The Thomas P. Hackett Lecture Award Neuropsychiatry A Delicate Balance W.A. LISHMAN, M.D., D.Sc., F.R.C.P., F.R.C.PSYCH.
I
t is a privilege to contribute to essays in memory of Dr. Thomas Hackett. What follows is based on an address to the Academy of Psychosomatic Medicine in November 1990. On a previous occasion in 1982 when 1 addressed the Academy, I was introduced by Thomas Hackett himself. Already by this time we had become firm friends with a strong bond extending across the Atlantic, even though we met infrequently. And I have wondered what it was that created such a bond from our first making one another's acquaintance. I think it was a combination of something very generous in Dr. Hackett's approach to visiting colleagues such as myself, along with a deep curiosity in him that made him such stimulating and refreshing company. One heard little of his own affairs and preoccupations until he was pressed-he preferred instead to search gently but insistently for one's own opinions and to draw one out in the most rewarding fashion, so that one was soon deeply involved in exchanging new insights and points of view. Dr. Hackett was, of course, tremendously interested in people as well as in clinical science. It was this last thought that led me to the topic for the present address. I had considered Dr. Lishman is professor of neuropsychiatry. Institute of Psychiatry. De Crespigny Park, London. Copyright © 1992 The Academy of Psychosomatic Medicine. 4
various options in the scientific domain by way of reviews of research or developments in psychiatry. But I wanted people to be in the very forefront of our attention as we honor the memory of Dr. Hackett today-people in their infinite variety and with their astonishing range of problems, conflicts, and ways of coping with adversity. Because I am a neuropsychiatrist and tend to see patients with brain disease, I felt it would be interesting to talk about the decisions we must often try to make on whether the problems we see in the clinic are "organic" or "functional"-more precisely whether they derive from a primary brain malfunction or from difficulties the patients are encountering in their lives. This is one of the great fascinations of psychiatry-that its territory is so immense and the options open to us so astonishingly wide. We need to embrace both of these sets of possibilities in diagnosis and most certainly in treatment. To ignore one or the other could be seriously misleading. This, then, is the "delicate balance" in the title: between our knowledge and understanding of the brain and our knowledge and understanding of people. In a sense. of course, we can view it as the balance between neurology and psychiatry-the two major clinical disciplines that deal with brain and mind. And we can perhaps pause for a moment to reflect on the differences between them. We can draw up a series of contrasts in their PSYCHOSOMATICS
Lishman
methods of approach to problems. I The neurologist starts out with physical disorders of the brain and nervous system. The psychiatrist takes as his point of departure affections of the mind. The neurologist must be expert at examining the nervous system-it was said of Gordon Holmes that he "could coax physical signs out of a patient like a Paganini on the violin."2 He explores the clinical history with scrupulous attention to any hint of physical symptoms. The psychiatrist's expertise generally lies in assessing a different range of phenomena. He deals with abnormalities of mood, qualities of thought disorder, false beliefs, and abnormal subjective experiences. Human behavior and experiencing are his primary concerns. This leads him into complex territories-minds can interact with other minds and be profoundly influenced by circumstance and social processes. In taking a history. the psychiatrist explores biographical data and processes of personal development. He must consider the patient's setting and the nature of his interactions with those around. Henry Maudsley wrote at the age of 25 that we must always take two elements into consideration: "the subject and the environment, the man and his circumstances, subjective force and objective forces, both passive and active.......1 What I hope to show in a moment is that we as psychiatrists must often combine the dual approach-neurological and psychiatric-in the evaluation of patients. Disease and disorder do not recognize the boundaries that have arisen between professional disciplines. Furthermore, we can look at the processes set in motion when these two sets of clinicians deal with the information they have gathered. The neurologist relates his data to a knowledge of certain well-defined disease entities. He must also rely on familiarity with the anatomy and physiology of the nervous system. He has to know how this complex machinery works in order to decide what may be adrift. He has nowadays, of course, a range of impressive technological developments to help him by way of investigation. The psychiatrist does something very different. He tries to relate his clinical information to a VOLUME 33· NUMBER I • WINTER 1992
