366
the reader to learn and to think, whereas
others are mired in the linguistics of so-
cial psychology research. Each chapter
closes with an extensive bibliography.
Stigma renders an individual different
and somehow less desirable, and this
volume attempts to understand the pro-
cess of stigmatization. The first chapter
poses the question, “Why do people stig-
matize?” The authors propose that there
are group benefits to the exclusion of
specific individuals: certain people are
perceived as a threat and cannot there-
fore be part of a group. (Clearly, for ex-
ample, identifying and ejecting thieves,
cheaters, and traitors is beneficial, and
for certain groups, excluding the physi-
cally or mentally ill, may be necessary
for survival.)
Subsequent chapters examine the links
between stigma, stereotype, prejudice,
and discrimination. Stigmatization and
its ef fects dif fer de pend ing upon
whether the stigma is visible or invisi-
ble, controllable or not. For example, the
individual with a birth deformity (visible
and uncontrollable) will elicit reactions
different from those elicited by a person
with an addiction. Several authors note
the relation of the Protestant work ethic
to the process of stigma formation. In
North America, the dominant ideology
is that we get what we deserve. This ide-
ology is an important factor in the evolu-
tion of stigma against obesity, sexual
preference, and addiction. Derision,
rather than sympathy, is provoked if we
believe that obesity is merely the result
of overconsumption, and AIDS the con-
sequence of sexual choice.
Other chapters investigate the effects of
stigma on self-esteem, cognitive pro-
cesses, and nonverbal behaviours. The
book does not limit itself to the discus-
sion of one type of prejudice but looks at
prejudice toward race, gender, physical
deformity, weight, age, addiction, and,
to a lesser degree, mental illness. Less
effort, however, is devoted to discussing
methods of disarming stigmatization.
Stigma is a complex topic linked to
many other psychological dimensions,
and the authors develop their theses by
citing current information on group dy-
namics, self-esteem, chronic stress, and
thought suppression, as well as research
The Canadian Journal of Psychiatry
on awkward moments and self-fulfilling
prophesies—excursions that are well in-
tegrated and fascinating.
As a psychiatrist working in a rural On-
tario community, I have been painfully
aware of stereotyping, prejudice, and
discrimination. When asked to review
this book, I was full of hope that some-
how, with more knowledge, I would
have greater power to combat stigma. I
learned more than I expected. Unfortu-
nately, I learned that many people, in-
cluding myself, live with little or no
appreciation of the process and effects of
stigmatization. This book is an excellent
reference for mental health profession-
als who wish to understand it.
With regard to presentation, I must note
that, although Guilford Press is known
for the outstanding quality of its publica-
tions, my copy was, unfortunately, miss-
ing the type on page 407.
Child Psychiatry
Asperger Syndrome. A Klin,
F Volkmar, S Sparrow, editors.
New York: Guilford Press;
2000. 489 p. CAD49.95.
Review by
Marcia Benjamin, Bsc, MD
Nasreen Roberts, MD, FRCPC,
MRCPsych
Kingston, Ontario
Child and adolescent psychiatrists only
began considering pervasive develop-
mental disorders (PDDs) frequently in
their differential diagnosis about 10
years ago—and Asperger syndrome
(AS) even more recently. This volume
represents a concerted effort by a hand-
ful of dedicated professionals, working
for their entire careers, to establish a re-
spectable knowledge base for this group
of disorders. The editors, themselves
well-known experts, have chosen emi-
nent pioneers like Wing and Wolff to
add to a list of internationally acclaimed
contributors. They provide us not only
Vol 46, No 4
with current scholarly research in such
areas as genetics and neuroimaging but
also with clinical studies and case vi-
gnettes of AS patients from childhood
on.
The comprehensive introduction, which
clarifies the text format and points read-
ers to their area of interest, is followed
by 5 sections: “Behavioural Aspects”;
“Family Genetic and Neurobiological
Aspects”; “Related Diagnostic Con-
structs”; “Assessment, Treatment, In-
ter ven tion and Adult hood”; and
“Perspectives on Research and Clinical
Practice and Parent Essays.” Each sec-
tion comprises several chapters.
Section I covers diagnostic issues, neu-
ropsychology, and motor and social lan-
guage func tion ing. Its chap ters are
understandably densely written, due to
the complexity of the subjects, and re-
quire some prior knowledge of the area
under discussion—they are definitely
not for the novice. The first chapter in
this section comprehensively reviews
the evolutionary process leading up to
our present diagnostic criteria and cur-
rent view of AS as compared with PDD
and autism. The passages on diagnostic
validity and neuropsychiatric profiles
are heavily weighted with statistical
analyses and are probably more suited
to psychologists and psychiatrists well
versed in this domain.
Section II, comprising chapters 5, 6, and
7, offers an exciting discussion of the
changes brought about by such techno-
logi cal ad vances as neu roi mag ing,
which bring psychiatry generally, and
PDDs specifically, into the 21st century.
