A Pioneer of Neuropsychiatry: Professor Alwyn Lishman

MS: Where were you brought up?

AL: In a small town called Houghton-le-Spring in County Durham; it was a mining town and my family had a business there going back many generations. I had been destined for the factory if I hadn't gone into medicine. Several previous generations of Lishmans had done dentistry, and there was a small medical part of the family, but most members were tied up in business including this factory.

MS: Why medicine?

AL: Enormous parental pressure, which I never understood. I discovered later, after my father died, that he had transferred from dentistry to become a medical student, but he had not managed to qualify because of illness he suffered as a prisoner of war in the Great War. So I suspect parental ambition, and being the only son. I didn't want to do it. I was not interested in science. I wanted to be a musician. However, they won and in those days you did what your parents told you! I chose Birmingham University because it had started a BSc degree in physiology and anatomy after the Second World War. I thought I would at least do the BSc and then decide about medicine.

I managed to get a scholarship, and was lucky in that Sir Solly (later Lord) Zuckerman had me in his department; that was something everybody wanted. I had a fascinating time; also unbelievably luxurious since I had a fulltime technician and a vast laboratory space.

I did a thesis on the maturation of behaviour in the hyperthyroid rat, with full technological back-up to do cell counts in the cortex. It was published at an early stage. This got me keen on the brain. Zuckerman was extraordinary. Scientific Advisor to the Government, he only came to Birmingham on Saturdays and Sundays but he always knew what we were doing, even the most junior student like myself. Much has been written about him, some of it controversial, but to a naïve student he was the perfect father-figure.

MS: Did you complete the BSc?

AL: Yes, and then went on to medicine. It was a toss-up whether to stay on as an anatomist or do medicine. By then I had friends studying medicine and telling me how exciting it all was. So I plunged in, and never regretted it. It was a marvellous medical school, with patients pouring through. Where colleagues had seen two or three cases of this or that condition, I had seen 20 or 30. It was very good training.

MS: What about the humanities, the other part of your life then?

AL: I went on having music lessons until I took my medical finals, and I also luckily obtained permission to attend the music department. I had access to organ, harpsichord and piano, and I got the academics there to teach me – in return for babysitting!

MS: At what point did psychiatry enter the picture?

AL: Not for years; my interest was in neurology. This was a direct outgrowth from the BSc. Having become involved in the brain, I never left it. My teachers, Professor Cloake and Dr Jefferson, were both exceptionally good clinical neurologists. I was also drawn to general medicine. I didn't like surgery although I did a neuro-surgical house job with Professor Brody Hughes, who had similar musical interests.

MS: Did neurosurgery engage you?

AL: No. I did think about it for a moment! I always became interested in what I was doing. But I was not tough enough physically for the huge operations, some lasting 8 hours. It was a hard life. I always thought I would be a physician. My options were superseded however, by the need to do National Service. I had 2 years in which to think about my career. Since I had done neurosurgery, I was posted to the Army Head Injury Hospital in Wheatley, near Oxford. It was like being in a teaching hospital all over again. The people who influenced me there were the civilian consultants who came in because they were also consultants to the Army Hospital. There was Ritchie Russell who had written a lot on head injury and Charles Witty, an expert in epilepsy. He and his wife virtually adopted me; I was always around at their house. Then there was the Honorable Honor Smith. She had departed from family traditions to do medicine. She ran a research unit on multiple sclerosis and TB meningitis and was greatly respected. I wrote papers with all three of them. It was just ridiculous to be doing research along with National Service! and I got my higher medical qualification, the membership of the Royal College of Physicians. It was a lucky break.

MS: I assume you encountered interesting problems of acquired brain injury, of epilepsy, and much more beside?

AL: It was a huge immersion, particularly in head injury. Because I was working both on the head injury and TB meningitis units, I literally flew about in a helicopter picking up patients. Television-type stuff! Doing cisternal punctures in the air – most exciting.

MS: What followed National Service?

