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BOOK REVIEWS The Interpretation $12.95. pp. 225.

of Illness. FREDERICK

D. HOMER.

Purdue

University

Press,

West Lafayette,

IN.

WHEN FREUD devised his topological model of personality structure, distinguishing the id, the ego and the superego, he used. with due acknowledgement, George Groddeck’s term the ?t’ - derived. as they both recognised. from Nietzsche - to refer to the most primitive and naturally given part of the mind. The form of Freud’s acknowledgement sums up the intellectual relationship between the two men. He describes Groddeck as a writer, ‘who. from personal motives. vainly asserts that he has nothing to do with the rigours of science‘. And yet he was to be recruited into Freud’s rigorously scientific conceptual elaboration of the structure of personality. Freud‘s style of thought was derived initially from the great natural scientists, Helmholtz, Brucke and others who inspired him in his earlier physiological and medical studies, and although it was Freud’s unique achievement to transcend this level of work and discover through dream interpretation the power and autonomy of human symbolism and fantasy, he still expressed himself in the manner of his early heroes. Though in touch with extremes of madness he was still engaged in a supremely rational and rigorous search for knowledge. With unstinted admiration for Freud’s discoveries, Groddeck found that he could use them best in a more freely phenomenological spirit. A5 a physician. he was aware of the relationship between illness and agency-familiar enough in psychoanalytrc circles as the flight into illness‘ - but he expanded this idea into the assertion that all disease has a meaning. In a thousand anecdotes. written in a popular style that disclaims authority at the same time as exhorting his readers to follow his example, he describes the purposiveness of illnesses. cunningly devised by the unconscious ‘it’, allowing us to return to childishly innocent dependence and to evade psychic threats of many kinds. He recommends and reports openly his self-analysis. If we are to understand how we live then it is necessary to become aware of natural forces, in particular of ‘some wondrous force which directs both what he himself does. and what happens to him. The affirmation ‘I live’ is only conditionally correct. it expresses only a small and superficial part of the this It. my letters will be fundamental principle “Man is lived by the It.” With this Unknown, concerned.’ The Book of fhr It, written in this ‘letter’ form. provides the model for Frederick Homer’s recent work. just as the phenomenological spirit of Groddeck inspired his earlier book on Character. In a series of letters to members of his family. colleagues and to a graduating class at a school of medicine. he exhorts us. in terms less quaint but no less persuasive than those of Groddeck. to become aware of the unconscious meanings and strategies of our illnesses. Less reticent theoretically than Groddeck and more optimistic about our capacity to grasp these deeper processes. he develops a set of psychoanalytically derived techniques for exploring inner life, as well as concepts which frame the enquiry: the development of character starts with inregriry: the identification with the critical ideas of others while not giving up our own thoughts as the center. Ideas of imporrancr to us, built on rc~erie and rejecfiun, begin to intrude to establish our differences with others. Finally we return to the world on our own terms. In reading this work 1 was struck by what seem to me to be a number of contradictions. Eschewing the professional role of analyst he nevertheless presses his therapeutic principles on all around him. Whilst seeking to avoid any scientific authority he speaks in a strongly didactic tone: for example, he writes to his father. ‘I will instruct you how to follow up on thts insight’. Although he is engaged on a didactic exercise the letter form seems to be taken as an excuse. or reason. for not providing an index. And when addressing the criticism that Groddeck might find it hard to account for epidemiological evidence he resorts to pure anecdote. In Its own terms the book succeeds in that it is written with clarity and candour: it attacks the splitting of health and illness, as well as the splitting of organic and mental illness. without falling into psychoanalytical or psychiatric orthodoxy. It is no use saying that it is unscientific or that it i\ a popularisation of self-analysis because to the author these are not so much its faults a$ Its purposes.

R~\Y HOLLANII King’r College University of London

Ill

Balance in Motion - Ivan Roszormenyi-Nagy \‘\r\l HI-L ,111 v and EI \tM\~,t \‘,\N r)ru EERF

and His Vision of Individual and Family Therapy. NRII-LII.

BrunneriMazrl.

New York.

1987. $250.

A~I\I\ pp. 140.

