Book Review
DILIP RAMCHANDANI, M.D.
The American Psychiatric
Publishing Textbook of
Psychosomatic Medicine
Edited by James L. Levenson,
M.D.
Arlington, Va.
American Psychiatric Publishing,
Inc.
2005, 1,120 pages, $169.00
ISBN 1-58562-127-7
Reviewed by Donald S. Kornfeld,
M.D., and
Ralph N. Wharton, M.D.
D r. James Levenson, the Editor, and
his chapter authors set out on a
daunting task, to write a comprehen-
sive textbook of our field that coincides
with its designation as a certified spe-
cialty and its first qualification exami-
nation. We believe they have success-
fully accomplished their mission.
However, this judgment is not ours
alone. We have enlisted the expertise of
the faculty of the Columbia Psychoso-
matic Service to review chapters in
their areas of expertise, as follows: On-
cology and HIV-AIDS, Jon Levenson;
Obstetrics and Gynecology, Jennifer
Downey; Pediatrics, Jonathan Slater;
and Psychodermatology, Iona Gins-
burg.
We would hope that Dr. Levenson
and his colleagues will find whatever
criticism is offered to be helpful in
writing, what will likely be, a second
edition.
The book is divided into four sec-
tions: General Principles in Evaluation
and Management; Symptoms and Dis-
orders; Specialties and Subspecialties;
Psychosomatics 46:1, January-February 2005
BOOK REVIEW EDITOR
and Treatment. We will review the
book’s chapters in that order.
GENERAL PRINCIPLES IN
EVALUATION AND MANAGEMENT
The chapter “Psychiatric Assessment
and Consultation” makes it clear that
while a psychiatric interview at the
bedside in a general hospital setting
may be based on certain basic psychi-
atric principles, it requires that the con-
sultant be prepared to work in some un-
usual settings. The authors provide
useful advice on how to deal with an-
other very basic difference: these pa-
tients rarely, if ever, have asked for our
help. They also point out the pitfalls
that can impede the successful imple-
mentation of our recommendations and
how to deal with them. Considerable
space is devoted to formal mental
status testing methods, which might
better be used to discuss how clinical
data alone can be adequate to make a
diagnosis. Not many situations allow
for the implementation of such testing.
There is a recommendation that the
consultation note begin with a review
of the summary of the patient’s medical
and psychiatric history. Our advice to
trainees is to begin with the reason they
have been asked to consult. Medical
history is likely reviewed elsewhere in
the chart and can be referred to. The
shorter the note, the greater the likeli-
hood that it will be read in its entirety.
We require that no note exceed one
page in length.
The chapter “Neuropsychological
and Psychological Evaluation” con-
tains useful information on a number of
tests that are available and frequently
used. It is helpful for a psychiatrist to
understand the advantages and disad-
vantages of each assessment and there-
fore how they can best be applied.
The chapter “Legal Issues” is quite
comprehensive and useful in reminding
us of how often we are involved in is-
sues that involve the law. However, a
psychiatric consultation must go be-
yond merely establishing a patient’s le-
gal competency. Our concern regarding
the law should not divert us from a
thorough evaluation of the wide range
of issues, as noted below, which cre-
ated the clinical impasse and produced
the consultation.
The authors of the chapter on clini-
cal ethics rightfully point out that prob-
lems formally designated as “ethical”
are in reality issues often best handled
by a psychiatric consultant. We agree.
A formal knowledge of ethical princi-
ples rarely, if ever, has led to a resolu-
tion of such issues at the bedside. Psy-
chiatrists are too often used merely to
determine mental capacity when the is-
sue is more likely a personal, family, or
staff conflict or a failure to provide pa-
tients with an adequate opportunity to
discuss their anxiety or anger. These
are not “ethical” issues and are better
solved by a consultation-liaison psy-
chiatrist1 than an “ethicist.”
A chapter “Psychological Re-
sponses to Illness” requires consider-
able experience in our field in order to
have witnessed the wide range of such
responses and the ability to clearly
categorize these observations. Green
and Muskin have combined their per-
sonal experience with such classic ob-
servations as those of Bibring and Ka-
hane to provide a useful review of this
issue.
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Book Review
SYMPTOMS AND DISORDERS
Delirium is given the attention it de-
serves. This is the book’s longest chap-
ter and necessarily so. Delirium is
probably the most common and most
serious of all clinical problems with
which consultation-liaison psychia-
trists must deal. Drs. Trzepacz and
Meagher have provided a very compre-
hensive up-to-date review of the com-
plexity of its diagnosis, etiologies, and
treatment. The chapter discusses strat-
egies to minimize the occurrence of de-
lirium as well as current data on the
apparently successful use of dexmede-
tomidine to diminish delirium follow-
ing cardiac surgery.
