Review of The Divided Mind by Edward Bullmore – Do we now know what causes schizophrenia? | Science and nature books

IIn 1973, the American psychologist David Rosenhan published the results of a bold experiment. He arranged for eight “fake patients” to attend appointments at psychiatric institutions, where they complained to doctors of hearing voices saying “empty”, “hollow” and “thud”. All of them were admitted and diagnosed with schizophrenia or manic-depressive psychosis. They immediately stopped showing any “symptoms” and started saying they felt fine. The first came out after seven days; Last after 52

When psychiatrists at a major teaching hospital were told about these findings, they found it hard to believe they had made the same mistake, so Rosenhan devised another experiment: Over the next three months, he told them, one or more phony patients would go undercover, and eventually, the staff would be asked to identify who had faked it. Of the 193 patients admitted, 20% were considered suspicious. It was then that Rosenhan revealed that this was a hoax as well: no bogus patients had ever been sent to the hospital. Not only did doctors fail to detect sane people among them; They could not reliably identify the actual maniacs.

The Rosenhan Gambit captured the public’s imagination. Were the men in the white suits just charlatans? Was mental illness real? Two years later, the film One Flew Over the Cuckoo’s Nest exacerbated the sense of reputational collapse, and the psychiatric establishment responded by dramatically tightening diagnostic criteria, boxing disparate symptoms into ever tighter boxes. The sheer challenge to psychiatry ended up sparking a kind of counter-reformation, making the profession even more medicalized than it had been for decades.

The whole affair is a fine example of the ideological regressions that Edward Bullmore charts in his brilliant and personally crafted book on the history of psychological ideas. It’s even more mind-boggling – pun intended – to discover that Rosenhan’s paper was largely fabricated. 2019 research by journalist Susanna Cahalan concluded that most false patients were invented; One colleague recalled the psychiatrist calling him “nonsense.”

Whether he lied or not, Rosenhan has exposed the fault line running through the stadium almost since its inception. Bullmore, a professor of psychiatry, blames this on a false dichotomy between body and mind. He calls this the “original schism,” which Descartes and Saint Paul before him bequeathed to us. It incorrectly suggests that our thoughts and any psychological distress we experience exist in a separate sphere, separate from the body. Diseases are either “organic” (such as cholera or Alzheimer’s) or “functional” (such as depression or schizophrenia), and mysteriously arise from a perfectly healthy body.

In practice, this dichotomy separates psychiatry from the rest of medicine, meaning that the physical health of patients with mental illnesses is often severely neglected. But it also creates a division within psychiatry itself, between what is casually referred to as the “brainless” tribe, which believes that biology explains everything, and the “brainless” tribe, which ignores neuroscience and looks for answers in a person’s upbringing and way of relating to the world.

We’re all familiar with Sigmund Freud, the patron saint of the mindless band (although the founder of psychoanalysis started out as a neuroanatomist, and—unlike some of his disciples—found it easy to imagine that advances in biology might one day replace “the whole structure of our artificial hypotheses”). But his giddy contemporary, Emil Kraepelin, is far less famous, “the most important psychiatrist you’ve never heard of,” according to Bullmore.

Kraepelin headed a German school of thought that viewed mental illnesses as manifestations of physical illness, and imagined that, as with tuberculosis, a causal agent or “germ” would one day be sure to be found to explain these illnesses. His focus – and Bullmore’s – is on the pattern of symptoms we know as schizophrenia, which Kraepelin called dementia praecox (early dementia). For him, the contents of any psychosis—the delusions and paranoid fantasies—were relevant only insofar as they indicated a diagnosis. Their explanation won’t help.

After Rosenhan’s antics, when the American Psychiatric Association issued a new diagnostic manual in 1980, it was called the “New Kraepelinian.” But before that, the pendulum had already swung several times – from the first rumblings of opposition by Freud and his followers, to the genocidal excesses of the German School under Nazism, to the “triumph” of refugee psychoanalysts in the aftermath of World War II. Bullmore is excellent at showing how our understanding of mental illness has not blindly “followed the science,” but rather gone with the currents of history. The mindless tribe won the literal war, and as a result it won the intellectual war as well.

But science does advance, and in the last four decades there has been a lot of it, which Bullmore depicts from his perspective first at the Maudsley in London, where the tribes gather in different parts of the canteen, and then at Cambridge University. Among his touchstones was Susan Sontag’s essay “Illness as Metaphor,” which showed how any “difficult and fickle” disease becomes a container for pathological delusions until such time as we get a better explanation. Now that we know that tuberculosis is a bacterial infection of the lungs, we are not inclined to believe that sensitive poets are naturally more susceptible to it, as we once did.

Schizophrenia may finally be on the cusp of that transformation – a momentous matter indeed, given the enigma that this strange and brutal disease has long posed. As Bullmore carefully explains, advances in the fields of surveying, mathematics, genomics and immunology have accumulated to give us a clearer understanding of disease. It is likely caused by abnormal development of brain networks in childhood and adolescence. Evidence suggests that this occurs under the influence of immune dysfunction, and is caused by variation in a wide range of genes, which interact in certain ways with the environment. Triggers can include infection, abuse, social stress, or drug use.

The emerging picture marries biology and experience in the way that was always inevitable, since they were never really divided at all – and offers promising new avenues for prevention. The next generation’s mission is to translate science into better real-world outcomes. Given what we know now, prevention, including improving health and social services for mothers and young children, must play a major role.

What about those colorful types, the anti-psychiatrists? In the 1960s, the shaman-like figure of R. D. Laing captured the zeitgeist with his idea that psychosis was merely a rational person’s attempt to “live in an unlivable situation”—a situation of which the modern world offered too much. Bullmore admits that anti-psychiatrists “have a lot of the best tunes.” I imagine that many of Laing’s visions could survive the new model of schizophrenia as descriptions of social pressure, but although he sympathized with it in a romantic way, Bullmore never really made a rescue attempt. Nor does it examine the harmful effects of powerful psychiatric medications taken chronically, and how these medications might confound some of the evidence of biological differences between people with schizophrenia—something on which modern anti-psychiatrists would no doubt disagree.

But he stresses the need to look into psychiatry’s dark past. When he began researching the Nazi program to exterminate psychiatric patients, he was surprised to find “very little” material in any language for him to look at. This is despite the deaths of some 260,000 asylum inmates, which follows directly from the theory of early dementia as a disorder of one or two faulty genes that can be wiped from the body. Folk. This violence continues to cast a shadow, and most psychiatrists, regardless of tribe, agree that “to recover from trauma, it is important to talk about it, in one way or another, at some point in the recovery process.”

Bullmore’s writing is characterized by flair and occasional flashes of anarchic humour. As with his 2018 study of depression, The Inflamed Mind, this book is intellectually stimulating and highly readable. Like the best of his predecessors in psychiatry, he is far from the strict paranoia of his caricature, driven instead by a desire to do right by his patients, and to transcend ideological commitments that slow progress and, above all, understanding.