E-therapy – your guide to mental health in cyberspacePeter Yellowleeshttp://www.Fatbrain.com (search term ‘yellowlees’)pp.320 US$12.00

This book is a combination of a consumer guide tomental health resources on the Internet and a medicalprimer on telemedicine and the Worldwide Web. The book,all 320 pages of it in manuscript form, consists of 10 chap-ters, a comprehensive list of useful e-therapy/Internetmental health sites and a glossary of terms. Chapters coverthe impact of health technologies on the treatment ofmental health problems (chapter 1); the type of personlikely to benefit from therapy on the net (with a quiz;chapter 2); hardware and technology (chapter 3); gettingconsultations and treatments on-line (chapters 4 and 5);how to select a teletherapist (with a quiz of 10 questionsto assess your therapist; chapter 6); the nature of the e-therapeutic relationship (chapter 7); what makes a goodteletherapist (chapter 8); telephobia and tele-addiction(chapter 9); and the future (chapter 10).

The book is easy to read, friendly, self-disclosing andinterspersed with dialogue from consumers in chat groupsor cyber-therapy. One of the best features of the book isthe list of useful e-therapy sites. Although the book is written for mental health consumers, much of it is alsodirected at medical practitioners, psychiatrists and otherinterested professionals. Therefore, the audience for thebook might be quite diverse, with medical practitionersattracted to detailed descriptions of telemedicine, andpotential patients reading sections on Internet help.

The book does not provide information on types oftreatment that have been found to be effective in thetreatment of different types of mental problems. All thera-peutic orientations (for example, cognitive–behaviouraltherapy, medication, dynamic psychotherapy) are dis-cussed impartially. The reader is provided with Internetsources that might be of help in researching their mentalhealth problems, including sources to clinical practiceguidelines (http://www.guideline.com). However, it is upto the consumers to initiate their own research anddiscuss this with their therapists.

The book is not strongly evidence-based. For example,although it is stated (p.159) that e-therapy is effective, thereis no systematic review of this evidence. A check-list isprovided to assess the quality of sites on the Internet, all ofwhich seem sensible (check credentials, contacts, web cur-rency, balance, avoid links to commercial sites, the pres-ence of a disclaimer). However, recent evidence suggeststhat not all these criteria predict the quality of site inform-ation [1]. Whether they predict the quality of the therapistis a question that could be evaluated by e-research!

While the book may lack a scientific perspective, itgets a big five-star rating (superb) from those who haveposted their feedback about the book on the Fatbrainwebsite! There is no doubt that this is a unique book,being the first to address e-therapy comprehensively. It islikely to be of interest and use to (i) patients and con-sumers with Internet confidence; (ii) researchers with aninterest in mental health on the Internet; and (iii) medicalpractitioners wishing to establish a web presence.

Reference1. Griffiths KM, Christensen H. Quality of web-based information

on treatment of depression: cross-sectional survey. BritishMedical Journal 2000; 321:1511–1515.

Helen ChristensenCanberra, Australia

Current diagnosis and treatment in psychiatryMichael H. Ebert, Peter T. Loosen and Barry NurcombeNew York: McGraw Hill, 2000ISBN 0 83851 462 6 pp.640 $94.95

The task of reviewing a new psychiatry text is associ-ated with mixed feelings on my part, including somehope that this will be a succinct, comprehensive andaccessible introduction and reference of use to manypeople with differing needs and levels of expertise, andsimultaneous apprehension that this may represent yetanother incomplete and flawed attempt to cover theimmense and wide-ranging subject of psychiatry for a potentially diverse audience. This latter concern isheightened by the fact that all printed texts are nowcompeting not only with those which have already beenpublished, but also with the easy availability of multiplereference sources and journals via the Internet. There-fore, the assessment of any new entrant into the marketshould consider advantages and disadvantages in com-parison with other reference books and electronicallyavailable references.

This book has a number of eminent contributors,almost exclusively drawn from the USA. This allows fora certain coherence across all sections, but also poten-tially limits the relevance of the book to readers outsidethe USA. The preface identifies the task of translating‘new discoveries into a form useful to clinicians’; andcontinues: ‘This text is intended to be practical, succinct,and useful for all health care professionals whoencounter and provide care for individuals with psychi-atric symptoms and behavioural disturbance’.

