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B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 5 ) , 1 8 6 , 8 1 ^ 8 4
Book reviews
Prader ^ Willi Syndrome :
Development and Manifestations
By Joyce Whittington & Tony Holland.
Cambridge: Cambridge University Press.
20 04. 220 pp. »6 0 (hb). ISBN 0 52184 029 5
One finding from the Cambridge Prader–
Willi syndrome (PWS) studies, summarised
in this book, seems to be worthy of
attention from psychiatrists in all specialties. It is that PWS caused by maternal
uniparental disomy (inheritance of two
chromosome 15s from the mother and
none from the father) is associated with a
prevalence of psychotic disorder that rises
so steeply in early adult life that it
approaches 100% by the age of 30 years.
The finding has now been replicated. Like
the association between Down’s syndrome
and Alzheimer-type dementia, there seems
to be a clue here from research into an
aspect of intellectual disability that has
the potential to further knowledge in
psychiatry more widely.
Prader–Willi syndrome was first
described by Prader, Labhart and Willi in
1956. These Swiss paediatricians described
a syndrome characterised by neonatal
hypotonia, impaired sexual development,
short stature, obesity and mental retardation. Further reports followed from around
the world, and it became apparent that the
obesity associated with PWS was a consequence of a severe eating disorder, and that
strict dietary control from early childhood
could prevent morbid obesity from
Descriptions of behavioural aspects of
the disorder ranged from early adjectival
descriptions such as ‘cheerful’, ‘somnolent’,
‘prone to temper-tantrums’, through
surveys of parent and carer organisations
with questionnaires, to more rigorous
studies using standardised behavioural
assessments and comparison groups. It
became apparent that PWS was associated
with a behavioural phenotype that ranged
from overeating (which is universal), to
vulnerability to a variety of sleep problems,
skin-picking, impulse-control disorders,
compulsive and ritualistic behaviours and
possibly vulnerability to severe psychiatric
Advances in genetics led to the
recognition that PWS was associated with
chromosome 15 abnormalities. Deletions,
which were always of paternal origin, were
found in association with about two-thirds
of cases of PWS. The cause of PWS in the
remaining third was eventually found to be
maternal uniparental disomy, a finding that
revolutionised thinking about human
genetics and led to the concept of genomic
imprinting. A small number of people with
PWS are now known to have an imprinting
error (in which the father’s copy of
chromosome 15 is ‘marked’ as though it
were the mother’s, leading to a situation
akin to maternal uniparental disomy).
Research into behavioural aspects of
genetic disorders (behavioural phenotypes)
has advanced greatly over the past 20 years,
and this book describes the culmination of
several programmes of research into aspects
of PWS centred on behavioural and psychiatric manifestations, but also including
aspects such as prevalence and mortality
rate (the latter found to be around 3% a
year, far higher than for the general
The book is divided into three sections,
giving an overview of the condition with
some historical information, a review of
genetics and biological aspects of the
syndrome, an introduction to the Cambridge PWS project (the findings from
which constitute the main part of the book)
and concluding with a consideration of the
future direction of research. It is written in
a style that makes assimilation of the
content easy for readers not versed in
genetics or familiar with behavioural phenotype research. Its strength is also its
weakness. By focusing almost exclusively
on the Cambridge studies it provides an
excellent overview of the findings from this
research programme and sets them in the
context of wider knowledge. There is
relatively little emphasis on giving information about management strategies for
psychiatric disorders or the practical applications of cognitive research for the
education of people with PWS.
Declaration of interest
D.C. has collaborated with Joyce Whittington and Tony Holland on research into
behavioural and psychiatric aspects of
David Clarke Consultant Psychiatrist in Learning
Disability, Lea Castle Centre,Wolverley,
Kidderminster DY10 3PP,UK
Somatoform Disorders:
A Medicolegal Guide
By Michael Trimble.
Cambridge: Cambridge University Press.
20 04. 254 pp. » 550
0 (pb).
ISBN 0 521 81108
8110 8 2
There have been many books published
recently on somatoform disorders, but this
one deals specifically with the medicolegal
perspective. The book is timely because
over the past decade a considerable amount
of research has suggested that psychosocial
factors are the key maintaining factors in
disorders such as whiplash neck injury,
upper limb pain (repetitive strain injury),
chronic widespread pain and functional
paralyses. Trimble starts well by taking a
swipe at commentators such as Micale,
helpful case vignettes, and Trimble introduces the term ‘lexigenic’ to emphasise
the legal equivalent of iatrogenic illness.
Chapters about mechanisms and causation
include descriptions of recent imaging
studies on hysteria and malingering.
