By Barry Blackwell M.A., M.Phil., M.D., FRCPsych. and David Paul Goldberg DM, MA, MSc, FRCPsych, FRCP
Aubrey Lewis was born into a new millennium (November 1900) in Australia and died in London at age 74 in 1975. After anthropology research in Australia and clinical work in America, Britain and Germany he joined the staff of the Maudsley Hospital in London in 1929 and was named inaugural Chair in 1946 when it also became the Institute of Psychiatry at London University. Knighted by the Queen in 1959 Sir Aubrey is recognized as having raised the profile and respect of Psychiatry in Britain and worldwide both through his own contributions and those of the Faculty and trainees he recruited and mentored. His major biographer notes (Shepherd 1986) that Lewis had a “formidable and disciplined mind” coupled with an empirical clinical approach that did much to dispel the then prevailing view that, compared to other branches of medicine, Psychiatry’s “pretensions were greatest and its foundations least secure.”
Far from being a psychopharmacologist himself Aubrey had his finger on the pulse of the discipline when, in 1957, he became a founding member of the Collegium Internationale Neuro-Psychopharmacologicum (CINP), one of only 3 psychiatrists from the U.K among 33 worldwide. All 3 clinicians were from the Maudsley, Aubrey Lewis, Michael Shepherd (Ibid) and Linford Rees (early work on imipramine in depression). The following year Aubrey Lewis chaired the opening ceremonies of the First International Congress of the CINP (Rome, 1958).
Sir Aubrey’s later contribution to psychopharmacology was not ‘hands on’ but generative, due largely to the atmosphere and environment he created. He built the Institute of Psychiatry with five full University of London departments including neuropathology, biochemistry, biometrics, physiology and psychology, coupled with a large emergency room and clinical units at the Maudsley and Bethlem Royal Hospitals. Trainees from Britain and around the world rotated through these programs and were exposed to an environment where the major impact was the “internalization of a high standard of critical capacity.”
Combined with a requirement for a research Dissertation (later M.Phil.) this created a seedbed for graduates who went on to populate many of the world’s leading academic institutions. Among them was a cadre of psychopharmacologists who became pioneers in the field. Included were, John Snythies (Hallucinogens and mechanism of drug action), Philip Connell (Amphetamine psychosis), Eugene Paykel (Depression), Malcolm Lader (Benzodiazepines), Trevor Silverstone (Bipolar Disorder), Ted Marley (Basic neuroscience), Alex Coppen (MAOI) and Barry Blackwell (MAOI and Tyramine and Lithium Prophylaxis).
Sir Aubrey’s views on the contribution of new drugs to the field of psychiatry were modestly stated in his paper, “Medicines and the Afflictions of the Mind.” (Lewis 1963).
“We are not living through a period that marks a new epoch; there is no Darwin, no Harvey or Newton in psychiatry and psychology, nor to put our aspirations on a more realistic plain, have there been discoveries during the last twenty years comparable to those that have signaled the growth of therapeutics and surgery in other fields. Psychiatric advances have been less dramatic and less conclusive. Still, to those who have taken part in them, they have given the satisfaction and excited the hopes out of which enthusiasm is generated.”
At the time this was written, in the heyday of new drug discoveries for every psychiatric disorder, the comment was viewed as skeptical, perhaps pessimistic. Today, as we wallow in the doldrums of no new drug development the words sound prescient.
Had Aubrey Lewis’ own work on the nosology and natural history of mental disorders been better known and understood by psychopharmacologists and clinicians five or more decades of frustrated optimism might have been abbreviated. His doctoral dissertation on melancholia recorded the putative biological components evident in this condition; anhedonia, early morning awakening, diurnal variation in mood, loss of libido, amenorrhea, loss of weight and appetite, and suicidal ideation. These peculiarities became lost in the DSM fog of “major depression” or worse still in the ignorant and indolent category, depression NOS. Specificty of outcome was diluted and disappeared in a flood of antidepressants allegedly differing in biochemical profiles but yielding undifferentiated outcomes.
