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The Meaning of illness
BOOK REVIEWS Dementia Edited by Charles E. Wells. 284 pp. $22. Philadelphia, F. A. Davis. 1977.
• A product of the combined efforts of 19 contributors, from leading universities, academicians in the fields of psychiatry, neurology, pathology, and radiology, this book provides comprehensive coverage of the subject of dementia. The information is of practical importance to the family physician, the internist, even the gynecologist and surgeon, as well as the psychiatrist and neurologist. All are likely to have early and recurring contacts with patients with dementia. As to a definition of dementia, much variation is mentioned; however, as employed in the book it is considered to be a spectrum of mental states resulting from disease of the cerebral hemispheres occurring in adult life. Absence of one single condition is stressed, and emphasis is placed upon the concept of a broad continuum of dysfunction ranging from barely discernible deviation from normal to virtual cerebral death. The standard diagnostic cri· teria-impairment of orientation, impairment of memory, impairment of intellectual functions, impairment of judgment, and lability and shallowness of affect-are presented; however, these are considered late manifestations. Early signs listed include reports or impressions that the patient is "just not himself'; that he struggles too hard to turn out usual performances; that he refers to notes, guides, calendars, and other reminders too freely; and that he is more annoyed with frustrations JULY 1978' VOL 19' NO 7
than previously. These may be subtle signs of dementia. The bulk of the book is made up of a thorough discussion of the many disorders producing dementia, under such general categories as dementia of old age, diseases presenting as dementia, normal pressure hydrocephalus, and viruses causing dementia. Basic pathologic and biochemical foundations are also presented. Another section deals with examination and evaluation procedures, such as psychologic testing, electroencephalography, and radiologic techniques. In each instance, the point is made that no one test can diagnose or evaluate dementia. It is a disorder of the mind as a whole, understandable only by a multifaceted approach. The treatment section is in two divisions: specific therapy to arrest the offending process (35% to 40% of demented patients can profit from therapeutic intervention other than purely symptomatic) and nonspecific treatment directed toward helping patients and families deal with their disabilities. The areas covered are restitution of lost functions, reduction of the patient's need for lost functions, and utilization of residual functions. This book is readable and concise, and yet it yields a thorough understanding of the subject. Fred o. Henker III, M.D. Little Rock, Ark.
The Meaning of Dlness By Georg Groddeck. 270 pp, $12.50, New York, International Universities Press, 1977.
• Georg Groddeck, M.D. (18661934) was an active general practi-
tioner and psychotherapist and a devoted student of Freud. In the introduction to this book, he is quoted as stating that he conducted "a sanitorium [in Berlin] which is visited by people who do not find help in other places." Of significant interest is that he was "faced with the necessity of evaluating unconscious processes in the treatment of organic disease." Groddeck believed that "Body and mind are one unit driven by an 'It,' a force which lives us while we believe we are living. The 'It' shapes man's nose and hand as well as his thoughts and emotions." This book of twelve selected papers from the author's prolific writings presents basically a study of the "It" and its manifestations. Groddeck's insistence that there is no essential difference between physical and emotional illness makes this newly-published collection of particular interest to psychosomatically-oriented physicians. Chapter I, "Correspondence with Sigmund Freud," summarizes Groddeck's thinking. The "It" governs behavior and determines health and disease; it cures, and the physician is merely the catalyst for the therapeutic process. The author informs us of the successful treatment through psychoanalysis of vaginal discharge, diuresis, boils, and endometritis, and he emphasizes the symbolism involved. The last disease, for example, is traced to the fear of pregnancy and the desire to humiliate the husband who had infected the patient with gonorrhea. In the other chapters, Groddeck elaborates on the "It" and urges that psychoanalysis not be re441
BOOK REVIEWS stricted to neurosis. Numerous clinical vignettes and interpretations are included. The author himself suffered a swollen throat, which subsided when self-analysis enabled him to recognize that he could not swallow Freud's priority in the discovery of the unconscious. Groddeck insists that physicians be aware of symbolism that reflects the drives of the "It." Authors, poets, and artists, he remarks, are "lived" by unconscious forces and through language and other activities. These forces shape the forms we see. The child views a chair also as a coach, a horse, or a dog, but the adult represses these added projections. The author contends that the unconscious is as responsible for a compulsive neurosis as it is for the invention of a telescope. The symbolism of vision receives considerable attention. Groddeck emphasizes that seeing is not governed simply by the laws of optics. Man sees without eyes in dreams, hallucinations, and visions. Too, the eyes are known to devour, murder, pierce, and menace-. The real image, Groddeck insists, comprises both the factual or real and the internal image, which blurs objectivity. If the averted gaze, the turn of the head or body, and closed eyelids are insufficient to avoid danger, illness or even blindness can develop. The author recommends that all physicians be trained to be aware of the total human being and that diagnosis include reference to the whole person, not only to the symbolic symptom. He recommends developing positive transference through attention, sympathy, support, catharsis, and massage. 442
"Proper therapy," he states "means taking the patient back to his childhood, to the age of 3." Groddeck deserves recognition for founding a systematic approach to psychosomatic medicine. His conceptualization of the "It," however, touches on the philosophical and teleological, and care must be exercised in interpreting and applying his writings. He reduces man's stature. To think of being driven, rather than holding the reins, is demeaning. Further, Groddeck's insistence that physical examinations and laboratory tests are only occasionally necessary, is extreme. Nevertheless, there is much that he offers. His enthusiasm and attentive concern for the patient are exemplary. A critique of his work is best left to Freud's comments in his correspondence with him. He would "let the respectable idiotic public have you with all your warts and originality and ask them to take you as you are." The book is well written and suggests a wider orientation and application of psychoanalysis. It should be of interest to all practitioners of mental health. A satisfying bibliography and a workable index are included. George J. Train, M.D. Brooklyn, N. Y.
