Review of Brain On Fire: My Month of Madness by Susannah Cahalan

Abstract

[Author Affiliation]Deborah M. Weisbrot. 1 Child & Adolescent Psychiatry Outpatient Clinic, Stony Brook University Medical Center, Stony Brook, New York.Alan B. Ettinger. 2 Albert Einstein College of Medicine, Bronx, New York, and Epilepsy Center, Neurological Surgery P. C. , Lake Success, New York.IBSN: 987-1-4516-2137-2. 2012. New York: Simon and Schuster. 263 pagesAddress correspondence to: Deborah M. Weisbrot, MD, Associate Professor of Psychiatry, Director, Child & Adolescent Psychiatry Outpatient Clinic, Stony Brook University Medical Center, Stony Brook, New York 11894-8790, E-mail: deborah.weisbrot@stonybrook.eduWhat is the value for doctors to read about the experience of illness? Certainly there is an abundance of books written by individuals who have suffered from assorted medical problems. If physicians conclude that the value is simply to remind them to be more sensitive or compassionate, they will miss the point of the extraordinary learning opportunities afforded by reading Brain on Fire.Brain on Fire will undoubtedly create healthy anxiety in medical readers who will have to ask themselves the crucial question, What would I have done if I had been in charge of this case? Brain on Fire will be both humbling and frightening for the neurologist or psychiatrist reader. Clinicians will ask themselves how many of their own patients could have had an unrecognized neurological syndrome of the type incurred by Cahalan. Even we, the authors of a soon-to-be-released text on neurologic differential diagnosis, scrambled to ensure that this particular diagnosis was adequately represented. Yet, hoping to figure out the enigmatic diagnosis misses the more important lesson. We would argue that the best physicians are not necessarily the most savvy or knowledgeable; rather, they are the ones with humility who asks themselves the vital questions, What else could this be? and, Should I get help?The initial symptoms experienced by author, Susannah Cahalan, were both neurological and Cahalan's experience early on with a psychiatrist who did not apparently inquire further about neurological symptoms might lead neurologists to feel justified in failing to bring in psychiatrists early in the evaluation of patients with altered mental status, out of concern that symptoms would be dismissed as merely psychiatric. This conclusion would be unfortunate since the broader concern is the frequent failure of neurologists and psychiatrists to communicate with each other. A better model of collaboration is demonstrated subsequently when the new psychiatrist appropriately states that bipolar disorder was a possibility, but only after neurological causes are excluded.It was disturbing to read the description of the original outpatient neurologist who dismissed Cahalan's symptoms as a result of drinking and partying. While this attribution was particularly egregious because it was completely unfounded, the reader's demonizing of the neurologist will also block consideration of a broader issue that affects all of us. How often do clinicians latch on to diagnoses that seem easy to package and most probable, rather than taking each and every case and wonder, What else could it be? How often do we discipline ourselves to ask Have we reasonably excluded other possibilities? How many of us take the time to examine the broad differential diagnosis for each case we encounter before moving on to the next patient in a busy work day?Furthermore, Brain on Fire poses a dilemma for all physicians who want to do well for their patients but find themselves practicing in a health care system that limits the amount of time which can be reasonably spent with each patient. Indeed, the emergency room physician evaluating Cahalan for a new-onset seizure followed typical clinical practice in discharging Cahalan after performing routine testing. Yet, taking more time to elicit a detailed history would have revealed her extraordinary change in mental status and that would likely have led to her admission and further investigations. …