knowledge of "mental diseases," but these are far from clearly defined. The range and variety of mental disorders and personal distress lead to difficulties with any classificatory system. He must be ready, furthermore, to think in terms of a range of variation that has nothing to do with disease; peculiarities of personality; abnormalities of mood; or modes of response to conflict, threat, or disaster. The psychiatrist must often rely on an appreciation of human situations and crises and the way predispositions can shape human behavior. Very briefly, as stressed by Sir Denis Hill. the neurologist's decisions and inferences hinge on matters common to all-their neural physiology and anatomy-whereas the psychiatrist's conclusions hinge very often on matters peculiar to individuals-the characters that make them unique.~ In our clinical psychiatric practice we will sometimes, indeed quite often, find ourselves tom between these two forms of approach. And as the neurobiological basis of behavior becomes increasingly understood, we will need to be vigilant in exploring possibilities on both sides of the fence. Let me now give some examples from clinical practice to illustrate what I mean. Case l. My first patient was a man of 38, referred with puzzling appearances of dementia. He had spent some months in hospital in East Anglia with serious memory problems, but careful investigations of his brain had shown no abnormality. Even recent CT scans and EEGs had proved to be negative. His behavior, moreover, was very variable from day to day. On some occasions he was oriented and lucid, on others hopelessly adrift. Sometimes, when questioned, he knew nothing of his family, not even, surprisingly, of the existence of his children. He was emotionally labile and prone to give approximate answers to questions. This had led to a diagnosis of hysterical pseudodementia or Ganser's syndrome. The quasi-organic features in his mental state were viewed with a certain reserve. This man had run into tremendous problems in his life. His business affairs were chaotic, and for the preceding year there had been mounting tensions in his second marriage. His first wife, in Spain, was threatening to send the two children of that marriage to live with him in England. He had begun drinking very heavily. 5
Festschrift for Thomas P. Hackett
Family discussions and attempts to explore his problems with him met with no response. He continued to deteriorate and at the point of referral for a second opinion had begun to show occasional myoclonic jerks of the limbs. Examination now revealed gross apraxia and muscle rigidity, and there was no doubt he had organic disease. Repetition of the scan, just 3 months after the last, showed commencing brain atrophy. The EEG now showed a markedly abnormal picture. Within a further few months he had died of Creutzfeldt-lakob disease. Comment The lesson we learn from this sad story is that we can remain perplexed for some time when an insidious brain disorder presents in a patient whose life is riddled with conflict. With neurological examination and help from the scans, an abrupt change took place from thinking in terms of his life situation to formulating the problem in terms of a brain disease. We note. moreover, that brain disease does not preclude the operation of psychodynamic factors-for example his forgetting of his children-indeed it may reveal their operation in an unusually striking fashion. Case 2, The next patient yielded similarly to a neurological approach. this time with a happier outcome. He was referred from the North of England. again with perplexing memory problems. These had set in after a severe pyrexial illness 10 months earlier. The referring psychiatrist was of the opinion that the amnesia was organic in origin. but his colleagues had raised the question of hysteria. Over many months he had shown marked variability with his memory and increasingly childish behavior. On home visits he was profoundly unable to cope. All investigations had drawn a blank. When we saw him he was something of a chameleon. On some occasions he was hopelessly disoriented and seemingly very vague. He would be unable to concentrate on a question or give a coherent account of himself. At other times he was oriented and reasonably able to converse and deal with his affairs. At the first interview with him he stated that his father was alive and well and described a good relationship between them. At the next he said that his father had died some twenty years ago. which proved to be correct. One could see why hysterical mechanisms had been considered. 6
The clue came when he had a grand mal fit on the ward and the EEG showed pronounced dysrhythmia. A peculiar intermittent jerking of the limbs had also been seen. He had had some sort of seizure earlier in his course, but the EEG evidence had then been equivocal. We decided therefore to begin anticonvulsant therapy while monitoring his memory function with simple tests from day to day. The result was gratifying. On anticonvulsants, the limb jerks ceased and his day-to-day memory showed detectable gains. This was monitored on a daily basis by simple tests administered by the ward staff-measures of orientation in time. ability to leam and remember itemized information. and ability to remember to carry out a task after 2 hours had gone by. Altogether he made substantial improvement on all memory tests. and his observed partial seizures fell in parallel. Though remaining somewhat impaired on full memory testing he regained independence and was able finally to return home. Comment Here a presumed encephalitic process had set in train a subtle form of epilepsy. It seemed reasonable to conclude that subclinical discharges had been leading to his variable confusion and problems with learning and recall. Only by postulating brain disease was it possible to find a simple treatment that benefited him very greatly. These two patients. then, illustrate one facet of the delicate balance. They both, admittedly, had rare conditions and ancillary aids to diagnosis had in the early stages failed to show what was afoot. The clinical pictures produced had within them elements that led one to think in terms of functional, hysterical disorder for considerable periods of time. Changes also occur in the opposite direction. for example each time we alter a diagnosis from neurological disease to hysteria. But the next patient represents a remarkable example when the change from organic to functional occurred abruptly and through fortuitous circumstances. This clinical problem presented in a particularly vivid and urgent fashion. Case 3. The patient was a recently retired lady whom I knew from various contacts over the years. PSYCHOSOMATICS
Lishman
