Barry Blackwell: Lithium Controversy

Hector Warnes’s response to Barry BlackwelL’s response

I beg to differ with Barry on the use of the word agnosia for a manic patient who had no reality testing or insight while he was indeed in a manic episode.  Agnosia has not been used in psychopathology in this sense as far as I am aware. The word agnosia is reserved for the complex of agnosia, apraxia and aphasia that appear in organic brain disorders.  The Greek aetiology of the word is right, as you pointed out, but we have chosen to use the words, loss of reality, lack of reality testing or lack of insight into his illness. D. Ewen Cameron often recommended to us to study in depth, Henderson and Gillespie’s Textbook of Psychiatry-Ninth Edition-Oxford University Press, 1962.  I shall quote from this edition revised by Sir David Henderson and Ivor R. C. Batchelor the following, regarding the difference between psychosis and neurosis (Freud in Neurosis and Psychosis- vol. XIX of the Standard Edition, p. 149 also addresses this problem in a memorable monograph) on page 132-133,  “As Meyer put it, a neurosis is a part-reaction (of the personality), while a psychosis is a total one. Furthermore, in a psychosis reality is changed qualitatively and comes to be regarded in a way very different from the normal, and the patient behaves accordingly; in a neurosis reality remains unchanged qualitatively, although its value may be quantitatively altered. But the neurotic acts always as if reality has the same kind of meaning for him as for the rest of the community. Psychopathologically, the psychotic change in reality-values is partly expressed as projection which consists in attributing an experience in origin entirely subjective to some external personal agency…in the neurosis language as such is never disturbed, whereas in the psychosis it often undergoes distortion….” The question about what kind of reality we are referring to would lead us to a philosophical discussion. Winston Churchill, in a speech to the House of Commons on Jan. 22, 1941 said: “I do not resent criticism, even when, for the sake of emphasis, it parts for the time with reality”. If we were to choose a Greek word I would prefer the word ‘anosognosia’, which according to the Psychiatric Dictionary (fifth edition, 1981) written by Robert J. Campbell and published by Oxford University Press reads: “Unawareness of physical illness. In persons with organic brain syndrome (first described by Anton in 1899), there is a tendency to suppress all knowledge of the disability. This is a protective mechanism that is particularly likely to occur when the incapacitation is total and so severe that the patient is unable to use the disturbed capacity at all” (p. 39). Please, notice that Campbell refers to ‘unawareness of physical illness’.   As you know, some delusional or manic patients have completely lost insight into their illness while others are able to retain partial insight which may also fluctuate. The Gabriel Anton and Joseph Babinski syndrome is known in neurology as cortical blindness or visual anosognosia.  Some patients with this neurological lesion in the occipital lobe may dismiss their blindness and confabulate in order to fill in the missing sensory input.

Regarding Schou and Pauling, I am in full agreement with Barry when he writes: “In assessing the accuracy of any scientist’s piece of work we can never take into account that the scientist’s reputation but must rely only on the integrity of the results and the methodology used to evaluate them. This is the whole reason for double blind methodology to substract the influence of persona judging validity”. I would add that most scientists have many failures before stumbling upon the moment of Eureka (from the Greek heuriskein, to find or discover). Pauling, indeed, merited the Nobel Prize but thereafter, he drifted into more swampy areas of research which led him nowhere.  We are aware of another great scientist Daniel Carleton Gajdusek, who was awarded the Nobel Prize in Physiology or Medicine in 1976 for his work an encephalopathy called Kuru (the word means to shake), which much resembles Creutzfeldt-Jacob disease, a transmissible spongyform prion disease just like the fatal familial insomnia.  Gajdusek was able to bring a sample from a diseased patient from Papua-New Guinea and injected it into two chimpanzees. It took two years for them to contract the illness.  Once I heard him lecture in Ottawa and was fascinated by the risks he took and the painstaking efforts to test his hypothesis (particularly the one regarding eating human flesh as a practice in a family mortuary). Later on, he fell in disgrace, not because of his outstanding scientific achievements but because of his outrageous moral conduct.

Martin Heidegger the greatest philosopher of the last century flirted with the Nazi ideology for a while but after a couple of years he withdrew into splendid isolation.

Finally, on purely clinical grounds, whatever your interpretation of the patient’s behavior and demeanor, if the patient’s depression has lifted it has lifted. However, we need more biochemical markers to ascertain your point of view by comparing the responders versus the non-responders to lithium therapy.

Hector Warnes

December 10, 2015