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Psychiatry, Psychoanalysis, And The New Biology Of MindReview - Psychiatry, Psychoanalysis, And The New Biology Of Mind
by Eric Kandel
American Psychiatric Publishing, 2005
Review by Roy Sugarman, Ph.D.
Feb 4th 2006 (Volume 10, Issue 5)

Eric Kandel has become a household name in some circles since his sharing of the Nobel Prize in 2000. He is on the second psychiatrist in history to have done so, and also the only American of that discipline to have done so.

Specifically for anyone who desires to read the book and doesn't know what he got the prize for for, well, you probably aren't going to enjoy the book anyway, as it may be outside of your field: however, for the sake of clarity, Kandel and his collaborators across the years refined their way of thinking about mind and brain, and illuminated for posterity the complex process of long term potentiation.  Simply put, we tickle the connections of neural networks to lay down passing memory, but major changes in the way the cell arranges its chemistry and expresses its DNA are required to enable to-be-remembered material to be stored and recalled later.  This is not exact, rather like recalling chocolate cake by finding the items of the recipe that made it.

For those who are already keen on Kandel and the other 10 Nobel Prize winners at Columbia, following the pathway he took to create and prove his award winning theories is a journey of devotion to science. 

This book is made up of eight previously presented works that Kandel believes exemplify the crucial aspects of his work and epistemology. They are thematically presented, rather than following their chronology. This is done to allow the reader to follow the journey, rather than the recipe of his arrival at the clarification of LTP and its role in laying down information within the neuronal pathways of the hippocampus and related structures.

Before each essay Kandel has invited commentary from various experts, thus this is the added value, not a simple rehashing, but rehashing with retrospective analysis.

The first essay, "Psychotherapy and the single synapse" leads Judith Rapoport to write of this 1979 work that we still have a long way to go in reconciling the relationship between Psychiatry and Biology, with more psychiatrists than ever practicing without neuroscience training.  The article highlights this duality.

The second essay attracts comment from Thomas Insel.  In the article, "A new intellectual framework for psychiatry", Kandel attempts once again, this time in 1998, to address the duality, to reconcile the interactions between cognition and behavior, and the brain's processes.  This search for a neuroepistemology, biological pluralism or systems biology leads Insel to comment that the scientific excitement generated has not yet filtered down well enough into clinical practice by refining diagnosis or informing treatment, and worse, it has so far been ignored by those who formulate training programs.  One of the notable exceptions occurs in fact in Adelaide, South Australia, where the SA Psychiatry Training Committee has introduced neuroscience into its curriculum, and even medical students can rotate through neuroscience blocks carried out on closed wards at the local state psychiatric unit.  However, this is not without protest from some postgraduates, leading some to comment that if one wants to leave medicine, one becomes a psychiatrist.  Recently too, there is tension between evidence based medicine and the moral imperative of engaging on a more humane and human level with patients possessed of mental illness.  Despite the years between the two first essays, Kandel is making his point early: revise and review what one considers the baseline reality for study in psychiatry, how brain produces mind.  Even within this simple concept, there is controversy, with Bill Blessing and other neuroscientists arguing that the brain is not entirely contained within the skull, and what we consider mind, or brain, is composed across wider referential points, such as the endocrine and blood systems.

Otherwise Psychiatry runs the risk of making a fool of itself as Othmer et al pointed out some years ago in a Psychiatric Clinics of America article: Here, the three Othmers warn of fat ankle syndrome.  Simply posed, a client wakes to find pedal oedema investing her ankles.  She goes to a doctor and he looks beyond her ankles and seeks out her blood, her cardiac status, her iron levels and so on.  Had she turned left instead of right and gone into the psychiatrist's rooms, she would have received the diagnosis of fat ankle syndrome: this is the danger of failing to deal with the mind brain dilemma, rather than the mind body duality loved by Descartes and refuted by Damasio.

The attention of a Nobel Prize winner tells you this is not trivial or inconsequential for the profession, and yet very little of this literature or of this debate enters the training of registrars in psychiatry.

Continuing in this way is the essay "Biology and the future of psychoanalysis" with commentary by Arnold Cooper.  Theoretical pluralism again dominates as the subject matter.  Attempts to adjudicate the superiority of one or the other viewpoint by detailed reporting of analyst-patient interactions have failed.  Predictably, Kandel's views in articles such as this 1999 one have raised vigorous support, and equal opposition. The problem posed here again is for psychiatrists to find a way to absorb the findings of neuroscience into the theories of psychoanalysis, which are concerned with much less precisely defined areas of the mind.  Yet, of course, if one reads Freud's dissections of the brain one sees precisely that he saw the one in terms of the other, and also, it was Freud himself who said that one day we would find that all the processes of the mind were indeed organic.  Simple, but contentious.  Within the references here, we find Kandel looked at the works of Mark Solms, who deals with this issue often, and translated Freud's dissections of the brain into English/

Donald Klein speaks before the next essay "From metapsychology to molecular biology" together with Joseph Le Doux who speaks of anxiety and Aplysia, playing with the name of the worm from which Kandel derived his theories, and on which he proved his case.  In 1983, Kandel writes that until that time the cell-biological mechanisms of mentation had eluded analysis.  Kandel uses anxiety as a platform, much as Othmer et al were later to do, and points out how body and brain combine to produce mind and anxiety, even in animals, as a learned response.  Even the humble Aplysia shows aspects of anticipatory and chronic anxiety, reducing this to cell-biological mechanisms, and sending Aplysia into a sprint away from danger, well, locomotive avoidance anyway.  Again, this lead Kandel into the idea that stimuli could change the way DNA is expressed, the way genes are expressed at a molecular level, and this of course is one of the mechanisms underlying LTP.

