Book Review

Psychiatric Care of the Medical Patient

N Engl J Med 1994; 330:1244-1245April 28, 1994

Article

Psychiatric Care of the Medical Patient
Edited by Alan Stoudemire and Barry S. Fogel. 977 pp. New York, Oxford University Press, 1993. $150. ISBN: 0-19-506477-1

This major textbook will be a standard reference in medical psychiatry. It is an expanded and revised version of the earlier Principles of Medical Psychiatry, with a change in title that provides a more accurate reflection of the subject than its predecessor. The goals of the book are clear: to provide an up-to-date overview of consultation psychiatry and the interface of psychiatry with medicine and surgery.

The book is divided into seven parts. The first section, on psychotherapeutic principles, contains chapters on general principles, family therapy, and group therapy, all with reference to medically ill patients. The next section deals with general issues of diagnosis and treatment and includes chapters on depression, suicide, alcohol and drug abuse, the intensive care setting, factitious disorders and malingering, and the management of acute and chronic pain. A section on neuropsychiatry considers testing, dementias and delirium, sleep disorders, and brain injury. The psychiatric complications and sequelae of many diseases are described next, largely demarcated according to medical specialty. A similar but much shorter section on illnesses requiring surgical treatment, surgical procedures and trauma follows. There is a short section on behavioral medicine, with an overview of strategies, followed by a discussion of the application of those strategies in the treatment of smoking and obesity. The book concludes with a brief section on forensic issues.

Most of the chapters provide excellent overviews of complex topics, with much good and accessible information. Pharmacology is especially well covered. I particularly liked the sections on chronic pain syndromes, the use of benzodiazepines, psychiatric aspects of renal dialysis, post-traumatic stress disorder as a sequela of burns, burns suffered by children, and eye diseases and injuries in children. The chapters on suicide, anxiety, laboratory testing and endocrine assessment, cancer, endocrinopathy, and dermatology are outstanding. The comprehensive table in the chapter on psychopharmacology will be helpful to many readers. The chapter on neurologic assessment, tests, and neuropsychology deserves a wide readership, with its extremely good sections on electroencephalography and neuropsychology. This chapter could well be expanded into three chapters. The chapter on cardiovascular diseases contains an excellent table on relevant drugs and their adverse effects. There is also a fine discussion of anesthesia. Much in this book ranges from very good to outstanding.

There are, however, some negative aspects. Almost no historical background is provided for the approaches of consultation psychiatry, information that I think would help integrate the disparate parts of the book. I think the possible roles of psychiatry in illness treated medically and surgically might be more clearly delineated, and a more distinct delineation between consultation and management would be helpful to many readers. More effort could have been made to distinguish the various symptoms and syndromes and illnesses outlined by the Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) and referred to by the author.

The index is poor. For example, the section on conversion disorders, which is essential in a book like this, is not indexed. In a work of 977 pages, the reader should be able to rely on a thorough and comprehensive index. In addition, some common disorders that are important in consultation psychiatry receive short shrift. The discussion of conversion deserves more than a handful of pages. It is sad that there is no reference to hysteria in the index, even in a historical context. Post-traumatic stress disorder in relation to illness is minimally considered. Discussions of the treatment of children and adolescents, with notable exceptions, are left out. There is inadequate discussion of complex partial seizures. The book considers hypnosis superficially and inadequately, and very little about cultural aspects of illness is presented. Similarly, the chapter on individual psychotherapy seems too short and general to be very helpful.

Balance is a problem. With 3 pages on conversion and 2 (albeit excellent) on hypochondriasis, how do the editors justify devoting 9 pages to sexual aspects of rehabilitation after spinal cord injuries, 21 pages to sleep, 15 pages to high-risk anesthesia for electroconvulsive therapy, and an inordinate number of pages to altitude sickness? The excellent chapter on neurology covers parkinsonism, myasthenia gravis, strokes, multiple sclerosis, and epilepsy, but consultation psychiatrists deal with many other neurologic syndromes. The same argument holds for the section on connective-tissue diseases.

I also have some comments about the editors' judgment. Gratuitous speculation about whether people undergoing dialysis pay income taxes and occasional phrases such as “the regressed chronic complainer” really do not belong in a book such as this. Some chapters imply more definitive approaches to treatment than we currently have. Finally, some of the writing is just bad: “A possible constellation syndrome is inherent in some cases.” What does this mean?

This book will be useful to consultation psychiatrists and belongs in the working libraries of many others. Much about it is truly excellent. This is an early version, with its inherent problems, of a book that is likely to become a classic. I look forward to the next edition.

Lloyd A. Wells, M.D., Ph.D.
Mayo Clinic, Rochester, MN 55905