Kenneth Lakritz, MD

 can be read in 2 ways. To start, it works as an engagingly written, accurate piece of science journalism (which is something that we need more of; it’s hard to imagine running a democracy without it).

Even before Oliver Sacks reconstructed the genre as high literary art, pop neurology books-often just compendia of freakish cases and brilliant diagnoses-had great entertainment value. But these books make their subject matter sound more frivolous than it is. Before functional MRI and implantable brain stimulators, neurology was an essentially passive and observational science. It was built from observation and clinicopathological correlation of just those odd “experiments of nature,” with their uncanny dissociations and disconnections, that make for a ripping yarn.

Damasio parades some spectacularly freakish cases, but he doesn’t stop there. As a reflective practitioner, he uses those cases to argue a distinctive and original theory of mental functioning. 

 should also be read as serious and original scientific research.

His first example is a classic. Phineas Gage was a bright, industrious 25-year-old in 1848, until an iron rod penetrated his frontal lobes in an industrial accident. Amazingly, he survived, with sensation, movement, speech, and reasoning apparently intact. But Gage’s personality changed. He became vulgar, emotionally shallow, shiftless, and unreliable. A completely different man.

Damasio’s second case, the index patient that launched his theorizing, is “Elliot,” formerly an intelligent, successful professional in his 30s, who lost parts of both frontal lobes to a meningioma. Elliot emerged from surgery as an impulsive, stimulus- bound, sleazy, unemployable jerk. Like Gage, he’d become cool and unemotive-transitory annoyance was his strongest remaining affect. And like Gage, his impairments were invisible to standard neuropsychological assessment: nothing worse than decreased autonomic response to fearful stimuli was detected.

From these 2, and a few other cases, Damasio and others extracted the key insight that acquired social incompetence and mood flattening were not dissociable; they always occurred together. They also localized a constellation of symptoms, “Gage syndrome,” to the ventromedian frontal lobes. Similar problems occur after bilateral amygdala damage and, in patients with anosognosia, after nondominant hemisphere strokes. In these cases, however, defective social reasoning is overshadowed by more gross neurological deficits.

In explaining Gage syndrome, Damasio distinguishes between primary and secondary emotions. The primary emotions, such as fear, elation, and disgust, seem to be hardwired and generated by phylogenetically old structures in the limbic system. What is more important, they evoke stereotypical, predictable body responses such as sweating and tachycardia. Secondary emotions by contrast are learned, variable, and nuanced. They originate in the frontal regions, but they work through the older primary circuitry rather than parallel to it.

The idea that the evolutionary process has built neocortical systems of regulation on top of older ones is crucial for Damasio. In this view, judging, reasoning, and subtle affective responses serve the same purposes-survival, homeostasis, reproduction-as the ancient limbic and endocrine systems. As we go about our lives, frontal mechanisms create associations between images in primary sensory cortices and physiological states of the body; images get somatically marked (the “somatic marker hypothesis”). Then, when we have to decide among competing courses of action, images of potential outcomes evoke the physiological states they’ve been marked with. In turn, these physiological states are themselves subliminally perceived, with the result that alternative actions with negative somatic markings are rapidly rejected and those with positive markings receive extra attention.

The body, then, is an essential part of the circuitry of thought and social judgment. When neurological injury prevents the generation and detection of somatic markers, we get Gage and Elliot, people disengaged from somatosensory feedback who, in subtle but crucial ways, cannot think. (The somatic marker hypothesis seems designed to describe social and personal decision making. Damasio equivocates about whether it models all thinking. He’d like to say that it does, that even the abstract reasoning that goes to prove a theorem or write a poem is, in attenuated form, continuous with the mechanisms of survival and homeostasis. Actually though, his clinical material suggests that some kinds of cool reasoning survive frontal injuries.)

