Dr Mike Fitzpatrick
Patients often come in these days with newspaper cuttings promoting some new wonder drug or after a tele-vision feature about the lethal side-effects of the medication they have been taking for years. This man brought a book recently published in the USA - Shadow Syndromes, by John Ratey and Catherine Johnson - in which he had discovered the true cause of his longstanding problems as the hitherto little recognised adult form of Attention Deficit Disorder. Following the recommendation of these authors, he requested a prescription for Ritalin, the drug now used on a wide scale in the USA (and increasingly in Britain) to treat this disorder in children.
Anticipating a wave of similar sufferers, I hastened to read Shadow Syndromes. Though the authors point out that the number of categories of abnormal behaviour recognised by the Diagnostic and Statistical Manual of American psychiatry has expanded from 60 in 1952 to 384 (plus 28 'floating' diagnoses) in 1994, they are concerned about the much wider prevalence of 'subsyndromal behaviour'. They reckon that many, if not most, people in society are suffering from mild or partial forms of familiar psychiatric conditions, such as depression and anxiety, obsessional compulsive disorder and autism. Unrecognised and untreated, these syndromes cast a shadow over the lives of sufferers, their families and society in general.
By way of introduction, Ratey describes his personal odyssey from radical intern influenced by the works of anti-psychiatrist R D Laing to his current position as assistant professor and practising psychiatrist. Clinical experience and researches into neurotransmitters and brain imaging techniques have convinced him that many of the problems of the 'worried well' as well as those of the mentally ill can be attributed to defective brain biology and treated with drugs and other treatments.
An older and a wiser man, Ratey now reinterprets his enthusiasms of the sixties: 'Many of the men and women we saw as heroes were essentially crazy people. Abbie Hoffman, Grace Slick, the SDS: whatever you thought or think of their politics, today they would have to be seen as suffering from disorders of mood and impulse. These were certainly not "normal" people.' (p12)
One of the striking changes in popular attitudes to mental illness over the past 30 years is how notions which were once peculiar to marginal intellectuals have now - in a more extreme form - taken over the mainstream. For example, Laing and other psychiatric radicals were fiercely criticised for depicting schizophrenia as a form of enlightenment that emerged in response to disturbed family and other social relationships. Today, the film Shine promotes similar ideas to mass audiences, celebrating the genius of the schizo-phrenic pianist David Helfgott, whose anguished and critically disparaged public performances receive popular acclaim. In films such as Rain Man and Forrest Gump, characters suffering from severe deficits in social and intellectual functioning are assumed to be morally superior.
While the mad are held up as repositories of genius and virtue, the normal are redefined as mentally ill. Ratey recalls how he once shared the radical conviction that 'normal' people were 'dull and conventional'. Yet today this familiar prejudice of adolescence has become amplified and codified in the diagnostic categories of his 'shadow syndromes'. Whereas in the past, 'normal' people had merely to endure being patronised by long-haired Ratey junior, they now face more intrusive intervention from his grown up white-coated alter ego.
The key feature in the changed perception of mental illness is the shift from distinct diagnostic categories to the notion of a continuum linking the pathological and the normal. The universal character of human experience and forms of expression and behaviour gives a certain plausibility to this exercise. It is true, for example, that it is possible to discover a rational kernel in the most florid delusions of a paranoid schizophrenic. The links between familiar experiences and common psychopathological states - sadness/depression, elation/mania, appre- hension/anxiety - are even easier to identify. But why has the concept of a continuum become so fashionable today, when in the past society was more inclined to emphasise the discontinuity between the normal and the abnormal?
For Ratey and Johnson, the justification for the idea of a continuum - and for their concept of shadow syndromes - lies in the advances of neuropsychiatry: 'a great deal of what we thought was due to (poor) upbringing is fact is heavily influenced by the genetics, structure and neurochemistry of the brain.' (p26) This does not, they are keen to emphasise, mean the end of individual responsibility, but its redefinition: 'our responsibility in this new era is to acknowledge our biology, understand our biology and take whatever steps we need to take in order to prevent that biology from harming our lives or the lives of the ones we love.' (p36)
Having established a direct link of determination that runs from the biology of the brain through the individual personality to the structure of society, they insist that it is the ultimate responsibility of the individual 'to do something about the way his brain works' (emphasis in original). In this profoundly conservative vision, human individuality is reduced to neurobiology and social responsibility is redefined in terms of accepting its constraints. When the authors claim that 'this is a book about living well' they really mean that it is a book promoting the morality of low expectations legitimised in terms of neuroscience (though it is some relief to discover their doubts over whether it is ever 'going to resolve the question of the human soul').
'Feed your head' sang Grace Slick in the Jefferson Airplane's most famous anthem; 'Care and feeding of the brain' is the not even slightly ironic final chapter of Shadow Syndromes. One of the positive features of the much-disparaged sixties was the enhanced sense of individual subjectivity expressed in popular defiance of established constraints in all areas of social life - including those long ordained by biology in matters of sex. No doubt there was much naivety, but it seems doubtful whether there was then a deeper disorder of mood and impulse than prevails in today's climate of despair. Better to have a few crazy heroes than to live as slaves to our neurotransmitters.
Reproduced from LM issue 106, December 1997/January 1998