Organic Psychiatry: The Psychological Consequences of Cerebral Disorder, 3rd edition

Multiauthored texts have many strengths. They draw upon diverse specialized perspectives and bodies of expert knowledge. In the rapidly expanding field of neuropsychiatry, with its explosion of technical information, germane multiauthored texts thus abound with good reason. Excellent examples include the Textbook of Neuropsychiatry, edited by Yudofsky and Hales,¹Principles of Behavioral Neurology, edited by Marsel Mesulam,² and Behavioral Neurology and Neuropsychology, edited by Feinberg and Farah.³

However, there remains a crucial place for the consummately literate single-authored text, written by a master clinician. Two such works include Clinical Neuropsychiatry by Jeffrey Cummings⁴ and Organic Psychiatry by William Alwyn Lishman. Cummings's book provides crystal-clear summaries of topics fundamental to the clinical practice of neuropsychiatry, but it has not been revised since the mid-1980s. This year, however, Blackwell Science has graced us with a third edition of Lishman's text, the first two versions having appeared in 1978 and 1987. The updated revision is a welcome addition to several generations of authoritative, well-organized, highly informative, and pleasurably written sources of wisdom for the practicing neuropsychiatrist.

Lishman's text successfully arms the practitioner with tools to meet perhaps the most difficult conceptual challenge that neuropsychiatrists face in their daily labors: flexible adaptation to shifting paradigmatic demands. Psychiatry has traditionally fixed its attention on developmental and other temporal patterns in order to distinguish between “state” and “trait” aspects of mental disorder. Until recently, interest in neuroanatomical localization has remained in the background. For most psychiatrists, even with the rise of modern pharmacotherapeutics, diffusely projective distributions of neuromodulatory substrates in the brain continue to limit the apparent relevance of cerebral localization. Yet for neurologists, precise cerebral localization is an absolute necessity. Temporal profiles are important as guides to pathophysiology, but the astute neurologist must separate such considerations rigorously from crucial neuroanatomical issues.

The hardest aspect of contemporary neuropsychiatry—demonstrated in behaviorally impaired patients more and more graphically by imaging technology—is the need to juggle both historical and anatomical factors with skill and insight in order to formulate incisive diagnoses and accurately targeted treatment strategies.

Organic Psychiatry lays out the means for meeting this eminently clinical task head on. Even as the third edition has admirably updated time-dependent details, the highly effective and durable overall organization of its predecessor from 1987 has been preserved. As a result, rigor and flexibility happily continue to complement one another.

Lishman still divides his text into two parts: Principles and Specific Disorders. The section on principles not only devotes systematic attention to neuroanatomical localization of lesions, but also integrates this approach into its perspectives on history taking, mental status and physical examinations, psychometric assessment, ancillary laboratory investigations, and differential diagnosis. The section on specific disorders takes the integration further by re-sorting its detailed discussions largely on the basis of pathophysiology, with chapter headings including such topics as cerebral trauma, tumors, epilepsy, infections, strokes, dementias, metabolic disorders, and toxic syndromes. There are also chapters on movement disorders and miscellaneous diseases like multiple sclerosis, Friedreich's ataxia, and narcolepsy.

Basic bedside data-gathering—both historical and localizing—and their pragmatic clinical coordination appropriately remain the primary focus in the new edition. Biochemical, immunological, genetic, imaging, and other research developments receive their fair share of coverage, and the text touches on the theoretical impact of late-breaking technological aids like SPECT, fMRI, BEAM, and MEG, but the book's overall thrust remains clinical. For example, Lishman's discussion of Alzheimer's disease includes recent provocative research findings concerning the distribution of beta-amyloid in affected brains, amyloid precursor protein mutations and apolipoprotein E gene coding phenomena on chromosomes 21 and 19, and comparisons with the normal aging processes; however, sections on the disease's clinical features, workup, differentiation from other dementias and pseudodementias, and management remain most relevant, lucid, and reliably helpful to clinicians.

It might be objected that a major work whose subject matter leans heavily on neuroanatomy should contain copious charts and diagrams; such visual aids are conspicuously absent in Lishman's book. However, part of the personal charm and merit of this single-authored masterpiece is its literary appeal, which imparts a feeling of intimate clinical instruction at the bedside without the interposed need for glossy graphical pyrotechnics. Therefore, the book's reliance on engaging prose with substantive content rather than on pictures emerges as a strength and not a weakness.

The third edition of the now-classic text Organic Psychiatry by William Alwyn Lishman should be a part of every neuropsychiatrist's library. It should also serve as a reminder that neuropsychiatric training programs must continue to promote personal clinical instruction, in the spirit of Lishman's prose, as a guiding bedside beacon to future practitioners.