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publishing manuscripts that focus on race-related issues, as

though the editorial process relies solely on editors.
Nevertheless, our analysis and critique of Hobermans false
equation does not detract from the value of the book to the
extent that we should conclude there is nothing to recommend it. Black and Blue examines interesting territory. In fact,
one of the books strengths is its extensive historical review of
how African Americans have been viewed as medical subjects.
The author documents numerous examples of what he refers to as defamatory racial folklore, wherein blacks were
regarded as an infectious reservoir of disease, lacking in selfdiscipline and intelligence, biologically degenerate, submissive,
primitive, savage, lazy, child-like, and sexually promiscuous.
While it is impossible to know with certainty when and how
these stereotypes were manifested in the medical care black
patients received from white doctors, these disturbing descriptions of black people by white physicians are documented in
the peer-reviewed medical literature from previous decades,
including AJP. These characterizations were clearly made before the emergence of the concept of political correctness.
Another area of the text worth our attention is the consideration given to psychiatry. Our specialty receives a great deal of
attention in Black and Blue. Stereotypes of the mental health
status of blacks with terms like drapetomania, describing the
inherent psychopathology of the runaway slave, at one end of
the spectrum and at the opposite end denying that blacks
were ever capable of being complex enough to present with
depression or anxiety are just a few of the historical examples
presented that exemplify yesteryears psychiatrists prejudiced
views of African Americans. Hoberman goes on to point out
how blacks own claims of their emotional hardiness and
stoicism may have partly accounted for their unwillingness to
seek psychological care. But white psychiatrists also relied on
these claims to justify their own inattention to black patients.
Hoberman is at his best when he brings to the fore the
history of medical racism in this country. This historical
aspect of the narrative can stand on its own, without its
having to be forced into the functional theorem of the book,
in proving certain groups responsibility for health care
disparities. So it is important to read his account of the
AMAs systematic bias against African American physicians
and how the AMA kept them out of the organization for many
years. And while the AMA in recent years issued an ofcial
apology to black physicians and has joined with the National
Medical Association to form the Commission to End Healthcare Disparities, it is necessary that black and white physicians
understand the history of this signicant organization called
the AMA. Of course, the unspoken point here is that many
young psychiatrists have little knowledge of the history of
APAs participation in this narrative of medical racism.
There is one last important reason for reading this book.
It concerns the indictment that Hoberman issues against
all physicians and all medical associations. He challenges us to
contemplate how much we have done to address the inequalities in medical care that black patients face and how much we
have done to challenge the status quo and catalyze needed
changes. If we have done nothing or little, we are therefore
guilty of being complicit in the silence that surrounds this
tragedy in American health care. Hoberman takes no prisoners
here. He offers no sympathy and does no serious exploration of
the reasons we might advance to account for how we have

Am J Psychiatry 170:5, May 2013

managed ourselves. We all have to look into our private

mirrors, make our assessments, and talk with our inner selves
about what weve done with our talents. But any book that can
produce such contextualized introspection is worth reading.
ANNELLE B. PRIMM, M.D., M.P.H.
Arlington, Va.
EZRA E.H. GRIFFITH, M.D.

New Haven, Conn.

Dr. Primm is Deputy Director and Director of the Ofce of
Minority and National Affairs, American Psychiatric Association, Arlington, Va. Dr. Grifth is Professor Emeritus and
Senior Research Scientist and Deputy Chair for Diversity and
Organizational Ethics, Department of Psychiatry, Yale School
of Medicine, New Haven, Conn. The authors report no nancial relationships with commercial interests.
Book review accepted for publication October 2012 (doi: 10.
1176/appi.ajp.2012.12101321).

Generalized Anxiety Disorder, edited by Michael Van

Ameringen and Mark H. Pollack. New York, Oxford University
Press, 2012, 120 pp, $24.95 (paper).
Generalized anxiety disorder is by no means uncommon
and often protean; it frequently appears as a complication of
medical illness or in association with major depression and
other mood disorders. With reported prevalence in the range of
2%6%, patients with generalized anxiety disorder report levels
of disability comparable to or greater than levels reported by
patients with serious physical and mental disorders (including
depression, arthritis, asthma, and diabetes) (1). Distinguishing
generalized anxiety disorder from normal worry is a clinical
challenge; patients tend not to self-identify. Given the importance of the disorder, there is certainly need for a simple,
straightforward guide for both primary care providers as well
as for early-career clinicians and other psychiatric practitioners.
This fact-lled monograph is part of the Oxford Psychiatry
Library series. Written by two distinguished experts in the eld,
Michael Van Ameringen and Mark Pollack, it offers a thorough
overview of the subject. Topics covered include diagnosis,
neurobiology, clinical features, pharmaco- and psychotherapy,
clinical management, and self-help resources. Its sleek, slim
exterior, similar in size to a Zagat Survey and with color reminiscent of a Michelin Guide, promises an experience of a handy
guide to a complex subject. Unfortunately, its interior is surprisingly difcult to navigate.
This volume does pack in a great deal of information (partly
through the use of a petit 7-point typeface font). The chapter on
diagnosis is a detailed discussion of the history of the classication
of anxiety and the complex debates around DSM-5. Its summary
of neurobiology contains an excellent overview of current imaging
and neurochemical literature. The section on pharmacotherapy
contains a comprehensive review of efcacy data, including the
melatonergic agent agomelatine, not currently available in the
United States. It features a six-page table listing many of the relevant randomized trials. The chapter on psychotherapy offers a
summary description of three cognitive-behavioral therapy approaches and 15 different techniques. This book turns out to be
a highly technical, academically oriented manual for practitioners
already well versed in the eld.

