Alan F. Schatzberg
Any living entity must adapt and change in order to survive and prevail. This axiom applies as uniformly to medical specialties and to medical textbooks as it does to plants and animals. Paralleling the field of psychiatry over the past 20 years, The American Psychiatric Publishing Textbook of Psychiatry (the Textbook) continues to change, adapt, survive, and thrive into its Fifth Edition. Given the “two-decade milestone” of the Textbook, I felt that my understanding of the new Edition would be enhanced through an appreciation of what has been changed and what has been preserved from the previous four editions. The Editors of the First Edition of the Textbook included John Talbott, M.D., in addition to Drs. Hales and Yudofsky, who have remained with the Textbook through this edition.
In the Preface to the First Edition, the Editors explicitly proclaimed their goal as “...to assemble a textbook that presents, as comprehensively as is possible in a single volume, the clinically relevant topics in psychiatry. . .We have thus endeavored to present a psychiatric text that may be used in a fashion similar to that of several other standard textbooks in other fields such as internal medicine, general surgery, pediatrics, endocrinology, and pharmacology: a text that is not only useful as a standard educational reference for psychiatrists and psychiatry residents, but that is also purchased and used extensively by medical students, residents, and more advanced professionals from other disciplines and specialties” (Talbott, Hales, and Yudofsky 1988, p. xvii). The Editors set for themselves an extraordinary challenge. As early as 1980, the most widely used psychiatric textbook of that era, The Comprehensive Textbook of Psychiatry, Third Edition (Kaplan, Freedman, and Sadock 1980), comprised three large volumes and 3,365 pages! Notwithstanding the exponential increase in the database and scope of the field of psychiatry over the past two decades, the Editors of The American Psychiatric Publishing Textbook of Psychiatry have stuck to their guns throughout the entirety of the five editions by maintaining a one-volume format with a remarkable consistency in the number of pages for each edition (i.e., 1,280 pages in Edition I; 1,610 pages in Edition II; 1,702 pages in Edition III; 1,648 pages in Edition IV; and 1,672 pages in Edition V).
With the aforementioned as prelude, I considered the following three questions in assessing the achievements of this edition of the Textbook: First, how well have the Editors accomplished the twin goals articulated in the Preface to the First Edition: maintaining a single-volume format while including the profusion of recently discovered, relevant information so essential for the practicing clinician? Second, has important information been omitted in order to accommodate the single-volume format? And third, are the unprecedented research advances in psychiatry since publication of the previous edition of the Textbook 5 years ago integrated into the chapters? At the top of my long list of such advances are 1) neuropsychiatric diagnostics and imaging, 2) basic behavioral sciences, and 3) evidence-based brief psychotherapies.
Let us first consider the related topics of neuropsychiatric diagnostics and neuroimaging in the Fifth Edition of the Textbook (Hales, Yudofsky, and Gabbard 2008, pp. 19–72). Chapter 2, “Laboratory Testing and Imaging Studies in Psychiatry,” by Drs. Kim, Schulz, Wilde, and Yudofsky, is entirely revised and extensively expanded from the previous edition. Written by two neuropsychiatrists, a neurologist, and a neuropsychologist, this chapter conveys a salutary reminder that psychiatric disorders are, first and foremost, brain illnesses. The authors make the important point that because a vast range of neurological and medical illnesses can give rise to psychiatric symptomatologies, a careful and comprehensive neuropsychiatric history and physical examination with judicious clinical laboratory testing constitute the primary and most important steps in the psychiatric evaluation. They further emphasize that a meticulous history and physical examination often can obviate expensive and invasive laboratory testing and diagnostic imaging. Also, because psychiatric symptoms tend not to be specific to a particular etiology, the practitioner must be particularly vigilant in identifying biological disorders that are reversible with treatment. A strength of this chapter is the review of those screening laboratory tests that have been demonstrated to be cost effective (e.g., serum glucose and blood urea nitrogen concentrations, creatinine clearance, urinalysis). Additionally, thyroid screening of female mood disorder patients older than age 50 years is justified because of the high prevalence of hypothyroidism in this group. The practicing clinician will find Table 2–2, a summary of laboratory screening tests useful in the neuropsychiatric workup, particularly valuable, with reference ranges that are difficult to locate in single sources (e.g., luteinizing hormone and follicle-stimulating hormone ranges for men and women). The authors go on to address a series of specific clinical presentations, providing guidelines for recommended diagnostic testing for patients with fluctuating mental status of acute onset, for patients in cognitive decline, for patients who abuse mind-altering substances, for patients with new-onset psychosis, for patients with new-onset depressive or manic symptoms, for patients with new-onset anxiety symptoms, and for