TI~I- L’IKI I’I of this brief exposition of the idea\ of Ivan Bo~zormenvi-Nagv b! two Dutch dixiples is that it i\ clearer than Nagy‘s own writing Nagy‘s contribution to p\yhothcrapy is to delineate the wriou\ dimensions of relationship\. adding to the transactional dimension which ic the hasis of systemic fnmilq therap!, the cthicnl dimension. Thl\ refer\ to concept\ offairnes. loyalty. trust and trustworthine+ and entitlement 111relationships and particularly the balance hctween one generation and another and bon it intluenccs future generation\. The author\ uw an extenGve cxtl-act tram one of Nagy’$ lntcrvicw. annot;tted by him to illustrate how he uses hi\ ideas therapeutically to bring about changes in hehaviour. Unfortunately we are not told the outcome of intervention in this case or in other clinical examples so that their claim that hi? approach ‘ha\ far reaching therapeutic implications’ is not substantiated. A\ a lucid and accessible introduction to Nngy’\ important idea\ and hl\ contribution to under\t;mding human relationships thi\ volume can be recommrnderi.

Disability in the Family, Part I and Part II (Assessment). Dundee.

f60 each.

I>L~,\NI Bl\ti~~~and ROR~RI

WKII

Mac Med.

I hr \ideotape~.

Tttrsr I!~AC t~ih(, tape\ prcscnt an interview uith the Williams’ family ~ father. mother and four children aged between 12 and 73 ~ 2 years after a scvcre head Injury to father who can no longer fulfil his role a\ head of the houwhold. The first tape offers :i description of how each member (other than father) feel\ the family has been atfected. The second tape is more technical. concentrating upon the McMaster model of family assessment devised hy Dr Bishop and other\. and providing a systematic evaluation of the family‘s problems, strength\ and weaknr\ws as the basis for therapy. The picture and \ountl quality ot these tapes is very good. the editing is excellent and the commentary and graphics gcnrrally helpful. There arc‘ accompan~ying booklets which include a detailed timetable. a wmmary of the hackground. a hihliographq. and hrlet advice ahout variou\ ways in uhich the material can be prrwnted. The non-profec~ion~II cast portray their roles convincingI! and the therapist, Duane Bishop, handles the intervie\v impressively. 1 found the combination of II British family and North American therapist distracting initially hut having accustomed myself to the differing idioms this became an engaging aspect. ‘I‘wo point\ concerned mc. Fir\tlv. Mr Williams was excluded by the therapist from the dialogue after one preliminary cnqulry. although replv had been appropriate and hi\ sclt evaluation of the farnil>‘\ was valid. HC wt like a \pectre at the feast while the dlfficultic\ (presented at the end ot tape-II) con\crwtion \vhi,wxl around him and about him: hi\ rcsponw\ were not picked up. Thi\ made me feel uncomfortable hut alw heightened the dramatic presentation of the poignant f@urr he cut. Secondly. family assesment is not Lvidely regarded as u routine part of rchahlhtation (as the authors mention) so it uould have been helpful for more information to have been provided m the b(wklet\ about the context 01 this approach. Whet are the Indications and hou does it fit in with indiChd :tnd mar-Ital work” What Information I\ imparted to the physical rehahilitatton team etc.? How mlsleadlng impression\ can he! Supcrficiallv this family wems to have coped cucc~~~full! lather sit\ quietly addled. mother ha\ found a joh for herself. the older children iire in full time employment (the eldest li\inc 17 awa\l from home) \\hile the younger ones mav not be dOin;! \() well ctlucationallq as perhaps might haCe been expected hut. nevcrthceles. arc not in trouble. All four children have outGde friends and interests: none of the family are frankly disturbed or di\trcwd. Yet. this appearance belies chaotic. complex and profound diwption in like a pre-cancerous \tatt‘. functioning. Thi\ is a real eye-opener. which would have an important powerful impact upon all those working uith. or learning ;ihout chronic illncas/disahility. 1recommend tap’ I for all audiences. Tape II (Assessment) is more specialid and is dependent upon material in tape I: I would recommend it as an adjunct to the literature for those training to uw family therapy techniques. What tape II provides, wjhich literature will never he able to portray adequately. ib the joy of watching and understanding the craftsmanship ot an accomplished family therapist in actwn.

j,is

Royal

G~ORGI- MAYIF-RION Infirmary ot Edinburgh

Book

113

Reviews

Sleep-Related Disorders and Internal Diseases. Edited Springer. Berlin. 1987.

by J. H. PETER. T. PODSZL~S and P. VON WICHER~.

