142 BOOK REVIEWS

haps, has mastered Lacanian concepts clearly!) and he has the ability to psychoanalytic express himself in a way that will make sense to an English-speaking tolerate ambiva audience without diluting Lacan's ideas. I can highly recommend this pacity to hate tl fascinating and clinically useful book. tal achievement and a prominen Gerald P. Perman, M .D. The book is I 2424 Pennsylvania Ave., N.W. Chapter 1 GhaE Suite 100 modernist and] Washington, DC 20037 ation. In Chapf gpperman @gm ail.com ence, recognizu of human life, , understand de] mental triggers, as he essentiall· the same. By P' of the genetics ( On Depression: Drugs, Diagnosis and Despair in the Modern World, by wrong." Nassir Ghaemi, M.D., Johns Hopkins University Press, Baltimore, MD, This bold ass 2013, 232 pp., $24.95. presents or otlu than genes goe. plain the simp] It was the title of this book that made me want to read and review it sion, the odds for the journal. is learning fascinating things about depres­ erably less thar sion, about the limitations of our knowledge, and about the contribu­ evant to this frl tions of genes and environment to depression. I hoped to learn how an it was publishe erudite and thoughtful might put it all together. Indeed, tion Study reSE Ghaemi does a creditable job of making his case for how to understand the Psychiatric these issues, but he omits important recent information that undercuts find any genes his position, and rarely misses an opportunity to take a swipe at, mis­ Polymorphism understand, or misrepresent Freud and . From my work of tens of thous in organized psychiatry I am familiar with such swipes at psychoanal­ for other disea ysis from those often untrained in it, though I am pleased that such ease . Genome swipes seem to be fading in light of emerging evidence of the efficacy environmental of psychoanalytic treatments, but not so from Ghaemi. ized in causing Despite his swipes at psychoanalysis, Ghaemi extols the virtues of to the heuristic some psychoanalytic concepts without recognizing them. An example 21st century by of this is in a late chapter on Leston Havens, surely a gifted clinician or alleles for the s "guide" as Ghaemi calls him, to whom Ghaemi properly assigns credit of depression 1 for emphasizing in his work with patients the importance of being able the least risk ( to hold simultaneously two conflicting ideas. Ghaemi fails to recog­ sity. These fine nize that here Havens is speaking a basic developmental notion from by environmei BOOK REVIEWS 143

!) and hehas the ability to psychoanalytic object relations theory. Achi evement of the capacity to eto an English-sp eaking tolerate ambivalence is a psychoanalytic notion with origins in the ca­ highly recommend thi s pac ity to hate the one we also need and love-a central developmen­ tal achievement, an essential part of achieving the depressive position, and a prominent clinical issue in our patients. The book is divid ed into four parts. Part I is called "Entrance." In Chapter 1 Ghaemi shows a sure hand, offering a concise overview of mod ernist and postmodernist persp ectives on our lives of quiet desper­ ation. In Chapter 2 Ghaemi takes on the varieties of depressive experi­ ence, recognizing helpfully that sadness, suffering, and grief are part of human life, and not the same as depression as illness. In seeking to understand depression as illness, sometimes with apparent env iron­ mental triggers, Ghaemi lays out his own pe rsp ective, quoting Aristotle as he essentially makes the case that correlation and causation are not the same . By page 19 he reaches the conclusion that "A prime feature of the genetics of depression, rarely emphasized, is that it proves Freud in the Modern World, by wrong ." ityPress, Baltimore, MD, This bold assertion is a non sequitur that does not fit the data Ghae mi presents or other data sug gesting that, althoug h clearly heritable, more than genes goes into the cau sation of dep ression . How else can we ex­ pla in the simp le fact that if one of a set of identical twins has dep res­ ant toread and review it sion, the odds that the second twin will have depression are consid­ . g things about depres­ erably less than 100%?Ghaemi's omission of interesting learning rel­ , and about the contribu­ evant to this from one recent mol ecular genetic study ma y be because .Ihoped to learn how an it was published after his book went to press. Genome Wide Associa­ t it all together. Ind eed, tion Study researchers (Major Depressive Disorder Working Gro up of efor how to understand the Psychiatric GWAS Consortium, 2013) have reported their failure to ormation that undercuts find any genes or even nucleotides (so called SNPs or Single Nucleotide to take a swipe at, mis­ Polymorphisms ) associated with major depressive disorder in studies eanalysis.From my work of tens of thousands of people, samples large enoug h to find such SNPs ch swipes at psychoanal­ for other diseases like some canc ers, typ e 2 diabetes, and Crohn's dis­ I am pleased that such ease. Genome Wide Association Study researchers ackn owledge that evidence of the efficacy environme ntal factors ma y be far more important than previou sly real­ Ghaemi. ized in causing dep ression. Ho we ver, Ghaemi also omits any reference mi extols the virtues of to the heuristic implications of one of the most cited studies of the early 'zing them. An examp le 21st century by Caspi (Caspi et al., 2003), in which homozygous "short" relya gifted clinician or alleles for the serotonin transporter promoter gene confer increased risk iproperly assigns credit of depression to those with early ad versity, like abuse, but also confe r importance of being able the least risk of dep ression to those without histories of early ad ver­ , Ghaemi fails to recog­ sity. These findings have led to intense interest in epigenetics, or gene elopmental notion from by env ironme nt interaction, and have led some mol ecul ar geneticists 144 BOOK REVIEWS

