Schizophrenia: Concepts and Clinical Management

Schizophrenia: Concepts and Clinical Management is written by Eve Johnstone and her colleagues from the University of Edinburgh. The volume was planned by the late George Winokur as part of a new series called Concepts in Clinical Psychiatry. Each of the 13 chapters is written by one of the authors, giving the book the strengths and weaknesses of a multiple-author work.

As indicated in Dr. Johnstone's preface, the book is written at a peculiar time. On the one hand, a great deal has been learned about schizophrenia in the hundred-some years after Kraeplin, and, she says, "Over the past 20 years there have been substantial advances in understanding the biological basis of schizophrenia." Dr. Johnstone justifies another book about schizophrenia on the basis of the many unresolved issues and the "ever-increasing problems related to risks and costs." The British perspective on these issues is enlightening given the current American preoccupation with managing both care and costs.

The book is largely successful in summarizing the state of the science and art. The strongest chapters are in the first half of the book. Dr. Johnstone gives a wonderful overview of the history of the concept of schizophrenia and the approaches to diagnosis. However, in some places I found myself lost. An excellent overview of Schneiderian symptoms, including a great table, is followed by a discussion of D₂ receptors, which leads logically to discussion of Crow's two-syndrome typology of schizophrenia. But the discussion of Schneiderian symptoms is abandoned without disabusing the reader of Schneider's notion that these symptoms are pathognomonic of schizophrenia, absent "coarse brain disease."

The chapter on differential diagnosis is particularly interesting in its discussion of substance abuse, cultural diversity, deafness, and developmental disabilities (referred to as learning disabilities) as confounding the diagnostic process.

I found the two chapters by Stephen Lawrie to be the strongest in the book. He provides a comprehensive overview of neuropathology and brain imaging in schizophrenia in one chapter and of the neuropsychology of schizophrenia in the other. These chapters are clearly written and have extensive bibliographies on this very complex material. The chapter on psychopharmacology is less satisfying, although it is interesting to read that atypical neuroleptics are apparently not used as first-line agents in the United Kingdom, as they are in the U.S.

The final chapters of the book focus on social and psychological treatments, service provision from an economic perspective, and legal and ethical issues. These chapters underscore that our colleagues in the United Kingdom are struggling with the same issues that trouble us in the U.S.—for example, how to get service systems to implement practices known to be effective, such as family psychoeducation; the appropriate role, if any, for the asylum; and the question of when it is appropriate for a person with schizophrenia to be incarcerated and held accountable for criminal behavior.

In summary, Schizophrenia: Concepts and Clinical Management provides a useful update on the state of knowledge about schizophrenia. It serves as an excellent resource on the history of the disorder, its biological underpinnings, and diagnostic approaches.