She was seen as an emergency, just 3 weeks before leaving for a holiday in a distant part of the world. I knew that she had been in the habit of visiting there. Some months earlier she had had a subarachnoid hemorrhage, had been seriously ill for several weeks. but had made a full recovery after clipping of an anterior communicating aneurysm. Virtually no residual impairment had resulted. During recent weeks, however. while preparing for the trip, she had become tremendously worried about herself. She seemed to have deteriorated abruptly. She could not think or plan properly, was sleeping badly, and seemed unable to concentrate or organize herself. Her affairs at home had become chaotic. She was very anxious and considerably depressed. This posed a serious problem. Could she be developing some late complication of the subarachnoid hemorrhage by way of hydrocephalus? Was it safe to let her travel? No definite signs could be found on neurological or cognitive examination. A conference was arranged next day with her neurosurgeon. We were wondering how to arrange a CT scan without upsetting her unduly when her son phoned with surprising information. In the holiday location she had a substantial problem. Over several years she had befriended a resident there whom she had tried to rescue from alcoholism. He was now an increasing burden. had got into debt, and had recently been plaguing her with phone calls in a disturbed state of mind. What had started as a diverting friendship some years before was becoming a nightmare. She was dreading the confrontation and felt unable to deal with it. Seen in this context, her symptoms acquired a new perspective. Once the ice was broken, it was possible to discuss this problem in some detail and decide on strategies and lines of action. She went on the holiday without any ill effect. All of this was 2 years ago. Since then, and with much discussion, she has managed gradually to withdraw from a complex emotional relationship. Her brain is working perfectly and we have still not done a scan.
Comment Here we see the need, in unusually acute form, for differentiation between cerebral disorder, namely hydrocephalus, and emotional turmoil occasioned by a crisis in a personal relationship. To clarify the former we would have needed to invoke the help of a piece of expensive modern technology. To clarify the latter we VOLUME 33· NUMBER I· WtNTER 1992
needed no more than information about the details of her trip. To help resolve the problem it was necessary to get to understand a situation replete with special meaning for the individual concerned. The upset had no doubt disturbed her cerebral physiology in a multitude of ways. But this disturbance could not be dissected by neurologicalor physiological means. In this sense it was a functional disturbance. This patient shows, among other things, the hazard of treating patients we know socially and who may therefore be unwilling to divulge full details of their lives. More importantly she shows the great significance that many attach to such details in reaching a COrrect appraisal of a crisis. When dealing with higher level human functioning-with emotions and behaviors of a complex kind-we can find ourselves with the need to ask the question, Is this determined by a pathological process within the brain, or has it been engendered by emotional turmoil and conflict? The answer is not always as quickly forthcoming as in the foregoing example. We must sometimes keep our suspicions and sensitivities alive for some considerable time. My final example is more complex in this respect, also in showing what in fact is very common-the interaction of both cerebral and personal factors. It concerns a well-known academic, who was prematurely retired from his university chair on account of suspicion of Alzheimer's disease. A long story must be briefly condensed. Case 4. This man had had a manic-depressive disorder, requiring treatment with lithium. During a hypomanic episode, haloperidol was given in addition. As the episode resolved he proved to be very considerably changed-dulled in personality, forgetful, and incompetent in his writing and teaching. Psychological testing ultimately showed a profound diminution of intellect, with a verballQ of 104 and a performance IQ of 62. His memory was faulty, he muddled left and right, and had clear visuospatial impairments. A decision was taken at another hospital to impose premature retirement. and an annual lecture was endowed in his honor. Some 18 months later his wife brought him for 7
Festschrift for Thomas P. Hackett
a second opinion because the diagnosis was being questioned. Though still dulled and generally incompetent. repeated scans had shown no atrophy. He had. moreover. shown occasional glimpses of the former man. Since retirement his life had changed dramatically. His wife structured each moment for him. with simple tasks to keep him busy. Helpers were employed to take him here and there. and he had no access to his finances. She dominated him entirely. and she had a forceful personality. She was herself extremely bitter that she was now the guardian of the man she had so much admired. An element of depression was suspected in the picture he presented. and antidepressants were eventually prescribed. This led to some improvement. with an increase in asseniveness and times when he seemed less adrift. Very gradually his wife was persuaded to lessen her over-protective attitude. to allow a measure of independence. and to encourage him with simple academic endeavors. He showed preserved abilities to translate from Latin and Greek and made an attempt at an essay on "Philosophers I Have Known." Her own demeanor changed over the next few years to a more relaxed and less critical approach. The patient continued to make slow but definite gains. though with persisting. clear cognitive impairments. Now. some 5 years after retirement. he attends the yearly lecture in his honor and has been known to take issue with the speakers.
