© 2001 WILEY-LISS, INC.

DEPRESSION AND ANXIETY 13:157–159 (2001)

Book ReviewsPRINCIPLES AND PRACTICE OF SLEEPMEDICINE. Meir H. Kryger, Thomas Roth,William C. Dement, editors. Third edition,Philadelphia: W.B. Saunders Company. 2000,1336 pp.

It is clear that sleep disorders medicine is a rapidlyevolving subspecialty. Interest in sleep disorders wasinitially dominated by psychiatry, neurology, and psy-chology. However, clinical data, basic research, and avariety of discoveries now make sleep medicine trulymultidisciplinary. The American Sleep Disorders As-sociation has sponsored the development of an Inter-national Classification of Sleep Disorders that includedyssomnias, parasomnias, sleep disorders associatedwith medical-psychiatric disorders, and a series ofsleep disorders proper.

Principles and Practice of Sleep Disorders is organizedin parts, sections, and numerals. Normal sleep (PartI) includes sections such as Normal sleep and itsvariations, Sleep mechanisms, Physiology of sleep,Chronobiology, Pharmacology, and Psychobiologyand Dreaming. Abnormal sleep (Part II) includes sec-tions such as Impact, presentation, and diagnosis,Disorders of chronobiology, Insomnia, Primary dis-orders of daytime sleepiness, Parasomnias, Sleepbreathing disorders, Medical and neurological disor-ders, Psychiatric disorders, and Methodology.

Each section is developed in numerals that cover thesection’s topic extensively. Each numeral develops itstopic with the detail of an extended review article. Ofspecial note is the system of forenotes utilized in eachnumeral, so that references in each numeral guaranteesits use in core reviews for research and clinical informa-tion. Each one of the 137 contributors has carried outextensive research in the assigned areas.

The initial sections contain interesting reviews ofthe history of sleep physiology and an overview ofnormal human sleep, aging, deprivation, and phyloge-netic aspects. The excellent section on sleep mecha-nisms includes a very solid review (numeral 10) ofbasic mechanisms of sleep-wake states. The sectionson physiology and chronobiology include topics ofmultidisciplinary and multispecialty interest for read-ers in search of both basic and core clinical informa-tion. Similarly revealing data are found in the sectionon psychobiology and dreaming. Of particular interesthere is the chapter on waking experiences and dream-ing, which includes a hypnogram with the varioustypes of mental activity obtained across the sleepcycles and a well-documented review of the factorsmediating the representation and consequences ofwalking in dreams.

Part II, on abnormal sleep, begins with an epide-miological overview that summarizes data origi-nated from the end of the 18th century up to thecontemporary era of evidence-based medicine. Thisis one of the more fascinating parts of the volumebecause it includes data about insomnia and the useof hypnotic agents, daytime sleepiness, narcolepsy,snoring, obstructive sleep apnea, and the para-somnias. This numeral demonstrates the currentimportance of sleep medicine and confirms, in ourview, the necessity of similar research studies inother latitudes and cultures.

The reviews of medical and neurological disordersin Part II have extraordinary information for manydisciplines. Topics covered include cardiological dis-orders, chronic fatigue syndrome, parkinsonism, de-mentia, cerebrovascular diseases, neuromusculardisorders, infectious diseases, and endocrine and gas-trointestinal disorders. Each numeral offers epide-miological data, clinical information, and direct andindirect treatments for the associated sleep disorders.The section on psychiatric disorders is particularlycogent. It begins with a review of anxiety disorders,which includes a discussion of panic disorder withclear and detailed descriptions of sleep panic and itsrelationship with sleep avoidance. Also included arediscussions of general anxiety disorder, social andspecific phobias, obsessive-compulsive disorder, andpost-traumatic stress disorder. This numeral includesseven illustrative and useful case histories.

The chapter on mood disorders emphasizes clinicaland therapeutic information, and includes “theoreticalissues” that focus in particular on the close associationbetween sleep and depression. The author describesseveral hypotheses: REM pressure, cholinergic-amin-ergic imbalance, phase-advance, and the two-process(sleep-inducing deficiency and circadian) model ofsleep regulation. Finally, the pathophysiology of sleepin schizophrenia, and the relationship between the“symptomatic” consumption of legal and illegal sub-stances, and the bi-directional malignant reinforce-ment of pathologies in the chapter on medication andsubstance abuse are clearly presented.

In conclusion, Principles and Practice of Sleep Disor-ders is a valuable source of information for a broadaudience, providing updated and well-documentedmaterial. We strongly recommend this volume foruse by clinicians and researchers alike. We agreewith the editors that a computer version of this bookwould not yet be optimal; however, generating apocket handbook for practical clinical purposes is anidea worth exploring.

Guido Mazzotti, M.D.Department of PsychiatryUniversidad Peruana Cayetano HerediaLima, Perú

158 Book Reviews

AFFECT REGULATION AND THEDEVELOPMENT OF PSYCHOPATHOLOGY.Susan J. Bradley. New York: The Guilford Press.2000. 320 pp, $40 (hardcover)

Contemporary neurosciences, psychiatric genetics,psychology, and other disciplines have gathered anenormous amount of data pertinent to the origin anddevelopment of various mental disorders. Neverthe-less, we lack an integrative view or theory synthesizingthis enormous amount of data and explaining it to anaverage clinician. Psychologically oriented researchersemphasize the significance of early losses and lack ofsecure attachment in the development of recurrent de-pression, while biologically oriented researchers em-phasize the role of genetic factors and kindling.However, our understanding of the reasons that cer-tain people develop a specific mental disorder withspecific clinical symptoms and syndromes is clearlylimited.

