152 Book Reviews

© 2002 WILEY-LISS, INC.

DEPRESSION AND ANXIETY 15:152–156 (2002)

Book ReviewsBIPOLAR DISORDERS. BASIC MECHANISMSAND THERAPEUTIC IMPLICATIONS. Jair C.Soares and Samuel Gershon, (eds.). New York:Marcel Dekker, Inc., 2000. XV+, 80 p.

The last 25 years of the nineteenth century wit-nessed a substantial growth of research devoted to theunderstanding of the pathophysiology of bipolar dis-order. The discovery of new drugs for the treatmentof this illness and the impetus to understand theirmechanisms of action have provided innovative linesof inquiry to investigate the basic mechanisms of bipo-lar disorder. The title of this book fully acknowledgesthis parallel pursuit, and its 26 chapters fulfill the in-creasing need to collect and present this informationin an organized and coherent fashion. The editors ofthis book set out the goal of filling the informationgap on the basic mechanisms of mood disorders,particularly the developments in the area of neuro-psychopharmacology that have recently focused onsignal transduction abnormalities.

The first chapter deals with the issue of classifica-tion. In this chapter, Bowden aptly discusses some ofthe inconsistencies and limitations that stem from theahistoric and atheoretical bias of DSM-IV, and arguesfor the cautious incorporation of dimensionally de-fined bipolar symptoms. Gary and colleagues comple-ment his views in chapter 21, where they examine thebiological differences between subtypes of bipolar dis-order. They review current information regardinganatomical, neurotransmitter, endocrine, and treat-ment response among bipolar disorder subtypes toilluminate the need for continued experimental evalu-ation in this area. These efforts will be not onlyimportant for classification but also for guiding phar-macological intervention.

The second chapter takes advantage of the somewhatlocalized neuropathology of some specific disorders,such as stroke, traumatic brain injury, Huntington’s dis-ease, Tourette’s syndrome, and multiple sclerosis,thought to be associated with secondary mania, to hy-pothesize that this disorder arises from the disruptionof the orbitofrontal-subcortical network. The authorspresent the available information about brain connec-tions and neurotransmitter function that modulateemotional and social behaviors and speculate that thesame structures altered in conditions associated withsecondary mania may also be implicated in primary bi-polar disorder. They temper their assumptions by in-sisting upon the fact that additional risk factors thatmust be concurrently present for secondary mania todevelop have not been ascertained. The chapter onthe genetic factors in bipolar disorder is clearly writ-ten. The authors review the meandering journey of

the history of the search for genes for bipolar disorder,including family studies, twin and adoption studies,and association and linkage studies with a focus onmethodological issues. They underscore the difficul-ties inherent in the attempt to locate causative geneswhen the model of inheritance is undefined and thegenetic validity of diagnostic criteria has not been es-tablished.

Jules Falret, in one of his lectures at the Salpêtrièrein 1851, described a condition that he termed “formecirculaire de maladie mentale.” This was the first recog-nition of the cycling nature of bipolar disorder. Antel-man and colleagues propose in chapter 4 a possiblecycling model of bipolar illness, based on the conceptof extreme sensitization that derives from their workon mood swings provoked by cocaine sensitization. Inother words, an oscillatory pattern of responsivenessarises when repeated exposure to stressors or drugsdrive sensitization to the extreme of physiologicalrange. Himmelhoch examines the companion conceptof switch process in chapter 14 with little overlapping.He first discusses secondary bipolar syndrome in thelight of effects of neuronal loss on the switch processand the intriguing concept of its adaptive value for abrain-injured organism. He then moves to the primarybipolar disorders to thoroughly discuss issues of age,gender, and effect or antidepressant treatment onrapid cycling and the switch process. Himmelhochalso discusses the relationship of bipolar depression toinvoluntary motor disorder in chapter 16. BenjaminBall was the first to observe the similarities betweenparalysis agitans and melancholia in 1882 [Ball, 1882].Since then, this parallel has been seldom visited. Inthis chapter the author reviews the evidence, albeittheoretical, of the relationship between Parkinson’sdisease and the bipolar disorders, including their psy-chopathological, neurophysiological, and pharmaco-logical intertwinings.

