[D66] NYRB: Changing Psychiatry’s Mind

[R.O.]

https://www.nybooks.com/articles/2021/01/14/changing-psychiatrys-mind/


  Changing Psychiatry’s Mind

Gavin Francis <https://www.nybooks.com/contributors/gavin-francis/>
Two books investigate the science and pseudoscience of diagnosing mental 
illness.

January 14, 2021 issue <https://www.nybooks.com/issues/2021/01/14/>

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Reviewed:

Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental 
Illness <https://www.bookshop.org/a/312/9780393358063>

by Anne Harrington
Norton, 366 pp., $27.95; $17.95 (paper)

This Book Will Change Your Mind About Mental Health: A Journey into the 
Heartland of Psychiatry <https://www.bookshop.org/a/312/9780571345977>

by Nathan Filer
London: Faber and Faber, 248 pp., £9.99 (paper)

Diagram of the cerebellum by Santiago Ramón y Cajal, 1894 
<https://cdn.nybooks.com/wp-content/uploads/2020/12/francis_1-011421.jpg>

Instituto de Neurobiología Ramón y Cajal, Madrid

Diagram of the cerebellum by Santiago Ramón y Cajal, 1894. Cajal’s 
drawings are collected in /The Beautiful Brain/, edited by Eric A. 
Newman, Alfonso Araque, and Janet M. Dubinsky and published by Abrams in 
2017. For more on Cajal, see Gavin Francis’s essay ‘In the Flower Garden 
of the Brain’ at nybooks.com/cajal.

Twenty-five years ago, at the end of my two-month rotation in 
psychiatry, Edinburgh Medical School delivered the results of our 
student assessments by posting three lists of names on a departmental 
notice board. It was a nerve-racking experience for all of us, who would 
learn of having passed or failed in full view of our peers.

A crowd gathered around the board, and one by one my classmates found 
their names on the pass list—or, even better, on the shorter list of 
those who passed “with distinction”—then cheered and went off to 
celebrate at the bar. But as I strained toward the lists I felt a ball 
of tension in my gut; I was a good student, had excelled in a few 
specialties so far, but couldn’t see my name. Then, /there it 
was—/unmistakably, on the dreaded third list of those who had failed. I 
felt a tap on my shoulder, someone pointed up at the distinguished 
students: /there it was again./ The test had combined a written exam and 
an appraisal of clinical competence; it seemed one of my assessing 
psychiatrists had deemed me a star student, the other, a failure. I 
reported upstairs for what turned out to be an awkward interview, the 
outcome of which was that both assessments had been wrong: I was an 
average student after all, neither struggling nor distinguished. I was 
left wondering if I’d make a good psychiatrist, an abysmal one, or both.

That experience was unique in my medical training: in no other specialty 
was there such confusion over what separates success from failure. If 
the psychiatrists couldn’t agree on the assessment of student 
performance, I wondered how much they’d agree on their assessments of 
patients. A thorny subject, perennially controversial, because mental 
health diagnoses have such power—to save lives, or ruin them. It’s a 
difficulty that Anne Harrington, a professor of the history of science 
at Harvard, tackles masterfully in /Mind Fixers: Psychiatry’s Troubled 
Search for the Biology of Mental Illness/,//which she divides into a 
history of how psychiatry has approached, characterized, treated, and 
maltreated mental illness since the 1850s (“Doctors’ Stories”); a 
section on depression, schizophrenia, and manic depression as the three 
most illustrative disorders (“Disease Stories”); and finally suggestions 
for the future of psychiatry, with an argument that a fundamental 
reappraisal is needed (“Unfinished Stories”).

I work now as a primary care physician in Edinburgh; approximately a 
third of my consultations concern mental health, and every day brings 
first-hand examples of just how variable the manifestations of mental 
illness can be, and how mutable its diagnostic labels. There are 
patients of mine who’ve had four or five different diagnoses since their 
career in the care of psychiatric services began, even though their core 
symptoms (and distress) have hardly changed. Most people who have lived 
a few decades with severe mental illness have seen their own label 
evolve, simply because the way their symptoms are characterized by 
psychiatrists has evolved. This is true as much for “major” psychiatric 
conditions, such as paranoid psychosis and psychotic depression, as it 
is for conditions habitually thought of as existing along a spectrum 
that reaches normality (whatever that is), such as autism or 
attention-deficit disorder.

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