There are a number of good things about this book inmatters of both style and substance. The descriptions are

Book reviews

sufficiently detailed, but also succinct and well refer-enced. The use of bold type to identify key terms ishelpful, and the definitions are clear and straightforward,making it of use to a reader new to psychiatry (or tosomeone unfamiliar with that segment of psychiatry).The decision to give key references at the end of eachbrief section gives the interested reader an opportunity tobegin further research into a particular subject, withouthaving to wade through a large list of barely relevantreferences. Some of the sections are of a standard similarto currently popular texts, but the overall coverage ispatchy in parts, and suffers from its exclusively NorthAmerican focus in others, so that what might be per-fectly reasonable for North American readers is eitherincomplete or inappropriate for readers from other partsof the world. For example, the book relies entirely onDSM-IV and makes no reference to the ICD classifica-tion system. The chapter headed ‘Mental Health ServicesResearch’ has a strongly North American focus and littlereference to activities elsewhere in the world. This is alsotrue of the section ‘Managed Care’.

A considerable part of the book is devoted to childand adolescent psychiatry, which is, of course, veryimportant for any general psychiatric text, but a morebalanced and comprehensive reference would have givenconsiderably greater emphasis to psychiatric disordersof old age. The section on personality disorders is welldescribed. Clinical findings and treatments are presentedin a practical and accessible manner. The first threesections of the book provide an easily accessible intro-duction to general psychiatry.

Overall, the book does do a number of things quite well,but I believe it has significant shortcomings for a reader-ship outside the USA. In view of these shortcomings, andthe availability of psychiatric texts that are more reflec-tive of local practices and issues (such as PsychologicalMedicine: A Companion to Management of Mental Dis-orders, edited by Beumont, Andrews, Boyce and Carr [1]),I would not recommend that any individuals purchase thisbook for their own use, and I would be hesitant to suggestits purchase by a hospital or university either in addition to,or instead of, established references such as Kaplan andSadock’s Comprehensive Textbook of Psychiatry [2].

References1. Beumont P, Andrews G, Boyce P, Carr V, eds. Psychological

medicine: a companion to management of mental disorders.Sydney; World Health Organization Collaborating Centre forMental Health and Substance Abuse, 1997.

2. Kaplan BJ, Sadock VA, eds. Kaplan and Sadock’sComprehensive Textbook of Psychiatry. 7th edn. Philadelphia:Lippincott, Williams and Wilkins, 1999.

Murray WrightSydney, Australia

Cognitive therapy for bipolar disorder: a therapist’sguide to concepts, methods and practiceDomenic H. Lam, Steven H. Jones, Peter Hayward andJennifer A. BrightChichester: Wiley, 1999ISBN 0 471 97945 7 pp.306 $54.95

This book makes an important contribution to thetreatment of individuals diagnosed with bipolar disorder,although it is important to emphasize that from the outsetthe authors of the book do not attempt to claim that psy-chological therapies are a substitute for mood stabilizers.Despite some challenges to the efficacy and effective-ness of lithium and the two anticonvulsants valproateand carbamazepine, those drugs are still the treatmentsof choice for the treatment of bipolar disorder [1,2]. Theauthors of this book present their psychological thera-peutic approach as a useful but important adjunct to theaforementioned pharmacotherapeutic interventions.

However, as the authors of this book note (and thisresonates with my own view as well) it appears that the success of the mood stabilizers has had the un-intended effect of thwarting the development of psycho-logical therapies in this area. A handful of studies haveassessed psychoeducational approaches directed atpatients with bipolar disorder and/or their families. Yet,it needs to be acknowledged that convincing empiricaltests of the efficacy or effectiveness of psychologicalapproaches aimed at directly treating individuals withbipolar disorder are lacking [1,3]. This situation is likelyto be rectified in the next few years, as there are currentlya number of ongoing studies evaluating cognitive–behav-ioural approaches for patients with bipolar disorder. Thisresearch is being carried out mostly in the UK, and theevaluations are occurring within the framework of ran-domized, controlled trials.

Organizationally, the book is divided into 13 chapters.The first three chapters are devoted to an introduction tobipolar disorder and overviews of pharmacological andpsychosocial treatments and models. The fourth chapterintroduces a specific cognitive–behavioural therapy (CBT)model for bipolar disorder. Chapters 5–11 contain detailsof the approach taken for assessment and therapy. Thetherapeutic approach detailed in these chapters hasfour basic foci. The first focus is on providing patientswith psychoeducation about bipolar disorder. The secondis on equipping patients with the necessary cognitive–behavioural skills to assess and cope with prodromes. Infact, a great deal of emphasis is given over to teachingpatients to identify and monitor antecedent events,warning signs and symptoms, including mood fluctua-tions. Chapters 7, 8 and 9 provide sound details as