AL: I was wondering what on earth to do when Ritchie Russell asked me to work as his registrar at the Radcliffe Infirmary in Oxford. I was flattered to be invited to work with this great man. I jumped at it. I was also invited to go back to Birmingham as a lecturer in general medicine. But I decided working with Ritchie Russell was too exciting to miss out on. I did further research but became increasingly aware of other interests. I had become hooked on neuropsychology. Moira Williams, a neuropsychologist, was well known in her day. We used to discuss her research and I thought: ‘This is far more exciting than neurology! I am looking at the mind!’ I was always frustrated that in neurology I was examining the motor and sensory system only and I thought this was a shame. I decided to leave neurology for a second reason. In those days, the late 1950s, I had skill in diagnosis but none in management. I felt strongly about this. The only people who seemed to help my patients were physiotherapists and social workers. I myself didn't seem to have much to offer. I had qualified in medicine but I was only a diagnostic machine. I was not helping people. I became more and more worried about it until I finally decided to do something. One day, I had an interview in the morning with the Dean of Moorfields, the eye hospital, thinking of ophthalmology. In the afternoon I met Sir Aubrey Lewis at the Maudsley Hospital, wondering about psychiatry. Aubrey was most encouraging. I could come for a year if I wished and then return to neurology. It would be good for neurology to have somebody with experience of psychiatry. My good friend, Bob Cawley (we had been students together), was at the Maudsley then and loving it. So I did my year and decided thereafter to stay for life. However, I did vacillate. I went back to Oxford to do advanced courses in neurology. I went to Queen's Square and did more neurology. But it seems I had decided to be a psychiatrist.

MS: Had you read any psychiatric literature?

AL: Yes. This is where Charles Witty, the neurologist at the Army Head Injury Hospital, was influential. He was passionate about psychoanalytic theory and he got me to read Jung and Freud. We discussed their ideas a lot. This promoted my interest in the mind. I thought it was all most exciting. I loved the ability to think in an entirely original way. I became wary of psychoanalysis later. It was a brilliant first attempt but wide of the mark! Also terribly suspect in that all the theories revolved around a handful of patients and yet it was seen to apply to mankind. A part of me always thought that a first attempt has to be flawed. But it was an honest attempt and of course led to a wealth of other ideas, many hugely important to psychotherapy, the fundamental clinical skill in psychiatry.

MS: It sounds as if there was a degree of freedom in your life at that time.

AL: Indeed! We weren't hide-bound the way people are now when you have to do specified clinical attachments to be eligible for a consultant post. I served on various committees of the Royal College of Psychiatrists in later years and was dismayed that it was getting so tight, that trainees were not able to move around and, if they did, that they would be wasting a lot of their time because they would have to make it up in other ways.

MS: How did your neurology colleagues respond when you announced you were heading off to the Maudsley?

AL: They were all very nice; they all understood. But they did try to persuade me to stay. Why not consider neuroradiology or neurophysiology? However, I wanted to be in a mainstream clinical discipline, dealing with patients and not looking at X-rays all my life. Some of my fellow neurology trainees were appalled and thought I was moving into a discipline which was suspect. I was brave, they felt, to give up a prospering neurology career and to move to a much less prestigious discipline.

It took a certain degree of unworldliness to make the move. Most people thought that if you could progress in neurology, you had a glittering career ahead of you. Psychiatrists were regarded as slightly odd. At the Maudsley there was no such feeling. With the rigor that Aubrey Lewis had instilled, Maudsley psychiatrists thought in just as rigorous a way as any neurologist. They were determined to bring psychiatry out of the shadows and they did. There were brilliant people there when I arrived, and once I saw that colleagues of this calibre were content to be psychiatrists, any remaining doubts evaporated.

MS: What were your first impressions?

AL: The people who made an enduring impact were Felix Post, who I thought was the cleverest clinician there, and Michael Shepherd, an academically brilliant but arrogant man with whom I didn't get on well. Willy Hoffer was a marvellous man, a psychotherapist who had been associated with Freud. He gave me a page of Mourning and melancholia in Freud's handwriting when he thought I had done rather well with a difficult patient. He said, ‘As a reward you can have this for the morning!’ Hoffer had several of Freud's original manuscripts given to him by Anna Freud. Eliot Slater, who ran the Genetics Research Unit, was an important influence. He was said to be the most brilliant mind at the Maudsley, and we all respected him enormously.

