The Brain is Back in Psychiatry

Neurobiology of Mental Illness By Charney Dennis S., Nestler Eric J., Bunney Benjamin S. New York: Oxford University Press (1999). 958 pp. $150.00In 1895, an accomplished neuropathologist decided to throw in the towel and walk away from biological research. He had started at the bench almost two decades earlier, at the age of 20, with microscopic studies of the developing fish nervous system, and moved on to studies of the pathological changes in the human brain that give rise to aphasia. But despite this large investment he reluctantly concluded, at the age of 39, that the behavioral disorders that he found most interesting couldn't be studied with the neurobiological tools of his time, and abandoned neurobiology in favor of a new investigative and therapeutic procedure that he called “psychoanalysis.” In the next 40 years the ex-neuropathologist, Sigmund Freud, formulated a psychoanalytic view of mental illness that was so persuasive that most psychiatrists eventually lost interest in neurobiology.Then, in the early 1950s, accidental discoveries of several effective psychiatric drugs stimulated a renewed interest in the neurobiology of mental disorders. First chlorpromazine (Largactil, Thorazine), a drug that had been developed as an antihistamine, was found to eliminate many of the troubling symptoms of schizophrenia such as paranoid delusions and auditory hallucinations. This was soon followed by the discovery that another antihistamine, imipramine (Tofranil), could alleviate the self-hatred and other symptoms of major depression. The remarkable therapeutic properties of these drugs led to intensive research on their neurobiological effects. The brain was back in psychiatry.In Neurobiology of Mental Disorders (Figure 1), the three distinguished editors, all Professors of Psychiatry at Yale, bring together the fruits of the half century of research that was set in motion by the discovery of these effective drug treatments. As the editors explain in the opening of their Preface (page vii):Figure 101View Large Image | View Hi-Res Image | Download PowerPoint Slide“Fifty years ago there were virtually no effective medications to treat the major psychotic, affective, and anxiety disorders. Mental illness was viewed in social and psychological terms, and a role for brain pathology was often seen as irrelevant. Today, there is an increasingly sophisticated appreciation of the biological basis of mental disorders. Moreover, it is now the rule rather than the exception that patients with these illnesses enjoy substantial benefits from available medical treatments. The preparation of this text is testimony to the very real progress we have seen in psychiatry. Such a project would not have been even imaginable a few decades ago, and even 10 years ago it would have been a difficult task.”In the 70 chapters of Neurobiology of Mental Illness the editors, joined by almost 140 expert contributors, summarize “the progress made in psychiatry over several generations” (page vii). Organized along the familiar lines of specialized textbooks, it begins with introductory sections called “Basic Neurobiology” and “Methods of Clinical Neurobiological Research.” These are followed by sections about specific categories of psychiatric disorders (“Psychoses,” “Mood Disorders,” “Anxiety Disorders,” “Substance Abuse Disorders,” “Dementia,” “Psychiatric Disorders of Childhood Onset”). The final section (“Special Topic Areas”) covers personality disorders, aggression, sexuality, social attachment, eating disorders, menstrual cycle–related mood disorders, and sleep. Each chapter is followed by a useful list of references to original articles.The editors have done an excellent job of arranging this vast amount of material. They “admit that the diagnostic categories used to organize these sections reflect our limited knowledge of these disorders. First, each classification covers a broad collection of vague syndromes that likely represent diseases of disparate and heterogeneous causes. Second, we may well learn one day that a particular genetic abnormality or pathological process transcends our current diagnostic classifications by predisposing to, for example, depression, anxiety, or substance abuse depending on other factors” (page viii). Nevertheless, the organizational scheme that they use makes it easy to dip into the book in search of information about particular topics.Also commendable is the sensitivity of the editors to the historical context of current research. Several sections begin with a chapter on changing views about the classification and diagnosis of particular groups of disorders. Many other chapters also explain the history of important discoveries and ideas.The most distinctive section of the book is “Methods of Clinical Neurobiological Research.” Edited by George Heninger, he sets it up with an informative introductory chapter (“Special Challenges in the Investigation of the Neurobiology of Mental Illness”). The remaining chapters in this section provide valuable introductions to the methodologies that are featured throughout the book (epidemiology, genetics, electrophysiology, neurochemistry, endocrinology, immunology, and imaging).Despite the rich collection of material, the editors express disappointment about our still limited understanding of the neurobiology of mental illness. They point out in their Preface that “this text … provides more of a progress report, as opposed to a definitive statement, on our ability to understand and treat mental illness… We … expect that the book will change dramatically with subsequent editions, because progress continues at an exciting pace in our field” (page vii).At 958 pages it is a weighty progress report, but one that fills a useful niche. It is much more appropriate for graduate students and clinical trainees than the still longer (2001 pages) Psychopharmacology: The Fourth Generation of Progress (edited by Floyd E. Bloom and David J. Kupfer, 1995 [New York: Raven Press]), which covers similar material. Although Neurobiology of Mental Illness leaves many questions unanswered, it would surely dazzle the self-taught psychoanalyst who reluctantly walked away from the brain sciences in 1895, but who always expected that the time would come when they would contribute to our understanding of psychopathology.