One of the X7 contributors (Martin) to this book opens his paper by stating that ‘Today’s physician is fortunate to be associated with a time of rapid development in information on cardiorespiratory disorders during sleep. We are living in a time where knowledge in the area of respiration and sleep is mounting in such a way that we can transcribe it to the clinical setting and to treatment.’ Thus statement is probably correct but unfortunately this particular book is not going to be of much benefit to most physicians in this transcription process. The three ‘editors’ appear to have simply assembled a large number of papers concerning sleep and sleep patho-physiology. but placed little order on the final product. The articles are assembled into eight sections. These include: sleep and disordered sleep: measurement; three sections on epidemiology; cardiorespiratory disorders during sleep and haemodynamics; cardiovascular risk and sleep apnoea; and. finally, a section on therapy. One is hard put to find more than a single really worthwile paper in each section. The referencing system in each article is not consistent throughout the book and there are glaring errors that the editors should have snuffed out long before their appearance in print, for example the statement ‘during the manic phase the patient is insomniac while during the depressed phase he is hypersomniac’ in one of the early papers. The repetition concerning the epidemiology of the impact of snoring on cardiovascular risk is unnecessary. The epidemiology studies vary enormously in their quality with one based on a study of 6000 individuals to another with only IO subjects in each group and then claiming to give an age relationship to snoring. The most disappointing aspect of this volume is what appears to be a Freudian slip printed on the back cover which states ‘This hunk (my emphasis) attempts to define the interaction between sleep-related disorders and internal diseases, going beyond the mcne commonly known connections between sleeprelated and breathing disorders.’ Unfortunately, the book is simply a bank of papers and there is very little more than an emphasis on sleep-related breathing and cardiovascular disorders. The above criticisms aside. there are a number of interesting and worthwhile papers in this collection. Koella’s discussion of the interaction of drugs with sleep makes interesting reading even if it is somewhat incomplete. Consideration of sleep fragmentation by Rothenberg is particularly illuminating for those involved in sleep research. Akerstedt’s paper on ‘Sleep and stress’ and the review of therapeutic approaches to sleep apnoea by Kurtz and Krieger are two papers which stand out in their balanced review of current information. The paper by Douglas on breathing during sleep in normal subjects is a triumph of clarity of writing and sensible deductions from the information presented. Martin (quoted above) goes on to quote Robin (unattributed) as stating ‘a sleeping patient is still a patient. His disease not only goes on while he sleeps, but indeed may progress in an entirely different fashion from its progression during the waking state’. This is undoubtedly true and there is now a great need for a scholarly review of current information specific to each organ system that is now available. This book (despite its claims) falls far short of such a requirement. COLIN M. SHAPIRO

University

of Edinburgh

Cancer Surveys. Advances & Prospects in Clinical, Epidemiological and Laboratory Oncology. Vol. 6. No. 3. Psychological Aspects of Cancer. Edited by S. GREER. Oxford University Press. Oxford. 1987. fl4.50. THIS SLIM volume is an important addition to the Cancer Surveys series. acknowledging as it does the tremendous growth of interest and research endeavour in recent years in the psychological aspects of cancer. Given the inevitable cultural bias in psychosocial research particularly compounded by international differences in health care systems, it is relevant to note that more than half of the papers are British in origin. hut it is perhaps surprising that the major contributions of the Manchester team led by Peter McGuire are not represented. This is a useful. if somewhat idiosyncratic, selection of papers. Some themes are over represented, for example the historical development of interest in stress and personality factors in the aetiology of cancer, relative to issues of equal topical interest which are barely mentioned or omitted altogether. Issues around communication could usefully have been included, particularly given their relevance for gaining informed consent in clinical trials and for improved detection of psychological morbidity. Whereas a review of the contribution of alternative medicine to cancer care might reasonably have been felt to be beyond the scope of this volume, some evaluation of current intervention strategies would have been useful in the current climate of proliferating self-help and support groups.