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regards goal setting, cognitive techniques and behaviouraltechniques respectively. The cognitive–behavioural strat-egies taught to patients essentially revolve around patientsslowing down and resisting goal-directed activity, when inthe prodromal phase of mania, and increasing activitywhen in the prodromal phase of depression. The thirdfocus is on communicating to patients the need for a soundsocial routine in order to minimize disruption of their cir-cadian rhythms. Activity scheduling assumes the utmostimportance here. The fourth focus is on the therapist col-laborating with the patient in examining past triggers ofepisodes (precipitating and, to some extent, predisposingfactors) and developing strategies and interventions todeal with these. An important aspect of the approach is onteaching patients how to deal with long-term vulnerabilityfactors (e.g. guilt and shame), which threaten the ‘self’.Chapter 11 details this aspect of the therapy. Throughoutthe book, case fragments are employed to good effect tohighlight points or treatment techniques; this reader foundthem to be both helpful and involving.

Currently, three of the four authors of this book areemployed at the Institute of Psychiatry, London, whilethe remaining author received his clinical training at thesame Institute. The book grew out of the clinical andresearch experience the authors have shared with bipolarpatients. The approach is adapted from traditional CBTapproaches associated with Beck, but in my view it doesassume that the reader possesses some understanding ofthe basic CBT therapeutic approach. The book wouldappear to be most suited to psychiatrists and clinical psy-chologists who see bipolar patients in clinical practice,and who are interested in pursuing a psychological ap-proach to treatment as an adjunct to pharmacotherapy. Ihighly recommend this book to those practitioners. It isan exciting addition to the compendium of innovativework emanating from the UK regarding psychologicalapproaches to the treatment of positive symptoms inschizophrenia and schizophrenic-spectrum disorders. Oneaspect of the book that is worthy of special mention isthe inclusion of various rating scales and educationalmaterial in the Appendices. These should prove useful tothe busy clinician.

References1. Roth A, Fonagy P. What works for whom? A critical review of

psychotherapy research. New York: Guilford, 1996.2. Keck PE, McElroy SL. Pharmacological treatment of bipolar

disorders. In: Nathan P, Gorman J, eds. A guide to treatmentsthat work. New York: Oxford University Press, 1998:249–269.

3. Craighead WE, Miklowitz DJ, Vajk FC, Frank E. Psychosocialtreatments for bipolar disorder. In: Nathan P, Gorman J, eds. Aguide to treatments that work. New York: Oxford UniversityPress, 1998:240–248.

Henry JacksonMelbourne, Australia

Panic disorder: assessment and treatment through awide angle lensFrank M. Dattilio and Jesus A. Salas-AuvertPhoenix: Zeig, Tucker, 2000ISBN 1 89194 435 5 pp.313 US$38.50

This new book by two prominent psychologistsworking in the field of anxiety disorders in the USA aimsto summarize the enormous, rapidly growing literaturerelating to panic disorder. Their aim is to summarize theo-retical and practical aspects of diagnosis, assessment andtreatment of this common condition into a concise volumefor use by both researchers and those in clinical practice.In general, they succeed. Some areas are well covered,while the information on treatment is generally current,practical and helpful. However, a number of deficien-cies remain.

There is an interesting discussion of the history of thevarious concepts of anxiety, as well as an overview of the evolution of the current concepts of panic disorder.The controversy regarding nocturnal panic attacks is alsoaddressed in a reasonable and reasoned manner. Simi-larly, the chapter on the theories of panic is well worthreading. There is a good concise summary of psycho-dynamic, biological and cognitive–behavioural theoriesin general, together with more detailed analyses of hypo-theses suggesting biological or psychosocial vulnerability.Hypotheses arguing for genetic predisposition, differen-tial respiratory response under stress, suffocation falsealarm, separation anxiety and cognitive vulnerability arethoroughly reviewed, assessed and criticized. These sec-tions are extensively referenced and provide an excellentyet still concise discussion of this complicated area. Thechapter ends with further discussion of precipitants ofspontaneous attacks, as well as a sensible discussionrelating to the controversial area of onset of first panicattack and the development of subsequent panic disorder.The importance of anticipatory anxiety, hypervigilanceand selective attention, misattribution and distorted beliefsand finally interoceptive conditioning is carefully pre-sented. In conclusion, the authors suggest that biologicalabnormalities may predispose a person to developingpanic disorder, while stating that the causal role of cog-nitions in panic has been established more precisely andmay be more reliable in explaining the onset of panic.

