Listening with the Third Ear….

 

I joined a group co-teaching a resident seminar in psychotherapy a few weeks ago.  It is an interesting exercise blending didactics and experience.  The format is an hour of psychodynamic focused didactics followed by an hour-long discussion of a transcript by everyone in attendance including residents and 4 faculty. That is an interesting discussion of the technical aspects of therapy as well as individual differences in interpretation and intervention.

Today’s session was about listening and how listening in therapy may be different from what people consider to be typically focused or unfocused listening.  There was some discussion of how you listen to friends as opposed to strangers.  There was a secondary discussion of the depth of listening with a focus on unconscious determinants.  It led me to reflect on a couple of things during the session.

The first was focus.  Very early in my discussion with patients I was focused on what they were saying.  My focus was the same focus I would have with friends or family even though none of my patients would ever enter that sphere. People knew that I was serious and took them seriously.  As I thought about the way I interacted with people over the years – it was apparent that even though patients are technically not friends within a very short period, I would know more about them than I knew about most of my friends.  In some cases, I was more worried about them and spent more time worrying about them than I ever worried about most of my friends. The difference was in the relationship.  With friends there is a mutual affiliation and expectation of support.  In the case of patients – the relationship is for the benefit of the patient. Apart from payment, the gratification of doing good work,  and the occasional thank you -  the therapist should expect nothing back from the patient. 

The focus in both diagnostic interviews and psychotherapy was meditative to me.  I felt extremely comfortable in that setting.  I looked forward to seeing people.  It was the place in life where I felt the most comfortable. I was not particularly interested in one problem compared with another – just hearing every unique story.  When you get to a certain point in your career you are full of confidence.  You no longer have to worry about running into an issue that you don’t know how to address. You know that most people will leave your office feeling better than when they entered – even if it is an initial evaluation. 

Focus in a psychiatric interview is multifaceted.  It involves hearing both the content of what is being said and whether it makes any sense.  Do all the elements hang together in a cohesive picture or not?  If not, the job is to immediately clarify what is happening.  That always leads me back to think of an Otto Kernberg seminar that I attended 30 years ago.  Kernberg described the process of confrontation as exactly that – an indirect inquiry that would facilitate bringing these seemingly disparate elements together.  An extreme example that I frequently use is from acute care settings.  In those settings, my first task of the day was to interview people who had been admitted on involuntary holds.  They were often very angry to be hospitalized and demanded to be released. Their first words were typically: “I want you to discharge me.  You have no right to hold me in this hospital and I want to be discharged.”  The reality is that I had never seen the patient before.  I had nothing to do with how they came into the hospital or the fact that they were on an involuntary hold. Restating those facts to the patient was the type of confrontation Kernberg discussed and it most frequently led to a more productive reality-based conversation.

The focus for me always has the elements of attention, testing what is being said against my internal knowledge of reality and doing the same with any emotional content, and thinking about underlying theories for what I am seeing. At times I will explicitly ask the patient for their theories about what is happening to them to see if they have any and if they do whether they are plausible.  It is generally important to try to figure out the meaning of certain patterns of thought and behavior including dreams fantasies, and other potential unconscious content.

There is also a focus of kindness toward the patient.  The relationship is one of beneficence.  It always reminds me of Jerry Wiener’s comments about the essence of psychotherapy “Be kind and say something useful to the patient.” When I bring that up – many therapists bristle at the apparent oversimplification.  Kindness does get directly to the point that the therapeutic relationship is different from the patient’s perspective in that they should experience the therapist as unique relative to the common experiences in their life. Some therapists I have encountered over the years have talked about “reality therapy” to mean that the therapist should be reacting to what the patient does just like everybody else.  This misses one of the main advantages of psychotherapy as an opportunity to examine what is really going on in those other relationships and correct it if necessary.        

I addition to attending to the primary problem in sessions the therapist must also have a focus on the relationship and empathic responses to communicate to the patient that he had an adequate understanding of the mental problem that the patient is describing and what all the elements may be.  The relationship aspect may include the stimulus value of the therapist and how that varies with age, sex, physical appearance, and communication style.  To cite age as an example – it is common for early career psychiatrists just out of residency to be greeted with: “You are too young to be a psychiatrist.  I have never seen a psychiatrist as young as you are”. Those statements come with varying degrees of enthusiasm and carry several implications that can be explored.  On the other end of the spectrum I have not had anyone comment on my advanced age directly – but have heard comments that some doctors are so old “they did not know I was in the room.” 