Pharmacotherapy and Psychothenpy: Pandoxes, Problems and Progress formulated by the Committee on Research, Group for the Advancement of Psychiatry, 175 pp, $8.95, New York, Brunner/Mazel, 1976.
• This volume reviews scientific studies of psychotherapy and phar-
macotherapy, and it lays to rest the myth that the two therapies are incompatible. In neuroses and non-psychotic personality disorders, effectiveness of psychotherapy itself is a formidable problem. Personalities of both therapist and patient are significant, as are their expectations and goals. However, controlled studies do indicate that a minor tranquilizer when added to psychotherapy by an experienced therapist accelerates symptomatic improvement and facilitates communication between doctor and patient. As for schizophrenia, studies indicate that combined therapy is superior to psychotherapy alone. Adding individual psychotherapy to medication offers little additional benefit during the period of acute hospitalization. In depression, possible positive effects of combined treatment include facilitation of accessibility and enhanced ego functioning. The request for drug treatment by the patient may be the vehicle through which psychotherapeutic help may become possible. Studies have indicated that combined therapy is beneficial in endogenous depressions but less so for reactive states. Despite general acceptance of this state of affairs, the Committee concludes thatthere still is a need for integrative research before these clinically accepted facts can be proven to their satisfaction. It is noted that panic anxiety attacks in agoraphobic and schoolphobia patients respond to antidepressants rather than to tranquilizers; anticipatory anxiety, however, responds fairly well to minor tranquilizers and not to anPSYCHOSOMATICS
• A product of the combined efforts of 19 contributors, from leading universities, academicians in the fields of psychiatry, neurology, pathology, and radiology, this book provides comprehensive coverage of the subject of dementia. The information is of practical importance to the family physician, the internist, even the gynecologist and surgeon, as well as the psychiatrist and neurologist. All are likely to have early and recurring contacts with patients with dementia. As to a definition of dementia, much variation is mentioned; however, as employed in the book it is considered to be a spectrum of mental states resulting from disease of the cerebral hemispheres occurring in adult life. Absence of one single condition is stressed, and emphasis is placed upon the concept of a broad continuum of dysfunction ranging from barely discernible deviation from normal to virtual cerebral death. The standard diagnostic cri· teria-impairment of orientation, impairment of memory, impairment of intellectual functions, impairment of judgment, and lability and shallowness of affect-are presented; however, these are considered late manifestations. Early signs listed include reports or impressions that the patient is "just not himself'; that he struggles too hard to turn out usual performances; that he refers to notes, guides, calendars, and other reminders too freely; and that he is more annoyed with frustrations JULY 1978' VOL 19' NO 7
than previously. These may be subtle signs of dementia. The bulk of the book is made up of a thorough discussion of the many disorders producing dementia, under such general categories as dementia of old age, diseases presenting as dementia, normal pressure hydrocephalus, and viruses causing dementia. Basic pathologic and biochemical foundations are also presented. Another section deals with examination and evaluation procedures, such as psychologic testing, electroencephalography, and radiologic techniques. In each instance, the point is made that no one test can diagnose or evaluate dementia. It is a disorder of the mind as a whole, understandable only by a multifaceted approach. The treatment section is in two divisions: specific therapy to arrest the offending process (35% to 40% of demented patients can profit from therapeutic intervention other than purely symptomatic) and nonspecific treatment directed toward helping patients and families deal with their disabilities. The areas covered are restitution of lost functions, reduction of the patient's need for lost functions, and utilization of residual functions. This book is readable and concise, and yet it yields a thorough understanding of the subject. Fred o. Henker III, M.D. Little Rock, Ark.
The Meaning of Dlness By Georg Groddeck. 270 pp, $12.50, New York, International Universities Press, 1977.
