"Medicine is a science of uncertainty and an art of probability" ~ William Osler

Where is Psychiatry's Blueberry Muffin? - author and medical student Hannah Black reflects upon models and the mind

The Bicameral Mind

At the front of the classroom, a muscled psychiatric resident oozed with enthusiasm. He strutted in front of the blackboards. He was proud to teach us, and his energy flowed into the room where it met a reluctant audience. We were freshly minted second year medical students, and we were slow to warm to our psychiatric block. There was a suspicion surrounding the subject that was hard to pin down.

Psychiatric medicine was different than anything else we’d learned so far. Gastroenterology and cardiology were concrete. We could see the intestines and the heart, and we had few preconceived notions about the pathophysiology of cardiac tamponade. Psychiatry is more abstract in nature, and it lacks a concrete analogy that we could draw on to understand it. The heart may be a pump combined with an electrical circuit, but what about the mind?

After a few practice scenarios based on hypothetical patients, a young student in a Hawaiian shirt was bold enough to ask a pointed question. “All these cases we’re talking about are so different. Bulimia, OCD, depression. Why is the right answer for treatment always an SSRI?”

The muscled resident’s head whipped around. He smiled brightly as he let us in on a secret. “The truth about SSRI’s is we don’t know exactly how or why they work. But we do know is they have a minimal side effect profile, and they help people feel better in 30% of cases.” The room was quiet. The resident wasn’t done. “And that’s the great thing about psychiatry! We don’t have to understand it perfectly to help people feel better.” He threw his hands up and shrugged.

The explanation didn’t perfectly soothe the room, but it was enough for that day. We accepted that psychiatry is an evolving field, memorized the latest DSM criteria, and passed the test. We respected the work that psychiatry had already done to define mental health conditions, but we kept in mind that ego dystonic homosexuality was listed as a pathology in the field as late as 1986. Like all of medicine, Psychiatry has room to grow.

Around the same time as the contentious Psychiatry block, I was in a long-distance relationship. The road trips to see each other weren’t ideal, but they gave me hours on end to neglect my studies and nurture a hardcore podcast addiction.

That night, just a few hours after my psychiatry final, I clicked on the next episode of my favorite random factoid podcast, “Stuff You Should Know.” The value of the podcast wasn’t usually in the topics, which ranged from grass to tax reform, but I looked forward to zoning out as I cruised through the Virginia countryside.

This episode was different though. The title was, “The Thrilling Bicameral Mind Theory,” and at the start the enthusiastic host Josh declared. “This may be the greatest episode we’ve ever done.” Over the next hour, I got an hour-long crash course on Julian Jayne’s Bicameral Mind theory.

Jayne’s was a Princeton psychology researcher born in 1920, and his theory outlined a construct for human consciousness. The main theory is best described through a simple analogy: When a mapmaker sails a coastline and records what he sees on a piece of paper, he is making an analog of that coastline. He is not literally recreating the coastline with sand and rock, but rather making a compressed version on a piece of paper that represents it. This map is a condensed version he can use to navigate the coastline again someday. Based on reality, the mapmaker carries with him an analog coastline in the form of a map.

As I drove by cows grazing at the edge of their pastures, I chewed on the idea that the google maps I was following was an analog of the highway I was on. It passed the gut check. My interest was piqued, and I turned the volume up to pay closer attention.

The details of the rest of the theory are nuanced and are elaborated on in Jayne’s 500 page tome outlining his theory, but the other main tenant is the idea of “the analog I.” Jaynes believed our minds held an “analog I”, a version of ourselves that can explore our internal world before we must act in the real world. We can imagine turning left down a street, picture the traffic on that route, and choose another route home. Our “analog I” can explore an “analog world” in our minds, and in the physical world we can make decisions that differ from those of our “analog I.” We can imagine turning left down the road but ultimately choose to go right down an unknown or unmapped path.

By the time the podcast was over, my mind was swirling. Jayne’s theory wasn’t provable or disprovable, but it was a remarkably intuitive theory of mind. In the wake of my psychiatry final, I couldn’t help but wonder if this was the kind of unifying analogy that psychiatry needed. What if some facets of psychiatric illness could be thought of as errant mental maps, poor analogs of the real world that lead their owner to crash repeatedly into the shores of the real world?

