Download A Brief History of Psychiatry: Evolving Paradigms

A Brief History of Psychiatry:
Evolving Paradigms
David A. Casey, M.D.
University Of Louisville
Louisville, KY
History of Psychiatry
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Why care about the history of psychiatry?
Our discipline is controversial
We are relatively young and rapidly evolving
We have many critics with disparate points of
view. Why don’t they like us?
We need to be able to critically view ourselves
Historical perspective locally as well as globally
An outline—not all inclusive
Paradigm
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A pattern or model
An organizing system of belief or set of
assumptions underlying a scientific discipline
Paradigms can evolve, suddenly shift, overlap or
even compete
The history of psychiatry can be viewed through
its paradigms
Paradigms
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Mental illness as a medical problem—problem
originates within the individual
Mental illness as a religious, spiritual or
supernatural issue
Mental illness as a result of family dysfunction
Mental illness as a social issue
Problem of personal responsibility
Mind-body duality; nature of consciousness
These issues have been present throughout the
history of psychiatry
Good and Evil: A Question Of
Brain Function or Choice
Asclepius
Ancient World
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Greece: cult of Asclepius
Mental illness not clearly separate from physical
illness
Individual out of favor with the gods; Hubris
The gods’ favor needs to be regained
A supernatural, but not necessarily moral, view
of the origins of mental illness
Hippocrates
(ca. 460-370 BC)
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Evolving view that mental illness represents an
imbalance of the body rather than a supernatural
event
Concept of melancholia and manic-depression
Classical Greece
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Rationalism
Plato’s (428-348 BC) views sometimes similar to
modern ideas
Psychological importance of childhood trauma
The unconscious
Psychological importance of meanings people
assign to events rather than events themselves
Rome
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“Four humours”—Galen (ca. 129-200 AD)
Phlegm-phlegmatic-winter, water, unemotional
Blood-sanguine—spring, air, fun-loving
Black bile-melancholic—autumn, earth, sadness
Yellow bile-choleric—summer, fire, passionate
Similar to the idea of “chemical imbalance”
Late Roman Empire to Middle Ages
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Christianity---mental illness as a moral issue
Consequence of sinning
Demonic influence or possession
Jesus Casting Out a Demon (Mark 5:1-20)
Malleus Maleficarum
“The Witches Hammer”
Germany, 1486-1487
St Joan of Arc Burning at the
Stake (1431)
Islamic World
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Maimonides, Avicenna, others taught a rational
rather than supernatural view
Psychiatric wards of major hospitals in Islamic
capitals
Maimonides 1135-1204
Psychiatric texts
Moises Maimonides
Avicenna
Bethlehem Hospital
“Bedlam”
Bedlam
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“The Rake’s Progress” 1735
“Moral insanity”—mental illness as a result of
immorality
Enlightenment
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Moral treatment—reformer of asylum approach
Shackles to be removed
Phillipe Pinel (1745-1826) at the Saltpetriere in
Paris
“Pinel Removing the Shackles”
Benjamin Rush
(1745-1813)
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Founder of APA
Signer of Declaration of Independence
American Enlightenment –moral treatment
Central State Hospital (1873)
“Lakeland”
Sigmund Freud (1856-1939)
Freud and Psychoanalysis
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Key ideas: the dynamic unconscious, internal
conflicts, defense mechanism, early childhood
experience, sexuality, drives, transference, stages
of development
Conscious, preconscious, unconscious:
Topographical model
Id, ego, superego: Structural model
A system of psychology as well as treatment
Deterministic---challenges ideas of free will
Ongoing controversy yet many ideas have
thoroughly imbued our culture
Carl Jung (1875-1961)
Carl Jung
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Collective unconscious
Archetypes—anima, animus, hero, etc.
Spirituality balancing rationality
Comparative religions, anthropology
Synchronicity
Analytic psychology
Conflict with Freud over importance of libido
Importance in art, literature
Controversies: antisemitism, Nazi collaboration
Psychoanalysis: Evolving
Schools
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Ego Psychology: emphasis on defense
mechanisms, unconscious fantasy; Hartmann,
Anna Freud, Arlow
Object Relations: ego exists in relation to
“objects”; internalized representations of self,
others which generate affects; Winnicott,
Fairbairn, Melanie Klein
Psychoanalysis: Evolving
Schools
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Self Psychology: Idea of Self-object; emphasis
on empathy as healing force
Brief dynamic therapies: Davanloo, Malan,
Sifneos, many others
Psychoanalytic ideas in social sciences, academic
post-modernism
Emil Kraeplin (1856-1926)
Alois Alzheimer (1864-1915)
Biological Psychiatry
The Biomedical Model
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Kraeplin: illness model, nosology, categorical
diagnosis
Alzheimer: correlating brain function and
pathology with clinical diagnosis
Origins of biological psychiatry—the biomedical
model
Social Psychiatry
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Harry Stack Sullivan
Mental Hygiene Clinic movement
Louisville Mental Hygiene Clinic eventually
evolved into Bingham Child Guidance Center
John B. Watson
B.F. Skinner
Behaviorism
Watson-classical conditioning
“Little Albert” experiments
Skinner-operant conditioning
Black box paradigm
Observable inputs-outputs
Adolf Meyer (1866-1950)
Psychobiology
Predecessor of biopsychosocial model
Psychobiology: view the patient in the context of their entire life experience-in
Opposition to Kraeplin’s views on categorical diagnosis
Spafford Ackerly (1895-1981)
1st full-time U of L Chair (1932/1947-1963)
Opened ULH psychiatry unit
