The anatomy of a psychiatrist

John G. Csernansky was attending medical school at New York University when he had one of those rare epiphanies that reveal a person’s true calling.

Medical students at NYU did their psychiatry rotations at Bellevue Hospital in Manhattan. Just the name “Bellevue” conjures up the image of a psychiatric hospital for many, but in fact, it is one of the world’s largest general city hospitals and provides health care to most of Manhattan. In the mid-1970s, it had 1,600 patient beds and a ’30s era building with 300 psychiatric beds.

During his rotation, Csernansky, now M.D. and the Gregory B. Couch Professor of Psychiatry, was assigned “Jane Doe,” a woman who had been picked up on the streets of Manhattan. She couldn’t tell people who she was because she spoke in a “word salad” with various unrelated words seeming to appear at random in her speech. She also had violent fits and would fling herself at things.

Her diagnosis — like so many other patients who had been given up on — was schizophrenia.

“They pointed and said, ‘Why don’t you go talk to her?'” Csernansky recalls. “And I remember saying, ‘Well, what do I say?’ and they said, ‘It doesn’t matter.’ They felt she was so ill and so unable to communicate that it didn’t matter.”

But after spending some time with her, he found that although the woman had trouble putting words together, she was very attentive and eager to communicate. So Csernansky got a legal pad and repeatedly asked her four questions: her name, the name of someone who would know her, that person’s telephone number and their address. As she answered, he took notes on the legal pad.

“When I asked what her name was, I recorded all of the proper names that she said, and it turned out that she said one name much more than any other,” he recalls.

The same thing was true for the name of a person who would know her, as well as their phone number and address. So he got a phone book and spent most of an afternoon matching names with addresses and phone numbers that turned up most often in her answers.

“After about a dozen calls to wrong numbers, I found somebody who knew her,” Csernansky says. “He hadn’t seen her in two or three years, but he was an old family friend, and he told me about her medical history.”

In fact, this “Jane Doe” did not have schizophrenia. She had a tumor in the left temporal lobe of her brain that interfered with her ability to understand her own speech. Because of the tumor, she also had epilepsy, so her fits were revealed for what they really were: seizures.

“Once we knew her history, she was treated with anticonvulsant medication, and she got better,” he says. “We were able to reconnect someone with her past and make her better, at least for a time.

“So I decided to become a psychiatrist.”

And now when medical students ask him what they should say to a patient in a psychiatric ward, Csernansky never says, “It doesn’t matter.”

“These are human beings,” he says. “They had parents. They had a childhood and a favorite pet or toy. They went to school and played on the football team.

“But if you just see them as a collection of signs and symptoms, you can’t make that connection.”

Inside the ‘black box’

After medical school, Csernansky did a residency at Stanford University. He wanted not only to be a psychiatrist, but also to study the brain.

His mentor was internist Leo Hollister, who was the first person to conduct a controlled clinical trial of an antipsychotic drug. During his years at Stanford, Csernansky learned the importance of bringing rigorous scientific principles into psychiatric research.

And that training prepared him well for Washington University. He arrived in 1990, hoping to collaborate with neuroscientists and radiologists to learn more about what happens in the brain during mental illness.

He began in treatment research, studying how people with schizophrenia respond to various therapies. It was done in a systematic, scientific way, but it didn’t reveal the underlying disease process.

“That kind of research treats the brain like a ‘black box,'” Csernansky says. “You can do it very systematically, but you’re still taking systematic ‘shots in the dark.’

“I felt that to develop more effective treatments, we needed to better understand the underlying mechanisms of mental illness.”

And to get a grip on the mechanisms, he decided that you first had to understand the anatomy of diseases like schizophrenia.

Unfortunately, much of the technology that now can identify the subtle changes in brain structure that characterize schizophrenia did not exist then. So Csernansky and his colleague Michael I. Miller, Ph.D., now the director of the Center for Imaging Science, the Seder Professor of Biomedical Engineering and professor of electrical and computer engineering at the Johns Hopkins University, began a collaboration.

“At the time, he was at the School of Engineering at the Hilltop Campus, and he’d been using computers to quantify the shapes of the simple parts of cells,” Csernansky says. “It took me about a second to realize that if we could apply those methods to the brain, we could learn a great deal about mental illness.”

By connecting magnetic resonance imaging scans to Miller’s computer algorithms, the two were able to map the anatomy of key brain structures and identify subtle differences between healthy brains and those with mental illness.

Nowadays, most of the work can be done on a laptop computer. But when the collaboration began, only a handful of computers in the United States (one which happened to be in the electrical engineering department at Washington University) could handle the complex mathematical algorithms required to perform those operations.

Miller recalls that the complexity never slowed Csernansky down.

“John is the kind of scientist who, when things get windy and rainy, just concentrates harder and keeps the boat moving in the right direction,” Miller says.

And in recent years, their complex imaging techniques have made it possible to identify subtle changes in the size and shape of brain structures that seem to serve as early markers of the disease process in patients with schizophrenia and Alzheimer’s disease.

Over the years, the imaging research effort has expanded, and now Csernansky directs the Silvio Conte Center for Neuroscience Research, which is based at Washington University but includes Miller’s group at Johns Hopkins and neuroscientists at Yale University.

They hope to find markers that may make it possible to identify mental illness before it becomes clinically apparent.

“Take hypertension as an example,” Csernansky says. “We don’t wait for heart attacks to begin treating hypertension. If we can identify subtle anatomical and cognitive risk factors for psychosis, it should be possible to begin treating people before mental illness devastates their lives.”

Playing the field

When he’s not developing new techniques to identify risk factors for schizophrenia, Csernansky has two hobbies that keep him humble. First, the Chicago native is a Cubs fan.

“Let’s just say it gives one a first-hand appreciation for long suffering,” he says. “My heart was broken in 1969, and it’s never healed. I’m still angry at the Pittsburgh Pirates for knocking the Cubbies out of the pennant race that year.

“Last season’s playoffs just tore open the old wound.”

His other hobby is a bit more relaxing: playing the violin.

“It’s what I do to calm myself,” he says. He played the instrument as a child and took it up again a few years ago.

“I am particularly impressed by the fact that John is an accomplished violin player,” says Deanna M. Barch, Ph.D., associate professor of psychology in Arts & Sciences and a collaborator at the Conte Center. “In addition to being the ‘cutting-edge’ scientist and clinician that he is, he even does some of his own yard work.”

As his son, Matt, a sophomore in Washington University’s School of Art, gradually fills Csernansky’s basement with various projects, Csernansky and his daughter, Julia, a high-school freshman, play duets. She’s a violinist, too.

“We live about two blocks away from the music school at Washington University,” Csernansky explains. “And as I drove past the school every day, gradually I thought I should take it up again. Fortunately, my daughter was at just about the right age to start, and we’ve been studying ever since.

“Also, music is good for the brain.”