Perhaps Sir Aubrey’s most prescient and potentially game-changing contribution on the relationship between drug use and psychopathology is contained in a short but sadly overlooked article he wrote in the mid nineteen sixties. (Lewis, A. 1967 ) This is emblematic of his intellectual and literary style and concerns the use of the term “anxiety” in the psychiatric literature at exactly that time when the “minor tranquilizers” were on their way to becoming among the most widely used drugs in medical practice. (Blackwell, 2015). Although the timing of Sir Aubrey’s article and its concerns may have been triggered by these unfolding events Sir Aubrey discretely avoids mentioning the role of medication use and the pharmaceutical industry in influencing psychopathology.
The article begins by defining the historical usage of the term “anxiety” first in France and Germany, then in Britain. He is careful to note this excludes literature from Russia, Scandinavia, Japan, Holland and other countries. He also notes anxiety’s tardy and sparse appearance in England despite the affects growing theoretical significance in Freud’s emerging psychological theories.
Concentrating on Anglo-American literature Sir Aubrey notes the “far from subtle or precise use” of the term anxiety which appears across a lexicon of emotional states that includes “insomnia, fears, phobias, apprehensiveness and depression as well as cognitive symptoms and social behaviors.” He dissects the ubiquitous use of the term in the psychosomatic and stress domains, the relationship of fear with anxiety and the use of the term, “unconscious anxiety” in psychoanalytic jargon which he dismisses as “a contradiction in terms”.
Sir Aubrey next refers to psychological attempts to define anxiety as a physiological conditioned response or a symptom on rating scales. “Critics emphasize that the scales measure and define only manifest anxiety. Other workers stress the need to recognize ‘unconscious anxiety’ but do not define it.”
Finally he notes attempts to identify and define anxiety in children by educational psychologists; “in regard to which there is much written but little clearly established.”
Sir Aubrey’s conclusions based on his review of the literature are characteristic of his pithy, frank and perceptive style. “Evidently while many voices proclaim that anxiety is the alpha and omega of psychopathology and that it permeates every sort of mental disorder, there are even more voices insisting that anxiety means what they choose it to mean.” Having reached this conclusion Sir Aubrey proceeds to provide his own succinct seven item definition of the term ‘anxiety’ and its manifestations.
1. It may be “normal” or pathological.
2. Mild or severe.
3. Detrimental to thought or action or, in some respect, advantageous.
4. Episodic or persistent.
5. Due to physical disease or, not of psychogenic disorder.
6. Accompany other mental disorders or alone.
7. An attack may or may not affect perception and memory.
This honest but highly ambiguous itemization leads Sir Aubrey to pose a final question about use of the term ‘anxiety’. “Should we do away with it?.”
His conclusion and its timing are prescient. “The prospect of killing the term is slender, as is the prospect of a successful convention devoted to making the concept and word scientifically successful.”
Over half a century later we can state in retrospect that the burgeoning use of drugs to stifle anxiety in its many manifestations succeeded in reifying the concept of “anxiety” and that while DSM nosology defined some of its manifestations the questions so elegantly posed by Sir Aubrey remain largely unanswered. (Blackwell, 2015)
Shepherd M. A Representative Psychiatrist: Career, Contributions and Legacies of Sir Aubrey Lewis. Psychological Medicine. Monograph Supplement 1986; 10: 1-31.
Lewis A. The Later Papers of Sir Aubrey Lewis. Oxford: Oxford University Press; 1979.
Lewis A. Medicine and the Affections of the Mind. Brit Med J 1963; 2 (5372): 1549-57.
Lewis A. Problems presented by the ambiguous word “anxiety” as used in psychopathology. Israel Annals of Psychiatry & related disciplines 1967; 5 (2): 105- 21.
Blackwell B. The Anxiety Enigma, INHN Controversies 03.10. 2014.
Barry Blackwell and David P. Goldberg