Abstract
Beginning psychiatry training in England's industrial north, I was given the disquieting news that my consultant (also his first post as such) would not be arriving for another month. Propelled in part by my terror at this state of affairs, I immediately purchased myself a paperback copy of the Oxford Textbook of Psychiatry, endowing it with almost talismanic significance. My consultant duly arrived and all was well, but I have retained an understandable fondness for cogent, general texts (such as the OTP). ‘Exciting and accessible’, being the stated goals of the editors of Essentials… I read on hopefully.
Essentials… at a little over a thousand pages is a synoptic text distilled from The American Psychiatric Press Textbook of Psychiatry. Roughly the same length as what was then the unabridged OTP, this initially seems like a reluctant culling, but there are surprising omissions. To give examples of personal interest; there are two chapters on psychotherapy, one entitled ‘Brief dynamic individual psychotherapy’, the other ‘Psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy’. There is however no chapter on the robustly validated and frequently useful Cognitive Behavioural Therapy and its scions.
Culture is mentioned as a prognostic factor in schizophrenia, and as an important consideration in diagnosis of both Trance Disorder and Personality Disorder, however, the recent wide ranging and instructive dialogue between anthropology and psychiatry is not coherently represented. The glossary's attenuation of the so-called culture bound syndromes to a list of five, tends only to exaggerate the unfortunate impression that these are a catalogue of exotic (i.e. non Anglo-American) diagnostic oddities, less an attempt to make the discipline conversant across cultures. Similarly socioeconomic status (SES), importantly if complexly related to all mental disorders, is mentioned in relation to an unmodified drift theory for schizophrenia, but otherwise disappears from view. There is a limited discussion of postnatal depression, but I could find no mention of puerperal psychosis or the ‘baby blues’ (or any useful grouping of the peripartum illnesses).
In addition I found some of the perspectives border on the idiosyncratic. Take for example the longish discussion of ‘supportive psychotherapy’, in the psychotherapies section. While any attempt to define and validate this is laudable, I wasn't convinced that this had been adequately differentiated from non-specific curative, therapist and therapy factors (which are mentioned earlier in the chapter), and other schools of counselling and therapy.
Addressing each in turn; I found the chapters in the first section, ‘Theoretical foundations and assessment’, impressive. The chapter, ‘The neuroscientific foundations of psychiatry’, whilst necessarily incomplete, is information rich comprehensible and well organised.
The second section's (Psychiatric disorders) strengths and weaknesses are in part linked to its adherence both structurally and philosophically to DSM-IV. The content is of variable quality; the Adjustment Disorders are dealt with carefully, with taxonomic and diagnostic dilemmas flagged helpfully. The section on PTSD is less critical. Schizophrenia is well covered but I felt that contemporary psychological approaches were underemphasised and crudely adumbrated.
But perhaps more importantly, DSM-IV for all its utility is neither the extent of psychiatry's scope nor is DSM-IV its vision. I was, and remain, drawn to psychiatry because it is interesting, grounded in lived experience, ranging in domains from the biomolecular to the cultural and spiritual, and drawing on insights from the physical sciences, philosophy, anthropology, and the arts to name a few. To foster an interest in, and capacity for, broad yet critical examination and integration is a primary task for those of us (and surely this means all, particularly those preparing introductory texts) charged with welcoming initiates into the discipline. I am not convinced that the text achieves this, imbedding itself so securely in DSM-IV and seldom indicating other possibilities. To give truly global coverage would explode the central, almost oxymoronic, dilemma of a synoptic text, but there are ways of intimating broader concerns without becoming unwieldy.
The third section on treatments is uneven, particularly the psychotherapies, and limited in scope.
Finally, a technical point. The use of the Harvard system of referencing makes the text quite interrupted. Combined with the telegraphic nature of the text fluency is affected. Take the chapter on pychoanalysis where one finds the following:
As in other medical treatments, there are contraindications to and dangers in the use of psychotherapy (Crown 1983; Hadley and Strupp 1976). Psychotherapy is both efficacious and cost effective (Crits-Christoff 1992; Lazar 1997). The effectiveness of psychotherapy is not argued now as it had been in the past (Luborsky et al. 1975; Parloff 1982; Parloff et al. 1986; Shapiro and Shapiro 1982; Smith et al. 1980; Spiegel and Lazar 1997). However, the answer to the question of which psychotherapy for which patient and by which therapist is still unclear (Parloff 1982).