Groundbreaking psychiatric curriculum
Incorporated Louisville Mental Hygiene Clinic
(predecessor of BCGC)
Media Scrutiny
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Barry Bingham, Sr (1906-1988) personally
investigated CSH and ESH as owner-publisher
of Courier-Journal
Courier-Journal: “They Can Be Cured” (1937)
Led to legislation and new standards here and
nationwide
Bingham continued to promote mental health
Electroconvulsive Therapy
ECT (1938)
Cerletti and Bini
Ugo Cerletti (1877-1963)
Egas Moniz (1874-1955)
Walter Freeman (1895-1972)
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Prefrontal leucotomy-- “lobotomy”
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Moniz—Nobel Prize 1949—a cautionary tale
Ed Landis
Founder of Norton Psychiatric Clinic-among first
general hospital psych units and academicprivate partnerships— 1949
Medical Director NPC 1949-1975
1st ECT in Kentucky 1949
Private Asylums
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OLOP-- 1950s-one of first and largest
freestanding psychiatric hospitals in the US
Psychopharmacolgy Revolution
1950s-Present
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MAOI
TCA
Antipsychotics
Lithium
1950s through present
Billy Keller
2nd U of L Chair (1963-1973)
WW II experience crucial in shaping psychiatry
here and throughout US: growth of
psychoanalysis and psychotherapy, groups,
outpatient treatment
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Novel by Ken Kesey, movie by Michael Douglas
Best picture Oscar
State hospital as model of repressive society
Foucault and Laing
Thomas Szasz
(b. Hungary, 1920)
(Published ca. 1962)
L. Ron Hubbard (1911-1986)
Founder of Scientology
Pub. 1950
Antipsychiatry Movement
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Within and outside psychiatry
Michel Foucault
R.D. Laing, Thomas Szasz
Complete rejection (and suspicion) of medical model and
psychiatry
Denial of reality of mental illness; romanticized psychosis
Belief in social causation
Faded but contributed to legislation limiting commitment,
requiring individualized treatment plans rather than custodial
treatment
L. Ron Hubbard and Scientology
Louisville Standard Gravure massacre 1989—the “Prozac trial”
Community Mental Health
Centers (1963-present)
Deinstitutionalization and
Community Mental Health
Movement
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State hospitals greatly deemphasized-1950s
CMHC established-1960s
KY one of first states to set up CMHC
CMHC never fully funded
Locally, River Region bankrupted and
reorganized as Seven Counties Services—
example of financial stresses
“Transinsitutionalization”- the “revolving door”
Medicare and Medicaid (1967)
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Psychiatry exclusions
Nevertheless fueled stupendous growth in
treatment
Explosion of medical school enterprise—faculty
increased by orders of magnitude almost
overnight
Tended to federalize financial responsibility for
care of serious mental illness
Systems Theory
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James Grier Miller, M.D., Ph.D. (1916-2002)
“Living Systems”
President of U of L 1973--1980
George Engel (1913-1999)
Biopsychosocial Model
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George Engel, M.D.—internist working in
psychosomatics
Seminal works early-mid 1970s
University of Rochester, Univ. of Cincinnati
Counterpoint to biomedical model
Current dominant paradigm in psychiatry
More of a philosophical viewpoint than a true
paradigm
Criticisms—eclecticism; additive rather than
John Schwab
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3rd Chair-1973-1991—internist/psychiatrist
Importance of family in psychiatric care
A founder of CL psychiatry
Biological Psychiatry and
Measurement
“Where measurement begins, science enters in…”
J. Willis Hurst, M.D.
“Statistical significance is not the same as clinical significance”
David Healy, M.D. (paraphrase)
DSM III (1980) and DSM IV
(1994; TR 2000)
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Attempt to standardize diagnosis
Explicit diagnostic criteria—a categorical approach
Attempt to establish validity and reliability of diagnosis
Evolved from need to standardize diagnosis for
research
Multi-axial system adapted from biopsychosocial model
Largely embraced by profession, government, insurance
industry
Field tested at NPC
Always controversial
Joel Elkes
Behavioral Medicine
U of L Genesis Center 1980s
Cognitive-Behavioral Therapy
CBT
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A new paradigm for psychotherapy
Here and now, structured, pragmatic
Addresses symptoms, behaviors, dysfunctional
thinking
Albert Ellis, Ph.D.--RET
Aaron Beck, M.D.
Jesse Wright, M.D., Ph.D.
Managed Care Psychiatry: A
Paradigm of Clinical Services
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Authorizations-cost controls, de facto rationing
Limits on care, especially hospital care
MD-limited to diagnosis, psychopharmacology
Leah Dickstein
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APA Vice-President; President AWP, AMWA
Women in psychiatry and medicine
Retired U of L Associate Chair
Allan Tasman
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4th Chair 1991-present
Past president APA
Editor “Psychiatry”
Timeline
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Supernatural paradigm-ancient world
Moral/religious paradigm-1st century-present
Asylum era-middle ages-1900s
Psychoanalytic movement-1890s-present
Modern biological psychiatry-1900-present
Psychopharm revolution-1950-present
General hospital psychiatry-1940s-present ?
Private freestanding hospitals 1950s-present
Timeline
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Antipsychiatry-1960s-present
Community mental health-1960s-present
Medicare and Medicaid- 1967-present
Biopsychosocial model-1977-present
CBT-1970s-present
DSM III -1980-present
Managed care-1980s-present
Future Psychiatry Paradigms
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Incorporate new knowledge of brain plasticity
and genomics
New appreciation of constant adaptation of
brain to internal and external conditions
Limits of DSM IV and biopsychosocial model
Interaction of psychiatry, religion, politics
Boundaries of psychiatry and other disciplines