Pharmacological treatment with
antipsychotic agents—both the most
common one, haloperidol, and the
newer atypicals—is discussed. The in-
adequacies of each in the treatment of
agitation are pointed out. Haloperidol
is not particularly sedating at lower
doses, and the most commonly used
atypicals are not available in parenteral
form. The authors describe a common
solution: combining haloperidol with
lorazepam for sedation, often given in-
travenously. They do note a potential
hazard: that halperidol given via this
route can produce torsade de pointes, a
fatal arrhythmia. However, these two
reviewers of an earlier generation must
point out that for many years chlor-
promazine, in appropriate doses, was
used very effectively to manage agi-
tated delirium without serious compli-
cations. It has the advantage of being
available in intramuscular, oral liquid,
and rectal preparations. Its use should
be considered more often.2
Dementia is becoming an increas-
ingly greater problem for an aging
population. This chapter is a very thor-
ough review of its diagnosis, underly-
ing neuropathology, manifestations
over its clinical course, and the avail-
96 http://psy.psychiatryonline.org
able psychopharmacologic and psycho-
social treatments. The bibliography is
particularly useful for those who wish
to delve further into the subject. There
is an excellent review of worldwide ep-
idemiological data and useful tables
that summarize the power of the known
predictor variables. Since the Mini-
Mental Status Exam is so universally
used, its value as well as its limitations
as a diagnostic instrument are appro-
priately discussed. The subcortical syn-
drome is a less well-known entity and
is well described.
We are all aware of the inadequacy
of definitive treatment. The chapter
was probably written before meman-
tine (Namenda威) became available, but
this new medication has not proven to
be particularly effective. It has been
suggested that its use in combination
with donezepil (Aricept威) may be more
effective, but there are not enough data
to support that claim. The use of psy-
chosocial treatments is also reviewed.
The authors of the chapter “Ag-
gression and Violence” do an excellent
job of reviewing the literature on such
behaviors in general. They provide in-
formation which a consultation-liaison
psychiatrist will find useful. They re-
view their occurrence in psychoses,
personality disorders, epilepsy and re-
lated neurological disorders, and sub-
stance abuse, and provide advice on
management. However, in their effort
to be comprehensive, they dilute this
basic information by using 20 pages to
transmit it.
The chapter on depression is ex-
cellent. There is a fine review of
screening instruments. It contains a
well-documented section on depression
in medical conditions and in heart dis-
ease and stroke in particular. The au-
thors also provide a useful review of
drugs that may cause depression. They
point out the important role of primary
care givers in the diagnosis and man-
Psychosomatics 46:1, January-February 2005
agement of depression and their need
to know when and how to refer patients
for psychiatric consultation.
The chapter on suicidality places
appropriate emphasis on the need to
train primary care physicians on the
identification of the problem and the
need for psychiatric consultation. More
should be written on what advice to
give our colleagues on how this can
best be done. There is also a review of
court rulings on the legal issues related
to physician-assisted suicide and the
experience of the Netherlands.
Similarly, while the chapter “Ma-
nia, Catatonia, and Psychosis” is very
thorough, we question how much of
this information needs to be included
in this particular textbook. We will add
one nugget: mefloquine (Lariam威), an
anti-malarial drug, can cause a range of
psychiatric disturbances including psy-
chosis.
The authors begin the chapter on
anxiety disorder with a formalized
method of diagnosing anxiety that is
unlikely to be used by the consultation-
liaison psychiatrists at the bedside.
They emphasize that our task is to iden-
tify pathological anxiety, or its absence,
in situations where anxiety is to be ex-
pected.
We agree with Breitbart et al.3 that
anxiety in delirious patients is better
treated with sedating antipsychotics
than benzodiazepines. Useful tables list
drugs that can cause anxiety and dose
equivalents of various benzodiaze-
pines. The rather detailed review of
SSRIs in this chapter could be elimi-
nated by referring to the chapter on
Psychopharmacology.
The authors of the chapter “So-
matization and Somatoform Disor-
ders,” through no fault of their own, are
saddled with the confusing DSM-IV
categorization of these disorders. We
are told that a committee is already at
work to devise a better diagnostic sys-

tem for DSM-V. However, once past
the problem of nosology, the chapter is
clinically sound. The writers point out
that most patients with somatoform dis-
order are managed by their primary
care physicians. Smith published a use-
ful paper on how that can effectively
be done to reduce hospital admissions
and medical costs.4 Another useful ref-
erence is the work of Raskin et.al. on
conversion disorder.5 They found that
the classic symptoms of la belle indif-
ference and the symbolism of the
symptom are not common. The chap-
ter’s authors provide a comprehensive
list of therapies that can be used. It
would be helpful to have clinical vi-
gnettes demonstrating how and when
and in what combinations they can be
used.
