Review Of_Schizophrenia, Madness and Modernism_Insanity in the Light of Modern Art, Literature, And Thought by Louis A. Sass

Schizophrenia -- Madness and Modernism: Insanity in the Light of ... Barglow, Peter The American Journal of Psychiatry; Jun 1995; 152, 6; ProQuest pg. 943

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monograph brings together an excellent collection of papers relevant to the possible neurodevelopmental origins of schizophrenia. Neither genetic nor environmental factors are likely to be the sole cause of schizophrenia in all cases. Genetic and perinatal factors interact in the prediction of developmental brain changes and later schizophrenia. The authors in this book hypothesize that disruptions in fetal neural development, especially in the migration, positioning, and connecting of young neurons, are an important part of the phenotypic expression of the genetic predisposition to schizophrenia. Fetal neural disruption may also be induced by teratogenic events (e.g., a viral infection) occurring during "critical" periods of gestation. For schizophrenia, the critical period may be during the second trimester, when brain growth exhibits maximal acceleration. Disorderly brain development during gestation may be responsible for some fundamental aspects of the symptoms of the schizophrenia spectrum, such as disorderly thought processes, sensory-motor coordination difficulty, and poor autonomic nervous system regulation. The authors propose a "two-hit" hypothesis of the pathogenesis of schizophrenia. The "first hit" consists of the failure of normal brain development during the second trimester. The "second hit" refers to a difficult delivery. According to Mednick and colleagues, genetically based neural structure and vascular anomalies during gestation give rise to the special vulnerability of these high-risk fetuses to delivery difficulties. The latency between the hypothesized prenatal and perinatal disturbances affecting brain development and the onset of schizophrenia in early adult life poses perhaps the most difficult issue for neurodevelopmental models of schizophrenia to explain. Several (not mutually exclusive) explanations have been described. These include brain maturational factors occurring during late adolescence and early adulthood, hormonal changes, and stress and other factors arising during postnatal social development. The book is divided into six parts. Part 1 is an introduction to the overall hypotheses proposed. Part 2 describes the development of the human and primate fetal brain. Part 3 discusses examples of genetic disturbances in brain development and possible genetic origins of a vulnerability to teratogenic agents. Part 4 provides a review of the literature on prenatal and perinatal complications that are reportedly common in patients with schizophrenia. Part 5 reviews studies of neuropathology and structural brain imaging in schizophrenia. Part 6 is a concluding section that attempts to integrate the basic fetal developmental research with the clinical, structural imaging, and neuropathological research in schizophrenia. With refreshing candor, Mednick et al. state, "This attempt to explain the complex syndromes of adult schizophrenia in terms of fetal developmental anomalies ... may go the way ()f earlier fads in psychiatric research. If that proves to be the case, we will contribute to fostering basic knowledge on how the human brain grows and how that growth can be best protected. At the moment, however, we judge that this enterprise merits intensified investigation in relation to schizophrenia." The editors are aware of at least one limitation. This volume does not address much of the work regarding the role of neurotransmitters in schizophrenia. The stated reason for this omission is that not much is known about developmental changes related to neurotransmitter expression. Another limitation is that no reference is made to schizophrenia that develops late in life-late-onset schizophrenia. Several recent studies suggest that late-onset schizophrenia is also likely to be neurodevelopmental in origin, although it is not yet clear what protects these patients from manifesting even prodromal

symptoms earlier in life and what factors precipitate the eventual breakdown. Overall, this is a very well-written, well-edited, and surprisingly readable book on an important topic. I strongly recommend it to all serious researchers and students of the biology of schizophrenia. DILIP V. JESTE, M.D. La Jolla, Calif.

Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought, by Louis A. Sass. New York, Basic Books, 1992,562 pp., $30.00. What relevance does Foucault's view of consciousness as "a strange empirico-transcendental doublet" have for psychosis? What is it really truly like-i.e., feel like, taste like, sound and smell like-to be typically schizophrenic? To gain access to the world of madness through the tools of the arts and humanities was once a potent incentive for medical students to become psychiatrists. This contemporary book reminds me so forcefully of this ancient perspective that now after seeing a patient I must linger to contemplate the realm of the patient's subjectivity for additional seconds before I write the mandatory neuroleptic prescription. Louis Sass, a psychologist, begins to cross his narrative bridge, which spans the uncanny ocean between psychiatrists and our sickest, strangest schizophrenic patients, by citing Borges' quoting an imaginary Chinese encyclopedia's categorization of animals: "(a) belonging to the Emperor, (b) embalmed, (c) tame, (d) sucking Pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i) frenzied, (j) innumerable, (k) drawn with a very fine camelhair brush, (I) et cetera, (m) having just broken the water pitcher, (n) that from a long way off look like flies" (p. 120). Sass notes that this passage captures some of the exaggerated "hyper-reflective ... pouring of scornful laughter on the whole of existence" associated with Modernism and suggests the flavor of its "tendency to order the world in accordance with highly idiosyncratic and impractical perspectives." The citation also hints of Modernism's negativity, heterogeneity, escape from the Parole (Saussure) of ordinary linguistic communication; its "rage for chaos and the new"; and its alienation from the bodily, the instinctive, and the emotional. Sass exploits Modernism's perspective to illuminate rather than explain the structure of schizophrenia. He succeeds beyond my wildest expectations with his beautiful demonstrations from philosophy, poetry, and literature as well as a stellar supporting cast from the visual arts. Yes, positive symptoms of thought disorder can surprisingly and fruitfully be regarded as self-conscious failures or refusals to inhabit the universe of common sense. Furthermore, the writer persuades me that the schizophrenic obsession that somebody who is still alive has been killed is conceptually related to Waiting for Godot, as in Lucky's monologue: "Given the existence as uttered forth in the public works of Puncher and Wattmann of a personal God quaquaquaqua with white beard quaquaquaqua outside time without extension who from the heights of divineapathia divine athambia divine aphasia loves us dearly." Madness and Modernism actually convinced me to jettison my lifelong belief in the psychic model of major mental illness characterized by the terms "primary process," "primitivity," "regression," and the familiar D words-"deficit," "dysfunction," "deterioration," and "disorder." On the other hand, Sass does not object to neurobiological bases of

Am J Psychiatry 152:6, June 1995

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schizophrenia, showcased in an epilogue chapter sandwiched between the body of the text and 163 pages of fascinating notes (the latter alone justify the book's purchase price). I was so excited, stimulated, and overwhelmed by this volume that I had great difficulty completing this review, wanting unwittingly to hide it until the arrival of the twenty-first century so that insights into schizophrenia that can compete with those of its author could be generated. To end with a return to my opening question about the "empirico-transcendental doublet"-the answer will be all too obvious when you finish this mind-blowing book. PETER BAR GLOW, M.D.

Berkeley, Calif.

SUBSTANCE ABUSE The American Psychiatric Press Textbook of Substance Abuse Treatment, edited by Marc Galanter, M.D., and Herbert D. Kleber, M.D. Washington, D.C., American Psychiatric Press, 1994,451 pp., $71.55. When one considers the broad and enduring nature of the problem of substance abuse and the fact that abuse of psychoactive substances has persisted in virtually all cultures since antiquity, the initial reaction to such a text as this, with its implicit offer of solution, is inevitably skepticism. How could anyone hope to reverse a practice that is at once so enticing to the participant, so easy to engage, and pharmacologically, interpersonally, and socially reinforced? These problems notwithstanding, the editors, both of whom are preeminent clinical scientists, leaders in research and public policy advocacy, directors of their own programs, and chairmen of panels on substance abuse for the APA Task Force on Treatment of Psychiatric Disorders, convey a decided optimism. Their preface cites substantial progress in research, increasing public awareness, changing attitudes of academic psychiatry, and treatment programs that are both increasingly refined and more accessible. Although the government's rhetorical "war on drugs" is acknowledged, the bias of the text is treatment and healing, not truculence. The volume is intended to update and expand the editors' contributions to their panels' reports in Treatments of Psychiatric Disorders (1). The editors' first task was to assemble competent contributors, and this has been particularly well done; the 45 highly qualified contributing authors have all built eminent careers as published clinicians, scientists, and academicians in their own right. All substantiate their authority by ample bibliographic citations from their own work. Their ideas and methods are presented in 29 chapters divided into three consecutive sections of five, 10, and 14 chapters. I found the arrangement of sections, titled Overview of Treatment, Treatment of Patients for Specific Drugs of Abuse, and Treatment Modalities, logical, useful, and consistent with the goals of a reference text. In chapter 1, "Goals of Treatment," Marc Schuckit admits that the ideal goals of therapy are obvious (and implicitly easy), but, because reality has us "reaching out to a pool of impaired individuals" who "have many more needs than we can possibly meet," the burden of decision-making placed on therapists and administrators can try the most experienced psychiatrists. This veteran administrator-clinician-researcher's consideration of the art-of-the-possible in clinical arenas (including dismissal of potentially inappropriate and