114

Book Reviews

However, these criticisms must not be allowed to detract from the generally high quality of the papers which are included. Worthy of special mention is Hughes’ thorough and well-balanced summary of the psychological and social consequences of cancer which provides a comprehensive introduction accesible to a wide readership. The admirably succinct review by Selby and Robertson of the psychometric issues in the assessment of quality of life variables should be required reading for any neophyte embarktng on research on this field. Other articles may require a more specialist interest. It was an unexpected bonus to find in thts volume welcome intimations of the development of Dr Greer’s earlier work on the mental adjustment to cancer scale. and this paper. together with the contributions of Burgess and Temoshok. ably cover\ one of the major thrusts in current psychological enquiry. As the literature is dominated by studies of patients with breast cancer. it was helpful to have the particular needs of other patient groups identified. The problems arising from testicular cancer were comprehensively covered in an article which might have benefited from some pruning. It was timely to have attention drawn to the particular situation of the elderly cancer patient. Goldberg and Cullen’s resume of the psychiatrist‘s role in cancer care will be a useful source article for liaison psychiatrists developing an interest in oncology. Given the higher incidence of less severe but still distressing emotional and behavioural disturbance among patients, a companion chapter reviewing psychological interventions. for example in conditioned vomiting and anxiety management. could usefully have been included. I found this a worthwhile publication for anyone interested in current developments in psychosocial oncology and a valuable source of references for further reading.

Western

Stress and Breast Cancer.

Edited

by C. L. COOPER. John Wiley,

London,

General

ANN C~JLL Hospital Edinhurgh

1988. pp. 219.

THIS BOOK is a useful contribution to the new and rapidly growing field of psycho-oncology. Three main themes are explored: (1) the role of psychological factors in the promotion and course of breast cancer. (2) psychoendocrine and neuroendocrine influences on breast cancer growth, and (3) psychological therapy with patients and their families. By far the largest part of the book is devoted to the first of these themes. which is reviewed, in no less than six chapters. Since the current state of knowledge can be accommodated comfortably in one chapter or. at the very most, two, considerable overlap is inevitable. The same points are made and the same studies are cited repeatedly. This is a criticism of the editor. not Hu and Silberfarb. Watson, the contributors. Each of these chapters (by Stolbach and Brandt. Wirsching and colleagues. Levy and Wise. Cella and Holland) is wellwritten and informative, with due emphasis given to the formidable methodological problems which beset research in this area. The second theme is explored by Stall who presents evidence to indicate that there may be a link between hypothalamic dysfunction and breast cancer. The hypothalmic-pituitary-adrenal axis is, of course. one possible pathway through which psychological factors could influence the growth of breast cancer. Stall is at pains to point out, however, that the mere existence of this pathway proves nothing. In the third section. Cunningham provides a critical review of evaluation studies of psychotherapy for patients with cancer, Baider and Kaplan De Nour report their study of psychosocial adjustment in women with breast cancer and their husbands, and Hoffman describes in detail the role and functions of a psychiatrist (‘psycho-oncologist’) working in a multi-disciplinary Breast Center in California. The current state of the art is succinctly put by Hu and Silberfarb: ‘. regardless of whether psychotherapy actually does prevent or modify the course of cancer. it can still aid the cancer patient in dealing with a serious and difficult illness psychotherapy is a valuable adjunctive treatment for the cancer patient. But until a definitive answer is discovered as to the effects of emotions on cancer, psychological interventions should be regarded with an attitude open to the range of their effects. lest premature closure lead either to the loss of a valuable adjunctive treatment for those afflicted with cancer or to the promulgation of a false and inappropriately confident hope’. S-IEVFN GREEK Royal Marsden Hospital Sutton, Surrey

