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Historical Study A-87. Madness and Medicine: Themes in the History of Psychiatry
Table of Contents
Reading
Week 1a
Week 1b
Week 2a
Week 2b
Week 3a
Week 3b
Week 4a
Week 4b
Week 5b
Zilboorg (319-341), Laffey, Harris
Foucault, Scull, Grob
Tomes, Dwyer
Showalter (101-120), Maudsley
Shorter (69-81), Germ of paralysis (NYT), Gross
Breuer, De Maurneffe
Shephard, WHR Rivers
Kraepelin, Bleuler, Shorter (99-109)
Cohen, Williams, Buck vs Bell summary
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Week 6a
Week 6b
Week 7a
Week 7b
Week 8a
Week 8b/9a
Week 9b
Week 10a
Week 10b
Week 11a
Week 11b
Week 12a
Week 12b
Week 13
Braslow, De Kruif, Ray, Cerletti, Shorter (192-196)
Pressman, Freeman, Kaempffert
Hersey, Neill
Strecker, Bateson
Ostow, Crane, Shorter (239-262)
Johnson, NDMDA website, Jamison selections
Healy (43-77)
Greenslit, Healy (179-224)
Dain, Szasz reading, Szasz website
Laing, Showalter (220-247)
Zeidner, Lehmann-Haupt
Rosenhan, Wilson, DSM IV summary
Kramer (sel), Rothman, convo with Herman, Letter by Mosher
Hyman, DSM IV entries (see syllabus)
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Feb 2, 7, 9 (three lectures)
Feb 14, 16 (two lectures)
Feb 21, 23 (two lectures)
Feb 28, March 2 (two lectures)
March 9, 14, 16 (three lectures)
March 21, 23, April 4 (film & two lectures)
April 6, 11, 13 (film & two lectures)
April 18, 20 (two lectures)
April 25, 27, May 2 (film & two lectures)
May 4, 12 (lecture and guest lecture)
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list of terms and their meanings throughout class ~15 words
list of terms and their meanings throughout class ~15 words
list of possible essay topics/themes and suggested responses
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Lecture
Other
key words
key words
Sample essay
READING
Week 1a
Zilboorg, Gregory. A History of Medical Psychology
This reading introduces the idea of the asylum as a therapeutic setting for the mentally ill. It describes how French
doctor Phillipe Pinel (1745-1826) in a revolutionary manner removed the chains of the inmates at the Parisian asylum
Salpêtrière. Believing that there was a distinction between “mentally ill” and “bad,” Pinel asserted that “one should try with
the most simple methods to restore their reason.” In addition to the removal of the inmates’ chains, Pinel dedicated himself to
reorganizing and training the personnel of the hospital. Also, in a pre-Kraepelinian style, he classified mental illnesses into
four distinct categories: mania, melancholia, dementia, and idocy.
With Pinel comes the beginning of the moral treatment movement in the history of psychiatry. Humane treatment, he
believed, would coax his patients out of their deliria and make them receptive to the idea of getting well again. However, this
approach would come under criticism by Michel Foucault and other radical theorists as merely a mechanism of social
control: though Pinel was removing the physical chains of the insane, he was merely forcing their internalization.
Key term: moral treatment- the humane treatment of the mentally ill as a means of healing
Laffrey, Paul. “Psychiatric therapy in Georgian Britain.” Psychological Medicine
This reading establishes William Tuke as the founder of moral treatment with his innovative facility “The Retreat.”
First, it discusses the secularization of madness, how conceptions of insanity shifted from diabolical and in need of Christian
theological explanations to medical and in need of physical remedies. With the Enlightenment came the idea that “bodies
needed attention if minds were to be fixed,” and remedies such as bloodletting were used to treat the mentally ill. Also with
the Enlightenment, however, came John Locke’s theory of incorrect mental organization: madness was the result of problems
with reasoning, not attacks of passion. His remedy for mental illness was to argue with the insane, theorizing that it would
convince them to abandon their irrational ideas. This approach is contrary to the “art of the pious fraud,” a method that did
not attempt to counter an insane person’s idea or bring on a ‘counter disease’ like shock treatment, but to approach it using
their own terms. Tuke, however, undertook the method of charismatic stewardship: by taking on a “father” status to his
patients, he established himself as the dominant partner in the doctor-patient relationship and his patients similar to aberrant
children. He sought to create a moral environment with minimal restraint, and he believed that the mentally ill were capable of
rationality and should be treated as so. Like the Pinel, Tuke and his Retreat mark the beginning of moral treatment. Instead of
mercilessly throwing the mad in anonymous asylums, Tuke’s belief that they were still capable of rationally brings the
humanizing aspect to moral treatment.
Harris, James. “Pinel delivering the insane.” Archives of General Psychiatry
In this article, Harris champions Pinel’s liberation of the insane. He describes Pinel as having “great compassion
towards his patients” and claimed that he “sought to integrate mental illness into medicine.” Harris credits him with the
creation of the “humane method” for treating the mentally ill, and in describing Muller’s painting, he praises Pinel as their
savior. This article provides a contrasting viewpoint of Pinel’s work in the asylum to that of Foucault; instead of criticizing
Pinel for maintaining a mechanism of social control, he is lauded for beginning a legacy of moral treatment and the scientific
study of madness.
Key term: humane method- a compassionate and moral approach to treating the mentally ill
Week 1b
Th, Feb 9 -The radical critics: Michel Foucault, Marxism, and new origin stories
Foucault’s argument in “The Birth of the Asylum”:
Historians try to paint a (falsely) rosy picture of asylums:
“benevolent” institutions, “liberation”
Mad no longer treated like prisoners – no more chains, barred windows, etc.
Pinel: “madmen are intractable only because they have been deprived of air and liberty, ”Tuke – “home” for the
insane
These stock images become legend, myth. But asylums weren’t really about liberty at all:
-Tuke’s retreat place of “moral and religious segregation” that surrounded madmen with world of exclusively Quaker values
Surface reason: madness caused/exacerbated by contact with the world’s corruption, profanity, evil. Separate madmen
from these influences and you’ll cure the madness
Actual reason (according to MF): religion becomes force of coercion, restraint – all the more powerful because it’s
internalized, self-imposed, and because it doesn’t require the tools of reason (which madmen may lack)
Asylums rely on patients’ fear of rule-breaking, guilt. Patients saddled with sense of responsibility, conscience
-Pinel’s asylums (Bicetre and La Salpetriere)
“Reason” rules
Religion must be kept in check so as not to lead to mania, excess, gets watered down to promote docility
Asylum is an entire society in miniature: recycles the values of religion, home, family, workplace
Conformity – “asylum reduces differences, represses vice, eliminates irregularities”
Need to “awaken” sense of morality in the insane, who according to the wisdom of the day probably went mad
precisely because they lost that sense of morality. 3 humiliating means of discipline: silence, mirror, perpetual
judgment (imposed self-consciousness)
Doctors become authority figures, but not just because of scientific knowledge – for Enlightenment, doctors carry
connotations of rationality, virtue, integrity. By extension, psychiatry becomes a science and a medicine. Birth of madmankeeper relationship using child-parent, transgressor-punisher model (comes to full fruition with Freud)
Key terms: moral segregation (keep patients in morally healthy climate), internalization (chains are within, self-imposed),
perpetual judgment (patient made to feel self-conscious, constantly scrutinized for behavior)
Links to other course ideas: Freud and doctor-patient relationship, moral treatment as means of discipline, psychiatry
“reinvented” as science just as it did again in the early 20th century (after “gatekeeper” attitude of degeneration) and later
(with rise of medical treatments like electroshock, lithium etc)
Scull’s argument, “Madness and Segregative Control: Rise of the Insane Asylum”:
Deviance and control go hand in hand in any society. In modern society, three hallmarks:
1 Involvement of state/central institutions of control, 2 segregation of deviants from surrounding society, 3
development of professional fields to classify, deal with deviants
Pre-19th century, those three characteristics didn’t exist: control of deviants done by families, communities without
segregation or professional element.
