First published in Neuropsychiatry News, Winter 2012, issue 6. Reprinted with permission.
In March 2012, I had the great pleasure of talking with Professor Alwyn Lishman for the Neuropsychiatry Newsletter in the first of what I hope to become a regular series of interviews of the great and the good in neuropsychiatry. I am grateful to Professor Lishman for his indulgence and patience and also to Dr Jonathan Bird who kindly orchestrated the meeting and joined us in the discussion.
Am I right in thinking you trained initially as a neurologist?
I didn’t have what you’d call a proper training. What happened was that I had to go into the army as a national serviceman. And when I went into the army I’d done 6 months of neurosurgery so I was drafted to the head injury hospital. And there I got my membership (MRCP) within the first year. And I took it, with minimal revision, and just happened to pass it, which was a tribute to my medical school I suppose. At that point the army was running down tremendously and they had no neurology specialist, so I was made an army specialist neurologist. I was put in charge of the hospital, medical division and given a rank of major, having just been a captain for a few months. So I’d been a sort of consultant neurologist in the army. Then I was beckoned to go to the Radcliffe, and Charles Whitty went to Australia for 2 months and I was a locum consultant neurologist. So I’d had an extraordinarily accelerated career to function as a neurologist.
How then did you cross over to psychiatry?
I can remember the very day I made the decision. A very great neurologist visited the hospital and I realised with a terrible thud that there was nothing he could do for patients that I couldn’t do, that the only thing he had over me was academic knowledge of the brain. And that was not my idea of being a doctor. So I thought: I want to stick with what I’ve got but broaden it. So that’s when I went to the Maudsley and learned about all the other avenues: talking, social psychiatry, holistic psychiatry. There were so many wonderful facets to psychiatry that there weren’t in neurology. I found that tremendously liberating and that’s what I enjoy doing as a doctor. I found some of the patients a terrible bore and a bind, but you always get that. But they were so much more of a challenge than neurological patients. By the time you’ve seen your fiftieth MS patient you really were just distressed for them. It was very difficult to know what to do next for them. Even Parkinson’s disease - there was very little you could do. Drugs hadn’t come in properly. So it was a barren field for me as a clinician.
Given all the treatments available today in neurology do you think you would make the same decision now?
No, it would be much harder for me to make that decision because not only have they got more treatment and more avenues, but being a psychiatrist is much less appealing as far as I can see. Community psychiatry would never have appealed to me, sitting around in a circle with lots of nurses. I think it’s very hard to get the right clinical atmosphere that suits your personality. I think I was always rather bossy - not obviously bossy, but secretly incredibly bossy. And that’s not good in modern psychiatry. I’d have found it hard being part of a team. Actually, I know what I’d have done: I’d have quickly become a proper neuropsychiatrist!
So, how did it come about that you became a neuropsychiatrist?
So I was at the Maudsley resisting becoming an academic for the simple reason that I thought of the awful things that happened to academics at the Maudsley. If they fell out with the head of department they perished. Aubrey Lewis was very autocratic. Aubrey Lewis wanted me to become a physiologist. He sent for me and said: ‘You’re wasting your time in psychiatry’. I was also a physiologist before I came into medicine. I did quite a bit of work and published quite a few papers. And he said: ‘We need a professor of physiology who is also a psychiatrist’. And I resisted it.
The first job I applied for was senior lectureship at the Royal London. And I didn’t get it. It went to Arthur Crisp. The next one I applied for was at King’s [King’ College London] but they appointed a man who had come from Sheffield and he lasted about 6 months and went to America. This sort of thing happened in those days. It didn’t matter how many prizes you got. And at that point Dennis Lee sent for me. He’d been on the appointments committee and he said: ‘I’ve got to tell you Lishman, I was the one who persuaded them not to have you. You’re a backroom boy’. This was going around because I was doing physiology on rats, as well as doing clinics. And it was very easy to get the wrong label stuck to you. So that was that.
