AJP nov97 Book Forum • The Psychology of Illness: In Sickness and in Health

Although psychiatry has failed in its attempt to gain official recognition as a primary care specialty, its persistent assertion that it is a medical subspecialty has captured the rapt attention of aspiring young psychiatrists. Today, more than a quarter of all general psychiatry residency programs offer combined training in internal medicine and psychiatry and in family practice and psychiatry, leading to dual board certification. Most psychiatric educators see this not as a fad but the standard of training for the future.

Thus, Richard Druss's book, a short, lucid, and informative text focused on the interplay between medicine and psychiatry, is indeed timely and should appeal to a wide audience of trainees and practitioners in all the medical, nursing, and social work fields. Mental health workers may better appreciate its fine points because of their specialized training, but all medical readers (and their patients) would benefit from the holistic perspective and practical clinical wisdom the author provides.

The text is divided into two sections: Sickness and Health. In the Sickness section, Druss includes chapters on the depiction of illness in popular literature, hypochondriasis in medically ill patients, pathological denial, and psychodynamic psychotherapy with patients suffering from serious medical illnesses; he also has a chapter explaining his treatment philosophy. In the second section, he looks at healthy denial; the role of courage when patients face chronic illness; and exercise, well-being, and restoration of health in patients.

Throughout the book, the author manages to convey a sense of optimism and an upbeat tempo. In the section on sickness, he excerpts engaging accounts from talented lay authors who report their experiences as patients. The serious reader may wish to compare these accounts with the detailed and somewhat technical perspectives of psychiatrists who report their encounters with serious illness in Illness in the Analyst (1).

I was intrigued with the way Druss tackled the issue of hypochondriasis in medically ill patients in chapter 2. He provides three interesting cases that are fairly characteristic of the disorder, i.e., showing that it is a chronic condition and has a high rate of psychiatric comorbidity. He speculates that very early illness or exposure to illness in others during childhood may sensitize one to developing hypochondriasis in later life; therefore, he suggests that an abreactive approach be part of the treatment strategy. As in other chapters in this book, Druss calls for a flexible and eclectic approach that uses psychodynamic psychotherapy, cognitive therapy, and psychotropic medications as clinically appropriate.

In the Health section, Druss reexamines the concept of positive denial and its role in healthy responses to illness and disability. From this chapter he goes on to look at the concept of courage, an underresearched area in psychiatry and psychoanalysis. To make his points, Druss employs vivid examples from the life of Robert Louis Stevenson, who was chronically ill most of his life and yet made great contributions to society. At the end of his book, Druss attempts to cover in eight pages the vast and intriguing field of exercise, well-being, and restoration; I found this area stimulating and open for exciting ideas but was disappointed by the limited discussion.

Paradoxically, the strengths of this book are also its shortcomings. Major issues are addressed—but not in great depth. The author draws on the clinical impressions and research findings of others, and, given the brevity of the book, he must integrate and condense a vast body of knowledge into an appealing and easily understood format. There is the potential danger of oversimplifying some very complex issues and perhaps creating the impression for beginners that understanding the psychology of illness is not all that difficult. To provide a proper balance, I would encourage residents and practitioners to peruse Rundell and Wise's Textbook of Consultation-Liaison Psychiatry (2) for a comprehensive overview of the interplay between medicine and psychiatry and Reiser's Mind, Brain, Body (3) for a more detailed dual-track approach.

For medical students and residents in all specialties who rotate through psychiatric consultation-liaison services, however, Druss's succinct and lucid text may well be destined to share the enviable fate of Brian Bird's classic primer on psychotherapy (4), which taught so many in the simplest of terms how to understand and do therapy with patients.