And that’s not all. “This right here?” He’s connecting some other blotches of color. “That’s the diamond-plus pattern. When I see this pattern I ask, Have you ever been traumatized? Sounds like growing up there was plenty of trauma in your family, that your mother was giving it regularly.” Which means, he says, that I am a candidate for a technique called EMDR—eye movement desensitization and reprocessing—to go along with the omega-3 fatty acids and L-tryptophan and maybe some SAM-e that he is recommending for my depression and ADHD. He’s not averse to pharmaceutical drugs—although he’s also skeptical of them and has done all his research independent of drug company money—and if the supplements fail, he thinks Effexor is the “right bullet” (“I guess that’s not such a good word for an antidepressant,” he adds quickly) because it “works on serotonin and dopamine and if you did just serotonin, your mood would be better and your ADHD would be worse and to do dopamine without serotonin your focus would be better and your worrying would be worse.”
Amen says some sensible things. “A diagnosis of depression is like a diagnosis of chest pain,” for instance, which strikes me as a concise way to get at the problem created by the DSM’s eagerness to turn all depression into a single disease. He thinks that the symptoms point to many diseases, each with its own brain pathology, and that the DSM-VI (an inevitable development, although the APA is only now working on the DSM-V) will be organized accordingly. He’s also honest about the economics of his efforts. He’s not in the pocket of the drug companies, secretly fueling their marketing efforts with his research. Instead, he asks his patients to sign a consent form allowing their scans to become part of his database, which he then uses to strengthen his case that certain psychological illnesses go along with the brain pathologies that he, more than anyone else, knows how to recognize and treat. These overlapping roles—researcher, clinician, entrepreneur—may create the grounds for all kinds of murky ethical problems. I didn’t exactly feel like I could refuse to sign the consent form, and the experience gave me a new appreciation for the team at Mass General; they hadn’t made me pay to be their guinea pig. But at least there isn’t any mystery about who is benefiting from Amen’s research, and how.
Still, however, as Amen goes on in his calm and confident way about empty cerebellums and hypoactive cingulates, too much serotonin and not enough dopamine, trauma diamonds and depression triads, and the bounty that awaits me when he balances my brain—“With a healthy brain,” he tells me, “your free will is greater, and so is your ability to have people trust you over time, be able to be engaged in a loving long-term relationship, be a good dad, to be more thoughtful and loving”—it’s impossible to shake the feeling that Daniel Amen is a high-tech, nuclear-armed quack and that I’ve stumbled into a twenty-first-century medicine show.
I’ll admit that this sentiment is not only uncharitable—not that he needs my charity, not at $3,250 a pop, not to mention the best-sellers and the lecture tours and the television specials—but it’s awfully convenient, self-serving even. I mean, it’s not like I didn’t go into this meeting with a deep suspicion of the project of rendering human life as a series of biochemical events, and of Thomas Insel’s vision of the psychiatry of the future. For that matter, it’s not like I didn’t go into this book without an idea about what is wrong with the medical industry’s invention of a brain disease out of our daily troubles and aspirations. After all, just because he’s a little too slick and greedy for my tastes, that doesn’t mean he’s wrong.
Amen has met the likes of me before—people who don’t want to accept the morphing of psychiatry into clinical neuroscience, of the mind into the brain, of discontents into glitches. “When I first started doing this work,” he told me, “I got no end of grief from my colleagues.” So, he says, he learned to shut up, speaking very little about what he was up to and only to what he thought would be sympathetic audiences. But in 1996, he gave a talk to a professional group, and one audience member, incensed, Amen says, by his claims to have discerned the physical foundations of mental illness, hauled him before the California Medical Board. He complained that Amen was practicing outside the standards of care, using equipment that only neurologists had the training to use—an offense for which a doctor can lose his license. Amen battled the board for more than a year and finally was cleared of the charges—but not before he realized what he was up against. “One is often labeled a heretic for trying to change religious beliefs,” he says.