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resource-wasting goals) is direct, clears out the rubbish that has accumulated around drug abuse and its treatment, and gives the front-to-back reader a sense of the book's posture. Those who use the book as a reference will find Dr. Schuckit's chapter a useful and stimulating guide to thinking and planning for specific problems. Chapter 2, "Typologies of Addiction" by Michael Bohn and Roger Meyer, is an erudite attempt to enumerate the many different types of alcoholism or drug abuse with which we may be faced as clinicians and program planners. Using Robert Koch's pioneering advances in classification of infectious diseases as a model, the authors attempt a pure typology of addiction disorders (not yet achieved) to assist in planning treatment and prevention of these conditions. Treatment of this topic, which properly requires book-length exploration, is abbreviated here, but the reader can plumb the almost four pages of bibliography for supplementary depth. A chapter on "Assessment of the Patient" by Richard Steven Schottenfeld and separate chapters on outcome research in alcohol (by Ried Hester) and drug abuse (by Dean Gerstein) complete the first section. The 10 chapters of section 2 cover virtually all of the substances known for abuse potential, except the volatile hydrocarbons (such as toluene). Substances are considered specifically (i.e., alcohol, cannabis, phencyclidine, tobacco) or in general categories (i.e., stimulants, hallucinogens, benzodiazepines and other sedative-hypnotics), plus three separate chapters on the opioids. Each gives a historical, precis, some of the pharmacology of the compounds, elements of psychopathology associated with them, and approaches to clinical management of patients involved with these agents. There are sufficient details in all of these aspects to recommend this section as a useful text for those in training as well as a ready reference for the more experienced practitioner. I believe it to be the main strength of the book. There are three subsections (on individual treatment, group and family therapy, and special programs) in the final group. In "Psychodynamics," the lead chapter of the first subsection, Richard Frances, John Franklin, and Lisa Borg advocate a sensible eclecticism, applying the contributions of psychoanalysis to broaden the therapist'S understanding of the substance-abusing patient and widen the variety of therapeutic options "in enriching and informing substance abuse treatment and improving the therapeutic relationship." They conclude with a list of "myths and pitfalls to avoid in psychodynamic therapy," which may be useful and instructive to a house officer but will probably strike seasoned practitioners as too basic to increase their fund of information substantially. Dr. Galanter's "Network Therapy for the Office Practitioner" quotes extensively from his previous publications on enlisting family and friends as part of a working team to assist the therapist in maintaining the patient's abstinence. It contains excellent practical advice and is supported by instructive case vignettes. "Individual Psychotherapy: Alcohol" by Sheldon Zimberg contains some inevitable redundancies and extensions of topics covered in earlier chapters on psychodynamics and network therapy but is adequately detailed and specific to the alcoholic patient. The title of chapter 19, "Individual Psychotherapy: Other Drugs," is somewhat misleading, suggesting that it will address drugs not heretofore discussed in the book. Instead, this chapter, by George Woody, Delinda Mercer, and Lester Luborsky, is a review of the rationale, research, and indications for psychotherapy and contains almost nothing about "other drugs." It would probably have been more appropriately included in section 1, under a more accurate title. In chapter 20, "Relapse Prevention," G. Alan Marlatt and Kimberly Barrett present their model for achiev-

Am J Psychiatry 152:6, June 1995

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.