Ten books

Don't get me wrong – I've nothing against books. In fact, I think books are great. It's just that I get annoyed by the attitude conveyed by some psychiatrists that the only qualifications needed to be a decent psychiatrist are a classical education, some foreign travel and the contents of a few good books. A bit like the diplomatic service. Although this may have been acceptable once upon a time, it isn't now. We have had at least 100 years to benefit from advances in the biological and social sciences and specific research in our field, so it is time we considered novels as holiday and recreational reading and not a substitute for study. That is one of the arguments set in train when I received the invitation to do ‘Ten books’. Another acknowledges just how much I enjoy reading other people's choices, both for forcing me to expand the ever-growing list of books I really must read and for what they say about the choosers.

What follows is an idiosyncratic compromise: ten books from the past 50 years, non-fiction and directly relevant to psychiatry (mostly). Giants like Darwin, Freud, William James, and Hughlings Jackson should be taken as read. Much as I would like you to carry on reading this article, if you haven't read these guys, you really should do that instead.

Consciousness explained?

One of the great mysteries that continues to excite scholars and lay readers alike and has reached a pitch of fevered activity in the 21st century is consciousness or, more specifically, why are there so many lousy books on the subject? It's a publishing phenomenon. Putting the ‘C’ word in the title of your monograph is like having David Beckham on the cover of your magazine. Guaranteed to boost sales but bound to disappoint those anticipating interesting content. The exception is the audaciously titled Consciousness Explained, by philosopher Daniel Dennett (1991). Where the author scores over other, lesser thinkers is in his deep grasp and genuine curiosity about cognitive psychology and neuropsychology, and in a writing style that manages to be unashamedly technical while at the same time combative and lucid. Critics and fans might agree that Consciousness Explained Away might be a more accurate but no less arresting title. One by one Dennett takes on our assumptions about consciousness: qualia (who needs them?); how do you know you are not a zombie? (you don't); unity of consciousness and sense of self (an illusion played out in the discredited theatre of Cartesian dualism). He does this through a painstaking dissection of a few key – quantifiable – psychological phenomena, for example the colour phi phenomena. This occurs when two lights in close proximity flash on and off successively, say red on one side and green on the other. The light appears to move from the first location to the second and change from red to green in mid-flight. This occurs even on the first trial. Clearly, we extrapolate back in some way from the green light to the red. Dennett points out just how disturbing this is. In some sense we see the green light, invent some pleasing sequence of events and then present this to ‘consciousness’, which accepts what it sees. Dennett teases us with two apparently competing explanations for this illusion. The first he calls Orwellian – that is, the true history of events (a red flash in one location and a green flash in another) is rewritten to accommodate a more acceptable ‘truth’ about the way the world should be (a light moving from red to green). The second he dubs Stalinesque – that is, the truth is repudiated, post hoc, in line with current dogma. As an analogy, remember tasting Scotch whisky for the first time. You probably were at a loss to explain why anybody (grown-ups exclusively) should wish to drink such an acrid, pungent concoction. Then, some years later you discover that it really is rather good. Is it that the very acrid pungency that was so aversive in youth is now appreciated (Stalinesque), or is it that mature taste buds register the very same input as both warm and bracing (Orwellian)? The answer is that this is a false distinction and that you would never be able to distinguish between the two. Both the timing and the content of phenomenal experience are unreliable. You'll have to read the next 300 or so pages of his book to get some sort of resolution to this uncomfortable state of uncertainty.

Modularity of the mind

Another Ivy League philospher–linguist who commands similar authority is Jerry Fodor. Like Dennett, he has a writing style unlike that of any comparable British academic: arcane, convoluted, playful, rambunctious. The Modularity of Mind (1983) is only 140 pages or so and manages to be incendiary as well as reassuring. Although explicitly about the mind rather than the brain, it gave neuroscientists the intellectual foundation for localisationism which had been lacking since the time of Gall. Fodor operationalised the properties of a ‘module’ (a computational entity, a processor), hard-wired to do what it does – process speech, recognise faces and so on – efficiently, mechanically, oblivious to what's going on elsewhere (informational encapsulation). You can't not understand speech in your own language no matter how hard you try. The implications for cognitive neuropsychology are immense and have not been fully assimilated. Modularity does not square with competing ideologies such as connectionism, which describes artificially created systems that, despite their simple, basic and uniform properties, can exhibit apparent specialisation, or the well-known theory of mass action. The implications of all this for cognitive neuropsychiatry are only beginning to be realised. Is loosening of associations a breakdown of informational encapsulation? Are delusions due to nonmodular processes (for example, beliefs) becoming modular?