This was all most exciting. and then of course there was Aubrey Lewis himself. Although he had mellowed by the time I arrived, people were terrified of him. He was so clever, and he showed off so much! For instance, if you cited Kraepelin, he would immediately ask to which edition you were referring; ridiculous things like that. I was his Senior Registrar for 2 years and did his out-patient clinic. However, he never saw the patient. Instead, the Senior Registrar discussed the case following the clinical interview and then went back to convey what the great man had pronounced.

MS: What was your first job?

AL: In the Professorial In-patient Unit. I found it fascinating but also a little academic. One had the feeling that patients were there to be dissected. I then moved to an admission unit, and that won me over. I could see the enormous fascination in acute psychiatry. I never worked for Sir Denis Hill but used to nip into his ward rounds, something you could do as a trainee.

The in-patient unit had 24 male patients in one ward, 24 women in another. The Maudsley was highly selective about the patients it admitted then. Most were specialist referrals from all over the south of England, others came for second opinions. You saw the whole spectrum of psychiatry. When I first began, no patient could be admitted against their will; it was an entirely voluntary hospital. As the years passed, patients were also treated on certificate.

MS: What treatments were provided?

AL: Drugs to treat psychotic symptoms and depression were just coming in which generated much excitement. But we were taught to talk to our patients. You had to write volumes and know everything about them. Lewis had been impressed by the Phipps Clinic in Baltimore and the psychobiological approach Adolf Meyer had adopted there. We therefore had to know every detail – occupation, schooling, family, wishes, hopes. We knew our patients as well as one knew anybody in the world by the time you had satisfied Lewis’ and Shepherd's requirements. Shepherd and two others ran the so-called Professorial Unit, to which Lewis came every week to see what you were doing. He made sure you had done everything perfectly. You also had a weekly admission and discharge conference in which he would bark questions at you. You were kept on your toes.

MS: It seems you took a strong interest in the academic side of psychiatric training.

AL: We had a rich program of lectures, seminars and journal clubs. We traipsed over the whole field of psychiatry, including psychotherapy, even though Lewis was not keen on it. But he made sure we all did it! Another example of the control he had over our academic training was the journal club. Held at 9 o'clock on a Saturday morning, nobody would have dreamed of not attending. The presenter was often in a state of intense anxiety for a month because you had to sit on the platform with Lewis where he questioned you until you were a nervous wreck. I had a double dose. Trainees usually had an hour and a half each, but in my case he made me do the whole three hours! The other thing about the academic training was the quality of the interaction between trainees. We had many different viewpoints and we would talk and talk about them. The junior common room and the canteen were great venues of learning!

MS: Were you viewed differently to other trainees given your membership of the Royal College of Physicians (MRCP)?

AL: Not at all. Most registrars had the MRCP. Indeed, you could be turned down by the Maudsley and told to get your membership. I think back to my peers: Bob Crawley with a PhD in medical statistics, Raymond Levy a PhD in neurophysiology, and others.

MS: Did you conduct any research as part of your training?

AL: You had to write a dissertation to obtain the Academic Diploma of Psychological Medicine. I selected head injury as my subject. I went back to Oxford and saw my old friend, Ritchie Russell, who gave me unrestricted access to all the head injury records from the Second World War and found money for me. The grant enabled me to travel back there every other weekend for two years to work. I re-established my link with Oxford and with neurology in this way. I wanted to capitalize on the years I had spent in neurology. I didn't want them to be wasted. I expanded the dissertation into a doctoral thesis a few years later.

MS: What was the theme of your dissertation?

AL: Psychiatric disability in soldiers who had had penetrating head injuries during the first 5 years after the injury. I didn't see any patients. Russell had set up an incredible follow-up system of all the head injured veterans. They were all invited back to Oxford for repeat examinations. I had been to Russell's unit as a medical student and seen the follow-up work. The research was very old fashioned. I selected 670 patients on various criteria and had notes on each one, including follow-up. I took a huge tape recorder to Oxford, the size of a suitcase, in my battered old car. I used to go through the notes and read into the tape recorder everything that I thought might be relevant. From the transcripts, I rated patients on 15 items as ‘no, mild or severe’ psychiatric disability. Items covered intellectual, emotional and behavioural deficits. Behavioural deficits were mostly frontal lobe, criminality exclusively frontal lobe, and psychiatric disability overall specifically related to left temporal lobe lesions. I was lucky to get the MD later because it was all second-hand work, albeit a huge amount.

