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Sunday, 26.03.2017

Reply to Aitor Castillo by Barry Blackwell

Barry Backwell: The anxiety enigma

I thank Aitor Castillo for being the first person interested or intrepid enough to comment on “The Anxiety Enigma.” He is kind to the messenger but critical of the message. I believe he is accurate about the former and mistaken concerning the latter!

It was not anxiety that drew me to America which, in those days, was still “the land of opportunity”, welcoming to migrants bringing talent from Europe.

First I take issue with Aitor’s claim that we are anywhere close to solving the enigma. Clinical research has added little or nothing in the last two decades due largely to the near extinction of meaningful or ethical clinical psychopharmacology on this or any other topic. His two clinical citations (9 & 10) are 14 and 22 years past due!  It is true that neuroscientists of a basic persuasion are still able to fan their fame and pad their resumes with isolated scraps of information marginal to the topic. The annual flood of poster sessions at the ACNP, some with as many as 20 authors, certifies that.  I note that 4 of his 5 recent basic science citations (4-18) have 3 authors and ‘et al.’ One is about depression, not anxiety (2), and another is 7 years old (3). The only recent citation is the DSM 5 (1) and we all know what a beating that has taken, all the way from the NIMH down to the public press.

Anxiety is like a large jigsaw puzzle from which it is possible to finger a piece or two, while the total picture remains a jumble of unplaced pieces within a frustrating blur. Surely, if we have learned anything in the last 50 years, it is to beware of premature exuberance over “recent findings.” We have endured a graveyard of neurochemical theories (the first won a Noble Prize) but never came close to the Holy Grail.

Aitor is perplexed by my use of “archaic” terminology - those crude inclusive names that described putative clinical targets.  The DSM system and the pharmaceutical industry did indeed enlarge and erode these boundaries so that “spectrum disorders” abound while “specificity” became a fantasy, replaced by the reality of ‘trial and error’ prescribing.  So where is a new and relevant taxonomy?  Should we simply refer to a single category of “pharmacologic panaceas” and hope that genetics or some novel nosology will rescue us from a clinical quagmire?

Next, Professor Castillo takes me to task for ignoring the work of “Roche Laboratories.” But the reach of his memory falls short. Almost half a century ago, Frank Ayd and I convened a conference in Baltimore honoring all the clinicians who did the original work establishing the efficacy of each category of psychotropic drugs (Ayd and Blackwell, 1970).  Irvin Cohen spoke for the benzodiazepines and gave clear credit to Sternbach and his work on this category of drugs beginning in the 1930’s, almost 20 years before he joined Roche and completed the task, in 1954.

The enigma was not who discovered these drugs but what became of them in the real world. Aitor mentions 3 other compounds that “represent some advances.”  If the market place is a measure of clinical utility, these were non-starters. The enigma exists in the remarkable success of these drugs for treating ‘anxiety’, not in the failures.

Perhaps the most contentious statement in this dialog is the assertion that “I have some sort of prejudice against biological treatments.” To support this straw man, Aitor cites as a fallacy my belief in the incontrovertible fact that drugs only stifle anxiety, providing a respite, while philosophical insights, cognitive-behavioral and psychotherapeutic strategies can permanently erase the root causes. Frank Berger, who discovered the first drug to treat anxiety, published a post-mortem book of his lifetime philosophical musings. Cited in my Enigma essay, the book has only a single sentence referring to Frank’s work with meprobamate. “They (the drugs) make you feel normal again, able to cope again, but are no substitute for philosophy.” (Berger, 2014)

To reinforce the idea of my perceived biological pessimism, Aitor quotes four conclusions of an International Panel of Experts on use of benzodiazepines (10). There is not one I disagree with and I challenge him to point out why he believes I do.

Rather than being prejudiced against biological psychiatry I espouse an approach that integrates and deals with all the social, psychological and biological aspects of a person’s illness. This conforms to an ideal demonstrated by each of the pioneers whose biographiesI have contributed to the INHN website in the last two years. In particular please read Joel Elkes who was psychoanalyzed (Blackwell, 2015a) as well as Jean Delay (Blackwell 2014) and Heinz Lehmann (Blackwell, 2015 b).

Aitor’s commentary ends by, once again, attributing my own anxiety as a driving force for the entirely imaginary dream scenario I use to portray the diversity of expert opinions about drug use for anxiety. This invented tale is based on the fully aware emotions experienced by trainees at the Maudsley, presenting a patient to Sir Aubrey Lewis during a case conference (Goldberg, Blackwell & Taylor, 2015).

As readers may perceive, I relish the cut and thrust of academic debate when those who would, at other times be best of friends, ‘go for the jugular’. Thank you, Professor Aitor Castillo, for entering the ring with me and for your kind comments. Now can we drink to one another’s health?


Ayd FJ, Blackwell B, editors. Discoveries in Biological Psychiatry.  Philadelphia: J.P. Lippincott; 1970, pp.11-29.

Blackwell B. Jean Delay. A Biography of Jean Delay. INHN Biographies 02.27.2014a.

Blackwell B. Frank Berger. A Man of Understanding. INHN Biographies 21.08.2014b.

Blackwell B. Joel Elkes. An Integrative Life. INHN Biographies 30. 07.2015a.

Blackwell B. Heinz Lehmann. INHN Biographies 12.11.2015b.

Goldberg D, Blackwell B, Taylor D. Sir Aubrey Lewis. INHN Biographies 19.02.2015.


Barry Blackwell

October 1, 2015