But compared to what the French and Dutch authorities did to Julien Offray de La Mettrie in the eighteenth century for suggesting that consciousness was the product of a machine-like brain, litigation with a medical board is a walk in the park. Similarly, my showing up here with a check, a brain, and my skepticism doesn’t seem so bad compared to what Mark Twain did to the American phrenologist Lorenzo Fowler in 1873.
By then, America had proven itself a hospitable home to the brand of phrenology originated by Franz Gall’s assistant Johann Spurzheim, who had redrawn the skull map in a way that eliminated the bad bits. Spurzheim had also declared that evil and suffering were not inherent properties of the brain but the result of pathologies that could be corrected. He did well enough in Europe, but Spurzheim’s science of self-improvement set off an outright frenzy in the land dedicated to the pursuit of happiness. Spurzheim arrived in New York in August 1832 and lectured in New Haven and Hartford before arriving in Boston to a reception so enthusiastic that he soon found himself lecturing to overflow crowds at the Masonic Temple, to Harvard students and faculty, and at the Boston Medical Society. It was a killer pace—literally. He died at the end of September of exhaustion and fever.
Those two months, however, were long enough to capture the attention of a young Amherst student and aspiring minister named Orson Squire Fowler. By the time he had graduated in 1834, Fowler had examined heads in and around Amherst with such success that he abandoned his plans for the ministry and became a full time phrenologist. With his brother Lorenzo, he married Gall’s brain maps and Spurzheim’s optimism to American pragmatism and took the resulting self-help science to the streets, offering readings intended to help common people learn “what they are, and what they can be as well as how to make themselves what they should become.” What Gall had eschewed, what Spurzheim had only implied, the Fowlers said right out in their phrenological self-instructor, one of America’s first self-help books: the purpose of life is happiness, which is achieved when the organism—specifically the brain—is functioning as it should. “Would you become great mentally,” they wrote, “then first become great cerebrally.” Or as Daniel Amen would say a century and a half later, change your brain and change your life.
The Fowlers built a therapeutic empire that eventually included not only the brothers but their sister, her husband, Lorenzo’s wife (who in 1850 became the second American woman to earn a medical degree), and their daughter. They set up shop in New York City, with satellite offices in Philadelphia, Boston, and even London. President James Garfield, Brigham Young, John Brown, and Oliver Wendell Holmes all offered their skulls to the Fowlers’ hands. Like everyone else, these luminaries went home with charts of their heads, on which their strengths were outlined in black and white for all the world to see.
By midcentury, phrenology had reached into most areas of American public life. But it was a particular hit with the literati. Horace Greeley published Combe’s lectures and suggested that railroad men be selected on the basis of the shape of their heads. Horace Mann called phrenology “the greatest discovery of the age.” Edgar Allan Poe wrote that “Phrenology… has assumed the majesty of a science, and, as a science ranks among the most important which can engage the attention of thinking beings,” and built a poetics on phrenological tenets. Ralph Waldo Emerson spoke favorably, if grudgingly, about the Fowlers’ achievements.
But no literary figure was more effusive than Walt Whitman. “Phrenology, it must be confessed by all men who have open eyes,” he wrote, “has at last gained a pos
ition, and a firm one, among the sciences.” The relationship between Whitman and the Fowlers was a mutual lovefest. He sang their multitudinous praises—inspired, no doubt, by Lorenzo’s reading of his skull, which proved him to be well endowed in the areas of Friendship, Sympathy, and Self-esteem, not to mention Voluptuousness and Amativeness—and Fowler & Wells, phrenology’s publishing arm, published his poems, including Leaves of Grass, which they then allowed him to review (anonymously, of course) in the American Phrenological Journal. Whitman gave the book a favorable notice.
We can only imagine how all this piety and respect sounded to a skeptic like Mark Twain, although his telling makes it clear that his motives were no purer than Joseph Wortis’s or David Rosenhan’s (or, of course, mine):
I made a small test of phrenology for my better information. I went to [Lorenzo] Fowler under an assumed name. He examined my elevations and depressions, and he gave me a chart… He said I possessed amazing courage, an abnormal spirit of daring, a pluck, stern will, a fearlessness that were without limit. I was simply astonished at this, and gratified too; I had not suspected it before… However, he found a CAVITY in one place where a bump should have been in anybody else’s skull… He startled me by saying that that CAVITY represented a total absence of a “Sense of Humor”!
