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BOOK REVIEWS |
Cognitive Neuroscience of Emotion
Richard D. Lane and Lynn Nadel
reviewed by Robert F. Ackermann
Hypochondriasis: Modern Perspectives on an Ancient Malady
Vladan Starcevic and Don R. Lipsitt
reviewed by Clifton K. Meador
Giving a Voice to Sorrow: Personal Responses to Death and Mourning
Steve Zeitlin and Ilana Harlow
reviewed by Charlotte Williams
University of Alabama in Birmingham, Center for Palliative Care, Birmingham, Alabama 35294, Email: cjwilliams@uab.edu
Steve Zeitlin and Ilana Harlow
A Perigee book, a division of Penguin-Putnam Publishing, New York, November 2001, 215 pages, $13.95
Strengths: readable, topical, genuine, literary and historical references.
Weaknesses: may seem "cliché" to some, lengthy and slightly repetitive introduction.
Target Reader: the bereaved, those counseling the dying or bereaved
As a specialist in Palliative Medicine, people often say to me that the field must be terribly depressing. The reverse is true in that the stories that we hear, or are privileged to witness, are quite inspirational and "Giving a Voice to Sorrow" is a testament to this truth.
This book is very readable and at only 215 pages, divided into five sections, is easily digested without excessive tissues. The introduction, which is the story that inspired the book, and sections covering three types of creative expression of grief: storytelling, ritual and ceremony, and commemorative art.
In the introduction, the authors describe the Buddhist tale that is their inspiration for writing this book. In the "parable," a young woman who is grieving the death of her child wears him strapped to her bosom and searches for a treatment to cure him. The people think she is mad. Desperate, she goes to see a holy man who tells her to bring him some mustard seed from a house where no one has died. She visits many houses and in so doing hears many tales of death and loss, but nowhere does she find a house that death has left untouched. The realization that she is not alone in her grief helps her to at last put her child’s body to rest and find peace. Thus, the authors set the scene for a book where many people come together in their different expressions of grief. These stories serve to help the bereaved reader feel less alone, feel less guilty about grief resolution, and to realize there is no one way to grieve because grief is a creative experience. The book serves as a reminder to be a patient listener to stories, to respect observed rituals, and to encourage creativity as a healing process.
It is the practice in palliative medicine to encourage the dying, and those involved with them, to record a life narrative in any form: spoken word recorded, diaries, a yearbook, photographs, film, and art. This helps the dying person to recognize that his/her life has meaning, a context, and helps all who are involved feel that the achievement of "immortality" through memories and "...help the living incorporate the departed into their lives".
The authors dedicate the second section of the book to the story of the death of a 19-year-old boy from a rare lymphoma. This tale illustrates the many different ways people find to express their grief, as each involved tells the story of how the boy touched his/her life. The authors bridge these stories using diaries and transcripts from interviews, and despite not meeting the boy themselves, obviously were touched by the stories they relate.
The third section begins by explaining why "telling stories" is so important to those approaching death, especially older persons. The authors recount several life stories and describe how the inferred meaning in a story may be a source of healing. For example, Jewish parents whose son dies and who then have a baby born exactly 11 months later share a story. In the Jewish tradition Kaddish, a Jewish prayer, is recited every day for 11 months after a death. "Some say that the end of saying the Kaddish is when the soul finds its resting place. So we said their two souls had just crossed."
The most poignant story for me, beautifully narrated by the patient’s mother, came in the fourth section of the book, which describes rituals and ceremony. A 6-year-old, Liza, had a precise idea in her head of how she wanted to die. She created her own ritual and in so doing preserved dignity and control. This 6-year-old’s acceptance of her own death and her family’s wonderful story honoring her short, but heroic, life is one example of an inspirational story that can touch our lives. Liza and her family narrate a tale that undoubtedly helped them with her death and may encourage others who find themselves in such a circumstance. In reading this mother’s tale, it is almost as if we know Liza too; she has come alive and this supports the idea that through storytelling we can give eternal life to the spirit of the lost person.