The chapter “Deception Syn-
dromes: Factitious Disorders and Ma-
lingering” is written by someone with
years of experience exploring this sub-
ject. Charles V. Ford, M.D. It begins
with a fascinating historical note, a de-
scription of medical deception in 200
A.D. He notes that it is essential in
management to distinguish among the
three categories of such patients: the
patient with the classical Munchausen
syndrome who may assume multiple
identities and plague many institutions;
the patient of established identity who
essentially remains the responsibility of
one physician and/or one institution;
and the patient who consciously feigns
illness motivated by anticipation of fi-
nancial or other benefits. While pa-
tients with true Munchausen syndrome
have proven, for the most part, to be
untreatable, not enough is written about
the potentially successful treatment ap-
proaches to patients in the second cate-
gory. Not making this distinction is a
very serious error. These are individ-
uals struggling with personal problems,
who have, for whatever unconscious
reason, chosen this unusual self-de-
Psychosomatics 46:1, January-February 2005
structive mechanism to deal with them.
The most difficult, but not insurmount-
able, task is to motivate these people to
enter psychiatric treatment without
feeling humiliated and risking severe
depression and even suicide. What is
needed is a sympathetic physician who
is able to communicate his appreciation
for the emotional suffering which has
driven the patient to such a desperate
solution of the problem, and also for-
mulate a treatment plan which mini-
mizes humiliation.
While eating disorder patients are
occasionally admitted to the hospital to
treat the severe medical/metabolic ef-
fects of starvation, they do not very of-
ten require the skills of a consultation-
liaison psychiatrist. Severe nutritional
or metabolic disorders are managed by
an internist. Internists can manage that
while the consultation-liaison psychia-
trist seeks a consultation with a col-
league who specializes in this disorder.
Knowledge regarding the diagnosis
and treatment of anorexia and other re-
lated disorders should be a part of any
good psychiatric residency program.
However, it is not needed in this text-
book. On the other hand, the absence
of a discussion of obesity is striking,
since it is certainly an eating disorder
more likely to be addressed by a psy-
chiatrist specializing in psychosomatic
medicine.
The chapter on sleep disorders
presents a short course in what is
known about the most common sleep
disorders. Is it needed in a textbook of
psychosomatic medicine? The case can
be made that consultation-liaison psy-
chiatrists should be able to provide ad-
vice to our colleagues in medicine
whose patients are most likely to pres-
ent with the “problem.” This chapter
meets that need quite well. It also pro-
vides a useful reference on a variety of
herbal agents commonly used for in-
somnia. In addition, it provides useful
Book Review
information on sleep apnea and narco-
lepsy. Surprisingly, however, it does
not discuss the use of modafinil (Pro-
vigil威) in the latter.
The authors of the chapter on sex-
ual disorders present a particularly de-
tailed review of the literature pertaining
to sexual disorders that occur either as
the result of illness or its treatment.
They begin with the cautionary note
that one must not too quickly eliminate
the role of psychological/psychiatric
factors in patients with medical disor-
ders that can produce sexual dysfunc-
tion. They provide clinical examples to
support that observation. There is a sys-
tematic review of the most common
medical and surgical disorders associ-
ated with sexual dysfunction: heart dis-
ease, malignancy, HIV/AIDS, neuro-
logic disorders (including spinal cord
injury), multiple sclerosis, dementia,
and stroke. They report the relatively
successful use of sildenafil. They also
discuss the use of this drug for individ-
uals without concurrent medical/surgi-
cal illness which need not have been
included here. There is a useful table of
medications, including nonprescription
substances, which may produce sexual
dysfunction.
The chapter on substance-related
disorders is a must read for core com-
petence in psychosomatic medicine.
Noted wisely is the frequent reluctance
of primary care givers to make referrals
to a psychiatrist for this problem, or to
do so effectively. It would be useful if
the authors provided advice to be con-
veyed to primary care physicians on
how to best accomplish this.
SPECIALTIES AND
SUBSPECIALTIES
The chapter “Heart Disease” begins
with a review of the role that emotional
factors can play at various phases in the
course of heart disease. Whenever pos-
http://psy.psychiatryonline.org 97
Book Review
sible, it includes a review of possible
associated psychophysiological mech-
anisms. It goes on to address the op-
posite problem, the psychiatric effects
which can arise as a result of heart dis-
ease and cardiac surgery.
Consulation-liaison psychiatrists
have played an important role at each
new phase in the history of cardiac sur-
gery. Their very important role in the
various phases of heart transplantation,
from the selection of recipients to re-
habilitation of heart transplantation, is
well described.
The final section addresses treat-
ment issues: the use of psychotherapy
to reduce psychological risk factors for
coronary heart disease and the after-ef-
fects of an infarction; the use and pos-
sible protective effect of antidepres-
sants in patients with coronary heart
disease and a review of how best to use
antipsychotic agents, anxiolytics, and
stimulants in cardiac patients.
There are two particularly useful
tables. One contains a list of cardiac-
psychiatric drug interactions and the
other a list of medications used in the
treatment of cardiac disease and their
psychiatric side effects.