patients with a range of other neuropsychiatric presentations. Similarly, the thorough review of medication monitoring and maintenance and the unusually clear presentation of pharmacogenetics and pharmacogenomics are remarkably comprehensive and up to date. I also commend to the reader's close review Table 2–12, in which investigational biological markers are presented and critiqued, as this table affords a unique and realistic glimpse into the future of psychiatric practice. The remainder of Chapter 2 is an equally lucid and thoughtful presentation of electrophysiological and neuroimaging studies in psychiatry. In an era in which considerable confusion prevails in regard to clinical rationales for specific diagnostic tests, the authors are careful to present full and current data on indications for and limitations of each specific test. For example, the authors note that 20% of patients with epilepsy will have normal electroencephalograms, while 2% of patients without epilepsy will have spike and wave formations. Particularly useful are the explanations of the comparative indications for magnetic resonance imaging (MRI) versus computed tomography (CT), and specifically Table 2–16, which compares SPECT, PET, and fMRI from the perspectives of resolution, scan time, and cost. New technologies such as diffusion tensor imaging (DTI) are also introduced to the reader.
Chapter 5, “Neuroanatomy For The Psychiatrist,” by Drs. Katherine H. Taber and Robin A. Hurley, is an excellent complement to Chapter 2. I fully agree with the assertion made by the authors at the beginning of this extraordinary chapter: “As structural and functional neuroimaging and genetics become more entwined in modern medicine, it has become more evident that practicing psychiatrists need to understand basic neuroanatomy and its relationship to psychiatric disease” (Ibid., p. 157). Thereafter, in the most systematic and original fashion, Drs. Taber and Hurley deploy a vivid series of brain imaging graphics to elucidate regional brain structures and to link these regions and systems to brain function and dysfunction. Table 5–1 extensively reviews functional anatomy pertinent to psychiatry and summarizes the functional impairments that commonly occur when the respective regions suffer injury. The authors make the important observation that the brain is the organ of our field. I commend this chapter as the best available resource to the resident studying for certification boards or to the practitioner who desires a practical review that links brain structures, systems, and functions.
In summary, I conclude that Chapters 2 and 5 have exceeded my expectations and requirements for a comprehensive and up-to-date presentation of diagnostics and neuroimaging.
Although the four previous editions of The American Psychiatric Publishing Textbook of Psychiatry each contained a section titled “Theoretical Foundations,” the Fifth Edition is the first to have an individual section devoted to basic science and brain development. This enhancement is doubtlessly in justifiable recognition in the unprecedented explosion in behavioral neurosciences since the turn of this century.
Chapter 4, “Cellular and Molecular Biology of the Neuron,” by Drs. A. Kimberley McAllister, W. Martin Usrey, Stephen C. Noctor, and Stephen Rayport, begins with the following premise: “Neuropsychiatric disorders are due to disordered functioning of neurons and, in particular, their synapses” (Ibid, p. 123). The authors argue that many neuropsychiatric disorders arise from aberrations in neurodevelopmental mechanisms, particularly in the initial assembly of the brain during infancy, and that these dysfunctions are most likely to be intrinsically or genetically based. They further posit that with maturation of the individual, life experience becomes the dominant force in shaping neuronal connections and regulation and, therefore, that neuropsychiatric dysfunction is usually experience-based. By contrast, geriatric neuropsychiatric disorders derive from neurodegenerative processes that “may unravel neural circuits by aberrantly engaging neurodevelopmental mechanisms” (Ibid., p. 123). McAllister and colleagues also maintain that the rapid rate of recent discoveries in the field has begun to yield insight into “how therapeutic interventions to correct aberrant neuronal growth and differentiation during development and maturation, or later to normalize neuronal signaling, may translate into revolutionary treatments for neuropsychiatric disorders” (Ibid., p. 114). Consistent with the chapter's title, they devote the largest proportion of their text to an explication of the cellular and molecular functioning of the neuron. With almost poetic economy of expression, the authors sum up neuronal functioning as follows: “Individual neurons in the brain receive signals from thousands of neurons and, in turn, send information to thousands of others...CNS neurons may be seen as part of dynamic cellular ensembles that shape their participation from one network to another as information is used in varied tasks. The sophistication of these networks depends on both the properties of the neurons themselves and the patterns and strength of their connections” (Ibid., p. 124). Addressing such broad topics as the cellular composition of the brain, neuronal shape, neuronal excitability, rapid postsynaptic responses, organization of postsynaptic receptors at synapses, and synaptic modulation in learning and memory, the authors bring to life the cellular and molecular functioning of the CNS neuron.
