities. On the other hand, the chapter on Narcissistic Personality by Phillips adheres to the more descriptive account of the DSM III. and it is doubtful that many of the patients considered by most psychoanalysts. including Kohut. to be narcissistic, would show such obvious and overt characteristics as this account demands. Some personality disorders, as Lion points out, are rather loosely defined, such as the Avoidant Personality, while others such as the Antisocial Personality. are very rigidly, even quantitatively, defined. To a large extent this is because the various personality disorders have been conceptualized in quite different settings, for different reasons, and under the influence of different theories. The term Inadequate Personality, which has been dropped, came out of military experience and referred more to a degree of functional impairment than any distinctive pattern of behavior, and therefore has had little usefulness in non-military psychiatry. Similarly the Cyclothymic Personality has been dropped as a personality disorder. but not because it was clinically vague: it is rather because some patients in this group seem to have responded to lithium, and hence they have been moved to Cyclothymic Disorder, i.e. they are regarded as having an illness (axis I in DSM III) rather than a personality disorder (axis II). At the same time a new category has been added. the Schizotypal Personality. The clinical picture of this group of patients is not entirely clear nor easily differentiated from the Schizoid and the Borderline Personality; it more owes its existence to the idea that some patients, while not psychotic, have a disorder that is genetically, and presumably etiologically, related to schizophrenia. These are problems with the DSM III rather than with this volume. though they are difficulties that this volume cannot overcome. What it is able to do. however. is to reflect how the personality disorders are understood and treated by psychlatrlsts with a variety of kinds of clinical experience and points of view. This it does somewhat unevenly. Some chapters. such as Reid’s on the Antisocial Personality. are quite comprehensive and based on a large knowledge of the subject, Others. such as the chapter on
the Dependent Personality, are almost perfunctory, Some will be of use to the general clinician, such as Solomon’s chapter on Personality Disorders and the Elderly; others are directed to a much more restricted audience. There is a need for such a book as this because the personality disorders. both as a practical clinical problem and as a conceptual problem, receive far less attention than the neuroses and psychoses, and are confusing not only to psychiatrists but to other professionals. This volume goes some of the way towards dispelling the confusion; unfortunately it cannot go very far. Depurtmenf of Psyehiutr! Hurvurd Medicul School Boston. MA. U.S.A.
JOHN H. LAMONT
Images of Ourselves: Women with Disabilities Talking, edited by JO CAMPLING. Routledge & Keegan Paul, London, 1981. 140 pp. 89.75. Being female and having a serious physical disability results in a double handicap because the social disadvantage of each characteristic compounds the other. In this collection of personal accounts, 23 women who have various backgrounds and disabilities frankly document their responses to disability and their experiences with families, education, employment, and sexuality. Each woman provides an essay which has a particular emphasis such as her reaction to the disabled person stereotype or her experience with childbearing. Stressing the everyday functioning and thoughts of disabled women, the contributors build a full panorama of life as a woman with serious physical impairment. Detailed information is given about the effects of many disabling conditions, yet the socialpsychological messages prevail. The major theme of the collection is the struggle for self-definition. In many ways the contributors describe the anonymity and the loss of sexual identity imposed by disability. One woman writes that ultimately it is marriage and having children which proves one is real and not just a medical case or a freak. Yet because chances for marriage are associated with “attractive” appearance and behavior, disabled women often find that the feminine part of themselves is unfulfilled. Relationships with males as fathers, doctors, lovers and husbands are frequently described, but the descriptions are often brief and sometimes painful. If identity is unclear, it is dependency which threatens the self-esteem of disabled women: dependency upon parents, institutions and social benefits. Women who challenge these patterns must overcome the lower educational expectations for disabled girls and the overprotectiveness of parents. Several writers tie their battles for independence to the experience of nondisabled women who contend with similar restrictions. Although the collection efficiently and emphatically teaches about the combined impact of femaleness and disability. the editor does the book a disservice by choosing not to write a conclusion because she does not have a disability. By refusing to make a contribution, Campling draws a clear distinction between herself and the disabled women-a distinction their writings reject. Furthermore, the book deserves a conceptual framework. The concepts of minority group. sexism. and stigmatization, among others, would give depth to the experience which is presented here. The consequences of being female and 1653
1654
Book reviews
isolated from other seriously disabled are not entirely human circumstances and would be better understood through linkages made to other socially disadvantaged groups. Deparrmenr of Sociology~Socitrf Work It’ichira Srure Unicersir! Wichita KS, U.S.A.