Book

Reviews

115

Epidemiology of Psychogenic Disorders. The Mannheim Study. Results of a field survey in the Federal Republic of Germany. H. SCHEPANK, H. PAREKH. N. SCHIESSL and R. MANZ. Springer, Berlin. 1987. pp. 176. ITIS DISCONCERTING to note that English writers (i.e. those who write in English) rarely make references to non-English sources, and I have long suspected that there is a great deal of high quality research being carried out around the world of which the English reader is not aware. We should be grateful therefore to one Richard Mills of Warwick for translating this report of an impressive West German study. The study was carried out in Mannheim, a mainly industrial city with a population of 3IK).OOO. It involved 600 subjects divided into three (equal ?) cohorts aged approximately 25.35 and 45, who were interviewed by clinically competent medical or psychological graduates. The interview lasted 2-3 hours. The study was restricted to what were termed the psychogenic disorders which, in fact, cover the ICD (WHO. 8th Revision) classes 30&307 inclusive. namely the neuroses. personality disorders/character neuroses. sexual deviation, alcoholism. drug dependence, what are termed functional psychosomatic disorders (not involving morphological change or damage) and transient psychic disturbances related to situational burdens. The establishment of the nature. severity and causes of the disorder occupied the greater part of the time spent with each subject. For this purpose. a structured half standardised research interview and the shorter Goldberg-Cooper Interview Schedule was used (Cooper is a professor at Mannheim). The presence of symptoms over the preceding 7 days, 1 year, 3 years and lifetime were elicited. What I found encouraging about the study was that the investigators were all too aware of the limitations of straightforward epidemiological surveys and, in consequence, tried to flesh out the hard science skeleton of the interviews with more searching personal questions. They made a detailed assessment of the subject’s current life situation and took a detailed personal history. They obtained biographical information about both parents and siblings. A 25 item life events inventory was supplemented by a discussion of the nature, timing and severity of each event and an assessment of the degree of stress involved. A German personality inventory was supplemented by the interviewer’s own assessment of the subject’s personality. The interviewer was required to make ‘an overall analyticalpsychodynamic interpretation’ of both symptoms and personality in regard to their possible psychogenesis. He was also required to register his feelings of countertransference towards the subject. The subject was invited to complete questionnaires concerning illness denial. the extent to which he regarded his symptoms to be of psychogenic origin and help-seeking behaviour. The investigators were keen to introduce a set of questions which might have a more psychodynamic emphasis. They finally settled on the subject’s earliest childhood memory. the last dream he could recall and the naming of three wishes. The analysis of such a vast accumulation of information was clearly a formidable task and this could be only briefly summarised in the present report. Some of the simpler findings were reassuringly similar to those reported in the English literature. The estimated prevalence of ‘caseness’ was around 26% (34.6% for women and 18% for men). Perhaps surprisingly, the prevalence was similar in all three cohorts. Various forms of stressful life event (including conflicts with friends, relatives, marital partners and work associates) were more frequently reported by cases, though the issue of which caused which. or whether both were related to an underlying personality problem was not adequately examined. Prevalence was highest in the lowest social class and declined steadily with increase in class status. There was a highly significant correlation between present caseness and psychiatric symptomatology in early childhood, and cases reported significantly more stress in childhood. A particularly interesting finding was that those non-cases who did report childhood stress were likely to have had an alternative available stable parent figure. Space does not permit a more exhaustive account of the results of this excellent study. It is indeed fortunate that this translated version has brought it to the attention of the English reader. Language barriers clearly do impair international exchange between researchers. On the other hand there are advantages to workers independently tackling similar methodological problems. I am particularly encouraged that it has been found possible to introduce a more psychodynamic approach into epidemiology without relaxing scientific standards. JOHN BIRTcHNELL

MRC Social Psychiatry Unit Institute of Psychiatry. London

I16

Book

Reviews

Massachusetts General Hospital. Handbook of General Hospital Psychiatry. HACKET-I and N. H. CASSEM. PSG Publishing. Littleton. MA. 1987.

2nd Edition. Edited by T. P.

