If the main purposes of a textbook devoted to a medical discipline are to present a thorough view of the current state of knowledge, a well-organized list of the changes since its previous edition, and a vibrant, exciting yet balanced perspective of the future, then Psychiatry, Fourth Edition, is that book. Two new editors joining Tasman, Kay, and Lieberman; 12 associate editors; and 342 contributors (42 of them from outside the United States) have produced a new version of, quite likely, the best text of its kind across the world. Ten sections, 132 chapters, and one appendix document eloquently, in the 2687 pages of the two volumes, the “imperative to integrate the best of our humanistic traditions with our cutting-edge scientific advances” and make it “the organizing heart” of the book's content, as stated in the Preface (p. XLI). Minor errors such as the repetition of one contributor's name or the academic appointment place of another do not take away a rich variety of innovations, both technical (i.e., companion Web site, available PDF copies, downloadable images) and structural (i.e., new topics, abundant and pertinent vignettes, very informative tables, beautiful illustrations), that vigorously confirm the presiding didactic philosophy of the text.
Section I is titled Approaches to the Patient. Its first chapter (Listening to the Patient) opens up with a storytelling-like sentence: “It was Freud…” aimed at a reaffirmation of his contribution to an essential component of the healing process. Another early and comforting note is Chapter 4, The Cultural Context of Clinical Assessment, a cardinal aspect of every clinical encounter with every kind of patient, and not only with minority members like the vignettes would suggest. Cultural competence as the initial step of a strong antistigma learning journey, cultural dynamics as part of a comprehensive process model of pathology, and cultural inquiries as an antidote against a priori conceived answers during the interview: are the pillars of this valuable approach.
Section II brings up a much needed developmental perspective that not only clearly describes (and distinguishes) classical terms such as personality, character, or temperament but also explains modern theoretical approaches and conceptualizations, from genetic to moral grounds, throughout the different phases of the life cycle. This is a cogent introduction to Section III on the Neuroscientific and Section IV on the Psychological and Socio-scientific Foundations of Psychiatry and Psychotherapy. The former describes the biological commonalities among different psychiatric disorders (“discrete entities vs. overlapping continua,” p. 245) and the daunting complexity of mental diseases and includes probably the best summary of the Research Domain Criteria, the National Institute of Mental Health's most precious theory nowadays. The latter delineates findings in efficacy studies, provides a nice presentation of psychiatric epidemiology, and although not dealing with subareas such as cultural epidemiology, analyzes the expanding scope of this field of inquiry. Chapters 26 to 29 do a similarly complementary job cleverly examining the cognitive and psychodynamic models of the mind as roots of precision medicine, “modularity,” and much needed integration. Chapter 30, Positive Psychology, revives and enhances Seligman's pioneer contributions and his pragmatic motto: “Build what's strong, fix what's wrong.”
A rational and reasonable pragmatism continues to permeate Section V, Manifestations and Assessments of Psychiatric Illness. It goes on fostering a multimodal approach that, of course, includes exhaustive clinical evaluation, instrumentalized testing (i.e., brain imaging) whenever possible, and cultural considerations of diagnosis and treatment. Not surprisingly, Section VI (Disorders) is the longest of the two volumes, with the chapters on schizophrenia, depressive, and neurocognitive disorders covering 63, 64, and 60 pages, respectively. A clarifying discussion of the new label disruptive mood dysregulation disorder is slightly marred by a confusion with Table 52-4 (misnumbered as 52-3 in the text) containing the diagnostic criteria. Similarly, there are interesting conceptual pronouncements about the new model on personality disorders now included in Section III of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, even though it is wrongly called “dimensional”: In reality, it is a “hybrid” or categorical-dimensional combination model, more in consonance with acceptable realities of today's clinical knowledge and practice about these disorders.
One of the most luminous chapters of the book is no. 87, the first of Section VII, Psychotherapeutic and Psychosocial Treatments. Titled Organization and Economics of Mental Health Treatment, it is an objective, dispassionate analysis of “how and where care is delivered and by whom to whom” (p. 1787), with sobering conclusions about the complexity and fragmentation of our current mental health “system.” A similar objectivity is the characteristic of further chapters on psychoanalytical and cognitive psychotherapies and early interventions. A “rapprochement” between therapist/clinicians and researchers in favor of a better practice is an underlying message that goes from a better knowledge of the neurobiology of psychotherapy to a “guided discovery” of clinical phenomena and proclaims to adopt new paradigms “critically, not idealistically” (p. 1990). And a fascinating exposition of telemedicine, tele-psychiatry, “smart” devices, social media, and the human/technology interface reveals the wealth as well as the potential conflicts of these at times overwhelming developments.
Some duplication of information inevitably occurs in printed works of this magnitude. Such is the case of Chapter 101 in Section VIII under the heading Pharmacological and Brain Stimulation Techniques. The first part includes, without naming it, a lot of the new subdiscipline of psychiatric pharmacogenomics (Mrazek, 2010), pointing out cross-ethnic and interindividual variations in drug metabolism. There is a uniform and impressive high quality in all the psychopharmacology chapters, with basic science explanations, mechanisms of action, updated lists of compounds, practice use alternatives, informative tables, and illustrations. This also applies to the topics of cognitive enhancers, treatment of neurocognitive disorders, brain stimulation techniques, and management of treatment-resistant depression. Integrative psychiatry, adherence, psychosomatic medicine, and collaborative care (the latter fully developed in Section IX) are, in addition, novel topics in the textbook. Interestingly, the terms culture or cultural factors are not mentioned in these chapters even though the topics unveil the demographic, family-based, and motivation- and belief-related implications of such perspective. The same can be said about the chapter on death and bereavement. Academicians and practitioners, researchers, and clinicians alike would greatly appreciate the clarifying models of integrated care and the everyday application of a genuine culturally competent management of diagnosis, outcome tracking, and stepped care treatment-to-target approaches.
Section X examines very pertinent issues of emergency psychiatric care, violence, and management of suicidal patient and behavior. And Appendix I includes a very well-written chapter on research methodology and statistics, and another (the last one, that I would have placed in a more prominent part of the book), a masterful brief history of psychiatry that takes us from the Iliad to the times of Buddha and early Biblical eras through the march of several centuries in mostly European settings to the more American 20th. and 21st., with Freud and his followers, Bleuler, Meyer, Sullivan, Wolpe, Winokur, van der Kolk, Kandel, or Priebe at the helm. A wonderful Chronology of Historical Events and Persons crowns this closing chapter.
Jaspers (1965) is not mentioned in the text, but I will finish this review quoting brief paragraphs of his that, eloquently, seem to emphasize the central features of Psychiatry, 4th Edition, as a classic in psychiatric teaching and learning. These are the words of a wise man about what psychiatric education, training, research, and practice must be:
…we must foster an attitude away from platitudinous speculation, dogmatic theorizing, absolutism in every form…(and)…emphasize the key role of recreating the patient’s anomalous experience through a process of empathic “imaginative actualization” and critical attention to both the content and the form of (his/her) psychopathological experience…If psychiatrists lack a sufficient level of general intellectual sophistication—if, for example, they knew only “compendiums” of symptoms and the like—their supposed expertise would in fact be superficial pseudo-knowledge….more subversive for practice than total ignorance.
Renato D. Alarcón, MD, MPH
Emeritus Professor of Psychiatry
Mayo Clinic College of Medicine
and Honorio Delgado Chair
Universidad Peruana Cayetano Heredia
The author declares no conflict of interest.