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Where it falls short is being a user-friendly overview for

the young professional or generalist, as its blurb promises.
Its many clinical pearls are often buried in the midst of long
paragraphs full of technical details. It includes an extensive
discussion of the variety of treatment approaches without a clear
set of recommendations for choosing between them. There is
but one treatment algorithm, which lacks specicity (e.g., it does
not provide a decision tool for choosing whether to begin
treatment with psychotherapy, pharmacotherapy, or both).
There are three omissions of particular note. Although
there is good evidence of the efcacy of the anticonvulsant
pregabalin for generalized anxiety disorder, at present the
Food and Drug Administration has not approved pregabalin
for this indication. This fact is mentioned in passing in chapter
5 (titled Pharmacotherapy); however, in chapter 7 (titled
Clinical Management), pregabalin is included in a list of
rst-line treatments with no mention of this proviso. The
chapter on psychotherapy does not include any discussion
of evidence-based psychodynamic approaches (although the
book does acknowledge Freud as one of the rst to describe
the disorder). An appendix including several useful rating
scales omits scoring instructions or norms for all but one. The
authors are to be commended for tting so much information into a small package, but this volume does not fulll its
promise of being a useful guide for those travelers with little
prior knowledge of anxietys multifarious domain.
Reference
1. Kessler RC, Mickelson KD, Barber C, Wang P: The association
between chronic medical conditions and work impairment, in Caring and Doing for Others: Social Responsibility in the Domains of
Family, Work and Community. Edited by Rossi A. Chicago, University
of Chicago, 2001, pp 403426

HENRY WHITE, M.D.

Brookline, Mass.

Dr. White is Clinical Director, Brookline Community Mental

Health Center, Brookline Mass, as well as Clinical Instructor,
Harvard Medical School, Boston. The author reports no nancial relationships with commercial interests.
Book review accepted for publication September 2012 (doi: 10.
1176/appi.ajp.2012.12091204).

American Madness: The Rise and Fall of Dementia

Praecox, by Richard Noll. Cambridge, Mass., Harvard University Press, 408 pp., 2011, $45.00.
A surgeon in Chicago performs a laparotomy to cure his
sons psychosis. A celebrity murder trial hinges on a psychiatric diagnosis. An upstart psychiatrist is the rst in North
America to publicize a method for classifying mental illnesses,
only later to repudiate it. Richard Noll brings these and
other tales to life in American Madness: The Rise and Fall
of Dementia Praecox as he elaborates the history of how
psychosis was named, classied, and understood in early
20th-century America.
Noll begins in 1892, when Swiss pathologist Adolf Meyer,
age 25, crossed the Atlantic to look for work. At the Illinois Eastern
Hospital for the Insane, Meyers lectures on what he knew of
psychiatry were received enthusiastically, and his advocacy for
the mentally ill soon reached the ears of the governor of Illinois.

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Through Meyers work, the American psychiatric community

came to accept a distinct label for psychosis: Emil Kraeplins
concept of dementia praecox. Until that time, asylum patients
had generally been labeled simply insane, following the theory
that all mental illness derived from a unitary psychosis.
But dementia praecox fell out of popularity as quickly as
it had risen. Central to Kraeplins concept was its course of
irreversible deteriorationdenable only in retrospect. Consequently, young people with an array of emotional or behavioral disturbances seemed at risk, an alarming prospect.
Clinical observations in America, however, contradicted this
notion: many patients recovered, while others proved to be
much less impaired than the label dementia had suggested.
Becoming less and less enamored of Kraeplins prognostic
gloom, Meyer and other American psychiatrists redened
dementia praecox, positing a premorbid personality that
delimited those at risk and dovetailed with recently elaborated psychoanalytic concepts such as unconscious conict.
Noll chronicles how this American dementia praecox was,
ironically, fertile soil for the introduction of its replacement:
Eugen Bleulers theory of schizophrenia. Bleuler viewed
hallucinations, delusions, and dementia as secondary symptoms, which arise as reactions to environmental inuences and to [the psyches] own strivings (p. 236), Splitting,
another element of Bleulers theory, made schizophrenia
attractive because psychological processes that were split
could, theoretically, be reunited. Bleulers ideas of reactions
to the environment, hope for cure, and a premorbid latent
schizophrenia resonated with the evolving American concept
of psychosis. A. A. Brill, a disciple of Meyers who had studied with Bleuler in Zurich, published the rst American report
of schizophrenia in the American Journal of Insanity (the
precursor of the American Journal of Psychiatry) in 1909 (1). By
the 1910s and 1920s, Bleulers schizophrenia, not yet dominant
in Europe, had largely supplanted Kraeplins dementia praecox
in America. The schizophrenia that we diagnose today is an
American amalgam of these two European theories.
Tales of personal drama enliven Nolls story in a way that
few would imagine possible for a historical account of nosology.
Kraeplinian terminology exploded into popular awareness in
1907, when the New York Times and newspapers across America
sensationalized the trial of a troubled millionaire who had
shot another millionaire, focusing on the defendants possible
psychiatric diagnoses. Meyer, insecure that he had contributed nothing original to psychiatry, ultimately spurned the
concept of dementia praecox and championed instead the
premorbid personality. Noll poignantly describes the desperation of a surgeon whose son was diagnosed with dementia
praecox. Spurred on by Kraeplins idea that dementia praecox
arose from a systemic process (autointoxication), the surgeons
research convinced him that the problem lay in the intestinal
tract. In 1916, he operated on his son. Tragically, the boy died.
Throughout his narrative, Noll encourages the reader to
consider the implications of viewing madness in particular
ways. As Kenneth Kendler has observed (2), if the tape of
history were rewound and replayed a thousand times, we
would probably not arrive at the same system of classication
each time. We are reminded that scientic theories are as
much historical accidents as they are accurate partitions of
the natural world. Therefore, Noll admonishes us not to let
classication schemes override observed clinical data.

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