This was in the days before computers. All the statistics had to be done on a hand operated calculating machine – literally hundreds and hundreds of correlation coefficients and regression equations; it was very boring. But it was a fine educational experience since I read all the literature on brain damage and regional brain dysfunction.

MS: Who else was working in that field?

AL: Virtually nobody. Other people wrote about brain damage, especially Henry Miller, the neurologist from Newcastle. We would lecture together at the Royal Society of Medicine but he was so charismatic that he won all the votes! We got on very well. A remarkable man. So, apart from Miller's writing, nobody at that time was looking at psychiatric aspects of head injury. Freda Newcombe, of course, continued brilliantly in the years that followed, calling up subjects from the series for detailed neuropsychological evaluation. and thanks to her foresight the records of these soldiers have now been preserved in perpetuity in the library of St Hugh's College, Oxford.

While I was doing this work, lo and behold, John Eayrs who had been my tutor in Birmingham got the Chair of Physiology at the Maudsley and I began doing animal experiments again. So, as the Senior Registrar, I was rushing up to Oxford to finish off my MD and I had one day a week doing physiology research assisted by a full-time technician.

MS: What kind?

AL: I was looking at memory in the rat. This was the era of taking one hemisphere out and seeing how much went across to the other. This led to a recurrence of doubt about whether I should go back to physiology. I continued for three years in the lab even after I became a consultant; three sessions in physiology as well as my clinical work. If I had been wiser, I would have tried to make my physiology more relevant to clinical problems. In those days, fundamental research was regarded as important whereas nowadays it is hard to get grants for it. I was fortunate to obtain a succession of grants from the Medical Research Council.

MS: Did you have an idea at this point what path you might take in your future psychiatric career?

AL: I realized I was stretching myself in too many directions. I was frantic! I would have to calm down. So, I got married and did calm down! I knew my future would be academic. I applied for a Senior Lectureship at the London Hospital but didn't get it. I tried for a clinical post and didn't get that either. Then, thank goodness, I got Eliot Slater's job at Queen's Square. He had been fascinated by brain-behaviour relationships. During the war, he wrote a crucial article on the association between stress and breakdown. He quantified the neurotic potential of a soldier in terms of childhood and family history and the amount of stress which had led to his breakdown and showed a mathematical relationship between the two. The more the neurotic potential, the less stress you needed to break down, and vice versa. Then he looked at a subgroup that had brain injury and showed that the injury disturbed the mathematical relationship. The brain injured soldier would break down under less stress and with less neurotic predisposition.

Later Slater became interested in hysteria, and the schizophrenic psychoses of epilepsy. I was moving into the shoes of a man who was a pioneer of British neuropsychiatry (although he never used the term). Sadly, he resigned from Queen's Square because he was so disappointed the neurologists wouldn't allow a chair of psychiatry to be established and came back to the Maudsley.

Queen's Square fuelled my interest in neuropsychiatry (although the word was not used in those days). I was dealing exclusively with psychiatric aspects of neurological disease and I was back working with neurologists. I also cemented my fascination in neuropsychology. Oliver Zangwill was producing brilliant neuropsychologists like Elizabeth Warrington, Malcolm Piercy and Maria Wyke. I used to wish that I had become a neuropsychologist instead of a psychiatrist.