The authors of the chapter “Lung
Disease” have organized this review of
the role of psychosomatic medicine in
lung diseases as they occur over a life-
span. There is no better place to begin
than with asthma, where the role of
psychosocial factors has been exten-
sively studied. We are alerted to the
need to use the methacholine test to dis-
tinguish anxiety attacks from asthma.
The extensive literature on the role of
psychosocial factors in provoking at-
tacks, the possible mechanisms by
which these effects can be produced,
and the effectiveness of psychosocial
interventions which have been used are
summarized. On the other hand, cystic
fibrosis is discussed from the stand-
point of the emotional impact of the
98 http://psy.psychiatryonline.org
disease on its victims and the coping
mechanisms they can utilize.
The increasing incidence of
chronic obstructive pulmonary disease
requires the serious attention the au-
thors provide. There are psychosocial
factors in play at different stages of the
illness, e.g., in its etiology (the inability
to stop smoking) and the influence of
depression and anxiety in the manifes-
tation and severity of symptoms and
level of disability. The neurocognitive
consequences of chronic oxygen dep-
rivation must not be overlooked. The
authors provide references to recent re-
views of psychotherapeutic, psycho-
pharmacologic and rehabilitation inter-
ventions and summarize these findings.
They provide a thorough review of
the large literature on the role of psy-
chosocial factors in the diagnosis and
treatment of hyperventilation. The
problem of nonadherence to tubercu-
losis treatment deserves more attention.
The section on ventilator weaning dis-
cusses the problems this creates at the
end of life but does not address those
difficulties associated with assisting pa-
tients to become independent of the
machine. There is a helpful review of
drugs used in the treatment of pulmo-
nary illness which may produce psy-
chiatric symptoms and also how best to
use psychopharmacological agents in
these patients. Space need not have
been devoted to lung cancer or lung
transplantation, since they are included
in the chapters on oncology and trans-
plantation.
The authors of the chapter “Gas-
trointestinal Disorders” begin by not-
ing the close relationship between the
gut and the psyche, well known to all
clinicians. The Second Brain by Ger-
shon6 would be a useful additional ref-
erence to help better understand possi-
ble neurophysiological relationships.
The authors note that their use of
the term “functional disorder of the
Psychosomatics 46:1, January-February 2005
bowel” refers to a multifactorial view
of gastrointestinal illness which helps
to avoid the artificial separation of
mind and body that so often plagues
this field. They point out, for example,
that while H. pylori is considered a
causative agent in peptic ulcer, not all
patients who carry the bacteria develop
the lesion. Much has been written on
the relationship between psychological
factors and inflammatory bowel dis-
ease. The authors thoroughly review
this work in all its complexity. They
provide a summary of pharmacological
and psychotherapeutic treatments and
how they can be used most effectively.
Their section on liver disease notes that
hepatitis C virus has become the lead-
ing cause of chronic liver disease in the
U.S. and that the most effective treat-
ment, interferon, has significant psy-
chiatric side effects, especially depres-
sion which can be severe. This was
probably written before the publication
of Musselman’s paper, which suggests
that SSRIs may be effectively used pro-
phylactically.7
Psychonephrology was created to
help nephrologists decide which pa-
tients were most suitable candidates for
renal dialysis, since initially the ma-
chines were not universally available.
Fortunately, that is no longer the case,
and with the subsequent availability of
renal transplantation, psychonephrol-
ogy has become a subspecialty dealing
with the needs of a unique group of pa-
tients. The authors of the chapter “Re-
nal Disease” do an excellent job of re-
viewing the psychiatric problems of
patients with end-stage renal disease at
different stages of that illness. They de-
scribe the responses of patients to the
symbolic and organic effects of chronic
dialysis. The major psychiatric prob-
lem is depression and the availability
of suicide by noncompliance is dis-
cussed. They provide a review of the
psychotherapeutic and psychopharma-

cologic treatments that are most effec-
tive in dealing with the symptoms in
this patient population. There is an ex-
cellent discussion of the role of the psy-
chiatrist in the vexing question of with-
holding or withdrawing treatment.
The authors of the chapter “En-
docrine and Metabolic Disorders” be-
gin by pointing out that the study of
endocrine disorders may present the
best opportunity to study the interac-
tion of psyche and soma. Diabetes, un-
derstandably, gets the greatest atten-
tion. The brief review of the
pathophysiology of Type 1 and Type 2
diabetes is useful. This is followed by
a review of the literature exploring the
possible role of psychiatric factors in
the onset and course of diabetes. The
literature on the role of “stress” is re-
viewed with the conclusion that the
psychophysiology of glucose metabo-
lism is still not clear. Of course, there
is a review of the literature on the re-
lationship of behavior (compliance) to
diabetic control. The complex relation-
ship between depression and diabetes
is thoroughly reviewed. There is a par-
ticularly interesting discussion of the
relationship between diabetes and eat-
ing disorders. The sections on the thy-
roid, parathyroid, and adrenal gland re-
view the associated psychiatric
disorders. In summary, a very thought-
ful review of a fascinating topic.
