Lishman's Organic Psychiatry: ‘no comparable book in the English-speaking world’

Summary

In 1978, William Alwyn Lishman's Organic Psychiatry: The Psychological Consequences of Cerebral Disorder was published, fostering the development of neuropsychiatry and leading to the recognition of Lishman as the father of neuropsychiatry. This article is a narrative account of his personal struggles, as well as conceptual dilemmas he dealt with while writing this book, and how through its four editions it has evolved to become an anchor for psychiatrists as they seek to develop understanding of the workings of the brain, and a beacon for them when they discuss clinical implications of diagnosis with patients and families.

The year was 1978 and Organic Psychiatry: The Psychological Consequences of Cerebral Disorder by William Alwyn Lishman (1931–2021) was published by Blackwell's. Before this time ‘many patients with complex and mysterious disorders of mind and body were denied expert psychiatric care’ (Illman 2021). Folstein in the preface to the fourth edition (David et al 2009) comments that with neurology and psychiatry becoming separate disciplines in the 20th century, ‘patients who had neurological disorders were often deprived of expert psychiatric care, and clinical research workers could not take advantage of [research] to aid their search for brain–mind connections’, and Lishman’s Organic Psychiatry, ‘reintroduced […] the psychiatric aspects of neurological disorders […] and fostered the development of the subspecialty of neuropsychiatry’. Incidentally, it would take another year for the Nobel Prize in Physiology or Medicine to be awarded to Cormack and Hounsfield, for the development of computer assisted tomography (CT), an innovation that would go a long way in understanding of the brain.

‘Putting the brain back into psychiatry’

Lishman, encouraged by Sir Denis Hill, began work on his classic book in 1970–1971. Hill, whom Lishman considered his ‘big hero’, had been Professor of Psychiatry at the Institute of Psychiatry from 1966 to 1979, setting up the electroencephalography laboratory, making fundamental contributions to our understanding of temporal lobe epilepsy and psychopathy in particular and, much against then prevailing winds, establishing psychotherapy as an academic and clinical discipline. On publication of Organic Psychiatry, Hill said that there was ‘no comparable book in the English-speaking world’ (Trimble 1999). Lishman had for 3 years resisted approaches from Blackwell's, who had been told (by either Sir Charles Simons or Norman Geschwind) that he was the person to write a book ‘putting the brain back into psychiatry’. Lishman would jocularly confess that ‘The reason why I finally did it was quite ridiculous. I'm slightly ashamed of this, but I wanted a Bechstein grand piano, and I saw one [ … ] I got the offer of a substantial advance for the book, so I thought I'd go for it’ (Poole 2013).

The following 7 years would be challenging. He was a full-time psychiatrist; he and his wife Marjorie adopted the first of their two children:

‘The month that I began we adopted a baby, so I'd get ready, with my desk and papers and all my books around me. And lo and behold the phone rang and this child arrived within 3 weeks. And so suddenly I was plunged into fatherhood. I still got on with it, with her in the highchair beside while I was writing for hours on end.’

He put the book aside for a year when his mother-in-law developed a brain tumour and later, when his mother developed Alzheimer's disease (Poole 2013).

Ron (2021) commented that Lishman would have needed all his innate perseverance and attention to detail, perhaps enhanced by the strict upbringing by his mother (a teacher, who Lishman would describe as something of a dragon who would lock him up with his sister until they finished their homework without any mistakes). It was his wife Marjorie, a social worker by profession, whom Lishman credited as being an expert in grammar who read his works and helped perfect his writing style, who insisted that he return to completing this monumental work. Lishman would retire in 1993 to look after Marjorie, who had developed a brain tumour and died in 2000.

‘Organic psychiatry’

Lishman, taken to task for using the term ‘organic psychiatry’ as a title for his book, shared his dilemma:

‘As I wrote the book I did the head injury, I did the epilepsy and I did the strokes, and then I decided I had to do the metabolic disorders and go into diabetes and all the parathyroid disorders and so on. And I realised that this would not be neuropsychiatry – it's general medicine in relation to psychiatry. So the book should have been called Neuropsychiatry/Organic Psychiatry/Liaison Psychiatry. I thought I'd found the best compromise with “organic”. But then people started talking about organic milk and organic meat and people made a lot of fun of it. I like the term less every time I go into a supermarket. It's been taken over, you see’ (Poole 2013).

