Psychiatry, 2nd Editionby Allan Tasman (Editor), Jerald Kay, Jeffrey Lieberman
Described as 'truly outstanding' by The New England Journal of Medicine and 'a gold standard for our field' by the American Journal of Psychiatry, the second edition of this flagship textbook has been extensively revised and updated to reflect progress and understanding in the field. Written by extremely well-known and highly regarded experts, it takes a patient-centered approach, presenting information on normal development and then the behaviour, signs and symptoms of disordered behaviour. Its excellence of authorship, depth and breadth of coverage set it apart as a truly impressive reference that will be indispensable for all those involved in the treatment psychiatric disorders.
Covering new and developing topics and treatments that have emerged since publication of the first edition, PSYCHIATRY, Second Edition incorporates:
- more than 20 new chapters including:
- neural development
mechanism of neural transmitter action
pathophysiology of addictions
premenstrual dysphoric disorder
- significant updates on psychiatric disorders and their treatment, including:
- extensive revision of the scientific foundations of psychiatry
- references updated to include the literature up until 2002
- the DSM-IV and ICD diagnostic classification systems
- tables, charts and illustrations to highlight key information
- clinical vignettes to illustrate current clinical practice
- diagnostic and treatment decision trees to help both the novice and experienced reader
- extensive references directing the reader to further information and reading for each topic
PSYCHIATRY, Second Edition will be indispensable for all those involved in the treatment of psychiatric disorders:
- from clinicians at all levels of experience
- to medical students wanting a quick review
- and health care professionals
Acclaim for the first edition:
"PSYCHIATRY is also noteworthy for the extraordinary breadth of topics covered. ... I was highly impressed by the depth of discussion, excellent tables and graphics, and extensive references. .. The chapters on the various psychiatric disorders and their treatment are written by eminent clinicians and researchers and are extraordinarily comprehensive."
Review by J. Kocsis MD in JAMA (June 1997)
"More than 200 extremely well-known and highly regarded experts, many of them luminaries, have contributed chapters. [The Editors] are men whose credentials reach high into the academic and research stratosphere ... Extremely user-friendly.... PSYCHIATRY is a wonderfully conceived and beautifully executed textbook. Each time I open it, I am more impressed by the quality of work of the authors and editors. They have given us the gift of a gold standard for our field."
Review by S. Vinogradov MD in American Journal of Psychiatry (August 2000)
"a truly outstanding textbook - in my view the best current textbook of psychiatry...This is a wonderful book. I urge all practicing psychiatrists, and especially all residents to purchase this book and read it."
Reviewed by L. Wells PH. D, MD in The New England Journal of Medicine 1997
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John Wiley & SonsISBN: 0-471-52177-9
Chapter OneListening to the Patient Paul C. Mohl
Listening: The Key Skill in Psychiatry
It was Freud who raised the psychiatric technique of examination listening-to a level of expertise unexplored in earlier eras. As Binswanger (1963) has said of the period prior to Freudian influence: psychiatric "auscultation" and "percussion" of the patient was performed as if through the patient's shirt with so much of his essence remaining covered or muffled that layers of meaning remained unpeeled away or unexamined.
This metaphor and parallel to the cardiac examination is one worth considering as we first ask if listening will remain as central a part of psychiatric examination as in the past. The explosion of biomedical knowledge has radically altered our evolving view and practice of the doctor-patient relationship. Physicians of an earlier generation were taught that the diagnosis is made at the bedside-that is, the history and physical examination are paramount. Laboratory and imaging (radiological, in those days) examinations were seen as confirmatory exercises. However, as our technologies have blossomed, the bedside and/or consultation room examinations have evolved into the method whereby the physician determines what tests to run, and the tests are often viewed as making the diagnosis. A cardiologist colleague expresses the opinion that, given the growing availability of noninvasive tests-echocardiograms, for example-he is not sure this is a bad thing(Hillis 2001, personal communication).
So can one imagine a time in the not-too-distant future when the psychiatrist's task will be to identify that the patient is psychotic and then order some benign brain imaging study which will identify the patient's exact disorder?
Perhaps so, but will that obviate the need for the psychiatrist's special kind of listening? Indeed, there are those who claim that psychiatrists should no longer be considered experts in the doctor patient relationship (where expertise is derived from their unique training in listening skills) but experts in the brain (Nestler 1999, personal communication). As we come to truly understand the relationship between brain states and subtle cognitive, emotional, and interpersonal states, one could also ask if this is a distinction that really makes a difference. On the other hand, the psychiatrist will always be charged with finding a way to relate effectively to those who cannot effectively relate to themselves or to others. There is something in the treatment of individuals whose illnesses express themselves through disturbances of thinking, feeling, perceiving, and behaving that will always demand special expertise in establishing a therapeutic relationship-and that is dependent on special expertise in listening.