To my mind, chapter 5 provides an informative and up-to-date review of current treatments for panic dis-order. Early in the book, the authors state ‘no particulartreatment can be all things to all people, and therefore,clinicians must remain open to various treatmentoptions’. In this context, the authors have chosen tocomment on a broad range of treatment options for

panic, while at the same time emphasizing cognitive–behavioural interventions as the most helpful, theoreti-cally and practically. They state that ‘distorted beliefsand catastrophic appraisal of bodily changes are crucialto the experience of panic’, and ‘consequently CBT inter-ventions appear to be a necessary component of a treat-ment protocol for panic that seeks to produce effectiveand permanent results’.

Despite this there is description of panic focusedpsychodynamic psychotherapy, psychopharmacologicaltreatment of panic as well as a number of non-traditionalapproaches, both psychological and pharmacological. Themain emphasis however is on CBT and the effectivenessof breathing techniques, biofeedback, cognitive restruc-turing and the different forms of exposure. The use ofinteroceptive exposure or exposure to internal bodilysensations is described in detail together with the combi-nation of this approach with cognitive restructuring.Research in this area is well described and contrastedwith the lack of detailed treatment research of othermethods. Good case examples are described within thetreatment chapter and in a separate chapter toward theend of the book, which describes brief and effectivetreatment with CBT for long-standing panic disorder.

A further positive in this book is the excellent pro-vision of references, suggested professional readings anda further useful list of suggested books for patients.Australian authors are recommended in all sections, anuncommon finding in my experience of American booksand journal articles.

Despite these positives, there are also some concerns.The chapter on treatment strategies suffers from attempt-ing to cover all areas briefly, by providing only limitedand generally inadequate information regarding effectiveprescription medications for panic disorder. Worse still is the equal billing given for homeopathic and non-traditional remedies, which, while interesting to some-one well versed in the treatment of this area, could beparticularly misleading to those with limited knowledgeof the efficacy of medication in particular.

Another quibble with the decisions made by the authorsinvolves their choice to include a lengthy chapter on theassessment of panic disorder, which consists largely ofan exhaustive description of all the possible rating scalesused in this area. While rating scales are clearly usefulfor researchers in this area, their value for clinicians isextremely limited in my experience and an excessivefocus on such scales tends to remove or alter rapport andmuch of the non-specific aspects of psychotherapy.Somewhat ironically, the chapter ends with a descriptionof self-monitoring forms and behavioural tests, whichare certainly more appropriate to general psychiatricpractice. I was reminded of the response of an eminent

presenter at a recent American Psychiatric Associationmeeting who, when asked to comment on the role ofguilt and shame in body dysmorphic disorder, replied,‘I don’t think we have a scale for that’!

Overall, researchers into panic disorders may havesome use for this book, but it is more likely to be help-ful for those in general psychiatric practice (of bothadolescents and adults) who wish to treat panic symp-toms and panic disorder. There are good practical dis-cussions of the cognitive–behavioural strategies shownto be effective for panic, some reproducible tables and figures, and lists of useful references for doctors andpatients. This book has added to my own treatment ofpanic disorder, although I suspect that I will use it onlybriefly in the future in conjunction with other books thatcontain more practical information. The best self-helpbook in this area [1] provides detailed information onthese techniques for both patients and doctors, whilethere is a companion guide for clinicians [2]. Similarly,the patient treatment manual provided in a currentAustralian text [3] is helpful, and those looking forfurther source material should look at David Barlow’sbooks [4,5].

References1. Zuercher-White E. An end to panic: breakthrough techniques for

overcoming panic disorder. Oakland: New Harbinger, 1995.2. Zuercher-White E. Treating panic disorder and agoraphobia:

a step by step clinical guide. Oakland: New Harbinger, 1997.3. Andrews G, Crino R, Hunt C, Lampe L, Page A. The treatment

of anxiety disorders – clinicians guide and patient manuals.Cambridge: Cambridge University Press, 1994.

4. Barlow DH. Anxiety and its disorders; the nature and treatmentof anxiety and panic. New York: Guilford, 1988.

5. Barlow DH, Cerny JA. Psychological treatment of panic:treatment manuals for practitioners. New York: Guilford, 1988.

Scott Blair-WestMelbourne, Australia

SchizophreniaMario Maj and Norman Sartorius (eds)New York: Wiley, 2000ISBN 0 47199 906 7 pp.250 £80.00

This book is the second volume in a three volume series,Evidence and Experience in Psychiatry, auspiced by theWorld Psychiatric Association. Volume 1 was DepressiveDisorder and the forthcoming title, Volume 3, will beDementia. All volumes are edited by Maj and Sartorius.