The final section describes art as a way to experience grief. There are the stories of a man whose children build a coffin for him as a testimony to the father they loved; pop-artists who spray paint large memorial murals on buildings dedicated to lost members of that community; quilts made from clothes or fabrics of the deceased; and descriptions of photographs, art, and music. The spirit of the deceased person is kept alive in these types of expression of grief through "quirkiness" or individuality of its form. The art "form" itself may make sense to only those who created it, or commissioned its creation, but in this way provokes others to ask, "What is this about?" "Why are you using this piece of music?" and it is in the answers to these questions that the person comes alive and crosses back into new lives.
A potential weakness to this book is that it is one of many in its genre and faces fierce competition from popular texts like the "Chicken Soup..." series or "Tuesdays with Morrie" to name but two. However, to its credit, it is unpretentious and remains faithful to its original narrators, and in so doing cannot be dismissed as a collection of sentimental clichés. The stories are real and the parable that began this book reminds us that none of us can claim to be untouched by death. We thank Zeitlin and Harlow for reminding us of the therapeutic benefit and the individual importance of those stories that honor the dead and help to find meaning for their lives as well as our own.
Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294, Email: rackerma@uab.edu
Edited by Richard D. Lane and Lynn Nadel
Oxford University Press, New York, 1999, 448 pages
Strengths: Comprehensive state of knowledge of brain processes that underlie emotional states.
Weaknesses: Minimal coverage of positive emotional states.
Target Reader: Researchers and clinicians interested in relationship of brain function and aversive emotions.
This book, which is the product of a conference, reviews clinical and experimental evidence that the brain mechanisms underlying cognition and emotion are intertwined. Much of the material in the 17 contributed chapters is academic but clinicians will find interesting several thematic issues and empirical findings.
The first chapter introduces the book’s main themes and outlines four general topics: 1) process of emotion generation; 2) functions of the amygdala; 3) conscious experience of emotion; and 4) emotion regulation and dysregulation. The thematic issue that runs through and unites these somewhat disparate topics is whether the processing of emotion-evoking stimuli necessarily involves cognitive process.
In the past few decades it has been repeatedly demonstrated that cognition involves unconscious processes. Furthermore, work by Demasio and colleagues on humans with frontal cortex lesions (Chapter 2) reveals that unconscious emotional processing is necessary for rational risk-based decision making. This is in contrast to the opposite assertion by Lane and colleagues (Chapter 1) that emotional responses are the result of cognitive processes that evaluate evoking stimuli. This question, the thematic crux of the entire volume, is addressed by chapter authors in various ways. The issue centers around facts that emotional responses tend to be stereotyped, frequently precede conscious awareness of stimuli, and are difficult to initiate or terminate volitionally—all contrary to intuitive notions of cognitive processes.
Lane et al. cite the case of patients suffering from prosopagnosia. Such brain-damaged patients have lost the ability to identify the faces of family members and friends, but nevertheless display increased sweating in response to familiar faces, indicating that a cognitive process has occurred despite the lack of conscious awareness. To Demasio, this ability to exhibit an emotional response without conscious awareness would be an example of the distinction between emotion and the "feeling of emotion." The work of LeDoux and colleagues (Chapter 7) provides a functional neuroanatomical model for this distinction. They have studied auditory Pavlovian fear conditioning in rats and demonstrate that a pathway between the thalamus and the amygdala is necessary for normal auditory fear conditioning.
If the thalamoamygdala pathway is interrupted, or if there is interference with amygdala function, auditory fear conditioning is disrupted. If instead, the thalamocortical pathway is interrupted auditory fear conditioning is not affected. This contrast is theoretically important because thalamocortical function is essential for conscious recognition of stimuli. This point is beautifully demonstrated by the "blindsight" work of Weiskrantz and colleagues (Chapter 12). They studied humans with lesions of primary visual cortex and discovered that subjects could respond correctly to stimuli that were not experienced consciously. Some subjects reported that they were "aware" of the presence of stimuli that they could not see.
