His research does go back in time and across disciplines and cultures, blending media reports, literature reviews and extensive interviewing. In his mission to build a case, Watters travels to Hong Kong, Sri Lanka, Zanzibar and Japan, thereby offering the physical and cultural settings in which his stories are told.

His discussion of the rush of trauma specialists into Sri Lanka after the tsunami and how these well-intentioned clinicians ran counter to the local customs and methods of grieving is a disturbing and convincing one. He falls just short of calling post-traumatic stress disorder a globally invalid construct, which would be a disservice to its many sufferers.

From Zanzibar, Watters elucidates the importance of culture, family structure and spiritual beliefs in a society's definition of what constitutes abnormal behavior.

He describes amazing resilience and acceptance in a family struck with severe psychosis. What's left out of this discussion, however, is a mention of gross human rights abuses of the severely mentally ill that persist in many parts of the developing world.

From Japan, he demonstrates just how corrupt and profligate giant pharmaceutical companies can be.

Watters describes the "nature versus nurture" origin of psychiatric illness. He rightly identifies many of the unintended consequences of promoting the idea that mental illnesses are exclusively brain disorders.

Taking a wealth of research into account, however, it's hard to argue that severe illnesses such as schizophrenia, bipolar disorder and severe depression are not primarily brain-based and universal.

In an essay adapted from the book and published in the New York Times on Jan. 10, Watters writes: "We in the West have aggressively spread our modern knowledge of mental illness around the world ... changing not only the treatment but also the expression of mental illness in other cultures."

But this raises the question: Who exactly are "we"? Who, or more precisely what, are these zealots and missionaries?

Something such as the globalization of the American psyche is unlikely to stand on the shoulders of a few intellectual giants, no matter how charismatic they are. Instead, the export of ideology must rely on the sheer power of institutional muscle and momentum.

In addition to Big Pharma, international media companies, which peddle sensational and dumbed-down news stories around the globe on a 24/7 basis, take some blame.

Watters also identifies the American Psychiatric Association as partially responsible, but mystifyingly does not flesh out the organization's culpability. One of the association's largest sources of revenue is the sale of its official source for categorizing psychiatric illnesses, the Diagnostic and Statistical Manual of Mental Disorders. Increasing worldwide sales adds handsomely to the organization's bottom line and reputation.

First published in 1952, the manual has been periodically modified to reflect advances in research and theory about what constitutes psychiatric illness. The current version was published in 2000. The fifth edition, now being drafted, is due out in 2013. But from a financial perspective, what's the rush? Not many other 10-year-old, 943-page books weighing in at just shy of 4 pounds, with a cover price a tad under a hundred bucks, have spent time in the double digits in the Amazon.com sales ranks.

While Watters does an admirable job of documenting a globally important phenomenon and raising public awareness about a topic that is both complex and obscure to most, one could argue that the real problem is not the export of psychiatric diagnostic categories but instead the broader issue of America's trafficking of commercialism and narcissism to the rest of the world.

This article appeared on page FE - 7 of the San Francisco Chronicle

Holly suffers from dissociative identity disorder (DID), formerly called multiple personality disorder. The American Psychiatric Association defines DID as "the presence of two or more distinct personality states that recurrently take control of behavior. ... Each personality may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name."

These personality fragments are formed in response to severe childhood trauma or loss. The incompletely formed identities are referred to in shorthand by therapists as "alters" who inhabit "the body." Alters are created by a person's unconscious mind after a period of dissociation, defined in part as an out-of-body experience, in which pieces of a person's psyche split off from the body to withstand episodes of abuse.

Due in part to an epidemic of multiple personality disorder diagnoses in the 1980s, DID remains a controversial diagnosis, based on the concept that a person's ability to remember events accurately cannot always be counted on. In brief, DID does exist, but is exceedingly rare. In more than 20 years as a clinically active psychiatrist, I've seen no more than half a dozen bona fide cases.

As the chain-smoking, kindhearted, face-forward core personality, Holly suffers from depression, social anxiety, distractibility and a proneness to panic attacks. She can be clingy or standoffish, but no one doubts her sincerity.