As the editors explain in the preface, these volumes arean attempt to bridge the gap between research and clini-cal practice. The objective is to help to achieve the goalof cross-communication between evidence-based research

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and the application of such research to the provision ofservice to suffering people.

It appears that advances in research so far have notbeen adequately reflected in changes in the day-to-daymanagement of schizophrenia. Two examples are theapparent underutilization of novel antipsychotics andcognitive–behavioural psychotherapies. There is alsoevidence that clinical innovations are not being fed backto research teams; or even that research teams are notshowing enough interest in what is happening ‘out there’.

This series attempts to address these issues using a novelformat that I have not seen before. Each of the six chaptershas a main topic that is introduced by senior authors fromEurope or the USA. The introduction takes the form of acomprehensive review article, followed by evidence-basedconclusions, under the headings ‘Consistent Evidence’,‘Incomplete Evidence’ and ‘Areas Still Open to Research’.Following this, there is a very comprehensive referencelist. A series of short individual commentaries on thereview, with individual references, concludes the chapter.The commentaries are written by an international group ofwell-known professionals, which includes Australians.

Some of these commentaries provide a very personalview that I find stimulating. The special format serves todivide up the text in an attractive way, making for easyreading. I found all of the main reviews to be compre-hensive and scholarly in approach.

The first review is ‘Diagnosis of Schizophrenia’. Forme, the most thought-provoking commentaries con-cerned the loss of capacity for social ritual as a diag-nostic indicator; the use of intuition in the diagnosis ofschizophrenia; a plea for a dimensional system of classi-fication of schizophrenia under the headings positive,negative, manic and depressive; and that Dr Tim Croweis still working hard at a unitary psychosis theory.

Under the heading ‘Pharmacological Treatments’,concern is expressed about the worldwide delay in thetaking up of new antipsychotics. It seems that theremight be two possible explanations: (i) economic reasons;and (ii) the lack of strong sedating properties of the newdrugs (compared with the older drugs).

‘Psychotherapies for Schizophrenia’ is an extremelythorough and comprehensive review written by MaxBirchwood and Elizabeth Spencer. It seemed to me thathuge research contributions have not yet produced con-sistent evidence to justify a firm clinical recommenda-tion for any of the therapies discussed. Most therapiesrequire highly trained individuals, or teams in specialcircumstances. As such, the therapies would need to berobust enough to be adapted for use by a variety of pro-fessionals, in order to justify costs. Some of the com-mentators do take up this theme.

‘Prevention of Disability and Stigma Related to Schizo-

phrenia’ confirms that this illness is not only a seriousclinical problem, but also a very major social problem inhuman societies everywhere.

The review ‘Schizophrenic Spectrum Disorders’ dis-cusses schizoaffective and schizotypal concepts. In hiscommentary, Dr Robert Cloniger administers a quietusto these concepts as far as I am concerned.

The final review ‘The Costs of Schizophrenia’ byKnapp et al. made it clear to me that in the not too distantfuture the Fellowship curriculum may well have toinclude the economics of psychiatry as a subject whichwould, at least, justify a question in the written paper.There were a few encouraging factors: some models ofcommunity care are cost effective; family interventionsdo reduce the cost of care and clozapine produces betteroutcomes at lower costs than older drugs. The jury is stillout on the others.

This is a very readable book for the psychiatrist whohas daily interest in and involvement with the illness thatthose of us who work in the public sector would nomi-nate as ‘the enemy’. Those involved in major researchinto schizophrenia might find that it helps them to retaina clinical perspective. Apart from the review on the psy-chotherapies in schizophrenia, I do not regard this bookas essential for trainees.

Terry HardikerMelbourne, Australia

Psychoanalysis with children: history, theory andpracticeLeonardo S. RodriguezLondon: Free Association, 1999ISBN 1 85343 440 X pp.250 $45.95

I always speak the truth. Not the whole truth, becausethere’s no way to say it all.

––Jacques Lacan

One of the unsettling aspects of the work of Frenchpsychoanalyst Jacques Lacan is that he wrote and spokewith his own peculiar style, one which is destined toevoke a response in the reader, and all too often a pre-mature dismissal of his work as incomprehensible. Inthis, he reflects the obstacles confronted by anyone whoattempts to hear or read the unconscious as it arrives inthe speech of a patient. Free association comes at thecost of angst on the side of the analyst. As Lacan said, hepreferred the way in to be difficult, a difficulty that nodoubt has more to do with the lack of increased interestin his work in the English-speaking world than with theproblems of translation.