Twain went back to Fowler three months later, this time “bearing both my name and my nom de guerre.” This time the news was different:
The CAVITY was gone, and in its place was a Mount Everest—figuratively speaking—31,000 feet high, the loftiest BUMP OF HUMOR he had ever encountered in his life-long experience!
It wasn’t Twain’s prank that undid phrenology, however, but rather the advent of scientific medicine, especially the nascent field of neurology. In 1848, for instance, a railroad worker in Vermont, Phineas Gage, was loading a hole with gunpowder when an errant spark set off the charge, sending the tamping iron through Gage’s skull, carrying with it a good portion of Gage’s frontal cortex. Gage was brought to a local physician, John Harlow, who treated him with the usual purgatives and poisons, amputated the herniated brain tissue, and closed his skull as best he could. Gage floated in and out of consciousness for a couple of weeks, but he was soon up and around and ready to get his job back. But the railroad didn’t want him. As Harlow reported, Gage was a changed man. “The equilibrium or balance… between his intellectual faculties and animal propensities,” he wrote in a medical journal, “seems to have been destroyed.” Gage, who was once a gentle and reliable man, had become irascible, unpredictable, and even mean—so much so that his friends, according to Harlow, reported that “Gage was no longer Gage.” Gage left Vermont, worked as a coach driver in Chile, and died in San Francisco in 1860.
Harlow was sympathetic to phrenology, but he didn’t report the fact that Gage was a changed man until 1868—perhaps because the areas of the brain wiped out by the tamping iron, according to Gall’s charts, governed functions like poetical talent and acquisitiveness, and not equanimity or amativeness. But by then, other discoveries had called the phrenological brain map into question. In 1861, for instance, Paul Broca, a doctor in Paris, autopsied an epileptic man who, before he died of gangrene, had lost the power of speech. He found a “softening” in an area at the rear of the left frontal lobe, a lesion that showed up subsequently in other people who could not speak. Broca’s area, as that section of the brain came to be known, was soon joined in the brain gazetteer by Wernicke’s area—a region discovered by German neurologist Carl Wernicke that, when damaged, causes receptive aphasia, the loss of the ability to understand speech. And in the 1870s David Ferrier, a British doctor experimenting on monkeys, found that frontal cortex damage like Gage suffered could induce profound changes in behavior.
These discoveries didn’t kill phrenology, not entirely. Doctors digging around in brains may have discredited the idea that the skull revealed the brain beneath it, but they also confirmed Gall’s basic insight (or maybe it was just a lucky guess): that the brain is divided into regions, and that those regions correspond to various functions. Gall was wrong in the particulars, but right that the brain, much as La Mettrie had said, was an elaborate clockworks.
At least that’s the story that historians of medicine like to tell: that real scientists managed to distill the gold of neurology from the dross of phrenology, Broca’s epistemological modesty triumphing over the Fowlers’ hubris, real doctors vanquishing the quacks. But the Fowlers’ version lives on, and not only at Daniel Amen’s clinic, where anyone can plunk down some cash and come away with a picture of the bumps on the inside of his head, a reading of their significance, and a program for brain improvement. It’s in the inescapable images in every magazine and newspaper and television program about health, the full-color scans showing the brain at work and relaying the news that doctors have planted the flag of science in our brains like sixteenth-century explorers, that they have discovered the real basis of empathy or racial prejudice or sexual orientation, claiming for the brain territories once thought to be the province of the mind.