Comment Here we suspect that the patient sustained some definite brain damage of a nonprogressive sort, possibly as a result of the combined pharmacotherapy with lithium and haloperidol. But this was then greatly compounded by the changed relationship with his wife that had resulted from the disaster and by a treatable element of depression that lay hidden in his dullness and apathy. By gentle and persistent attention to his wife's own reaction these secondary developments have come under a degree of control, enabling him to function much better in spite of a damaged brain. A balance has again been required between appraisal of the organic component in the disorder and a component which is essentially interpersonal. This balance creates a tension within psychiatry that gives it much of its richness as a clinical 8
discipline. We must seek to refine our knowledge of brain physiology and pathophysiology. yet at the same time retain our curiosity about the human condition. Furthermore, we must sidestep the risk of becoming too far seduced by one or other pole of this dual requirement. The complexity and the delicacy of the balance is such that it has been necessary to give detailed examples from clinical practice in order to show its essence. And perhaps the most important point to stress in closing is that the problem will always be with us. Knowledge of brain functioning is destined to continue to increase remarkably as the next decades unfold. Brain biochemistry becomes daily more complex and with increasing relevance to emotional and behavioral disorder. Pharmacotherapy is one of the resounding achievements of mid-twentieth century psychiatry. and psychopharmacology slowly extends its territories. We are now in the era of increasingly sophisticated brain imaging techniques that can monitor brain structure and function to a quite astonishing extent. We can visualize the brain minutely with magnetic resonance imaging, including the limbic system; with positron emission tomography we can monitor brain metabolism and investigate neurotransmitter processes. We can visualize the increased blood flow to frontal regions when a normal subject engages in a category sorting task and show that equivalent dynamic shifts are defective in the schizophrenic brain. 5 All of these are wonderful gains for our understanding of the processes occurring as a background to disorder, most certainly as aids to diagnosis and ultimately no doubt for treatment. The psychiatrist of the future will increasingly need to be a neuroscientist, well versed in all that we learn about the brain. He will need to keep pace with all such advances if he is to give maximal benefit to patients. This stated, however. we must not in the midst of such wonders lose sight of the cardinal requirement to retain our basic psychiatric skills. The psychiatrist of the future will still need to relate to patients in such a manner that he can appraise their particular situations and difficulPSYCHOSOMATICS
Lishman
ties, assess their environments, and explore the network of relationships that influence their lives. Neglect of such matters will not only destroy the fascination of psychiatry, it will also imperil patients. It would curtail in drastic fashion our capacities in diagnosis and in the treatments we can offer. In seeking to unravel some of the most sensitive problems in psychiatry we must keep all options open. We need to be vigilant in our thinking about such matters, and vigilant particularly in our
trammg of new generations of psychiatrists. While welcoming each advance in the neurosciences we must retain awareness of the need for something more. Dr. Hackett, if he were here, would be among the first to remind us that we must not lose our skills, or our commitment, to interact with patients and to treat them with what will always remain basic to our craft-something that is perhaps best defined quite broadly as human understanding.