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This book joins a growing list of texts that purport tooffer an introduction to the work of Jacques Lacan via asynopsis of its development: a more approachable accountof his concepts. Let me say that it is my personal preju-dice to prefer to read an author in the original. Nobodysuggests we consider the work of an author such asShakespeare via a summary, without recourse to theoriginal, as if we could more easily enter the complexitiesby another path. Nonetheless, a text that is well refer-enced can provide the initiate with an introduction that,at the least, has a bibliographic status.

The majority of this book consists of a historicalaccount of the major names in ‘child psychoanalysis’including Freud, both the father and the daughter, Kleinand Winnicott, among others, but, in line with the self-professed aspirations of the author, it is clearly promot-ing a Lacanian approach. The longest chapter in the bookcontains an overview of the fundamental analytic con-cepts that Lacan reworked from his important dictum,‘the unconscious is structured like a language’. As such,it presents little that is better or worse than a number ofother attempts to summarize the Lacanian corpus. In thebook there is a lack of interpretation of what Lacan haswritten, which leaves it unclear as to how the authorperceives the important distinctions that can be madebetween Lacan and other theorists. There is little of theauthor’s own clinical work presented to explicate hisviews, perhaps reflecting the usual problems of confi-dentiality, but also possibly the origins of this book,which was written essentially as a PhD thesis, thus deriv-ing from academic or university discourse.

Although entitled Pschoanalysis with Children, theauthor is of the opinion (with which I agree) that the dif-ference in working with children compared with adults isa question of technique rather than method. The childcan present a demand for analysis and be analysedaccording to the principles that guide any analysis. Thisopens the question as to what purpose is addressed byspecifying the ‘child’ in the title when the theory pre-sented is not directed towards ‘child analysis’ as essen-tially distinct from work with adults.

In attempting to imagine what a reader naive to Lacanwould make of a precis of his work, I would hope thatan introduction would comply with its inherent taskand lead the truly interested back to the original texts. I am not convinced that this book will produce thateffect. I would suggest that unless the empty space inone’s bookshelf is adjacent to the works of Freud andLacan (his Ecrits for example) there exists a lack thisbook will not fill.

Rodney KleimanMelbourne, Australia

Crying as a sign, a symptom and a signalRonald G. Barr, Brian Hopkins and James A. Green (eds)London: Cambridge University Press, 2000ISBN 1 89868 321 2 pp.228 $148.30

In 1985, Daniel Stem published his book The Inter-personal World of the Infant. His first sentence read asfollows, ‘Anyone concerned with human nature is drawnby curiosity to wonder about the subjective life of younginfants’. I doubt indeed if this were true then or even now,and certainly 30 years ago it was of interest to very fewindividuals as the subjective life of infants was left almostentirely to the curiosity of their mothers. Since then, therehas been increasing interest in infants and, as this bookshows, an interest in the crying of babies has developedalong with research into what this might mean.

The editors of this book see it as a venue for gatheringtogether modern ideas about crying. They have used thealliterative subtitles (Sign, Symptom and Signal) to‘capture the three primary themes in what might becalled the modern era of cry research’.

A sign is seen as an objective indicator of the conditionor state of the infant. The symptom is understood as acomplaint highlighting the possibility of somethingbeing ‘not right’. The signal implies that ‘crying func-tions in context and that function or functions includesreception and interpretation of that signal but it need notentail that the signal is intentional’. The book sets out to explore ways of understanding crying, the universalexpression of infants, and there are three main themesexplored. The first theme is understanding the cry alone.If we could discriminate and learn about the specificityof the cry we would be nearer to translating accuratelythe meaning of the cry.

The second theme is understanding the symptom: theusual clinical question. What do we understand aboutthe crying baby in the emergency room or the paediatri-cian’s consulting room? The ubiquitous problem of colicis given considerable space and prominence. Barr’s chaptersuggests that colic is a transient benign condition due toincreased responsivity in the infant at that time, ratherthan due to a difficult temperament which has long-termimplications. The outcome of colic is seen as positive,although hidden in the group of babies that cry exces-sively will be some that will have ongoing problems. Thedifficulty for the clinican is to recognize which baby willneed ongoing care and supervision.