The chapter “Oncology,” written
by two leading psycho-oncologists, is
a state-of-the-art review of clinical psy-
cho-oncology. The chapter is organized
into several segments, starting with a
section devoted to psychological fac-
tors affecting cancer risk and progres-
sion, followed by a review of psychi-
atric disorders in cancer patients
(depression, anxiety, mania, and delir-
ium) and a brief section on pain man-
agement (the book also contains a
chapter devoted to pain management).
There is a section devoted to the psy-
Psychosomatics 46:1, January-February 2005
chiatric issues in specific cancers (pros-
tate, breast, colorectal, lung). The re-
maining sections include psychiatric
aspects of cancer treatments (chemo-
therapy, radiotherapy, and bone mar-
row transplantation). The chapter con-
cludes with a summary of the uses of
psychotherapy and psychopharmacol-
ogy. Particularly relevant today is the
section devoted to the use of comple-
mentary and alternative medicines, of-
ten used without the supervision or
knowledge of the patient’s oncologist.
There is an interesting short section on
what is referred to as cancer survivor-
ship. The chapter would benefit from
the use of case vignettes. The section
on bone marrow transplantation might
also have included a discussion of stem
cell transplants, now used for a variety
of cancers. The many summary tables
are quite well done.
The authors of the chapter “Rheu-
matology” address the two primary au-
toimmune disorders, rheumatoid arthri-
tis and systemic lupus erythematosus.
They begin with a thorough review of
the diagnosis and treatment of central
nervous system pathology. We believe
it would have been preferable to begin
with the discussions of the two diseases
and place the CNS segment with the
section devoted to systemic lupus ery-
thematosus, where these problems pri-
marily occur. They do an excellent job
of reviewing the emotional reactions to
rheumatoid arthritis with emphasis on
the detection and treatment of depres-
sion. They note the research linking
stress and depression to immune dys-
function but express a reasonable de-
gree of skepticism on any direct link to
the disease process. Patients with sys-
temic lupus erythematosus are much
more likely to manifest psychiatric
symptoms as a direct result of the dis-
ease process and its treatment, usually
with steroids. They provide a useful ta-
ble to help distinguish these corticoste-
Book Review
roid-induced symptoms from those
caused by the illness itself.
The chapter “Chronic Fatigue and
Fibromyalgia Syndromes” addresses
what may be the most frustrating di-
agnostic and therapeutic problems in
medical practice today. These are pa-
tients with often disabling symptoms,
without enough convincing evidence of
pathophysiology, but with enough find-
ings so that they cannot be assumed to
be free of physical disease. The authors
do an excellent job of laying out the
conflicting facts as they appear in the
literature. They argue convincingly that
it is a major clinical error to take an
extreme position by attributing the
symptoms to either an organic or psy-
chogenic etiology (which reflects our
own experience). They point out that
the authors of DSM-V will struggle to
find a category for these patients.
The chapter contains an excellent
clinical description of each of these dis-
orders, which have much in common.
Fibromyalgia is referred to by some as
fatigue with pain while chronic fatigue
syndrome is fatigue without pain. In
our experience the differences are more
distinct. The authors also treat them as
separate entities with overlapping fea-
tures. Chronic Fatigue Syndrome is
considered by some to be the same ill-
ness previously described as post-viral
fatigue syndrome or chronic Epstein-
Barr virus infection.
The authors provide a useful table
of diagnostic criteria for chronic fa-
tigue syndrome and also present the di-
agnostic criteria of the American Col-
lege of Rheumatology for the diagnosis
of fibromyalgia. It includes the need to
demonstrate pain on digital palpitation
at 11–18 specific body sites. They do
an extensive review of the literature on
possible etiological factors which they
categorize as predisposing, precipitat-
ing, or perpetuating. Recently, brain
imaging has been used as a diagnostic
http://psy.psychiatryonline.org 99
Book Review
tool and produced findings which are
tantalizing but not definitive.
They do an excellent job of de-
scribing how these patients might best
be treated with a combination of sup-
portive psychotherapy, psychopharma-
cology and physical therapies, with the
goal of maximum function, but not
elimination of symptoms.
The fascinating chapter “Infec-
tious Diseases” reviews infections by a
multiplicity of agents: bacterial, viral,
prion, parasitic, fungal, and pfiesteria
(look it up) and the neuropsychiatric
problems that can accompany them.
