This book is a landmark in the rehabilitation, within psychiatry, of the psychoanalytic method. An earlier, rich, clinical psychoanalytic neuropsychiatric literature, exemplified by the work of Schilder
(1), demonstrated many neurological symptoms to be within the realm of psychological functioning by addressing their multiple determinants and functions (including defensive). Working with brain-injured patients on a neurosurgical rehabilitation unit, the authors of
Clinical Studies in Neuro-Psychoanalysis, both psychoanalytically trained neuropsychologists, modestly present their courageous efforts to reach deeply into the internal experience of the patient. They propose a bridge, namely, the clinicoanatomical method, between psychoanalysis and the neurosciences.
In a scholarly but quite readable style, they begin with a review of the historical underpinnings of their work, the highly productive, dynamic approach beginning with Freud and the Soviet neuropsychologist/psychoanalyst A.R. Luria. Brainstem activation of diencephalic structures proceeds to the cortical areas, the anlage of the ego apparatus, an ever-changing, distributed structure consisting of linked components operating in concert to subserve different psychological functions. A concise review of the authors’ own neuropsychological studies of dreaming supports Freud’s earlier theories of motivation and meaning. The authors suggest that “it is possible that anything that arouses a sleeping brain has the potential to trigger the dream process.”
Next, the authors point out that different brain areas support symbolic and concrete visual spatial representations (left and right parietal), visual imagery (occipital and temporal), and motivational impetus (ventromedial frontal). Dreaming and reality may be blurred with frontal limbic lesions. There appears to be a “backward projection” from higher-order constructs to concrete perceptual representations; they quote Freud, “The fabric of the dream-thoughts is resolved into its raw material.”
Process notes and discussions of the treatment of 12 patients with a variety of lesions illustrate the power of the method. Neurological reductionism withers in the face of the authors’ struggles to compensate for devastating loss of function. For example, in exploring how patients with right perisylvian lesions can have both melancholic and paranoid syndromes, they point out that “the same lesion can produce two diametrically opposite emotional states.”
In their striving for a bridge between basic and clinical neuroscientists and psychoanalysts, perhaps the authors are overly apologetic about the psychoanalytic end. Their striking therapeutic reversal of hemineglect challenges the still common assumption that “neurological” disorders are “hard-wired” and therefore not amenable to psychotherapeutic understanding or change; indeed, it challenges the very concept of a mind-brain dichotomy. It is not an overstatement that this book should be required reading for any psychiatrist or mental health professional, not only those working with neurological patients.
