Oxford Textbook of Philosophy and Psychiatry

Oxford Textbook of Philosophy and Psychiatry

BOOK REVIEWS principles, working with parents, management of suicide and homicide risk, role of individual and group therapies, and treatment setting...

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BOOK REVIEWS

principles, working with parents, management of suicide and homicide risk, role of individual and group therapies, and treatment settings. The chapters on psychopharmacological treatments provide extensive information on the use of antipsychotic, mood-stabilizing, and anticonvulsant medications, including summaries of evidence-based studies of these medications in children and adolescents, suggestions for initial and maintenance dosing, detailed descriptions of side effects, an overview of findings from the Clinical Antipsychotic Trials of Intervention (CATIE) in adults, and appendices listing drug interactions for atypical antipsychotics and describing conventional (first-generation) antipsychotics. It should be noted that the survey of side effects of atypical antipsychotics is organized around the medication class rather than specific drugs. The caveats in the book about the importance of advising parents and patients about limitations in the evidence base regarding the effectiveness and safety of the drugs discussed are complemented by specific recommendations regarding questions to ask in eliciting side effects and an excellent chapter filled with practical suggestions about management of problems that may be related to medications, including QTc prolongation, weight gain, dyskinesias, and cognitive blunting. Cepeda succeeds in maintaining a clear focus on clinical relevance in his discussions of the multiple facets of psychotic symptoms and provides plentiful references for readers seeking more systematic reviews of various topics. Psychiatrists as well as mental health clinicians in other disciplines will find this book an excellent place to turn when seeking help in determining whether the symptoms of a child or adolescent patient may have crossed the line from reality into psychosis and what to do about it. In its steadfast insistence on the care of the whole patient from symptom to side effect, this singleauthored volume convincingly demonstrates the role of psychiatry as an integrative medical specialty. A. Reese Abright, M.D. St. Vincent_s Hospital-Manhattan New York Medical College New York

Disclosure: The author has no financial relationships to disclose. Cepeda C (2000), Concise Guide to the Psychiatric Interview of Children and Adolescents. Washington, DC: American Psychiatric Press

Oxford Textbook of Philosophy and Psychiatry. By K.W.M. Fulford, Tim Thornton, and George Graham. New

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York: Oxford University Press, 2006, 872 pp., $100.00 (softcover). The value of philosophy isIto be sought largely in its very uncertainty. The man who has no tincture of philosophy goes through life imprisoned in the prejudices derived from common sense, from the habitual beliefs of his age or his nation, and from convictions which have grown up in his mindIWhile diminishing our feeling of certainty as to what things are, [philosophy] greatly increases our knowledge as to what they may be; it removes the somewhat arrogant dogmatism of those who have never traveled into the region of liberating doubt, and it keeps alive our sense of wonder by showing familiar things in an unfamiliar aspect.

VBertrand Russell (1912/1959) Psychiatrists generally pretend to be humanists, but we are not. Most of us are undereducated in the humanities, and among those with some humanities background, knowledge of philosophy is uncommon. For some reason, psychiatrists denigrate philosophy. DespiteVor perhaps precisely because ofVbeing seen by other physicians as abstract and philosophical, we see ourselves as practical and goal oriented. Philosophy is up in the clouds, up there with Aristotle and Plato in the fog of history; we are in the real world, with patients and pills, with parity and third-party payers. There is another approach to philosophy though, one having nothing to do with ancient metaphysics, a new approach that William James defined as Ba stubborn effort to think clearly[ (James, 1890/1950). In the modern BritishAmerican Banalytic philosophy[ tradition, philosophy is seen as having two roles: first, to define and clarify the meaning of our concepts as expressed in language and, second, to examine the logic of our discussions (i.e., to state premises and conclusions, and to see whether they logically follow; Ayer, 1936/2001). This approach is all about conceptual clarification and nothing about metaphysical speculation. What does it mean to say that someone has psychosis? What is depression as opposed to sadness? What is implied in deciding to use medications versus not? If we simply define philosophy as these two roles of linguistic meaning and logical validity, one can hardly see how any practical-minded person could quarrel with it. Unfortunately, many psychiatrists misunderstand philosophy, and, consequently, they misconstrue psychiatry as well. About 20 years ago, a number of psychiatrists and philosophers in the United States and Europe, aware of this dilemma, formed the Association for the Advancement of Philosophy and Psychiatry (AAPP Web site, 2006). Among the founders of that group was a British psychiatrist who had also received a Ph.D. in philosophy, K. William Fulford, the author of an excellent book on the nature of values and medical concepts of disease and health (Fulford, 1989). Fulford has in the intervening years

