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BOOK REVIEWS |
Psycho-Oncology
edited by Jimmie Holland
reviewed by Amanda Sutherland
The Psychotherapy Documentation Primer
edited by Donald E. Wiger
reviewed by Paul M. Cameron
Geriatric Psychopharmacology: Medical Psychiatry Series - No. 9
edited by J. Craig Nelson
reviewed by Karen Smith
Standards and Guidelines for the Psychotherapies
edited by Paul Cameron, John Ennis, and John Deadman
reviewed by Paul Steinberg
The Video Study Guide: A Biopsychosocial Approach to Irritable Bowel Syndrome: Improving the Physician-Patient Relationship
edited by J. Robert Swenson
reviewed by W. Grant Thompson
Behavioral Health Center, Carolinas Medical Center, Randolph, 501 Billingsley Road, Charlotte, NC 28211
Edited by Jimmie Holland
Oxford University Press, New York, 1998, 1189 pages
Strengths: comprehensive, well written, authored by international leaders in the field of psycho-oncology
Weaknesses: none
Target reader: anyone who provides psychosocial care to patients with cancer.
Having frequently referred to the Handbook of Psycho-Oncology: Psychological Care of the Patient with Cancer (Jimmie Holland and Julia Rowland, editors, 1989) while working with oncology patients as a consultation liaison psychiatrist, I was eager to read and review this new incarnation. The original volume, Handbook of Psycho-Oncology, consisted of 785 pages, which were contributed by 38 authors from Memorial Sloan-Kettering Cancer Center. Psycho-oncology has 1189 pages that have been contributed by 156 authors from centers around the world and reflect the increase in interest in, and knowledge of, the psychosocial treatment of the patient with cancer. The diverse backgrounds and philosophies of the contributors allow for Psycho-Oncology to have an unusually broad scope.
The book is usefully divided into sections. Part I contains two brief but helpful chapters. The first gives a historical perspective of psycho-oncology. Facts revealed here include that the first psychiatric unit was established at Memorial Sloan-Kettering Cancer Center in 1950, but it was not until late in that decade that the first papers on psychological reactions to cancer appeared. The second chapter provides a very condensed review of the essential medical facts of cancer.
Part II explores the "Psychological and Behavioral Factors in Cancer Risk." This section includes chapters on smoking, alcohol, diet, sun exposure, personality, social support, and other factors that may contribute to an individual’s risk for developing cancer. Chapter II reviews the scientific evidence supporting the role of a variety of factors in the incidence and prognosis of cancer. Dr. Bernard Fox, the author, concludes that there is no convincing evidence to support the popular beliefs that stress, emotional repression, depression, and bereavement contribute to the development of cancer or its poor prognosis. This may be helpful information for cancer patients who are feeling guilty for being unable to avoid stressful life events. In Chapter 12, the authors review the research on the role of the immune system in cancer and the impact of psychosocial factors on the immune system. They conclude that although there is strong support for the hypothesis that stress and distress alter immune function, the conclusion that psychoneuroimmunology is involved in cancer remains highly controversial. Chapter 13 reviews the state of knowledge about the hypothalamic-pituitary-adrenal axis in depression and cancer. Together, these two chapters highlight the need for ongoing research in this complex area.
Parts III and IV deal with cancer screening and high genetic risk, issues that were not addressed in the 1989 text, but which have implications not just for individual clinicians, but also for program planners and researchers.
Part V contains two chapters relating to adaptation. The first explores which patients cope well, or which types of coping responses are helpful. The authors make the very important point that having cancer is not a single stressful event, but a series of interconnected stressful events. The second chapter, by Alice Kornblick, reviews the quality of life in cancer survivors. It is an excellent, comprehensive analysis of studies culminating in five clinical recommendations. The 12-page appendix to this chapter, which is a table summarizing empirical studies of the psychosocial adaptation of adult cancer survivors, is a wonderful reference for anyone who works with cancer patients.