It is now clearly recognized that neurotransmitteractions are not the only mechanisms by which neu-ronal function is regulated. In addition, intracellularsignal transduction pathways play an essential role inneuronal communication and constitute an importantarea of research aimed at elucidating the mechanismsof action of mood stabilizers as well as illuminatingthe molecular and cellular events that underlie thepathophysiology of bipolar disorder. The chapters onneurotransmitter dysfunction and intracellular signaltransduction in bipolar disorders are some of theclearest presentations that can be found in the litera-ture. However, this is not to belittle the other chap-ters, since they are all excellent. The chapter byThase on the psychotherapeutic interventions in bi-polar disorder is refreshing. The psychotherapeuticmechanisms that may enhance medication effects ordampen illness pathophysiology are well explained.Unfortunately there is a dearth of research in thisarea, probably because the training of psychothera-pists and pharmacotherapists diverge and few people

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can move at ease in both areas of research. Thereforewe can only speculate about the potential benefit ofpsychotherapeutic interventions in bipolar disorder.Our own work with bipolar families show that someaspects of family dysfunction can predict treatmentcompliance and that interventions aimed at correct-ing these dysfunctional structures may have a positiveimpact in treatment outcome of bipolar patients [DeLeón et al., 1985].

Other chapters range from cellular abnormalities toviral etiologies, neuroimaging methods, postmortemstudies, electroencephalogram findings, the role ofenvironmental stressors, and the sensitization and kin-dling model. The biological factors in bipolar disor-ders in young age and late life are also well reviewed.

As may be gathered from this review, this book col-lects a group of significant contributions to the field ofbipolar disorders. These essays, written by recognizedexperts, reflect the richness and diversity of the con-temporary research being pursued in this area. Theapproach to the subjects is scholarly, but at the sametime the book is written in clear language throughout,with little overlapping, reflecting a strong editorialhand. The editors succeed in their stated goal of pre-senting “a complete and accessible reference to themost updated information on the biological basis andemerging therapeutics of these disorders.” The bookis accessible to a wide range of readers, researchers,and clinicians that have an interest in bipolar disor-ders, and who are keen to learn about the latest devel-opments in the neurobiology of bipolar disorders andthe implications for treatment.

REFERENCESBall B. 1882. De l’insanite dans la paralysie agitante. l’Encephale

2:22–32.De León OA, Rodríguez V, Medina I. 1985. Transacciones famil-

iares y adhesión a la farmacoterapia con litio. Acta Psiquiatrica yPsicologica de America Latina 31:7–16.

Ovidio A. De León, M.D.Department of PsychiatryUniversity of Illinois at ChicagoChicago, Illinois

DOI: 10.1002/da.10029Published online in Wiley InterScience (www.interscience.wiley.com).

MOOD AND TEMPERAMENT. David Watson.New York: The Guilford Press, 2000. 340 p.$40.00

“Mood and Temperament” presents the author’s re-search program and his exploration of the emergingliterature on the topic. The main purposes of the book

are to summarize key findings on the subject, topresent relevant theoretical views, and to examine thenature and significance of two biobehavioral systems.The intended audience includes clinicians, neurosci-entists, scholars, and professionals with a reasonablebackground in psychological and psychiatric research.

It can be said that the book is, in essence, an explo-ration of feelings, arguably the most recognized butthe least scientifically studied concept in psychology.In his famour book “General Psychopathology,” pub-lished in 1942, Jaspers comments that we call feelings“all psychological concepts that could not be in thesame level with conscious, instinctual, and voluntaryacts.” Forty-six years later, Stagner comments: “Un-fortunately, until quite recently, mood fluctuationscould only be studied through careful introspection, anotoriously unreliable and scientifically unsatisfactoryapproach.” Through a well-organized sequence, backedup by 40 pages of references, the author of this booktakes us from the simple to the complex, from feelingsand mood to temperament, exploring relations be-tween psychological, social, and environmental fac-tors, and biobehavioral systems.

The introductory chapter describes the book’s pur-poses with a Cartesian accuracy, dissecting objectcharacteristics and differentiating similarly soundingconcepts. It tells us that waking consciousness is expe-rienced as a continuous stream of affect, traits, andtemperament that include associated cognitive and be-havioral characteristics. Upon this conceptual basis, aschematic model of affective experience is presentedincluding exogenous and endogenous factors, socio-cultural rhythms, and characterological variability.