This is a valuable text for psychiatrists
involved in medicolegal work, especially
those asked to provide reports on patients
with unexplained gait disturbances, whiplash neck injuries and symptoms that
are not matched by organic findings.
The Department for Work and Pensions
informs us that 70% of patients on longterm disability benefits have symptoms that
are essentially medically unexplained:
Trimble’s book explains how to assess
these patients when they are involved in a
legal claim and how to prepare a coherent
report for the court.
Showalter and Shorter, who suggest that
‘Victorian faints, swoons and convulsions’
are now rare and have largely disappeared
from clinical practice. Any clinician currently working in the borderland between
neurology and psychiatry would dispute
this observation. Indeed, in October 2003
the first international conference on psychogenic movement disorders was held in
the USA (Trimble and I attended), and it is
clear that these disorders are becoming so
common (1 in 30 of consecutive referrals to
a movement disorder clinic) that even
neurologists are taking note and wanting
help. Trimble’s elegant riposte to the social
historians is that ‘hysteria has never risen
from the ashes: the fires have been burning
brightly all along’. He goes on to criticise
the diagnostic categories of both the ICD
and DSM as being arbitrary (we all agree
with that) and argues that, in a medicolegal
setting, their use can be not only misleading
but also mischievous.
Chapters on the clinical presentations
and assessment are sound and well written,
but I found most useful the chapters dealing
with the legal context and issues of causation and compensation. Trimble outlines
the shortcomings of Lord Woolf’s reforms
and the role of the single joint expert (SJE),
who is unlikely to satisfy the needs of both
parties in complex psychiatric cases. There
are up-to-date accounts of compensation as
well as the problems of legally aided claims.
Issues of forseeability and rules for secondary claimants/victims are described, with
Christopher Bass Consultant in Liaison
Psychiatry, Department of Psychological Medicine,
John Radcliffe Hospital, Headley Way, Headington,
Oxford OX3 9DU,UK
Self-Made Madness: Rethinking
Illness and Criminal Responsibility
By Edward W. Mitchell. Aldershot: Ashgate
Publishers. 20 03. 272 pp. » 50
5 0 (hb). ISBN 0
754 62 332 7
To what extent could we hold people with
mental illness responsible for their own
disturbed states of mind? And what would
this mean for those individuals with mental
illness who are charged with criminal
offences? These questions are explored by
Edward W. Mitchell in an erudite and
complex analysis of what he terms ‘metaresponsibility’. He offers both a conceptual
analysis, and an empirical investigation of
how mock jurors would judge a defendant
who had committed a violent offence
while non-compliant with prescribed
psychotropic medication.
Mitchell found that his mock jurors
gave intriguing answers to questions of
meta-responsibility. Although some took
the view that the defendant was criminally
responsible because of the causal link
between non-compliance and relapse, they
also took the view that he could not be
responsible because he had relapsed. There
was also a suggestion that it was the
decision to come off medication that should
be judged for culpability, and not the
offence itself.
The issues Mitchell raises are of profound importance for both psychiatrists
and mental health service users. Current
Department of Health policy emphasises
the importance of involving patients in the
management of their condition; of treating
the patient as their own ‘expert’. However,
when it comes to mental health, government policy seems to assume that service
users cannot be trusted to manage their
own condition, and are uniformly incapacitous in terms of responsibility for criminal
offences. Numerous homicide inquiries
have criticised professionals who have tried
to share clinical decision with their patients
and allowed the patients some control over
their medication.
As clinicians, we know that mental
illness does not necessarily abolish the
capacity to form meaningful and competent
intentions. There must therefore be some
pressure on those with mental illness who
have acted violently to explain why their
disorder should be both an explanation,
and exculpation, for their behaviour. From
my own clinical experience, these questions
are as troubling for patients who have been
violent when psychotic as they are for the
rest of us.
The more expert and autonomous the
patient seeks to be, the more responsibility
they must take for their actions. In ethical
terms, not to respect autonomy when
present is both to act disrespectfully and
to act unjustly. However, this approach is a
radical challenge to the traditional belief
that those with mental illnesses should not
be held responsible for their behaviours.
The circular which mandates inquiries after
homicide is evidence of a widespread social
assumption that any history of any mental
illness throws responsibility into doubt.
The beneficent ideal of medicine assumes
that we take care of patients because they
cannot take care of themselves; it is only
recently that the assumed incapacity of
psychiatric patients has come to be
Mitchell ends his book with an entertaining fantasy that Dr Jekyll is put on trial
for taking a substance that allows Mr Hyde
to emerge. His argument deserves attention.
Although not always an easy read, his book
is thought provoking and I recommend it.