References I. Lishman WA: Neurologists and psychiatrists. In The BritlRe Between Neurology and Psychiatry. Edited by Reynolds EH. Trimble MR. London. Churchill Livingstone. 1989. pp 24-37 2. Critchley M: Gordon Holmes: the man and the neurologist. In The DiI'ine Banquet of the Brain. New York. Raven. 1979. pp 228-234 3. Lewis A: The twenty-fifth Maudsley lecture-Henry
VOLUME 33· NUMBER I • WINTER 1992
Maudsley: his work and influence. Journal of Menial Science 97:259-277.1951 4. Hill 0: The bridge between neurology and psychiatry. Laneet 1:509-514. 1964 5. Weinberger DR. Berman KF. Zec RF: Physiologic dysfunction of dorsolateral prefrontal conex in schizophrenia. I. Regional cerebral blood flow evidence. Arch Gen Psychiatry 43: 114-124. 1986
9
I
t is a privilege to contribute to essays in memory of Dr. Thomas Hackett. What follows is based on an address to the Academy of Psychosomatic Medicine in November 1990. On a previous occasion in 1982 when 1 addressed the Academy, I was introduced by Thomas Hackett himself. Already by this time we had become firm friends with a strong bond extending across the Atlantic, even though we met infrequently. And I have wondered what it was that created such a bond from our first making one another's acquaintance. I think it was a combination of something very generous in Dr. Hackett's approach to visiting colleagues such as myself, along with a deep curiosity in him that made him such stimulating and refreshing company. One heard little of his own affairs and preoccupations until he was pressed-he preferred instead to search gently but insistently for one's own opinions and to draw one out in the most rewarding fashion, so that one was soon deeply involved in exchanging new insights and points of view. Dr. Hackett was, of course, tremendously interested in people as well as in clinical science. It was this last thought that led me to the topic for the present address. I had considered Dr. Lishman is professor of neuropsychiatry. Institute of Psychiatry. De Crespigny Park, London. Copyright © 1992 The Academy of Psychosomatic Medicine. 4
various options in the scientific domain by way of reviews of research or developments in psychiatry. But I wanted people to be in the very forefront of our attention as we honor the memory of Dr. Hackett today-people in their infinite variety and with their astonishing range of problems, conflicts, and ways of coping with adversity. Because I am a neuropsychiatrist and tend to see patients with brain disease, I felt it would be interesting to talk about the decisions we must often try to make on whether the problems we see in the clinic are "organic" or "functional"-more precisely whether they derive from a primary brain malfunction or from difficulties the patients are encountering in their lives. This is one of the great fascinations of psychiatry-that its territory is so immense and the options open to us so astonishingly wide. We need to embrace both of these sets of possibilities in diagnosis and most certainly in treatment. To ignore one or the other could be seriously misleading. This, then, is the "delicate balance" in the title: between our knowledge and understanding of the brain and our knowledge and understanding of people. In a sense. of course, we can view it as the balance between neurology and psychiatry-the two major clinical disciplines that deal with brain and mind. And we can perhaps pause for a moment to reflect on the differences between them. We can draw up a series of contrasts in their PSYCHOSOMATICS
Lishman
methods of approach to problems. I The neurologist starts out with physical disorders of the brain and nervous system. The psychiatrist takes as his point of departure affections of the mind. The neurologist must be expert at examining the nervous system-it was said of Gordon Holmes that he "could coax physical signs out of a patient like a Paganini on the violin."2 He explores the clinical history with scrupulous attention to any hint of physical symptoms. The psychiatrist's expertise generally lies in assessing a different range of phenomena. He deals with abnormalities of mood, qualities of thought disorder, false beliefs, and abnormal subjective experiences. Human behavior and experiencing are his primary concerns. This leads him into complex territories-minds can interact with other minds and be profoundly influenced by circumstance and social processes. In taking a history. the psychiatrist explores biographical data and processes of personal development. He must consider the patient's setting and the nature of his interactions with those around. Henry Maudsley wrote at the age of 25 that we must always take two elements into consideration: "the subject and the environment, the man and his circumstances, subjective force and objective forces, both passive and active.......1 What I hope to show in a moment is that we as psychiatrists must often combine the dual approach-neurological and psychiatric-in the evaluation of patients. Disease and disorder do not recognize the boundaries that have arisen between professional disciplines. Furthermore, we can look at the processes set in motion when these two sets of clinicians deal with the information they have gathered. The neurologist relates his data to a knowledge of certain well-defined disease entities. He must also rely on familiarity with the anatomy and physiology of the nervous system. He has to know how this complex machinery works in order to decide what may be adrift. He has nowadays, of course, a range of impressive technological developments to help him by way of investigation. The psychiatrist does something very different. He tries to relate his clinical information to a VOLUME 33· NUMBER I • WINTER 1992
