Ten books

It is difficult, if not impossible, to systematically identify ten books that have been influential over a professional lifetime, not least since many have probably exerted their influence in long-forgotten ways: part of that semantic sediment laid down by protracted reading (and conversation). However, I do know that George Orwell was the first serious writer whom I read ‘of my own free will’ and I know that I would not wish to be without the works of Anthony Burgess, Albert Camus, Bruce Chatwin, Don DeLillo, Graham Greene, Henning Mankell or W.G. Sebald. I can remember that books on Buddhism sustained me through senior house officer jobs in a number of medical specialties (trying to focus, single-mindedly, on the task in hand rather than my tiredness or distraction), and I suspect that the metaphors of my thought and speech had already been much influenced by exposure to the Bible. Here, I focus on those books that have informed the way I think about psychiatry right now and how it might be practised.

Gray's Anatomy

I studied at Guy's Hospital, London, in the early 1980s and at that time the culture was very much one of our undergoing a medical apprenticeship. We were privileged to be educated in relatively small groups in a rather antiquated atmosphere that continually reminded one of the profession that one was hoping to enter: plenty of wood-panelled rooms and corridors, silent library stacks, museums containing the wax simulacra of dissected bodies and numerous diseased organs floating in jars. At that time, Guy's was very much the home of Gray's Anatomy, two Guy's men having edited the 1980 edition. ¹ I still find it exquisite, and subsequent editions have continued to capture the intrinsic beauty of human anatomy: function given form. In one sense, we may understand the range of human capabilities by studying the machine that facilitates them.

Recently, I have had reason to think about the parameters of human action once again. ² I offer one example: our ability to move an index finger, independently of other digits. It seems simple, yet it is the product of quite specific neural constraints: we are able to move this finger discretely because of the ratio of upper motor neurons forming synapses with alpha lower motor neurons in our cervical spines. Without these specifications the finger would not move independently; indeed, such is the case with many of our primate cousins – they must move all their digits simultaneously. We can be subtle; our anatomy determines the parameters of our possible behaviours. Also, physiology protects us from potential mishap: if we dream of moving an index finger the action is virtual, it is not executed ‘in the world’ as our cervical spines are then hyperpolarised, courtesy of the reticulospinal system. Should such a system fail, then a man may act out his dreams with potentially violent consequences. ^3,4

The frontal lobes

What is the difference between catching a ball and throwing it? Well, apart from the obvious differences in trajectory, one notable difference is the brain structures implicated in each movement. While reacting to the external environment (catching) evokes the contribution of lateral premotor cortical regions, throwing an object, especially if doing so spontaneously, requires the contribution of medial premotor systems, particularly the supplementary motor area (SMA). Such is the centrality of these systems to spontaneous action that we witness the impact of their dysfunction in Parkinson's disease and apathetic states, when the person cannot act. Conversely, we might observe paradoxical kinesia, for example when a patient with Parkinson's disease catches a ball, owing to the relative preservation of their lateral premotor systems. To understand such physiological bases of volition there is no better place to start than Passingham's The Frontal Lobes and Voluntary Action, ⁵ a book that systematically unveils the workings of the primate frontal lobes and then recursively considers human actions in a similar light.

Dopamine

Interfering with dopamine neurotransmission in the human brain has been one of the main therapeutic interventions offered by ‘biological psychiatry’ over many decades. We spend much of our time prescribing drugs that ‘block dopamine’. But how do they work? Do they do what we think they do? Which brain systems are involved? The clearest text that I have found dealing with this aspect of neurochemistry is Dopamine in the Pathophysiology and Treatment of Schizophrenia, edited by Shitij Kapur and Yves Lecrubier. ⁶ There is a helpful chapter by Anissa Abi-Dargham that sets out the neuroanatomy of dopaminergic systems in such a way that the reader may understand what it is that antipsychotic drugs actually do in vivo. If we are to give patients powerful drugs that alter their neurotransmission then it behoves us to have the best possible grasp of what it is that these agents are doing. This book is a solid place to start.