I thought this would be the pattern for the rest of my career. It didn't turn out this way. I came back to do 9 years of general psychiatry at the Maudsley at the invitation of Denis Hill and only became a ‘neuropsychiatrist’ again when I was nearly 50. He became a guiding figure for me. It was he who said: ‘You ought to develop the discipline of neuropsychiatry’. This had been close to his heart given that he had been a pioneer in electroencephalography and had been running the Maudsley's Epilepsy Unit, working with the neurosurgeon, Murray Falconer. Back in 1964 he had published his immensely perceptive essay on ‘The Bridge Between Neurology and Psychiatry’. Hill pointed out the huge field that was then developing. So I started by writing a textbook. Towards the end of preparing the manuscript, he urged me to leave my consultant post and come across to be an academic in his department. He put together the funds for a chair in neuropsychiatry. I suppose I would have headed for this myself if I had had more vision but I was always interested in what I was doing, and liked general psychiatry.

MS: Were any neurologists at Queen's Square sympathetic to psychiatry?

AL: McDonald Critchley, Dennis Williams and Sir Charles Symonds. An early clinical paper I wrote was with Symonds. When I was in the Army I gave a lecture on what I thought was a new form of epilepsy and he was in the audience; he suggested we cowrite a paper and generously gave me senior authorship. The other neurologists in the audience all argued that my observations were nonsensical. Symonds then proclaimed that he had seen four cases similar to mine. When I got to Queen's Square he had just retired but he came in once a week and we lunched together. He was very sympathetic to psychiatry. Luckily, some younger consultants appointed at the same time as me were equally sympathetic. Roger Bannister was one of them. Many others were totally dismissive! They would ask me to see their patients but would often ignore what I said! That used to upset me. They had been horrid to Elliot Slater too in the correspondence that followed his paper on hysteria. For instance, Sir Francis Walshe commented that neuropsychiatrists were amateurs at both neurology and psychiatry! There was no such thing as a neuropsychiatrist, they proclaimed.

MS: When did you decide to write your text on neuropsychiatry?

AL: I started writing in 1970. It was 7 years growing. The reasons it took so long are twofold: we had our two children during those years as well as parental illness and death – my wife's mother died from a brain tumour and my mother developed Alzheimer's. I put the manuscript away for a year or two at a time. For the first edition I was given two weeks study leave but most of it was done getting up at five in the morning and spending three hours writing before going to the hospital. It was a tremendous strain. The Maudsley had no leeway to give people time off to write books.

I had good luck with the book. It didn't have competitors and it therefore did well – went into second and third editions. The idea of it was relatively new. The reason it was ever written at all was that somebody (I don't know who) had given my name to Blackwells and they began pestering me. ‘We have been advised that there is a need for a book on your subject and that you are the person to write it.’ I kept saying: ‘I'm too busy with other things’. The idea of labouring over a book did not appeal initially but later I realized I had given so many lectures at Queen's Square and the Hammersmith Hospital on all aspects of psychiatry in relation to medicine and neurology that I could put my lectures together. I agreed to do it. I had inherited £100 and been offered a £500 advance. Just then, I saw a Bechstein grand piano for £600 and my wife told me to ‘go for it’. We bought the piano, I signed the contract. Blackwell's were delighted because they had got me to decide after 4 years. I wrote the first chapter on head injury and was alarmed to discover that it occupied almost a third of the word allocation for the entire volume. They were very good about it: ‘We don't care how long it is or how long it takes as long as you keep going’. Later, Blackwells engineered a fellowship for me in Oxford to write the second edition but I only got two months. I wrote the third edition during my retirement.

MS: You gave it the title Organic psychiatry, not Neuropsychiatry.

AL: Yes, for two reasons. I planned to cover systemic as well as brain disorders and I did not want it tarred with the brush of the ‘old’ neuropsychiatry. Instead, it should be seen as written by a real psychiatrist with an interest in many approaches.

MS: A chair in neuropsychiatry was important to you. Why?

AL: Several reasons. I wanted more time for research. I was tired of doing it in the evenings and on Sundays. Second, I was keen to establish a teaching program in neuropsychiatry. We did in fact achieve this with marvellous help from the basic departments like neurochemistry, neuropathology, neurophysiology and neuropsychology, complemented by seminars on clinical aspects of dementia, head injury, epilepsy, and so on. Third, I wanted to recruit a group of people who would become the neuropsychiatrists of the future. I wanted to provide a forum where the interested person could be assured of a post. Many people got fellowships and did two or three years with me. Some now hold chairs of neuropsychiatry in teaching hospitals. I think there is only one London teaching hospital where there isn't one of my ex-fellows. Finally, I wished to bring a sharper focus to my clinical work. Before I took the chair, I'd ended up overwhelmed with all manner of referrals. I thought the chair would give me a valid reason to say: ‘I'm sorry – find another colleague’. I was exhausted with a clinical routine which was preventing me from developing a speciality.