Why do those 3 hallmarks, which together make the asylum system, happen?
Capitalism – erodes sense of social responsibility to care for the poor (no more noblesse
oblige if there’s no nobility). Greatest evil is the inability or refusal to “carry your own weight.” Need institution to
inculcate proper work habits.
- Insanity becomes a separate category of deviance because: 1) capitalists need way to distinguish able-bodied poor from nonable-bodied poor. Only the latter should get aid or relief, since the former ought to be working to promote the economy. 2)
madmen mixed with other “deviants” in workhouses would distract from the work at hand
- Asylums modeled after industrial revolution’s methods of managing large numbers of people. Becomes big business – huge
buildings, hundreds or thousands of inmates. Because of this, has mostly lower-class clientele, which makes psychiatry a lowprestige profession.
- Rothman is wrong: R argues Americans “discovered” the asylum as a manifestation of its 1) anxieties about being an
unstable society, and 2) utopian ideals of a perfectly-ordered place. R wrong for 2 reasons: 1) not a nation-wide anxiety but a
class anxiety. 2)makes theory US-specific, which fails to explain why asylums also flourished in UK, France, etc at same
time.
Key terms: capitalism (society ordered around market relationships, people/things reconsidered as capital, commodities),
deviant (someone who disturbs the smooth operation of society), control (institution that keeps deviance in check)
Links to other course ideas: role of market forces on psychiatry’s motives seen again in debate over pharmaceuticals.
Psychiatry as big business re-emerges in 20th century.
Grob’s argument in “The History of the Asylum Revisited: Personal Reflections”:
Up until radical critics, history of psychiatry told as the gradual triumph of reason and science (by Zilboorg et al)
Story changed in the 60s
1) because of cultural climate: instability and unrest of war, racism, class leads to across-the-board revolutionary
spirit. Seen in psychiatry critics like Foucault, Szasz, Laing, Goffman (who coined “total institution” and links asylums to
same social forces that create prisons, concentration camps, etc), Rothman (theorized early American need for institution of
authority to cope with social instability, Scull (Marx-capitalism theory)
2) because of “labeling theory” in medical circles – suspicion that taxonomy of mental illness was artificial, had little
to do with hard medical science
No historian is wholly objective; always the product of his/her time. Even basic, objective definitions almost impossible: e.g.
“mental illness,” “asylum,” “social control – have connotations, shades of meaning. “History is not the past” (J.H. Plumb).
Key terms: history (meaning subjective interpretation of the past, influenced by culture of the present), labeling theory
(taxonomy of psychiatry not real science but categories based on societal norms, New Left (socio-political movement of 60s
characterized by criticism of establishment)
Week 2a
Nancy J. Tomes A Generous Confidence: The Story of Kirkbride’s Philosophy of Asylum Construction and Management
Summary: Tomes tells about the American Asylum Superintendents obsession with the construction of mental hospitals. A lot
of the Psychiatric literature in the mid-1800s dealt with building design rather than (or as a way of) treatment. “Every detail,
from the design of the window frames to the table settings in the ward dining rooms, had to be arranged to sustain the
impression that here was an institution where patients received kind and competent care. She draws evidence from Kirkbride’s
annual reports which “functioned primarily as brochures designed to attract and inform readers who might be considering
asylum treatment for an insane relative or friend.” Kirkbride created a plan based on a central building with wards on both
sides and extensive grounds. The wards were segregated by gender and separated by degree of insanity. For example the worst
cases would be farthest from the central building. However, Kirkbride’s idealistic reports cannot be taken as a reflection of the
reality within asylums. Soon the beautiful new buildings were housing far more people than they had been designed for, and
the ideal of an asylum was lost as the buildings were word down.
Why it is important: The Kirkbride plan and the obsession with architecture reflect two important themes: therapeutic
pessimism and the public image of the mental hospital. Asylum superintendents sought to create buildings to humanely house
the insane and to attract potential donors and customers. There was much less interest in curing them. They also tried to create
beautiful buildings that could be civic monuments in towns.
Key Terms: Thomas Story Kirkbride, Kirkbride Plan, On the Construction, Organization and General Arrangement of
Hospitals for the Insane, the Association of Medical Superintendents of American Asylums for the Insane (precursor to the
APA.)
Ellen Dwyer, Life within the Asylum Walls
Summary: Dwyer investigates the different perceptions of the asylum in the 1800s. She focuses on the New York State
Lunatic Asylum at Utica and the Willard Asylum for the Chronic Insane. The beautiful grounds were often at conflict with the
dreadful existence inside. Both asylums “classified patients on the basis of their self-control rather than their disease.” Rigid
daily schedules, including work for the patients, governed the lives of both the patients and attendants. Patients and attendants
frequently bent the strict institutional rules. There was rigid sex separation, occasional violence and frequent tours of outside
citizens.
Why it is important: Dwyer’s research offers a contrast to Kirkbride’s idealized view of the 1800’s asylum. She offers details
of the daily life and experience of the asylum. She confirms the therapeutic pessimism and the problems with overcrowding
and overworked attendants.
Key Terms: New York State Lunatic Asylum at Utica (Utica Insane Asylum), Willard Asylum for the Chronic Insane
Week 2b
On the Borderland: Henry Maudsley and Psychiatric Darwinism in The Female Malady
Elaine Showalter
“Ideal” asylums were rapidly falling apart by end of 1800s, leading to the rise of “therapeutic pessimism.” Moral care
is hard to maintain in overflowing asylums, so discipline and regimentation replaced therapeutic care. The popular media
portrayed these asylums as prison-like. Superintendents had particularly low status in the psychiatric realm and became
focused on administrative matters. Their wives stayed away so as not to tarnish their reputations.
A new generation of psychiatrists apply Darwinian theories in order to make psychiatry more scientific. Instead of
blaming social problems, these theorists claimed so many poor ended up in the asylums because their pedigree was tainted and
had been made worse by bad habits. The instruction of moral hygiene was supposed to help prevent madness and every other
form of degenerate behavior. Their degenerate theories moved beyond simple insanity and included other forms of deviance
and eccentricity. Essentially, people in the “Borderland” between sanity and insanity had seeds of madness just waiting to
sprout. Psychiatrists could theoretically recognize those in the Borderland. The Borderland included Mazeland, Dazeland and
Driftland, the latter of which was for idle rich men. Those who did not have self-restraint appropriate for the Victorian era
were likely to pass from Borderland to insanity. Madness was viewed as regression, and people were considered predestined
to it.
