During my time on the stand during cross examination in a case where a man had committed a murder after being thrown from a train, the lawyer asked me if a behavior that was observed was 'functional' (i.e. psychological) or neurological. The Supreme Court judge answered for me, before I could say anything erudite: I preferred his comment to anything I might have said. "If the accused's behavior had emanated from his backside, you would have to call on a proctologist to take the stand. Given the accused's behavior had to emanate from his brain, whether so-called functional or psychological, it emanated from a clearly damaged organ. So I presume that aberrant behavior emerged from an aberrant brain and Dr. Sugarman dare not say otherwise".
So too have the authors here reverted the term 'functional' to its original meaning, namely that it refers to a physiological disturbance, rather than as an epithet for a psychological, stripping away Cartesian dualism, and thus putting to rest another archaic distinction: organic versus functional. Freud himself said that he believed that one day, the causes of all so-called functional disorders would be found to be organic in origin. Simply put, if there were a blood test for a mental disorder, than the disorder would have to be said to be physical or physiological more precisely.
The first edition of this iconic book was published in 1987, the second in 1995, this last one, last year. Spanning the period from DSM-III to the –R and then DSM-IV period, the authors lament that psychological theorizing eclipsed biological psychiatry, accelerating the divisions between neurology and psychiatry. The old joke was that doctors left medicine, and instead went into psychiatry. Despite these fits and starts, and the 13 years that passed, the third edition clearly begins to show how neuropsychiatry has thrived, and how much we are beginning to understand about bad behavior that really is bad brain.
The book starts with a chapter on principles of brain function, fusing genetics, physiology and chemistry, with a special focus on the neurotransmitter receptor sites, and what drugs work as either agonists or antagonists, in helpful tables for serotonin and adrenaline. The section on neurotransmitters is tight and useful. There is a tiny paragraph on CNS cellular inflammation, with the powerful comment "the ratio between pro-inflammatory and anti-inflammatory cytokines can be measured, and has been shown to relate to psychopathology" (page 29), and is quite a comment, especially in light of the body and brain connection, the damage done by sedentary lifestyle, and so on. A second part to this, chapter two, refers to the anatomy of the related systems, and is a great primer on the brain.
Brain behavior relationships of course are the core of biological psychiatry, and chapter three is accordingly the start of this. The focus on the anatomy here is reasonably the hypothalamus and peptides, the insula, cingulate, with a passing reference to emotional recognition disorders in the insula, without naming names (Disgust is the emotion typically, see Disgust and Its Disorders). The hippocampus and the associated areas of the parahippocampal gyrus and the entorhinal cortex are also not forgotten here, as are the precuneus, the amygdala and the entire autonomic nervous system, as well as many other areas.
Chapter four describes classification and clinical investigations, examining in some detail how one would set about examining and investigating disorders using a variety of neuroradiological techniques, leading us to something others may be surprised about, the Personality Disorders in Chapter 5. This is not surprising to those of us in the industry, as this has been a most contentious area, this bad person vs. bad brain scenario. This is the battleground of biology versus psychology at its most fierce. Whether the DSM-V will lead to a similar battle around disorders of mathematics or worry will prove interesting. This has been somewhat bolstered by the findings in genetic studies that there is a clear connection between personality disorders and genes, and individual disorders at that. There are certainly metabolic and chemical findings as far as somatic variables go, and the metabolic by-products of some neurotransmitters, and neuroradiological and clinical findings. Some outstanding issues are also itemized.
Anxiety disorders and the Schizophrenias (sic) follow in the next two chapters, the last one, a group of syndromes, bringing in not just the dopamine hypothesis, but the noradrenalin and glutamate hypotheses as well, not to mention the viral hypothesis. Despite the time and effort put into Schizophrenia, many many problems remain in identifying the causes and underlying elements that contribute to the different presentations, including environmental variables, the 30-40 candidates for genes, and the absence of many of the dopamine-related gene suspects among them. These issues run to multiple pages of script.
The affective disorders are next. Clearly here the confusion with the nosology, including things from the past like endogenous depression and melancholic depression has confounded research and consensus. Despite the ubiquitous nature of depression, the picture is not clear from any point in regard to what and how it evolves, how one tests for it, and there are outstanding issues, not to be resolved I am sure very soon, and not in the DSM-V.
Addictions and disorders of motivation share a chapter, treating these conditions has largely been hindered by the silo effect in government agencies, each concerned with their own turf. The term disorders of motivation is scarcely recognized, but the authors make a clear case for that here.
Chapter ten now refers to Epilepsy, a condition with multiple neurobehavioral consequences, both ictal and interictal. For most of us, the concept of forced normalization is a heroic one, and leads to interesting discussion in psychiatric units, as the EEG paradoxically improves as behavior declines.
Chapter 11 covers the dementias, and increasingly gloomily looming one for most advanced societies owing to lifestyle issues, as well as longevity. Alzheimer's is of course the most common, and covers multiple pages here, followed by frontal dementias, and then the vascular. There are of course others, namely Huntington's, CNS Syphilis, HIV, Creutzfeldt-Jakob and other prion diseases, and hydrocephalus, and other causes, as well as other areas of dementia are described.
Chapter 12 looks at treatments. This chapter covers the major elements known, such as antipsychotics and antidepressants for instance, and the substrates and chemical kinetics of these treatments. Beta-blockers, Lithium, anticonvulsants, drugs for treatment of dementia and addiction, and brain stimulation therapies such as convulsion therapies, transcranial magnetic stimulation, vagal stimulation, deep brain stimulation, sleep deprivation and psychosurgery are explored.
This leads the authors finally to their swan song, an investigation of the progress made over the last decades of a neuroanatomically, biological-psychiatrically informed classification scheme in psychiatry. This does not take long, just a few pages, just under 4 exactly. 70 pages of small font references make up the rest of the book.
Once again, the power of these authors is in their powerful, concise, easily readable condensation of an immense and troublesome field. Stuck between psychiatry and neuroscience, with some pressures from both sides, they have seen the psychologists moving to neuropsychology increasingly, psychiatrists to neuropsychiatry, and neurologists to behavioral neurology. Whether the high road and the low road ever meet, is debatable. What is true is that psychiatrists and neurologists fractionated, the one to work with disorders they can never really visualize, the other, only with disorders they could see, and then, neither seems to be able to treat anything to remission with any real lasting success: recidivism, morbidity and mortality remain high in both arenas.
And there are the stubborn creatures who still have their clients lie on couches metaphorically and look to talking cures where none is to come. Sadly for neuropsychiatry, Positive Psychology, CBT, Interpersonal Psychotherapy, Motivational Interviewing and other talking cures have managed to secure quite nice success rates, the CATIE and STAR-D studies do not get a mention, although Rush is mentioned here and there, Kirsch and colleagues not at all. The failures of the medication in these cases to show advances in biological care beyond earlier treatments is not actually the fault or the area of biological psychiatry apparently, but the method of classification, as Steve Hyman has mentioned elsewhere in his hope that the field of neuroscience would inform on the DSM-V, a hope that has faded somewhat I am sure.
There is not much to touch Trimble and George, with the vast volumes from Gazzaniga and Kandel and his colleagues, much heavier in neuroscience detail beyond the scope of this book, but one would have to combine these huge tomes with this book, to get to grips with the field, a big ask generally. If you are going to choose where to fork out the money, it would be here, for the most practical understanding of brain-behavior science, and these authors I am sure will continue to be leaders in this field, with perhaps only Lishman challenging them for the buck.
© 2011 Roy Sugarman
Roy Sugarman PhD, Director: Applied Neuroscience, Athletes Performance