The map analogy offers a simple, palatable, explanation for the efficacy of talk therapy. If your internal map is wrong, then talking to someone and comparing maps can help set yours right. To the extent which people can recover from anxiety or depression, the analogy would say facets of their experiential map can be rewritten. The extent which cognitive behavioral therapy can be used to treat OCD, patients can learn to map new routes around triggers and obstacles in their daily lives.

To go out on a limb, perhaps SSRI’s and their impact on neural chemistry helps patients be more receptive to subconsciously rewriting some facets of their internal, experiential map. This could explain why SSRI’s are efficacious for a wide range of disparate psychiatric conditions.

Of course, the map analogy is imperfect and overly simplistic, but it could offer a clearer starting ground for patients and clinicians alike. From the student perspective, hearing a simple analogy would help alleviate the sense that psychiatric diagnoses are plucked out of the ether and floating around in clouds or clusters. For the public, an easily accessible analogy could lend credence to the psychiatric establishment, which has long been plagued by suspicion and distrust. Ice pick lobotomies were a reality of psychiatric care in the 1950s. 

While it may seem odd to lean on analogy, particularly for something as serious as psychiatric illness, we must not forget that the history of science is built on analogy. When we learn, we learn first by association, then by abstraction.

For example, when high school students first study the structure of the atom, they are taught two famous analogies that were used by real life scientists to structure their theories. One theory held that atoms were like the solar system, with electrons orbiting the nucleus like the earth orbits the sun. The other was the blueberry muffin model, which posited that electrons were randomly distributed throughout the atom like blueberries in a muffin. The analogies helped those scientists ground their theories, and they help high school students today understand the basics of atomic structure.

Similarly, when Physicists explain space and gravity, the bowling bowl on a trampoline analogy is used as a conceptual starting point. As someone who understands very little physics, I find this analogy piques my interest and invites me to learn more.

Medical education is also rife with analogy. Lysosomes are the trash cans of the cell. The heart is a pump driven by an electrical circuit. Our knees are hinges and our gut is a tube connected to the outside world on two ends. None of these examples capture the profound nuance that medical students will go on to learn about these organ systems, but they are a starting point to ground our understanding. I think psychiatry needs a simple unifying analogy like this.

Lastly, the idea of the bicameral mind is not so far into the realm of fantasy to be totally unfounded. Neuroscience has demonstrated the existence of mirror neurons in our brains. These mirror neurons work such that, when watching someone kick a soccer ball, the neurons in our own mind fire as though we were kicking that soccer ball ourselves, minus the physical movement. Mirror neurons show that we can directly translate external experience to internal mapping.

We also know that when we dream, our brain activity looks the same as when we are awake, minus the dream actions being translated to real life actions. Perhaps dreaming is an act of our “analog I” exploring and remapping our analog maps?

The bicameral mind theory may not ring true for everyone, but it is a starting point. Surely, one day psychiatry will have its own foundational analogy, its own blueberry muffin.

In the meantime though, I think back on the words of that muscled resident who taught us about SSRI’s. He was brave to admit that psychiatry doesn’t have all the answers. Despite imperfect knowledge, there are still patients in need. Perhaps the greater lesson is not that psychiatry lives in the realm of ambiguity, but rather that there are physicians who try and help patients.

It's a lesson in the art of medicine, and that resident led by example. Admit your shortcomings and show up anyway.


A few sentences about the author in her own words:


I grew up in the Appalachian Mountains of Western North Carolina and attended the North Carolina School of Science and Mathematics (NCSSM) for high school. In my junior year, I won the BookLogix Young Writers Contest with my debut novel, Nothing But Your Memories, which was published in 2013. I then pursued a degree in Chemistry at Pomona College in Southern California, where I also studied creative writing with the acclaimed author, Jonathan Lethem. After graduation, I was fortunate enough to be accepted into the UNC School of Medicine, and during the year before starting, I dedicated my time to reading and writing. Currently, in my clinical clerkships, I continue to pursue my passions for both the humanities and medicine.












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