The theme of the signal remains unsatisfactory andelusive. It was a relief to read Blackman’s chapter wherehe states quite unequivocally that crying is the earliestand most powerful form of communication. Perhaps theproblem lies in what is understood by communication as

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a signal seems to imply one-way communication (thesmoke signal or the Mayday call for help). This might beso, but for whom is the help: the baby or the parent?Communication implies a two-way exchange such asconversation.

Professor Trevarthen’s work on early communicationshows clearly the capacity of babies to engage in a to andfro exchange. Why is crying not a conversation that tellsof pain, unhappiness or distress? If it is a communication,might not the cry of the baby be a reaction to what she hasheard or seen in the gaze and voice of the mother?

Implicit in this book is that, while crying is universaland normal, excessive crying and the abnormal cry areseen as problems. What about the baby that cries toolittle or too weakly? Perhaps with more awareness of theinterpersonal and intersubjective world of the infant, thisaspect would also be looked for and understood.

This book will be a helpful and valuable addition to apaediatrician’s library, but we need to explore further theunderstanding of the baby’s cry.

Ann MorganMelbourne, Australia

Hormones, gender and the ageing brain: the endocrinebasis of geriatric psychiatryMary F. Morrison (ed.)Cambridge: Cambridge University Press, 2000ISBN 0 52165 304 5 pp.359 $170.00

For several centuries health professionals have postu-lated the existence of a link between hormones and beha-viour. Myxoedema madness, caused by hypothyroidism,is a classical early example of this association. Morerecently, researchers have made use of technologicaladvances in biochemistry, imaging and molecular biologyto clarify how hormones work and contribute to influencebehaviour. This multi-author American book, edited by M.F. Morrison (from the University of Pennsylvania), pre-sents a comprehensive review of our current knowledgeon how some hormones may influence the ageing processand behaviour in later life.

The book is divided into four parts and 16 chapters thatfocus mostly on the effects of sex hormones on mood andcognitive function. In fact, only three chapters addressissues not related to the effects of oestrogen, progesteroneand testosterone on mental state. Hence, this is not a bookfor people whose interest in endocrinology is not directlyrelated to sex hormones. On the other hand, there isplenty of useful data and references for those eager tolearn more about the effects of sex hormones on beha-viour. The two chapters that review the role of oestrogen

and testosterone on depressive disorders are particularlygood, although I regret the authors’ choice not to discussthe relevance of studies linking premenstrual dysphoriaand post partum blues to depression in the peri and post-menopausal periods. The chapter on sex hormones, cog-nition, dementia in the elderly is also good, but has twomain limitations: (i) all of the information described hasalready been published as a systematic review by theauthor [1]; and (ii) the review does not include recentinformation on clinical trials of oestradiol replacementtherapy for the treatment of Alzheimer’s disease, forexample, studies by Henderson et al [2] and Mulnard et al.2000 [3]. But then, a limitation of most medical textbookspublished nowadays is that they are outdated when theyfinally come into the market. Other areas that are coveredin this book include hypothalamic-pituitary-adrenal axis inageing, hypothalamic-pituitary-thyroid axis, gender andschizophrenia, sex steroids and anxiety, gender and theimmune system, gender and pain, and psychotropic differ-ences in drug metabolism. All of the information describedin these chapters is useful, but not particularly new.

I liked the layout of the book, but warn readers that thisis not the sort of book they can easily browse through tofind the information they are looking for. Most chaptersare entirely descriptive and have no tables or graphics toassist with the location of data, nor do they quickly sum-marize key points. Readers can partly get around thisproblem by making use of the headings and index, whichwas obviously carefully prepared.

I believe this book would be a good starting point forpeople who want to learn more about the effects of sexhormones on depression and dementia in later life. If youalready work in the area you may enjoy having the bookaround for reference, but will probably be disappointedthat new developments (such as the effect of testosteroneon beta-amyloid metabolism) did not make it to theprinters. Libraries should certainly consider getting acopy of the book. If your librarian gets a copy, I wouldnot recommend that you spend your money.

References1. Yaffe K, Sawaya G, Lieberburg I, Grady D. Estrogen therapy in

postmenopausal women: effects on cognitive function anddementia. Journal of the American Medical Association 1998;279:688–695.

2. Henderson VW, Paganini-Hill A, Miller BL et al. Estrogen forAlzheimer’s disease in women: randomized, double-blind,placebo-controlled trail. Neurology 2000; 54:295–301.