By giving Holly's alters a place to live, a body to inhabit and a wardrobe, Mahaffey, a San Francisco writer, uses more than a little poetic license. Directing the nearly sixth-of-a-ton Ruffles to occupy the left side of Holly's head with a resultant tilt, Mahaffey creates comic relief while making her characters more tangible.

Holly makes the best of her challenging situation when she uses her alters on the job - Ruffles and Betty Jane, in particular, share an ability to make demanding customers lighten up. In the guise of Betty Jane, Holly is discovered by a Hollywood sharpie who recruits her to become a voiceover artist for the main character of a new animated television series.

The particulars of how Holly developed DID, beginning midway through the book, provide the overriding strength of the novel. The author intrigues the reader with a plot that is delightfully surprising and suspenseful, slowly uncovering the various sources of Holly's alters, showing that these personas do not just appear out of someone's overactive imagination.

Mahaffey documents a realistic setting and progression of psychotherapy. Though Holly has been in twice-a-week therapy for six years, she is just now nearing the ultimate goal of DID treatment - that of integrating her disparate personalities into a core identity. Her veteran psychologist, Milton, is portrayed as a skilled therapist - direct, flexible, interactive and pragmatic.

Not surprisingly, Holly's rediscovering the sources of her alternate personalities provides the necessary tools for the ultimate healing of her self.

At turns both funny and poignant, "Sounds Like Crazy" celebrates resilience as an essential element of the human condition.

Paul R. Linde, a clinical professor of psychiatry in the UCSF School of Medicine.
This article appeared on page F - 4 of the San Francisco Chronicle

"The Soul of Medicine" works well on multiple levels: as a collection of fascinating medical exotica; as a primer on the anatomy and physiology of both the normal and the diseased body; as an application of the history of medicine to modern-day practice; as an exploration of the best, and sometimes the worst, deeds of physicians and surgeons in the last half-century; and as a chronicle of the healing arts.

This is Nuland's 12th book. While his career as an academic surgeon at Yale was winding down in the early 1990s, Nuland, also a bioethicist, began his vocation as an adept and prolific writer. He captured a zeitgeist in his landmark book, "How We Die," winner of the National Book Award in 1995.

Nuland's own tale kicks off this book dramatically. It's a bizarre case of an abnormal chest X-ray revealing fecal matter misplaced in the lungs of a young boy. The medical sleuthing has begun.

"The Dermatologist's Tale," as an example, explains the ways in which a specialist systematically untangles a clinical puzzle, which Nuland refers to as "The Riddle."

Nuland is equally skilled at writing about matters of heart, soul and spirit, most often observed within the context of a partnership between doctor and patient.

He comes closest to capturing the soul of medicine in the tales told by an internist, cardiologist and kidney specialist. These illuminate the intangibles of the art of medicine and demonstrate the ways in which resilience in the face of overwhelming illness and impending death can bring out the best in both doctor and patient.

"The Cardiologist's Tale" is the most compelling. In it, he tells the story of a long-standing, respectful relationship between doctor and patient. The account peaks when the doctor, seeing that he can do no more to address his patient's end-stage heart failure, writes a prescription for the rare books librarian to tell his life story. The Rx reads: "One set of memoirs."

But, just as in our day-to-day lives, the sacred and the profane are juxtaposed. Three of the stories could be scripts for a reality-television series of "Surgeons Behaving Badly."

These include the rogue, probably sociopathic, resident surgeon who made it his mission to sleep with as many student nurses as he could while he was on call. And the attending surgeon afflicted with bipolar disorder who stopped taking his lithium while on a three-week vacation and came back to perform unspeakable mayhem in the operating room. Not to mention the surgical fellow who impulsively stuck his unwashed bare hand into an open abdominal wound.

Though well written, the book suffers from two minor problems.

Although Nuland's attempt to cloud the identity of his home hospital as "Canterbury" was done with good intentions - to further protect the confidentiality of both doctors and patients described here - the device unfortunately distracts the reader ever so slightly from the universal lessons to be learned in each story.

In addition, it would have been more effective for Nuland to integrate his commentary into the body of each tale rather than placing it as an aside in a separate companion chapter.

Nuland, along with fellow Yale surgeon Richard Selzer, is a likely candidate to be elected dean of living American physician-writers. His work can be considered in the same realm as the quintessential example of physician-penned nonfiction - "The Doctor Stories," by William Carlos Williams, compiled by Robert Coles.

