Metaphorical Brain Talk

 

There is a current paper written by Kenneth Kendler on metaphorical brain talk in psychiatry (1).  It is open access and I encourage people to read it.  I automatically read anything written by Kendler because he is probably my last remaining hero.  That is ironic given that he is only slightly older than me.  If you are not familiar with his work there is a Wiki page that will partially bring you up to speed.  I have referenced him many times on this blog.  His writing is consistently next level when it comes to psychiatric research and theory.  If you find yourself reading collections of “greatest papers in psychiatry” and don’t find his work there.  Throw that collection away and read Kendler.

In this paper he reviews the history of metaphorical brain talk (MBT) in psychiatry and what he sees as four implications for the field. He defines this as describing the altered brain function is psychiatric disturbances in a way that seems explanatory but have no explanatory power.  Examples would include the infamous chemical imbalance trope.  He reviews MBT across discrete periods in psychiatric history and gives examples in each one of these time frames.  Since this is an open access paper – I encourage any interested readers to look at all the examples.   I will touch on a few points that I find interesting.

He first reviews Asylum Psychiatry from 1790-1900.  Several authors wrote about conditions they observed in their patients using descriptive phrases like brain excitement, disordered nervous system, morbid action of vesicular neurine, peculiar and special force in the cerebral masses, excitement and vividness always emanate from one portion or spot of the brain, etc.  On the one hand the metaphors are obvious and consistent with Kendler’s characterization that they are biologically meaningless.  On the other the images are vague and the significant part of the metaphor is descriptive language of mental activity. 

In other writing Kendler has referred to this era is psychiatry as the era of protopsychiatrists. I have reviewed that history on this blog and agree that psychiatry as the profession we know today probably did not start until the 1920s in the US even though it was well established in Europe for a longer period.  The European version included physicians who were also described as neurologists, neuropathologists, psychiatrists, psychologists, and alienists.  If you read references to these physicians today – the descriptions are often interchangeable and research is required to clarify their qualifications and training. 

There was more going on during this period than meaningless metaphors.  Alois Alzheimer was a psychiatrist and neuropathologist (11).  Between 1891 and 1907, Alzheimer described several neurodegenerative diseases including vascular dementias and the disorder that would eventually come to be known as Alzheimer’s disease along with the clinical correlations of memory loss, inadequate self-care, and paranoia. Otto Binswanger (1852-1929) was a Swiss psychiatrist, neurologist, and neuropathologist who was also active at the time. In 1894, he described “encephalitis subcorticalis chronica progressive” while attempting to differentiate types of dementia from dementia caused by tertiary syphilis that was called general paresis of the insane or GPI at the time.  GPI was a very common reason for institutionalization at the time accounting for 20% of admission and 34% of the death in asylums in the 19th and early 20th century before the advent of antibiotics.  Both Alzheimer’s Disease and Binswanger’s Disease remain controversial entities to this day in terms of the definitive neuropathology and likely etiopathogenesis.  An important historical lesson is that these early psychiatric researchers did practice psychiatry while doing neuropathology and often had students who went on to have significant contributions to the field outside of neuroanatomy.  In the case of Alzheimer, Franz Nissl (1869-1919) became his longtime collaborator and head of the Psychiatric Clinic at the University of Heidelberg where Karl Jaspers (1883-1969) was his student.  Jaspers wrote his text General Psychopathology while working for Nissl.         

His next historical period is The First Biological Revolution in Psychiatry 1870s – 1880s.  Griesinger was a key figure and his central thesis that mental illnesses were brain diseases.  He also published an influential textbook and journal.  His students promoted neuropathological research through autopsies as the primary method of scientific inquiry during that period. Kendler concludes that this method of research was a dead end for classical psychiatric disorders – but there seems to be more going on in the field than that.  Several of these physicians over the next 50 years identified themselves not just as psychiatrists but also neurologists and neuropathologists. Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868) were designated as neurologists and psychiatrists.  Freud (1856-1939) did 6 years of basic research in comparative neuroanatomy, published a monograph on aphasia (6) wherein he coined the term agnosia, and was a Privadozent in neuropathology.  All of that before he invented psychoanalysis.

 The Reaction to the Revolution 1880-1910 is described next with a critique by Kraepelin of excessive and speculative biological theories of psychiatric disorders.  The critique largely is focused on Meynert’s (1833-1891) work.  The critiques focus primarily on highly speculative hypotheses based on neuroanatomy. Meynert’s neuroanatomy work and that of his colleagues and students is still recognized today (2-4).  His poetic license may have been excessive, but the neuroanatomy was solid.

Metaphorical Brian Talk of the 20^th Century focuses initially in Adolf Meyer. Like the other psychiatrists discussed so far, Meyer had additional skills and was employed as a neuropathologist following his emigration to the United States from Switzerland. He famously said: “My entrance into psychiatry was through the autopsy room”(8).  Meyer had an indirect link to Meynert because his supervisor August Forel was one of Meynert’s students.  A quote is included from a 1907 paper in which Meyer suggests that early American psychiatrists:

“…pass at once to a one-sided consideration of the extra-psychological components of the situation, abandon the ground of controllable observation, translate what they see into a jargon of wholly uncontrollable brain-mythology, and all that with the conviction that this is the only admissible and scientific way.”

