Ten books

While academic books are integral to developing a broad understanding of psychiatry, literature opens many doors to the internal worlds of others and enriches both our own understanding and inner world. In this, psychiatry, literature and philosophy have close ties. In addition to technical considerations, a good book is one that resonates in some way with the reader and allows the experience of being immersed in another's internal world. This can build understanding of unexperienced phenomena or a sense of solidarity for experience held in common, but in either case it develops a sense of the universality of human nature and our potential for self-reflection.

Love in the Time of Cholera by Gabriel García Márquez

Set in South America, Love in the Time of Cholera ¹ weaves a path through the decades bookmarking the turn of the 20th century. The fight against cholera is the life's work of one of the main characters, a rather urbane and cultured doctor (Urbino), and the pursuit of his wife Fermina is the life's work of Florentino. García Márquez depicts the effects of ‘love’ as being at times indistinguishable from infectious disease in terms of somatic symptoms and its life-changing outcomes.

The opening paragraphs describe the home of a man who has died by suicide and sets the scene for the rest of the novel, despite having little bearing on the remainder of the plot. Despite the theme of love as an illness as pernicious as cholera, García Márquez elected not thwarted love as the reason for this suicide, but rather fear of impending old age (another key theme throughout). Furthermore, it appears as a ‘rational’ suicide rather than one predicated on mental illness. In a form of macabre symmetry, the novel has another death by suicide towards the close: this death appears to be due to unhappy love, but another reading might suggest its origins in a fundamental distortion of the idea of love.

García Márquez captures the variety of human experience of the three main protagonists and portrays this as a deconstructed romanticism, certainly not a romanticised view of love. Florentino exhibits a range of predatory behaviours that are difficult to reconcile with his central role as a romantic hero. Dr Urbino might be argued to violate boundaries in his style of commencing relationships with his wife, and later with another woman, both of whom he encountered initially as patients. Despite these unsavoury aspects of their characters, it is hard not to empathise with them and even become invested in their success, leaving the reader with a rather uncomfortable feeling of collusion. Perhaps this is what García Márquez is really trying to express: that any human enterprise is corrupted by the foibles of the human condition, and the often romanticised idea of love is no exception.

The Story of San Michele by Axel Munthe

This quasi-memoir of Axel Munthe inspired me to study medicine on first reading at age 17, attracted by Munthe's heroic descriptions of practising medicine in Parisian slums, during a cholera epidemic in Naples and treating earthquake survivors in Sicily. The Story of San Michele ² was a best seller when first published in 1929: over a million copies were published to an interwar world eager for Munthe's lyrical description of life on Capri. Despite the decline in popularity of this book, his home on Capri still receives a steady stream of visitors, likely due to its beautiful location rather than any association with Munthe's now unfashionable and long out of print works.

Munthe, a physician, depicts clinical issues of his time: Russian patients with rabies (or hydrophobia, as he calls it) with terminal delirium and the distraught figure of Pasteur unable to alleviate their suffering. However, his descriptions of Charcot as his professor at the Salpêtrière are the most enduring. Charcot, at that time interested in hypnotherapy as a method of accessing the unconscious mind of his patients, favoured public-exhibition style lectures and demonstrations, complete of course with swooning woman. Aspects of this seem anachronistic, even jarring, to the modern reader, but this is offset by the almost palpable air of excitement around the discovery of new frontiers in medical understanding of the still opaque links between the body and mind.

Psychological Treatment in Disease and Illness by Matthew Hodes and Stirling Moorey

Psychological Treatment in Disease and Illness ³ is a small volume, but one of the most accessible and relevant introductions to the psychotherapies and their application to the relationship between body and mind. Published in 1993 and not reprinted since, it contains many valuable insights into the use of various psychotherapies in the management of physical health conditions, especially functional disorders. Fonagy & Moran's chapter on a psychoanalytic approach to ‘brittle diabetes’ remains ground-breaking in its approach to this topic, a major focus of research interest in the 1980s and since under-researched, probably because of the inherent complex dynamics, which have become more prominent as technology such as insulin pumps have improved the physical aspects of treatment.⁴

The Master and Margarita by Mikhail Bulgakov

This absurdist tale describes Moscow life under Stalin's regime, bringing strands of Goethe's Faust⁵ to a 20th-century setting satirising state interference in the arts. In The Master and Margarita ⁶ the main character, ‘The Master’, shows the mental strain of living under a regime that places little emphasis on individual happiness or freedom, yet expects artists to perform where they cannot fulfil the role of true art in showing a mirror to society and its failings. The dangers of subverting true art to a pseudo-art little better than propaganda leads to rejection of more ‘authentic’ art at a societal level. This is to the personal cost of The Master, who is admitted to a psychiatric facility, although admittedly without any clear evidence of mental disorder as we know it. In the context of a state that subverted psychiatric hospitals as virtual annexes to their gulags, the line between mental illness and disobedience to the state was often blurred. Bulgakov's own background as a physician and specialist in infectious disease gave him familiarity with psychiatric and neuropsychiatric conditions (in particular, the neuropsychiatric effects of tertiary syphilis), which he draws on in his description of other patients, especially the poet Ponyryov. It would also have given him a unique insight into how the medical profession was subverted, like art, to the purposes of the state. Despite drawing heavily on the Faust story (with more overt reference in the Walpurgis night scene to Goethe's treatment of this story),⁵ it is a much more ambivalent, even nuanced, perspective on the relationship between good and evil, and how even creative and healing forces can be subverted by malign influence.