MS: What sort of research did you concentrate on?

AL: Once I got the chair I decided that my major emphasis would be to exploit brain imaging in relation to psychiatry. We were very lucky in that we got the first CT scanner in a British psychiatric hospital. I hoped to use the scanner in relation to alcoholism and schizophrenia. I wrote an extensive program grant that took months of work but the answer from the Medical Research Council was that I could only have one or the other. I don't quite know why but I chose alcoholism, an interest that endured for years. I assembled a team to develop computerized methods to analyse the scans in a more sophisticated way than the neurologists were doing since I knew any changes in psychiatric patients were likely to be subtle. Then, of course, just when our methods were coming to fruition, MRI appeared and the CT stuff looked primitive by comparison. Such is the way of research. Later we began to study the schizophrenic psychoses of epilepsy, using neuropsychology and brain imaging. That was the last major research activity in which I was involved.

MS: How did your view of research in neuropsychiatry compare to your predecessors?

AL: The great German professors of psychiatry were all neuropsychiatrists and saw the brain as central. Trained in both neurology and psychiatry, they gave birth to such conditions as Alzheimer's disease, Korsakoff's psychosis, Pick's disease and GPI. Nearly all the notable academics were also neuropathologists. This approach was of benefit in the case of the diseases that I have mentioned, but it fell on its face for most other mental illnesses. There had been a long struggle to establish the pathology of schizophrenia which led to very little. Griesinger had declared that: ‘Mental diseases are brain diseases. Psychiatry and neuropathology are but one discipline and the same laws rule in both’. He was steadfast in refuting the idea there was more to psychiatry than brain disease. As people became more sophisticated in the 20th century, they poured scorn on these monolithic German ‘empires’, which had proved so narrow-minded. It took a long time for neuropsychiatry to live that down.

I never thought neuropsychiatry had to be this narrow since I saw it as part of general psychiatry. There was no more reason in neuropsychiatry to forget about interpersonal relationships when treating someone with dementia and the impact of culture when dealing with alcoholism. Everything we had learned applied to people with neuropsychiatric conditions.

When the British Neuropsychiatry Association (BNPA) was launched in late 1987 under my chairmanship, I was convinced of this position. Some people felt it was as much the province of neurology as of psychiatry and pointed to neurologists in the US who wrote about neuropsychiatry. I disagreed, believing they were handicapped in terms of what they could offer our patients. I felt neuropsychiatry was a living branch of psychiatry. Otherwise, it would deserve the criticism people had shown towards it a 100 years earlier. I was therefore keen people should only become neuropsychiatrists after a full psychiatric training.

We formed the BNPA with certain principles firmly in mind. We envisaged that since our aim was to provide a forum for cross-disciplinary, clinical and non-clinical discussion the association would only prosper if the membership contained psychiatrists, neurologists, psychologists and neuroscientists. This has in fact been achieved with 200 psychiatrists, 75 psychologists, over 50 neurologists, nine clinical neurophysiologists, three neuropathologists and even a neurosurgeon! What a marvellous cross-section of people interested in the brain and behaviour from diverse angles. Topics at our meetings have covered schizophrenia, social aspects of neuropsychiatric disorders, pain, epilepsy, head injury, laterality and frontal lobe pathology.

We used to combine our scientific meetings with pleasures like a harp recital or a wind ensemble. I was keen that we should be seen as a cultured group. The Americans followed suit and called their organization the American Neuropsychiatric Association.

MS: Have you ever had an interest in forensic aspects of neuropsychiatry?