Meyer is credited with psychobiology model of psychiatry.  He saw the brain and mind as an evolved unitary and dynamic structure reacting to the environment.  As such it would not necessarily show typical disease related changes at the gross or microscopic levels and could only be studied if environmental and social variables were considered. 

Meyer’s psychobiology approach championed a detailed clinical approach to psychiatric disorders and avoidance of biological reductionism.  That would put Meyer along with Kraepelin squarely in the camp against not only MBT but also any theory suggesting that there was a direct biological explanation for mental behavior or psychiatric disorders. Both were trained as neuropathologists and Kraepelin worked with Alzheimer. That would seem to lend a measure of credibility to their concerns.  

Kendler ends that section with a quote from Jaspers that the neuroanatomy discovered by the neuropsychiatrists is one thing but it cannot possible be correlated with mental phenomenon.  He refers to this as “brain mythologies”.  Meyer’s and Karl Jasper’s approached have been credited by McHugh and Slavney in their comprehensive 4 perspective approach to mental disorders (7).

Kendler concludes that the metaphorical brain talk in psychiatry arises from several sources.  First, our identity as physicians dictates that like other specialists, we need an organ to focus on and that has been the brain. That relationship was impacted by neurology seeming to take over conditions with overt and definable brain pathology.  He concedes that there is overwhelming evidence that psychiatric disorders arise in the brain (in fact he is a world expert in this) but there are still no specific mechanisms.  MBT is one way to address that fact.  He defers to a historian that this may be status anxiety relative to other specialties with more definable pathology and in some cases mechanisms and MBT is a way to address that.  His own take on MBT is much more reasonable when he describes it as a wish that at some point we will get to the deeper understanding of the brain that we all seek.

Despite the historical digressions, Kendler comes to the same conclusion that I did decades ago.  We do not have to make things up in discussions with patients and we do not need to use metaphors devoid of biological reality.  That does not mean there is no room for real brain talk – the kind that occurs when you are discussing the effects of brain trauma, strokes, dementia, epilepsy, and endocrinopathies.  It does mean that you can flatly say for any diagnosis there is no known etiology but the research supports this treatment plan and beyond you can provide a discussion or references to the latest research.

The explanatory gap in psychiatry between the biological substrate and mental life or associated disorder is obviously there but it is present in every other organ system to one degree or another.  It is quite easy to pretend that basic medical conditions like asthma or diabetes have all been worked out with biologically precise mechanisms of action – but nothing could be farther from the truth.  Endophenotypes exist for both conditions, most people are symptomatic despite treatment, and death still occurs even in mild cases. There is a definite dynamic of idealizing medical conditions as completely knowable and treatable – when they are not.  In those cases, the explanatory gap is very basic between biology and wheezing or blood glucose. In the case of psychiatric disorders – many more symptoms and ordinary functions are across that gap.  The explanation is much harder and any symptoms are less clearly rooted in biology.  

I am less concerned about the effects of MBT and how it potentially affects understanding the mental life of our individual patients.  That is what psychiatrists are trained to do.  We are face-to-face with a person who we are supposed to help and, in that situation, it is doubtful that MBT will add much. 

There are a few other reasons that may have facilitated MBT in the historical contexts discussed. Rhetoric is a powerful and rarely discussed aspect of the scientific and medical literature.   The metaphor users were all active neuroscientists in their day.  As such they were likely competing for positions, labs, associations, recognition, and funding.  This is commonly how rhetoric occurs in research communities and scientific literature. 

 A related issue is personality and notoriety. It is rare to see much commentary about these issues with 19th and 20th century scientists.  Once a certain level of fame is reached, are you more likely to speculate and theorize?  Can some of those speculations take on the form of MBT?  One of the most criticized neuropsychiatrists in this paper was Meynert for suggesting overly elaborate mechanisms that had no basis in science.  On the other hand, Meynert is still renowned for some of his neuroanatomical findings (4).  Is it possible that a scientist with that level of accomplishment did not care about the difference between speculation and scientific findings?  Is it possible that his students and post docs encouraged him to speculate beyond his findings – just brainstorming? Is he just taking a chance that he might be correct in order get credit for an innovative finding?  I suppose a translation of his book might offer a few addition clues, but the reason I have these suggestions is that I have seen this happen in current times.  We might reassure ourselves that our publications are not suffering from metaphorical overreach but problems with irreproducible findings suggest otherwise.          

The state of neuroscience for much of the timeline of this paper could be a factor.  Not a lot was known about neurons or neuronal transmission.  Neuron theory and the term neuron did not happen until 1891. I have a slightly different take on the history of psychiatry in the US and how psychiatry and neurology split.  Until 1934, most psychiatrists were also practicing neurology. Many were self-designated as neuropsychiatrists.  The ABPN decided to require board exams in both neurology and psychiatry to practice both and at that time psychiatry began to grow disproportionately relative to neurology.  It is still possible to be doubled boarded in both. It is also possible to practice neuropsychiatry or medical psychiatry based on residency training and practice.  I have long promoted the idea that modern day psychiatrists should practice intellectually interesting psychiatry and for me that uses the DSM as a scope of practice specifier and knowing all the medicine and neurology necessary to care of those patients.  