Chapter 2 presents the author’s approach to themeasurement of mood. Watson discusses the structureof the scales that he and his colleagues developed(PANAS-X) and establishes three properties of moodratings: convergent, discriminating, and hierarchical.In chapter 3, the author starts to illustrate this modelof affective experience with the exploration of the situ-ational and environmental influences on mood. Hebrings up factors such as stressful events, strongly asso-ciated with transient elevations of negative mood, butinconsistently related to changes in positive mood. An-other factor, social interaction, has a much stronger as-sociation with positive than with negative mood. Aslong as the pattern of social interaction is systematic,even relatively small affects can exert a powerful influ-ence on mood over time. Exercise and physical activityproduce a significantly improved mood in individualswho are initially dysphoric. Furthermore, virtually ev-eryone believes that his or her mood is significantly af-fected by the weather, yet, the few available studies arequestionable because of methodological problems.One tentative conclusion for the reader is that researchevidence has established important disjunctions be-tween our beliefs and our actual affective experience.

Chapter 4 discusses endogenous and socioculturalrhythms that produce systematic patterns in positive

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and negative affects: diurnal, seasonal, weekly, andmenstrual cycles. Positive affect exhibits a strong sys-tematic circadian rhythm, not displayed by negativemood. In general, good seasonal research is extraordi-narily complicated. Similarly, methodological prob-lems in the study of the menstrual cycle’s affectivepatterns further confuse the issue, making it very diffi-cult to reach definite conclusions.

After presenting and discussing moods, in chapter 5,Watson examines the two most important affectivetraits, Negative and Positive Affectivity. He presentsevidence that trait scores show a reasonable level ofconsistency or generalizability across different situa-tions and contexts. Job satisfaction and relationshipsatisfaction are significantly associated with positiveand negative affects. The two basic dispositional param-eters, mean level and variability, fluctuate indepen-dently of one another across individuals. Consequently,systematic variability is a predesigned and innate fea-ture of the BFS (Behavior Facilitation System) and hasimportant clinical and theoretical implications for bi-polar disorders.

Watson affirms that positive and negative affects“represent the unifying glue that form higher-orderdispositions and maintains them as integrated wholes.”Utilizing the five factors model, he suggests that theaffective nature of Conscientiousness and Agreeable-ness has been unrecognized in the literature, and bothdisplay specific low-order associations with affectivity.Conscientiousness is strongly correlated with Atten-tiveness, and highly conscientious individuals reportelevated levels of determination, concentration, andalertness. Agreeableness is strongly negatively corre-lated with hostility, and agreeable individuals experi-ence low levels of anger, irritability, and scorn. OnlyOpenness shows little relation to emotional experi-ence. Neuroticism and Extraversion display stronglyand extensive correlation with individual differences inNegative and Positive Affect. All these traits are asso-ciated with a wide range of cognitive, attitudinal, andbehavioral characteristics that are systematically re-lated to affectivity, and give coherence to the conceptof temperament.

In chapter 7 the author analyzes individual differ-ences in affect and wellbeing. He states that “con-temporary research has concluded that happiness isprimarily a subjective phenomenon,” depending sub-stantially on attitudes, orientation toward life, andtemperamental factors. Affect and wellbeing showvirtually no age-related effects, and only few differ-ences between men and women in non-clinical trials.Income, education, and employment status have sur-prisingly little impact on wellbeing. Marriage per sehas little overall effect on rated happiness. Evidenceconcerning religion, faith, and commitment is posi-tive and suggests a moderate degree of association.On the other hand, a large amount of data demon-strate that affect and wellbeing are heritable, as 53%of the variance in stress reaction could be attributed

to genetic factors. Research on brain asymmetry(particularly in prefrontal areas) and neurotransmit-ter systems leads the author to offer, at the end of thechapter, a “general theory of happiness,” a desirableif not utopian blend of psychosocial and neurobio-logical principles.