Transference and countertransference are obviously relevant here but I want to stay with the focus in interviews and sessions.  In the seminar today, a paleontology metaphor was described about mining the different layers of the unconscious and how to get there.  That suggests a lot of heavy lifting to me. I see it as a much more dynamic situation.  After all – here I am extremely comfortable and interested listening to people and editing their comments for plausibility, cognitive and emotional content, defensive patterns, and their own theories about what may be happening to them.  Together we are defining what brought them in to see me along with all the relevant cultural, social, biological, and developmental factors.  This is all unfolding in the context of a specially defined relationship.  Throughout that session I am switching between listening mode and an interventional mode that involves supportive, clarificatory, and interpretive remarks.  That switching needs to be dynamic, context based, and is not the same for any two patients.  There is also the practical or real relationship including payment arrangements, appointment times, call instructions, and emergency contact instructions.

There is a check that must happen during or between sessions. Every therapist has to ask if they really understand what this patient is saying and if the patient is being helped.  That check can occur as early as the first interview.  In some cases, the therapist may consider the patient’s problem to be outside of their field of expertise. This can also happen after prolonged therapy where the benefit to the patient is uncertain – but they want to continue the therapy.

The title of this blog post refers to a famous book called Listening with the Third Ear by psychoanalyst Theodor Reik. I purchased the book in 1986 on the recommendation of one of my psychotherapy supervisors.  The subtitle of the book says it all: “the inner experience of the psychoanalyst.”  Reik was one of Freud’s first students.  In the chapter “The Third Ear” he describes attending to various cues of the unconscious life of the patient as well as what may prevent the analyst from perceiving them. He illustrates how the subjective reaction of the analyst to the patient can be one of those clues.

Reflecting on this essay so far – the one dimension that needs additional commentary is the non-linear nature of listening and the interview process. It is easy to think of the process as a matrix dependent on focused attention and a long sequence of questions.  That is the format of a structured interview. In many cases these interviews are algorithmic based on hierarchies and inclusion and exclusion criteria.  In a clinical and psychotherapy setting the focus is more on all aspects of the presenting problem. What the patient brings in to the session and the continuity over multiple sessions is more of a priority. Reik describes a patient who caused him to feel annoyed, two different patients walking by a mirror outside his office and how they react to the mirror, and the way a patient looked at him as well and what that meant for their unconscious life. 

In a subsequent chapter he goes on to describe how the analyst must avoid selective attention to what they might want to hear and how they must attend to everything.  He points out that Freud used the term gleichschweben  that has the connotation of equal distribution and revolving or circling (p. 157).  He suggests the terms freely floating and poised attention.  He adds Freud’s rationale for this type of attention as being two-fold.  First, it avoids exhaustion since it is impossible to attend to anything for an hour.  Secondly, it avoids biasing the interview or session toward a particular aim or goal.  The session after all is directed at what the patient is deciding is relevant.

As I revisited my technique, this captures what I tend to do in interviews and sessions. Since I read this book nearly 40 years ago – I cannot claim to have invented it.  I can add a little to what Reik and Freud have to say especially in diagnostic interviews.  It is possible to incorporate free-floating attention and transition to a more structured interview as necessary. Most psychiatric practices these days require that psychiatrists seen anywhere from 2 to 5 new patients per day.  Most of those patients will not be seen in either psychoanalysis or psychodynamic psychotherapy. But most of those patients will benefit from the listening techniques and interventions that can be attributed to the early analysts. It is also possible to add a psychotherapy component to practically every patient seen by a psychiatrist over time – even in relatively brief appointments.  

 

George Dawson, MD

 

References:

Reik T.  Listening with the Third Ear. Farrar, Strauss, and Giroux. Toronto. 1948: 144-172.

 

Supplementary 1:  Both Drs. Otto Kernberg and Jerry Wiener in the above essay are psychoanalysts with extensive teaching and publication experience. They are both medical doctors.  I left the qualifications out for the sake of brevity. I heard Dr. Wiener’s remarks at one of the Aspen Psychotherapy Conferences organized by Jerald Kay, MD.   

Supplementary 2: According to Reik, The metaphor listening with the third ear was borrowed from Nietzsche -  Beyond Good and Evil, part VIII, p.246.  A partial excerpt follows:

"What a torture are books written in German to a reader who has a THIRD ear! How indignantly he stands beside the slowly turning swamp of sounds without tune and rhythms without dance, which Germans call a "book"! And even the German who READS books! How lazily, how reluctantly, how badly he reads! How many Germans know, and consider it obligatory to know, that there is ART in every good sentence--art which must be divined, if the sentence is to be understood! If there is a misunderstanding about its TEMPO, for instance, the sentence itself is misunderstood!..."