Revisiting the main point of Kendler’s paper.  In his summary he states his major concern has been an impoverished conceptual foundation in the field based on a brain centric focus and metaphorical talk about it.  I agree with anything metaphorical and on this blog have numerous posts addressing the chemical imbalance and biomedical metaphors being paced upon us by our critics.  In many ways – I don’t think the clinical brain focus has been enough. Psychiatrists need to be able to rapidly recognize neurological and medical emergencies in addition to the medical and neurological causes of psychiatric syndromes. Psychiatrists need to be able to diagnose aphasias as well as they can diagnose thought disorders.  Those skills can all be traced back to late 19^th century and early 20^th century psychiatry. I also see that era as precipitating controversy, dialogue, and pendulum swinging so far in the other direction that at one point the medical internship was temporarily removed from residency programs.   

The reality is that we will see people referred to us or walking in off the street who have brain lesions and/or medical problems or not. They will generally have a psychiatric problem that has been assessed and treated by several other people that did not work. Our job is to do a thorough assessment of their physical and mental problem and come up with a plan – even when there is no known treatment.  That plan includes relationship building, helping them be more competent, and helping them make sense of their world. 

All the irrelevant metaphors can easily be ignored.

 

George Dawson, MD, DFAPA

 

 

1:  Kendler KS. A history of metaphorical brain talk in psychiatry. Mol Psychiatry. 2025 Aug;30(8):3774-3780. doi: 10.1038/s41380-025-03053-6. Epub 2025 May 13. PMID: 40360726; PMCID: PMC12240831.

2:  Liu AK, Chang RC, Pearce RK, Gentleman SM. Nucleus basalis of Meynert revisited: anatomy, history and differential involvement in Alzheimer's and Parkinson's disease. Acta Neuropathol. 2015 Apr;129(4):527-40. doi: 10.1007/s00401-015-1392-5. Epub 2015 Jan 30. PMID: 25633602; PMCID: PMC4366544.

3:  Meynert T, Putnam J (translated) (1872) The brain of mammals. In: Stricker S (ed) A Man. Histol. W. Wood & company, New York, pp 650–766

4:  Judaš M, Sedmak G, Pletikos M. Early history of subplate and interstitial neurons: from Theodor Meynert (1867) to the discovery of the subplate zone (1974). J Anat. 2010 Oct;217(4):344-67. doi: 10.1111/j.1469-7580.2010.01283.x. PMID: 20979585; PMCID: PMC2992413.

“The presence of neurons in the subcortical white matter of the human brain was first described and illustrated by Theodor Meynert in 1867, and additionally commented on in his subsequent publications (Meynert, 1867, 1872, 1884). Meynert illustrated these cells in both superior frontal (Fig. 1A) and primary visual (Fig. 1B) human cortex and pointed out that these are spindle-shaped (fusiform) neurons which are oriented vertically to the pial surface within the gyral crowns, but horizontally at the bottom of sulci. He also suggested that they have a special functional relationship to short corticocortical association fibres (fibrae arcuatae, or Meynert's U-fibres) and that these fusiform cells may therefore be regarded as intercalated cells of his Associations system of short corticocortical fibres (Meynert, 1872).”

5:  Cowan WM, Kandel ER.  A brief history of synapses and synaptic transmission. In:  Cowan WM, Sudhof TC, Stevens CF.  Synapses. The Johns Hopkins University Press, Baltimore, 2001. pp.  3-87.

6:  Freud S.  On aphasia: a critical study.  International Universities Press. New York, 1953.  Translation of 1891 German publication and introduction by E. Stengel.

7:  McHugh PR, Slavney PR: The Perspectives of Psychiatry, 2^nd ed. Baltimore, Johns Hopkins University Press, 1998

8:  Lamb S. Social Skills: Adolf Meyer's Revision of Clinical Skill for the New Psychiatry of the Twentieth Century. Med Hist. 2015 Jul;59(3):443-64. doi: 10.1017/mdh.2015.29. PMID: 26090738; PMCID: PMC4597240.

9:  Lamb S.  Pathologist of the Mind – Adolf Meyer and the Origins of American Psychiatry.  Johns Hopkins University Press,Baltimore, 2014. p. 255.

10:  Rutter M. Meyerian psychobiology, personality development, and the role of life experiences. Am J Psychiatry. 1986 Sep;143(9):1077-87. doi: 10.1176/ajp.143.9.1077. PMID: 3529992.

11:  Goedert M, Ghetti B. Alois Alzheimer: his life and times. Brain Pathol. 2007 Jan;17(1):57-62. doi: 10.1111/j.1750-3639.2007.00056.x. PMID: 17493039; PMCID: PMC8095522.

Photo Credit:  

I thank my colleague Eduardo Colon, MD for the surreal photo of the Foshay building in Minneapolis. 

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.