Chapter 8 discusses the relationships between affectand psychopathology. Basic affective systems fulfillsignificant adaptive functions. However, everybodycan respond at times in a dysfunctional way. Dysfunc-tions may arise from variations in intensity, duration,and frequency or can be situationally inappropriate.Positive affect is much more relevant to depressionthan to anxiety and, with some specific anxiety factorsrelated to somatic tension, constitutes the dimensionsfor the tripartite model Watson proposes.

The last chapter focuses on affect, personality, andhealth vis-à-vis maladaptive emotional responses. Thestrongest conclusion here is the link between negativeemotionality and health complaints. Yet, none of theproposed models offers a complete explanation; hence,like in most areas explored by the book, more and newresearch is needed to clarify the issues.

The merits of “Mood and Temperament” tran-scend the book’s stated goals and its heuristic weak-nesses. Its research methodology includes goodplanning techniques, careful execution, rigorousanalyses, and conclusions based on strength of the as-sociations, temporality, consistency with other studiesin different fields, biological credibility, and predictivevalue. New areas for the study of psychopathology, di-agnoses, and taxonomy of mental disorder are openedup, and the importance of affect in almost all psychiat-ric diagnoses is consistently demonstrated. Finally, thebook leads to areas of future research without neglect-ing the examination of conceptual and practical ob-stacles that may lie along the way.

Jaime Arroyo, M.D.Schools of Medicine and Public HealthUniversidad de PanamáRepublic of Panamá

DOI: 10.1002/da.10031Published online in Wiley InterScience (www.interscience.wiley.com).

BIPOLAR MEDICATIONS, MECHANISMS OFACTION. Edited by H.K. Manji, C.L. Bowden,and R.H. Belmaker. American Psychiatric Press,Washington, DC. 488 p. $58.50

Highly praised by Frederick Goodwin in the pref-ace, and by Ross Baldessarini on the cover, this book“speaks eloquently to clinicians whose interest andcuriosity are beyond the textbook level, . . . repre-sents an undertaking of massive scholarship . . . [and]

Book Reviews 155

. . . gives the reader a real feel for the future andprovides solid support for therapeutic optimism.”Yet, this reviewer still hopes to find some room fordiscussion, if not dissent. First, the book clearly pre-sents a tremendous amount of information with morethan half of its content about lithium; however, it iswritten in a “journal” style and with many distractingreferences in the middle of the text. Whatever oneneeds to know about the still unknown mechanism ofaction of lithium is certainly here. The phosphatidylinositol signaling, polyamine stress response, neu-ronal signal transduction systems, C-FOS expression,and behavioral correlates on second messenger sys-tems—all these hypotheses are included. Yet, a wordof caution is needed: the pure clinician may find ithard to read. It doesn’t cease to be amazing that therichness of all we know collides with the clinical fu-tility of now knowing how these medications workfifty years after Cade treated the first patient withlithium.

On the other hand, only 5 of the 19 chapters dealwith treatment issues, and the rest (11 of them aboutlithium) have to do with basic neuroscience performedin experimental animals. There is nothing wrong withthis, of course, but it would have helped the busy cli-nician if the editors would have written a summary orcritical appraisal of each chapter “at the textbooklevel” (to paraphrase Goodwin). Such is the case ofChapter 10, written by R. Post and collaborators atthe NIMH, as they explain in a very good review thebiochemical and neurobiological mechanisms of lithi-um, carbamazepine, and valproate. The chapters ad-dressing treatment issues (58 pages out of 405) aregood reviews of the current state of the treatment ofbipolar disorders with different medications, a sectionabout carbamazepine being conspicuous by its ab-sence. Furthermore, there is a chapter on the use ofatypical antipsychotic agents in mania, even thoughthe jury is still out on how good these medications are,with the exception of Clozapine, as mood stabilizers.

In summary, this is a book with lots of neuro-scientific data, limited treatment information, and ahumbling message about the difficulties of studyingbrain mechanisms and the way medications work. Theamazing, baffling, intriguing, and disconcerting fact isthat after 50 years of using these medications we knowthat they work (not for everybody though), but nothow they do it; this remains one of the most fascinat-ing challenges in the century of the human genome.

Luis F. Ramirez, M.D.Department of PsychiatryCase Western Reserve University

School of MedicineCleveland, Ohio

DOI: 10.1002/da.10032Published online in Wiley InterScience (www.interscience.wiley.com).