Damasio’s great predecessor is William James

 (and, before him, David Hume), and his metaphysical adversary is Ren Descartes. As early as 1884, James proposed that emotion is perception of a somatic state; for example, subtract the tense muscles, tightening gut, and tachycardia from the sense of anger, and nothing is left. Damasio acknowledges the intellectual debt but faults James for vagueness and neglect of neuroanatomical details.

Descartes stands, metonymically, for the philosophical tradition of mind-body dualism, the idea that mind-an immaterial thinking substance-exists separate and distinct from the body. For the Cartesian, reasoning at its best is a pure and dispassionate product of higher brain systems. Emotions and their physiology can do nothing for reason but get in its way.

As a practical matter, Damasio claims that his model should incline medical practice toward holism, but good psychiatrists hardly need the nudge. We’re all biopsychosocial practitioners by now, diligently checking thyroid and vitamin levels and trying to steer our patients away from metabolic syndrome.

More fruitfully, Damasio’s ideas ought to direct our clinical attention to the neglected territory of judgment, that is, emotional IQ, social competence, or common sense. If Gage and others are rare instances of impaired judgment in pure culture, the partially impaired are ubiquitous: they’re all the patients, friends, and relatives who make you want to shout, “What were you thinking!”

Sociopathy is close to Gage syndrome as are, to a lesser extent, autism spectrum disorders and syndromes of impulsivity. Geriatricians know that failing social competence is an early marker of frontotemporal dementia. We, as psychiatrists, have our own judgmentally challenged anosognosics: the many psychotic patients unaware of their illness.

Finally, there’s the legion of the awkward, gauche, and clueless-undiagnosable, but problematic all the same. Axis VI, anyone?

 10th ed. New York: Penguin Books; 2005.


Insight and Psychosis: Awareness of Illness in Schizophrenia and Related Disorders

. Oxford, UK: Oxford University Press; 2004.

Articles

Descartes’ Error1 can be read in 2 ways. To start, it works as an engagingly written, accurate piece of science journalism (which is something that we need more of; it’s hard to imagine running a democracy without it).

Antonio Damasio’s Descartes’ Error: Emotion, Reason, and the Human Brain

Psychiatry is eminently corruptible. Soviet psychiatrists of the 1950s disgracefully organized themselves into the medical arm of the Gulag state. Political dissidence became prima facie evidence of impaired reality testing, of “sluggish schizophrenia.” We like to believe in the benefits of scientific progress, but for Soviet inmates, progress was prefixed with a minus sign; every apparent advance in psychiatric technology left them more tightly controlled and worse off.

What if we were doing the same thing? Might our every step forward in brain imaging, genetics, and psychopharmacology promote unconscious agendas of domination and conformity? Not likely. We still live in a democracy of sorts and most Americans-if they’ve had the good fortune not to join the National Guard-still don’t take orders from the government.

Who could seriously promote such a perverse idea? Only someone with an intuitive sympathy for the most abased and marginal members of society and with a violent contempt for science, medicine, and authority in general. And, if he were to convince anyone else of his outlandish views, he would be a dialectical and rhetorical genius. But that was Michel Foucault (1926-1984)-a lifelong political and philosophical radical, erstwhile Communist, a vo­tary of the student insurrections of 1968, apologist for the Iranian revolution, prison rights campaigner, AIDS activist, and early AIDS victim. Yet, Foucault was equally a mitre penseur, an intellectual rock star in the mold of Camus and Sartre, and a professor installed at the apex of honor and respect in his nation’s rigidly hierarchical university system. Only in France!

Madness and Civilization, a reworking of Foucault’s doctoral dissertation, undertakes an “archaeology” of our system of psychiatric no­sology and treatment.

 Foucault is a relativist concerning mental illnesses; our medicalized understanding of them is a social invention, localized to our episteme, or conceptual scheme. Knowledge generally, and psychiatric practice in particular, cannot be understood in isolation from other institutions of coercion and discipline.