The authors note that such neurological
and psychiatric symptoms can be the
result of the direct effect of the organ-
ism, the body’s efforts to thwart it or a
combination of the two. The list of or-
ganisms is comprehensive and there are
some details of which most consula-
tion-liaison psychiatrists may be un-
aware. For example, how many of us
know about PANDAS (Pediatric Au-
toimmune Neuropsychiatric Disorder
Associated with Streptococcal Infec-
tion)? Of course, there are reviews of
the literature on controversial topics
such as chronic Epstein-Barr virus and
Lyme disease and a reminder that syph-
ilis, in its various manifestations, may
be having a resurgence. This chapter
will be a useful resource.
The chapter “HIV/AIDS” is orga-
nized into the following sections: a
brief overview of the epidemiology of
HIV, a strong section entitled Neuro-
psychiatric and Medical Complications
of HIV (including cryptococcal men-
ingitis, toxoplasmosis, cytomegalovi-
rus infections and PML [progressive
multifocal leukoencephalopathy], fa-
tigue, and CNS neoplasms). Another
outstanding section reviews the diag-
nosis and treatment of the psychiatric
conditions associated with HIV: delir-
ium, dementia, major depression, bi-
polar disorder, schizophrenia, PTSD,
100 http://psy.psychiatryonline.org
and substance abuse. This latter section
is extremely well written, detailed, and
well referenced. The discussion of HIV
dementia is exemplary. The area of per-
sonality and personality disorders is
based primarily on the authors’ own
experience and would benefit from a
review of the pertinent literature. The
section dealing with psychosocial in-
terventions to prevent HIV transmis-
sion and adherence and nonadherence
to treatment regimens is well done. The
chapter would benefit from a review of
the basic diagnostic tests and current
medical treatments, especially of drugs
such as efavirenz (Sustiva威), which has
known neuropsychiatric side effects.
The author of the chapter “Der-
matology” describes skin diseases that
are affected by psychosocial factors as
well as psychiatric illness in which the
skin is the target of disordered thinking,
behavior, or perception. In the first
category are such illnesses as atopic
dermatitis (eczema), psoriasis, urti-
caria, and acne. This chapter also pro-
vides another example of the problems
that DSM-IV has had in dealing with
such disorders. In the second category
are impulse control disorders (psycho-
logical excoriation) such as trichotil-
lomania and formication. A table has a
useful list of the cutaneous effects of
psychiatric medications. It would have
been useful if there were a similar list
of the psychiatric side effects of medi-
cations such as corticosteroids, com-
monly used in dermatology.
We would have wanted the author
to devote more space to the psycholog-
ical impact of skin disease on individ-
uals, since that is usually what brings
the patient to a psychiatrist. The author
also discusses in some detail the use of
pimozide for delusions of parasitosis
without a discussion of the use of the
atypical antipsychotics, which are com-
ing into greater use. However, we are
Psychosomatics 46:1, January-February 2005
unaware of any studies comparing their
effectiveness.
The authors of the chapter “Sur-
gery” review psychiatric issues as they
pertain to the basic experience of sur-
gery: preoperative anxiety, the re-
sponse to early post-operative compli-
cations, and the adjustments required
for a successful recovery after hospital
discharge. The authors also deal with a
common, but little discussed, issue: the
transference and countertransference
responses of surgeons to their patients.
They provide a comprehensive review
of the management of the post-opera-
tive problems, some of which are ge-
neric, such as post-operative delirium.
One reviewer (D.S.K.) was pleased to
note that they pointed out the danger of
invoking the misuse of the diagnosis of
ICU psychosis while not pursuing
more likely underlying pathophysio-
logical etiologies. They also discuss the
psychiatric problems that are proce-
dure- and specialty-specific, for exam-
ple, phantom limb after amputation, the
treatment of severe burns, and surgery
for severe obesity as well as those as-
sociated with gynecology, cosmetic
surgery, and ophthalmology.
In the 50 years since its first suc-
cess, organ transplantation has become
accepted as almost a routine procedure
by the medical community, but it con-
tinues to be perceived as miraculous by
organ recipients and their families. The
chapter “Organ Transplantation” is
very well done. It reviews the roles of
the consulation-liaison psychiatrist as a
critical participant in the initial evalu-
ation of the potential recipient and, per-
haps, a living donor; in pre-operative
preparation of patients and donors; in
hospital post-operative management,
and finally, dealing with patients’ re-
actions to their efforts to re-enter the
world of the well while they must still
deal with the demands of their lifelong
life-saving medical regimens. The au-

thors do an excellent job of providing
the knowledge required to assist a psy-
chiatrist at each of these stages. The in-
formation provided comes with an ex-
cellent review of the pertinent
literature.
The various psychological instru-
ments most often used as initial screen-
ing devices for transplant candidates
are described. The use of self-report
methods is efficient, but is it adequate
for this task? Can it replace the value
of an interview by a psychiatrist who
knows what lies ahead for the potential
patient? The authors believe that psy-
chiatrists play a complex role in which
their primary goal is to serve the needs
of the transplant team and not those of
the patient. To strike a balance between
these two responsibilities may be the
greatest challenge, and an even more
daunting one as living donors are being
used more frequently.
