“Mixed Bag” is a series on Psychiatry at the Margins where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item they have to explain why they selected it and what it signifies. — Awais Aftab

Jesus Ramirez-Bermudez, MD, PhD works at the National Institute of Neurology and Neurosurgery of Mexico, where he is engaged in clinical practice, teaching, and research in the field of neuropsychiatry and clinical neurosciences, focusing on issues such as psychosis, catatonia, and cognitive disorders. He has published several books that straddle the divide between the genres of literary essay and clinical narrative. He received the Literature Award in 2009 from the National Institute of Fine Arts of Mexico. He tweets at @JRBneuropsiq.

Book — “What Makes Us Think?: A Neuroscientist and a Philosopher Argue about Ethics, Human Nature, and the Brain,” by Jean-Pierre Changeux and Paul Ricoeur

Ramirez-Bermudez: This book offers a memorable discussion about human nature, but it also puts on stage the values of an ethics of debate. Ricoeur speaks from the philosophical traditions of phenomenology, hermeneutics, and existentialism, and from a religious background. Changeux, a neuroscientist, embraces Democritus’s sense of humor and his materialist ontology while studying the neural basis of mental objects, moral decision-making, and aesthetic experience.

Changeux stresses the epistemological advantages of a third person perspective that protects the value of objective knowledge, even when the aim of the scientific project is to bring knowledge about the psychological aspect of our lives. Ricoeur replies with these words: I will modestly but firmly restrict myself to considering the semantics of two distinct discourses - one of which concerns the body and brain, the other I will call “the mental.” My initial thesis is that these discourses represent heterogeneous perspectives, that is, they cannot be reduced to each other or derived from each other. In one case, the question refers to neurons and their connection in a system; in the other case, one speaks of knowledge, action, feelings - acts or states characterized by intentions, motivations, and values. Therefore, I will combat the type of semantic amalgam that one finds summarized in the formula “the brain thinks.” Ricoeur clarifies that, according to his conception, the mental is not equivalent to something immaterial or non-corporeal. Both authors believe that the mental is inseparably bound to life and corporality and warn against slipping from a dualism of discourses into a dualism of substances, as each field of study typically defines itself in terms of a final referent.

The discussion between Ricoeur and Changeux offers important insights for medicine, neuroscience, and the psychological sciences. A significant proportion of patients diagnosed with psychiatric disorders have life experiences that require an idiographic understanding; psychosocial factors may be the primary cause of some clinical problems, or they may interact with biological factors in other cases. To provide quality care, it is necessary to conduct a thorough exploration of conscious experience, intersubjective frameworks, and the sociopolitical aspects of mental health. However, we must also be mindful to recognize cases in which a neurobiological explanation presents an opportunity to alleviate suffering and restore health. As mental health professionals, it is important that we strive to be epistemic polyglots, to the extent possible.

Concept — Clinical Narrative

Ramirez-Bermudez: I am interested in the literary tradition that exists in the borderland between scientific reports and creative writing, which I refer to as “clinical narrative.” This form of literature offers a multifaceted viewpoint on clinical experiences, including first-person, second-person, and third-person perspectives. While the tradition is rich with stories written by physicians and psychologists such as Alexander Luria and Oliver Sacks, clinical narratives are not exclusive to these professionals.

One of the central themes in clinical narratives is the problematic aspect of conscious experience. I'm not referring to the “hard problem of consciousness” as defined by David Chalmers, but rather to texts that offer detailed accounts of human illness and disease, such as Being Ill by Virginia Woolf and Darkness Visible by William Styron. Some works highlight the conflict between the subjective perspective and the interpretations of the social actors who interact with a patient, within specific historical contexts. This is the case of Gerard de Nerval and his novel Aurelia (1855). The poet was admitted to a psychiatric hospital during an episode of mania —according to the diagnosis of the time- and he died by suicide, with a copy of Aurelia in his pocket. The text reveals his account of the episode: it narrates the ascent to an illuminated eternity.

A foundational moment in the tradition of clinical narrative appears with Chekhov, in the tale entitled Room number six (1892). It is a work of literary fiction based on his experience as a doctor in psychiatric asylums in the 19th century. In her historical essay about the largest mental asylum in Mexico, La Castañeda, Cristina Rivera Garza suggests that the culture of mental health is the result of a confrontation between many voices: As they clashed and negotiated, the patients of the psychiatric hospital and their doctors produced tense and volatile narratives of mental illness, texts with multiple voices in which both actors implicated and interweaved their own relational concepts of body, mind, and society.

Some books—like Music, by Yukio Mishima—focus on psychotherapeutic relationships outside of Western societies. Other texts evoke the experience of illness, and reconceptualize it through contemporary science. In Brain on Fire, the journalist Susannah Cahalan wakes up in a hospital with no memory of recent events and discovers that an autoimmune disease attacked her own brain; an immunological treatment restored her lucidity. Brain on Fire is a scientific autobiography that reinterprets the myth of madness through neuroscience. More disconcerting is My stroke of insight (2008), by Jill Taylor—a Harvard neuroanatomist—who suffered from a brain hemorrhage in the left hemisphere and experienced a prolonged mystical state; she could not communicate the ecstasy because the hemorrhage had taken away her language. The tradition of clinical narrative embodies the tension between the diverse perspectives in the field of mental health, including stories that directly challenge the medical narrative, as would be the case of Building a life worth living, by Marsha Linehan. But the narrative arts can act as mediators or even peacemakers, by fostering an understanding between the opposing views. Clinical stories are open to multiple interpretations, preserving the diversity of discourses on human meaning and avoiding the imposition of monolithic versions of our humanness.

