Bookpleasures.com welcomes as our guests, Dr. Edward Shorter and Dr. Max Fink authors of The Madness of Fear: A History of Catatonia.

Dr. Shorter has held the Hannah Professorship in the History of Medicine at the University of Toronto’s Faculty of Medicine since 1991.  In 1996 he was cross-appointed as Professor of Psychiatry in recognition of his rising profile as a historian of psychiatry.

He is the author of numerous books on the evolution of the discipline, including A History of Psychiatry (1997);  Shock Therapy (2007); Before Prozac (2009); Endocrine Psychiatry (2010);  How Everyone Became Depressed (2013); What Psychiatry Left Out of the DSM-5 (2015).

Dr. Fink received his B.A. at New York University in June 1942.  His admission letter to the NYU Bellevue School of Medicine came on December 6, 1941, the day before Pearl Harbor was attacked.  He was enrolled in the Army physician training program graduating in June 1945. After an internship, 2 years in the military service and 6 years of residency training, he was certified in Neurology, Psychiatry and psychoanalysis by 1954.

He set up an EEG laboratory at Hillside Hospital, received an early NIMH grant for EEG study of ECT, and organized the Hospital’s Research Department.  After the usual moves on the academic ladder at Washington University and New York Medical College he came to SUNY at Stony Brook in 1973 as Attending and Chief of ECT at the University Hospital. 

He studied the clinical and pharmaco-EEG of new drugs, ECT and Insulin coma therapy, examined heroin, methadone and their antagonists, hashish and THC-Δ-9 tolerance, wrote a text on ECT in1979 and launched the journal for ECT (Convulsive Therapy) in 1985.

Norm: Good day Dr. Shorter and Dr. Fink and thanks for participating in our interview.

In terms of your respective careers, what would you say you are most proud of?

Dr. Shorter: I am most proud of using history in order to improve diagnosis and treatment in Psychiatry today.  There is much that clinicians can learn from history.  Psychiatry is among the oldest specialties, beginning late in the 18th century.  And over that time an enormous amount of wisdom has been accumulated -- almost all of it forgotten today.  

There are valuable lessons about diagnosis, concerning conditions such as melancholia and catatonia, that we can learn from the past.  And even in therapeutics, we know that such agents as opium are very helpful in depression.  The diagnosis catatonia is particularly interesting because after 1930 it became treatable.   If I can help make this knowledge available to the present, I should consider this an accomplishment.

Dr. Fink: I came of age when clinical research in neurology and psychiatry was extolled with electroshock and insulin coma, then Chlorpromazine and Imipramine, became the clinician's challenges.  

We had EEG and other brain imaging tools to study the effects of our interventions. How these changed brain functions became of increasing interest. At the time, psychiatry extolled social issues and symptoms of the mentally ill, ignoring the "medical model of diagnosis and treatment".  

I was fortunate to have skilled students (Michael Alan Taylor, Richard Abrams) who applied the medical model to the syndromes of catatonia and melancholia, emphasizing the importance of symptoms and course, of verifying laboratory tests and applying the effective treatment of induced seizures.  

The separation of catatonia from the" hodge-podge" of schizophrenia, encouraging its widespread recognition (about 10% of patients admitted to medical hospitals) and its effective treatment, and the history with Ned Shorter is a culmination of that effort.

Norm: What do you feel is the major change in psychiatry since you both started your careers? As a follow-up, what would you believe is one of the biggest unanswered question in the field of psychiatry? 

Dr. Shorter: (a) the biggest change is Psychiatry is the decline of Freudian psychoanalysis and the triumph of a very narrowly conceived kind of psychopharmacology.  

Drug treatments are hugely important but "pharma-reductionism" narrows the treatment possibilities available to patients. (b) One of the biggest unanswered questions is: What are the real psychiatric diseases? They surely don't all boil down to "depression" and "schizophrenia." There must be deeper currents within the brain that throw off these patterns of symptoms -- and many others. What are these deeper currents?

Dr. Fink: The enthusiasm for social and psychological theories as the basis for identifying behavior disorders misled clinicians from applying medical principles to picturing disorders for which treatments were ineffective.

Physicians abjured their medical roots and became enamored of stories.  The enthusiasm for pharmacology and brain imaging continues to mislead neuropsychiatrists to label disorders according to symptoms without identifying systemic causes.

Each Diagnostic and Statistical Manual of Mental Disorder (DSM) has been a gross fantasy that continues to mislead the profession.

The elucidation of  neurosyphilis as a systemic disorder, followed by the elucidation of catatonia and melancholia, offer medical models for the identification of behavior disorders.

Norm: What drew you to the study of catatonia?

Dr. Shorter: I am a student of Max's, and it was he who pointed the way. This particular way -- detaching catatonia from "schizophrenia" and making it independent -- has turned out to be a very productive idea. Max, and Dr Michael Taylor did the same thing with melancholia.

Dr. Fink: In mid-1970s two students Abrams and Taylor liberated catatonia from its burial in schizophrenia. Then we recognized that neuroleptics precipitate a malignant, occasionally fatal, illness in catatonic patients. When the effective treatment for NMS was shown to be induced seizures, catatonia became an identifiable, verifiable and treatable syndrome, leading to Taylor and my writing our 2003 textbook and then Ned and my telling the present history.  The potency of benzodiazepines and electroshock distinguished catatonia from other behavior disorders.