Where does Queen’s Square fit in?
That was the third one I applied for. I went to see Eliot Slater. Eliot had a terrible time there. He got the funds together for a chair and the medical committee voted not to accept them. So he said to me: ‘Go there, have a wonderful time but don’t stay more than a couple of years, because they’ll do to you what they did to me’. In fact they were very welcoming to me and very helpful indeed. When Denis Hill beckoned me to come back [to the Maudsley] I thought: I’ll do what Eliot said, I’ve had my two years and it’s been interesting. Also, some of the neurologists were extremely hostile to a psychiatrist. I won’t mention their names even now, but the ones who were wonderful I will: Dennis Williams, Macdonald Critchley and Charles Simons were marvellous. But others were very dismissive. They would ask you to see a patient and you’d spend hours, and you’d come back tomorrow and the patient would have been sent out. They weren’t good doctors some of them. They were fascinated by patients as specimens, really. I didn’t want to live in that world forever.
When were you at the Maudsley?
The first 12 years I was a consultant from 1967 onwards. I was a general psychiatrist there, and I took my share of all the patients with everyone else. Then, I began to specialise. There were no neurologists on the staff of the Maudsley, so if someone had a patient who was twitching or something odd was going on, they’d ask me to see them. So I became a sort of quasi-neurologist specialist. And that meant that I in fact began taking over patients on other wards into my own care and I got to be increasingly neuropsychiatric instead of general. Then, I got a personal chair and the chair was called neuropsychiatry and that was when I was 49 years old. And it was the first time I was ever paid as an academic. I had always had an NHS salary. So as usual I had sort of drifted. I never determined things for myself, I drifted.
What qualities do you think make a good neuropsychiatrist?
First of all, you’ve got to be a good neurologist and a good psychiatrist. I don’t mean that you have to have a lot of experience of neurology but you have to have a passion to understand the brain. And then the rest of it is being a good psychiatrist and treating patients properly and well. And being able to teach is terribly important, being able to pass all that knowledge on. That, by the way, was partly why I took on the book.
How did the first edition of Organic Psychiatry come about?
I can tell you exactly. For about 3 years Blackwell’s had been getting in touch with me, saying: ‘We have been advised that there is a need for a book to get the organic slant on psychiatric illness that puts the brain back into psychiatry. We’ve been advised that you’re the man to do it’. I think it was Sir Charles Simons who was advising them because he and I were very friendly at that time. Either him or Norman Geschwind in America. Anyway, they kept going on at me and I kept saying no. I was getting advice from people who said ‘don’t get tangled with that’. The reason why I finally did it was quite ridiculous. I’m slightly ashamed of this, but I wanted a Bechstein grand piano and I saw one. I happened to be left a very small legacy, £200 or £300 from an uncle. The same week I got the offer of a substantial advance for the book, so I thought I’d go for it.
I have heard writing the first edition was very hard.
Oh yes, terribly hard. The month that I began we adopted a baby, so I’d got ready, with my desk and papers and all my books around me. And lo and behold the phone rang and this child arrived within 3 weeks. And so suddenly I was plunged into fatherhood. I still got on with it, with her in the highchair beside while I was writing for hours on end. She was a marvellous child. The next thing that happened was that my mother-in-law got a brain tumour and I put the book away. I got it out again a year later and my own mother got Alzheimer’s, 300 miles away. And I had to go up and down to the north of England a great deal, so I had to put the book away again. So it was very, very traumatic, and each time I put it away it was my wife who was saying: take it out again. So it was 7 years being written. And it was colossally difficult because I’d never written anything that long before. With the subsequent editions I got into a sort of writer’s frame of mind. And I was able to keep going, sometimes for 24 hours at a stretch, which is like being an athlete in a sort of way. The first edition was training me to write, and I was very obsessional about the grammar being right. My wife was an expert in this sort of thing, so she read it all and perfected my style. It was an incredible experience to do it. I’m not sure it was wise to do it. I then had to do a second edition and a third edition. It absorbed a lot of my life.
