The Unbalanced Mind

This book addresses the question of whether the human mind, and in particular the disordered mind, can be entirely explained through the emerging insights of molecular genetics. Its main aim is to “temper this Orwellian view of the future.” Leff, who is eminently well placed to challenge a biologically driven reductionist’s view of the human mind, presents a series of findings on psychological, social, and cultural factors underlying mental illness. Leff discusses successively most of his own studies and findings on the role of stress and life events in mental illness, the introduction of the Present State Examination, the International Pilot Study of Schizophrenia, the expressed emotion concept, and the role of the family system in schizophrenia patients. This latter is one of Leff’s most important contributions and rightfully is the focus of a substantial portion of this book.

Other noteworthy chapters deal with the role of traditional healers, the toxic effect of cities, and the effects of cultural factors in schizophrenia. There is also a clear critical message for American mental health professionals when Leff talks about diagnostic practices that are formulated under political pressure or attain wide endorsement due to the power of commercial forces and health reimbursement dollars. The most evident shortcomings in this book are the examples given of biological findings. Most are outdated and at times incorrect. A good example is on page 38, where Leff talks about newer antipsychotics having “little or no blocking action against dopamine.” If he refers here to the atypical antipsychotics, he is obviously wrong. He uses this argument to challenge the dopamine theory of schizophrenia, stating that this theory “as yet has not been replaced by an alternative theory.” However, one significant alternative theory, which has been extensively explored, is the N-methyl-d-aspartic acid theory of schizophrenia (1). Another example of incomplete data use is on page 145, where the author reports on findings from longitudinal cohort studies investigating precursors of later schizophrenia. While the author mentions that lower sociability is found in children who later develop schizophrenia as adults, he does not mention other, more recent findings, such as later development of speech and other cognitive deficits (2), which all contribute to lower sociability and may be more biologically rooted.

The different findings are well presented, but it is not clear whom this book is addressing. If it addresses readers who are not in the field of mental health, the content may be too complex; if it addresses mental health professionals, and in particular psychiatrists, its style is too simplistic.

In presenting many of his findings in social and cultural psychiatry in a cogent and very readable fashion, the author unfortunately often creates a straw man out of outdated and incomplete biological findings in order to better demonstrate their shortcomings. In addition, he brings the reader back to the simplistic dichotomy of nature versus nurture, which is not helpful as an explanatory model for the causes underlying mental illness. Although the account in this book of the social and cultural factors underlying mental illness is laudable and interesting for the novice in the field, it fails to break any new ground or vision in explaining the unbalanced mind.