Is Modern Psychiatry Too Intellectually Restrictive?

The inspiration for this post comes from my reading the history of psychiatry. That was not a particular interest of mine until I began researching threads of knowledge going back into time. Then I started to look at how American psychiatry evolved and the fact that it did not really exist at the same time psychiatry existed in Europe.  This is historically confusing in the US, where certain movements try to connect psychiatry to historical events where there are no connections.  The development of psychiatry in Europe is a complicated and interesting story.  The most striking feature is that those early psychiatrists were trained in neuroanatomy, neuropathology, neurology, and psychiatry.  Freud was a Privadozent in neuropathology.  Adolph Meyer emigrated to the US as a neuropathologist and eventually became the chairman of psychiatry at Johns Hopkins eventually influencing a significant number of American psychiatrists. 

In reading about these early psychiatrists, some authors will refer to them as neurologists even though the person in question identified as a psychiatrist (examples include Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868)).  Others like von Economo (1) were designated psychiatrists and neurologists.  After graduating from medical school in 1901 von Economo spent a year working in an internal medicine clinic and over the next four years worked at various clinics in Europe with Marie, Kraepelin, Alzheimer, and Oppenheim learning psychiatry, neurology, and hypnosis. He returned to the University of Vienna in 1906 and was appointed Professor of Neurology and Psychiatry in 1921. This was an observation from his book Encephalitis Lethargica (2):

"Towards the end of 1916 the wards of the Vienna Psychiatric Clinic contained quite a number of patients with a strange variety of symptoms - cases which had apparently only one feature in common - a difficulty to fit into any known diagnostic scheme.  They had been admitted under the most varied descriptions, such as meningitis, acute disseminated sclerosis, amentia, delirium &c.  The patients all showed a slight influenza-like prodromal condition with trifling pharyngeal symptoms, a slight rise in temperature, soon followed by a variety of nervous symptoms, though generally one sign or another pointed to the midbrain as a source...."

From there von Economo goes on to describe encephalitis lethargica in great detail.  He was subsequently nominated for the Nobel Prize in Medicine four times for this work.  He also worked on neuroanatomy - where he made additional discoveries. His education and career contrasts well with current psychiatric education in the US where it seems that too little content is being spread over too many years - even more if you want to be certified in both neurology and psychiatry. He apparently got what he needed in 4 years while living in 4 different European cities.  Places like the Vienna Psychiatric Clinic also do not exist today - where the only solid criteria for admission is dangerousness and all admissions need to be medically cleared  by somebody (physician or extender) that may be oblivious to neurological and psychiatric presentations of acute illness. 

More to the point – they were probably neuropsychiatrists and that has relevance for the system of board certification in the US.  Prior to board certification most psychiatrists in the US were neuropsychiatrists and practiced neurology and psychiatry. That all changed in 1934 when the American Board of Psychiatry and Neurology (ABPN) – made the rule that all psychiatrists practicing both specialties must pass both board certification exams.

Reading the paper (3) about Bleuler was interesting because it is an easy read that emphasizes several concepts in psychiatry that just repeat if you don’t understand them.  First is the age-old debate about categorical versus dimensional diagnoses.  The author’s conclude that Bleuler supported dimensional diagnoses but it seems they are describing his process as one of detailed formulation rather than dimensions. This was rooted in his method of clinical psychiatry. I suppose a four dimension scale could be envisioned based on Bleuler’s “4 As” (see below) – but my interpretation is that he was looking for detailed medical, family, social, and developmental history.  He is described as a clinician who had close contact with patients rather than an experimentalist – that is the data he was interested in.

Second, the richness of the psychiatric landscape during Bleuler’s time cannot be denied. The psychiatrists were writing and researching across the spectrum of neurology, neuroscience, psychology, and theoretical psychiatry. There was no shortage of ideas about describing clinical phenomena or possible treatments.  Bleuler had contact with many prominent psychiatrists of his time and his opinions about some of their theories was known.

Third,  Bleuler’s approach could be considered pluralistic to use today’s jargon.  He was  clearly engaged in doing the subjective realm and individualized evaluations.  He thought that schizophrenia could be an exaggerated neurosis from psychological conflicts.  He believed that the disease process had a biological basis but he was focused on a psychological treatment.  He also did not see schizophrenia as having a uniformly deteriorating course. His thoughts about the biology of the disorder were undoubtedly affected by the facts that he was not an experimentalist, there were no useful biological treatments and despite many autopsy studies there were no good gross anatomical or histological correlates of schizophrenia.