Parts VI and VII review psychological concerns that are relevant to different treatment modalities and different cancer sites (including unknown primaries). The chapter on bone marrow transplantation includes reference to psychological issues of marrow donation. Rowland and Massie, in the chapter on breast cancer, in addition to providing a thorough review of the topic, discuss the quality of sexual functioning, the role and care of the family, and suggest several books that may be of help to patients and their families.
Part VIII: "Management of Specific Symptoms" addresses issues of huge importance to patients with cancer, including: palliative and terminal care; pain; cancer cachexia; nausea and vomiting; fatigue; sexual dysfunction and the neuropsychological impact of cancer and its treatment. In addition to reviewing opioid and nonopioid analgesics, the chapter on pain discusses adjuvant psychotropic analgesics and nonmedication therapies such as relaxation techniques, cognitive behavioral techniques and hypnosis. It is particularly heartening to see the addition of the chapters on fatigue and neuropsychological changes, because these are concerns often expressed by patients with cancer, but until recently, underappreciated by physicians.
Part IX is a high quality review of common psychiatric disorders. The chapter by Drs. Massie and Popkin on depressive disorders includes a table of studies estimating the prevalence of depression in cancer patients. They discuss problems measuring depression in cancer as well as common drugs and medical conditions that may contribute to depressive symptoms. The chapters on substance abuse disorders and alcoholism and cancer are timely additions to this text. Posttraumatic stress disorder and somatoform disorders are not uncommon in oncology patients, but previously have not received the attention they have deserved. The chapters on delirium, chemotherapeutic agents and their neuropsychiatric side effects, and neuropsychiatric symptoms due to metabolic disorders are complementary and well-written and should be required reading for all oncology residents and consultation liaison psychiatrists.
Part X, "Interventions" contains chapters ranging from comprehensive reviews of standard topics such as screening procedures for psychological distress through telephone counseling; bedside intervention; meditation; religion and spiritual beliefs; spiritual assessment, screening and alternative/complimentary therapies. The chapter on brief crisis counseling is a chapter that a novice counselor should read. It contains basic guidelines for crisis counseling that should be taught to all professionals who work with oncology patients (eg, saying "I know how you feel" may not be helpful). Fawzy and Fawzy critically analyze studies of psychoeducational interventions from 1978 to 1994. Classen et al. examine the conflicting results of studies of life extending psychosocial interventions. The chapter by Spira on group therapies would be particularly helpful in planning delivery of psychosocial services to cancer patients. Psychotherapeutic issues, written by Sourkes, Massie, and Holland is a brief, sensitive exploration of the issues specific to the psychotherapeutic treatment of patients with cancer. It is required reading for any therapist new to psycho-oncology. Unfortunately, the chapter on alternative and complementary therapies did not include a review of common herbal therapies and what is known about their risks, benefits, and potential interactions with other medications.
Part XI, "Persons with Special Needs" addresses the needs of the elderly; underserved patients; patients from other cultures; and individuals who believe they have suffered a dangerous environmental exposure.
Part XII, "The Child with Cancer" includes a chapter on the biology of childhood cancers, which provides a useful context. The remainder of the chapters deal with the distress associated with treatment for childhood cancer, the psychiatric, psychosexual and cognitive sequelae seen in survivors of childhood cancer, and psychopharmacologic, cognitive-behavioral, and psychotherapeutic interventions. To a psychiatrist consulting at a bone marrow transplant unit that occasionally performs transplants on children, these chapters provide welcome practical suggestions for the management of children with cancer.
Any clinician who has ever felt out of his depth when dealing with the family of a cancer patient will appreciate Part XII. Chapter 85 reviews family issues in general. There are also chapters on palliative homecare and bereavement, both of which briefly address the impact of death and dying on children. The chapter on family therapy contains several case examples and specifically addresses common difficulties encountered in families of cancer patients.
Part XIV is essential reading for psycho-oncology program planners, administrators, and educators. Topics range from minimizing and managing staff stress, establishing a psycho-oncology unit, and training staff.