This modern conceptual framework began to form in the “Classical” period of the 17th and 18th centuries. The midsection of Madness and Civilization is a dreary recital of the  unfounded theorizing and hopeless treatments of that time-a tale of vapors, humors, shackles, purges, and cold showers. But this account is bracketed by Foucault’s provocative description of 2 great historical discontinuities: steps backward that looked like steps forward.

Foucault contrasts classical theory with  a medieval and a Renaissance view of mad­­ness that he reconstructs from contempora-neous art and  literature, especially the hal­lucinatory images created by Pie­ter Bruegel and Matthias Grne­wald, and the caricatures in Erasmus’s The Praise of Folly. This view holds that madness is a sinful state, a fall from grace, an alternative to reason. Madness is accorded a fearful respect, as temptation and delusive freedom. By contrast, in the protoscientific classical view, madness is externalized, isolated, and investigated. The dialogue with madness ceases.

The objective correlative of this conceptual reorganization and the first of Foucault’s discontinuities, is the “Great Confinement” of the 17th century; the abrupt incarceration of mass populations within a newly organized network of custodial institutions throughout Europe. With his Frankocentric perspective, Foucault fastens particularly on an edict of 1656 that established the Hpital Gnral of Paris. The name is deceptive; the Hpital was not a medical institution. It, and kindred establishments, housed not just the insane (a term that covered psychosis, mental retardation, dementia, epilepsy, and all the rest of organic psychiatry) but also debtors, vagrants, petty criminals, and political and religious dissenters. Officially, the Confinement took aim at poverty and idleness. Foucault suggests that it was really a moral panic provoked by rural displacement, industrialization, and a new class of urban surplus labor. Whatever the reason, millions were locked away without any recourse.

Foucault’s second discontinuity is the dismantling of these institutions at the end of the 18th century. The heroes of this movement are the Quaker Samuel Tuke (founder of the York Asylum) and Philippe Pinel (representative of the French Revolution, who reorganized the French hos­pitals). In the  received view, Tuke and Pinel brought liberation, un­der­­standing, and kindness to the mentally ill. (Every text­­­­­book of medical history re­produces a painting by Robert-Fleury of Pinel righ­teously striking the chains from the inmates of the Salptrire).

Foucault, controversially, will have none of this. He describes the work of these reformers as “a gigantic moral imprisonment.” They merely replaced crude force with more subtle, intimate, and pervasive means of control. Mental illness was reconceptualized as moral failure, to be treated with constant observation and regimentation, with appeals to guilt and religious sentiment. The inmate is perpetually judged, threatened, and corrected. The hospital caricatures the family-with the psychiatrist assuming the mantle of benign but demanding paternal authority. Crucially, the patient internalizes this authority, becoming more compliant but also more self-alienated, divided, and less free even than his or her enchained predecessors. Foucault even suggests that the grand hysteria described  by Charcot, Freud, and Pierre Janet 100 years later is the “precipitate” of this authoritarian regime.

A central meta­phor for Foucault is the Panopticon of Jeremy Bentham. Bentham, a British philosopher, was the foun­der of Utilitarianism and an avatar of instrumental reason gone wild. His Panopticon was a cunningly designed prison-never actually built-that permitted a few guards to observe a huge number of inmates. Bentham’s scheme relied on internalization: once prisoners know that someone may always be watching, they watch themselves. (Just as in George Orwell’s 1984, state terror is maintained even when no one knows whether the omnipresent telescreens are actually operating.) Never mind The Matrix . . . modern psychiatry and penology have converged. Foucault claims that we all live inside the Panopticon. And if you’ve tried to board an airplane recently, you might agree.

Foucault’s writings have offered intellectual heft to enemies of organized psychiatry, from the anti-psychiatrists of the 1960s to today’s Scientologists. But his greatest influence came in that unlikely alignment of doctrinaire Libertarianism, pharmacological presumption, and Foucauldian cynicism that produced our own “Great Deconfinement”-the emptying of our state psychiatric hospitals. To paraphrase Foucault’s compatriot Anatole France, “the mentally ill are once again free to beg in the streets and sleep under bridges.”