The internal supervisor

The clinical academic has to avoid keeping his or her head too long in the clouds. On Learning from the Patient, by Patrick Casement (1985), is the best and perhaps only book that tells you what it is really like to be a practising psychiatrist, in a room, alone, with a patient. I found it invaluable as a trainee and still do. Although writing from a psychoanalytic perspective, Casement recreates everyday dialogue, which he annotates with comments and interpretations, some as they occurred at the time and others in retrospect. He introduces the notion of the internal supervisor – a benign super-ego, comprising the best of our teachers and colleagues – which should be consulted whenever a comment doesn't add up, an unexpected feeling is aroused or reaction evoked. Forget continuing professional development and clinical governance. Develop a good internal supervisor, remember to use it and you will never go too far wrong.

The beginnings of ‘group diagnosis’

Experiences in Groups was written by maverick post-Freudian Wilfred Bion (1961), a decorated First World War veteran, who spent most of his professional life doing individual psychoanalysis. He invented an obscure quasi-mathematical notation to explain interpersonal interactions that may be brilliant but probably isn't. He is best known for Experiences in Groups. From the first paragraph, Bion gently unravels the initial reactions, hostilities, defences, postures, rivalries and insights of the group. He is always rational but never cold, incisive but unpatronising, and what is so interesting is that he is clearly learning, maybe inventing, the field of group dynamics as he goes along. The value of Bion's writing goes way beyond group therapy. It is about every committee, working party and ward round you have ever been in, not to mention every reality TV show you may have had the misfortune to watch.

Lishman's guiding principles

Lishman's Organic Psychiatry is an obvious choice. The only question is, which edition? It is now in its third, with an edited 4th on the cards. I am going to go for the first compact, if not slim, edition published in 1978. Why? Neuropsychiatry is the only sub-speciality capable of genuine evolution. General psychiatry is always about rearranging the same elements (schizophrenia, affective disorder, neuroses...) according to the latest diagnostic scheme. When a psychiatric illness becomes a disease, i.e., when its pathophysiology is uncovered, it joins the ranks of neuropsychiatry. The paradox of Organic Psychiatry is that, although prions, HIV, classifications of dementias based on molecular genetics, novel pharmacotherapies et cetera demand space in successive editions, such changes serve only to highlight the guiding principles which, thanks to Alwyn Lishman's exquisite prose, are timeless. The introductory chapters of the first edition are simply the best introduction to the whole of psychiatry that I have read.

A life-saver

We have all heard someone make the melodramatic claim that a certain book, poem, song or whatever ‘saved my life’. Medical Emergencies (Robinson & Stott, 1976) may not have saved my life but it has saved countless others. This miniature miracle-worker fitted neatly into the pocket of a white coat. It could be consulted in the lift down to casualty or during the quick march from the doctor's mess to the admissions ward. By the time you got there, you knew how to calm a thyrotoxic crisis and steady a ventricular arrhythmia. I include the book here not only for the concrete information it contains, but also as a symbol. It reminds me that psychiatry is, and always should be, a branch of medicine; that if you do the right things, patients may get better; and, finally, that with a few moments of preparation you can at least pretend you know what you are doing.

Phenomenologist and icon

The Divided Self (Laing, 1959) has made several appearances in previous top tens, despite the opprobrium R. D. Laing received from the psychiatric mainstream in his heyday. A book on schizophrenic and schizoid psychopathology is an unlikely classic, which suggests that it is more often quoted than read. Much of the book is a dense, jargon-heavy analysis of existentialism but working through it pays dividends. Laing was an extraordinary phenomenologist. His ear for the language of alienation and the nuances of inter- and intra-personal conflict was acute. In The Divided Self his humanity shines through without his later misguided identification with patients, over-politicisation of their plight and alcohol-fuelled excesses. It is the main reason I wanted to become a psychiatrist. If he had come along a few years later and had the right training to convert his ideas into proper research, he would have made a decent social psychiatrist. Instead, he had to make do with being a cultural icon. His first and only published volume of autobiography (Wisdom, Madness and Folly, 1985) provides some useful background. Laing talks about how, as a recently qualified doctor, he proposed leaving Glasgow to study with philosophical psychiatrist Karl Jaspers, then in Basel. This was declined on the grounds that the doyen of psychopathology had become ‘just’ a philosopher in his later years. A magical realist playwright might consider creating an imagined meeting between the two. Wee Ronnie Laing going up to the old man and saying: ‘I reckon the symptoms of so-called schizophrenia can be rendered socially intelligible if only we understand the context from which they emerge’. ‘Vot rubbish, dummkopf’, retorts the elderly professor. ‘Don't you realize zat psychosis is un-understandable by definition?’ ‘OK. Fuck off then’.