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become something of a political leader in the international movement for philosophy and psychiatry. Along with other colleagues in England, he started the first M.A. program in philosophy and psychiatry (at the University of Warwick), and he successfully lobbied the British psychiatric establishment for the inclusion of a philosophy requirement in the British psychiatry specialty examinations. In AmericaVthe land of practicality that has given the world the light bulb, the airplane, and the telephoneVsuch an outcome is hard to imagine. I joined AAPP as a resident about 15 years ago and have never failed to be impressed by the charisma, intellectual honesty, and dedication of its founders and leaders. Now we have perhaps the central result of their efforts, the first formal textbook of psychiatry and philosophy. This was an immense undertaking: The Oxford Textbook of Philosophy and Psychiatry comprises 872 pages. It is not meant to be read and digested whole, but to paraphrase Francis Bacon, only tasted. It is a textbook, based on the syllabus for the master_s program in philosophy and psychiatry at the University of Warwick led by the authors. As such, it has five parts that can be read separately, although much reference is made to the earlier chapters it builds upon. The fact that such a syllabus is now available in one place is in itself a major achievement. A unique feature is that this book is actually written by the authors (with some acknowledged assistance from others in a few chapters). These days in academia, one gets credit for writing a book if one simply gets one_s friends to each write a chapter. Edited books, however, are notoriously choppy, with some good chapters, some poor ones, and usually little internal consistency. Perhaps the reason academics tend to edit books rather than author them is because most academics do not want to master an entire field, but rather their little corner of it. In contrast, this is a refreshing textbook, with a basic approach and style that is consistent from beginning to end; in fact, it is bound to be the text of reference for this field. It does an excellent job of presenting philosophy from the perspective of analytic Anglo-American (as opposed to BContinental[) philosophy, and it does so at the high level befitting an M.A. syllabus in academic philosophy. Such a level, considerably higher than comfortable for the average psychiatrist, is both the major strength and weakness of the book: the authors are setting a high bar and asking psychiatrists to rise to it. Whether many psychiatrists are willing or able to do so is unclear. (The book seeks to be a source for the new philosophy requirement of the British specialty certification in psychiatry; I have little experience in Britain, but in the United States, my estimate would be that most psychiatrists are unaware of 95%, and unable to understand 50%, of the material in this book.)

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The beginning of the text presents the core concepts of philosophy in mental health, which essentially introduces the basic ideas of analytic philosophy to psychiatrists, followed by a section that seeks to explain basic aspects of nosology and psychopathology to philosophers. It is my hunch that philosophers will much better appreciate this material than psychiatrists. The second part focuses on psychopathology, especially the contributions of Karl Jaspers. (The section on Jaspers misses an important aspect of his work, his basic pluralistic approach to philosophy and science [Ehrlich, 1994; Ghaemi, 2003], instead putting the common emphasis on his BVerstehen[ method of empathy. Although I found the historical detail about him and his predecessors useful, introductory readers may be less attracted to it.) The authors also emphasize the utility of psychopathology for philosophers, as opposed to abstract Bthought experiments.[ The next section, on philosophy of science, is particularly strong. They then move on to discussions of ethics and then to special topics like philosophy of mind and the mind/body problem. At more than 800 pages, what is left out needs to be considered in light of not being able to include everything; nonetheless, some readers may have preferred less nosology and ethics and more discussion of other topics, such as the biopsychosocial model, which is mentioned only once briefly and without any critical discussion, even though many psychiatrists view this model as the theoretical core of modern psychiatry (Gabbard and Kay, 2001). Throughout the work, the basic approach is to emphasize the analytic approach to philosophy, especially through the British philosopher J.L. Austin_s concept of Bphilosophical fieldwork[ (Warnock, 1989), meaning looking at how concepts are used in real life rather than just defining them. The authors also take a rigorous nondogmatic approach, living out Russell_s maxim: both psychoanalysis and biological views are viewed as having strengths and limitations and not simply rejected or accepted outright. One also finds engaging original nuggets of thought. For instance, the authors distinguish between Bmanic[ and Bdepressive[ approaches to philosophy, the former seeking to do more than it can, and the latter thinking itself less capable that it is. As a practical matter, it is rather cumbersome to go back and forth between the accompanying CD, which contains readings, and the text, which discusses those readings. Although useful for a course, informal readers will experience some inefficiency of effort. For scholars the references and annotated bibliography are remarkable. In sum, this textbook can only move our field forward. The question is whether psychiatrists and other mental health professionals can be convinced of the importance of