(Belsky et al., 2009) to question the entire premise of genetic "vulner­ resent psycho ability" (a premise Gh aemi adheres to) in favor of the concept of genetic for example, ( "plasticity," in which the same genetic makeup (e.g., Caspi's sero tonin based on the tra nsporter promoter gene short alleles) may confer an increased risk does Ghaemi of dep ression in the presence of early environme ntal adversity, but a Part IV, en decreased risk of depression with an early beneficial env ironme nt. analysis, this It sho uld be noted that short alleles do not account for a large amount our confusion of the variance in who becom es depressed . This is not "the gene" for from continu de pression by any means. Studies like those of Casp i and Belsky are im­ 2 portant for their heuristic value . They highlight assump tions we have about what c made that may be false, like Ghaemi's that dep ression is demonstra­ reade r is no II bly and principally the result of gene tic vulnerability. As I have arg ued ysis, when eil in this journal in the past (Plakun, 2012), if emerging genetic research when he is ql demonstrates that the environme nt is far mo re important than we had "the three ba realized in the causation and treatment of mental disord ers like depres­ 168). If Freud sion, then psychoanalysis and Freud, far from being proven wrong, zling . Ghaen may be esse ntial to psychiatry if it is going to make sense of env iron­ related to Gl mental factors in com plex, textured, and sophisticated ways. mediocre "[u Now this is very complex material, and Ghaemi is entitled to his uttere d by a: opinion about how all this should best be understood , but he is not yea rs, thougl entitled to his own facts. And I qu estion why he would present such efforts to unc conclusions to his read ers while omitting such heuristically important he is focused molecul ar gene tic research. In many r, Part II is entitled "Pretenders." In Ch apter 6 Ghaemi makes an ef­ analysis, bu: fort to debunk postmod ernism, and with it, what he sees as its link to it, for exam] psychiatry in the form of the biopsychosocial model, which he explains pharmacolo) as a notion that all answers are right so any thing goes. Here Ghaemi his criticism shows his preference for simple explanations over complex ones, even standing ala if things are complex and not simple, which is wha t the emerging sci­ I would 1001 ence seems to be revealing. His certainty and his categorical "this is mend Ghae right and that is wrong" stance, in which he rep eatedly sets up false what those dichotomies, did not persuade this reader to give up entirely on the bio­ up against it psychosocial model , postmod ern perspectives, or even the DSM, which he sees as a postmod ern instrument. I will give him credit for ma king me think, thou gh . REFERENC In Part III, entitled "Guides," Ghaemi speaks about mentors and col­ leagues who have helped shap e his point of view. These include Vic­ Belsky,J.,[onz tor Frankl, , Elvin Semrad, Leston Havens, Paul Roazen, and Vulnert Karl Jaspers. These moving, often quite personal accounts of how these Caspi, A., SUI thinkers influenced him, were the best part of the book. I am afraid, (2003) . though, that throughout this section, for example as noted above about in the 5 Havens, Ghaemi never misses a chanc e to misunderstand or misrep- BOOK REVIEWS 145