These advances are especially impres-
sive when one considers the limited time
period within which our thinking has
shifted from the concept of the “refrig-
erator mom” to the details discussed in
these chapters. These chapters reflect
the shift from folklore and myth to
evidence-based psychiatry, with its ad-
vances in diagnostic assessment, drug
treatment, and management of various
accompanying deficits—advances that
provide hope of a better future to par-
ents, to persons with the disorder, and to
May 2001
health professionals (and for some par-
ents, alleviate a sense of personal culpa-
bil ity). Dis cus sion of the re search
exploring the neuroanatomical basis of
AS is highly informative. Particularly
in ter est ing is the dis cus sion of the
amygdala’s role in relation to AS and
autistic disorder: it is proposed that a
malfunction may result in early emo-
tional learn ing fail ures, with far-
reaching ef fects on so cioe mo tional
functioning in all its complexity. The
last chapter of this section is an excellent
review of prescribing patterns for multi-
ple comorbidities of AS. It highlights
evidence-based medicine’s deficient use
of psychotropics and selective serotonin
reuptake inhibitors (SSRIs) in the treat-
ment of AS and Autism both. As well, it
reminds us directly that these medica-
tions lack core symptom-specific effects
and indirectly that a multipronged ap-
proach to management is important.
Section III (chapters 8, 9, and 10) fo-
cuses on diagnostic concepts associated
with AS. The chapter on nonverbal
learning disability describes the condi-
tion and compares it with AS, offering a
thoughtful and well-researched discus-
sion that sug gests a neu ro cog ni tive
model for understanding AS. Other
chapters in this section compare right
hemisphere syndrome and receptive lan-
guage disorder with AS and autism, elo-
quently naming them the “Borderlands
of Autistic Disorder.” Over the years,
much confusion has resulted from the
different terminology used to describe
these overlapping disabilities, and the
text suggests that all these entities may
be different descriptors based in the dis-
ciplinary origin of their authors (who
may, for example, be speech patholo-
gists, neurobiologists, psychiatrists, or
psychologists). Further, it is suggested
that a review of each disorder’s key defi-
cits and neurobiological evidence may
well prove them to be the same diagnos-
tic entity. The chapter by Sula Wolff de-
scribes several children diagnosed with
schizoid personality who have been fol-
lowed up since the 1960s. This author
highlights the importance of recogniz-
ing constitutional factors rather than
Book Reviews
attributing the condition to poor parent-
ing. Her discussion of a possible contin-
uum from autistic traits to schizoid
personality and schizophrenic thought
disorder is thought-provoking, despite
the lack of definitive research. The most
impressive elements of this section are
the detailed life histories of the children
and the eru dite dis cus sion of each
history
Section IV (chapters 11, 12, and 13) of-
fers a practical guide to assessing, treat-
ing, and managing the child, adolescent,
and adult with a diagnosis of AS. Key
emphasis is placed not so much on the
diagnosis as on the area of deficit. Thus,
behaviour management, social-
adaptation skills, need-specific educa-
tion, and vocational training of these in-
dividuals form the bedrock of treatment
planning. Klin and others walk the
reader through the assessment process,
discussing the rationale for each step and
providing a framework to help launch
individualized treatment according to
areas of strength and deficits. Tantum’s
first-person chapter adds a personal
touch that yet remains very scholarly in
its discussion of the real-life problems
that face these children as they negotiate
the changing social demands of adoles-
cence and young adulthood.
Throughout these chapters, the discus-
sion of each deficit, its etiology as cur-
rently understood, and how best to
address the problems arising from it is
extremely helpful. These chapters pro-
vide pragmatic, jargon-free guidelines
for treatment that will be useful to physi-
cian and nonphysician alike.
Section V starts with a brief but thought-
ful chapter on “Perspectives on Classifi-
cation of AS.” This is followed by a
chapter entitled “Past and Future of Re-
search on AS,” written by pioneer Dr
Lorna Wing. Dr Wing made Asperger’s
text available to the English-speaking
world and coined the term “Asperger
Syn drome,” com par ing As perg er’s
work to an opened Pandora’s box, the
consequences of which could not be pre-
dicted. Wing recapitulates past and
367
current research and admits that there is
“no dearth of firmly held beliefs but a se-
rious dearth of established facts.” I was
hoping, however, for more discussion on
the subject of future research
suggestions.
The last chapter is entitled “Parent Es-
says”; it offers a rare glimpse into the
world of AS, its impact on the family,
and parents’ ways of coping with daily
struggles in caring for these children.We
are indebted to them for sharing their in-
timate knowledge with us.
The editors’ purpose in this book was
twofold: first, they wished to compile
the currently available clinical and re-
search knowledge, and second, to as-
semble the best possible guidelines for
clinical practice and research. They have
met these goals. Comprehensive refer-
ences for extant clinical and research lit-
erature afford the reader informed and
up-to-date evidence-based guidelines
for diagnosis, treatment management,
and future research.
Currently, there is no other book on AS
that brings together in a single volume
the knowledge of major international
academics, researchers, and clinicians.
It will be an excellent reference text for
health science libraries, for child and
adolescent psychiatrists, and for resi-
dents and psychologists with a special
interest in this field. The chapters on
management may be extremely perti-
nent to the educational authorities re-
sponsible for funding this group of
students.
Psychoanalysis
Spleen and Nostalgia: A Life and
Work in Psychoanalysis. John Gedo.
Northvale (NJ): Jason Aronson; 1997.
339 p. USD40.00.
Review by
By Paul Ian Steinberg, MD, FRCPC
Edmonton, Alberta