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by James Whitney Hicks
Yale University Press, 2005
Review by Roy Sugarman, Ph.D. on Jun 27th 2006

50 Signs of Mental Illness

Although it seems a most unlikely thing to do, Dr Hicks has set out to create an A to Z cocktail menu of the diagnoses that could theoretically plague us if we developed signs of any of them.  How politically correct, or wise, this may be is put aside for a moment, as one contemplates the blurb on the inside dust cover.  This book is written for anyone concerned, amongst other things, about symptoms observed in family or friends.  Such an assertion I am sure brings chills to a scientologist’s spine, well, possibly to many spines, fostering a hoard of family psych-sleuths to venture forth and be diagnostic. 

Its not quite an A-Z, covering 50 titles, from (no not anxiety) anger to trauma. Yet it is enough to worry a few people I can think of.  The introduction is sobering enough, warning that these are signs and symptoms, but that one does not know what causes them. We are warned that normality is not an absolute, nor a cultural universal, and is somewhere on a continuum.  Why it starts with anger, I am unsure, but we are informed about how to deal with someone who is angry, as if it were a disorder, but its useful information.  Anger, jealousy, delusions, all such signs are elaborated on so that the reader may follow them into the various conditions of which they may be a feature.  So Jealousy may reflect on some paranoia, or dementia, or erotomania.

Each segment starts with a person talking in the second person, a little vignette that sets the scene for the discussion that follows.  So for antisocial behaviour, we are listening to someone chatting to a felon released from prison, with a sense of entitlement and lots of victim blaming.  Anxiety is a commentary on someone whose daughter’s wedding coming up soon evokes an exacerbation of their natural tendency to fret, a lot of worrying and some pretty sad sobbing.  Anxiety is passed off as a mental illness immediately, and, quite correctly, as being part and parcel of most disorders, but not in this book as a perfectly normal phenomenon which in evolutionary terms has kept us alive for millennia.  Further, his advice on ways to avoid anxiety by breathing or relaxing is no longer considered state of the art, and is hard to reconcile with modern views on the subject. The advice on medication is wise enough, but no mention of the long-term effects of using antidepressants or the problems in getting off the stuff, rebound anxiety and so on.  Nowhere do we see what the Barlow NIMH studies found out, or the value of psychotherapy; he is an MD after all, so his focus is elsewhere.

Appetite however is regarded as one of the more human drives, although anxiety didn’t fare so well.  Avoidance gets its own chapter, related more to personality than to avoidance of anxiety, and the body image vignette is somewhat unimpressive, and a mother who watches her teenage daughter fiddling with a hair iron, and a zit on the face, would probably seek help after reading this vignette, and its assertion about irrational preoccupations with appearance.

The compulsive section is better; the confusion section is, well, confusing.  Cravings, deceitfulness, delusions, denial, depression, dissociation, euphoria and fatigue all follow in their turn.  While on the subject of dissociation, he handles this controversial and contentious set of issues well, with a passing reference to psychodynamic theory: 'The use of hypnosis or anxiolytic medications may help the therapist to uncover the psychological conflict or trauma that caused the symptoms.  Once the conflict is made explicit, the symptoms promptly resolve' (page 110).  This is perhaps a little contentious in itself.

Fears, flashbacks and grandiosity are next, followed by grief.  This last is done well, with lots of sensible advice, and I wish some of the GP’s around my area would understand the limits of antidepressants in such applications.

Jealousy is an interesting, later one, as are learning disorders.  Physical complaints and pain are made contentious with the inclusion of premenstrual dysphoric disorder, something feminists are likely to be fed up with by now, and still petition against.  Hicks notes dissociative identity disorder as a contentious issue, but this one slips under the radar.  A lot of the statements appear to reflect on his own practice, and his own views, which is fair enough, but as the saying goes 'a little knowledge can be a dangerous thing' and I am unsure what the ramifications there might be for the impressionable.  The extent of the discussions appears random, driven by his whim really, and not by what people might need to know.  So he discusses antipsychotic medication but not ECT, and avoids the topic, although we hear about the long-acting Risperidone.  Many of the newer medications can cause weight gain and sedation he notes, but not that the big culprits are olanzapine and clozapine, about which latter drug he rightfully waxes a little lyrical.  Although he talks about TD, and asserts that all of the drugs with the exception of clozapine can do this, he neglects the accepted fact that quetiapine doesn’t, although it is sedating.  Many of these drugs have been implicated in contentious studies about the risks of death in the elderly, indeed those embarking on clozapine can be at risk of heart failure, and so I am not sure about his choices on what to leave in, or leave out.  I am slightly perplexed by this lack of information, as I am sure he knows all of this, and chooses his market in some way unknown to the reviewer.

Self injurious behavior is dealt with in the usual way, no mention of stress disorder and the like, although he refers in passing that so many who engage in this behavior have been sexually abused.  As with dissociation, the reference frame is that of psychodynamics, rather than of neurological substrate.

In any event this compendium reflects a somewhat traditional approach to psychiatry, not so much a more modern, neuroscientifically based and biopsychosocial approach, so one has sign x because of the illness y, and there is little respect for the audience, whatever that might be, that these are illnesses decided on by committees, with global acceptance despite the lack of evidence, and that the variance within diagnostic categories is often greater than that found between actual categories.  I am concerned that this book may mislead rather than inform the layman, and create anxieties about someone on the extreme end of the continuum of normal behaviour.  We have medicalised so much of human behaviour, and I remain unsure whether this book adds or detracts from that situation.  I leave the reader to decide, and perhaps this book goes next to the Reader’s Digest, not the DSM-IV-TR.

A recent post on the Yahoo Psychiatry Groups newsletter spoke of finally adding Symptom Deficit Sydrome, in response to a patient who protests that they are normal, and solidly so despite the evidence to the contrary, only just tongue in cheek.

I wonder what Associate Professor Hicks would say to that?

© 2006 Roy Sugarman

 Roy Sugarman PhD, Acting Director of Psychology Royal Rehabilitation Centre Sydney; Conjoint Senior Lecturer in Psychiatry University of New South Wales, Australia