ise of genetic "vulner­ resent psychoanalysis. On page 124 of the chapter on Havens, again, of the concept of genetic for example, Ghaemi makes the sweeping claim that (e.g., Caspi's serotonin based on the psychoanalytic tradition are wholly intellectual. Where onfer an increased risk does Ghaemi get such an absurd idea? ental adversity, but a Part IV, entitled "Exit," begins with another swipe at Freud and ficial environment. analysis, this time blaming Freud for confusion in the field : "Much of ount for a large amount our confusion about mental health (and indirectly mental illness) stems 'sis not "the gene" for from continued Freudian influence" (p. 153). He especially targets aspi and Belsky are im­ Anna Freud and here, and Freud's response to a question t assumptions we have about what constituted mental health as "to work and to love." The pression is demonstra­ reader is no longer surprised, given Ghaemi's bias agains t psychoanal­ bility.As I have argued ysis, when eight pages later is onto something important erging genetic research when he is quoted as asserting that the fundamental choices of life are important than we had "the three basic ones.. .to live, to love and to work" (italics in original, p. I disorders like depres­ 168). If Freud says it, it is wrong, but if James says it, it is wisdom. Pu z­ being proven wrong, zling . Ghaemi also has a particularly vitriolic perspective on analysis ake sense of environ- related to Grinker's concept of the homoclite (highly no rmal, highly ticated ways. mediocre "just plain gu ys") . This is a concept that I haven't even heard aemi is entitled to his uttered by anyone in or out of the field of psychoanalysis in over 40 derstood, but he is not years, though Ghaemi presents it as what is wrong with psychoanalytic he would present such efforts to understand normality. Here Ghaemi misses the forest because heuristically important he is focus ed on a rather unimportant tree that he dislikes. In many respects, Ghaemi sets himself apart not only from psycho­ Ghaemi makes an ef­ analysis, but from much of mainstream psychiatry in his criticism of at he sees as its link to it, for examp le in his disdain for the DSM and his sense that psycho­ odel,which he explains pharmacologists tend to overprescribe. Here he is on solid ground in . g goes. Here Ghaemi his criticisms, but by criticizing in all directions, he comes across as rer complex ones, even standing alone, while certain he has the answers. This is not the stance what the emerging sci­ I would look for in a "guide ." On balance, it would be hard to recom­ his categorical "this is mend Ghaemi's book as one worth reading except to get a sense of peatedly sets up false what those of us in psychodynamic psychiatry or psychoanalysis are upentirelyon the bio­ up against in our efforts to look at things in complex and textured ways. reventhe DSM, which him credit for making bout mentors and col­ REFEREN CES ew. These include Vic­ Belsky, J.,[onassaint , c.,Plu ess, M., Stanton, M., Brummett, B., & William s, R. (2009). rens,Paul Roazen, and Vuln erability genes or plasticity genes? Molecular Psychiatry, 14,746-754. accounts of how these Caspi, A., Sug den, K., Moffitt, T. E., Taylor, A., Cr iag, 1. w., Har rington, H., et al. the book. I am afraid, (2003). Influen ce of life stress on depression : Moderat ion by a polymorphism easnoted above about in the 5-HTT gen e. Science; 301(5631), 291-293. derstand or misrep- 146 BOOK REVIEWS

Plakun, E. M. (2012). Treatment resistance and ps ychodynamic psychiatry: Con ­ He is not just try cep ts ps ychiatry needs from ps ychoanalysis. Psy chodynamic Psychiatry, 40(2), god-given task t< 183-209. is accessible to II Major depressive disorder working group of the psychiatric GWAS consortium. (2013). A mega-analysis of genome-wide association studies for major depres­ While he relentle sive disorder. M olecular Psychiatry, 18(4),497-511 . ism, doubting til from being giver battle fields. Yet Eric M. Plakun, M.D. quirers fail to dis Austen Riggs Center, PO Box 962 25 Main Street to destroy pretei Stockbridge, MA 01262-0962 the polis. It is hi [email protected] portant to cultiv, questioned, and Kierkegaard e journal that iron stitutes becomin Socrates' existen whether there V\ A Case for Irony, by Jonathan Lear, Harvard University Press, Cam­ concerned with 1 bridge, MA, 2011, 210 pp., $31.50. tense as meanin] rience of irony c thinks one is an This book contains the two "Tanner Lectures on Human Values" that just referring to , Jonathan Lear gave at Harvard University, along with responses by grabs one and sh commentators and Lear's responses to these comments. Jonathan Lear, miliar. Such an e: the philosopher (he is also a psychoanalyst), agrees with Kierkegaard one cares about t and Plato that irony is fundamental to the human condition, but poorly being serious ab understood. In this book, Lear tries to make clear what irony is and sizes this positiv why it matters. One answer is that it matters because Lear conceives of The ability for it as an essential aspect of living a distinctively human life. What matters is The title of the first lecture, "To Become Human Does Not Come That bility of ironic e) Easily," is a quote of a comment Kierkegaard wrote in his journal in While irony OpE 1854. Becoming human is viewed as a task, following a philosophic knowledging thi tradition since Plato that argues that self-constitution is indeed an social life. achievement. The second lee The importance of irony is best understood when we look at Socrates' are we like such life. bluntly, "What a ~ According to Kierkegaard, Socrates' life was irony, and he writes is a possibility fc about his own existence as really the deepest irony. What is meant by quality like reasi this is that neither Socrates nor Kierkegaard assumes that he knows that what is right. They question, but do not know. As mentioned, Lear is ironic activity. TI interested in the affirming nature of irony. He admires Socrates' ease at fied self. Lear bel blending positive and negative aspects of ironic existence. Socrates ex­ marked by disru amines everyone he meets who has a pretense of knowledge of virtue. ability to be disn