AL: It cropped up a great deal but I didn't have time to become involved. If you do a lot of medico-legal work, you can be subpoenaed no matter what you are doing. I remember a subpoena from a London court when I was about to deliver a lecture in Edinburgh. I had to cancel the lecture and proceed to court, only to find out that I wasn't called. I don't think I am very good at arguing in a court of law. I quite enjoyed it but the people I sent my cases to were superb at the job. I've done a bit in retirement but have tended to get impossible cases where 17 views contend with one another. I'm told most barristers have a copy of my textbook. I suppose I am in some way part of the forensic scene.

MS: Tell me about the research you did on memory.

AL: I had always had an interest in memory, both physiologically in the rat (as I mentioned earlier) and in relation to cerebral disease, and had written quite a bit. I thought it would be interesting to study determinants of memory in healthy people. I focused on whether things we liked had a stronger retention in memory than things we didn't like. This was a crude approximation of testing Freud's theory of repression. I devised methods to examine the effect of the hedonic tone of material on how well it was remembered. I would ask people to rate a number of topics – like the Labour Party, ‘my mother’, the countryside, living in London – in terms of their pleasantness or unpleasantness. I went back to the same group two weeks later, admitted my request to them had been a memory test, and asked them to write down as many topics as they could remember. There was a highly significant effect of recall of pleasant material over unpleasant material which persisted after applying appropriate controls. I then looked at the speed of recall of past events and the same pattern emerged. We turned to people with a depressive illness and found that they showed the reverse effect, that is they recalled unpleasant over pleasant. Other researchers like John Teasdale (of Oxford and subsequently Cambridge) took the work further and were able to show that in depressives with diurnal variation, the memory effect changed from morning to evening.

I also took on administrative roles with the Medical Research Council (MRC). As a member of the Neurobiology and Mental Health Board, I was asked to nominate a priority area for research. I chose the dementias. As a result the MRC put a huge amount of money into this area in the 1970s and '80s. I wrote a report on dementia research but it rather fell on its face because it was published just as the cholinergic deficit was being discovered. We hadn't predicted this at all! We had certainly highlighted biochemistry and neurochemistry but with no mention of the cholinergic system. This was a bit embarrassing when it came out.

My emphasis at the time was that we had gone up the wrong avenue regarding dementia merely as part of the ageing process. I felt dementias were brain diseases as researchable as any other. I felt we had been misled by the similarity in pathology between old age and senile dementia, when the same picture was found in cases of dementia in their 40s and 50s. I recommended epidemiological research to ascertain the true prevalence of the dementias and investigating early stages lest treatment might work at this stage but not later in the disease process. Immunological aspects, I thought, were of interest too, especially in relation to the formation of amyloid plaques.

MS: What was the fate of your report?

AL: It influenced the Department of Health and the MRC inasmuch as they set aside funds for research, encouraged people and convened meetings to generate new ideas.

MS: How did your entry into brain imaging research come about?

AL: This was developing in the late 1970s when I entered my new academic post. As I mentioned earlier we were fortunate to install the first CT scanner in a UK psychiatric hospital, the result of an enormous fund-raising drive by Denis Hill. Maria Ron (now a Professor at Queen's Square) and I did work on alcoholic patients but also developed methods to quantify scans objectively, in a finely graded manner. I knew of the longstanding dispute about brain shrinkage in the alcoholic patient and the difficulty of sampling errors. We found that alcoholic patients had larger ventricles than nonalcoholic controls, related to the duration of abstinence. We turned to members of Alcoholics Anonymous who had been abstinent for years and noted they still showed residual shrinkage. Thus, complete restitution did not occur. Other people (in Australia) went on to look at the histology and were able to show neuronal fallout in various areas and impoverished dendritic growth. We also discerned the female brain's greater susceptibility to the effects of alcohol compared to the male brain (just as the female liver is more susceptible than that of the male).

We then turned to Korsakoff patients. We saw more cortical atrophy than ever. Korsakoff himself had thought the lesion was cortical but others had located it at the base of the brain and turned their back on the cortex. In fact, the cortex of the Korsakoff patient is shot to pieces. This has led to grand theorizing, yet to be tested, that two forms of insult occur in alcoholism – via nutritional deficiency and through a direct toxic effect. Furthermore, nutritional damage is at the base of the brain and toxic damage in the cortex. We ourselves found that if you compared alcoholic patients with memory impairment with those not so affected, the former had larger third and lateral ventricles (almost as bad as that in Korsakoff patients) whereas intact memory patients resembled normal controls. Thus the Korsakoff state could be the end stage of dual damage occurring over a long period. The question of what precipitated the catastrophic memory loss of Korsakoff syndrome per se remained unclear because it seemed as though many alcoholic patients moved along that dimension in terms of brain scan changes long before they became diagnosable as Korsakoff. This matter will no doubt be clarified in due course.