As many others, the author of this book notes thepolarization between biological and psychological ap-proaches in contemporary psychiatry and psychopa-thology, and the lack of a theory that would integrateboth without doing an injustice to the main tenets ofeither. She feels that this polarization has hindered thedevelopment and understanding of psychopathology.Dr. Bradley proposes an integrative theory, accordingto which the regulation of affect or emotional arousaland the failure to regulate this arousal plays a centralrole in the development, recurrence, and maintenanceof various forms of psychopathology in a wide rangeof disorders. Her book contains a major literature re-view in support of this theory.

The volume is divided into four parts: I. Overview,II. The evidence, III. Clinical syndromes, and IV. Fi-nal remarks. Part I contains one chapter, “The modeland its rationale,” which is basically a brief summaryof the entire book. It begins with the definitions ofaffect and emotional feelings. The chapter further re-views the evidence for general arousal factors in psy-chopathology, along with risk factors and therapeuticeffects. It addresses brain factors related to the controlof affects, as well as mind factors related to regulationof affects. Finally, it incorporates Dr. Bradley’s inte-grative model and provides some syndrome illustra-tions. The model proposes that negative affectivestates are generally more important than positive af-fective states in the development of psychopathology,since the negative states tend to produce greaterphysiological arousal. The author suggests that vari-ous risk factors (e.g., loss, trauma, abuse, and attach-ment difficulties) produce high levels of arousal (moredifficult to regulate) or interfere with the developmentof strategies for regulation arousal. She suggests thatthere is a general vulnerability to high arousal (whichcan be genetic in origin and/or can arise from experi-ence) and that this vulnerability, in concert withstresses, gives rise to psychopathology. She empha-

sizes that management of arousal is a developmentalprocess that depends on genetic or biological factors,as well as on infant caregiver attachment and other ex-periences. Furthermore, the attachment system is con-ceptualized as a mechanism for regulating distress.She also proposes that many psychotropic medicationsthat are effective across disorders exert their effectsthrough reducing distress or arousal, and that psycho-therapy also appears to have general effects in thesame direction.

Part II consists of seven chapters. Chapter 2, “Anintroduction to affect regulation and its development,”reviews the literature on what constitutes affect, itsfunctions, and regulations. It further describes the ca-pacity to regulate affects, how affect influences latersocial competence, and how this all becomes a stabiliz-ing factor over time. The final part of this chapterdeals with longer-term outcomes of affect dysregu-lation. Chapter 3, “Constitutional and genetic fac-tors,” focuses on the concept of nervous excitatory andinhibitory processes, reviews studies of inhibition andits relationship to the internalizing disorders, namely,anxiety and mood disorders, and comments on studiesof temperamental factors related to the externalizingdisorders, mainly disruptive behavior disorders. Chap-ter 4, “The caregiving environment,” emphasizes itsmajor role in determining how an individual respondsto affect-provoking situations. It also reviews the at-tachment theory and related research (e.g., the workof Bowlby and Harlow). A substantial part of thischapter focuses on dysfunctional parenting. Chapter 5,“Stress, trauma, and abuse,” discusses the roles oftrauma and abuse (chronic arousal situations) in gen-erating affect dysregulation, which is especially impor-tant in the developing individual, when learningeffective coping strategies may require some distancefrom the stress. Chapter 6, “Coping: learning and ex-perience,” discusses various coping responses (e.g.,social referencing) and addresses the role of attach-ment, caregiving, language, cognition, and peer rela-tionships. Chapter 7, “The neurobiology of affectregulation,” provides an overview of the basic neu-roanatomy and neurophysiology (neurotransmittersystems, the amygdala system as an “emotional net-work,” and the frontal lobes as “guides to behavior”)needed to understand the development of affectregulation. Chapter 8, “Therapeutic considerations,”emphasizes that all effective interventions influenceaffect regulation. The chapter also notes the increas-ing likeness of the three main branches of psycho-therapy (psychodynamic, cognitive-behavioral, andexperiential) and the similarities in their outcome.Finally, it briefly reviews the role of psychopharma-cological and other biological interventions in affectregulation. A very interesting, yet short, part of thischapter deals with “therapist factors,” e.g., the char-acteristics of a successful therapist.

The three chapters in Part III of the book elaboratethe specific aspects of affect regulation theory in anxi-

Book Reviews 159

ety, mood, psychotic, and disruptive behavior disor-ders. This is an interesting and occasionally moreclinically applicable discussion. Readers well versed invarious theories of psychopathology development willnot find much new information here, but the integra-tion of various findings is valuable. As for future direc-tions, the author suggests that psychotherapy maybring about more changes in the prefrontal cortex,hippocampus, and amygdala, whereas medication mayhave a greater influence on overall modulating sys-tems, such as dopaminergic or serotonergic systems.

This is an interesting book that seriously attempts tointegrate the biological and psychological aspects of thedevelopment of both child and adult psychopathology.It does not contain any new and/or earthshaking find-ings or theories but rather a meticulous review and in-tegration of known facts. It is a solid, well-writtenreview. Among its strengths, one may cite its fairlygood organization, comprehensiveness, extensive list of

references, and a summary of each chapter. On theother hand, the text tends to overgeneralize and be-comes a bit vague at times. This could be a reflection ofour general state of knowledge. The final index of thebook is, surprisingly, not very comprehensive.

This book can be useful mainly for professionals in-terested in developmental psychopathology, child psy-chiatrists, psychiatry residents, graduate students, andresearchers interested in attachment issues. A busy cli-nician or a well-advanced researcher may not find it tobe fitting for their respective preferences: while theintegration effort is worthwhile considering, the yieldmay still be small.

Richard Balon, M.D.Department of Psychiatry and Behavioral

NeurosciencesWayne State University School of MedicineDetroit, Michigan