Henry Maudsley was a particular proponent of such degeneration theory. He claimed that physical marks gave away
those with an “insane temperament.” His colleague Cesare Lombroso studied the physical traits that were representative of
criminal faces as well. A doctors focused specifically on the traits of the deadly criminal woman and her horrific facial
features. Furneaux Jordan proposed that battered women essentially asked for it because of their physical features. All of
these features were considered convincing scientific evidence for degeneracy theory and psychiatric Darwinism. The rich
were clearly of a better, more mentally healthy breed. This theory also took away any sense of guilt for the suffering of the
poor. Cities contributed, however, to bad behaviors that led to madness, and those who were simple and coarse were the most
likely to go mad. Some advised purposely neglecting the paupers so that they would die off. Some supported eugenics in
order to get rid of bad germ lines.
The discovery that general paralysis of the insane (GPI) was linked to syphilis was used as scientific evidence that
immoral behavior (sexual promiscuity) led directly to madness. Darwinian psychiatrists “described GPI as a degenerative
disease caused by disposition to vice.” The discovery of the syphilitic spirochete in 1913 confirmed the link of syphilis to
GPI. Other scientific evidence was expected to follow linking other forms of madness to immorality.
Henry Maudsley became spokesman for Darwinian psychiatry just as John Conolly had for Victorian psychiatry.
Unlike the genial, optimistic Conolly, however, Maudsley (who married Conolly’s daughter) was serious and severe and
pessimistically thought that immoral men were dooming their children to madness, and he became rich off of his work.
Maudsley believed that mental illness is physically based and believed in the hereditability of mental weakness. The sins of
the father are visited on the children. Maudsley was academically successful from an early age and very arrogant. He thought
most of the mad should be kept at home and didn’t think asylums helped anything. He was critical in writing a memoir of
Conolly, whom he called feminine. Maudsley and other psychiatrists of the time highly valued athleticism and manliness.
Maudsley edited an important psychiatric journal and began to publish important psychiatric works, including “Body and
Mind.” In one he claimed that the “wicked” have a “natural affinity for evil” (as well as being recognizable by physical traits)
and hence thought criminals could not be reformed. Degeneration thrived, he believed, in the sin and vice of the era, and that
sometimes the immoral were the fittest to survive in such an environment. Eventually his pessimism and arrogance resulted in
personal isolation and even he admitted degeneracy theory was overextended. He died disillusioned.
Body and Will, Henry Maudsley
“Survival of the fittest does not mean always survival of the best.” Rogues survive among rogues like parasites
among parasites. People can degenerate much like ideas do when they are taught to savages, who cannot grasp higher
meanings. “Disuse of function leads everywhere to decay of organ.” This gets compounded over generations, and a line may
evolve or degenerate. In order to have good we must also have evil, and the sum of the two in the world remains constant, so
the bad will always exist.
Degeneration is “unkinding,” where there is a loss of one’s kind. It is the dissolution of an organism from more to
less complex, and is as complex as evolution. The more complex, the more diseases that are possible. But the regression is
not that of a return to monkey-kind, but a return to a new, abnormal breed which can no longer evolve and so degenerates
because it must do one or the other. New degenerative elements appear that were not existent in our ancestors, such as the
wide range of sexual vice and deviancy that is widespread today. Degenerates can be more inhuman than animals. The brute
within degrades the human. Just as humans evolve, however, they must inevitably degenerate.
The highest forms of evolution are least stable and therefore the first to degenerate. Imbeciles arise because of the
degeneracy in their forefathers. People are either ascending or descending, and dooming their descendent to do the same.
Idiots “want in moral feeling and will” and this is ingrained in their nature. An example is that of a young boy who cannot
control his cruel, mischievous and destructive impulses and punishment does not keep him in line. He is a moral idiot but
may still be keen in terms of other types of intelligence. He is asocial and has no sense of “right” and is “congenitally
conscienceless.” This type of child is invariably the descendent of a line that includes epileptics, insanity, or other mental
degeneracy that resulted from bad character. The child inherited it, but the parent was the one who chose to exhibit bad
behavior. The parent does not exercise his highest social morality, so it falls into disuse and deteriorates. The child of this
parent is then close to madness and criminality, and the third generation reaches full idiocy (and may or may not be as
intellectually weak as they are morally weak). One generation acquires a weakness and passes it on to the next. One
example is a boy who could not focus and who talked of cruel things whose father had died of a “softening of the brain” at age
40 and his grandfather had died in an asylum.
Mental pathology includes: a lack of moral sense and an asocial nature that is incapable of assimilating higher moral
thought; an inability to focus so that he cannot learn; and an active yet undisciplined imagination.
If an infant had the power of a man, it would be as dangerous as a madman. Children are immoral: conceited,
boastful, envious, selfish, etc. We describe them as pure, but they are just as pure as the savages who exhibit similar traits.
Everyone has the seeds of a liar, cheat, etc. within them although with different potentials of exhibiting these traits. All men
have secret, immoral thoughts that pass through their brains. Most, however, have high levels of inhibitory functions and a
strong self will. When reason and will is overthrown then the seeds grow to fruition. Man is not culpable for having these
seeds, much as he is not culpable for what passes through his mind in dreams. It is his responsibility to maintain control over
the wanderings of his mind.
Idiots may be active and anti-social or passive and anti-social, depending if he shows vicious tendencies or is just a
vegetable. Idiots have a dulled sensibility. Many do not feel pain, and more are morally insensitive. Some are physically
deficient as well. Psychologists can recognize and idiot by his “walk as well as his talk.”
Key terms:
Degeneration theory: The concept that disadvantaged groups have problems because of defective biology. Bad behaviors in
parents get passed on to children, who show more degenerate tendencies than their parents. A pessimistic theory explaining
the rise of mental illness and other social problems of the time.
Cesare Lombroso: Said that sometimes people exhibit traits the illustrate a throwback to their less evolved ancestors. This
can crop up out of nowhere. These atavists can be recognized by physical features, such as large ears and low brows.