Article — “Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin” by Thomas A. Pollak and colleagues. (2020)

Ramirez-Bermudez: I should explain that I work at a neurological hospital where I focus on caring for individuals who experience drastic changes in behavior. Some of these patients suffer from hallucinations, delusions, cognitive disturbances, and catatonic states. As part of the clinical neuropsychiatry team, I am responsible for determining if these changes align with psychiatric syndromes such as psychosis, delirium, or catatonia. In doing so, we must also decide if the patient requires hospitalization for further medical evaluation to identify the potential presence of autoimmune encephalitis. Recent research has indicated that the vast majority of patients with autoimmune encephalitis display severe psychiatric symptoms. A patient received messages from God on his cell phone telling him to recklessly pass a truck on the highway; another patient believed that he was trapped inside a false world which was created by some enemies, so he attempted suicide. Without the specific treatment, the mortality rate and the amount of long-term disability rates are significant. The 2020 paper by Pollak et al, Autoimmune Psychosis: An International Consensus in Lancet Psychiatry, has been instrumental in guiding our decision-making process and reducing the likelihood of both type I errors (false positive diagnoses) and type II errors (false negative diagnoses).

In the broader field of mental health, there is a tendency to reify psychiatric disorders through reductionist approaches to neurobiology. On the other hand, the anti-biological critique of psychiatry dismisses the potential for neurobiological factors being relevant in specific forms of psychological suffering or divergent behavior. My working hypothesis is that neuroscientific research will not uncover a single biological marker for schizophrenia or other primary psychiatric disorders. Instead, it is likely that we will discover specific diseases that cause psychiatric syndromes such as psychosis, catatonia, cognitive dysfunction, and affective syndromes, accounting for some cases that are currently categorized under broad and imprecise labels such as schizophrenia or major depression. This is already happening in small scale when it comes to autoimmune encephalitis, neurodegenerative diseases, or neurodevelopmental conditions.

Person — Sor Juana Inés de la Cruz

Ramirez-Bermudez: The greatest poet in Mexican tradition—and a herald of feminism—was born in the 17^th century in the small town of Nepantla, near my hometown. My family would visit the ruins of her house when I was a child. While studying the cultural history of melancholy, I became fascinated by the most ambitious work by Sor Juana, a philosophical poem within the tradition of the baroque. First Dream, by Sor Juana Inés de la Cruz, contains physiological concerns about the nature of wakefulness, sleeping and dreaming, but also about the epistemological limits of knowledge. The Mexican poet Octavio Paz argues that First Dream deals with the contemplation of nature and the disquiet of the spirit—anxiety, turmoil, decline, rebellion—when not being able to transform that contemplation into an intellectual form or idea. Sor Juana observes with irony and melancholy the similarities between humanity’s material creations and its cognitive buildings. The pyramids and palaces have the same ambition and vanity in her eyes as our philosophical systems, but also the same limits: they are ephemeral works of the soul during the search for an eternal essence.

Sor Juana shares her search for a primordial essence that would be the First Cause of the Universe and of the human mind. But the search for absolute knowledge is frustrated. Resignation in the face of the impossible knowledge places the nun on the grounds of immanence. Her dream journey is not a flight to fantasy nor a metaphysical delusion. Sor Juana knows that her intellectual vision is finite and cannot contain the infinite. The nun explores rational forms throughout the poem and finds a melancholic reason. The adverse effect of rationality is the loss of the infinite, which even takes her away from the divine. But she finds a sincere knowledge about knowledge: one that can be shared as a poem.

Surprise Item — The History of Lev Zazetsky

Ramirez-Bermudez: L.Z. was one of the unknown heroes who stopped the Nazi advance in Russia. His testimony forms the central narrative of The Man with a Shattered World. The chaos of the early pages of the book is because the soldier has received a bullet impact to the head. At the worst moment, he has forgotten his personal identity. His doctor, Alexandr Luria, author of the book, finds him in a hospital with serious neurological problems.

Zazetsky’s skull is broken: there is a serious injury to the left parietooccipital cortex inside. The subject can't see the right side of the universe. He closes one eye, then the other: the invisibility of the right hemispace remains unchanged. He discovers with amazement that he has forgotten letters: he, a fourth-year student of Mechanics University, has become illiterate again. If the doctor gives him a hand, L.Z. doesn't know which one to extend. The chair is farther away than it seems; the fork doesn't obey him, and he can't pierce the meat. Suddenly I come to myself and I'm horrified to realize that I'm missing half my body. With a frightened look, I think: where have my right arm and leg gone?

He is not just any soldier. His father died in a coal mine when L.Z. was two years old. He was educated along with three brothers by an illiterate mother. Zazetsky yearned to attend university to help his mother, to be a multifaceted Soviet man, capable of offering the nation help in the field of science and technology. That optimistic naivety, which allowed him to dream in adolescence of a world of letters, liberating and fraternal, will allow him to courageously face the world shattered by neuropsychiatric illness. At first, it's impossible for him to read and write, because he tries to copy the texts written by others, but one day a doctor asks him to write his own ideas. Surprisingly, he discovers that he can write fluently, but he can't read what he wrote. Technically, it's a case of alexia without agraphia. The rediscovery of writing will allow him to rescue fragmentary evocations of war and illness. Above all, it restores the continuity of his personal identity. A pile of yellowed notes will accumulate in disarray. After twenty-five years of clinical work, Doctor Luria will give them a logical arrangement for publishing the book The Man with a Shattered World: a story about war, the left hemisphere, and the power of writing as an artifice for remembrance.

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