The patterns and themes noted in this paper run throughout the history of psychiatry.  Since psychiatry became the default profession for treating severe mental illnesses, there have been hypotheses about the nature of the illnesses, how to medically evaluate them, and how to treat them. As illustrated on this blog, there are often critics outside of the field who seem to ask these questions as if no psychiatrist has ever thought about them in the past.

In many ways the intellectual landscape of turn of the century psychiatry was richer than it is today. We currently have a refined product in terms of classification, but many of the questions relevant of psychopathology and neuroscience remain open. The basic problem of biological complexity is not easily answered and it is only recently being approached.  Biological and psychotherapy options appear to have been maxed out by heterogeneity problem.  From a historical perspective, what is most alarming to me is that there has not been a synthesis of these questions and approaches to bring current psychiatrists and trainees up to speed.  Much of the time seems to be spent on the same research techniques and critiquing endless clinical trials.

At a global level, the intellectual landscape of the field seems constricted.  The board certification process has certainly been part of that as well as the general goals of standardization.  There has been an enormous effort on standardizing nomenclature at the cost of de-emphasizing psychopathology. Clinical practice has been standardized largely based on settings and administrative codes. Documentation has been standardized by the same codes and electronic health records.  Much of the documentation is essentially worthless in describing patient progress or the unique features of the individual and is essentially there to satisfy business administrators.  The training of new psychiatrists is standardized in some areas - but there are very few specifics in terms of what trainees need to see in order to be good psychiatrists.  For example, there is an apparent assumption that if you spend a month or two in a neurology clinic - you will have adequate exposure to accurately assess neurological problems presenting as psychiatric problems and make the correct triage or treatment decisions.   

 I don’t think expanding the intellectual landscape for residency programs would take much.  It will take a bit of integration.  The sanctioning bodies of medical education have made the task harder than it should be by not specifying all of the important educational topics and letting the programs each sort it out on their own.  That means residents will see certain concepts inconsistently if at all, presentations and seminars will depend on the availability, interest, and quality of the teaching staff, and even then, topics are likely to be followed too rigidly.

The first question is what exactly should that landscape be?  Residency requirements by the ACGME are surprisingly vague.  They are focused primarily on clinical experiences based on clinical populations and settings, availability of supervision, and overriding goals of excellence, motivation, and interest on the part of the teaching faculty. There are some broad technical markers of specific experiences by psychiatric subspeciality or skill (eg. psychotherapy, managing drug interactions, etc).  I know that the residency directors meet frequently and it would not surprise me to find out that there are more detailed approaches shared among them – but if that occurs, I do not know where to access it.

My suggested approach at integration would be teaching the historical controversies and concepts that are still relevant all at once.  There are several integrative papers in the literature already.  There are also still some big concepts that need formulation and discussion like the biological diversity and heterogeneity issues that run throughout all of medicine. A potential academic model for this approach already exists and I suggest it is in the Voet, Voet, and Pratt - Fundamentals of Biochemistry - 6th edition.  One of the issues that frequently arises during discussions of this nature is how much philosophy needs to be included. My reading of the literature suggests that if anything there has been an excess of philosophy being applied to psychiatry.  At times psychiatry is made to seem like psychiatrists themselves have never considered the obvious questions. Teaching residents about psychiatry and the way that psychiatrists have attempted to formulate and solve problems seems like as good a place to start as any to me.

It can start with the names in this paper.    

Pattern matching also needs to be reemphasized. The reason a psychiatrist can diagnose bipolar disorder is that they have seen many cases and many variations - not because they have read the DSM.  The same is true for all of the mimics of bipolar disorder including neurological conditions. I am concerned about the level of exposure that residents have to acute neurological problems, especially now that many inpatient neurology services have been replaced by hospitalists with neurology consultants. There is a long list of acute neurological presentations that every psychiatrist must see and diagnose in training and distance from our neurology colleagues makes that more difficult. 

 

George Dawson, MD, DFAPA

 

References:

1:  Kaya Y, Uysal H, Akkoyunlu G, Sarikcioglu L. Constantin von Economo (1876-1931) and his legacy to neuroscience. Childs Nerv Syst. 2016 Feb;32(2):217-20. doi: 10.1007/s00381-015-2647-0. Epub 2015 Feb 24. PMID: 25707481.

