The year 1984, which now seems like ancient history, was a formative one for me and a landmark year in the field of psychiatry. I had graduated from residency two years earlier and was just starting my academic career in Boston, a city that was teeming with intellectual excitement and that contained more psychiatrists in each square mile than many western states had in total. 1984 was also the year psychiatrist and researcher Dr. Nancy Andreasen published one of the most influential and popular psychiatric books of the 1980s: The Broken Brain.
To appreciate the impact of this classic book, you need to understand that, by 1984, the field of psychiatry was at a critical juncture. The allure of Freudian psychoanalysis had faded — its heyday in the United States was in the 1950s and ‘60s — and many psychiatrists were questioning the entire Freudian framework. Biology, like a bright and rising star, was in the ascendant. Many psychiatrists were convinced that psychiatry was on the verge of a momentous breakthrough, a genuine “revolution” (as Andreasen’s book made clear) that would explain many mental illnesses in largely biological terms.
The most exciting aspect of psychiatry in the early ‘80s was the hope that we would soon be able to grab devastating illnesses such as schizophrenia by their twisted biological roots. This, in turn, would allow us to devise medications targeting the specific biochemical imbalance driving the disease — for example, by blocking (apparently) excessive levels of the neurotransmitter dopamine in schizophrenia. Alas, nature had other things in store for psychiatry. Early biological discoveries related to schizophrenia, major depression, bipolar disorder, and other serious illnesses were of great theoretical interest but failed to generate powerful new treatments. In effect, the research findings were “lost in translation.” Eventually, many psychiatrists disavowed the “chemical imbalance theory” of mental illness, which the general public had come to associate with depression and with “SSRI” antidepressants such as Prozac. In truth, the chemical imbalance theory was never a bona fide scientific theory so much as a simplistic slogan propagated by direct-to-consumer pharmaceutical company advertising.
So, with 20/20 hindsight and the benefit of nearly four decades of experience, where do we position Andreasen’s groundbreaking book? Was it really an extended argument for a “biological revolution” in psychiatry? Or was that a popular, and even a professional, misrepresentation of Andreasen’s core thesis? (And no, you can’t always judge a book’s thesis by its subtitle.)
How much did Andreasen’s book get right about the nature of mental illness, and where did it go wrong? How many of Andreasen’s predictions regarding the treatment of mental illness were borne out? And, more broadly, what was the effect of the book on the popular culture of the 1980s and beyond?
Using the best scientific studies then available, Andreasen wrote this book for the general public. Her goal was to set forth what psychiatrists and neuroscientists knew, or thought they knew, about severe depression, schizophrenia, and other serious psychiatric illnesses. The gushy blurbs on the back cover from some of this country’s top psychiatrists established the book as “an extraordinary achievement” and a “clarion call signaling the biological revolution in psychiatry.” That last description is a plausible but somewhat misleading read of the book. To be sure, there are tons of biological claims, brain images, and laboratory studies in The Broken Brain. And why not? That’s where psychiatry was, in the early ’80s, and Andreasen was eager to share the data and her enthusiasm. And yes, Andreasen uses the phrase “chemical imbalances” in a few instances.
But The Broken Brain was no brief for a purely biological or neurochemical theory of mental illness. Throughout the book, Andreasen allowed for the role of psychosocial and environmental factors in the genesis of psychiatric illness. For example, she writes:
“An inherited lack of emotional resilience may be the predisposing factor — the necessary but not sufficient cause — in the development of affective [mood] disorders. This resilience could be programmed in the brain in its neurotransmitter systems, such as the norepinephrine and serotonin systems … [but] the environmental or social factors that trigger the development of affective illness may be either physical or psychological … social factors can include acute stresses, such as a loss or accident … sometimes a series of very small stresses may have a cumulative effect … especially if the person is already predisposed to develop depressive symptoms.”
Andreasen’s comprehensive framework is close to the current consensus view within American psychiatry and aligns very closely with Dr. George Engel’s “Biopsychosocial Model.” Engel’s model was developed in the late 1970s and has functioned as the “backbone” of academic psychiatry in the U.S. to this day. In that sense, Andreasen “got it right,” and it is a mistake to take the subtitle of the book as an accurate representation of her thesis. That said, I don’t like the word “broken” in the main title of the book. It suggests something shattered and irreversible, and that is not the case, even for the most serious psychiatric disorders. For example, a substantial proportion of people with schizophrenia will recover completely, and many more will regain good social functioning.
To her credit, albeit near the end of the book, Andreasen addresses the brain’s “plasticity”: its ability to “adapt and change in response to injury or to changes in the environment.” In this sense, “malfunctioning” might have been a better word choice than “broken.” Aside from that, and allowing for the passage of four decades, with hundreds of new biological studies of mental illness, I don’t believe Andreasen’s book made any glaring or substantive errors.
She was also correct with respect to psychotherapy. In a section titled “Will Psychotherapy Disappear?” Andreasen answers, “Not likely.” She even adds — correctly, in my view — that “psychotherapy is probably the preferred treatment for some types of problems,” such as low self-esteem or excessive guilt. On the other hand, substantially fewer psychiatrists are providing psychotherapy now than in the 1980s. Andreasen seems to have foreseen this trend, too. “As insurance companies try to place a ceiling on the rising costs of health care, elective psychotherapy for mild problems is an obvious place to cut.”
She also correctly foresaw that “the fifteen-minute appointment [will replace] the fifty-minute hour for many patients.” However, I think Andreasen went too far with her further comment that “much of the time, fifteen minutes is long enough for doctor and patient to talk to one another about the patient’s symptoms and how they are affecting his personal life.” (When I was treating seriously disturbed outpatients suffering from schizophrenia, I found it often took 10 minutes just to ease them into speaking a single word. I am not a fan of the 15-minute “med check.”)
Finally, what was the effect of The Broken Brain on the popular culture of the 1980s and beyond? Clearly, that’s a hard question to answer with scientific confidence. How, after all, do we measure the impact of any book on popular culture? Nevertheless, my impression is that The Broken Brain helped reinforce, in the minds of the general public, the entirely valid concept that psychiatric illnesses have a strong biogenetic basis. But if so, that has proved to be a double-edged sword. On the one hand, this knowledge may have reduced some of the stigma associated with mental illness and encouraged the use of beneficial medications such as lithium in the treatment of bipolar disorder. On the other hand, The Broken Brain may inadvertently have reinforced the “chemical imbalance” myth, to the detriment of both psychiatry and the very people psychiatrists treat. Yet, I don’t believe for a moment that is what Andreasen intended.
So — you say you want a revolution, as John and Paul once sang? In psychiatry, we must be careful what we wish for.
Ronald W. Pies, M.D., is a psychiatrist, medical ethicist, and writer who holds faculty positions at SUNY Upstate Medical University and Tufts University School of Medicine. He is also editor-in-chief emeritus (2007-2010) of Psychiatric Times.