Other important terms highlighted in notes
Week 3a: Shorter 69-81
The First Biological Psychiatry
 Marked by a shift away from asylum psychiatry, emphasis on university teaching and research institutes
 Mental illness cam to be understood as an illness of the nerves and brain rather than an issue of morality
 Medicalization of psychiatry- emerged from guild status to general medicine circles
 German’s dominated the field:
 Griesinger- single most influential representative of 1st biological psychiatry, professor of psychiatry in Berlin, helped
university psychiatry triumph over asylum psychiatry, helped psychiatry shift from custodial to teaching and research
 Meynert- a pupil of therapeutic nihilism, believed he was in psychiatry to do research, not to cure patients, who were
all beyond help-was devoted to microscopy and brain and spinal cord anatomy
 Freud was a pupil of Merynert, who later became the object of mockery of Freud’s followers
 1st biological psychiatry died because it detached itself too completely from patients and their world
 Wernicke tried to map psychiatric symptoms to specific brain regions (“brain mythology”)
 It was the historic victory of Kraepelin’s views over Wernicke’s that marked the end of the 1st psychiatric biological
psychiatry
Terms: Nihilism (belief that the psychiatric diseases were incurable, treatment of untreatable diseases is useless so there was
little interest in clinical psychiatry)
Relation to course material: The 1st biological psychiatry marked the shift from a psychological to a biological approach to
psychiatry, and psychiatry’s attempt to merge with mainstream medicine
Germ of Paralysis
 Article in New York Times reporting the discovery that general paralysis is due to the presence in the brain of syphilis
germs!
 “Now that we know that general paralysis is caused by microbes which penetrate the brain, we can endeavor to find a
way of destroying them without injuring the fragile precious matter which these infinitely small germs slowly ruin”
Relation to course material: This discovery was made in the beginning of the 20th Century as the "First Biological Psychiatry"
was coming to an end. It used the techniques of the first biological psychiatry--analyzing brain tissue, conducting experiments,
etc--however, it went against the belief held by biological psychiatrists which was that psychological illness could not be
cured. Now that they could isolate the cause of the disease, microbes, they could seek a cure.
Gross “Syphilis responsible for 10% of Patients at St. Elizabeth’s
 overall number of mentally ill admitted to St. Elizabeth’s is increasing about 5% per year, suggested that this is the
result of syphilis
 the most important and prevalent type of insanity is produced by syphilis, and known as general paresis/paralysis
 now know that GP is always caused by syphilis (either congenital or acquired), causing inflammation of the brain
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Occurs 3x more frequently in men than in women who have had children (claimed childbearing helped protect against
showing signs of disease)
takes 5 to 20 years after initial infection to develop GP (only happens in 2-3% of the infections)
some symptoms include: convulsions, grandiose delusions, depressive delusions, defective judgment, restlessness,
insomnia
Until now most patients died 2-4 yrs after showing signs
Can be treated biologically in early stages through inoculation with malaria
Key terms: syphilis (STD) and general paralysis (neuropsychiatric disorder affecting the brain and central nervous system)
Relation to course material: The discovery that general paralysis was a biological disorder and caused by the same bugs that
caused syphilis rocked the psychiatric world. It changed the perception that psychiatric illnesses were the result of immoral
behavior (i.e. behavior associated with contraction of syphilis) and instead was a biological illness that could be treated like
any other disease.
Week 3b
Joseph Breuer’s “Studies on Hysteria: Anna O” from The Freud Reader
Summary: Breuer describes his treatment of Anna O. (real name: Bertha Pappenheim). Anna suffered from hysteria from
July 1880 to June 1882. Anna’s symptoms included squinting, headaches, paralysis of one arm and both legs, hallucinations
of black snakes, disorganized speech and later loss of speech, and two entirely separate states of consciousness—one normal
and one psychotic, in which she was often destructive and violent. Breuer claimed that the immediate cause of Anna’s
hysteria was her distress at her father’s illness and death. He says that Anna’s illness followed a predictable pattern: she woke
up and had hallucinations in the morning, she got sleepy in the afternoon, and after sunset she fell into a hypnotic state during
which Breuer had her relate all the hallucinations she had had earlier in the day. If she told all of them, then she would wake
up calm, cheerful and rational, go to sleep around 4 in the morning, and repeat the whole process the next day. If she failed to
relate her hallucinations, she became increasingly unhappy, psychotic and violent over the next few days, and when the
“talking cure” resumed, she would have to recount all the accumulated hallucinations of the last few days before she became
rational again. Besides the hallucinations of the current day, Anna also began recounting hallucinations from the previous
year. Later Breuer was able to trace each of her psychotic symptoms to their original cause by questioning her while she was
in a hypnotic state. Anna was cured when she finally recounted all her hallucinations and traumatic experiences—the
experiences mostly involved her failing her father in some way while he was sick.
Significance: According to the sourcebook, Anna O. “may claim the distinction of being the founding patient of
psychoanalysis.” Breuer used hypnosis in a new way: to uncover repressed memories. Anna O.’s case led to the theory that
repressed memories, not bad biology, caused hysteria.
Freud was fascinated by Anna’s case. He claimed that Breuer had missed the sexual aspect of Anna’s hysteria.
Although Freud looked up to Breuer and they had been close friends, Freud’s public analysis of the case ended their
friendship.
Key Terms:
Anna O.—her case led to the founding of psychoanalysis—the “talking cure.”
“talking cure”—curing patients by forcing them to talk about their repressed, traumatic memories, thus bringing the
memories into conscious recognition. (a.k.a. psychoanalysis)
Sigmund Freud’s “Katherina” from The Freud Reader
Summary: Freud tells a story about a young woman named Katherina whom he met on vacation and psychoanalyzed in a
single day. Katherina suffered from anxiety attacks and had hallucinations of an “awful face.” By questioning her, Freud
came to the conclusion that Katherina’s hysteria was due to traumatic memories of her uncle attempting to have sex with her
when she was only 14, and memories of seeing her uncle having sex with her young cousin Franziska. Katherina discovered
her uncle and her cousin having sex and eventually told her aunt about it, which led to a divorce. Freud determined that the
horrible face was a hallucination of her uncle’s face when he was very angry at her for revealing his secret. Freud hinted that
Katherina was cured by this single meeting, although he never saw her again. He reviews the specifics of the case for the
benefit of people studying his methods. He comments on the fact that he often finds “a mere suspicion of sexual relations
calls up the affect of anxiety in virginal individuals.” Freud revealed in a footnote that Katherina was in fact the man’s
daughter, not his niece. Freud eventually chose to reveal this because “distortions such as the one I introduced should be
altogether avoided in a case history.”
Significance: Katherina’s case was one of Freud’s early attempts at psychoanalysis, before his method had been fully
solidified. It shows Freud starting to form his theories about psychoanalysis and the underlying sexual nature of mental
illness. It demonstrates his early psychoanalytic technique—Katherina is haunted by traumatic memories and is cured by
talking them through. According to the sourcebook, Katherina’s case also “illustrates Freud’s early excessive confidence; he
was later compelled by his clinical experience to abandon any hope that a single ‘session’ might wholly sure hysteria.” The
case also “dramatizes the tension between the physician’s need to respect his patient’s privacy and to publicize his cases in the
interest of science.”
Key Terms:
Katherina—girl whom Freud psychoanalyzed and whose case history he used for teaching purposes. Her case demonstrated
the “talking cure.”
