Home movie mystery

When David and Cutting perceived the need for a book on the neuropsychology of schizophrenia, they organised a two-day conference at the Institute of Psychiatry. The authors were determined that this was not to be just the book of the conference in 1991, and in this they have been entirely successful. The chapters, written by international leaders in this field, are well-written, comprehensive and up-to-date: this book represents the standard reference text on the subject.

Each chapter comprises a summary abstract, an introduction which reviews the topic, followed by the author's research findings, theoretical conjecture or both. Ideas and priorities for future research are abundant. The contributors were chosen for their communicative skills as well as their distinction, and it shows.

The "levels of understanding" model of schizophrenia suggests that neuropsychology is central to a number of alternative ways of studying the disease, in its simplest position bridging the gap between neuroscience and phenomenology. The remit of the book exploits this to the full: in addition to sections on neuropsychological deficits in schizophrenia in general, there are data on the neuropsychology of particular phenomena (hallucinations, delusions and misidentification), the associations between neuropsychology and development, and between neuropsychology and neuroimaging.

Chapters on candidate brain structures and systems (the right hemisphere, the striatopallidal system, fronto-subcortical structures) go very much beyond the "classical" neuropsychological approach with all its problems. Indeed, a wide variety of research methods are exhibited, including the application of standard neuropsychological tests (eg D. Rodgers), novel tests (eg P. J. McKenna) use of high technology (eg T. S. Early) and educational achievement records (P. Jones). There is a fascinating study by E. F. Walker, who studied the home movies of children who went on to develop schizophrenia.

These disparate areas are nicely brought together by Chris Frith's short chapter on metarepresentation and theory of mind in schizophrenia, which presents a unifying hypothesis. We await with interest further attempts to test this conjecture, perhaps requiring yet another paradigm shift as psychologists attempt to develop assessments of metarepresentation which relate reliably to both symptoms and neuroscience. This is going to be a huge task since any real understanding, let alone explanation, of schizophrenia is predicated on a knowledge of the workings of the normal brain.

Despite accelerating advances in knowledge of its structure and function, its complexity presents enormous problems to the point that the brain is still probably the least understood organ in the body. If this were not so, it could be argued that the disciplines of neurology and psychiatry would have merged by now, or at least that psychotherapy would have become a completely separate discipline perhaps even outside the remit of medicine.

There is little on the neuropsychology of schizophrenic speech, language and affect - all topics that have not been very adequately researched. Psychopharmacological issues are also almost absent -we are still far from a complete appraisal of how drug treatment impinges on neuropsychological function in schizophrenia, in contrast to our knowlege of its effects on symptoms and neurotransmitter systems.

The book is well produced and well illustrated (apart from a rather underexposed and fuzzy photograph of the authors); tables and figures are clear and adequately annotated. Each contribution is individually referenced and there is a master author index at the end.

To whom would this book be most useful? As a standard work of reference it should be acquired by postgraduate libraries. It presumes a fairly extensive knowledge of both schizophrenia, psychiatry and general psychology: trainees in psychiatry will find it too specialised for membership examinations: it is likely that they would find themselves telling the examiners things the latter did not know - not always to their advantage. For junior psychiatrists its purpose is their education (sadly neglected these days) rather than training.

This book is of most obvious use to the academic psychologist or psychiatrist with an interest in schizophrenia. There is little of immediate practical value for the treatment of patients, although P. Slade has a good try. Reading the book left me feeling pleasantly removed from the day-to-day struggle of providing a service. So much here is new knowledge, yet to what use it may be put for the benefit of patients remains indistinct. Some of the findings must have potential implications for prevention, therapy and levels of service provision: perhaps the eminent contributors could turn their expertise to this issue for the next conference.

One use of this volume may be to underline the increasing body of evidence that schizophrenia is indeed an organic condition rather than anyone's fault: professionals like these authors may take that for granted, but others involved with patients do not and this can result in arguments for inappropriate service provision or for no adequate provision at all.

Ann Mortimer is senior lecturer in psychiatry and consultant psychiatrist, Charing Cross and Westminster Medical School.