Book Reviews PSYCHOTHERAPY AND PSYCHOANALYSIS-THEORY, PRACTICE, RESEARCH. By Robert S. Wallerstein, M.D., International Universities Press, Inc., New York, 1975, pp. 475. The author is an outstanding physician, psychoanalyst, teacher and writer who has contributed substantially to psychoanalytic growth. This book is a collection of 16 papers, four of which are co-authored. They consist of clinical, theoretical and interactive concepts with research material derived from the Psychotherapy Research Project of the Menninger Foundation. The objectives are the growth and development of psychoanalysis, both as a profession and a science interactive with a moving world and seeking articulation with other behavioral sciences. The promise is fulfilled. Dr. Wallerstein makes every effort to clarify his concepts. Indeed, it is comforting to recognize the difference between his modest evaluations of psychoanalysis and those of other Freudian scholars who taught with certainty. He summarizes the contributions of other investigations and then presents his own position. In a clinical paper "Treatment of the PSyChosis of General Paresis with Combined (oral) Sodium Amytal and Psychotherapy", Wallerstein demonstrates convincingly the pharmacologic reversibility of psychosis where the previous use of malaria and penicillin had arrested the organic damage, but not the psychosis. In a second clinical paper "Reconstruction and Mastery in the Transference Psychosis", the delusional reconstruction within the transference psychosis is revealed and so constitutes a "relative" contraindication to psychoanalysis. The third clinical paper "Psychotherapy: Differential Treatment Planning and Prognostication" (with Robins) reveals the concepts used in the research project at the Menninger Foundation to delineate the patient's chosen dynamics and that of psychoanalysts. Theoretical papers include: "Values in Mental Health and the Assessment of Change in Psychotherapy"; "The Goals of Psychoanalysis"; "The Role of Prediction in Theory Building in Psychoanalysis"; 'The Current State of PsychotherapyTheory, Practice, Research"; 'The Relationship of Psychoanalysis to Psychotherapy-Current Issues"; "Transactional Psychotherapy: Critique of a Viewpoint"; "Pain, Fear and Anxiety: A Study in Their Interrelationships" (with Ramzy); "Issues in Research in the Psychoanalytic Process" (with Sampson); "The Role of Research in Training Psychotherapists"; "The Futures of Psychoanalytic Education"; "Psychoanalysis and Sociology" (with Smelser): "The Challenge of the Community Mental Health Movement to Psychoanalysis"; "Psychoanalytic Perspectives on the Problem of Reality". This questioning, probing, assessing work is thought stirring. In describing the contributions of psychoanalysis, Wallerstein correctly states it "delivered the practice of psychiatry from neurological and institutional fetters". Its psychodynamics enriched psychiatry. Moreover, he emphasizes we should be able to explain the therapeutic maneuvers and the results of nonanalytic therapies according to psychoanalytic lights." In my opinion, where support and suggestion operate helpfully, the common denominator is the strength of the transference which, of course, is a fertile area for research. Yet, psychoanalysis is troubled and the author probes its roots with scientific objectivity. There is the need to establish it as 54
a science since, for example, "prediction in our science is less firmly secured" compared with other disciplines. Moreover, there is the clash of conflicting theories which has led to semantic confusion, vested interests and multiple schools. Note the debate between Conn and Engel. Too, there is the problem of therapy-its restriction to the "educable" and analyzable few, its effectiveness and the intrusion of values. As an end result of analysis, the elimination of symptoms is insufficent. For permanence, a structural change is essential. The studied follow-up of patients to assess this problem is not a simple matter. But, I opine this may be overcome by the study of certified analysts who it is assumed have profited maximally. It would also be desirable to learn what happened to those children and adults who were exposed to psychoanalysis through Anna Freud's educational efforts in pre-Hitler Vienna. Psychoanalysis is also burdened by the intrustion in our literature of such terms as "optimism, pessimism, belief, consensus and feeling". This betrays the authoritative influence. Moreover, misinterpreted emphasis on "ego psychology" weakens the need to deal with it and repressed drives. Students as well as the public are less enchanted with psychoanalysis than formerly and research is required to raise its credibility. In