Presented as a clinical companion resource for the third edition of a textbook by Maxmen, Ward, and Kilgus published in 2009, this volume includes a total of 38 clinical cases organized in five groups of “pathologies”: thought, mood, anxiety, blended, and pervasive. The Introduction, an essay titled Clinical Decision Making, is a suggestive distillation of reflections about the crucial exercise that we clinicians call diagnosis, an area that, in psychiatry, has reached almost a mythical status (if we consider myth as both a fantasy-impregnated legend and a stabilizing force in the historical route of collectivities). In such context, this opening chapter deserves as critical an examination as the clinical cases themselves because of its uneven combination of luminous insights and superficial assertions. The readers, of course, will elaborate their own conclusions.
The authors pay tribute to “clinical experience,” the level of mastery that, full of fluidity, confidence, and deftness, grows as the years pass, in the same way that the dexterity of painters and other artists reaches its peak. They announce the structure of the cases as an effort to respond to a list of questions that go from the patterns of clinical presentations to estimations of clinical course and mention of systems-based practice issues (legal, ethical, cultural) through crucial information about functional impairment, differential diagnosis, and treatment options. Most of these aspects are cogently elaborated and will certainly contribute to the student’s or trainee’s capturing details of deep relevance in the clinical evaluation process. In that sense, yes, the text “opens a window into the minds of senior clinicians” (p. 1) for the young men and women to enjoy the landscape.
On the other hand, statements like “psychopathology is the manifestation of three primary aspects (mood, anxiety and thought)” (pp. 1–2) sounds as belittling (some could conceive the term pre-Jaspersian psychopathology) as the one that affirms that “researchers simplify and look at disruption in a single sphere (e.g., mood)” (p. 2). Similarly misleading, “if psychiatric symptoms remain vivid over time, their chronic presence becomes incorporated into the person’s personality and interferes with normal and adaptive human development. These individuals develop a pervasive and usually maladaptive pattern of interacting with others that is almost immutable—a personality disorder” (pp. 2–3) describes a questionable, almost upside-down etio-pathogenesis of personality disorders (PDs). If the purpose of assertions like these is to generate discussions with and among the students about critical concepts in our field, so be it, but supervisors must make clear that PDs are not as simple as the quote above may lead to.
There is also in the Introduction a precious analytical summary of the outcome of the stormy debates about Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), now happily among us. By the same token, some readers would look, expectant and illusioned, for the content of the subsection on “evidence-based biopsychosociospiritual treatment options” in the clinical cases, only to be disappointed by commonplace statements, unaware of the big steps taken by DSM-5 to give culture and proven cultural components a better place in diagnosis and clinical management. Quite original sections for each case are those that discuss clinical course without and with due treatment and the history, terms, and resources that provide quite practical parameters and recommendations, bibliography, and even movie lists that illustrate, sometimes better than scholarly dissertations do, the meanders of complex psychopathologies.
There are nine cases in the Thought Pathology (Part I), mixing major cognitive disorder, delirium, psychoses, insanity, delusions, autism, and attention problems, certainly a mixed bag. Part II, Mood Pathology, includes four cases and uses mnemonics in some of them, as a consolidating diagnostic tool; care should be taken, however, about the meaning of some terms: It is said, for example, that dysphoria is “sadness” (when general agreement is that dysphoria represents a mix of irritability and anxiety) or that “indecisive” means “poor concentration” (pp. 185–186). There are no cases of dysthymia or of the new disruptive mood dysregulation disorder. Five other cases constitute Part III, Anxiety Pathology, where school refusal is considered but not panic disorder (this diagnosis “in childhood” goes in the next section); here, the opportunity is also missed to include, for instance, the “cultural syndrome” most studied in the literature, ataque de nervios, an accepted differential diagnosis of generalized anxiety and panic in DSM-5.
Not surprisingly, Blended Psychopathology (Part IV) offers the largest number of cases (16) “that may have originated from a dysregulation in one of the primary groups and progressed to involve the others” (p. 3). To generalize “unexplained physical symptoms” as conversion disorder and to mention that somatization is “reportedly seen more in rural, low socioeconomic, and less educated populations” reflect only the poor information about and intriguing complexity of some clinical occurrences. The heterogeneity of “blended disorders” will hopefully convey to students and trainees these features (complexity and limited knowledge) among many psychiatric conditions: The case on pain is dramatically dense along these lines.
Finally, Pervasive Psychopathology (Part V) seems focused mostly on traits of four of the 10 DSM-IV PDs. It starts with the conceptually and nosologically weakest narcissistic PD, even though the case is wisely titled “Narcissism” (p. 537) to reflect perhaps the predominant nature of the concept as a trait or a domain, not a single clinical entity. Dominant characteristics of borderline, obsessive-compulsive, and antisocial PDs fill the next presentations, all of them with abundant and pertinent information. To say that psychopathology is “pervasive” in most, if not all, types of psychiatric entities may sound more like a soft reproach than a substantial objection.
The line above somehow summarizes the overall impression with which the reader is left at the end. Teaching the clinical exploration of psychopathology is fundamentally a labor of love, nourished of course by experience, ingenuity, and steps systematically taken. This book, which could stand independently from its parental volume, attempts to take the trainee by his/her hand into the roads of complexity and confusion that every clinical assessment is. In the end, it is humanity facing adversity that requires generous broadness even if blurry at times, that attempts thoroughness even if sometimes ambiguous, and that determines coherence even if occasionally fragile. This casebook plays its role satisfactorily. Teachers and educators of several mental health professions will appreciate its merits and improve its accomplishments as they read it.
Renato D. Alarcón, MD, MPH
Emeritus Professor of Psychiatry
Mayo Clinic College of Medicine
Honorio Delgado Chair
Universidad Peruana Cayetano Heredia
The author declares no conflict of interest.