GERIATRIC MENTAL HEALTH CARE: ATREATMENT GUIDE FOR HEALTHPROFESSIONALS. Gary I. Kennedy, MD. TheGuilford Press, New York, 2000. 347 p. $42.00

Geriatric psychiatry is a rapidly growing branch ofmedicine. Acknowledging such growth and its impor-tance, the American Board of Psychiatry and Neurol-ogy recognized it as a subspecialty in 1989. This hasresulted in a large body of geriatric psychiatry litera-ture addressing different aspects of the field, includingquality of care, longevity, prevention, and diagnosisand treatment of mental disorders in late life. Thiswealth of knowledge, however, is of limited utility un-less it is provided in a simple and concise manner. Inhis book “Geriatric Mental Health Care: A TreatmentGuide for Health Professionals,” the author achievesthe goal of providing state-of-the-art information ongeriatric psychiatry in a manner that is solid yet acces-sible, quite informative and yet manageable.

“Geriatric Mental Health Care” is a novel volumethat provides answers to some important questions ingeriatric psychiatry. It delivers well-documented infor-mation to both medical and non-medical audiences. Itprovides practical advice on managing the elderly pa-tient from the waiting room to the family meeting;from early observation to diagnosis and treatment; andfrom the clinic to the nursing home. Family caregiversand health care providers learn about legal, financial,ethical, and sexuality issues of the elderly in sicknessand in health. Chapter One serves as an introduction tothe topic and sets the tone with a discussion about themyths and realities of aging. This key chapter helps thereader understand the difference between normal agingand psychiatric problems of late life, emphasizing thatcontrary to common belief the majority of older adultsare not ill, rather two thirds rate themselves in good/excellent health, and three fourths report no more thanminor limitations in daily activities.

The chapter on dementia is a “must read” for all pro-fessionals who are involved in the care of these patients.It covers every aspect of the disorder from epidemiologyand genetic to diagnosis, differential diagnosis, cognitiveand functional assessment, and treatment. Of special in-terest is the section on behavioral symptoms of demen-tia where the author discusses the possible roots ofbehavioral problems and explores their management inan etiological context. The author also discusses syn-dromes that emerge from dementia such as psychosis,sleep disturbances, and depression. The discussion oflegal, financial, and caregiver burden (which are oftenignored in clinical practice) makes it thorough andcompelling. An hour reading of this chapter providesinformation to the geriatric practitioner on managingcognitive, behavioral, and emotional problems and howto make proper referrals. The book reveals that currentresearch is improving the quality of life of the elderlyand has revolutionized the treatment of dementia.

156 Book Reviews

The chapters on depression, anxiety, psychosis andmania, and sleep disturbances are valuable reading be-cause of the unique issues they review in the treatmentof older adults. There is an excellent discussion onpharmacological treatment. Similarly, sexual problemsin the elderly are addressed, using a direct and open-minded approach that does not ignore the importanceof the needs of the elderly. Statements like “most sexualactivity among nursing home residents is neither patho-logical nor acting out” stir the readers interest and setthe tone for an ongoing reflection.

Substance abuse, suicide, elder abuse/neglect, and le-gal and ethical issues are often ignored in the evaluationof an elderly patient. A comprehensive review on thesetopics is provided in the book. Data included in thechapter on substance abuse explain the risks and dan-gers associated with alcohol abuse by the elderly, pro-viding much needed insight into a serious problem.

No psychiatric book is complete without a discussionof the psychotherapeutic approaches in the treatment ofcommon mental disorders. The book describes practical,

focused, and in-depth interventions in this area. On theother hand, it is unfortunate that gender, race, ethnicity,and religion are discussed only superficially. Several psy-chosocial problems emerging from such sensitive issuescan be disturbing to the patients and their families.

In summary, graduate level students, professionals,and lay public readers of “Geriatric Mental HealthCare: A Treatment Guide for Health Professionals,”will find the accessible language and depth of thisbook the hallmarks of an excellent reference.

Mohammed Memon, M.D.Jacobo Mintzer, M.D.Department of Psychiatry and

Behavioral SciencesMedical University of South CarolinaCharleston, South Carolina

DOI: 10.1002/da.10033Published online in Wiley InterScience (www.interscience.wiley.com).