Eric Nestler comments on "Neurobiology and molecular biology" which Kandel also produced in 1983. Here, he takes the molecular argument for a neuroepistemolgy of mental illness forward. Or otherwise, is such reductionism too limiting, should we find we come to a mechanistic understanding of complex behavior under normal and pathological conditions.

Steven Hyman, the ex-head of the NIMH takes on "Neural Science" which Kandel produced in 2000, nearly 20 years beyond the previous two.  He is quick to point out, on reading Kandel that far too many contemporary psychiatrists act as if Descartes was right in his dualism.  Nevertheless, he wryly notes that we cannot understand an entire organism from the activities of its tiny bits, as the gestalt provides the challenge, more so than the constituent parts.  Kandel produced the article, which examines a century of progress, with Albright, Jessell and Posner, all of whose names should be familiar, if you recognize Kandel, anyway.  This is a walk through history in the eyes of these luminaries, and it makes superb reading.  Ramon y Cajal's sketch of the hippocampus is still in my overheads today, with its annotations of the CA fields, the subiculum, the whole gyrus, perfect in its rendering.  Yet, can we distinguish between the feeling of thirst and the resultant search for water, as Bill Blessing at Flinder's University puts it?  This mammoth chapter covers 132 pages, a book in itself, and defies comment, even by one such as Hyman.

It is then Charles Zorumski's opportunity to comment on the article "The molecular biology of memory storage" which gets to the heart of the Nobel matter and is adapted from Kandel's address to the Nobel Foundation.  After 50 years at work at the bench, Kandel was able to address what he called the dialogue between gene and synapse.  This epitomizes the work of this genius researcher, who was able to show definitively that we can dissect out tiny processes within tiny animals in order to understand much more gross behaviour in large primate mammals.

One is now talking of the biology of brain, which Kandel began to illuminate in his search for a neuroepistemology.

John Oldham addresses "Genes, brains and self-understanding" which Kandel wrote or at least revealed in 2001. This is the onset of his work in enhancing biology's aspirations for a new humanism.  Kandel's aspirations comprise what he calls Kandel's Laws.

The first, is that producing knowledge and training young students is vital to progress.  Teaching there is thus rewarding (second law).  Patient care is our most important responsibility (three).  The book closes with Kandel's afterword, his revisiting of his first essay in the book.

Compelling here in this last chapter is the realization that alive in a man such as Kandel is his belief, rare in a biologist, that psychotherapy is as important as neuro-imaging and psychopharmacology.  Not for Kandel is the pompous view still taken by many of my colleagues that psychologists are the handmaidens of psychiatry, and both ineffective and unnecessary.  Australia is happily embarking on reducing psychologists to generic allied health titles, and supporting four- year degrees as sufficient, so that unlike the doctoral programs of other countries, we can provide ever more mediocre therapy to ever increasing numbers, rather than provide excellent and informed care to the patients. If only Kandel's laws were propagated down under.

Sad too is the realization for many of us who train psychiatrists and medical students that the two major areas they need to be proficient in, namely psychopharmacology and neuroscience, comprise only a small portion of their training.  Perhaps this unhappy situation explains why so many state hospitals cannot recruit specialists, or nurses with expertise in mental health.

For what Kandel's journey informs us is that this is the last frontier for medicine, with all the excitement of a dynamic neuroscience available if we only observe Kandel's Laws.  I note however that recent books reviewed on this website speak of the failure of universities to deliver substance in their courses in mental health, to deliver clinically useful training, rather then the dry between groups evidence based science that teaches nothing of the moral engagement of Kandel's third law.

This is the gift of Kandel: he can easily navigate from molecules to humanity, from evidence based to moral encounter, and sadly, this appears to be rare.

It's a book filled with eight essays of stunning revelation and scientific brilliance, a balanced view of worm's gills and mankind's misery.  One could expect nothing less from this man, who brings glory and hope to a dismally disliked profession, parodied and mocked in the media, comfort to one of the few medical professions that dies at the hands of its patients.  He sees systems within systems in biology, and that is no small task, confounding Descartes and Damasio alike.  It should be required reading for everyone, everywhere, if they have just the capacity to read it through, and the courage to engage both moral and scientific issues in human suffering.

If there is a weakness, it is that the commentaries are weak, pale by comparison with the writing that follows each: I believe they could have risen to the challenge and done better with what they read.

 

© 2005 Roy Sugarman

 

Roy Sugarman, Ph.D., Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia


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