Ulysses by James Joyce

Having trained in psychiatry on the Dublin street where Joyce's Leopold Bloom commenced his Homeric journey, it is hard to disconnect Ulysses ⁷ and psychiatry. The neurologist Dr Joseph Collins saw a similar relationship, writing in a review in The New York Times: ‘I have learned more psychology and psychiatry from it than I did in ten years at the Neurological Institute. There are other angles at which “Ulysses” can be viewed profitably, but they are not many’.⁸

While many other novels describe the inner lives of their protagonists over at least several days, Ulysses brings an extraordinary level of granularity to the events of just one day. This one day is taken from the perspective of a number of characters, but it is the character of Bloom whose perspective the reader enters into most deeply. Ulysses is a book written for an epidemic, where we have time to read slowly and deeply.

Initially banned in several countries, it has become rather more mainstream in the decades following Joyce's death in 1941. Perhaps this is a sign of a greater acceptance of the variation of humanity and the decline in the censorious spirit that sought to suppress the (subjectively) less acceptable aspects of the human condition.⁹

Lishman's Organic Psychiatry: A Textbook of Neuropsychiatry by Anthony David et al

Inspirational is a word rarely used with respect to textbooks. Lishman's Organic Psychiatry ¹⁰ is an inspiring textbook, and even if only read for its section on head injury, it earns its large footprint on your bookshelf. Other highlights include the extensive sections on movement disorders and epilepsy. Part 1 considers the principles of neuropsychiatry, neuropsychology and clinical assessment, while part 2 describes discrete clinical disorders. This large volume is one of the few comprehensive and authoritative sources in this area, and it answers most questions that any clinician in psychiatry or neurology is likely to encounter in neuropsychiatry.

It's All in Your Head: Stories from the Frontline of Psychosomatic Illness by Suzanne O'Sullivan

Apart from the rather off-putting title, this is a most enjoyable introduction to the world of functional disorders. As a title, It's All in Your Head ¹¹ undermines the current understanding that body and mind are not as separate as previously held, and that emotions can be experienced in your body, in addition to your head. O'Sullivan's clinical stories are based on patients, and provide a rich and detailed insight into the experience of functional neurological disorders on peoples’ lives. In addition, they are interwoven with reflections on the historical and cultural factors that influence the emergence of these conditions. Most of all, this is a sympathetic account of a patient group that are marginalised more than any other group, and it promotes a nuanced understanding of functional disorders.

The God of Small Things by Arundhati Roy

Roy's defining novel is a profound and elegant depiction of the consequences of adverse childhood experience on adult life – we see the effect of early loss in childhood on the main protagonist, and the more devastating effects of sexual abuse on her brother. The central theme of The God of Small Things ¹² at first appears to be death and grief, and the varying ways in which people respond to the death of a child. The entire central family have experienced various forms of adversity, despite being on the surface quite privileged compared with many of their neighbours, who have suffered from social exclusion and poverty. The most formidable and, at various times, cruel and comedic character is the great-aunt of the family, whom we realise as the story progresses has experienced her own adversity. We see the effect of trauma and grief, and the different responses of each individual to stress and the marks that adversity, even in adulthood, can leave on a person's life.

Anna Karenina by Leo Tolstoy

In Anna Karenina,¹³ Tolstoy delivers a glimpse of imperial Russia, with high society and rural life at a time of rapid social change, including the liberation of the serfs and the development of rail travel. This anti-romantic novel oscillates between two main storylines: that of Levin and his internal struggles is the one considered to be autobiographical. However, it is the depiction of the inner life of the eponymous character and her downfall (both her societal descent and her internal unravelling) that have cemented Tolstoy's reputation. Earlier in the novel, he describes Vronsky's survival of a suicide attempt and Kitty's development of somatic symptoms in response to a romantic rejection.

Hypocrisy is a key theme: Anna's actions are judged severely by society, culminating in her death by suicide. There is no judgement in Tolstoy's account of Anna, but he contrasts her reception by society with that of the men: Vronsky and her brother Stiva, who remain accepted by society despite their affairs. The difference is not wholly attributable to gender: Anna's friend Betsy, known to have many affairs, is more discrete and retains her social standing.

Tolstoy describes Anna's inner experience as she undergoes the transition from a respected member of society to an outcast. The downward spiral of her thoughts includes the development of quasi-paranoid beliefs in response to the extraordinary stress she is placed under. Tolstoy's ability to describe and to empathise with Anna's mental state is likely based in his personal experience of low mood and suicidal thoughts. Her final moments of horror at what she has done, that instant of regret before the train strikes, seems to echo the regret we often hear in people who survive attempts at suicide.

The Magic Mountain by Thomas Mann

Thomas Mann won a Nobel Prize in Literature for his account of life in an alpine sanatorium in the early 20th century. The Magic Mountain ¹⁴ follows a young man, Hans, who lives in the sanatorium for 7 years and experiences not only the institutionalisation of illness but also the effects of this environmental malaise on perception of the passage of time. The sanatorium contains a wide range of personalities from a variety of backgrounds, bringing a range of philosophies and political perspectives. They discuss the issues of the day and debate the prevalent concerns and might be seen as a microcosm of the wider world. The novel ends with the tragic irony: Hans recovers from tuberculosis and leaves the sanatorium to fight in the First World War: an almost certain death. Mann, like Bulgakov,⁶ uses a Goethe-inspired⁵ Walpurgis night theme to bring together various minor themes and motifs.

Above all, Mann highlights the connection between body and mind and the connection between physical and mental illness. Many of the characters demonstrate symptoms of depression; some describe suicidal ideation or die by suicide. The atmosphere is permeated by melancholy and steeped in loss: loss of health, of role, of hope, of future, of identity. At the time, there were no treatments for tuberculosis and no effective treatments for depression: isoniazid (with its secondary antidepressant qualities) was yet to be discovered.¹⁵ Mann has much to tell us about the deep human cost of an epidemic and the strange suffering of isolation.