Anxiety - The Inside Story - How Biological Psychiatry Got it Wrong

Modern mainstream psychiatry really can’t be bothered with anxiety. For orthodox psychiatrists, anxiety is not an SMI (Serious Mental Illness) so it is generally treated as second rate and handed to psychologists. Very often, it is called ‘comorbid,’ meaning it occurs with something else, mostly depression but also alcoholism and other addictions, chronic pain and so on. The way psychiatrists use the word ‘comorbid,’ they mean ‘trivial, irrelevant, a sideshow which need not be taken seriously.’ In this book, I will argue that anxiety is not a sideshow, it is the biggest show in town and it has to be taken very, very seriously. Anxiety is much bigger, much more dangerous and much more difficult to understand and manage than, say, depression. But before I set out my case, it would help if you had some background so you can understand how I arrived at this almost sacrilegious position.

I studied medicine in Perth, Western Australia, which takes pride in its reputation as the most isolated capital in the world. But I was the only student in my year who came from a country high school, all the rest had been to school in the city. I was the first of my entire family to complete high school, the first to go to university, and I knew just one person in the city when I arrived there. As a scholarship boy, I was able to attend the most prestigious residential college but right from the beginning, it was clear to me, and to everybody else, that I didn’t fit in. What spoiled it was that not only did I not fit in, but I had no intention of fitting in. And this continued throughout my studies. I spent my summer holidays working on isolated farms far from the city, I took history, politics and religion and other Big Ideas very seriously and slowly, it dawned on me that I didn’t like anybody with power or money. I liked ordinary people, I was at one with them and that hasn’t changed.

Throughout the six years of my medical course, my plan had been to train to become a country general practitioner. I never intended nor expected to stay in the city longer than I had to but in my first posting of my first year, that all changed. I was sent to the neurosurgery unit and loved it, to the extent that two years later, I managed to get another three months on the unit. It was a busy life. In the good old days, we were rostered on duty in the hospital for as much as 103hrs a week. If you slept for a few hours here and there, you were lucky. On several posts, I was routinely rostered on continuous duty from 8.00am Friday to 6.00pm Monday. It was not unusual to work until sunrise on Saturday, or even longer. Yes, it was dangerous but there was no point complaining as many of our consultants had served in the Second World War and they scorned anybody who complained about being tired. Convinced that I had found my purpose, I applied to begin the training. A neurosurgeon must do the same training as a general surgeon, then a further two years in his specialty. I threw myself into the reading program, essentially basic medical school again, anatomy, biochemistry, physiology, pathology, with a big emphasis on neuroanatomy and neurophysiology.

At the end of my three years as a junior medical officer, just before I was due to start formal surgical training, I was given the choice of yet another term in the emergency department or going to the psychiatry ward. Psychiatry? It seemed that would be helpful for a neurosurgeon so that’s what I chose. My first day wasn’t much fun, it was difficult to reconcile all this talking with the idea of cutting heads open but within a few days, I realised that this was what I had always been interested in: Big Ideas. And psychiatry, of course, deals in the biggest ideas of all: mind, reality, the lot.

After three months, I left to go to another hospital to start as a surgical registrar, or trainee (resident, in the US). I’d already had nearly three years of surgical jobs so it was back to the routine of dealing with lumps and bumps, blood and pains, smashed bodies, burns and the like. During the afternoon of my second day, halfway through the second gall bladder and before I started on my list of haemorrhoids, I realised I couldn’t spend the rest of my life doing this. Two hours later, I left the operating theatre and rang the head of the psychiatry department in my old hospital to see if he could give me a job. Yes, he said, we’re very short, when can you start? I had to wait three months but this time, I knew exactly what I wanted. There were two things that psychiatry could give: Big Ideas, and real contact with people. Remember this was the 1970s, there were lots of Very Big Ideas being tossed around at the time. One of them was Always Be Nice to Each Other. It would be very nice, I thought as I drove home, to be among people who care about humans and are hooked on Big Ideas.

Most psychiatrists had decided during medical school, or even earlier, what they wanted to do. As soon as possible, they began their specialist training, which took them out of the mainstream of medicine. My route into psychiatry was rather circuitous, and it took just two and a half days for this to show. Our training program was held in the university department of psychiatry every Wednesday afternoon. On my first afternoon, I met my new colleagues who had started three months before me, and settled down to await with great interest the first lecture in my new career, on depression. It was not at all what I had expected. The professor, a taciturn man who clearly had little time for human beings, came in, stood at the lectern and immediately started to talk about brain chemistry.

With my colleagues industriously copying his every word, he announced that depression was caused by an imbalance of what he called biogenic amines in the hypothalamus. Antidepressant drugs were therefore used to correct that imbalance. The symptoms of depression were just the effects of a molecular brain disorder, just as a hyperglycaemic state was the effect of not enough insulin, or inflammation was the effect of a foreign organism in the body. The psychiatrist’s role was to ask the patient for his symptoms, here you see them in this list, in fact you can hand the patient the list and get him to tick the relevant boxes himself, then you add up his score. If it’s over 25, that says he’s got depression and you give him the drugs or ECT (electroconvulsive therapy, or shock treatment) or both. Any questions?

Well, yes sir, I have some questions. For a start, I’ve just spent an extra three years studying the brain and I can state flatly that what you said about the neurochemistry of the hypothalamus is simply not true. Also, the neural pathways you showed in your slides are out of date, and nobody knows enough about the hypothalamus to be sure of its role in emotion. And is depression the sort of thing you can “get” like you get syphilis, or is it a frame of mind? Sir.

With a strange look, which I later learned was caused by grinding his teeth, he picked up his files and stalked out, muttering over his shoulder something about next week’s lecture as he went.

“What do you think you’re doing?” the other registrars hissed as the door slammed shut behind him. “If you want to get kicked off this program, that’s a great start. Don’t ever, ever disagree with him. You’d better learn to knuckle under or start looking for another job.”

But knuckling under had never been my strong suit and, aged nearly twenty-seven, it was a bit late to start learning.

By the end of my first week, my thoughts of a fascinating career in an atmosphere of genteel intellectual camaraderie had turned to dust. I realised that the only way to survive in what was little better than an academic cat fight was to know the stuff better than everybody else. That meant hitting the books and fortunately, I’m good at that. I’ve never watched TV or played cards or most of the other distractions that medical students indulge so I started at one end of the section of psychiatry in the library and set to work.

In those days, certainly in Australia, psychiatry was seen as a very mild-mannered endeavour, a flea on the tail of the medical dog, you could say. Psychiatrists were seen as other-worldly, often lazy, if not half-crazy themselves, and generally irrelevant to medicine’s real job of fixing sick people. The psychiatry department was tolerated only because nuisance patients or the genuinely insane could be sent there before they wrecked the place: out of sight, out of mind. The subject matter of psychiatry was airy-fairy, an amorphous mishmash of some Freudian stuff, which was good fun because it allowed junior doctors to talk about their favourite subject, a bit of “rats and stats” and some hard stuff like shocking brains or cutting them. That bit I knew about. In my anaesthetics term, I had put many people to sleep so they could be given electrically-induced fits and, in neurosurgery, I had actually assisted at almost the last leucotomy (lobotomy) operation performed in Western Australia, on a 34yo man. But the rest was new and fascinating.

In those halcyon days, there were three themes in psychiatry. The first I’d met in my first lecture, the notion that all mental disorder is just a special sort of brain disease. People who believed this called themselves biological psychiatrists and spent their time talking to patients and junior doctors about brain...