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book review

Wilder Penfield was an early brain mapper.

The Tale of the Dueling Neurosurgeons: The History of the Human Brain as Revealed by True Stories of Trauma, Madness, and Recovery
By Sam Kean, Little, Brown and Co., 416 pages, $30

Suspicious Minds: How Culture Shapes Madness
By Joel Gold and Ian Gold, Free Press, 352 pages, $32

Wilder Penfield was among the most important explorers of the 20th century. A former Princeton class president and varsity athlete, Penfield traded in his all-American credentials to establish an unorthodox medical practice in Montreal in the late twenties. He specialized in neurosurgery, and according to author Sam Kean, "probably did more than any other scientist to explain how the brain works in real time." Penfield kept his patients awake, a common practice, given that the upper brain isn't receptive to physical pain. By administering low-level electric shocks to different parts of the cerebral cortex, he conjured dramatic sights, sounds, or sensations in his subjects' minds. His experiments took medical knowledge past the familiar and into the neurobiological badlands. Prior to his interventions, Kean writes, "whole continents of the neural hemispheres remained as sketchy as early-1500s maps of the Americas."

Penfield is one of the many eccentric visionaries who populate Kean's engrossing, cleverly narrated book The Tale of the Dueling Neurosurgeons: The History of the Human Brain as Revealed by True Stories of Trauma, Madness, and Recovery. Kean draws on bizarre anecdotes (many could be described as tall tales if they weren't actually true) that reveal surprising insights about human cognition. He considers phantom limbs, the complex mechanisms behind facial recognition (and misrecognition), neuroplasticity, synethesia and other discoveries that elevated neuroscience to the forefront of both medical practice and popular culture.

Any history of neuroscience is at least a partial history of psychiatry too, since neurobiology is such a prevailing force within psychiatric thought.The old argument about whether mental illnesses are biologically determined or the product of childhood experiences has had many iterations over the decades since psychoanalysis came to prominence. You can easily see why neurobiological theories became so important. Consider Penfield's experiments: with a simple electrode, he triggered sensory experiences – hissing or thumping sounds, visions of shadows or crosses – that had no basis in external reality. In doing so, he showed delusions for what they are: errant electrical impulses in the human brain. It's hard to imagine a more straightforwardly anatomical illustration of how disordered thinking happens.

Neurobiological breakthroughs pushed the hokier psychoanalytic clichés to the margins of clinical theory. Kean discusses Capgras syndrome (arguably one of the most unsettling conditions out there), in which you become convinced that the people you love have been hollowed out and replaced by robots or clones. The man who discovered the disorder roughly a century ago, French psychiatrist Joseph Capgras, had a stock explanation: repressed incestual urges. Experimental data, however, points to problems with the brain's limbic system, which, among other things, produces a warm feeling of recognition in the presence of somebody you love. Take away that feeling, and even the most familiar face can seem eerily vacuous. Clinicians can assess limbic recognition – or its absence – by monitoring sweat levels on a person's skin. Clearly, Capgras syndrome is a biological disorder with measurable bodily effects. "In light of brain discord," Kean writes, "many delusions seem, if not rational, at least comprehensible. They're simply the failings of a fragile brain."

We can make arguments like this because, at last, we're beginning to feel our way around that complex, ridged and grooved organ beneath our skulls. This is, in many respects, a positive development – one that has enabled effective new drug treatments – but have we gone too far in our efforts to medicalize psychiatry? Today, many specialists, including experts in psychosis and delusion, are trying to shift our attention back toward social and cultural theories of mental illness. If we're going to better understand psychiatric disorders, they insist, neurobiology has to share space with social studies.

In Suspicious Minds: How Culture Shapes Madness, New York University psychiatrist Joel Gold and McGill psychiatrist and philosopher Ian Gold cite a wealth of peer-reviewed data suggesting that schizophrenia and various schizoaffective disorders can be triggered by real-world circumstances. The Gold brothers show that people who have experienced poverty, racism, sustained bullying, physical or sexual violence, abandonment, or emotional abuse are more likely than others to develop psychotic conditions. (Individuals living in high-density areas are also more susceptible to psychosis, a fact that is often attributed to urban alienation.) This data doesn't scuttle the biological argument, but it complicates it a bit. Current psychiatric models still treat genetic susceptibility as a pivotal factor. As the Gold brothers explain, a person with high susceptibility may develop a delusional disorder regardless of life circumstances; somebody with moderate susceptibility might only become delusional through exposure to trauma; and people with no susceptibility will probably resist psychosis no matter how many curve balls life throws their way. Even among survivors of extreme hardship, rates of delusional disorders are, in absolute terms, low.

To explain the connections between trauma and psychosis, the Gold brothers consider the suspicion system: the brain mechanism that processes wariness, fear and panic. It's a primitive function – having supposedly evolved around the time that our ancestors began living together in communities – and it favours hunches over sober, evidence-based thought. This makes sense: nefarious people are rarely open about their intentions, so when deciding whom to trust, we should probably look for ambiguous cues instead of hard data. As the Gold brothers argue, the suspicion system enables all of us would-be Othellos to identify the scheming Iagos in our midst before they get to us. Delusions, they theorize, may be the product of a disordered suspicion system, one that has been pushed into overdrive by traumatic life events.

The Golds are particularly interested in the Truman Show delusion, a mostly 21st century condition named after the 1998 film in which Jim Carrey plays a naïve everyman whose life is the basis of a reality TV show. (The brothers gave the disorder its name in a widely read 2012 paper on the subject.) People with Truman Show delusions believe that the world is watching them. They are living under the gaze of a million hidden cameras, and the people around them – colleagues, acquaintances, lovers – are actually actors employed by a sadistic television studio.

Can a movie really trigger a whole new category of delusional thought? Probably not. But the release of the film roughly corresponds to a dramatic spike in surveillance technology. The Gold brothers suggest that, in an era of closed-circuit television cameras, biometric identification, and now dragnet data collection, the fear of being monitored may be more prevalent than ever. Surveillance, like racism or bullying, is a type of social trauma. It puts all of us on edge, and sends some of us over it.

Whether or not you buy into the suspicion-system theory – i.e. the notion that contemporary culture is triggering psychosis within our mistrustful, cavemen brains – depends on your taste for evolutionary psychiatry. Many people, including experts, find these arguments convincing. I'm not one of them. My suspicion system starts to tingle whenever somebody suggests that the way we are today can be accounted for by the way we used to be. Evolutionary theories can make for compelling reading, but we probably gain more by confronting disorders themselves than by speculating about their ancestry.

Still, Suspicious Minds is an important book. It's sharp, compassionate and incredibly well researched. It gives a window into current psychiatric debates, and it builds toward a theory that is at least plausible and definitely thought provoking, which is all that theory needs to be. While Kean's Dueling Neurosurgeons recounts how neuroscience became such a powerful force, the Gold brothers consider what needs to happen next. Neurobiology has pushed the nature-nurture debate toward the nature end of the spectrum; the Gold brothers and other likeminded clinicians are nudging it an inch or two in the opposite direction.

For this reason, Suspicious Minds works best when dealing with the present, not the distant evolutionary past. The Golds suggest that, in a world with lower levels of inequality, violence, and perhaps surveillance too, we would be less burdened by delusional psychosis. Schizophrenia and schizoaffective disorders aren't only internal conditions – they're social maladies too. The book stands, then, as a powerful argument for the psychiatric benefits of social justice.

Simon Lewsen is a writing instructor at the University of Toronto and a contributor to Hazlitt, Reader's Digest, Toronto Life and The Walrus.