Daphne de Marneffe’s “Looking and Listening: The Construction of Clinical Knowledge in Charcot and Freud”
Summary: De Marneffe compares the methods of Charcot and Freud. Charcot, who worked at the Salpetriere, employed the
clinicoanatomic method—he “analyzed and categorized clinical phenomena into ‘archetypes,’ fully developed examples of
the disease.” He believed there was a biological basis of hysteria (brain lesions) and believed in the hereditary nature of the
disease. Charcot ignored what his patients said, dismissing it as babbling. He created very detailed case histories and relied
heavily on visual observation and photography to document mental illness. His photographs are a hybrid between medical
documents and art, and are extremely contrived. Despite this, Charcot believed photography was a completely objective way
to document and study mental illness. One of his patients, “Augustine,” appears frequently in his photographs. Charcot used
to her to document his proposed stages of hysteria. Charcot knew that Augustine had suffered much sexual abuse starting
from a young age, but he ignored the “centrality of sexual trauma” in his hysterical patients, favoring an entirely biological
explanation of the disease. Charcot employed hypnosis as a means of inducing symptoms in his patients in order to study
them.
Freud believed that hysteria resulted from repressed traumatic memories. He focused on the psychological, rather
than the biological, basis of hysteria. In contrast to Charcot, Freud paid very careful attention to what his patients said,
believing that their stories could reveal the cause of their illness. Freud believed that hysteria could be cured through talking
about repressed memories. Freud employed hypnosis in a different way than Charcot; he used it as a way to uncover
repressed memories. He also used free association for this purpose, allowing his patients to talk freely about whatever they
liked. Freud acknowledged the subjective nature of his methods and attempted to compensate for it by detailing what he said
and did in his case histories.
Significance: Charcot ignored his patients’ stories and had an entirely biological view of hysteria; Freud emphasized the
importance of listening to patients, and preferred a psychological explanation of hysteria. Charcot failed to acknowledge the
subjective nature of his observations; he regarded photographs as completely objective evidence. Freud realized that his
“talking cure” was entirely subjective and attempted to account for this by detailing his role in the treatment process. Charcot
attempted to achieve “static objectivity,” in which the scientist is entirely detached from the patient; Freud attempted
“dynamic objectivity,” in which the scientist employs subjective methods but maintains validity by accepting and explicitly
revealing his influence on the patient.
Key Terms:
clinicoanatomic method—Charcot’s biologically-based method of categorizing mental disease into archetypes (characteristic
examples).
archetype—a fully-developed, picture-perfect example of a mental disease.
Augustine—fifteen-year old patient of Charcot whom he photographed frequently to depict the classic archetype for hysteria.
static objectivity—state in which the scientist is entirely detached from the patient; assumes that the scientist does not
influence the patient in any way.
dynamic objectivity—state in which the scientist employs subjective methods but maintains validity by accepting and
explicitly revealing his influence on the patient.
Week 4a: Shephard, W.H.R. Rivers
Key Terms
Shell-shock: WWI term for war-induced neurosis, psychosomatic illness.
Repression: Freudian term borrowed in treatment of shell-shock (specifically by Rivers), believed that if shell-shocked men
stopped repressing bad war memories, would be cured
Re-education: term used to describe many treatments of shell-shock (Yealland’s, Rivers’, etc.), indicating that much of the
treatment was to re-educate a patient to think in a different way (for Rivers, patients were taught not to repress and to see their
experiences in a positive light; for Yealland, they were made to believe that their physical symptoms would go away, etc.)
A War of Nerves, by Ben Shephard (2001)
Prologue: The Shock of the Shell (1-3)
- winter 1914/15 first cases of shell-shock (unable to stand, speak, urinate, had tremors, amnesia, paralyzed, blinded,
deafened, muted, etc.)
- Cambridge psychologist Dr. C.S. Myers dealt w/ first case/s of shell-shock, coined term Feb‘15
- seemed like came from shock of an exploding shell - first interpreted as physical reaction
- made sense to ppl that this was a new illness b/c the way the war was being fought was thought of as very new: trench
warfare was new, new, more powerful, more destructive weapons, etc.
- ppl didn’t really know much abt how physical forces of shells could influence nervous system
- also confused by “fatal shell-shock”, where ppl died instantly in shellfire w/o external wounds
Chapter 6: Homefries (73-95)
- ppl fascinated by shell-shock, always in the news
- many patients were officers so no talk of degeneracy
- lack of resources to deal w/ this problems: many ended up in regular hospitals, too many cases and too few beds, doctors and
nurses not trained to deal w/ these cases, etc.
- asylum doctors had experience w/ mental disorders, but not helpful w/ shell-shock: b/c thought of mental illness as physical,
hereditary, and untreatable, so thought of shell-shock cases in a fatalistic manner, thinking of them as inferior ppl
- so, no clear communication of what to do from leaders of the profession, mostly b/c symptoms of shell-shock took
everyone by surprise, and also b/c british neurologists were waiting for research and ideas to come from France as they were
accustomed (ex: Charcot)
- ppl were eager to discharge as many soldiers as possible, b/c not much expectation of cure
- but by 1917, neurologists beginning to help and psychological treatments being developed
- Edgar Douglas Adrian + Lewis Yealland: members of wartime staff in Nat’l Hospital Queen Square in Eng.
- their method was to convince patients that they would get better and then to bring in electrical equipment as a
psychological prop to effect the cure: dramatic
- re-education was after electricity used, patient was brought to a room where told would be able to move a paralyzed arm or
see w/ blinded eyes, etc. – treatment worked!
- end of ’17, Adrian + Yealland split up, and Yealland’s treatment became even more dramatic, “pulling out all the stops”
but still using electricity to bend patient’s will
- Dr. Arthur Hurst: theatrical, influenced young men easily
- appreciated “proper atmosphere of cure” like Adrian and Yealland
- at first, treated patients w/ hypnosis or electricity, then began to believe that 24 hrs of just talking to patient would cure
- but really just removed physical symptoms, which was too often considered a cure
- Ronald Rows: worked at Maghull, hospital for epileptics in Liverpool
- shell-shocked patients were encouraged to discuss their problems in a sympathetic enviro.