Why did you call the book Organic Psychiatry rather than a neuropsychiatry text?
The reason I called it Organic Psychiatry is very simple. As I wrote the book I did the head injury, I did the epilepsy and I did the strokes, and then I decided I had to do the metabolic disorders and go into diabetes and all the parathyroid disorders and so on. And I realised that this would not be neuropsychiatry - it’s general medicine in relation to psychiatry. So the book should have been called Neuropsychiatry/Organic Psychiatry/Liaison Psychiatry. I thought I’d found the best compromise with ‘organic’. But then people started talking about organic milk and organic meat and people made a lot of fun of it. I like the term less every time I go into a supermarket. It’s been taken over, you see.
Although Lishman’s is a text on biological psychiatry it does not ignore the psychological and social aspects of illness.
You have got to have a finger in every pie in psychiatry and be ready to turn your hand to whatever is the most important avenue: an EEG one day, a bit of talking about a dream another day. You just follow your nose. All psychiatrists should be all types of psychiatrist. You shouldn’t turn your back on talking therapies as many patients need this. I’ve always said the fundamental skill of a psychiatrist is being able to talk meaningfully and helpfully with patients. Just as the fundamental skill of the physician might be using the stethoscope, we use talking, so I made a bit of a fuss about that over the years. I get less and less patient with psychoanalysis as I get older. It wasn’t a bad first go but is full of desperately silly fallacies and the other awful thing is you need to be a millionaire to have a proper analysis. Briefer forms are so important because life is just too short and people don’t have enough money for that sort of indulgence, certainly not in England. The sort of psychotherapy that I believed in was distributive I suppose you would call it. Just going through people’s problems with life and trying to help them with it in a straightforward, commonsensical way.
Who inspired your career in neuropsychiatry?
I’m very inspired by the people who have done doctorates with me or worked closely with me: Michael Kopelman, Tony David, Robin Jacobson, Maria Ron, Simon Fleminger and Eileen Joyce. They, I think, are the leaders at the moment. But in terms of the great neuropsychiatrists of the past, before my time? I didn’t know them. They were just names to me. Plus Denis Hill of course. He was the prime example of all. He was known as the epilepsy psychiatrist but he was a much more broadly based man than that. He was incredibly broad because he was a proponent of psychoanalysis. His wife was a psychotherapist. So he would be my big hero. And who else would there be? Willy Mayer-Gross, who I got to know a little when he came to England. Before that neuropsychiatry got a bad reputation. That was Wilhelm Griesinger at the Charité Hospital. He said mental disorders are brain disorders, full stop. And he tried to make the whole of psychiatry nothing but brain science. Of course that made it very unpopular in the world in general because people were saying: this is a ridiculously narrow view. What he did was, he managed to produce lots of people, like Alzheimer and Wernicke, whose names have lived on. But it was a very narrow approach and I doubt if you talked to your patients very much. I suppose he would have given them pills if pills had been around, but he was a very narrow-minded man. And that was another reason I didn’t like to call my book Neuropsychiatry. I was frightened it would be made unpopular by its title.
But you never planned a career in medicine or psychiatry?
My father had started medicine but then went to the First World War and had been a prisoner of war. He went back to medical school but could never pass his exams because he’d been so ill. So my parents were saying ‘Alwyn’s going to be a doctor’ ever since I was 3 years old. I never knew why until after my father died. I don’t blame them. He would have been a wonderful doctor, far cleverer than me but he worked in a very humble capacity all his life.
Music was my passion as a child. I demanded a piano from the age of 5 and they couldn’t prise me away from it. I took music lessons until the month before my finals. I was equally in the music department and the medical department. I have always split myself like that, doing two things at once, neurology and psychiatry, physiology and neurology. It’s extraordinary how I’ve never been content to do just one thing.