Lishman began his preface to the first edition thus:

‘The impetus for writing a book on organic psychiatry has come largely from clinical practice and teaching. Both reveal the lack of focused knowledge concerning the overlapping territories between psychiatry and neurology – a gap manifested in the paucity of textbook literature on the subject [ … ] It has therefore seemed worthwhile to attempt a comprehensive review of the cognitive, behavioural and emotional consequences of cerebral disorder, and the problems in this area which are encountered in clinical practice’ (Lishman 1978: p. 12).

This tradition set by Lishman in nurturing clinicians with knowledge of psychiatric aspects of neurological disorders would remain manifest in the most recent fourth edition.

When the third edition was published in 1997 (Lishman 1997), the book had attained the prestigious status of the reference book for organic psychiatry across the world. Trimble, in his review of the volume, noted that the page count had reduced from 999 pages in the first edition to 952 (interestingly, the fourth edition has 952 pages). He writes ‘The pale green cover of the first edition, measuring some six by nine inches, has been transformed into the much more luscious blue and red front of the book, which now measures nine by eleven inches’, humorously remarking ‘One disadvantage of this transformation is the inability of the new edition to fit into any section of the bookcase, except the lower one usually retained for coffee-table size art books’ (Trimble 1999). By then, Lishman had arrived at a refined definition of organic disorders: ‘those in which there is a high probability that appropriate examination and investigation will uncover some cerebral or systemic pathology responsible for, or contributing significantly to, the mental condition’ (Trimble 1999).

The fourth edition, by David et al (2009), had a new title: Lishman's Organic Psychiatry: A Textbook of Neuropsychiatry. This reflected an evolution in the understanding of brain correlates of mental disorders and psychiatric symptoms of neurological disorders and acknowledged the pioneering work by Lishman in co-founding the British Neuropsychiatry Association. It is rich in basic concepts of neuropsychiatry, neuropsychology and clinical assessment as a lead to understanding specific disorders while retaining timeless clinical descriptions (‘the selection of case reports will sometimes illustrate rare conditions or phenomena, if case presentation seems much better than lengthy description for communicating the essence of the matter’; Lishman 1978: p. x). This most recent edition incorporated advances in classificatory systems, understanding of pathophysiology from the latest studies on structural and functional imaging as well as of biological systems, and modern treatments that provide a whole new perspective on prognosis.

A man of compassion, curiosity and enthusiasm

In 2003, I read with enthusiasm the third edition, given to me by my then consultant Dr Ramakrishna Madina, who wanted me to improve my knowledge on dementia. Since then, I have always recommended Lishman to any aspiring psychiatrist. I asked my once trainee and now a psychiatrist in Mauritius, Dr Nirja Beehuspoteea, about her thoughts on Lishman and she said: ‘Reading Lishman reminded me of why I chose psychiatry as a career; it helped me consolidate my learning in an organised manner. These days when I refer to it, I find that the passionate and rich writing never fails to deliver prudent answers’. In preparing this article, I read the chapter on dementia from the first edition. Lishman with his simple words inspires his reader to be a compassionate clinician. He writes of conversation with someone with dementia: ‘[tell] him for example that “there appears to be some trouble [ … ] which has caused your memory to be faulty, and we are going to try to remedy it”’; and he advises that, in speaking with the relatives, ‘it is reasonable to emphasise the variability in the rate of progress [ … ] from one patient to another, and to stress that one can only wait to observe what course is followed in each particular example’ (Lishman 1978: p. 585).

In his obituary for Lishman, David (2021) wrote in that ‘A colleague recalled giving a talk in 2017 for a care home and seeing Lishman in the front row; despite the effects of dementia, his curiosity and enthusiasm shone through’. Lishman's immortal book, inseparable from the writer himself, is an expression of that curiosity and enthusiasm to observe, to learn, to refine and to teach. This, reflected in his description and analysis, will remain as an inspiration for readers across generations to conduct empathetic and purposeful assessments followed by person-centred treatment plans built from such rich observations.