Psychiatric Management in Neurological Disease
Effectively managing psychiatric problems in the context of neurologic diseases is a complex and challenging task. Although a number of reference textbooks address such management strategies in extensive detail, the scope and depth of such texts is often beyond the immediate patient-related need for information of practicing physicians. In this context, Dr. Lauterbach and colleagues have developed a concise and practical synopsis of the psychiatric management of a variety of neurologic conditions.
The book contains 10 chapters, including a comprehensive review of psychiatric management principles in neurologic disease, 8 neurologic condition–specific chapters, and a chapter on family management issues. The text is multi-authored, and many of its contributors are experienced, well known, and highly regarded experts in the areas covered in their respective chapters. Several more junior contributors also co-author several excellent chapters with their senior colleagues.
The introductory chapter, written by the editor, is a content-rich summary of several fundamental concepts in clinical neuropsychiatry, including an excellent and concisely written review of frontal-subcortical circuitry. This review and related figures are then referenced in many of the subsequent chapters. This chapter also uses clinical problems and findings to illustrate brain–behavior relationships, including the neurobehavioral aspects of frontal-subcortical circuits, cortical and subcortical signs, movement disorders, cerebellar signs, tremors, and psychogenic neurological findings. Classical problems in behavioral neurology (e.g., aphasia, apraxia, agnosia, hemineglect) are briefly reviewed, as are issues in neuropsychiatric differential diagnosis (e.g., depression versus apathy). The presentation of neuropsychiatric treatment modalities notes the importance of support groups, rehabilitation programs, and compensatory strategy-building (for gait disorders, specifically), but it is largely focused on pharmacology. The review of pharmacologic treatment in this population is thorough and well written. The tables used to organize this large body of information are likely to make this chapter particularly useful to practicing physicians.
The content of subsequent chapters echoes that presented in the introduction and offers a survey of conditions that affect the brain at multiple levels. Topics reviewed include conditions affecting frontal- subcortical circuits (Parkinson's, Huntington's, Wilson's, and Fahr's diseases, as well as dystonia), white matter (multiple sclerosis), and mixed cerebral areas (stroke and AIDS). The editor is clear in his intent to include disorders that are not often considered at this level of detail elsewhere and, conversely, to exclude discussion of conditions that are frequently and extensively reviewed elsewhere (e.g., Alzheimer's disease and epilepsy). This strategy is effective, and this work now contains the most current and practical reviews of the neuropsychiatry of Fahr's syndrome, Wilson's disease, and dystonia presently available (all authored by the editor). Although Fahr's and Wilson's diseases are relatively uncommon, their discussion serves not only to educate clinicians about these conditions but also to illustrate the fundamental concepts in clinical presentation, differential diagnosis, evaluation, and treatment of diseases affecting subcortical areas.
All of the neurologic condition– specific chapters are consistently concise and accessible, a remarkable accomplishment in light of their considerable depth. Each includes sections on epidemiology, neurologic and psychiatric presentations, the neurobiologic bases of psychiatric symptoms caused by these conditions (where known), and basic principles of evaluation (including laboratory tests and neuroimaging) and management. Clinical genetics, iatrogenic exacerbation of neurologic and psychiatric problems, and drug– drug interactions are covered in most chapters. These chapters are also notable for their discussion of sexual disorders in these conditions, a topic that is too infrequently included elsewhere despite the magnitude of distress it generates in many patients and their partners.
The final chapter (also by the editor) reviews family management issues in patients with neurologic conditions and emphasizes the value of support groups, educational interventions, and the potential benefit of family or group therapies. The author notes the dearth of intervention outcome data available to guide the development of effective treatments for family members of psychiatrically impaired patients with neurologic disabilities. As a whole, the book provides relatively less information about the most useful psychotherapies (e.g., individual, group, compensatory strategy-building) for these patients, reflecting similarly scant intervention outcome literature in this area. As the editor notes, additional research in these areas is needed and may facilitate a more lengthy discussion of them in subsequent editions of this book.
In all, this is a well-written and practical book that effectively addresses the need for both a concise reference textbook and a practical guide to psychiatric management in neurologic disorders. This book should be strongly considered for use by all general psychiatrists, neurologists, and neuropsychiatrists engaged in the care of neuropsychiatrically ill patients, and it will undoubtedly be a useful teaching tool for residents and students.
Dr. Arciniegas is Assistant Professor of Psychiatry and Neurology at the University of Colorado Health Sciences Center and a Research Associate Physician at the Denver Veterans Affairs Medical Center, Denver, CO.