The authors provide a very com-
prehensive review of the specific psy-
chopharmacologic and psychothera-
peutic knowledge required to manage
the wide range of psychiatric problems
which may emerge along the way. This
includes the specific information
needed in the management of the trans-
plantation of each of the organs most
commonly transplanted: kidney, heart,
liver, and lung.
The authors of the chapter “Neu-
rology and Neurosurgery” observe that
for some, the divide between neurology
and psychiatry has been a “historical
artifact.” Certainly, recent develop-
ments in both fields suggest that may
be true. Their chapter reviews the vari-
ous clinical states in which a knowl-
edge of both is required for optimal pa-
tient care.
The issues encompassed by the
chapter “Obstetric and Gynecology”
should not be confined to the knowl-
edge base of consulation-liaison psy-
chiatrists alone. They are matters which
Psychosomatics 46:1, January-February 2005
should be of concern to all practicing
psychiatrists. Reproductive issues in
women are likely to arise in a psychi-
atrist’s practice every day.
The chapter begins with issues in
benign gynecology: gender identity, in-
fertility, contraception, sterilization,
hysterectomy, abortion, chronic pelvic
pain. The second section deals with is-
sues of pregnancy, psychiatric disor-
ders during pregnancy, denial of preg-
nancy, pseudocyesis, hyperemesis,
postpartum psychiatric issues, and fi-
nally, psychiatric treatments (drugs,
psychotherapy, and ECT) during preg-
nancy and lactation. Following these,
there are sections on premenstrual
problems, perimenopause and meno-
pause, urinary incontinence, and a brief
section on how these issues affect the
men in women’s lives. The authors
may have assumed that gynecologic
oncology would be covered in the On-
cology chapter, which it is not. A future
edition can address that.
It might have been preferable to
organize the latter section by phases in
a woman’s life, i.e., beginning with
pre-menstrual disorders rather than
placing it together with problems such
as menopause and urinary inconti-
nence, which affect older women. It
might also have been preferable to dis-
cuss treatments during pregnancy in the
same section devoted to psychiatric
disorders of pregnancy.
The references are up to date and
relevant. However, future editions
should include the most recent edition
of Drugs in Pregnancy and Lactation
by Briggs et al.8 Still, there is much that
is valuable here for all psychiatrists.
Overall, the chapter “Pediatrics” is
a comprehensive and useful overview
of the identification, evaluation, and
management of psychiatric syndromes
seen in children with medical illness or
children who present with physical
symptoms. Its strengths include litera-
Book Review
ture reviews of data on psychiatric ill-
ness and symptoms in specific popu-
lations of medically ill children;
recommendations for factors to con-
sider when evaluating specific popula-
tions of medically ill children; and the
treatment sections, which include re-
views of psychotropic agents that can
be used in specific syndromes.
Also strong are discussions of chil-
dren’s cognitive understanding of ill-
ness; the importance of a focus on fam-
ily systems issues; the relationship of
depression to functional disability; the
importance of social support; the dif-
ferential diagnosis of mood and anxiety
symptoms, and the importance of
screening and prevention measures.
There is an important discussion of
problems of adherence to treatment and
the issues surrounding death and dying.
Delirium and the management of
chronic somatic symptoms are ad-
dressed, including the lack of utility of
the “organic vs. nonorganic” dichot-
omy. A number of specific illnesses
were addressed in order to emphasize
the potential psychological factors that
can affect medical morbidity. Unfortu-
nately, the section entitled “Psychotro-
pic Medication,” focuses exclusively
on potential cardiac side effects of psy-
chotropic medication (perhaps that
could have been reflected in the title),
rather than giving any overview of
other potential side effects or the use of
such medication. The authors might
have referenced Scahill et al.’s Text-
book of Pediatric Psychopharmacol-
ogy.9
Our role in “Physical Medicine
and Rehabilitation” deserves more at-
tention than it currently receives in
consultation-liaison training programs.
This chapter will help. It begins with
the current WHO classification system
of disabilities, The International Clas-
sification of Functioning, Disability
and Health (ICF) which now treats the
http://psy.psychiatryonline.org 101
Book Review
burden of all illnesses, including men-
tal illness, equally. It focuses on two of
the most common disorders: traumatic
brain injury and spinal cord injury, and
their psychiatric consequences.
The chapter reviews the fascinat-
ing sequence of pathophysiological
events following traumatic brain injury,
which produce varied psychiatric pa-
thology: depression, anxiety (including
PTSD), anger, agitation and aggres-
siveness, and the postconcussive syn-
drome. A similar thorough approach is
used in the discussion of spinal cord
injury. Each diagnosis is discussed in
depth with a thorough review of the
pertinent literature providing useful
tools in diagnosis and treatment. The
discussions of the merits of various
psychotherapeutic and psychopharma-
cological interventions are thorough
and helpful. In summary, this is an out-
standing effort on a subject which mer-
its it.