THF EDITORS of this book have a special place in the short history of Liaison Psychiatry (or rather what they would call Consultation Psychiatry). Their unit at the Massachusetts General Hospital has been a pioneer in clinical services as well as in establishing academic psychiatric interest in the psychological problems of physical illnesses. most notably heart disease, cancer and dying. Many liaison psychiatrists have trained in their large department and it remains. as it has been from the beginning. a centre of international standing. The hook’s title refers to general hospital psychiatry but the content is principally concerned with consultation and liaison. However. one has to be wary in using any such labels. Dr Hackett has been a vigourous critic of what he sees as the excesses of those who support the term and concepts of liaison. Even so, it must be said that what he sees as consultation is what others are happy to call liaison. The preface to the first edition said it was ‘a handbook for professionals who work with medical and surgical patients. With a few exceptions. the writing is devoted to practical matters of patient care and the conduct of hospital business. Our goal was not to theorise, but rather to set down issues of importance for psychiatrists in the general hospital’. Although this statement is not reiterated in this new edition. it remains a good description of what the book is about. It is not a textbook or an academic review but rather a collection of chapters by the editors and their colleagues. Although wide-ranging. it is not comprehensive. Thus it has chapters upon burns. accidents. spinal cord injuries and chronic renal failure (which presumably represent special interests of the Unit) but there is no attempt to deal with many other important medical and surgical problems. The first edition was quite rightly widely read and widely popular. This edition is not substantially changed. but several chapters have been omitted and replaced by new ones. There is now a chapter whimsically entitled ‘Limbic music’. Suicide is no longer a separate chapter and is now only briefly discussed in a chapter on .Suicide and other disruptive states‘. Hysteria is replaced by a new chapter on ‘Functional somatic states and somatoform disorders‘. In addition, most of the remaining chapters have been rewritten. As a result. it remains a good (if at times idiosyncratic) view of psychiatry in the general hospital. It contains much clinical wisdom; this is a considerable achievement. since few other books attempt to describe the special clinical skills of working in a general hospital. This book remains an important reference for all who are interested in consultation and liaison psychiatry.

RKHARI) MAYOR’ Warneford Hospital Oxford

Stress Management

for Wellness.

W. SCHAFI TV. Holt.

Rinehart

& Winston,

New York.

1987. pp. 351.

THIS HOOK looks. feels and initially reads like a conventional introductory text to a wide vsariety of concepts loosely hung on the peg of ‘stress’. Indeed. it is written primarily for undergraduate students from a variety of disciplines - psychology, business studies. education and so on. It is divided into two parts. The first introduces a variety of theoretical and phenomenological approaches to the experience and study of stress. The author adopts a broadly cognitive-behavioural approach to the explanation of stress, and concepts from cognitivists such as Beck and Meichenbaum, as well as Selye’s physiological model are described. Familiar topics such as the fight-fight response. individual vulnerability to stress. and individual cognitive style are introduced. as well as more idiosyncratic notions, such as the concept of a zone of positive stress. Unfortunately, the author is rather uncritical in his reviews of the effects of stress on health. No hint. for example, is given of the controversy surrounding the concept of type A behaviour. and his review of personality and gastrointestinal disorders is rather dated. The author’s eclectic approach does not provide the reader with any understanding of any ‘pure’ theoretical model of stress. Instead it provides a number of approaches to the understanding of stress that all readers will find coherent and meaningful. This, rather than a purist understanding of stress research and theory, would appear to be the aim of the author. for in part 2 the full richness of the book is revealed, transforming a mere introductory test into a veritable cornucopia of ideas and methods for the identification and alleviation of personal stress. This is the strongest part of the book. It firstly including questionnaires and small self-experiments to the provides a compendium of approaches. assessment of personal stress. including the impact of life events. physiological signs of stress. cognitive style. and stressed behaviour (including anger and type A behaviour). The author then introduces a variety of approaches to the remediation of any identified stressors. Relaxation. meditation. coping.

Book

117

Reviews

self-talk, cognitive challenging and many other techniques for the alleviation of stress are well described. with manageable goals for change suggested in the text. In addition to these psychological techniques. the value of balanced diet and exercise programme are discussed in a lively and comprehensive section. The author’s description of each technique is simple. balanced. lively and excites the reader to. at least. try them out and experiment with different and new ways of coping with stress. Within the confines of a broadly cognitive-behavioural approach. this book provides the undergraduate reader with a powerful armamentum toward the alleviation of personal stress. The jaded or new counsellor too may find fresh exciting ideas and intervention approaches. each of which may be selected and implemented as appropriate. Read and enjoy.

Coronary

Heart

P.\L,I. BEKNF I I Disease Prevjention Programme Selly Oak Hospital. Birmingham