Especially depression. Pick up the October 16, 2008 issue of Nature—okay, it’s not exactly light reading, but it is about as mainstream science as it gets—and you’ll find out just how far into the brain the depression doctors have penetrated. After you hear from two of the leading lights in the field that “the official diagnosis of depression is subjective” and that its cause is “far from being a simple deficiency of monoamines”—once again, doctors can acknowledge to one another that what they tell their patients is not true—you’ll learn that depression can be found in the grey-matter volume and glial density of the prefrontal cortex and the hippocampus, in the amygdala and subgenual cingulate cortex and the nucleus accumbens. You’ll find that the reason SSRIs work, when they work, may be that they cause secondary neuroplastic changes, themselves perhaps the result of upregulation of the calcium-binding protein p11 or the transcription factor CREB, which, following the logic of psychopharmacology, indicates that those are the causes of depression. Or maybe the culprit is a lack of brain-derived neurotrophic factor or vascular endothelial growth factor leading to a decrease in hippocampal neurogenesis, or too many cytokines or glucocorticoids floating around the brain or just glitches in the intracellular interactions between brain macrophages. You’ll also discover that resilience, the ability to withstand stress and adversity that the depression doctors define as health, may be due to a good supply of ΔFOSB, especially in the midbrain periaqueductal grey nucleus and a relative lack of Substance P, or even a reduction in the stress-related increased excitability of VTA dopamine neurons caused by upregulating voltage-gated potassium channels.
And if that doesn’t convince you that doctors are hot on depression’s trail, take a look at the New England Journal of Medicine, in which a team of French doctors reported that a very strange thing happened when they were treating a sixty-five-year-old woman with deep brain stimulation (DBS) for her Parkinson’s disease. That procedure involves inserting tiny electrodes into carefully chosen individual neurons and turning on a low-voltage electrical current, which generally relieves the tremors and spasticity associated with Parkinson’s. In this case, within a few seconds of receiving the charge, the woman, who had previously shown no signs of depression, started to cry. “I no longer wish to live, to see anything, to feel anything,” she said. “I’m fed up with life, I’ve had enough.” And in case her doctors missed the point, she continued, “Everything is useless, always feeling worthless, I’m hopeless, why am I bothering you?” Ninety seconds after the stimulator was shut off, her depression disappeared.
A few weeks later, the woman agreed to try it again. This time, the doctors took pictures, which they published with the article. The first photo shows a relaxed woman with a Mona Lisa smile. Within thirty seconds, her right hand is gripping the lower part of her face, pushing her mouth into a pout; her eyes are downcast, and she looks thoughtful and worried. Four minutes later, she is weeping, her eyes squeezed shut aga
inst the feeling that, as she puts it, her “body is being sucked into a black hole.” Five minutes after that, she is smiling again, this time broadly, as if in celebration. “The neural networks involved in this particular case have not been clearly identified,” the doctors wrote, although it may have involved the ventral nuclei of the thalamus or perhaps the activation of the left pallidum. Whatever the specifics, they wrote, the important thing is that the stimulation affected only “a few cubic millimeters of neural tissue,” which means that “the depression probably resulted from the stimulation of afferent, efferent, or passing fibers within the substantia nigra or from the inhibition of those fibers.”
If you don’t understand any of this brain talk, don’t worry too much. I don’t really understand it either, any more than Walt Whitman really understood the Fowlers when they went on about his philoprogenitiveness or his inhabitiveness or than I fully understand what Daniel Amen means when he tells me about my cingulate-basal ganglia-thalamus triad. I mean, I know where those regions are, more or less, and I have some idea about what goes on, electro-chemically speaking, in them—and so could you if you spent just a little time with a basic neurobiology textbook—but I really don’t understand how they bring about my experience of depression. Even more important, I’m not entirely sure that they do, at least not all by themselves. I’m not sure what makes the depression doctors so certain that they do know, but when they write about depression as a disease that is the result of pathophysiological processes, when they say that the circuitry of depression, whatever it is exactly, gets turned on by stress—“kindling,” they call it—and then in some unlucky segment of the population stays on even when the stress is over, creating its own stress, which creates its own depression, the brain consuming itself like a serpent eating its tail, depression an exercise in meaningless suffering, they sure sound as if they do.
Manufacturing depression Page 35