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Substituting a curate's egg for clinical wisdom
on 20 June 2008
Following an invitation to hold a series of seminars on the phenomenology of mental illness in the Department of Psychiatry of the University of Manitoba, Frank Fish brought together the classic descriptions of psychiatric symptoms which, at that time, were not easily found in the English literature. The seminars were published in 1967 and 'Fish's Clinical Psychopathology' rapidly became an essential text for medical students, psychiatric trainees and practising clinicians. After his death the text was revised and updated by the late Max Hamilton in 1974 and 1985.
'Fish's Clinical Psychopathology' was out of print for several years but has now been re-issued by the Royal College of Psychiatrists in a third edition. The authors, Patricia Casey and Brendan Kelly, have updated the references and expanded the chapter on abnormal personalities added to the last edition by Hamilton. They have also included two appendices covering unusual psychiatric syndromes, defence mechanisms and cognitive distortions.
In their preface - those by Fish and Hamilton have been omitted - Casey and Kelly express the hope that despite the additions and revisions of the language, `so as to take account of changes in linguistic conventions', the text `remains true to the spirit' of Fish's original work. Alas, a comparison of this volume with the previous editions reveals it to be something of the proverbial curate's egg.
In his revision of the original text Hamilton provided a detailed but succinct overview of the historical and philosophical underpinnings of phenomenology and psychopathology in an attempt to counter the lack of philosophical training of many English speaking psychiatrists. This material has been omitted from the new edition and, instead, the unwary reader is repeatedly invited to genuflect before the twin altars of the ICD-10 and DSM-IV. As a result, much of the clinical wisdom - and wit! - of the original authors is lost, potentially to the detriment of good clinical practice. In view of the recent repressed memory and multiple personality debacle in North America, it is regrettable that Casey and Kelly have chosen to omit the original, well founded, scepticism about the various dogmas of the psychodynamic schools of psychiatry. Instead, Appendix II blandly lists the `most commonly seen' defence mechanisms, ostensibly `used by the psyche to protect itself', without even hinting to the naïve reader that these `techniques' cannot be observed, measured or even refuted and that despite their enduring popularity, these concepts are not facts.
Appendix I perpetuates the questionable tradition of referring to several colourful and unusual phenomena as syndromes when, in reality, most are symptoms which occur in a variety of clinical, neuropsychiatric, settings. Their listing is also made redundant by earlier - and sometimes better - descriptions elsewhere in the text. The scholarship in this section is further marred by a number of unfortunate errors. The delusion of subjective doubles is not characterised by the belief that the patient has a double or Doppelgänger (a term misspelled throughout the text but omitted from the index). The so-called Windigo delusion is mentioned as one of the culture-bound disorders, much beloved by Anglophone psychiatrists, without giving any indication that there are serious doubts that this phenomenon has ever been observed in a clinical setting. While controversy has, undoubtedly, surrounded the concept of Munchausen syndrome by proxy, it is, pace the tabloid papers, not the case that `convictions based on this diagnosis have also been overturned in the courts in Britain'.
Finally, given the widely acknowledged limitations of the categorical approach to personality disorders, it is a pity that not more space is given to the alternative dimensional conceptualisation which has demonstrated better reliability with respect to interdiagnostic agreement, temporal stability and clinical validity.
The return of 'Fish's Clinical Psychopathology' after such a long absence is indeed welcome but this reviewer regrets that a golden opportunity has been missed to revise and update the text fully in the spirit of the original so as to provide the `firm basis for clinical work and research' which Fish had endeavoured to provide.
Karel de Pauw
Consultant and Senior Clinical Lecturer in Psychiatry