knowledge of "mental diseases," but these are far from clearly defined. The range and variety of mental disorders and personal distress lead to difficulties with any classificatory system. He must be ready, furthermore, to think in terms of a range of variation that has nothing to do with disease; peculiarities of personality; abnormalities of mood; or modes of response to conflict, threat, or disaster. The psychiatrist must often rely on an appreciation of human situations and crises and the way predispositions can shape human behavior. Very briefly, as stressed by Sir Denis Hill. the neurologist's decisions and inferences hinge on matters common to all-their neural physiology and anatomy-whereas the psychiatrist's conclusions hinge very often on matters peculiar to individuals-the characters that make them unique.~ In our clinical psychiatric practice we will sometimes, indeed quite often, find ourselves tom between these two forms of approach. And as the neurobiological basis of behavior becomes increasingly understood, we will need to be vigilant in exploring possibilities on both sides of the fence. Let me now give some examples from clinical practice to illustrate what I mean. Case l. My first patient was a man of 38, referred with puzzling appearances of dementia. He had spent some months in hospital in East Anglia with serious memory problems, but careful investigations of his brain had shown no abnormality. Even recent CT scans and EEGs had proved to be negative. His behavior, moreover, was very variable from day to day. On some occasions he was oriented and lucid, on others hopelessly adrift. Sometimes, when questioned, he knew nothing of his family, not even, surprisingly, of the existence of his children. He was emotionally labile and prone to give approximate answers to questions. This had led to a diagnosis of hysterical pseudodementia or Ganser's syndrome. The quasi-organic features in his mental state were viewed with a certain reserve. This man had run into tremendous problems in his life. His business affairs were chaotic, and for the preceding year there had been mounting tensions in his second marriage. His first wife, in Spain, was threatening to send the two children of that marriage to live with him in England. He had begun drinking very heavily. 5
Festschrift for Thomas P. Hackett
Family discussions and attempts to explore his problems with him met with no response. He continued to deteriorate and at the point of referral for a second opinion had begun to show occasional myoclonic jerks of the limbs. Examination now revealed gross apraxia and muscle rigidity, and there was no doubt he had organic disease. Repetition of the scan, just 3 months after the last, showed commencing brain atrophy. The EEG now showed a markedly abnormal picture. Within a further few months he had died of Creutzfeldt-lakob disease. Comment The lesson we learn from this sad story is that we can remain perplexed for some time when an insidious brain disorder presents in a patient whose life is riddled with conflict. With neurological examination and help from the scans, an abrupt change took place from thinking in terms of his life situation to formulating the problem in terms of a brain disease. We note. moreover, that brain disease does not preclude the operation of psychodynamic factors-for example his forgetting of his children-indeed it may reveal their operation in an unusually striking fashion. Case 2, The next patient yielded similarly to a neurological approach. this time with a happier outcome. He was referred from the North of England. again with perplexing memory problems. These had set in after a severe pyrexial illness 10 months earlier. The referring psychiatrist was of the opinion that the amnesia was organic in origin. but his colleagues had raised the question of hysteria. Over many months he had shown marked variability with his memory and increasingly childish behavior. On home visits he was profoundly unable to cope. All investigations had drawn a blank. When we saw him he was something of a chameleon. On some occasions he was hopelessly disoriented and seemingly very vague. He would be unable to concentrate on a question or give a coherent account of himself. At other times he was oriented and reasonably able to converse and deal with his affairs. At the first interview with him he stated that his father was alive and well and described a good relationship between them. At the next he said that his father had died some twenty years ago. which proved to be correct. One could see why hysterical mechanisms had been considered. 6
The clue came when he had a grand mal fit on the ward and the EEG showed pronounced dysrhythmia. A peculiar intermittent jerking of the limbs had also been seen. He had had some sort of seizure earlier in his course, but the EEG evidence had then been equivocal. We decided therefore to begin anticonvulsant therapy while monitoring his memory function with simple tests from day to day. The result was gratifying. On anticonvulsants, the limb jerks ceased and his day-to-day memory showed detectable gains. This was monitored on a daily basis by simple tests administered by the ward staff-measures of orientation in time. ability to leam and remember itemized information. and ability to remember to carry out a task after 2 hours had gone by. Altogether he made substantial improvement on all memory tests. and his observed partial seizures fell in parallel. Though remaining somewhat impaired on full memory testing he regained independence and was able finally to return home. Comment Here a presumed encephalitic process had set in train a subtle form of epilepsy. It seemed reasonable to conclude that subclinical discharges had been leading to his variable confusion and problems with learning and recall. Only by postulating brain disease was it possible to find a simple treatment that benefited him very greatly. These two patients. then, illustrate one facet of the delicate balance. They both, admittedly, had rare conditions and ancillary aids to diagnosis had in the early stages failed to show what was afoot. The clinical pictures produced had within them elements that led one to think in terms of functional, hysterical disorder for considerable periods of time. Changes also occur in the opposite direction. for example each time we alter a diagnosis from neurological disease to hysteria. But the next patient represents a remarkable example when the change from organic to functional occurred abruptly and through fortuitous circumstances. This clinical problem presented in a particularly vivid and urgent fashion. Case 3. The patient was a recently retired lady whom I knew from various contacts over the years. PSYCHOSOMATICS