Norm: What is the most common misconception that people have concerning catatonia?

Dr. Shorter: That it involved people somehow over-reacting. "I became catatonia when I saw the Dow." That catatonia involves stupor, staring, posturing, repetitive movements, mutism, food refusal and the like is almost entirely unknown to the public.  Yet these symptoms are very common.

Dr. Fink: That all catatonias are mute, rigid, and posturing, ignoring other forms as delirious mania, malignant catatonia, and self-injurious behaviors.

Norm: How prevalent is catatonia and do you believe that catatonia is under diagnosed? If so, why?

Dr. Shorter: Vastly under diagnosed! One out of every ten urgent admissions to a psychiatric unit has symptoms of catatonia.

Dr. Fink: Different assessments of hospital populations using defined rating scales find from 7% to 20% of hospitalized patients, especially among the delirious in medical units, the acutely ill in emergency rooms, and in neurology and psychiatry wards.

Norm: What is the criteria for the diagnosis of catatonia?

Dr. Shorter: There are the clinical criteria:  raising the patient's arm and it stays up, a negativistic refusal to do the opposite of what one is asked to do, etc. But a "lorazepam (Ativan) challenge" will seal the deal.  If the patient gets better on a short course of the benzodiazepine drug lorazepam, bingo.

 Dr. Fink: An acute onset syndrome at any age with two or more catatonia signs for 24 hours or longer.  Various rating scales identify from 18 to 30 behaviors as within the catatonic spectrum. The Bush-Francis scale (23 items) was developed in my unit at Stony Brook in 1990s and is widely accepted to identify catatonia.

We have also identified the lorazepam verification test, and effective treatment protocols that are accepted world-wide.

 Norm: What would you consider is most challenging when dealing with patients with catatonia?

Dr. Fink: Consent. Negativism is a catatonia characteristic so consent for IV medication and electroshock therapy is a common hurdle in treatment.  

Norm: What would you say is most rewarding when you deal with patients with catatonia?

 Dr. Fink: The successful resolution of catatonia within one to two weeks, from life-threatening to normal behaviors, is most gratifying.

 Norm: Is catatonia common in patients with autism? If so, how is it treated

Dr. Fink: We recognize self-injurious behaviors among ASD patients as a treatable form of catatonia. The frequency of catatonia among ASD patients warrants detailed surveys.

Norm: What motivated you to write The Madness of Fear: A History of Catatonia, what purpose do you believe your book serves and what matters to you about the book?  

Dr. Shorter: The book will help clinicians to recognize catatonia and treat it properly.  It will help patients to understand that they may have a disorder their doctor is unfamiliar with.  Outfitted with correct information, they can then request a reassessment.  (Also, for lay readers who are just interested in matters psychiatric, the book will be an eye-opener.  It shows how badly Psychiatry, a supposedly scientific field, can run off the track.)

Norm: What was the most difficult part of writing your book and how much research went into it?

Dr. Shorter: A lifetime of research went into it. When one has an urgent mission, writing is not difficult.

Dr. Fink: I had been studying catatonia since 1980, was delighted by the recurrent success in finding, treating, and relieving the syndrome. Once we had completed our melancholia story, the catatonia story came to the fore.  

As a retired academic, with much help from the SBU archivist Kristen Nyitray, the research files at SBU were readily available.

Norm: Who do you think will most benefit from your book and why?

Dr. Shorter: The book will help clinicians become sharper diagnosticians; it will help patients better understand their problems; and it will give the general reading public an inside look at how Pschiatry is supposed (not) to work.

Dr. Fink: If clinicians read and learn, then patients will be the beneficiaries. We have already seen a rising interest in catatonia publications in Pub Med and in medical society catatonia meetings. 

Norm: Where can our readers find out more about you and The Madness of Fear: A History of Catatonia?

Dr. Shorter: Dr Fink is an internationally distinguished psychiatrist, and further information about him may easily be googled. Same for me.

Dr. Fink: Pub Med, Google, Stony Brook Medical Library archives

Norm: What is next for you both?

 Dr. Shorter: We are now very interested in the overlap between catatonia and melancholia, and in the possibility that there is some deeper brain disorder that drives both of them forward.  This could be significant from the viewpoint of finding new treatments.

 Dr. Fink: I spent 35 years studying the effects of psychoactive substances and procedures on quantitative EEG measures.  This field has been bypassed and warrants, I believe, re-examination.

Norm: As this interview comes to an end, what question do you wish that someone would ask about your book, but nobody has?

Dr. Shorter: How is it that Psychiatry could have committed a blunder of this magnitude, concealing a disorder of capital importance -- catatonia -- under the shell of another disorder -- schizophrenia -- the very existence of which is questionable.  In any event, catatonia is not a subtype of schizophrenia and we have succeeded in giving it an independent status. Nobody has ever really asked how this original disaster came about.

Norm: Thank you so much for taking the time to answer my questions. It's been an absolute pleasure to meet with you and read The Madness of Fear: A History of Catatonia.

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