- Maghull doctors interested in memory, dreams, conscious minds, emotional states
- Rows thought that if could find the cause of the terrible emotion in a patient, and if it was explained to the patient that his
illness was caused the memory that was the cause of the emotion, he would realize that he did not have a terrible, incurable
disease, and would get well
- Maghull = military hospital, not place for research, so supposed to return men to front but ppl began to realize that was
useless to return chronic cases to front
- W.H.R. Rivers came to Maghull July ‘15: interested in anthropology, which made it so that knew how to question ppl abt
feelings, which made him a good wartime psychotherapist
- not Freudian, but saw that some Freudian understanding might help shell-shock patients
- transferred to Craiglockhart Oct 1916
- Craiglockhart: 1 of 6 special hospitals for shell-shock, physical activity very important
- Rivers had dream of his own which showed a repressed wish, so began to believe that Freud was right but not abt sexual
stuff, just abt repression and dreams being able to show this
- believed that concepts like “repression” and the “unconscious” were helpful in this treatment
- technique dependent on personality of the healer, and ppl believed that men got better b/c wanted to please Rivers
- worked best w/ intelligent, educated patients that could engage in psychoanalysis
- thought had to find way to let patient confront repressed memories that “re-educated” him to fact that memory could be
seen in positive light
- biography written by homosexual lover Siegfried Sassoon who had been his patient
- but Rivers not first: David Eder 1916 was first person to adapt to warfare Freudian idea that neurosis is produced by mental
conflict
- thought source of neurosis was conflict betw. sense of duty and unconscious wish to survive
- didn’t think necessary to go all the way back to childhood, but did keep some of ideas of sex
- 2nd Lieutenant W.E.S. Owen: treated by Rivers starting Jun ’17, returns to light duty Oct ‘17
- phenomenon of Battle Dream (replaying of war experiences in dream); repetitive
- Owen wrote down dreams in poetry, feelings, experiences, becomes famous poet
- Arthur Brock was therapist, thought that patient must learn to help himself, and called treatment “ergotherapy”, which was
“treatment by functioning” – patients supposed to do work (this was also called re-education: showed patient that could
function)
The Repression of War Experience, by W.H.R. Rivers (1918)
- there is a diff. betw. repression and suppression: repression = process of putting something out of one’s mind, suppression =
state of constant repression
- process of repression takes active part in maintenance of war-induced neurosis, which hospitals do not help to eliminate:
patients usually told to try to forget about trauma, but should actually stop repressing and learn to see experiences in positive
manner. ex: Rivers cured shell-shocked man having dreams of mutilated friend, b/c made man see that degree of mutilation of
friend probably meant that friend had died quickly and painlessly (ex. of re-education)
- but sometimes method not applicable. ex: man had been flung down by shell explosion, face hit distended belly of rotting
corpse, ruptured belly and filled mouth and nose w/ decomposed entrails. couldn’t be seen positively, so recommended that
should go live in country for relief
- believed that some ppl more likely to be shell-shocked: maybe was innate, b/c of illness, or b/c had been hypnotized before
- distressing memories and painful anticipations of going back to the front were believed causes
- Rivers supposed to return as many ppl to front as possible, comments on this: sometimes officers wanted to go back to war,
so this desire actually made get better faster. he didn’t believe that all should be sent back, however. it is “inexpedient” to sent
more chronic cases back
- thought necessary to adopt middle course: don’t repress, but don’t obsess abt memories either
Week 4b
The origins of modern psychiatry Ed. Thompson
Dementia praecox and paraphrenia (1919) and Introductory lectures on clinical psychiatry (1906) III Dementia Praecox – by
E. Kraepelin
Dementia Praecox: the name Kraepelin uses to describe one of his two major psychiatric disorders (the other being manicdepression). The Kraepelin way emphasized the course and history of an illness, and its outcome, rather then caring about
causes. He could detect dementia praecox by the following:
“Weakening of those emotional activities which permanently form the mainsprings of volition [aka will].” – “the
annihilation of personal will.”
“loss of inner unity” – meaning emotions don’t correspond with idea
Kraepelin things the two groups are very connected.
In the introduction to his lectures, he explains the disorder in more detail: patients act in a way that seems depression like,
except it’s not a real dejection of spirit, rather just an overall lack of will. He has a full consciousness to his surroundings, he
just doesn’t care. He has “no strong feeling of the impression of life.” There is also a “weakness of judgments and flightiness”
also, may patients have a vacant laugh lacking any real emotion. Its dementia when “the faculty of comprehension and the
recollection of knowledge previously acquired are much less affected than the judgment, and especially then the emotional
impulses and the act of volition eh stands in closest relation to those impulses”.
He explains that the point of this description will enable people to recognize dementia praecox from the start even though
there isn't necc. A cure for it 9although some improvement may be possible).
An article about him and pages 99-109 in Shorter's history explain the following:
Kraepelin: he is all about the classification and diagnosis, a major cataloger of parents’ personal histories. He was a warm
person, but kept distance and detachment from his patients. He really established a system of diagnosis that enabled science
medical practice and treatment, and focused much less on causes. He really publicized the term “dementia praecox” and gave
it a clinical description that did not really discuss cause. As Shorter explains, he was all about the prognosis. And he believed
manic-depression was the curable disorder, while dementia praecox was pretty incurable. He brought the end of the first
biological phase in psychiatry’s history.
The origins of Psychiatry. Ed C. Thompson:
The fundamental symptoms of dementia praecox or the group schizophrenics. By Eugen Bleuler, 1911
Schizophrenia: This is the term Breuler created for Kraepelin's dementia praecox, because it didn’t necessarily begin in the
youth. He thought t was defined by the following symptoms:
Association: patients seem to be “lacking – the concept of purpose” when they speak, so although thoughts may be
connected because they’ll discuss the same thing they are just a random list of information with no real aim or point.
There’s also “BLOCKING” which is when one suddenly stops and can not remember or return to what he was saying
and either must begin in some unrelated way or remains frozen where he stopped. Thanks Kraepelin for noticing this
blocking as a main diagnosis symptom of dementia praecox.
“in the normal thinking process, the numerous and latent images combine to determine each association in schizophrenia,
however, single images or whole combinations may be rendered ineffective, in an apparently haphazard fashion. Instead,
thinking operates with ideas and concepts which have no, or completely insufficient, connection with the main idea and
should therefore be excluded from the thought process. The result is that thinking becomes confused, bizarre incorrect, abrupt.
Sometimes, all the associative threads fail and the though chain is totally interrupted; after such “blocking” ideas may emerge
which have no recognizable connection with proceeding ones.”
Affectivity: this term describes a state of “emotional deterioration” with indifference as the external sign. Patients don’t
seem to care about themselves or others. They do have some moods (show irritability and happiness) but not
accurately connected to the context. It’s not quite indifference but rather an inability to modulate and show
adaptability. People do continue to care about their children, and may have sympathetic feelings towards others, bur
overall there's a real sense of not caring. There are also unprovoked fits of emotionless laughter.
Ambivalence: this refers to a state where the patient “endow[s] the most diverse psychism with both a positive and
negative indicator at one and the same time.” They have an ambivalence of will (ex. I want to eat and I don't want to
eat), intellectual ambivalence “I am dr. h, I am not dr. h), and affective ambivalence (loving and hating your wife at
the same time).
There are also a few secondary symptoms, but not of real importance, because they can be confused with symptoms of
other diseases.
Autism: this refers to how one’s inner-life takes over. “Neither evidence not logic have any influence on their hopes and
delusions” their fake world is real to them, to the point that they can’t distinguish between reality and fantasy.
All these symptoms indicate schizophrenia.
Bleuler: basically, he coined the new term schizophrenia, adding to Kraepelin’s method and knowledge base. He has been
regarded “as the initiator of a new tradition” of a humanitarian psychiatrist, but some debate if he is as significant or rather
just another part of a natural historical flow. He was much closer to his patients than Kraepelin, and also more optimistic –
believing that there may be a cure to schizophrenia. He also focused on symptoms rather than causes.
Week 5b. Cohen, Williams, and Buck v. Bell.
Sol Cohen. The Mental Hygiene Movement, The Development of Personality and the School: The Medicalization of American
Education. 1983.