The remainder of the text is aimed at more specific audiences, as it addresses ethical issues, research methods, international aspects, and policy issues. Psycho-oncology is a wonderful, comprehensive text that contains something for anyone who works with patients with cancer. It is a reference text that summarizes the state of research, but the numerous clinical examples and practical suggestions reflect the clinical backgrounds of the contributors. It should be available not just on psycho-oncology units, but also on all oncology and psychiatric units.
Professor of Psychiatry, Director of Psychotherapy Program, Department of Psychiatry, University of Ottawa, Ottawa Hospital, General Campus, Room 4422, 501 Smyth Road, Ottawa, Ontario K1H 8L6
Donald E. Wiger
John Wiley & Sons, Inc., Publishers, New York, 1999 190 Pages, $40
Strengths: very practical with examples
Weaknesses: perhaps too basic for experienced mental health professionals
Target reader: students and those beginning practice
The author has written a very basic textbook giving practical suggestions as to how to document all phases of assessment and treatment of patients receiving psychotherapy. He states that the practice of psychotherapy did not have the dimension of accountability until recently. He goes on to state that practitioners and mental health clinics must now "... justify the treatment of patients to outside review entities which control payment of fees." Although the practice of psychotherapy and psychiatry is somewhat different in Canada and other countries than it is in the United States, the same need for accountability to third-party payment agencies is occurring in many parts of the world.
Wiger indicates the important legal issues in documentation pointing out that the most common grounds for malpractice are:
He continues by emphasizing that mental health services from any theoretical model can be documented in a measurable manner and in behavioral terms.
Two chapters, "The Biopsychosocial Assessment" and "The Mental Status Exam," emphasize that both client strengths and weaknesses are important to document as well as collateral information from knowledgeable other people. In a chapter entitled, "Validating the Diagnosis," the author points out that the mere existence of symptoms does not validate the need for treatment unless there is significant impairment. He advocates an emphasis on impairment, showing what behaviors and restrictions occur in the patient’s life because of their illness.
The most creative chapters in the book are those on "Treatment Planning" and "Progress Notes." Among the most practical suggestions was to write a treatment plan; this will prevent misunderstanding about why treatment was necessary and that it was carried out. The treatment plan will show that the goals and objectives will be measured and that any setbacks in treatment will be documented. The revision of objectives and treatment goals can be documented allowing for an explanation as to why treatment may continue longer as was originally considered.
The chapter on "Progress Notes" suggests the outline described by the acronyms SOAP or DAP. The SOAP format covers Subjective aspects, Objective aspects, Assessment, and Plan. The DAP format covers Data, Assessment, and Plan. This gives some structure to how progress notes can be developed. The author suggests that time can be saved by writing progress notes during a session. The book ends with some examples of good progress notes and examples of where improvement could occur. A brief chapter on some examples of "Outcome Measures" is included.
In summary, this book is practical, readable, and reasonably brief. There is little written information providing advice or structure on how to document psychotherapy. The book, therefore, has some value in providing a beginning for psychotherapists to create their own method and realize that they need to improve their system or lack of system that they are currently using.
Geriatric Psychiatry Program, Royal Ottawa Hospital, Ottawa, Ontario, Canada
Edited by J. Craig Nelson
Marcel Dekker, Inc, New York, 1998, 488 pages, illustrated, $175
Strengths: broad range of topics, includes medical disorders associated with psychopathology
Weaknesses: expensive, some chapters poorly written
Target reader: general, consultation/liaison or geriatric psychiatrist, family practitioner, internist
This book provides an overview of many topics within the realm of geriatric psychopharmacology. Overall, this task is completed well by the authors. However, the brevity of some chapters creates problems, such as listing references instead of adequately covering a topic and placing unrelated facts within the same paragraph. Most authors, however, have achieved a thorough and succinct coverage of their subjects.
The book begins with a review of general principles, which includes chapters on 1) neurochemistry of aging, 2) pharmacokinetics of psychotropic drugs, and 3) drug interactions.
It is unfortunate that the first chapter suffers from a number of problems that may dissuade the reader from continuing, because the other chapters are written better. For instance, Figures 2 and 3 tabulate changes in human brain neurotransmitter systems in aging and in dementia of the Alzheimer type, respectively. The table does not seem to be referenced completely, and the degree to which changes in Alzheimer brain neurochemistry differs from normal-aging brain remains unclear. Moreover, the writing in this chapter is disjointed, which lends to unsatisfactory reading.