The authors of the chapter “Pain”
provide a comprehensive review of the
topic. They describe the management
of acute pain and the common chronic
pain syndromes. Each of the latter is
well described and, where known, the
underlying pathophysiology is re-
ported.
Consulation-liaison psychiatrists
often play an important role in the man-
agement of both acute and chronic
pain. With acute pain, they must be pre-
pared to deal with the persistent reluc-
tance of physicians to provide adequate
treatment with narcotics for fear of pa-
tients developing addiction.
The discussion of each chronic
pain syndrome contains a review of the
current treatments and their relative
merits. The chapter includes an impor-
tant section on the psychiatric comor-
bidity that is common in these patients.
Particular attention is paid to the com-
plex role of depression. The chapter
concludes with a summary of the vari-
102 http://psy.psychiatryonline.org
ous pharmacological and psychological
treatments used for the treatment of
pain. Acupuncture and hypnosis are not
included and should be discussed since
they are in common use, and consula-
tion-liaison psychiatrists should be
aware of how they might be used most
effectively.
TREATMENT
The chapter “Psychopharmacology” is
very well done. It initially reviews prin-
ciples of pharmacokinetics in the med-
ically ill and drug-drug interactions. In
addition to the standard psychiatric
pharmacopiae there is an interesting
section on Complementary Medicine,
including herbal compounds. Particu-
larly pertinent for the users of this text-
book is the excellent section reviewing
drugs that require particular monitoring
in patients with renal and hepatic in-
sufficiency. The table would be even
more useful if it included patients with
cardiac failure and pulmonary insuffi-
ciency. The final review of P450 inter-
actions is also particularly useful.
The chapter “Psychosocial Treat-
ments” includes a thorough review of
the non-pharmacological therapies. A
variety of group therapies are evalu-
ated, as well as hypnosis, psycho-edu-
cation, and family treatment. The sum-
mary tables unfortunately demonstrate
the need for more well-designed statis-
tically significant outcome studies of
these modalities. The lack of such data
should not be interpreted to reflect
negatively on their potential value,
Since a convulsion is no longer
produced in this treatment we believe
the chapter “Electroconvulsive Ther-
apy,” should be retitled “Electrical
Stimulation Therapy.” That would be
technically more correct and less likely
to produce the fear and stigmatization
associated with use of the older termi-
nology. We also doubt the need to in-
Psychosomatics 46:1, January-February 2005
clude this subject in a book for trainees
and practitioners of psychosomatic
medicine.
The final chapter, perhaps appro-
priately, deals with “Palliative Care.”
This is a valuable contribution at a time
when hospitals have become increas-
ingly aware of the needs of terminally
ill patients. These needs are being met
by the creation of multidisciplinary pal-
liative care services. The crucial role of
the psychiatrist in these services is well
described in this excellent chapter. It
reflects the authors’ vast experience in
dealing with these issues at the Me-
morial Sloan Kettering Cancer Center,
and their knowledge of the pertinent lit-
erature. They begin with a useful list of
books on the subject for those who
wish to explore it in more depth. A use-
ful addition would be Becker’s Denial
of Death.10 The subtext of the entire
chapter is a description of the complex
psychological process of dying. Lay-
ered upon that is a description of the
variety of ways in which the psychia-
trist can play a therapeutic role.
They point out the need to distin-
guish clinical depression from what
others may consider the “normal reac-
tion” to the situation and how to make
that distinction. There is a sophisticated
discussion of suicide, assisted suicide,
and the desire for hastened death. They
deal with the detection, assessment,
and management of these different re-
actions to the impending end of life.
The chapter also includes a discussion
of the pharmacological issues to be
considered for patients at this late stage
of illness, and the psychotherapeutic
interventions that have been utilized
and where they seem to be most effec-
tive. While the symptoms of pain, as-
thenia, anorexia, and nausea are usually
considered the responsibility of other
caregivers, this chapter provides useful
information and references for the psy-
chiatrist who may ultimately serve as a

patient’s primary physician when an in-
terdisciplinary palliative care team is
not available.
SUMMARY
This is a very well written comprehen-
sive textbook. Like previous books on
this subject (quaintly entitled Textbooks
of Consultation-Liaison Psychiatry), it
is over 1000 pages long and weighs al-
most seven pounds. This size reflects
its successful effort to be comprehen-
sive; however, like its predecessors, it
unnecessarily includes information that
its audience of trained psychiatrists
should already know, in addition to
what fellows in training should learn
and practitioners should have available.
Psychosomatics 46:1, January-February 2005
The weightiness of our specialty need
not be demonstrated by the heft of our
textbooks (or the length of its book re-
views).
Dr. Kornfeld is the Associate Dean
of Faculty and Dr. Wharton is Clinical
Professor of Psychiatry at Columbia
University College of Physicians and
Surgeons.
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