Key Terms: Mental Hygiene, Mal/Adjustment
Key Themes: origins of/responsibility for mental illness, role of the psychiatrist, public opinion of psychiatrist
Mental hygiene philosophy: mental illness is a result of poor development of the personality. As childhood is a key time for
this development, schools ought to focus on personality development rather than any other form of education.
National Committee for Mental Hygiene: Founded in 1909, by 1920 it had expanded its initially small-scale investigation of
institutionalized mental illness into a large-scale push to prevent mental illness. Crucially, “Mental illness was not a
‘disease’ of the brain or of the nervous system but a personality disorder,” one that grew gradually, with the
foundation for illness or health formed childhood.
Impact of WWI: Shell shock 1) confirmed their ideas about personality and mental illness, 2) showed that psychiatrists could
be useful outside the asylum.
They formed a two-pronged attack against mental illness: Parents and Schools
Parents: NCMH encouraged parent education through the Bureau of Child Guidance (1920s) and liaisons with major parentoriented interest groups. Unfortunately, parents can’t be forced to be educated. Kids can and are every day.
Schools: The goal was to change the school’s view of the role of education. Hygienists targeted 1) failure 2) academic subjectmatter-centered curriculum and 3) disciplinary procedures, each of which damaged the child’s adjustment.
Misbehaving children were now those who were healthily rebelling. The shy, shut-in ones were those who were
“problems”: they showed symptoms of maladjustment. All this put enormous pressure and responsibility on the
teacher. The 1922 Program for the Prevention of Delinquency provided visiting teachers to educate parents and
teachers and provided psychiatric aid for children in need.
Dissemination of information: enormous numbers of articles, pamphlets, talks, lectures… Textbooks for teachers were also
important (1930s and 40s).
In 1930, the Whit House Conference on Child Health ad Protection advocated the mental hygiene view of education,
providing it national legitimacy
By 1950s, NCMH had pretty much run its course. Mental hygiene was firmly embedded in the national consciousness and
education.
Although mental hygiene was considered to be scientifically-based, little research was actually done on its effectiveness
before it was so widely adopted into “common sense.” Future reforms of education must acknowledge and correct
this.
Frankwood E. Williams, Community Responsibility in Mental Hygiene. 1923
Key Terms: Mental Hygiene, Mal/Adjustment
Key Themes: origins of/responsibility for mental illness, degeneracy theory (in an odd way), public opinion of psychiatrist
A description of the dangers of childhood (malformed joints, tuberculosis, delinquitism) and how science and medicine have
helped. A description of the increasing numbers of institutionalized mentally ill and the suggestion that something
needs to and can be done. Uses a cute analogy to our ancestor, Probably Arboreal, and sharks (mental illness to the
psychiatrist) v. gods and devils (mental illness to the uneducated).
Describes the possible paths for youths if left unadvised. All of them lead to some form of mental illness, some less severe,
some demanding institutionalization. Emphasizes that the quite types, not the stereotypical raucous “problem
children”, are the ones in danger of mental illness. Advocates a new kind of degeneracy theory where the mental
illness isn’t genetically inherited, but a maladjusted grandparent will distort the parent who distorts the kid.
Our only hope are the psychiatrists who recognize the true source of mental illness to be sharks, not devils, and hence are
something that can be handled.
Supreme Court Case, Buck v. Bell, 1927. http://www.crimetheory.com/Archive/BvB/index.html
Key Terms: none, really.
Key Themes: Patient rights, (modified) degeneracy theory
Summary: “Buck versus Bell, heard before the U.S. Supreme Court in 1927, was heard to decide the Constitutionality of
involuntary sterilization. Carrie Buck was a minor sent to the Virginia State Colony of Epileptics and Feeble Minded,
and was to be sterilized under Virginia's new statute of 1924 enabling salpingectomy, or surgical sterilization, "for the
protection and health of the state." John Bell, the superintendent of the State Colony, had won two previous rulings by
the lower courts; the Supreme Court was now to decide. Their decision placing the health of the nation over the rights
of the individual legitimated sterilization procedures in Virginia from 1927 until 1974.”
Council For Carrie Buck: “If this Act be a valid enactment, then the limits of the power of the State (which in the end is
nothing more than the faction in control of the government) to rid itself of those citizens deemed undesirable
according to its standards, by means of surgical sterilization, have not been set.”
Council for John Bell: (I thought this was the most interesting argument, although the key one is simply that this sterilization
procedure is thoroughly and carefully considered before it is performed and it is not cruel or unusual.) “The precise
question therefore is whether the State, in its judgment of what is best for appellant and for society, may through the
medium of the operation provided for by the sterilization statute restore her to the liberty, freedom and happiness
which thereafter she might safely be allowed to find outside of institutional walls.”
Although degeneracy theory is not explicitly cited, this ruling acknowledges the inheritability of mental illness and, like the
degeneracy theorists, deems it a cultural danger. But rather than let the mental illness simply die out naturally (as I believe the
degeneracy theorists did), this case called for the US to take a more proactive approach and actively inhibit propagation.
Week 6a Summary
“The Influence of a Biological Therapy on Physicians’ Narratives and Interrogations” by Joel Braslow
Key term: Malaria Fever Therapy (MFT) - Injecting a strain of malaria into the patient’s blood to cause abnormally high body
temperature – used as a tool to treat GPI
Summary:
 Wagner von Jauregg concluded that fevers were beneficial in treating psychiatric disorders.
