The Schizophrenias: A Biological Approach to the Schizophrenia Spectrum Disorders

In this age of managed care and managed cost, The Schizophrenias is a potentially important book. The authors, internationally known experts on autistic disorders, remind us of the heterogeneity of the group of disorders we call schizophrenia and the importance of a complete workup to rule out other treatable conditions. They remind us of the strongly supported notion that schizophrenia is "a behavioral syndrome that represents the final common pathway of a number of different developmental, physical, enzymatic, infectious, and other injuries."

This volume, then, is intended to review the medical differential diagnosis of schizophrenia. In fact, I think it would have been more appropriately subtitled The Differential Diagnosis of Schizophrenia. Its stated goal is "to help physicians to be sure that every patient with a potentially treatable form of schizophrenia has had an accurate diagnosis and a subsequent opportunity for a trial of therapy." Drs. Coleman and Gillberg remind us of the tremendous cost that schizophrenia imposes on individual patients and society and argue that it is both medically necessary and cost-effective to complete a comprehensive medical evaluation. The passion of their position is admired and appreciated, but I suspect their argument about cost-effectiveness is open to debate.

After establishing their goals, the authors present an overview chapter called "The Heterogeneous Etiologies of Schizophrenia." Here they provide three very useful tables: one on "treatable or preventable disease entities that can present with schizophrenic symptoms," a second on similar disorders for which there is no current treatment, and a third on disease entities whose association with schizophrenia may be coincidental. Much of the rest of the book goes into all of these disorders in more detail, organized according to the nature of the dysfunction. They cover the gamut from Addison's disease to zinc deficiency.

Besides an excess of typographical errors, my major criticism of this book is its organization. I think the authors' argument supporting the need for a comprehensive medical evaluation of patients presenting with schizophrenia-like disorders would have been more compelling if a section of the book focused exclusively on the treatable disorders. Instead, the authors lump together treatable and untreatable disorders that can mimic schizophrenia, along with extensive reviews of evidence supporting various possible theoretical etiologies for "idiopathic" schizophrenia. Unfortunately, at times the untreatable disorders overwhelm the treatable ones.

The penultimate chapter lays out a minimal acceptable medical workup needed to identify the common treatable disorders that present like schizophrenia. It is quite comprehensive and goes beyond other experts' recommendations. For example, Coleman and Gillberg include a brain imaging study (computed tomography or magnetic resonance imaging scan) as part of the routine workup, while other experts recommend such studies only on an individually determined basis (1).

This book may serve as a helpful counterpoint to the current trends to do less evaluation and more rapid intervention. One hopes that the debate about what constitutes state-of-the-art, cost-effective care will continue.