Traditionally, this kind of listening has been called "listening with the third ear" (Reik 1954). Other efforts to label this difficult-to-describe process have developed other terms: the interpretive stance, interpersonal sensitivity, the narrative perspective (McHugh and Slavney 1986). All psychiatrists, regardless of theoretical stance, must learn this skill and struggle with how it is to be defined and taught. The biological or phenomenological psychiatrist listens for subtle expressions of symptomatology; the cognitive behavioral psychiatrist listens for hidden distortions, irrational assumptions, or global inferences; the psychodynamic psychiatrist listens for hints at unconscious conflicts; the behaviorist listens for covert patterns of anxiety and stimulus associations; the family systems psychiatrist listens for hidden family myths and structures.
This requires sensitivity to the storyteller, which integrates a patient orientation complementing a disease orientation. The listener's intent is to uncover what is wrong and to put a label on it. At the same time, the listener is on a journey to discover who the patient is, employing tools of asking, looking, testing, and clarifying. The patient is invited to collaborate as an active informer. Listening work takes time, concentration, imagination, a sense of humor, and an attitude that places the patient as the hero of his or her own life story. Key listening skills are listed in Table 1-1.
The enduring art of psychiatry involves guiding the depressed patient, for example, to tell his or her story of loss in addition to having him or her name, describe, and quantify symptoms of depression. The listener, in hearing the story, experiences the world and the patient from the patient's point of view and helps carry the burden of loss, lightening and transforming the load. In hearing the sufferer, the depression itself is lifted and relieved. The listening is healing as well as diagnostic. If done well, the listener becomes a better disease diagnostician. The best listeners hear both the patient and the disease clearly, and regard every encounter as potentially therapeutic.
The Primary Tools: Words, Analogies, Metaphors, Similes, and Symbols
To listen and understand requires that the language used between the speaker and the hearer be shared-that the meanings of words and phrases are commonly held. Common language is the predominant factor in the social organization of humanity (Chomsky 1972) and is probably the single most important key to the establishment of an active listener/engaged storyteller dyad which the helping alliance represents. Indeed, the Sapir Whorl hypothesis suggests that what we are able to think is limited/determined by the language with which we are working (Carroll and Whorl 1956, Sapir 2000). Patients are storytellers who have the hope of being heard and understood (Edelson 1993). Their hearers are physicians who expect to listen actively and to be with the patient in a new level of understanding. Because all human beings listen to so many different people every day, we tend to think of listening as an automatic ongoing process, yet this sort of active listening remains one of the central skills in clinical psychiatry. It underpins all other skills in diagnosis, alliance building, and communication. In all medical examinations, the patient is telling a story only she or he has experienced. The physician must glean the salient information and then use it in appropriate ways. Inevitably, even when language is common, there are subtle differences in meanings, based upon differences in gender, age, culture, religion, socioeconomic class, race, region of upbringing, nationality, and original language, as well as the idiosyncrasies of individual history. These differences are particularly important to keep in mind in the use of analogies, similes, and metaphors. Figures of speech, in which one thing is held representational of another by comparison, are very important windows to the inner world of the patient. Differences in meanings attached to these figures of speech can complicate their use. In psychodynamic assessment and psychotherapeutic treatment, the need to regard these subtleties of language becomes the self-conscious focus of the psychiatrist, yet failure to hear and need such idiosyncratic distinctions can affect simple medical diagnosis as well.
In psychotherapy, the special meanings of words become the central focus of the treatment.
How Does One Hear Words in This Way?
The preceding clinical vignettes, once described, sound straightforward and easy. Yet, to listen in this way the clinician must acquire specific yet difficult-to-learn skills and attitudes. It is extremely difficult to put into words the listening processes embodied in these examples and those to follow, yet that is what this chapter must attempt to do.
Students, when observing experienced psychiatrists interviewing patients, often express a sense of wonder such as: "How did she know to ask that?" "Why did the patient open up with him but not with me?" "What made the diagnosis so clear in that interview and not in all the others?" The student may respond with a sense of awe, a feeling of ineptitude and doubt at ever achieving such facility, or even a reaction of disparagement that the process seems so indefinable and inexact. The key is the clinician's ability to listen. Without a refined capacity to hear deeply, the chapters on other aspects of interviewing in this textbook are of little use. But it is neither mystical nor magical nor indefinable (though it is very difficult to articulate); such skills are the product of hard work, much thought, intense supervision, and extensive in-depth exposure to many different kinds of patients.