The subsequent chapters in the initial segment of the book offer organized coverage of pharmacokinetics of psychotropic drugs, as applied to the aging patient and drug interactions, which are important to know for patients of any age. There is particularly good coverage of the cytochrome P450 enzyme family as it pertains to psychotropic and other important drugs. The two tables that contain this information are worthy of being made into copies for the office, for easy access to this key information.
The second segment of the book contains several chapters pertaining to the treatment of depression. Chapter 4, written by J. Craig Nelson, focuses on the treatment of major depression and includes a section on diagnosing depression in the elderly, in which factors are outlined that can make the diagnosis more difficult in this population. A table outlining the prominent medical disorders and medications that are associated with depression would be more useful than just references to other papers. The author also reviews studies of antidepressant treatment, providing helpful summaries of some of these studies. Dr. Nelson suggests that, despite the commonly held belief that the elderly should be treated and maintained on lower doses of drugs than younger patients, this is inadvisable for some of the safer drugs such as selective serotonin reuptake inhibitor (SSRIs). He summarizes, "There are no data supporting the efficacy of low-dose SSRI treatment in the elderly and few data suggesting that a low dose is necessary." A well-written chapter on psychotic depression follows, which provides valuable information on its diagnosis as well as treatment guidelines. Subsequent chapters about the treatment of depression during bereavement and maintenance treatment of depression, respectively, are informative and interesting. Despite this being a book about psychopharma- cology, both chapters appropriately address psychotherapeutic treatment options.
The book next shifts its focus to the treatment of depression associated with medical conditions, including cardiac disease, stroke, cancer, Parkinson’s disease, and dementia. In general, these are quite thorough reviews. Chapter 8 is a good overview that surveys the effects of antidepressant medications on different aspects of cardiovascular function, including blood pressure, left ventricular function, cardiac conduction, and rhythm. Although most studies have been done on tricyclic antidepressants, recent research on nontricyclic antidepressants such as bupropion and SSRIs is also presented. The next chapter, dealing with poststroke psychopathology, examines depression, depression with cognitive impairment, mania, anxiety, and emotional disorders. Brain lesion correlates are provided as well as treatment strategies for each disorder. A useful protocol for the evaluation and management of the elderly cancer patient with depression is outlined in Chapter 10. Comorbid depression and Parkinson disease is thoroughly reviewed, with emphasis on various treatment options. The combination of depression and dementia is examined adequately in terms of assessment and diagnosis; however, details about treatment are lacking. This portion of the book concludes with a look at the use of stimulants in elderly depressed patients with concurrent medical illnesses. Although evidence points to antidepressant efficacy of psychostimulants, as the authors note, "There is a paucity of controlled research on the effect of psychostimulants on depression in geriatric medical patients."
Three chapters highlighting the treatment of bipolar disorder constitute the next section of this book. The first two cover the use of lithium and lithium toxicity, respectively. The use of lithium in both depressed and manic phases of bipolar disorder is adequately described with practical guidelines for its application. This includes the concomitant use of adjunctive medications such as neuroleptics, benzodiazepines, and antidepressants as well as electroconvulsive therapy (ECT). It does not, however, address the concomitant use of anticonvulsants with lithium. A subsequent chapter about anticonvulsants in the bipolar elderly is disappointing in many respects. It is another example of a poorly written and edited chapter of this generally well-written book. There are several instances of ideas strung together without adequate development of each, resulting in a disjointedness that is unpleasant to read.
After the section on bipolar disorder is a section on late-life psychosis. An overview of neuroleptics and associated risks and benefits in the elderly is presented. The delineation of side effects with special consideration in geriatric patients is particularly well done in this chapter. Again, the shortage of adequate controlled studies features in the discussion of treatment guidelines. Treatment of psychosis in the context of Parkinson disease poses a unique and difficult challenge, and is given its own chapter. This comprehensive review presents the clinical features to assist in the differentiation of psychosis from dementia and delirium, a neurochemical basis for treatment with dopaminergic and serotonergic agents, and an up-to-date description of treatment strategies.