• Georg Groddeck, M.D. (18661934) was an active general practi-
tioner and psychotherapist and a devoted student of Freud. In the introduction to this book, he is quoted as stating that he conducted "a sanitorium [in Berlin] which is visited by people who do not find help in other places." Of significant interest is that he was "faced with the necessity of evaluating unconscious processes in the treatment of organic disease." Groddeck believed that "Body and mind are one unit driven by an 'It,' a force which lives us while we believe we are living. The 'It' shapes man's nose and hand as well as his thoughts and emotions." This book of twelve selected papers from the author's prolific writings presents basically a study of the "It" and its manifestations. Groddeck's insistence that there is no essential difference between physical and emotional illness makes this newly-published collection of particular interest to psychosomatically-oriented physicians. Chapter I, "Correspondence with Sigmund Freud," summarizes Groddeck's thinking. The "It" governs behavior and determines health and disease; it cures, and the physician is merely the catalyst for the therapeutic process. The author informs us of the successful treatment through psychoanalysis of vaginal discharge, diuresis, boils, and endometritis, and he emphasizes the symbolism involved. The last disease, for example, is traced to the fear of pregnancy and the desire to humiliate the husband who had infected the patient with gonorrhea. In the other chapters, Groddeck elaborates on the "It" and urges that psychoanalysis not be re441
BOOK REVIEWS stricted to neurosis. Numerous clinical vignettes and interpretations are included. The author himself suffered a swollen throat, which subsided when self-analysis enabled him to recognize that he could not swallow Freud's priority in the discovery of the unconscious. Groddeck insists that physicians be aware of symbolism that reflects the drives of the "It." Authors, poets, and artists, he remarks, are "lived" by unconscious forces and through language and other activities. These forces shape the forms we see. The child views a chair also as a coach, a horse, or a dog, but the adult represses these added projections. The author contends that the unconscious is as responsible for a compulsive neurosis as it is for the invention of a telescope. The symbolism of vision receives considerable attention. Groddeck emphasizes that seeing is not governed simply by the laws of optics. Man sees without eyes in dreams, hallucinations, and visions. Too, the eyes are known to devour, murder, pierce, and menace-. The real image, Groddeck insists, comprises both the factual or real and the internal image, which blurs objectivity. If the averted gaze, the turn of the head or body, and closed eyelids are insufficient to avoid danger, illness or even blindness can develop. The author recommends that all physicians be trained to be aware of the total human being and that diagnosis include reference to the whole person, not only to the symbolic symptom. He recommends developing positive transference through attention, sympathy, support, catharsis, and massage. 442
"Proper therapy," he states "means taking the patient back to his childhood, to the age of 3." Groddeck deserves recognition for founding a systematic approach to psychosomatic medicine. His conceptualization of the "It," however, touches on the philosophical and teleological, and care must be exercised in interpreting and applying his writings. He reduces man's stature. To think of being driven, rather than holding the reins, is demeaning. Further, Groddeck's insistence that physical examinations and laboratory tests are only occasionally necessary, is extreme. Nevertheless, there is much that he offers. His enthusiasm and attentive concern for the patient are exemplary. A critique of his work is best left to Freud's comments in his correspondence with him. He would "let the respectable idiotic public have you with all your warts and originality and ask them to take you as you are." The book is well written and suggests a wider orientation and application of psychoanalysis. It should be of interest to all practitioners of mental health. A satisfying bibliography and a workable index are included. George J. Train, M.D. Brooklyn, N. Y.
Pharmacotherapy and Psychothenpy: Pandoxes, Problems and Progress formulated by the Committee on Research, Group for the Advancement of Psychiatry, 175 pp, $8.95, New York, Brunner/Mazel, 1976.
• This volume reviews scientific studies of psychotherapy and phar-
macotherapy, and it lays to rest the myth that the two therapies are incompatible. In neuroses and non-psychotic personality disorders, effectiveness of psychotherapy itself is a formidable problem. Personalities of both therapist and patient are significant, as are their expectations and goals. However, controlled studies do indicate that a minor tranquilizer when added to psychotherapy by an experienced therapist accelerates symptomatic improvement and facilitates communication between doctor and patient. As for schizophrenia, studies indicate that combined therapy is superior to psychotherapy alone. Adding individual psychotherapy to medication offers little additional benefit during the period of acute hospitalization. In depression, possible positive effects of combined treatment include facilitation of accessibility and enhanced ego functioning. The request for drug treatment by the patient may be the vehicle through which psychotherapeutic help may become possible. Studies have indicated that combined therapy is beneficial in endogenous depressions but less so for reactive states. Despite general acceptance of this state of affairs, the Committee concludes thatthere still is a need for integrative research before these clinically accepted facts can be proven to their satisfaction. It is noted that panic anxiety attacks in agoraphobic and schoolphobia patients respond to antidepressants rather than to tranquilizers; anticipatory anxiety, however, responds fairly well to minor tranquilizers and not to anPSYCHOSOMATICS