A little insight

The radio programme ‘Desert Island Discs’, the model for ‘Ten books’, has elecited some infamous examples of self-serving vanity such as Elizabeth Schwartzkopf choosing entirely her own operatic recordings, and Otto Preminger selecting only theme tunes to films he directed. Undaunted and conspicuously lacking in insight, I will try and justify nomination of one of my own books, Insight and Psychosis (Amador & David, 1998). First, I did not write it but was merely a co-editor. Second, the book, despite a long and painful gestation, helped forge a number of close friendships with a range of collaborators, which I hope will sustain the project into a revised edition. Third, compiling Insight and Psychosis was an enormous learning experience for me as I tried to digest the contributions of anthropologists, philosophers, psychologists and clinicians that I admire. Finally, while Laing first got me interested in understanding schizophrenia, trying to get to grips with insight is what keeps me interested, despite repeated failures to gain such understanding. I hope it exemplifies the need for both bottom-up neuroscientific and top-down sociocultural understanding in psychiatry.

The element of life

Primo Levi, chemist, writer and holocaust survivor, has many reasons to be on a list such as this. The Periodic Table (1975) uses each of the elements as a mnemonic trigger or metaphor for an anecdote or reverie, often related to experiences in Auschwitz. The last, most compelling and irrepressibly optimistic, is a tone poem reflecting on carbon, the element of life. It ends:

‘One [carbon atom], the one that concerns us, crosses the intestinal threshold and enters the bloodstream: it migrates, knocks at the door of a nerve cell, enters, and supplants the carbon which was part of it. The cell belongs to the brain, and it is my brain, the brain of the me who is writing: and the cell in question, and within it the atom in question, is in charge of my writing, in a gigantic minuscule game which nobody has yet described. It is that which at this instant, issuing out of a labyrinthine tangle of yeses and nos, makes my hand run along a certain path on the paper, mark it with these volutes that are signs: a double snap, up and down, between two levels of energy, guides this hand of mine to impress on the paper this dot, here, this one.’

One reason this is so moving is the unbearable tragedy of Levi's death. As one too many carbonated molecules of dopamine leached out of his substantia nigra, the crippled and depressed survivor threw his own life down a flight of stairs. His death leaves an emptiness which must be but a pale shadow of that experienced by any loved one, bereaved by suicide. And it teaches us that despite what we know about life and science we never really know why a man kills himself.

A good enough talent

I vowed to stick to non-fiction but have slipped in one work of fiction – Pictures of Fidelman, by Bernard Malamud (1958).

This is a short collection of picaresque episodes tracing the adventures of the hapless Arthur Fidelman. It was an influential book for me as an adolescent – passed between my wonderful, creative group of friends as we made the transition to adulthood. The book addressed our youthful obsession with the nature of Art and personal, including sexual, identity. Now, as I, let's say, approach middle age, I find that the book still resonates strongly with me, but for different reasons. Is this re-reading Orwellian or Stalinesque – who knows? Fidelman travels from America to Italy to study the Renaissance master Giotto, to paint and to discover who in truth he really is – perhaps Fidelman is to do with fidelity. He learns eventually and with some pain that he is no scholar and certainly no artist. Instead, he winds up becoming a glass-blower. He discovers he has talent and he can still be creative and fulfilled within the defined parameters of his craft. This, for Fidelman, has to be good enough. Choosing ten (or, at least, nine) great books is a bit like that. Standing on the shoulders of giants, and even standing on the shoulders of those who stand on the shoulders of giants, you get a good view of many things, including yourself.