The use of sedative/hypnotics in the elderly is quite extensively covered in Chapter 19. A practical approach is taken which includes nonpharmacological therapies such as stimulus control, sleep restriction, relaxation techniques, and others. This is followed by a chapter on the treatment of generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder. Unfortunately, it lumps all of these anxiety disorders together in the discussion of treatment and does not mention the use or addition of nonpharmacologic treatment strategies, which are known to be efficacious in these disorders.
The final section of this book focuses on dementia, with separate chapters on cognitive enhancers, neuroleptics for behavioral complications, and nonneuroleptic treatment of complications of dementia. The first of these examines current cognitive enhancers. Included are agents considered part of the "alternative" medicine realm, such as Ginkgo biloba, which the authors note has actually been well studied and is approved for use of dementia in Germany. Consideration is also given to future agents thought to potentially slow the course of Alzheimer’s disease and the rationale for such hypotheses. The chapter on neuroleptic treatment for behavioral disturbances in demented patients is fairly straight forward. The final chapter is devoted to the description of a systematic approach to treatment of behavioral disturbances in dementia. The authors report a unique method to guide selection of psychotherapeutic agents using "psychobehavioral metaphors" which represent a "cluster of the most salient signs and symptoms that are roughly analogous to a drug-responsive system." These are categorized into 1) psychotic features, 2) depressive features, 3) manic features, 4) anxious features, 5) agitation/aggression, and 6) other behavioral clusters. They then match these behavioral clusters to the most "potentially relevant medication class."
Overall, I would say that this book generally provides an adequate coverage of a broad range of topics within the pharmacologic treatment of psychogeriatric disorders. It is a compact book, hence, there are limitations to the amount of details provided on each subject. However, it is not intended to be a comprehensive textbook on psychogeriatrics, and references abound. Despite the two notable exceptions, the chapters were generally easy to read and quite well conceived. The price of $175 is somewhat daunting, and may dissuade those who already have a standard textbook on geriatric psychiatry from purchasing it, particularly with the rapidly expanding sources of pharmacotherapeutic information available in journals. On the other hand, it provides some of the basics on which to formulate sound therapeutic decisions, which may not be found in journals.
Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
Edited by Paul Cameron, John Ennis, and John Deadman
University of Toronto Press, Toronto, 1998, $75 Hardcover; $35 Softcover
Strengths: admirably fulfills the purpose for which it was written; subject matter handled competently and clearly; a standard reference in the field
Weaknesses: no important weaknesses
Target reader: psychiatrists, psychiatric residents, psychologists, social workers, some family physicians and other mental health professionals who engage in any of the psychotherapies
This book very competently fills a gap in the psychotherapy literature that badly needed filling. There is much that is impressive about this text, but what stands out overall is the consistent high quality of the chapters by knowledgeable and thoughtful authors, despite that this is an edited text with many authors. The individual chapters are scholarly contributions by informed authors that represent the state of the art of the subject. The editors have done an excellent job in promoting the consistency of the text, which reads smoothly with no obvious stylistic differences between the chapters.
It is reasonable to call this a seminal work. It has an organized and comprehensive approach toward the psychotherapies, and deals with diverse subjects such as stalemated treatment, treatment contracts, clinical concepts, and indications and techniques of individual psychoanalytic psychotherapy. The authors seem to be balanced and practical in their approach. They have considered a wide range of background work, including Canadian Medical Association guidelines for clinical practice, the Quality Assurance Project, and American Psychiatric Association practice guidelines.
