Book Review

The Divided Mind

by Edward Bullmore (New River Books, 2025)

The title of this book by eminent psychiatrist and neuroscientist Edward Bullmore could not be more apposite. It encompasses not only the Descartesian divide between mind and body but the equally large chasm between psychiatrists of a psychological or organic bent and, in a gentle way, the early divide in Bullmore’s own mind, as he grappled with the countless contradictions he encountered as he wended his way through his career.

He attributes much of the controversy to ignorance of mental illness, further slowing down progress. “Research funding agencies have said that they want to spend more on mental health; but when they convene the experts for a brainstorming session there is no agreement between them about what the key questions are or how to tackle them” – the upshot being that the different factions merely criticise each other’s proposals. Bullmore recalls how, in his time at the Institute of Psychiatry, the big divide played out even in the canteen where “the organic, genetic tribe and the functional, environment tribe tended to eat [at separate tables], chatting in their own specialised dialects and apart from each other”. This lack of diversity could only have strengthened confirmation bias.

And then, when Bullmore went to Cambridge to take up his role as professor of psychiatry, he experienced the other divide – psychiatrists not being seen as ‘proper doctors’, with neurologists the most keen to differentiate between their brain expertise and the more functional –“or should one say fictional?” – approach of colleagues in psychiatry. Bullmore had to smile and bear it as just “another manifestation of the same deep split between mind and brain, bio-medical and psycho-social and the traditions of Kraepelin and Freud, which has prevailed continually from the 19th century to the present day.”

Bullmore goes into great depth about several towering figures in psychiatry and really brings them to life. Sigmund Freud and Emil Kraepelin were contemporaries (born in the same year) and complete opposites: the former remains famous worldwide to this day but had minimal impact on schizophrenia; the latter remains virtually unknown, yet his work continues to dominate thinking about the condition – it was his ideas that found their way into the various editions of the Diagnostic and Statistical Manual of Mental Disorders. The pair strongly disliked each other and each other’s views, and this antagonism, continued by their tribes, led ultimately, Bullmore suggests, to the dark, dark period in which, in Nazi Germany, German psychiatrists facilitated eugenic and genocidal policies, first directed against schizophrenics and based on Kraepelinian ideas. (Freud and his Jewish psychoanalytic colleagues had by this time been forced into exile or worse. After the war, Kraepelin’s biological tribe ended up disgraced, while psychoanalysis triumphantly resurrected itself, particularly in America, where much of the Jewish diaspora had taken up residence.) This dreadful period, Bullmore believes, still influences thinking and fears about schizophrenia.

It is refreshing that Bullmore, who appears on paper to have had an orthodox career, was always sceptical of given understandings about schizophrenia. In his early hospital days, rarely did he come across a ‘florid’ case of hallucinations and delusions. More usually what he saw was quietness and withdrawal – the negative symptoms attributed to the disease. “People with schizophrenia tended not to do much or move much. They tended not to talk unless spoken to and in response to direct questions their answers were often brief. A patient’s immobility would often become more obvious cumulatively, as you spent more time with them in the interview room, gradually picking up their lack of facial expressiveness or the stiffness of their arms and hands. People with schizophrenia were also socially quiet. They generally kept themselves to themselves on the wards, had few friends and often minimal contact with their families.”

All this was to make sense decades later, as he pieced together a variety of research findings which throw a completely new light on the origins of the condition. But, at the time, he and his fellow student doctors, while cheerfully agreeing that insanity was “all bollocks”, had to concentrate on committing to memory the approved thinking, so that they could recite to examiners what the latter wanted to hear.

Bullmore appears to have enjoyed writing this book, joyfully meandering off into great detail about one or other significant figure in the story (such as Melanie Klein) or suddenly delving into unexpected explorations of geocentric astronomy, fractals and worms and the physics of airlines – but always eventually linking this back to the development of his story.

And the story he builds is truly fascinating, accommodating nature and nurture, as he ranges over discoveries, via MRI scans, of highly relevant lesions in the brain; findings from epidemiology about differences in behaviour in schizophrenics as adolescents; the relevance of genetics – hundreds (or maybe thousands) of genes are likely to be involved, not a few killer causative ones, as once hoped, but that does not make them irrelevant. Indeed, the extent of gene involvement, especially through epigenetics, appears to explain so much about the symptoms attributed to schizophrenia. We learn that the immune system, once thought to have no connection whatsoever with the brain – indeed, a ‘fact’ so etched into medical brains that it is still taught today – is the most key, genetically, in determining likelihood of developing schizophrenia. Bullmore presents to us the understanding that we all have the genes for schizophrenia; it is just a case of whether they get switched on – which is down to epigenetics. Thus, if immune cells are strongly activated at formative times for the brain by, say, an extreme biological or social assault (such as serious neo-natal infection or physical or emotional childhood abuse), the memory stays in the system. Then, if further highly damaging assault occurs in someone’s first two decades, when the malleable brain is still developing, protective behaviour change (such as the withdrawal and submissiveness much observed by Bullmore?) may become permanent.

There is so much to it and Bullmore unravels the evidence piece by compelling, painstaking piece. It is an exciting read. “But what makes this moment epochal, rather than merely triumphant,” he says, “is how it promises to lead us across the schism, rather than reinforcing old divisions to the advantage of one side versus the other.” Knowing what we know now, he says, we should be thinking urgently about prevention – improving child health and social services and redesigning mental health treatments into pathways that cohere over a person’s life, instead of sharply splitting onto two tracks at 18 – when schizophrenia most generally emerges. Because this isn’t about nature or nurture. It is both.

Reviewed by Denise Winn (Jan 26)