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the task. Some of our masters would only lead us astray. Freud, for instance, famously advocated a studied ignorance of philosophy (Freud, 1914/1966). He could not have given worse advice because the problem in psychiatry is not too much philosophy, but too little. We are about as simple-minded and narrow-focused a profession as anyone could imagine, and worse, we think we are broad-minded and wise. Instead of Freud, we should have listened to his contemporary Karl Jaspers (a psychiatrist who became a philosopher) who argued that the worst attitude toward philosophy is to pretend that we do not need it because then we simply use and enact our philosophical assumptions without realizing that we are doing so and without analyzing the limits and weaknesses of our assumptions (Jaspers, 1959/1997). Perhaps no better critique could be given of Freud or, perhaps more accurately, of his orthodox followers and their lost century of psychoanalytic navel-gazing. For those who love Freud, or dislike Jaspers, let them listen to a wise man from another field entirely: John Maynard Keynes, the economist, who remarked that B[t]he ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist[ (Keynes, 1936). Replace economist with philosopher, practical men with psychiatrists, and you have a key to the historical debility of psychiatry as a discipline. But with works like this text, we can see a new royal roadVone that leads to doubt and uncertainty, but also to less ignorance.

S. Nassir Ghaemi, M.D., M.P.H. Emory University School of Medicine Atlanta

Disclosure: Dr. Ghaemi receives research grants from GlaxoSmithKline and Pfizer. In the past year, he has been on the speakers_ bureau of GlaxoSmithKline, AstraZeneca, and Abbott Laboratories, and in previous years has served on the advisory boards of GlaxoSmithKline, Janssen, Pfizer, and Abbott Laboratories. AAPP Home page (2006), Association for the Advancement of Philosophy and Psychiatry Web site. Available at: http://www3.utsouthwestern.edu/ aapp/. Accessed January 10, 2007 Ayer AJ (1936 (2001)), Language, Truth, and Logic. New York: Penguin Ehrlich E, Ehrlich L, Pepper G, eds. (1994), Karl Jaspers: Basic Philosophical Writings. Atlantic Highlands, NJ: Humanities Press Fulford KWM (1989), Moral Theory and Medical Practice. Cambridge: Cambridge University Press Freud S (1914/1966), On the History of the Psycho-Analytic Movement. New York: Norton Gabbard GO, Kay J (2001), The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? Am J Psychiatry 158:1956Y1963 Ghaemi S (2003), The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness. Baltimore, MD: Johns Hopkins University Press James W (1890 (1950)), The Principles of Psychology. New York: Dover Jaspers K (1997 (1959)), General Psychopathology: Vol. 1 and 2. Baltimore, MD: Johns Hopkins University Press Keynes J (1936), In: The General Theory of Employment, Interest, and Money. London: Macmillan, p. 383 Russell B (1912/1959), Problems of Philosophy. Oxford, UK: Oxford University Press Warnock G (1989), J. L. Austin. London: Routledge

Note to Publishers: Books for review should be sent to Steven Schlozman, M.D., Department of Child Psychiatry, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 6900, Boston, MA 02114.

ERRATUM

The BPractice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disoder,[ which appears in the January 2007 issue of the Journal ( J Am Acad Child Adolesc Psychiatry, 46:107Y125), includes an incorrect citation for I. Hellander 2002 in the reference list. The correct reference is Hellander M (2002), Child and Adolescent Bipolar Foundation: Membership Survey. Data Presented at: Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder, sponsored by the American Academy of Child and Adolescent Psychiatry; June; Chantilly, VA. All references to Hellander, 2002 apppearing in the text refer to the M. Hellander 2002 citation appearing here.

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Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.