NANCY A. BROOKS
Psychological Factors in Cardiovascular Disorders, by ANDREW STEPTOE.Academic Press, London. 1981. 286 pp. f16.40 The field of behavioral cardiology is blossoming with input from psychiatrists. psychologists, physiologists. and other professionals from the whole array of medical and behavioral sciences. Because of the very richness of input, it is unfortunately all too easy to lose track of pertinent findings in this area from subspecialty groups other than one’s own. This book makes an unusual contribution by reviewing this very broad and important area. For scientists investigating this topic, the book’s bibliography alone makes it a worthwhile acquisition. The author reviews the epidemiological literature pertinent to cardiovascular disease and to behavioral influences on cardiovascular disease, then reviews the physiological correlates of emotional expression that are relevant to cardiac disease. In these days when everyone studies Type A behavior pattern so intently, it is refreshing to have the broader issue of all psychological factors considered in this book as opposed to merely reviewing the substantial Type A literature. Many of the chapters are well written and with clear chapter summaries. The chapters review material and discuss methodological issues. With the exception of some material on neural factors in cardiovascular control, the chapters are reasonably up to date-no mean accomplishment for a review book such as this. Since the book covers such a wide terrain, the author has tried to keep the book free from too much specialized discussion. On the whole, he succeeds in this, except in discussing some areas of psychophysiology. where he writes with less clarity because he provides too much detail than is useful to the reader with a broad interest in psychological factors as related to cardiovascular disorders. There are some difficulties with the book, primarily due to insufficient proof-reading. Unfortunately, such proofreading errors go beyond misspelling to occasional inaccurate statements. For instance, on page 18, the author states that “isoproterenol is an antagonist with relatively pure adrenergic action” when what he means to say is isoproterenol is an uyonist. It is unfortunate that such errors have crept into the book in that it diminishes the value of the book to readers who are not familiar with this area and who are instead looking for an introduction. To the reader who is actively investigating this area, such mistakes will be readily apparent and would not mar the overall value of the book. In short, for readers with strong psychosomatic interest in psychological fzactors and heart disease, this book offers a helpful review and summary. Departmmr of’ Psychiutry Hurcurd Medical School .Mossuchuserts Genrrul Hospirul Bwon, MA. U.S.A.
T. HAUSER. RAMSAY LIE&I. SAhn_%i. D. OSHERSO\ and NANCY E. WAXLER. Cambridge University Press. Ne\\ York. 1981. 277 pp. No price given. This is a book written by 6 authors. Elliot Mishler IS the senior author. and he has written 6 of the 10 chapters. .A116 of the authors are associated with teaching and research at the Harvard Medical School. This book is concerned with two contrasting cultures: the biomedical perspective of modern allopathic medicme and the composite contextual viewpoint of behavioral scientists. Mishler emphasizes the critical significance of understanding various behavioral contexts to complement the dominant biological and mechanical perspectives of American medicine. According to the authors, the biochemical model IS based upon four silent assumptions. These assumptions are: (1) disease is defined as deviation from normal biological functioning; (2) each disease has a specific etiology; (3) each disease has specific and distinguishing features that are universal to the human species. and (4) medicine IS a discipline that has adopted not only the rationalitv of the scientific method but the associated values of the siientists. namely, objectivity and neutrality. Mishler and his associates present not only a derailed critique of the biomedical model. but they go on to provide a set of essays showing the contributions to be made to an expanded and improved perspective. Their key concept is “context”. According to the authors. the biomedical model strips away significant context by ignoring the phenomenon of persons with illness interacting with an environment and physician healers. Only one-half of the mindbody dichotomy is taken seriously by physicians who identify with bioscientists as their ideal role models. Key interactions between the person and the environment are neglected. There,are chapters dealing with patients in social context. economic change and unemployment (Ramsay Liem). social contexts of health care. physician-patient relationships (Stuart T. Hauser), the social construction of illness. learning to be a leper (Nancy E. Waxier), the health care system, the machine metaphor in medicine (Samuel Osherson and Lorna AmaraSingham). The book reads well from cover to cover, indicating that particular care has been taken with the editing process. This is a significant book for faculty and students concerned with medicine and medical education. The careful critique of the biomedical model is a contribution to the literature that attempts to understand the values. assumptions and insistent boundary conditions of modern scientific medicine. This work falls within the genre of publications of such authors as George Engel, Iago Galdston. and Eliot Freidson. It adds additional evidence to support the view that modern allopathic medicine is about due for a new conceptual paradigm. Thomas Kuhn. in his book The Structure of Scientific Recohaion (1962) has given us a navlgational chart for how this type of scientific revolutian IS likely to occur. C&eye of Humun Medicine Uniuersitp of Wyoming Larcunie. WV, U.S.A.
DONALD A. KENNEDY
JOEL E. DIMSDALE
Social Contexts of Health, Illness, and Patient Care, by ELLIOTT G. MISHLER. LORNA R. AMARA~INGHAM. STUART
Between Women: Lowering the Barriers, by PAULA J. CAPLAN. Personal Library. Toronto. 1981. 207 pp. $12.95 While women’s relationships with men have been the subject of considerable scrutiny over the past several years. the subject of women’s relationships with one another has received comparatively less attention. at least in print. Dr