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Wednesday, 19.06.2019

INHN: Celebration of Max Fink’s 96th Birthday
Edward Shorter for Max Fink’s 96th birthday

 

            Max Fink turned 96 this year and remains highly productive.  He and I have just published a book with Oxford University Press: The Madness of Fear: A History of Catatonia.  And so, a few words are in order.

            What is striking is not merely reaching 96 in good order, but also a lifetime of contributions.  Very few investigators in psychiatry have anything like his lifetime experience.  Most of us stagger out a thought or two and then fall silent;few big names in psychiatry have been productive into their nineties.  Thus, it is producing a lifetime's worth of important literature that is the feat here, not simply achieving a record age for an active scholar.

            Max is, of course, closely identified with rescuing ECT from a looming oblivion. 

And I think it is true that, if Max had not campaigned vigorously on behalf of  ECT, a procedure that was in the 1970s very much stigmatized, we wouldn't have it today. This is of particular importance because ECT is currently undergoing a revival and many younger psychiatrists, untroubled by the association of ECT with a toxic Hollywood movie ("One Flew Over the Cuckoo's Nest," 1975), now routinely prescribe it. 

            But I would like to enlarge the frame a bit.  Max's contributions to scientific psychiatry have by no means been limited to convulsive therapy.  In 1962 he and Don Klein virtually pioneered the RCT in the United States with their trial at Hillside Hospital in New York that determined that anxious patients with panic disorder responded to imipramine but that anxious patients with phobias  did not.    Two years later, Don Klein nailed this distinction firmly.  This use of a "pharmacologic torch" to differentiate disease entities is among the key findings of modern psychopharmacology.  Here the credit is shared with Dr. Klein.

            After moving to St Louis in the mid-1960s, Max and Turan Itil opened up the whole area of "pharmaco-EEG," using EEG to differentiate the effects on the brain of different classes of psychopharmaceutical agents and to show that these brain effects were associated with different behavioral outcomes.  Today, interest in pharmaco-EEG has lapsed,but the finding was a basic building block in neuroscience and this alone would have entitled its originator to a place in history.

            Max's efforts to preserve ECT from extinction -- and to return it to the central place it now has in scientific therapeutics -- began in the 1970s with his return to New York.  The mob was virtually howling to ban ECT, certainly in children, and it was an act of almost personal bravery to stand against this tide and to insist on ECT as the most powerful therapy that psychiatry had to offer.  It is for this battle against the forces of negativism that Max is probably best known -- "Dr. Shock" -- and this achievement alone would have guaranteed its champion remembrance in history.

            I'm going to mention two more achievements, this time in the area of diagnosis rather than treatment. Both are huge. DSM-III, of course, effaced melancholia as a distinct disease entity, making it part of the vastly heterogeneous category "major depressive disorder." This was a serious scientific blunder and a number of investigators, including Bernard Carroll and Gordon Parker, have allied themselves against it. The book, Melancholia, that Max and Michael A. ("Mickey") Taylor authored in 2006 (Cambridge University Press) was the first modern guide to the treatment of melancholia and Max's writings have done much to re-establish melancholia as a distinctive, treatable entity, responsive to tricyclic antidepressants and ECT. Nine years later, Max and Mickey Taylor did the same thing for catatonia (Cambridge University Press, 2003).  There is a large overlap between melancholia and catatonia; in both, there are very similar stupor states and both are exquisitely responsive to ECT. 

            This overlap sets some of the scientific agenda for the future. It opens the question:  Are melancholic and catatonic symptoms just epiphenomena? What are the real diseases deep down in the brain that spin them off, so that at one point distress is registered as catatonic in nature, at another as melancholic?  What are the vast underlying neural rivers that heave off these surface symptoms? Whoever answers these questions will be a candidate for a Nobel Prize. But it is Max's work that has laid the basis for it.

            I have now listed five major contributions of Max Fink to modern psychiatry.  One major contribution would secure a historic reputation for many investigators.  Five is "Kraepelinian" in scale.

 

References:

Fink M, Taylor MA. Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cambridge: University Press; 2003.

Shorter E, Fink M.  The Madness of Fear: A History of Catatonia. Oxford University Press. 2018.

Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology and Treatment of Depression. Cambridge: Cambridge University Press; 2006.

 

January 17, 2019