A second major consideration of Chapter 4 is the development of neurons, which is a “hot” current topic and has promise for opening new avenues for both understanding and treating psychiatric illnesses. The authors of this chapter are renowned scientists, each of whom has made original and seminal contributions to the chapter's subject, and this is especially evident in the sections covering the birth and migration of neurons, the identification of neuronal progenitor cells (Dr. Noctor), the migration and organization of brain neurons, synapse formation, neuronal maturation and survival, experience-dependent synaptic refinement, and neurotrophic and neurotoxic actions of neurotransmitters. From my perspective, Chapter 4 is a tour de force of presentation, organization, and relevance. I particularly appreciated the creative and compelling graphical depictions of synaptic transmission, including neurotransmitter transporters.
Psychiatric genetics is a second key area of exponential growth in the 5 years since publication of the Fourth Edition of the Textbook of Psychiatry. I reasoned that coverage of this subject would be another major test of the Editors' success in maintaining the scientific currency of the Fifth Edition while keeping the length down to a single volume. In Chapter 6, “Genetics,” the authors note that the goal of psychiatric genetics is to identify susceptibility genes and elucidate the neural mechanisms by which genetic variation influences the risk of mental illness in an individual. The authors' expressed objectives for their chapter are 1) to present the fundamental principles of classical and molecular human genetics, 2) to summarize the results of selected studies aimed at deciphering genetic contributions to the most common and disabling psychiatric illnesses, and 3) to speculate about the future of psychiatric genetics research, with particular emphasis on new psychiatric drug development based on genetic etiological findings rather than disease phenotypes or symptoms. Highlights of this chapter include up-to-date and comprehensive reviews of the evidence supporting the genetic transmission of prevalent psychiatric disorders and the hereditary risks for the development of these conditions, particularly evidence from twin and adoption studies. This chapter is unusually strong in its presentation of genetic linkage analysis and association studies, realms that students and practitioners of psychiatry must understand (but often do not). I particularly appreciated the highly topical presentation of candidate genes for schizophrenia (there are at least 18) and Table 6–3, which summarizes this complex subject so well. In my opinion, no area of psychiatric genetics is more productive and exiting than that of mood disorders. As outlined in Table 6–5, there are currently 12 candidate genes for bipolar disorder and at least 5 candidate genes for major depressive disorder. Chapter author Prabhakara V. Choudary, Ph.D., is a leading scientist in this realm, with pioneering research on two candidate genes for major depressive disorder. Indeed, one of the most important scientific discoveries of the past 5 years was reported in Caspi and co-workers' paper on the serotonin transporter gene, SLC6A4 (Caspi, Sugden, and Moffitt et.al. 2003). Caspi and associates devised an experiment to answer, in part, the fundamental question of why certain people are more vulnerable to developing depression as the result of life stress. Specifically, they investigated a functional polymorphism in the promoter region of the SLC6A4 serotonin transporter gene, which is responsible for the reuptake of serotonin at brain synapses. The polymorphism entails a short (“s”) allele of the transporter that is less efficient at than the long (“l”) allele. Analyzing a cohort of 1,037 subjects from Great Britain for the association of life stress and major depression, Caspi and colleagues found that the short (“s”) polymorphism in the promoter region of the serotonin transporter gene increased the influence of stressful life events on the development of depression. Thus, they isolated and demonstrated a genetic–environmental interaction in which the influence of stress on the development of depression is affected by a subject's genetic makeup. I was pleased to note that this notable research finding was discussed not only in the chapter on genetics but also in the chapter on cellular and molecular biology of the neuron and the chapter on mood disorders—evidence of an excellent integration of basic neuroscience and clinical psychiatry in the Fifth Edition of the Textbook.