a studyl of what doctors of medicine should know in psychiatry, psychologists, psychiatrists and non-psychiatric physicians gave psychoanalytic theory and psychodynamics low ratings. Applications to psychoanalytic schools, Wallerstein states has diminished from one in seven in 1945 to one in 20 in 1972, students having been drawn to other "prestigious" disciplines and rejecting intensive training in psychoanalysis. In the "schools" he asserts, there exists the fear of authoritative consensus which may destroy intellectual freedom and should the student protest, it is regarded as resistance and he does so perilously. Another area which is troublesome is the discouragement of therapeutic commitment. This intensifies the student's doubt and insecurity and stirs a defensive attitude towards other therapies. Finally, once certified, is the analyst able to endure with flexibility the demands of a suffering community? Public consumerisms seeks the magic bullet and instant curethe "here and now" as opposed to the psychoanalytic "there and then". The multiple "cures" offered at varying costs of time and money are bewildering. The National Health Program will note these differences and naturally the "cheapest" will be attractive. We who mind the store await the help of researchers. Thus far it appears that a compromise is essential in practice to combine the gold of analysis and the copper of suggestion which Freud recognized as necessary. Indeed, the Menninger name is electrifyingly supportive and the research at the Foundation must consider this non-analytic "curative" factor. Just as love is not enough, providing the tools of transference and interpretation are not enough therapeutically. In the struggle to gain the respect of university level colleagues, a need which Wallerstein emphasizes, we may lose the respect of the public for popular appeal in psychotherapy is a greater problem today than scientific creditability. Care must be exercised lest classical psychoanalysis fades as Gall's phrenology. It is in danger of much ado for the few. This collected works of Wallerstein is imperative reading for all researchers in human behavior including sociologists. Practitioners of psychotherapy will find a glimpse of the complexiVolume XVII
BOOK REVIEWS ties of psychoanalysis. The clinical papers are useful for clinicians. REFERENCE 1 Johnson, W. and Snibble, J., "The Selection of a Psychiatric Curriculum for Medical Students," Am. J. Psychiat., 132:5 May 1975, p. 513. GEORGE J. TRAtN, M.D. Brooklyn, N.Y.
SOMATIC MANIFESTATIONS OF DEPRESSIVE DISORDERS. Edited by Ari Kiev, M.D.; Excerpta Medica-Amsterdam, American Elsevier Publishing Company, New York. Pgs. 128; published 1974, $13.50, paperback. The somatic manifestations of depression are often not recognized as emotional illness, frequently serving as a mask to cover up the depression. The thrust of this monograph is that psychological and interpersonal symptoms are the result of physiological or biochemical changes. This is in agreement with the many studies on endogenous depression but certainly remains to be proven for the depressions that are presently labeled as "reactive" or "neurotic." Dr. Ari Kiev, in the introductory chapter, cites the figures from the National Institute of Mental Health in which eight million people per year are said to suffer from a depression severe enough to warrant treatment. A review of the biochemical aspects is followed by a listing of present antidepressants and their dosage. It is noted that patients least likely to have a good response are those with chronic severe psychopathology and negative treatment responses. Where the patient has secondary gains from his symptoms, he may remain chronically ill. Lithium is seen to be of benefit in stabilizine individuals with mood swings and electroshock treatment is still considered to be of value in severely retarded or agitated patients and in a cutely suicidal patients. The gastro-intestinal tract is then considered by Dr. Chaplan. He reviews psychosomatic concepts and theories of mind-body interaction. Here a differentiation between reactive and endogenous depression is noted; those with reactive depression are seen to be less prone to serious somatic symptoms. The author reviews the psychodynamic aspects of depression, pointing up the loss of self esteem which is most important. It is his feeling that depression and gastro-intestinal disorder are two of medicine's most prevalent ailments. Problems of interdisciplinary communication may result in the individual physician treating only one aspect of the combination. Dr. Feighner considers sleep and depression. On the basis of current data, the tricyclic antidepressants are the drugs