Although it's easy to say goodbye to the vestiges of sexism and racism in medicine, it's much harder to part with the laying-on-of-hands, the precision and beauty of a well-done physical exam, and the trust that was often constructed in an era when doctors spent more time listening to their patients.

Ultimately, "The Soul of Medicine" works well in that it pays proper respect to the healing art of medicine.

Paul R. Linde is a psychiatrist at San Francisco General Hospital. His second book, "Danger to Self: On the Front Line with an ER Psychiatrist," is due out in early 2010 from the University of California Press.

sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/04/28/DDSM16LGPL.DTL
This article appeared on page E - 10 of the San Francisco Chronicle

Issues of shame and secrecy swirl around all of them. The paraphilias most commonly identified - pedophilia, exhibitionism and voyeurism - are those most likely to catch the attention of police and judges. Others include fetishism, sadism and masochism, frotteurism, zoophilia and necrophilia.

Daniel Bergner's most recent book, "The Other Side of Desire: Four Journeys Into the Far Realms of Lust and Longing," chronicles the internal lives and experiences of four individuals living with paraphilias.

In it, the New York Times Magazine writer skillfully weaves sympathetic, emotionally rich life stories with intellectual background gleaned from historical research and interviews with leading sexologists. Some of these psychiatrists, neurologists and psychologists emphasize biological hard-wiring as an explanation for such behaviors, while others search for answers among psychological or social-learning theories.

Bergner's subjects include: a foot fetishist who is remarkably inhibited, distressed and ashamed; a true female sadist, distinct from society's widely advertised poseur dominatrices, who is flamboyant and enjoys a passionate following; a pedophilic middle-aged father, superficially an anxious everyman, who's in court-mandated treatment on a 30-year supervised probation for transgressing sexual boundaries with his 12-year-old stepdaughter; and a "devotee" commercial artist who's found requited love with a tenderhearted woman who underwent bilateral above-the-knee amputations after a horrific motor-vehicle accident.

The book does satisfy one's voyeuristic tendencies, no pun intended. Disturbing, stomach-churning scenes, such as those involving overt child molestation or that of a man being roasted on a revolving spit over a charcoal fire, can be found, to be sure, but they do not distract the reader from what is a consistently engrossing and highly edifying read.

By investigating four dissimilar paraphilias and personalities, Bergner is able to tease out the complexities and highlight the vast differences between these varieties of phenomena.

Scientific research supports the notion that people with paraphilias often possess a greater orgasmic capacity than do the rest of us. The book's female sadist, the Baroness, describes the orgasms she achieves in "vanilla sex" with her husband as "spikier" and those she gets with her submissives as "far longer (and) deeper," leaving her "half-blind, mostly deaf, mute, slack-jawed."

Freud wrote, "The only unnatural sexual behavior is none at all."

Sexual interests, erotic desires and behavior all coexist on a vast spectrum. Using the example of libido, or sex drive, alone, one can find tremendous variability among "normal" people.

And as society evolves (or devolves, depending on your perspective), norms change.

Homosexuality is now understood as a sexual orientation. It is considered neither a psychiatric illness nor a preference. Until the early 1970s, the APA included homosexuality as a disorder in its diagnostic guidebooks. And, except in the deepest regions of the Bible Belt, psychotherapy is no longer directed at gays and lesbians to try to recondition them into "straight people."

Fellatio and cunnilingus were considered deviant practices until as recently as the late 19th century. They are now commonplace in the bedrooms of the masses, referred to by people with paraphilias as practitioners of "vanilla sex."

As demonstrated in this book and his prior body of work, Bergner is the kind of author who is able to delve deeply into the darkest and most forbidden realms of the human psyche and behavior.

By deftly blending curiosity and compassion in "The Other Side of Desire," Bergner shows that, if he had not chosen a career as a journalist, he would have made an exceptionally good psychotherapist.

Paul R. Linde is a psychiatrist at San Francisco General Hospital. His second book, "Danger to Self: On the Front Line With an ER Psychiatrist," is due out in early 2010 from the University of California Press.

sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/02/15/RVKK15OVLB.DTL
This article appeared on page J - 5 of the San Francisco Chronicle