1. Foucault M. Madness and Civilization: A History of Insanity in the Age of Reason. Howard R, trans. New York: Vintage; 1965.

Michel Foucault’s Madness and Civilization:  A History of Insanity in the Age of Reason

, David Lodge's comedic novel of academic life, the junior faculty in literature at a provincial English university play a game called Humiliation. In turn, each names a classic that all professors should have read but have not. Finally, one junior lecturer gets carried away, admits that he's never read 

Everyone has these guilty secrets . . . there are just too many books. Moreover, many of the best books are length­y, densely argued, and stud­ded with long Latinate words. In our atten­tionally challenged era of blogs and twitters, sitting down to read such wor­thy tomes seems ever less feasible.

Book reviews have long been a first defense against scholastic overload. Generations of high school students have bypassed 

in favor of CliffsNotes, and now Wiki­pedia. Many people use the 

less to plot future reading than to pick up enough talking points about this week’s bestseller that they can skip it but still sound intelligent. Recently, litterateur and psychoanalyst Pierre Bayard anatomized this art of faked literary chat in his nearly serious study, 

How to Talk About a Book You Haven’t Read

Psychiatrists, like everyone else, bear shameful educational omissions. We’re all short of time and the required reading list gets longer every year. This new column aims to review important books you may have passed over. No confession required. Maybe it will inspire you to actually read a book. If not, at least you’ll have some clever opinions on the ready.

Otto Kernberg was born, appropriately, in Vienna in 1928 and fled to Chile in 1939, one step ahead of the greatest pathological narcissist of them all. He’s now been in the United States for 50 years, first at Menninger and now Cornell, devotedly leading me­ticulous, long-term studies of intensive psychotherapy for patients with personality disorders.

Borderline Conditions and Pathological Narcissism 

(New York: Jason Aronson; 1975) is the archetypal unread classic. It’s an acknowledged landmark; the culminating and most characteristic expression of generations of psychodynamic observation and theorizing about severe personality disorders. But reading Kernberg is a hellacious experience.

First, he’s a true-believing psychoanalyst, so your reaction to him will follow your opinion of analysis; if you’re allergic, stop reading now. Kern­­berg takes for grant­ed the causal and explanatory power of infantile sexuality and unconscious mental pro­­cesses. He ignores biology; hypomania, for him, is character pathology. He blithely lumps homosexuality among the personality disorders. He prescribes intensive psychotherapy for almost every­one, and recommends a few months of hospitalization for regressed patients. I can’t sign on to all of this. And yet, I admire psychoanalysts’ willingness to immerse them­selves in the lives of severely disordered patients. I wouldn’t do it. And I wouldn’t trek to the South Pole or ride a diving bell to the floor of the Pacific either. But I’m curious about what these extreme explorers bring back.

The second barrier is stylistic. Kernberg is an analyst speaking to other analysts. He’s logical and well organized but offers no concessions to outsiders. He writes an argot, not quite English. It’s page after page of “oral rage,” “pregenital strivings,” “structural derivatives of object relations,” “sadistic precursors of the super­ego,” and “pathological refusion of self and object images.” You don’t read Kernberg, you decipher him.

If you’re still with me, recall that our now ubiquitous DSM isn’t all of psychiatry but only the current incarnation of the “objective-descriptive” tradition, tracing back to Kraepelin. The focus is on clear and reliable observation with a minimum of speculation. Diagnostic categories bubble up from observed clusterings of symp­toms rather than being imposed by a preordained theory. The results are familiar but also mysterious: Why do extremely sad people wake up too early? Why is unipolar depression common but unipolar mania rare? Why do the female relatives of socio­paths become somatizers? What’s the link between tics and obsessions?