Gwen Adshead Forensic Psychotherapist,
Broadmoor Hospital,Crowthorne,
Hospital, Crowthorne, Berkshire
Clinical Trials in Psychiatry
By Brian S. Everitt & Simon Wessely
Oxford: Oxford University Press. 20 04.
189 pp. » 27.5
0 (pb). ISBN 0 19 852642
8526 42 3
Everitt & Wessely are to be congratulated
on producing an excellent guide to
help overcome the snags in clinical trial
research. Clearly written and in an engrossing style, the book is likely to become a
classic textbook on clinical trials, and not
just in psychiatry. The authors’ enthusiasm
and grasp of clinical trial research make for
a gripping and insightful read.
The first chapter deals with the bleak
history of non-evidence-based treatment
of mental illness. The ‘slow march from
dogmatic, even mystical, certainty to
proper scientific uncertainty’ is painfully
described. Exorcism, bleeding, vomiting,
purging, spinning on a pivot, removal of
teeth and tonsils all came into fashion, were
taken up and then dropped. Chapter 2,
describing the slow move from expert
opinion to the development of the clinical
trial, is liberally interspersed with illuminating case histories and quotations: ‘the
plural of anecdote is not evidence’. Chapters 3 and 4 cover the design and special
problems of trials in psychiatry. As shown
by the typical Cochrane review, previous
trials have generally been of poor methodological quality, too small and have used
the wrong outcome measures. Everitt &
Wessely note the overemphasis on symptoms and recommend patient-rated
functional outcome measures. For maximum relevance, trials should be pragmatic,
and set as close to real-life clinical practice
as possible. Chapters on statistical analysis
and systematic reviews are aimed also at
non-statisticians and avoid being overtechnical. The final chapter covers the
arguments for, and against, clinical trials
in an objective and balanced way. Appendices on practical issues are informative
and well-referenced.
The book is well set out, with a
summary at the end of each chapter. It is
excellently researched with many recent
references. It should be essential reading for
anyone involved in clinical trials in psychiatry, whether a researcher or a user of
research evidence. I would also recommend
it to a much wider readership – it is one of
the very best books that has been written on
clinical trials.
policies and progress of different countries
in integrating comprehensive mental health
services. Much less space in the book is
devoted to human rights; there is no
comparative analysis of the countries or
any account of the policies of those
agencies with a global remit, such as the
World Health Organization and other
United Nations agencies, or international
organisations such as the World Federation
for Mental Health, the World Psychiatric
Association or Amnesty International; nor
an overview of the influence of dictatorships, democratisation or public health
renewal on the evolution of mental health
services within countries.
Most of the chapters provide straightforward descriptions of the history of the
evolution of services, their current situation
and future aspirations and, as such, are of
considerable interest in their own right. The
UK chapter is somewhat disappointing,
being a cursory and parochial antipsychiatry, anti-government polemic which
thereby misses a golden opportunity to
make a constructive dispassionate analysis
of the levers and barriers to progress in the
Fortunately the other chapters are generally very informative, clearly written, and
helpful to readers from other parts of the
world. For example, the Australian chapter
contains an important analysis of the
development of mental health consumerism, and the need to ensure it does not
undermine the other important contributions to mental health policy, including a
Richard Gray Professor of Medical Statistics
and Director,University of Birmingham Clinical Trials
Unit, Park Grange, 1 Somerset Road, Birmingham
B15 2RR,UK
Mental Health Global Policies
and Human Rights
Edited by Peter Morrall and Mike Hazelton.
London: Whurr. 20 04. 196 pp. » 25 (pb).
ISBN1 86156 388 4
The title of this book turns out to be a bit of
a misnomer. Its main focus is on the
sense of community and a common cultural
The book is largely focused on high(UK, USA, Australian) and middle-income
countries (China, Russia, Egypt and Brazil)
with only one low-income country represented (Mozambique). The chapter on
Egypt is a particularly rewarding read,
giving an overview of the Arab and Islamic
approaches to understanding mental
health, as well as the development of the
current service infrastructure and its future
developments. It summarises existing epidemiological information and also explores
some of the complex ethical issues around
removing homosexuality as a diagnostic
category in these societies where it is
considered a sin which is otherwise subject
to significant societal sanction and
On the whole, an interesting book to
have on the bookshelf.
Rachel Jenkins Director,World Health
Organization Collaborating Centre, Institute of
Psychiatry, De Crespigny Park, Denmark Hill,
London SE5 8AF,UK
Somatoform Disorders: A Medicolegal Guide
Christopher Bass
BJP 2005, 186:81-82.
Access the most recent version at DOI: 10.1192/bjp.186.1.81-a
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/letters/submit/bjprcpsych;186/1/81-a on October 25, 2017
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