The 19 chapters of this book do cover the psychotherapy waterfront. Two initial chapters define psychotherapy and outline general guidelines for psychotherapy practice. In the latter chapter the authors describe the literature regarding the "controversy" about sexual contact between therapists and former patients, but do not express their own opinion, to which I think the reader is entitled. Some redundancy in the text is noted between chapters; for example, factors affecting the therapeutic frame is repeated in virtually an identical form. The chapter "Empirical Evidence for the Core Clinical Concepts and Efficacy of the Psychoanalytic Psychotherapies" by Norman Doidge provides a scientific foundation for psychotherapy. This has also been published in Psychoanalytic Inquiry in a very similar form. I am not sure whether this chapter, however important, conforms to the goals set for the editors at the beginning of the book. Perhaps presenting the empirical evidence for efficacy of the psychoanalytic psychotherapies is, among other things, so important from a strictly political point of view that this in itself justifies its inclusion.
Guidelines for the Practice of Cognitive Behavioral Therapy (CBT) is a readable, concise summary of CBT efficacy with appropriate, although sparse, references to guidelines. For example, it suggests that it is important to maintain boundaries if treating a patient with obsessive-compulsive disorder (OCD) in his/her own home by having a chaperone. I felt there should be more details about standards and guidelines that are specific to CBT, and if there are few differences from other therapies, this could be stated. The next chapter, "Guidelines for the Practice of Brief Psychodynamic Psychotherapy" is clear and well organized. One error (page 166) states the opposite of what is intended; "the capacity to engage without difficulty" likely should read "the capacity to disengage." In this chapter, Howard Book suggests that the psychotherapeutic focus is worked through and resolved in treatment, without qualifying to what extent working through can be accomplished in 12 to 16 sessions. Book, however, does make the important point that brief therapy is not equivalent to long-term therapy and is not the treatment of choice for many patients. He adds that long-term therapy is indicated in patients who wish pervasive shift in character structures, and refreshingly refers to the risk that because profitability is a major concern, clinicians may be pressured to use brief therapy inappropriately. It is gratifying to see a proponent of brief therapy making realistic distinctions between what brief and long-term therapy offer, as opposed to the impression that is sometimes left that brief therapy offers similar results to long-term therapy.
"Guidelines for the Practice of Couple and Family Psychotherapy" is especially well done. The authors present a contradiction that they do not resolve in suggesting that in couple therapy the clinician should warn both partners that privileged confidentiality between him/her and one of the partners is incompatible. However, they indicate in some cases that the therapist may recommend alternating sessions with the couple and sessions with one of the partners alone, and conclude that it is important for the therapist to preserve the freedom to use clinical judgment about when to discuss material from an individual session in a couple session. In my opinion, this situation poses a considerable risk of boundary crossing or violation, and would best be avoided. If one member of a couple in therapy requires individual treatment, ideally this would be done by another therapist, possibly best when the couple therapy was over.
The chapter on group psychotherapy is an excellent summary of the scientific basis and efficacy, mechanisms of change, indications and contraindications of group therapy. It also deals with preventing negative outcomes, the setting and frame of group psychotherapy, and the training of group therapists. A chapter on supportive psychotherapy refers specifically to psychiatrist- and physician-patient relationships. Almost all of this applies to nonmedical therapists, who should not be discouraged from applying these standards and guidelines. A thoughtful and scholarly chapter on psychotherapy with children and adolescents is followed by a chapter on guidelines for combining pharmocotherapy with psychotherapy. This provides useful vignettes which represent a well thought-out and practical approach to combined therapy. The description of the patient as "consumer" is antithetical to a main thesis of this book, which is the importance of psychiatrists as psychotherapists. A chapter on psychotherapy with patients suffering from severe and persistent mental illness offers a comprehensive approach to the integration of a wide range of psychosocial and management approaches in the treatment of severe mental illness.
The chapter "Standards and Guidelines for Psychotherapy Training" is a powerful argument for residency program directors and psychotherapy training coordinators to bring psychotherapy training up to acceptable standards. This is a very well-organized, comprehensive chapter. The guidelines and standards seem, at least from the viewpoint of one who works in a medium-sized medical school, to be impossibly high and goals to be striven toward, but not necessarily reached by all training programs. Useful additional chapters include "Guidelines for Psychotherapy Supervision," "Cognitive Behavioral Psychotherapy Supervision," "Gender Issues in Psychotherapy," "Cultural Issues in Psychotherapy," "Consent Issues in Psychotherapy," and "Standards and Guidelines for Psychotherapy Record Keeping."