MS: May I return to the state of neuropsychiatry today. How is it doing?

AL: Neuropsychiatry is healthy. This is partly fortuitous in that brain imaging now shows us how interesting the brain is in psychiatric disorders. Neuropsychiatry pervades many areas of psychiatry – schizophrenia, affective disorder, obsessive-compulsive disorder. It is fascinating that so many conditions are repaying neuropsychiatric study, both brain imaging and neuropsychology. The development of sophisticated, computer-based psychological testing is most exciting. Many chairs of neuropsychiatry exist now, positions which we never dreamed about. When I got my chair, it was the first in the UK; now they are all over the place!

We also have a new special interest group in the Royal College of Psychiatrists. This is a mixed blessing. I detect a certain ossification in subspeciality training – the requirement to fulfil multiple criteria before one can apply for a post. It would be a pity if that happened with neuropsychiatry because it embraces the whole of psychiatry. Any training program would have to include at least a year of neurology, a knowledge of electroencephalography and its modern derivatives, expertise in brain imaging in all its forms and neuropsychology. My fear is that if these aspects were covered they would necessarily have to poach time from general psychiatry training. I don't see how you can take all that on and also become a skilled clinician and a psychotherapist, which I think all psychiatrists have to be.

MS: There are interfaces between neuropsychiatry, old age psychiatry and behavioural neurology. How do you see these developing?

AL: The answer with respect to old age psychiatry is easy in that an enormous amount of what goes on there is neuropsychiatry. Managing dementia and cerebrovascular disorder and the like requires both neurological and neuropsychiatric expertise. Of course old age psychiatrists have a much broader brief than these two conditions, being deeply involved in affective disorder, paraphrenia, and even personality disorders and family conflict. In my time at the Maudsley there were always cross-referrals between neuropsychiatry and old age psychiatry. Pioneers in old age psychiatry also pioneered neuropsychiatry. For example, Sir Martin Roth and Felix Post – two illustrious leaders of old age psychiatry – both used neuropsychiatric techniques from the beginning. Roth clarified the dementias, looking at the histology with Tomlinson, and sorted out the dementias, acute confusion, affective disorders and paraphrenia, a task very much using neuropsychiatric insights. Post, who was well tutored in all facets of the brain, researched diverse aspects of psychogeriatrics, including a look at psychological deficits and at sedation thresholds (he studied the amount of amylobarbitone needed to cause confusion). These were early ways of examining brain function in affective disorders and the dementias.

The current requirements for training in old age psychiatry in the UK do not include any exposure to neuropsychiatry, brain imaging, electroencephalography or neurology. In terms of intellectual exchange, you could have the spectre of different specialist groups dealing with the dementias independently of one another. Fortunately, cross-fertilization does occur. Neuropsychiatrists and old age psychiatrists do confer and both speak to neurologists.

MS: What about behavioural neurology?

AL: Behavioural neurology as practised in the US is a neurological subdiscipline and therefore lacks the richness of a full psychiatric understanding of the patient. Instead of putting the person at the centre, brain mechanisms take precedence. In a recent survey, neurologists endorsed twice as often as psychiatrists the notion that neuropsychiatry is synonymous with behavioural neurology. I think neurologists are still a long way from having an interest in behavioural disorder generally, although advances in neuroscience are likely to have made emotion, consciousness and even will more respectable to the neurological mind.

This said, I must acknowledge my admiration and personal indebtedness to two leading behavioural neurologists in the US – Norman Geschwind and Frank Benson. I had the opportunity to study with both in Boston in the 1970s and they taught me an immense amount. Frank and I became especially close, with frequent visits to each other's units over the years and a lively exchange of ideas.