The third area of area of accelerated expansion of psychiatric knowledge over the past 5 years has been in evidence- based psychotherapies, and I was curious to see how the Editors responded, in the Fifth Edition of their Textbook, to this growth. Drs. Hales and Yudofsky have been the sole Editors of the Textbook over its previous two editions, and their subspecialty interest is neuropsychiatry. As it turns out, Hales and Yudofsky made significant changes in the Fifth Edition in recognition of the advances and expansion of knowledge in psychotherapies. Glen Gabbard, M.D., noted psychoanalyst and highly regarded researcher, theoretician, and author on psychodynamic psychiatry, was invited to be the third Editor for the Fifth Edition of the Textbook. Dr. Gabbard was given the responsibility to develop a revised and expanded consideration of psychotherapies. New to the Fifth Edition are individual chapters on supportive psychotherapy and combining psychotherapy and pharmacotherapy, in addition to chapters on brief psychotherapies, psychodynamic psychotherapy, interpersonal psychotherapy, cognitive therapy, couples and family therapy, and group therapy. The authors of these chapters represent a veritable “Who's Who” of experts in the respective therapies, and they have done an outstanding job of crafting chapters that allow readers to incorporate the knowledge and skills imparted by the text into their practices.
Comprising 46 pages, Chapter 31, “Cognitive Therapy,” by Drs. Jesse H. Wright, Michael E. Thase, and Aaron T. Beck is as thorough and well-wrought a chapter on this important subject as I have read anywhere. One of the best parts of this chapter is the section documenting the effectiveness of cognitive therapy (CT). The authors point out that more than 350 randomized controlled trials of CT have been conducted and that CT has been demonstrated to compare favorably with other treatments for depression (including psychopharmacology); for anxiety disorders; for the symptoms of certain eating disorders, including bulimia nervosa and binge-eating disorder; and even for psychotic symptoms.
Chapter 33, “Combining Psychotherapy and Pharmacotherapy,” by Drs. Michelle Riba and Richard Balon also reviews the available published literature documenting that combining these treatments improves outcomes for patients with major depression, bipolar disorder, bulimia nervosa, and nicotine dependence. This chapter also does an excellent job of distinguishing between integrated and split treatments and of providing practical and helpful guidelines on such topics as questions to ask a patient in the initial telephone call for an appointment, key ingredients of the first session of combined treatment, and special issues involving medications.
I found the cluster of chapters on psychotherapy not to be repetitive, but rather integrated and complementary, and this reflects well on both the chapter authors' and Dr. Gabbard's editing. The net result is that Fifth Edition's presentation of psychotherapies essentially represents “a book within a book” and a product that manages to exhibit both economy of scale and completeness.
In summary, I believe that the Fifth Edition of The American Psychiatric Publishing Textbook of Psychiatry is an altogether worthy reflection of the robust and remarkable progress of the field of psychiatry over the past several decades. The Editors have worked hard on updating, bridging, and integrating such classical topics as psychoanalytical psychotherapy with recent discoveries in cell biology, molecular biology, and genetics. In addition, the Editors have preserved in the Fifth Edition the organizational concepts that were delineated in the First Edition, including the single-volume format. The net result is that the Textbook has not only survived to its Fifth Edition but has flourished. I found myself enjoying the chapter presentations of the Fifth Edition, which so keenly reflect the state of the art in psychiatric diagnosis and treatment in 2008, while also looking ahead with eager anticipation to the achievements and transformations that inevitably will follow in the years to come—substantive and thrilling advances that are certain to be embraced and skillfully presented in future editions of the Textbook. I trust that you, the reader, will enjoy this book as much as I have, and I congratulate Drs. Hales, Yudofsky, and Gabbard, and all of the other editors and contributors, for a job well done.
Caspi A, Sugden K, Moffitt TE, et al: Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 301:386–389, 2003
Kaplan HI, Freedman AM, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 3rd Edition. Baltimore, MD, Williams & Wilkins, 1980
Hales RE, Yudofsky SC, Gabbard GO (eds): The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition. Washington, DC, American Psychiatric Publishing, 2008
Talbott JA, Hales RE, Yudofsky SC (eds): The American Psychiatric Press Textbook of Psychiatry. Washington, DC, American Psychiatric Press, 1988