This text is a singular achievement and promises to be the standard text on standards and guidelines for the practice of the psycho- therapies. Its comprehensiveness really makes it a reference text, which may not best be used by being read from cover to cover. I found reading the entire book a rather arid experience. Rather, one may read individual chapters, keeping the book handy for frequent future reference. One thread running throughout this text is the emphasis on the psychiatrist’s functioning as psychotherapist. This is appropriately supportive of psychiatrists’ roles as specialist physicians, as therapists, and as leaders of mental health teams. Useful comments are made regarding the paucity of training available in family, couple, and brief psychotherapies in psychiatric residency training programs. This text is a major contribution toward the process of integration of the psychological approach and the biological approach in the management of psychiatric disorders.
Emeritus Professor of Medicine, University of Ottawa, Ottawa, Ontario Canada
J. Robert Swenson Editor
Douglas A. Drossman
Zancom International, Mississauga, Ontario, Canada, 1997, $100 for the videotape & study guide (53 pages); order online at www.med.unc.edu/medicine/fgidc/ibsvideo.htm
Strengths: well presented, demonstrates interviewing skill, reasoned approach
Weaknesses: a bit long, some tests and treatments impractical to primary care in many communities
Target reader: primary care physicians, all who must care for patients with the IBS
This educational video for physicians is sponsored by Solvay Pharmaceuticals and bears the imprimaturs of The University of North Carolina Functional Digestive Diseases Center and the International Foundation for Bowel Dysfunction. Certainly, Dr. Drossman is a leading authority on functional gut disorders, and by being trained both in psychiatry and medicine, he is well positioned to champion both the physical and psychosocial characteristics of people who consult doctors with these disorders. The term "biopsychosocial" is a mouthful, but it simply implies that one must take into consideration all the factors that make a patient feel unwell whether they be physical, dietary, psychological, social, or responses to the slings and arrows of fortune.
With the skillful use of graphics and an easy narrative style, Dr. Drossman begins by summarizing what we know about the irritable bowel syndrome (IBS); its epidemiology, the theories of its etiology, how it may be positively and economically diagnosed with few tests, and the available treatments. In brief, the IBS is ubiquitous, idiopathic, easily recognizable, and without cure.
The core of the video, however, is the presentation of three patients with a principle diagnosis of IBS who are, respectively, mildly, moderately, and severely ill. Mild patients are typical in primary care and require little investigation or treatment. Moderately affected patients are more likely to be referred to specialists and require more time and care. Severely affected patients are typical of those seen in academic centers and represent as few as 1% of all those with IBS. This intensely studied subgroup is most likely to include patients suffering from anxiety, depression, and memories of physical and sexual abuse.
Each subject, portrayed by actors, presents his or her case as one would to a doctor, helped along by an interview by Dr. Drossman. The encounter is occasionally interrupted, and Dr. Drossman appears in a window to explain his interviewing technique or point out cues to the patient’s needs. In keeping with Dr. Drossman’s background and research, the emphasis is on the patients’ psychosocial history and an effective doctor-patient relationship. Some would give more attention to diet and lifestyle issues. On the other hand, most experts would agree with Dr. Drossman that medication (other than for the treatment of depression or anxiety) plays a minor role in the treatment of this disease. On the whole, the approach is reasonable, balanced, and in keeping with what little we know about the pathogen‘esis of the disorder and the accompanying co-problems that propel some patients through the health care system.
I found the tape a little long (45 min). Busy practitioners may not have the time. Most gastroenterologists would not recommend colonoscopy for all IBS patients, and if a colon test is required, a barium enema is more practical for primary care physicians. It is doubtful if the stool test for occult blood is very helpful in office practice. It remains controversial even as a screening procedure. Some of the sophisticated psychological treatments are beyond the resources of many medical communities. Nevertheless, this is a clear and sophisticated treatment of a difficult and complex problem, and could help any doctor to manage the IBS, indeed any other chronic, functional disorder. I don’t believe it has any serious competition.
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