If, as David Brooks recently wrote in the New York Times, psychiatrists are “heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives,” then consider Untangling the Mind, by psychiatrist Theodore George and co-author Lisa Berger, a heroic piece of neo-functional neuroanatomical romanticism. At its best, this is a book about how to make your life better by recognizing biological processes just below the brain’s cortex, “sub-cortical” processes that drive rage, sadness, panic and cold-heartedness. At times though, this author forgets that his work itself is art, making an impossible leap from how to why — or what French psychoanalyst Jacques Lacan termed transcendence of the Imaginary into the Real.

Fundamentally, Untangling the Mind is a book that locates our most problematic emotions in the “sub-cortical” region of the brain, specifically a mid-brain structure called the periaqueductal gray (PAG). Armed with data from functional magnetic resonance imaging (fMRI), George contends that this region “serves as a platform for the expression of anger, fear, depression, and flat emotion to produce behaviors of fight, flight, shutdown, and predatory actions.” Those first four phenomena — anger, fear, depression and absence of emotion — provide the basis of the book.

George, a psychiatrist at the National Institutes of Health, contends that the nature of this region renders an exploration of why we feel the way we do — that is, psychological inquiry — meaningless. “Patients and psychiatrists assume that there is a psychological reason to explain why emotions and behaviors spin out of control. A more accurate reason may have nothing to do with personality or individual experiences but may be neurological.” The author then outlines his practical approach to problematic emotion, which he demonstrates through a series of patient vignettes. In each of the cases, George shows how helping people recognize the “neurologic-ness” (my term) of their symptoms, allows them to transcend blaming circumstances or themselves, empowering them to better manage the primitive thoughts and feelings.

In this readable synthesis of his experience as a scholarly psychiatrist, George takes readers on an elegant journey. In the spirit of a TED Talk, George uses plain language, bullet-point summaries, explanations from the American Psychiatric Association’s Diagnostic and Statistical Manual and stories of patients to make his PAG model of psychopathology come alive. Striking a balance between rigor and accessibility, the book is expansive in its scope but promising as a way to help individuals understand from a neurological perspective how it is that they feel so overwhelmed.

In the same essay quoted above, David Brooks also wrote that “psychiatry is better in practice than it is in theory.” The same can be said for George’s book. As a practicing child and adolescent psychiatrist who reviewed this book in my spare time, I have found myself, unexpectedly, quoting it from time to time. The results were remarkable, with patients appreciating the insights that I — well, George — offered them about how to better manage emotional problems related to the dysregulation of primitive, mid-brain functions. Great — in practice.

But in terms of theoretical rigor, this book has many weaknesses, including a too-grandiose title that promises readers a novel explanation of “why we behave the way we do” as opposed to “how.” In general, it offers little new insight. A century ago, Sigmund Freud too cast doubt on the notion that we think, feel and behave for all the reasons we believe we do. Freud, who trained as a neurologist, employed a chaise instead of positron emission tomography (PET) and fMRI scanners to build his theories, but his message was very similar. “The ego,” Freud wrote, “is not master in its own house.” One might say that George has simply replaced Freud’s Ego consciousness with the higher cortex, and has replaced the Unconscious battles waged between the punishing Superego, the pleasure-seeking Id and the managerial Ego with the struggles between how we want to behave and our ruthless, often out-of-control PAG.

To say this, though, simply presents a new dilemma regarding etiology: What are the influences on our Unconscious (ahem, PAG) that create the very neurologic disruptions that Freud and George write about? Simply to say we behave one way or the other because of our PAG presents only tautology. If George truly wants to write the book of “why,” he needs to transcend this and offer specific theories on the very neural structures and related behaviors that he details in his book. What is it about someone’s genetic complement, his or her early relationships and neuronal insults such as toxins and environmental factors, that produce certain behavior? To answer those questions would truly untangle the mind. As it is, George’s text makes for a stimulating synthesis and practical poetry, but groundbreaking neuroscience this is not.

Craigan Usher is director of Child and Adolescent Psychiatry Education at Oregon Health and Science University;his courses find students tackling neuroscience, models of the mind and Disney’s Tangled.

comments powered by Disqus