3. Mulnard RA, Cotman CW, Kawas C et al. Estrogen replacementtherapy for treatment of mild to moderate Alzheimer’s disease:a randomised controlled trial. Journal of the American MedicalAssociation 2000; 283:1007–1015.

Osvaldo P. AlmeidaPerth, Australia

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BOOK REVIEWS260

The collapse of the self and its therapeutic restorationRochelle G. K. KainerLondon: Analytic Press, 1999ISBN 0 88163 317 8 pp.206 US$34.50

I came to this book curious as to the validity of theclaim made by Grotstein in the foreword that the authorhad been successful in integrating various strands ofpsychoanalytic thought, including object relations, inter-subjectivity, self-psychology and what he refers to as rela-tionism. In considering the collapse of the self and itstherapeutic restoration, Kainer covers large areas of psy-choanalytic theory, providing interesting case examplesalong the way. However, for my money, the book does notachieve the claimed integration. It lacks sufficient intel-lectual and academic rigour for that task. Nevertheless, ittraverses interesting territory on the health and pathologyof the self in the course of its 206 pages.

The Collapse of the Self and its Therapeutic Restor-ation is in three parts. Part 1 (‘Creating the Self’) occu-pies three chapters exploring the nature of identification.Kainer distinguishes between healthy and pathologicalidentifications, an area seldom covered. The third chapteron sadomasochistic identification is particularly good,although it does not cover new ground.

Part 2 (‘Collapse of the Self’) explores narcissisticinjury and its relation to paranoid-schizoid collapse; com-pulsive eating as an act of autistic self-soothing in a neurotic structure (an illuminating discussion); psychoticresidues in a neurotic structure; and, last, a case study.This case, that of Ms G. (Chapter 7) is a salutory exampleof the severe, therapist-taxing problems usually associatedwith patients with borderline personality organization.Many diagnoses have been applied by consultants towhom Ms G. is referred for an opinion and many medi-cations concurrently and sequentially prescribed, withoutbeneficial effect. Ms G. responds over time to psycho-analysis, and is presented to show the ongoing need forpsychoanalytic approaches in the era of neurobiology.

Part 3 (‘Therapeutic Restoration of the Self’) alsocovers a huge field. Its three chapters explore the role ofprojective identification in imaginative empathy; theimplications for treatment of psychic catastrophe and thepremature psychological birth of the self; and, last, anarea whose title reveals the integrative endeavour:‘Lifting the shadow of the object: reworking pathologicalinternal object relationships and transforming self-objectfailures’. This latter section lacks depth of exploration

and drags the reader past complex ideas and concepts,without due pause for reflection. A pity and an opportun-ity missed! The author attempts to cover too much in thespace available. The integration of various streams ofpsychoanalytic thought demands more detailed ana-lysis and exposition. Kainer simply states that inte-gration presents problems of mixed metaphors andcreative wills. Indeed. And how has Kainer dealt withthese problems?

Kainer makes a significant bridge between object rela-tions and self-psychology in her inclusion of the con-tainment of strong affects (famously elucidated by Bionin his metaphor of the container/contained), as a self-object need (pp.125,182) to be added to those alreadydelineated by Kohut. This is an important conceptualiza-tion. It is an ideal place for Kainer to demonstrate herapproach to the difficulties raised by the mixing of themetaphors of container/contained and self-objects. Eachof these metaphors is central to the theoretical frame-work of its author, so her solution to the difficultiesinvolved in constructing this bridge is crucial to the inte-grative endeavour.

A further plea for integration of the two theories lies inher discussion of imaginative empathy as representingthe communicative use of projective identification (PI).She asks self-psychology to re-evaluate PI in this light:to reconsider its rejection of the concept, based on theoriginal Kleinian emphasis on the evacuative function of PI. Her point is well made. Where, for example, nega-tive therapeutic reactions are viewed as caused by deathinstinct phenomena in the patient, and the analyst’s ownfunctioning in the interpersonal field is not considered,the potential for permanent damage to the treatment isenormous. While Kainer acknowledges the contributionof self-psychology to this area, she does not adequatelyrecognize the part object relations theorists have playedin elucidating the communicative aspects of PI. Heimann,Balint, Bion and others have laboured over many yearsto balance the understanding of PI. Perhaps the questionnow is whether theorists from both fields can have con-structive dialogue.

This attempt to integrate psychoanalytic theories lacksdepth but has some redeeming features. It is useful inregard to the health and pathology of the self, particu-larly in the area of identification. Those readers averse tomore academic texts will find it an accessible read.

Josephine BeatsonMelbourne, Australia