Lishman
She was seen as an emergency, just 3 weeks before leaving for a holiday in a distant part of the world. I knew that she had been in the habit of visiting there. Some months earlier she had had a subarachnoid hemorrhage, had been seriously ill for several weeks. but had made a full recovery after clipping of an anterior communicating aneurysm. Virtually no residual impairment had resulted. During recent weeks, however. while preparing for the trip, she had become tremendously worried about herself. She seemed to have deteriorated abruptly. She could not think or plan properly, was sleeping badly, and seemed unable to concentrate or organize herself. Her affairs at home had become chaotic. She was very anxious and considerably depressed. This posed a serious problem. Could she be developing some late complication of the subarachnoid hemorrhage by way of hydrocephalus? Was it safe to let her travel? No definite signs could be found on neurological or cognitive examination. A conference was arranged next day with her neurosurgeon. We were wondering how to arrange a CT scan without upsetting her unduly when her son phoned with surprising information. In the holiday location she had a substantial problem. Over several years she had befriended a resident there whom she had tried to rescue from alcoholism. He was now an increasing burden. had got into debt, and had recently been plaguing her with phone calls in a disturbed state of mind. What had started as a diverting friendship some years before was becoming a nightmare. She was dreading the confrontation and felt unable to deal with it. Seen in this context, her symptoms acquired a new perspective. Once the ice was broken, it was possible to discuss this problem in some detail and decide on strategies and lines of action. She went on the holiday without any ill effect. All of this was 2 years ago. Since then, and with much discussion, she has managed gradually to withdraw from a complex emotional relationship. Her brain is working perfectly and we have still not done a scan.
Comment Here we see the need, in unusually acute form, for differentiation between cerebral disorder, namely hydrocephalus, and emotional turmoil occasioned by a crisis in a personal relationship. To clarify the former we would have needed to invoke the help of a piece of expensive modern technology. To clarify the latter we VOLUME 33· NUMBER I· WtNTER 1992
needed no more than information about the details of her trip. To help resolve the problem it was necessary to get to understand a situation replete with special meaning for the individual concerned. The upset had no doubt disturbed her cerebral physiology in a multitude of ways. But this disturbance could not be dissected by neurologicalor physiological means. In this sense it was a functional disturbance. This patient shows, among other things, the hazard of treating patients we know socially and who may therefore be unwilling to divulge full details of their lives. More importantly she shows the great significance that many attach to such details in reaching a COrrect appraisal of a crisis. When dealing with higher level human functioning-with emotions and behaviors of a complex kind-we can find ourselves with the need to ask the question, Is this determined by a pathological process within the brain, or has it been engendered by emotional turmoil and conflict? The answer is not always as quickly forthcoming as in the foregoing example. We must sometimes keep our suspicions and sensitivities alive for some considerable time. My final example is more complex in this respect, also in showing what in fact is very common-the interaction of both cerebral and personal factors. It concerns a well-known academic, who was prematurely retired from his university chair on account of suspicion of Alzheimer's disease. A long story must be briefly condensed. Case 4. This man had had a manic-depressive disorder, requiring treatment with lithium. During a hypomanic episode, haloperidol was given in addition. As the episode resolved he proved to be very considerably changed-dulled in personality, forgetful, and incompetent in his writing and teaching. Psychological testing ultimately showed a profound diminution of intellect, with a verballQ of 104 and a performance IQ of 62. His memory was faulty, he muddled left and right, and had clear visuospatial impairments. A decision was taken at another hospital to impose premature retirement. and an annual lecture was endowed in his honor. Some 18 months later his wife brought him for 7
Festschrift for Thomas P. Hackett
a second opinion because the diagnosis was being questioned. Though still dulled and generally incompetent. repeated scans had shown no atrophy. He had. moreover. shown occasional glimpses of the former man. Since retirement his life had changed dramatically. His wife structured each moment for him. with simple tasks to keep him busy. Helpers were employed to take him here and there. and he had no access to his finances. She dominated him entirely. and she had a forceful personality. She was herself extremely bitter that she was now the guardian of the man she had so much admired. An element of depression was suspected in the picture he presented. and antidepressants were eventually prescribed. This led to some improvement. with an increase in asseniveness and times when he seemed less adrift. Very gradually his wife was persuaded to lessen her over-protective attitude. to allow a measure of independence. and to encourage him with simple academic endeavors. He showed preserved abilities to translate from Latin and Greek and made an attempt at an essay on "Philosophers I Have Known." Her own demeanor changed over the next few years to a more relaxed and less critical approach. The patient continued to make slow but definite gains. though with persisting. clear cognitive impairments. Now. some 5 years after retirement. he attends the yearly lecture in his honor and has been known to take issue with the speakers.
