Long-awaited third edition suffers from word processor-itis. Colour photos less than impressive and clear need to move into a new publishing field to meet with fast changing subject.

Organic Psychiatry (Third Edition) is a book written by a psychiatrist that is most useful for psychiatrists in medical settings. It provides the unique perspectives of its author William Alwyn Lishman who began writing the First Edition in 1977. The author explains why he began writing the text in his "Preface to the First Edition". Through clinical practice and teaching he observed the large "borderland" zone between neurology and psychiatry. His initial goal was to look at the psychiatric consequences of a cerebral disorder from either structural or systemic disease. His intent was to avoid the speculative mechanisms of biological psychiatry and restrictive definitions of neuropsychiatry. He is aware of the fact that the term "organic" has lost favor as markers of brain dysfunction become more sensitive. On the other hand he considers it a practical definition to designate disorders where there is a high probability that the appropriate evaluation will yield "cerebral or systemic pathology responsible for, or contributing significantly to, the mental condition."

The book is laid out in two sections. The first section entitled "Principles" consists of four chapters dedicated to the assessment and differential diagnosis of psychiatric disorders associated with brain dysfunction. Cognitive and psychiatric symptoms are presented from the standpoint of phenomenology and cerebral localization. In the assessment chapter the medical evaluation is discussed and there is a summary of psychometric tests and their relative applications. The differential diagnosis section explores a number of useful dimensions to assist in the consideration of determining whether a non-psychiatric illness is causing the symptoms. The etiologies are given in table form and they roughly correspond to subsequent chapters. The second section "Specific Disorders" looks at a wide variety of medical problems associated with brain dysfunction. It is grouped into eleven chapters by general disease process or affected system. The book ends with a 118-page reference section.

Lishman's text has practical application in the complex cases seen in inpatient psychiatric practice. For example, it is common these days to receive a patient transferred from a medical service where the diagnosis and etiology of delirium versus psychosis is unclear. Frequently these patients have unexplained medical symptoms early in their course such as an acute febrile illness or unequivocal signs and symptoms of physical illness. The usual course of events is that the transferring service has done brain imaging studies, a chest X-ray, blood and urine tests and cultures, and possibly obtained a neurological consultation. The receiving psychiatrist is in the position of receiving a patient who may still appear delirious. All of the accompanying tests and procedures must be reviewed. There are frequently findings like elevations in cerebrospinal fluid proteins, mild pleocytosis, or abnormal electroencephalograms that require explanation. That psychiatrist is also in the position of evaluating a patient who may not be capable of providing an accurate history. Additional interviews with family members and other informants are often necessary to get a detailed description of cognitive changes and the development of psychiatric symptoms. When that information is obtained, a correlation with markers of medical illness is sought. I have found that in these situations referring to specific chapters in this text is indispensable. For example, "Chapter 8: Intracranial Infections" provides a thorough review of the common and more esoteric causes of psychiatric syndromes associated with these diseases. He details the clinical features of these illnesses and using an approach applied to other chapters discusses the results of clinical investigation, differential diagnosis, pathology and treatment. The diseases are categorized by both infectious vector (HIV, syphilis) and syndrome (encephalitis and various viral subtypes).

Controversies are given adequate discussion. In the case of encephalitis lethargica, the relevance of a presumably infectious disease that causes psychiatric and neurological disease is emphasized. He states that this illness "Had an important influence on psychiatric thinking at a time when psychodynamic explanations for mental pathology were gaining too much ground." In comparison to a standard neurology text, there is more description of specific acute and post encephalitic syndromes. He provides evidence for sporadic cases since 1930 and what implications this illness has for current problems like catatonia.

The infectious disease chapter illustrates the real strengths of Organic Psychiatry. There is an abundance of clinical information that is relevant to the psychiatrist. While some of the discussions are not exhaustive, details and references are presented that you will not find in other texts. The author is aware of the balance required to assess non-specific symptoms and not miss a medical diagnosis. There is a level of systematic and critical analysis applied that could be considered a gold standard for diagnostic reasoning in clinical psychiatry. In comparison with American texts there are significant differences. There is a lack of discussion about receptor systems. American psychiatry is often focused on receptor physiology and possible mechanisms for psychiatric syndromes. Lishman's approach is to discuss the pathology where it is known and possible mechanisms episodically such as the excitotoxic theory in traumatic brain injuries and the role of interferon in the symptoms of chronic fatigue syndrome. In his preface to this edition he points out that the sections on HIV related disease and neurodegenerative dementias has been rewritten to incorporate broadening research of the last decade.

Given the stated goals of this text are there any shortcomings? One useful approach might have been to consider the physical examination and review of systems in more detail. This provides a prospective look at findings that might have diagnostic importance in the evaluation of problems associated with psychiatric symptoms. It provides the additional perspective of looking at findings that might be more closely correlated to psychiatric symptoms. Lishman puts the findings in subsections like "clinical features" and "abnormalities on examination". This is consistent with his editing goal of keeping the size of the text to a manageable level. The text is also has fewer graphics than a typical psychiatric text. There are 19 color plates at the front of the book and 18 tables. I did not find this to be a significant problem considering that the most likely use of this book will be for reading about the psychiatric complications of specific illnesses - a few pages at a time.

There can be no doubt that Lishman has succeeded in providing a comprehensive review of diseases important to psychiatrists. His book provides the right amount of information and relevant references for clinical psychiatrists who practice medical psychiatry, hospital psychiatry, and neuropsychiatry. It is also a book that I recommend to colleagues, and medical students. I teach a seminar in the medical evaluation of psychiatric patients and include this text as a reference for that course. In this age of financial constraints, psychiatrists are receiving more patients who are medically stable but do not have a clear medical diagnosis that explains their psychiatric symptoms. Organic Psychiatry provides the important signposts needed to navigate this borderland zone.

George Dawson, MD

Lishman's mega-work is an absolute necessity for any psychiatrist, psychologist, behavioral neurologist, and neuropsychologist. He covers literally every medical condition that has CNS effects - from the mundane to the obscure - as well as standard functional disorders. This is a major resource for the student, teacher, researcher, or practicing clinician in the neurosciences. If you are studying for the Boards, preparing course lectures, or just for your own clinical 'edification', this is the best reference of its type. Lishman is authoritative & complete, with outstanding and up-to-date references on all topics, clinical presentations of syndromes, laboratory studies, large N studies, and case studies, as well. He has really done his homework in a very thorough and professional way. This is a highly recommended must have!