Psychiatrists, more than any other physicians, must simultaneously listen symptomatically and narratively/experientially. They must also have access to a variety of theoretical perspectives that effectively inform their listening. These include behavioral, interpersonal, cognitive, sociocultural, and systems theories. Symptomatic listening is what we think of as traditional medical history taking, in which the focus is on the presence or absence of a particular symptom, the most overt content level of an interview. Narrative experiential listening is based on the idea that all humans are constantly interpreting their experiences, attributing meaning to them, and weaving a story of their lives with themselves as the central character. This process goes on continuously, both consciously and unconsciously, as a running conversation within each of us. The conversation is between parts of ourselves and between ourselves and what Freud called "internalized objects," important people in our lives whose images, sayings, and attitudes become permanently laid down in our memories. This conversation and commentary on our lives includes personal history, repetitive behaviors, learned assumptions about the world, and interpersonal roles. These are, in turn, the products of individual background, cultural norms and values, national identifications, spiritual meanings, and family system forces.
It seems that three factors were present that enabled the psychiatrist in the above vignette to listen well and identify an unusual diagnosis that had been missed by at least three other excellent clinicians who had all been using detailed structured interviews that were extremely inclusive in their symptom reviews. First, the psychiatrist had to have readily available in mind all sorts of symptoms and syndromes. Second, he had to be in a curious mode. In fact, this clinician had a gnawing sense that something was missing in his understanding of the patient. There is a saying in American medicine designed to focus students on the need to consider common illnesses first, while not totally ignoring rarer diseases: when you hear hoofbeats in the road, don't look first for zebras. We would say that this psychiatrist's mind was open to seeing a "zebra" despite the ongoing assumption that the weekly "hoofbeats" he had been hearing represented the everyday "horse" of clinical depression. Finally, he had to hear the patient's story in multiple, flexible ways, including the possibility that a symptom may be embedded in it, so that a match could be noticed between a detail of the story and a symptom. Eureka! The zebra could then be seen although it had been standing there every week for months. Looking back at Clinical Vignette 3, we see the same phenomenon of a detail leaping out as a significant piece of missing information that dramatically influences the treatment process. To accomplish this requires a cognitive template +(symptoms and syndromes; developmental, systemic, and personality theories; awareness of cultural perspectives), a searching curious stance, and flexible processing of the data presented. If one is able to internalize the skills listed in Table 1-1, the listener begins to automatically hear the meanings in the words.
Listening as More Than Hearing
Listening and hearing are often equated in many people's minds. However, listening involves not only hearing and understanding the speaker's words, but attending to inflection, metaphor, imagery, sequence of associations, and interesting linguistic selections. It also involves seeing-movement, gestures, facial expressions, subtle changes in these-and constantly comparing what is said with what is seen, looking for dissonances, and comparing what is being said and seen with what was previously communicated and observed. Further, it is essential to be aware of what might have been said but was not, or how things might have been expressed but were not. This is where clues to idiosyncratic meanings and associations are often discovered. Sometimes, the most important meanings are embedded in what is conspicuous by its absence.
It was Darwin (1955) who first observed that there appears to be a biogrammar of primary emotions that all humans share and express in predictable, fixed action patterns. The meaning of a smile or nod of the head is universal across disparate cultures. This insight was lost until the late 1960s when several researchers from different fields (Tiger and Fox 1971, Tomkins and McCarter 1964) returned to it and demonstrated empirically the cross-cultural consistency of emotional expression. LeDoux (1996) has been a leader in identifying the neurobiological substrate for these primary emotions. Leslie Brothers (1989), using this work and her own experiments with primates, developed a hypothesis about the biology of empathy based on seeing as well as hearing. Both she and Damasio (1994) have identified the amygdala and the inferior temporal lobe gyrus as the neurobiological substrate for recognition of and empathy for others and their emotional states. Further research has identified that these parts of the brain are, on the one hand, pre-dedicated to recognizing certain gestures, facial expressions, and so on, but require effective maternal infant interaction in order to do so (Schore 2001). The "gleam in the mother's eye" of Mahler and colleagues (1975) is literally translated into the reflection of the mother's fovea as she gazes at her infant, stimulating the nondominant orbital frontal cortex which, in turn, completes the key temporal circuits.
All of this is synthesized in the listener as a "sense" or intuition as to what the speaker is saying at multiple levels. The availability of useful cognitive templates and theories enables the listener to articulate what is heard.
As has been implied, not only must one affirmatively "hear" all that a patient is communicating, one must overcome a variety of potential blocks to effective listening.
Common Blocks to Effective Listening
Many factors influence the ability to listen. Psychiatrists come to the patient as the product of their own life experiences.
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