Comment Here we suspect that the patient sustained some definite brain damage of a nonprogressive sort, possibly as a result of the combined pharmacotherapy with lithium and haloperidol. But this was then greatly compounded by the changed relationship with his wife that had resulted from the disaster and by a treatable element of depression that lay hidden in his dullness and apathy. By gentle and persistent attention to his wife's own reaction these secondary developments have come under a degree of control, enabling him to function much better in spite of a damaged brain. A balance has again been required between appraisal of the organic component in the disorder and a component which is essentially interpersonal. This balance creates a tension within psychiatry that gives it much of its richness as a clinical 8
discipline. We must seek to refine our knowledge of brain physiology and pathophysiology. yet at the same time retain our curiosity about the human condition. Furthermore, we must sidestep the risk of becoming too far seduced by one or other pole of this dual requirement. The complexity and the delicacy of the balance is such that it has been necessary to give detailed examples from clinical practice in order to show its essence. And perhaps the most important point to stress in closing is that the problem will always be with us. Knowledge of brain functioning is destined to continue to increase remarkably as the next decades unfold. Brain biochemistry becomes daily more complex and with increasing relevance to emotional and behavioral disorder. Pharmacotherapy is one of the resounding achievements of mid-twentieth century psychiatry. and psychopharmacology slowly extends its territories. We are now in the era of increasingly sophisticated brain imaging techniques that can monitor brain structure and function to a quite astonishing extent. We can visualize the brain minutely with magnetic resonance imaging, including the limbic system; with positron emission tomography we can monitor brain metabolism and investigate neurotransmitter processes. We can visualize the increased blood flow to frontal regions when a normal subject engages in a category sorting task and show that equivalent dynamic shifts are defective in the schizophrenic brain. 5 All of these are wonderful gains for our understanding of the processes occurring as a background to disorder, most certainly as aids to diagnosis and ultimately no doubt for treatment. The psychiatrist of the future will increasingly need to be a neuroscientist, well versed in all that we learn about the brain. He will need to keep pace with all such advances if he is to give maximal benefit to patients. This stated, however. we must not in the midst of such wonders lose sight of the cardinal requirement to retain our basic psychiatric skills. The psychiatrist of the future will still need to relate to patients in such a manner that he can appraise their particular situations and difficulPSYCHOSOMATICS
Lishman
ties, assess their environments, and explore the network of relationships that influence their lives. Neglect of such matters will not only destroy the fascination of psychiatry, it will also imperil patients. It would curtail in drastic fashion our capacities in diagnosis and in the treatments we can offer. In seeking to unravel some of the most sensitive problems in psychiatry we must keep all options open. We need to be vigilant in our thinking about such matters, and vigilant particularly in our
trammg of new generations of psychiatrists. While welcoming each advance in the neurosciences we must retain awareness of the need for something more. Dr. Hackett, if he were here, would be among the first to remind us that we must not lose our skills, or our commitment, to interact with patients and to treat them with what will always remain basic to our craft-something that is perhaps best defined quite broadly as human understanding.
References I. Lishman WA: Neurologists and psychiatrists. In The BritlRe Between Neurology and Psychiatry. Edited by Reynolds EH. Trimble MR. London. Churchill Livingstone. 1989. pp 24-37 2. Critchley M: Gordon Holmes: the man and the neurologist. In The DiI'ine Banquet of the Brain. New York. Raven. 1979. pp 228-234 3. Lewis A: The twenty-fifth Maudsley lecture-Henry
VOLUME 33· NUMBER I • WINTER 1992
Maudsley: his work and influence. Journal of Menial Science 97:259-277.1951 4. Hill 0: The bridge between neurology and psychiatry. Laneet 1:509-514. 1964 5. Weinberger DR. Berman KF. Zec RF: Physiologic dysfunction of dorsolateral prefrontal conex in schizophrenia. I. Regional cerebral blood flow evidence. Arch Gen Psychiatry 43: 114-124. 1986
9
