Authors: Jeffrey A. Lieberman
Tags: #Psychology / Mental Health, #Psychology / History, #Medical / Neuroscience
One example of such synergistic effects is combining cognitive-behavioral therapy with D-cycloserine, a drug initially approved for the treatment of tuberculosis. Scientists have learned that D-cycloserine enhanced learning by acting on glutamate receptors in the brain. When D-cycloserine is used with cognitive-behavioral therapy, it appears to enhance its effects. Similar joint drug-psychotherapy treatments have also been successfully applied to patients with obsessive-compulsive disorder, anxiety disorders, and PTSD.
Another recent example came from the lab of my colleague Scott Small, a neurologist at Columbia University. Small found that a concentrated extract of flavanols from cocoa beans dramatically enhanced the memory of people with age-associated memory impairment by stimulating neural activity in the hippocampus. Such neutraceutical compounds may provide a new approach to cognitive rehabilitation.
We are also seeing the start of a flood of Internet-based applications for mobile devices that assist patients with treatment adherence, provide auxiliary therapeutic support, and enable patients to remain in virtual contact with their mental health providers. David Kimhy, the director of the Experimental Psychopathology Laboratory at Columbia University, developed a mobile app that schizophrenic patients can use when they are in distress. If their auditory hallucinations intensify, they can launch a cognitive-behavioral script on their smart phone that instructs them how to cope with their symptoms:
Screen 1: Do you hear voices right now? [Yes / No]
Screen 2: How strong is the voice? [1–100 scale]
Screen 3: What would you like to do?
Screen 4.1:
Relaxation Exercise
:
[Run on-screen guided breathing exercise for 45 seconds]
Richard Sloan, director of Behavioral Medicine of Columbia Psychiatry, monitors bio-signals (including heart rate, blood pressure, respiration, temperature, muscle tension) of patients by having them wear accouterments ranging from wrist bands to vests tricked out with sensors that transmit data in real time, thereby providing a virtual display of a person’s emotional state.
Psychiatry has come a long way since the days of chaining lunatics in cold stone cells and parading them as freakish marvels in front of a gaping public. After a difficult and often disreputable journey, my profession now practices an enlightened and effective medicine of mental health, giving rise to the most gratifying moments in a psychiatrist’s career: bearing witness to clinical triumphs. Often, these are not merely the relief of a patient’s symptoms but the utter transformation of a person’s life.
A few years back I had a patient like Abigail Abercrombie who suffered from panic attacks and had been homebound for two decades. At first, I had to make house calls just to see her, since she refused to leave the dismal safety of her cramped Manhattan apartment. When she was finally able to visit me at my office, she sat near the open door with her bicycle perched just outside so she could flee at any moment. Today, she goes hiking with her husband, socializes with friends, and takes her children to school, telling me, “I feel like my world has become a hundred times larger.”
I treated a fifty-year-old man who suffered from a nearly lifelong depression and twice tried to kill himself. He quit several jobs and was unable to maintain a romantic relationship. After two months of treatment with antidepressant medication and psychotherapy, he felt that a veil of gloom had been lifted and asked, “Is this how most people feel? Is this how most people
live?
”
My friend Andrew Solomon also suffered from suicidal depression for years before receiving effective treatment. He wrote eloquently about his illness in
The Noonday Demon: An Atlas of Depression
, a Pulitzer Prize finalist and winner of the National Book Award. Today, he is happily married and enjoys a very successful career as a writer, activist, and highly prized speaker. “Without modern psychiatry,” Solomon assures me, “I truly believe I might have been dead by now.”
Not so very long ago, those suffering from bipolar disorder, such as Patrick Kennedy, had every reason to believe that their lives would inexorably lead to financial ruin, public humiliation, and wrecked relationships. Kay Jamison, another dear friend, was whipsawed between careening flights of mania and crushing bouts of depression when she was a graduate student and junior faculty member in psychology at UCLA. Her prospects looked bleak. Today she is a tenured professor of psychiatry at Johns Hopkins and was named a “Hero of Medicine” and one of the “Best Doctors in the United States” by
Time
magazine. Her writing, including five books, is highly acclaimed and earned her an honorary doctor of letters from the University of St. Andrews. She says psychiatry “restored her life.”
What about the most severe and frightening of psychiatry’s flagship illnesses, the supreme scourge of the mind: schizophrenia? Today, if a person with schizophrenia, the most virulent form of psychosis, comes to the psychiatry department of a major medical center and fully avails herself of quality treatment—and sticks with it after she is discharged—the most likely outcome is recovery and the ability to have an independent life and continue her education or career. Consider my friend Elyn Saks.
She grew up in an upper-middle-class family in Miami, where she enjoyed the love of her parents and the sunny comforts of a Norman Rockwell–like childhood. Though in retrospect there may have been a few clues about her mental illness to come—when Elyn was eight, she would not go to bed until all her shoes and books had been carefully arranged in unvarying and precise order, and she often hauled the covers over her head because some menacing figure was lurking outside her bedroom window—any casual visitor to the Saks home would have found a happy, intelligent, and perfectly normal little girl. It was not till she went to college, at Vanderbilt University in Nashville, that her behavior began to change.
At first, Elyn’s hygiene deteriorated. She stopped showering regularly and often wore the same clothes day after day till her friends told her to change them. After that, her activities grew downright disturbing. On one occasion she bolted from her dorm room for no discernible reason, abandoning a friend who was visiting her from Miami, and dashed around the quad in the freezing cold waving a blanket over her head and declaring for all to hear that she could fly. However, these foreboding signs failed to elicit treatment for her, nor did they prevent her from graduating as class valedictorian and winning a Marshall scholarship to study in England at Oxford University.