Findings such as the above are important to psychiatry/psychology in that they demonstrate that conscious awareness of cognitive processing is graded. Close and Ortony (Chapter 3) review studies in which unperceived "priming" stimuli were shown to affect subsequent conscious perceptions. Such subliminal priming effects disappeared when the subject was made aware of them; this was true also of potentially supraliminal stimuli that were not attended to. These findings should be of interest to clinicians because, as Close and Ortony point out, the latter phenomenon formed the basis of Freud’s "talking cure" of therapeutic techniques.
A substantial portion of this book is devoted to the role of one particular brain structure, the amygdala, in the generation of fear responses. We do not yet possess theoretical constructs to account for this fact and with a lack of such constructs, one too easily resorts to phrenology and anthropomorphism. For example, LeDoux (Chapter 7) uses the following language to describe amygdala function: "The existence of a subcortical pathway allows the amygdala to detect threatening stimuli in the environment quickly..."; "A loud noise may be sufficient to alert the amygdala, at the cellular level, to prepare a response to a dangerous predator lurking nearby..." Similarly, Emery and Amaral state (Chapter 8), "As for the other behaviors described in this chapter, the amygdala may be important for aggressive behavior by interpreting social signals as threatening and initiating appropriate neural, hormonal, and behavioral actions."
Another concern is with key terms in the book’s title. The term cognition receives little explicit definition or discussion in the 17 chapters of the book, and the term emotion should imply a more general discussion than is found here. The book is predominantly about the relationship between the generation of fear responses and amygdala function. Positive emotions receive scant attention, despite the interesting contrast that such consideration could have offered. For example, there is no account in this book of the powerful ability of music to evoke a spectrum of emotions in humans (and perhaps other animals?). Such quibbles notwithstanding, this book remains a valuable compendium of the methodological and conceptual approaches that creative modern researchers have taken, in defiance of the likes of both Descartes and Skinner, to reunite body and mind. This is exciting "must" reading for anyone interested, as Freud originally was, in the relationship between human experiential and physiological states.
Vanderbilt University, School of Medicine, Nashville, TN 37203, Email: clifton.meador@mcmail.vanderbilt.edu
Edited by Vladan Starcevic and Don R. Lipsitt
Oxford University Press, New York, 2001, 402 pages, $65
Strengths: exhaustive review of the world literature on the subject.
Weaknesses: the necessary narrow focus and in-depth treatment will limit the audience of primary care physicians. These are the physicians most in need of knowledge of this subject.
Target reader: all mental health professionals, particularly those in research.
My first impression on reading this book was admiration for all of the authors for taking on this most difficult of clinical topics. As an internist with a long interest in patients who have multiple symptoms but no definable "medical or physical disease," I find this book to be extraordinary and encyclopedic in scope and breadth.
It is difficult to improve on the first paragraph on the cover as a summary of the book:
"Hypochondriasis remains controversial, despite its 2000-year history. Although it is considered a mental disorder, hypochondriasis is often regarded as a defense mechanism, a peculiar cognitive/perceptual style, a means of nonverbal communication, a response to stress, an abnormal illness behavior, a personality trait, a distinct personality disturbance, and as a part of other mental disorders. Disagreements about the etiology and pathogenesis of hypochondriasis go hand in hand with disagreements about its treatment."
The multiple authors, chapter by chapter, trace all of the above considerations in detail. The bibliography in each chapter is extensive. The book is divided into three sections: I, Clinical and Diagnostic Considerations; II, Theoretical and Etiologic Aspects; and III, Treatment Considerations.
The Epilogue, written by both editors, summarizes the efforts of all of the authors in a concise and thoughtful manner.
The book does not resolve the controversy that has been around for 2000 years neither does it attempt to "sell" any particular point of view. This is a reference book best suited for those professionals who have focused on patients with hypochondriasis, either in practice or research. The appendices give details on several useful assessment tools. I found the section on treatment to be particularly helpful, especially the sections on use of the serotonin reuptake inhibitors and the possible relationship between hypochondriasis and obsessive-compulsive disorders.
The book leaves me with much hope for these patients who are often rejected, demeaned, abused, and often shifted from doctor to doctor. It should be read by all internists and family physicians who struggle to care for these trying patients.
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