If these questions persist, at least the boundaries of the major 

 Axis I syndromes are clear. But ev­ery­body knows that Axis II doesn’t work as well. The clustering breaks down. Patients drift from one personality disorder to another or qualify for 3 at a time. And the diagnostic criteria seem devoid of an inner logic. What do identity diffusion, brief psychotic episodes, and intolerance of solitude have to do with one another? Personality disorders stretch the purely observational framework of 

Kernberg elides these dilemmas by switching attention from borderline personality disorder to borderline personality organization (BPO). BPO extends across many 

 categories; on Kernberg’s accounting, it’s found in most DSM borderline narcissistic and antisocial personalities but also in most addicts, some histrionic characters, and many people with chronic depression. It comes complete with a developmental theory, an explanation of characteristic interpersonal relations and defense mechanisms, and even recommended modes of treatment. BPO explains a lot, but at a price; it’s a theoretical entity-distant from observation.

BPO arises, we are told, in infants who can’t integrate their positive and negative experiences, either because of high innate aggressiveness, excessive anxiety, or harmful early experiences. (All explanations must stop somewhere and Kernberg stops here. Margaret Mahler and others propose that borderline parents reproduce the disorder in their children because they can’t tolerate their infant’s healthy aggression or later need to separate. Still others assert the etiological primacy of childhood abuse and molestation and emphasize the importance of dissociation in bor­derline symptoms.) To protect their good experiences from “contamination,” future borderlines come to rely on splitting-the desperate device of sequestering good and bad internal representations of self and others-rather than on repression as their primary defense mechanism. Secondarily, they employ the primitive de­fenses of projective identifi­cation, denial, omnipotence, and devaluation. (For a cat­alog of defense mech­a­nisms, try 

Dependence on these primitive defenses gives rise to “ego weakness”-lack of anxiety tolerance, impaired im­­pulse control, and a paucity of con­flict-free spheres of expression. Kernberg ingeniously and economically explains how BPO explains the “surface” bor­derline symp­toms we’re all familiar with-splitting as a defense, of course, but also intense, unstable, and exploitative relationships, identity diffusion, boredom, intolerance of solitude, global anxiety, and self-destructiveness.

Kernberg also describes the common missteps in treating borderline patients: the uncritically “nice” therapist mistakenly allows the patient to gratify his other aggressive urges. At the other extreme, under the influence of projective identification, the unwitting therapist may sadistically re-enact the patient’s disastrous early relationships.

Kernberg famously advocates early confrontation and interpretation of the patient’s hidden or overt aggressiveness, and this gives his writing a tough, almost angry tone. In this, and especially in the treatment of narcissistic personality disorder, he contrasts markedly with his great rival Heinz Kohut. Kohut viewed pathological narcissism as a stop on the road to healthy narcissism rather than as a pathological deviation (see his The Analysis of the Self), and encouraged idealization and “mirroring”-a shared bubble of grandiosity-between patient and therapist.

Is Kernberg’s theory true? It cannot be the final word, because it disregards neuroscience and the real world of social relations. Despite Kernberg’s laudable emphasis on empirical research, his work is unconvincing by the scientific standards of hypothesis generation and falsifiability. No one will ever conduct a double- blind, placebo-controlled study of psychodynamic psychotherapy, much less of psychodynamic metapsychology. But, for sympathetically understanding the experiences of our most primitive and difficult patients, Kernberg is essential.

Book reviews have long been a first defense against scholastic overload. Generations of high school students have bypassed Wuthering Heights and The Scarlet Letter in favor of CliffsNotes, and now Wiki­pedia. Many people use the New York Times Book Review less to plot future reading than to pick up enough talking points about this week’s bestseller that they can skip it but still sound intelligent. Recently, litterateur and psychoanalyst Pierre Bayard anatomized this art of faked literary chat in his nearly serious study, How to Talk About a Book You Haven’t Read.

Kenneth Lakritz, MD

Articles

Antonio Damasio’s Descartes’ Error: Emotion, Reason, and the Human Brain

Michel Foucault’s Madness and Civilization: A History of Insanity in the Age of Reason

Kernberg’s Borderline Conditions and Pathological Narcissism