2:  von Economo C.  Encephalitis Lethargica.  Oxford University Press, London. 1929. page B.

3:  Heckers S. Bleuler and the neurobiology of schizophrenia. Schizophr Bull. 2011 Nov;37(6):1131-5. doi: 10.1093/schbul/sbr108. Epub 2011 Aug 26. PMID: 21873614; PMCID: PMC3196934.

Open Access <-you can read this paper

Supplementary:

I just accessed and read the following paper this morning several days after the above post.  It is an open access paper that can be read and downloaded.  It basically makes the same argument that my post makes - an integrated approach to psychiatry and neurology (and neuroscience) is preferable.  It is written from the neurology perspective and that may be why the suggested remedies fall short.  Integration between the specialties is really not possible as long as one (psychiatry) is disproportionally rationed and is under an administrative burden that divorces it from clinical reality. 

Perez DL, Keshavan MS, Scharf JM, Boes AD, Price BH. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):271-278. doi: 10.1176/appi.neuropsych.17100200. Epub 2018 Jun 25. PMID: 29939105; PMCID: PMC6309772.

Neuron Perspectives in Neuroscience

Eric Kandel's thought, research, and writing have been a major source of inspiration to me ever since I read his neuroscience text and his classic article Psychotherapy and the Single Synapse in the New England Journal of Medicine nearly 34 years ago.  I was very pleased to see that he wrote the lead article in Neuron's   25th Anniversary edition entitled "The New Science of the Mind and the Future of Knowledge."  I read the article in the same spirit that I read the original NEJM article, guidance from a world class neuroscientist who was also trained as a psychiatrist.  At that level the article is quite exciting because somewhere along the line Dr. Kandel has clearly been following concepts that are far removed from the synapse and does a good job of summarizing the major points and the current deficiencies.  He also comes back to the idea that psychotherapy is a biological treatment as he proposed in the original 1979 article.

One of the most interesting aspects of the article is that Kandel does not apologize for psychoanalysis.  He is also not excessively critical.  I read an article about his residency class at Harvard and psychoanalysis was certainly prominent at the time.  Although it is fashionable these days to throw Freud under the bus, he points out that Freud and subsequent analysts were right about a number of issues that neuroscience has caught up with including:

1.  Unconscious mental processes pervade conscious thought.
2.  The importance of unconscious thought in decision making and adaptability.

The probable link here is that Freud, psychoanalysis, and current neuroscience is focused on the mind rather than descriptive psychiatry.  At some point the majority of the field got sidetracked on the issue of identifying a small number of pathological conditions by objective criteria.  The mind was completely lost in that process and those few psychiatrists who were focused on it were engaged in generating theories.  He criticizes the field for a lack of empiricism but recognizes that has changed with clinical trials of psychodynamic psychotherapy and recent interest in testing psychoanalytical theories with the available neuroscience.  He also points out that Aaron Beck was a psychoanalyst when he developed cognitive behavior therapy focused on conscious thought processes and became a leading proponent for an evidence based therapy.

It was good to see a discussion of the hard problem of consciousness.  I was on the ASSC listserv for many years until it eventually lost a home and was shut down.  Many of the experts in consciousness studies posted on that thread but there was very little neuroscience involved but plenty of discussion of the neural correlates of consciousness.

Information flow through the brain has always been one of my interests.  The idea that information flows through biological systems at both chemical and electrical levels is a relatively recent concept.  At the clinical level behavioral neurologists like Mesulam and Damasio discussed it based on cortical organization and information flow primarily at cortical levels.  I taught a course for many years that talked about the basic information flow through primary sensory cortex, association cortex and then heteromodal cortices.  The model had good explanatory power for any number of syndromes that impacted on this organizational model.  For example, achromatopsia made sense as a lesion in pure sensory cortex and posterior aphasia made sense as a lesion of heteromodal cortex.

Using this model, overall information flow from the sensory to the motor or output side could be conceptualized, but there were plenty of open boxes in the flowchart along the way.  The theory of how consciousness is generated from neural substrates was still a problem.  Social behavior was another.  Despite decades of descriptive psychiatry, the diagnostic criteria for major psychiatric disorders still depended on symptoms.  In many cases aberrant social behavior was a big problem and often a more accurate reflection of why patients were disabled, unable to work and had limited social networks.  Even though there were scales to rate positive and negative symptoms in schizophrenia, aberrant social behavior cut across a number of major psychiatric disorders.  In my first job as a community psychiatrist, we rated social behavior of the people in our community support program and it was a better predictor of disability than diagnosis or ratings of positive symptoms.  The neuroscience of social behavior remained resistant to analysis beyond the work done on cortical lesions and obvious comparisons to those syndromes.  But people with schizophrenia had no obvious frontal lesions.