Listening to Prozac

By now, the ‘non-biological’ reader may have given up on this author as a lost cause. Is psychiatry all about anatomy and drugs? No. But there is some interesting reading to be had in the psychopharmacological hinterland. Here I nominate Peter Kramer's seminal text, Listening to Prozac, ⁷ which I must admit I approached with a degree of scepticism. How can one combine drugs and psychotherapy? Is it not all rather artificial? Who wants ‘insight’ if it is chemically mediated? (Noting, meanwhile, that we do not tend to balk at restoring insight with antipsychotic drugs, above.) The saving grace of Kramer's book is the subtlety of his project and his thinking. He appears to be observing an existential experiment: how do people change when they are exposed to fluoxetine? What do they notice about themselves? The results are still fascinating and recently one aspect has been of renewed interest to me. ⁸ What do we conclude if the morality of a person shifts under the apparent influence of a drug? What if their behaviour becomes ‘better’ both in their own eyes and those of the people who know them? If one had access to both states of mind, might one choose the ‘better’, medicated state? Would one be insincere or weak to do so? Might one be pro-social, altruistic? The more subtle emotional effects of serotonin modulation have recently attracted empirical investigation. ⁹

Virtual reality: Neuromancer

Something one notices, having spent more than a decade frequenting brain-imaging laboratories, is how feasible it becomes to comment upon what a person is doing in the scanner, without one actually being there, from merely examining their brain activity on a computer screen. One cannot say what Mr Jones is thinking, but one can probably say whether he is moving his left hand, engaging in a visual discrimination task or generating words. One might even discern that he is thinking about moving without actually moving (his SMA ‘lights up’ while his motor cortex remains ‘silent’). ^10,11 However, such an insight is not without its risks; there is an existential impact to learning to see mental states as physical states of the brain and some newcomers find the experience quite depressing. How does one reconcile one's ‘real-life’ with the biological life of the brain? What struck me on entering this field was how often researchers referred to science fiction in their understanding of themselves. It was as if a manic defence had obliterated the challenge of our materiality by it wholeheartedly embracing ‘the future’, some other way of being human. So it was that when I was at Hammersmith Hospital in the 1990s I began reading William Gibson, the author who christened ‘cyberspace’ and whose cyberpunk novels evince a pragmatism that sweeps aside philosophical reflection. Gibson's characters are engaged in survival, utilising whatever technology comes to hand; there is a gritty realism, albeit combined with an intuition that ‘somewhere’, ‘out there’, at the limits of space or the internet, there persist Good and Evil.

In Neuromancer the protagonist, ‘Case’, shares subjectivity with another person, his consciousness yoked to that of a female confederate in such a way that his thought insertion seems to mirror her simultaneous thought broadcast:

‘The abrupt jolt into other flesh. Matrix gone, a wave of sound and colour… She was moving through a crowded street, past stalls vending discount software, prices feltpenned on sheets of plastic, fragments of music from countless speakers. Smells of urine, free monomers, perfume, patties of frying krill. For a few frightened seconds he fought helplessly to control her body. Then he willed himself into passivity, became a passenger behind her eyes.’ (pp. 71–72) ¹²

Now, I feel duty-bound to comment that such phenomenology implicates Case's parietal lobes! ¹³

Inner reality: Psychic Retreats

Of course, we all inhabit virtual spaces within our minds, and one of the challenges of psychiatry is the notion of accessing other people's space. Perhaps the psychodynamic school still devotes the greatest attention to this project and I must say that I gleaned a great deal from exposure to psychodynamic psychotherapy and its supervision. Imagine if all psychiatric practice received the same level of scrutiny, thought and reflection. How rich our discipline would be. While training in London I also benefited from having to use London underground trains; a great place to consume slim paperbacks: Freud, Klein, Jung, R. D. Laing, Anthony Storr and various European philosophers whose work has influenced psychoanalysis. Here I nominate John Steiner's Psychic Retreats, ¹⁴ mainly because it reminds me of the insularity of an inner life, but also for its focus upon constraint. The individuals subject to Steiner's analyses are impeded because they have retreated into various mental stances relative to the world. They may be ‘safe’ but only because they have withdrawn. His analysis of their actions is fine-grained, thoughtful.

