Book review: The Meaning of Madness

To many new principals and registrars, the name Neel Burton will be associated with one of the more comprehensive and popular OSCE revision guides. Others may be familiar with his prizewinning psychiatric writings. Now we are presented with a refreshing approach to the age-old question of ‘personhood’ through a blend of psychiatry and philosophy.

Using memorable instances from literature and the history of medicine, Burton covers personality disorders, schizophrenia, depression, bipolar disorder, anxiety, and suicide, using each in turn to re-examine the human condition. What is schizophrenia? What are the boundaries between mental disorder and normality?

The case of Phineas Gage, the US railroad worker who survived having an iron bar through the frontal lobe is used to open discussion on what personality is and where it comes from. Although he survived, Gage became a ‘different person,’ someone ‘fitful, irreverent, indulging at times in the grossest profanity.’ As a sixth former in 1995 I remember Susan Greenfield entrancing a hall full of Oxford applicants with this story which stirs anxieties at the core of one's being. Thought experiments involving (among other things) hypothetical total and partial brain transplants illustrate the problem that identity is far from a simple concept. If, for example we transplant Brown's brain into Robinson's body, the person resulting is Brown. This is either because he is Brown's brain, or because he is psychologically continuous with Brown. However if you could (for the sake of argument) divide Browns brain in two and transplant it into two bodies — would they both be Brown? This philosophically rich, engaging approach runs throughout the book. Chapters may be read on their own or as part of the whole.

Like many popular and readable books, the occasional misleading oversimplification or misconception does creep in. Burton refers to Dr Jekyll and Mr Hyde by RL Stevenson as an example in literature of ideas around schizophrenia. Although he describes multiple personality as rare and not a core feature of schizophrenia — he goes on to describe how 65% of psychiatrists at most, agree on what is schizophrenia — The Jekyll and Hyde narrative is, if anything, more ‘psychoanalytical’ in its themes. In his (sadly incinerated) first draft, Stevenson allegedly did not envisage a physical change in his hero but a disguise that allowed Jekyll to get away with things his position did not allow. Influences on Stevenson included the tale of Deacon Brodie: cabinet maker by day and burglar by night. By contrast, the subtext of Bram Stoker's Dracula is far more illustrative of mental disorder in the context of madness and society, madness and religion and madness and criminal responsibility. In the narrative, Professor Van Helsing (a psychiatrist) describes the vampire as of ‘child brain’ and therefore, ‘predestinate to crime’. In using Jekyll, Burton makes a point by reinforcing a misconception which stems from Hitchock's Psycho.

Other criticisms include a reference implying that the practice trepanning/trephination in ancient times represents evidence of schizophrenia — a conclusion which is by no means obvious. The influence of Cicero on illness as an emotional imbalance is tantalising but all too brief.

Fine-print aside however, I would echo Professor Bill Fulford's endorsement, ‘This remarkable book … by combining literary, philosophical and scientific sources, shows the deep connections between ‘madness’ and some of our most important attributes as human beings.’ This book engages with the reader's own hopes, fears and prejudices — highly worthwhile edu-tainment.

• © British Journal of General Practice, 2010.