of choice and barbiturates are contraindicated. Studies indicate that there is a significant decrease in Stage 4 sleep and a probable decrease in REM sleep. Stage 4 deprivation leads to decreased activity, fatigue and diminished performance. Deprivation of REM sleep results in a heightened CNS response state with increased anxiety, tension and irritability, hyperactive and labile behavior, diminished concentration and memory and impaired motor coordination. Drs. Kamo and Hoffman consider the Pseudoanergic Syndrome. This is a syndrome consisting of feelings of fatigue, weakness (asthenia), and loss of energy. They named it "pseudoanergic" because the complaint is subjective without objective signs. The symptom of prolonged fatigue without discernible cause is considered to be depression. A characteristic symptom is the lack of the feeling of reward that the patient obtains for his effort. The authors wisely note that pseudoanergia may occur concomitantly with organic illness so that the physician must remain alert. Jan.lFeb.lMarch, 1976
Sexual Dysfunctions are then considered by Dr. Renshaw. The frequency of sexual dysfunction in depression at an ages is underscored. It is nevertlleless necessary to rule out organic disease. Alcohol and drugs are frequent causes of lowered libido. Psychodynamic considerations likewise need evaluation. The final chapter, Pain and Depression, is contributed by Dr. Sternbach. It is noted that there is a tendency for pain, like other somatic complaints, to mask and hide a depression. When "psychogenic" and "organic" pain patients are compared, there is no evidence that there are significant differences. Psychogenic pain patients apparently begin with high neuroticism scores, (MMPI) consisting primarily of hypochondriasis and hysterical denial as defenses against depression and anxiety. Organic pain patients apparently end with virtually identical characteristics after about 6 months of pain, probably depending upon their personality structure and the severity of the pain. The author concludes that pain is a symptom of disease: it is about equally likely to be a symptom of mental or of physical illness. When it is a symptom of mental illness, it is likely to be a neurotic one (either neurotic depression or anxiety hysteria). In depression, the somatic etiology of pain is not clear. The psychodynamic etiology emphasizes the roles of loss and identification with the lost person, and of intrapunitive anger, with guilt because of aggressive impulses. Antidepressants help to relieve pain when depression is clearly a factor. In summary, this is an excellent review of somatic symptoms in depression. Psychodynamic factors are not excluded. so that a total picture of this affective state is presented. The book should b:.: of value both to psychiatrists and to those primarily engaged in somatic medicine. W.O. ANNUAL REVIEW OF PHARMACOWGY, Edited DJ Henry W. Elliott, Ronald Okun and Robert George. Volume 14. Annual Reviews Inc., Palo Alto, California, 1974, 594 pp. The basic science of pharmacology has provided us with a body of tIleoretical knowledge concerning tile effects of drugs on various biochemical processes in the brain. This annual review contains tIlree articles that summarize the current state of knowledge in tllis area. The first artich:, "Drug Effects and Hypothalamic-Anterior Pituitary Function" by de Wied and de Jong from the University of Utrecht, is a review of recent data concerning tile neuroendocrine control of anterior pituitary function by drugs iliat affect tile release of hypothalamic hypophysiotropic factors through tIleir action on brain neurotransmitters. Variations in pituitary-adrenal activity and stress, as well as cyclic changes in tile release of pituitary gonadotropin, are associated witll variations in neurotransmitter activity of the hypoilialamus, as determined by alteration in content, turnover, rate of syntllesis from labeled precursors, enzyme activity, and histochemical fluorescene. Studies in various species of animals suggest tIlat epinephrine, norepinephrine. and dopamine affect tile release of growth hormone. Data on tile neuroendocrine regulation of thyrotropin hormone release are scarce, but tile introduction of radioimmunoassay of this hormone should make tIlem available soon. The second article, "Regulation of Biosynthesis of Catecholamines and Serotonin in the CNS" by Costa and Meek of tile National Institute of Mental Health, reviews data on tile factors affecting the biosyntllesis of tIlree neurotransmitters in the central nervous system: norepinephrine, dopamine, and serotonin. This review brings into focus the molecular nature of tile various processes involved in tile regulation of 55