‘Train hard, fight easy’

Much as I should have loved to have claimed that I encountered Field Marshal Suvorov's advice in the original Russian, I must admit to having lifted it from Michael Caine's character ‘Harry Palmer’: he recites it in the film Funeral in Berlin. ¹⁵ Nevertheless, his advice is sound: if one wants to be a good doctor, then one must see a lot of patients; to be a good researcher, one reads everything one can about a subject (especially the work of one's competitors); and if one wants to pass examinations, then one practises! However, there is a problem in psychiatry in that the subject does not lend itself to examination books: lists can seem banal and conditional, reviews can be dense yet overlook specific questions. I found that I got most benefit from books of short cases and the best I have read is Case Studies in Psychiatry for the House Officer by David Tomb and Daniel Christensen. ¹⁶ It is a curious looking book: the typeset appears to be that of a fairly average typewriter, as if the whole was collaged from lecture notes. But looks are deceptive and the text is excellent: there are detailed case vignettes, questions, wide-ranging answers and appropriate references. Published in 1987, it is still a very good read.

The Prince

This is rather a claustrophobic book, best read with the window open. ¹⁷ A recipe book for psychopaths: so why bother reading it? My response: because one encounters so many others who profess to have done so already! If one moves within hierarchical organisations then it is striking how many people like to quote Machiavelli (as if this were a good thing!). The Prince outlines how a ruler might go about retaining control in a world where others cannot be trusted, and where power and prestige are the prime motivations for action. It is an understandable product of the author's own time, of political turmoil, when order was at a premium; and it draws explicitly on Machiavelli's own encounters with powerful figures when he was acting as a diplomat. ¹⁸ His own justification of the work was that it describes how the world is and how men are, not how they should be in some idealised philosophical construct. He is addressing the ‘real world’. Hence, it is desirable to appear good but to behave badly when expedient; it is best to deploy cruelty early on in one's reign (and to wipe out potential adversaries and their families); better to be feared than loved by one's subjects (who come across as pretty fickle); and good to be an accomplished liar.

Machiavelli is also interested in constraints: the difficulty people have in changing their characters when ‘fortune’ changes. He advocates being a changeling, while acknowledging that few leaders are capable of altering their behaviours. Nevertheless, if they cannot adjust to changing circumstances then they are doomed.

So, is there any antidote to the Machiavellian in the workplace? I doubt it, but I offer one small consolation: The Prince was written while its author was in exile. Hence, even being an expert on the manipulation of others is not in itself a guarantee of continued success!

Pathological lying

The biology of deceit has formed one strand of my own recent work, and so the representation of deception in literature has been of renewed interest. Here I nominate Siri Hustvedt's What I Loved, an elegiac account of the lives of a small circle of New York intellectuals and bohemians ensconced in SoHo. ¹⁹ Written in the voice of Professor Leo Hertzeberg, an ageing art historian now becoming blind through macular degeneration, it charts the thoughts and relationships of Leo, his artist friend Bill, their wives, offspring and acquaintances. Sadly, their idyllic existence is ruptured by a terrible event and Hustvedt's accomplishment is to subtly convey its repercussions, played out over the ensuing years. Leo loses much and endures his suffering bravely. However, the second half of the novel is taken up with his dawning realisation that one of his circle is a pathological liar. He struggles with his own ‘truth bias’: he keeps on trying to believe in the honesty of his interlocutor, even when his life is threatened. Leo is an almost saintly character: despite his blindness, he does not turn away; he does not ‘turn a blind eye’. He keeps trying to understand; he keeps on looking.

The Idiot

‘[T]here was a moment… in his epileptic condition almost before the fit itself… when suddenly amid the sadness, spiritual darkness and depression, his brain seemed to catch fire…’(p. 243) ²⁰

I can still remember the shock of reading Dostoyevsky's novel, concerning as it does a young man who undergoes ecstatic seizures. I was undertaking an intercalated BSc in psychology and attending a neuropsychology module that dwelt for some time upon the problem of temporal lobe epilepsy. Was spiritual revelation ‘merely’ the aberrant activity of temporal lobe neurons? Certainly ecstasy could be captured, empirically. ²¹ Was this all there was to it?

I must say that over time I have lost interest in what one might call the ‘special effects’ school of transcendence. I am much more inspired by the spirituality one finds in barren places: no flashing lights or special messages, just the spirit that keeps people going when they have nothing left, no one to turn to; what it is that they find to excavate when life itself seems hopeless. This is the kind of courage that we may find among our patients and their carers, although we seldom seem to speak of it.