Dr. Kandel points out the developments in these areas ranging from de novo point mutations affecting circuitry in the frontal cortex to mirror neurons to the neuroendocrinology and genetics of social behavior.  The review of Thomas Insel's work with voles and the extension of that work by Bargmann in C. elegans highlights the importance of specific systems in social behavior and how these systems are preserved across species.

One of the most interesting areas outlined by Dr. Kandel was the issue of art and the neuroscience of its creation and perception.  I have just posted on abstract art and was able to locate a quote from Kandinsky:

"The abstract painter derives his "stimulus" not from some part or other of nature, but from nature as a whole, from its multiplicity of manifestations which accumulate within him and led to the work of art.  This synthetic basis seeks its most appropriate form of expression which is called "nonobjective".  Abstract form is broader, freer, and richer in content than objective [form]." (Kandinsky Complete Writings on Art - p 789)

Kandel develops a narrative based on Viennese art historians and the importance of the aesthetic response to art.  That response is an emotional one based on the life experience of the viewer and the neuroscience of that response can be studied.  He looks at the inverse optics problem, facial recognition, and comes up with a flow diagram of the processes involved in viewing visual art.  I did not realize it until I read this article but he has a new book on the subject and ordered a copy to review at a future date.

Some of the conclusory remarks about neuroscience and what it means to society are the most important.  It is easy to be cynical about any scientific endeavor and it is also very easy to be political.  Neuroscience has to endure (although to a much lesser degree) than what psychiatry endures.   There are people out there commenting on neuroscience who don't seem to know much about it.  In many cases they are not scientists.  Even in the case of scientists, it is often easy to forget that the public will probably not hear the most objective and the most scientific.  They will typically hear from the experts who unambiguously support one side of the scientific argument as opposed to the other.  Kandel is cautious in his suggested applications of neuroscience to society.  He does not view it as a panacea or an explanation for behavior necessarily.  An example:

"Attributing love simply to extra blood flow in a particular part of the brain trivializes both love and the brain.  But if we could understand the various aspects of love more fully by seeing how they are manifested in the brain and how they develop over time, then our scientific insights would enrich our understanding of both the brain and love."    

Hopefully you will have time to read this paper.  I have highlighted a few more based on my reading about neuroscience over the past 20 years or so.  I will end with a paragraph on technical expertise.

When I was interviewing for residency positions 30 years ago, one of my questions that drew the strongest emotional reaction was: "Does your program have a reading list for residents?"  That question on average elicited shock or at least irritation from the average residency director.  The only exception was Johns Hopkins.  They handed me a neatly bound list of several hundred references that they considered key references that every psychiatric trainee should read.  I should have taken it as a sign and applied there, but my trajectory in life has been more random and circuitous than studied.  If I was a current residency director, I would have a list with a neuroscience section and the following articles from this volume of Neuron would be on it.  People often recoil when I talk about the technical expertise needed to be a psychiatrist.  Technical seems like too harsh a word for most psychiatrists.  Most of the media debate after all is essentially rhetorically based political discussions  I would say that if you read these articles, you can consider them to be a starting point for what you might need to know about neuroscience and psychiatry in the 21st century.

George Dawson, MD, DFAPA

A reading list for psychiatrists of the future (all available free online at the above link):

Kandel, Eric (2013) The New Science of Mind and the Future of Knowledge.  Neuron 80: 546 – 560

                             

McCarroll Steven A, Hyman Steven E (2013) Progress in the Genetics of Polygenic Brain Disorders: Significant New Challenges for Neurobiology. Neuron 80:578-587.

Südhof Thomas C (2013) Neurotransmitter Release: The Last Millisecond in the Life of a Synaptic Vesicle. Neuron 80:675-690.

Huganir Richard L, Nicoll Roger A (2013) AMPARs and Synaptic Plasticity: The Last 25 Years. Neuron 80:704-717.

Dudai Y, Morris Richard GM (2013) Memorable Trends. Neuron 80:742-750.

Shadlen Michael N, Kiani R (2013) Decision Making as a Window on Cognition. Neuron 80:791-806

Buckner Randy L (2013) The Cerebellum and Cognitive Function: 25 Years of Insight from Anatomy and Neuroimaging. Neuron 80:807-815.