I read somewhere that if your favourite subject in your last year at school was English Literature (or American Literature I’m sure for the USA readers) and you did medicine, then you had a high likelihood of becoming a psychiatrist. This was certainly true for me. I didn’t ask Nick Earls (another medico turned writer) what his favourite subject was when I met him recently at a writer’s retreat, but he bypassed psychiatry, went into medical writing and then into fiction. Clearly Irvin Yalom, an American professor of psychiatry, still writing in his 80’s, had the bug for writing, though I prefer his case histories to his fiction. Now another American professor of psychiatry, Jeffrey Lieberman, has launched into print with a popular non-fiction title, Shrinks: The Untold Story of Psychiatry.
I have read a couple of reviews of this book which unsurprisingly has been controversial: before DSM (the diagnostic bible) he relates a story where psychiatrists were all asked to see the same person and each came up with a different diagnosis. This was not thought to be scientific and hardly encouraged faith in the profession and lay at the heart of the creation of the DSM. But even now with the bible, though he doesn’t explore this (as a clear champion of the DSM), there are still real issues with diagnosis, primarily because the manual relies on symptom clusters and as complex as the brain is—what we observe when things go wrong, is in contrast, quite crude.
As previous reviews have noted, this book includes stories that have been well told despite its subtitle, and is the story of American Psychiatry (not all Psychiatry) with acknowledgement to the few Europeans that got things started, and for a while according to Lieberman, derailed and stopped progress. This said, I think for a lot of (non-psychiatrist) readers, much of this will be new, and the American-centric aspects not necessarily off putting. They are after all responsible for DSM, which here in Australia we largely rely on, and have put a lot of money into neuropsychiatric, biological research. And Lieberman does at least mention our very own John Cade, who discovered lithium, which remains the most highly effective mood stabiliser in bipolar disorder.
There is the tale of the 8 pseudo patients planted into psychiatric hospitals that went undetected, a triumph according to the anti-psychiatrist, Rosenhan, which to me really shows how much we rely on what we are told and perhaps don’t trust our instinct enough (doctors are human, not infallible and if we want to help and care about people do we really want to train our registrars to be skeptics?)—but what are we without trust which surely needs to go in both directions?
There is the somewhat sad acknowledgement that the first Nobel prize in psychiatry went to Wagner-Jauregg’s fever cure of General Paralysis of the Insane (caused by syphilis) by giving patients malaria! Of course now such infectious causes of psychiatric symptoms are the domain of other physicians, occasionally highlighted by Consultation Liaison psychiatrists when it has been missed by the “real” doctors. The second Nobel prize (technically to a neurologist) was for leucotomy’s—yet none awarded for the still life saving electroconvulsive therapy. Kandel’s Nobel prize, the third, was for opening up much of what we mostly consider (and Lieberman certainly does) the new directions of understanding and mapping the brain.
Lieberman is mostly critical of psycho-analysis but does note the important roles of psychotherapy (some indeed evidence based). No matter how much we map the brain and find chemical causes for each and every emotion, there is no changing the fact that psychiatry differs from the rest of medicine in its acceptance of the interplay between emotions and genetics and early childhood. Loneliness is not an illness, but can it become one? Is it an illness if it means that the person can’t work or only if they can’t and want to? Epigenetics is the current buzz term and it is the developments here I find exciting to read about. But as a clinician I deal with the day to day angst of my patients, their own individual dilemmas, which they are often ill equipped to deal with because they were exposed as children to parents who were miserable and didn’t know how to solve it (so they have no positive role model—such children are already saying by age five “I’m no good at this” when they lose a game, rather than ‘let’s plat something else’ which is what the children of non-depressed parents are more likely to say), have the genes to be depressed (and possibly a low IQ which also mitigates against problem solving) and because they don’t do well in school, drop out or don’t achieve (and continue therefore to feel bad about themselves), don’t get stimulating jobs (or well paid) and are likely to marry someone like the parent they grew up with; hence the cycle continues.
Of course this is not what everyone’s story is—and that is the psychiatry at the coal face, where DSM is only a small chunk in the overall story. Freud and other uncoverers of the unconscious have given us every bit as much help in understanding and helping people as Kandel and the neuroscientists. Maybe one day they will have all the answers, but as long as we have choice and terrible things happen to us, we will be quintessentially human; we will grieve, be sad and lonely and get angry. Medication only helps with these feelings when they are beyond the normal bell curve. For them, don’t get me wrong, the discovery of Chlorpromazine and the Tricyclic antidepressants, has been nothing short of breath taking in helping close the asylums (though we have perhaps gone too far with this, leaving many vulnerable people to fend for themselves).
For the rest—Lieberman calls them the worried well, but I challenge this, because many of the women I see in domestic violence relationships, struggling to do their best, are more than worried and not exactly well—or at least their environment is never going to help them be as well as they can be. Solace through talking, learning mindfulness and problem solving and CBT techniques, none of which DSM helps with, are still the core of the sort of psychiatrist I am.
And as for Shrinks? It’s readable, smart and interesting, and the more psychiatry is demystified, the better as far as I’m concerned.