In England she experienced her first psychotic breakdown. She describes this episode in her award-winning book
The Center Cannot Hold: My Journey Through Madness:
“I was unable to sleep, a mantra running through my head: I am a piece of shit and I deserve to die. I am a piece of shit and I deserve to die. I am a piece of shit and I deserve to die. Time stopped. By the middle of the night, I was convinced day would never come again. The thoughts of death were all around me.”
She was hospitalized with the diagnosis of schizophrenia, yet—this being 1983—she was treated mainly with talk therapy. No medication was prescribed for her.
After she was released, she somehow completed her studies at Oxford and was even admitted to Yale Law School, but her illness worsened. In New Haven, Elyn started to believe that people were reading her mind and attempting to control her movements and behavior. Moreover, her thoughts were disjointed and bizarre, and when she spoke she was barely coherent. One afternoon she visited the office of her contracts professor, a smart, funny woman whom Elyn liked and idealized because “she’s God and I will bask in her God-like glow.” When Elyn arrived, looking and acting strange, the professor informed her that she was concerned about her and suggested that Elyn come home with her as soon as she finished up some work in her office. Delighted, Elyn promptly jumped to her feet and climbed out the window onto the ledge. Rocking and kicking her feet, she began belting out Beethoven’s “Ode to Joy.” Elyn was hospitalized again, this time against her will, and was placed in physical restraints and forcibly medicated.
Elyn told me that this was the worst experience of her life, the moment when it really sank in that she was mentally ill—suffering from incurable, perpetual, mind-warping schizophrenia. She felt sure she would never have a normal life. “I thought I would need to reduce the scope of my dreams,” she said. “Sometimes I just wanted to be dead.” But in New Haven, she encountered a pluralistic psychiatrist (“Dr. White,” in her memoirs)—a Freudian psychoanalyst who embraced the therapeutic power of psychopharmaceuticals—who provided her with both structure and hope by talking with her each and every day while waiting for her medication to take hold and continuing thereafter. She eventually was placed on clozapine, a new antipsychotic drug with superior therapeutic powers, approved for use in the U.S. in 1989.
Encouraged by Dr. White, Elyn decided that she would not let her illness dictate her fate. She began learning everything she could about schizophrenia and diligently participated in all of her treatments. Before long, she was functioning well and living a clear-headed life once again. She believes her family’s, and subsequently her husband’s, unwavering love and support were essential to her success, and having met them, I wholeheartedly concur.
Supported by her loved ones and by a pluralistic psychiatry, Elyn has gone on to enjoy an extraordinary career as a legal scholar, mental health advocate, and author. Today she is an associate dean and professor of law, psychology, psychiatry, and the behavioral sciences at the University of Southern California. She won a MacArthur “Genius” award and recently gave a TED talk urging compassion for those with mental illness, recognizing the importance of human empathy in her own recovery, and wrote her bestselling book.
Elyn Saks, Kay Jamison, and Andrew Solomon didn’t just have their symptoms alleviated. With the aid of effective, scientifically based, compassionate, and caring treatment, they were able to discover entirely new identities within themselves. This was an impossible dream a century ago and was not the norm even thirty years ago, at the start of my medical career. Today, recovery is not just possible, but expected. A self-determined, fulfilling life is the goal for all people with mental illness.
However, despite this progress and the proliferation of auspicious developments in our society’s understanding of mental illness and psychiatry, I am under no illusion that the specters of psychiatry’s past have vanished, or that my profession has freed itself from suspicion and scorn. Rather, I believe that after a long and tumultuous journey, psychiatry has arrived at a pivotal and propitious moment in its evolution—a moment well worth celebrating, but also an opportunity to reflect on the work that still lies ahead. In doing so I am reminded of Winston Churchill’s famous declaration after Britain’s long-awaited triumph at the 1942 Battle of El Alamein. It was the Allies’ very first victory in World War II after an extended series of demoralizing defeats. Seizing the moment, Churchill announced to the world, “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”
I am fortunate to have received much guidance and support in the course of my life and career. Writing this book was no exception. My greatest debt is to my parents, Howard and Ruth, whose love and influence formed my values, moral posture, and view of the world, and to my wife, Rosemarie, and sons, Jonathan and Jeremy, who have enriched my life immeasurably, supported my efforts, and graciously tolerated my many absences from them and family life as a result of my chronic overinvolvement with my professional activities (otherwise known as “workaholism”).
When I first thought seriously about writing this book, Jim Shinn, a dear friend and professor of political economy and international relations at Princeton, helped me to crystallize the nub of the story from an inchoate conglomeration of ideas. He also pointed me in the direction of oncologist and fellow Columbia faculty member Siddhartha Mukherjee, who was kind enough to spend an illuminating hour with me. I have looked to Sid’s Pulitzer Prize–winning book,
The Emperor of All Maladies
, as a model and a source of inspiration.
With a plan in mind, I sought advice from friends who also happen to be brilliant writers. Kay Jamison, Oliver Sacks, and Andrew Solomon offered encouragement, guided my formative thinking about the content, and helped me to navigate the publishing landscape and process. Peter Kramer gave helpful advice as a psychiatrist writing for the general public.
I owe thanks to my friend and neighbor Jennifer Weis, an editor at St. Martin’s Press, who introduced me to my agent, Gail Ross of the Ross-Yoon Agency. Gail took the idea I pitched to her, expertly fashioned it into something more accessible, and connected me to Ogi Ogas, a skilled writer and neuroscientist. Ogi and I bonded and became virtual Siamese twins for the next eighteen months while developing the story and creating the manuscript. His invaluable contributions and unwavering dedication to the project were apparent throughout, but never more dramatically than when he convinced his fiancée to postpone their honeymoon so that he could finish the book with me on time.