 First used the blood of a malaria infected shell-shocked soldier in 1917 to treat GPI patients – successful
 MFT spread rapidly in the early 1920s
 Before MFT neurosyphilitic patients seen as bad, immoral people – advent of MFT restructured patients’ and physicians’
perceptions of themselves and each other in a positive way
 MFT served as pace setter but didn’t have much hope for other diseases – need new treatments
“The Pale Horror” by Paul de Kruif
Key Term: MFT (see above)
Summary:
 Wagner von Jauregg proved fever kills the “pale spirochete” responsible for both syphilis and GPI
 Attempted first with TB on GPI patients – already hopeless cases – no harm in trying
 Willis R. Whitney came up with fever cabinet – machine that could control a person’s fever – “fever is one of nature’s ways
of fighting death”
“The Insulin Hour” by Marie Beynon Ray
Key term: Insulin Coma Therapy (ICT) - the administration of sufficient insulin to induce convulsions and coma
(hypoglycemia) in attempt to treat mental illness
Summary:
 ICT introduced accidentally by Manfred Sakel – used to treat schizophrenia
 Patients given excess insulin until they go into a deep coma then revived with sugary drink – patient undergoes process of
evolution until he gets back human functions - patient no longer hears voices, emotions and attitudes toward people have
changed – later that afternoon back to demented self
 Jekyll-Hyde type transformation
 Possible theory – frequent or prolonged insulin shocks sometimes destroy isolated neurons in various parts of brain
 Most efficacious form of treatment for schizophrenia at that time
“Old and New Information about Electroshock” by Ugo Cerletti
Key Term: Electroconvulsive therapy (ECT) – Administration of electric current to the brain through electrodes placed on the
head in order to induce seizure activity in the brain, used in the treatment of certain mental disorders (when first introduced –
used for schizophrenia, now for depression)
Summary:
 Shift from convulsing drugs to convulsions with electric current resulted from the study of changes in nervous structure
following experimental epileptic convulsions in animals
 Ugo Cerletti experimented with dogs – duration not voltage applied is most dangerous
 Later experimented with pigs shocked with voltages in slaughter houses
 1938 - finally experimented with a schizophrenic vagabond – successful – ECT was born
 1942 – Cerletti’s colleague Bini suggest that repetition of ECT results in “severe amnestic reactions that appear to have a
good influence in obsessive states, psychogenic depressions and even in some paranoid cases”
“Fever Cure and Neurosyphilis” by Edward Shorter
Key Terms: MFT (see above)
Penicillin - antibiotic drug discovered by Alexander Fleming, most active against gram-positive bacteria and used in the
treatment of various infections and diseases – used to treat neurosyphilitic patients after it was first discovered
Neurosyphilis – a chronic infectious disease caused by a spirochete in the nervous system leading to general paresis
Summary:
 MFT was first successful physical therapy in psychiatry – treated Neurosyphilis
 Wagner-Jauregg’s fever cure broke the therapeutic nihilism that had dominated psychiatry in previous generations
 1910 - Paul Ehrlich discovered that Salvarsan blocked development of syphilis – but needed to be implemented very early in
order to work well
 Invention of penicillin put definitive end to Neurosyphilis story
 Began in 1929 Alexander Fleming discovered that mold cultures of penicillin inhibited growth of bacteria – 1944 – tried on
patient – success
Overall Synthesis of Material with rest of course:
The asylum had previously been the heart and soul of psychiatry. In the 1920’s, the asylum was under funded and depressive,
and the number of patients in the asylum was increasing, but little could be done. These were very demoralizing days for the
asylum. But with the introduction of the somatic therapies (or biological treatments), the asylum could once again claim that it
was a therapeutic institution. These biological treatments were the first of their time and thus set the stage for other
biologically related treatments to follow. This also represented a tremendous shift away from Freudian thinking (as he was
presenting many of his theories at approximately the same time).
Week 6b
Walter Freeman, James Watts: “Prefrontal Lobotomy in the Treatment of Mental Disorders”
Prefrontal lobotomy operation introduced by Egas Moniz of Lisbon in 1936
His surgeries began as injection of alcohol into frontal lobes, got to incisions with an “apple borer” style tool.
In intial trials, no patient died and none made worse…all except one returned home…some no longer need nursing
care…all more comfortable…one back working
He does not think it is a cure, just a means of relief of symptoms not helped by psychoanalysis or other techniques
Physical condition of patients also improved
Describes the technique, which is very technical and I doubt we will need to know it, just know that he bores into skull
with apple borer and severs the connections in frontal lobes
Patient left hospital 1-2 weeks after surgery
Conditions of 6 trials after surgery has been as good or better than desired
Then describes the details of the 6 patients before and after…many don’t remember why they were angry, many don’t
understand what made them mad, many very thankful and normal feeling, all pretty much coherent and normal. Only
the patient number 6 later went back to institution
Emphasizes that indiscriminate use of technique could result in vast harm…should only be used if other techniques fail
Overall immediate results satisfactory, but will have to see how they function in jobs over period of time and at home to
see if long term is good and if it could be considered a cure
Kaempffert: “Turning the mind inside out”
At least 200 men/women had troubles cut out of them…many have become normal members of society
Nothing wrong physically in brain being operated on- it cannot think logically-the brain of a mind that lives in an
impossible illusory world of its own creation
Psychosurgery turns the right mind outward
It took much research in past to see that brain has locations of specific function
Ever since WW1, brain ceased to be sacred: studies, dissections, other stuff showed that when a part of the brain is
messed up or destroyed, another part adjusts to handle the functions of the destroyed part- not always as efficient
After Neurological Congress of 1935, Egas MOniz decided time had come to cut out worries from brain. Saw how
stereotypes symptoms were, and decided that they must all be localized problems in same part of brain-brain cell
patterns could be fixed and person would be too
Longlasting dementia praecox cases not helped, but hypochondriacs, suicidals were
Though results met with skepticism, results proved point: fixed ideas could be dissipated by breaking up fixed groupings
of nerve cells in fixed pathways
In America Freeman(neurologist) and Watts(surgeon) followed Moniz- started with his borer but soon developed their
own techniques
They believed that brain was made up of 12 brains-each individual one was a remnant from primitivity-animal like brains
that when added together gave us our superior one
Mainly interested in 2: thalamus and cerebrum with its cortex- they cut the pathways b/n these 2 regions
Thalamus very old, the raw seat of emotion-makes you want to kill
Cerebrum new, human, makes man the inventor, creator of music, moralist, scientist- keeps you out of jail for murder
Our brains are a battleground where the old thalamus and new prefrontal lobes(cerebrum) struggle for victory
In mental dosirder the thalamus has overpowered the frontal lobes
So after surgery there is a bit of dissociation, but then the processes that were inhibited are taken over by frontal lobes
restoring sanity and normality
Instead of apple corer have long needle w/ hollow shaft to probe and a special knife to cut. Also, go through temples
instead of top of head like Moniz
Freeman and watts worked on about 70 patients:Results good in 65%, fair in 20%, poor 15%- 3 patients died
Describes technique, but again, to technical
After surgery a critical week in hospital is necessary: disorientation b/c a personality that has been disrupted is trying to
piece itself together again in a new mold- called “rebirth”
Old habits persist at first after surgery, but eventually go away(ex. Alcoholic pours and drinks invisible drinks)
Most patients placid and indifferent, but few very wild and aggressive
After 5 days new personality ½ born, after 10 get to go home, at home social readjustment continues for months or even a
year
In reasonably short time self-restreint, memory and intelligence return
They operate to alleviate fear: “anything that is a threat to the integrity of the personality”
Intelligence is hardly changed at all
Frontal lobes make us see ourselves, see what we can and should do, predict and make judgements- when mental, cant
predict and mind breaks down as such- thalamus blocks this straight thinking
Chance of success is carefully considered before surgery: hundreds of factors weighed. Decision of surgery not easy and
much grave responsibility assumed when made
Freeman and watts don’t operate on insane, criminals, or anyone who taked pleasure in cruelty, or people who are
hopeless
The fear in people must be grave and almost incapacitating before they will decide to operate as a treatment
Jack Pressman, “John F. Fulton and the Origins of Psychosurgery”
Psychosurgery: the use of brain operations such as lobotomy or leucotomy for the alleviation of mental or behavioral
disorders
In 1970’s procedure denounced as ultimate form of mind control
Can be seen as tale of science gone awry
Why would reasonable physicians value this treatment so much only to abandon it completely soon after?
Typically presumed that life course of a medical innovation is determined mostly by that treatment’s medical soundness
There is no assurance of an inherent medical value when scientists begin the consideration of a new treatment
This paper focuses on role of John Fulton in the origins of psychosurgery
Moniz received Nobel Prize in 1949 for psychosurgery father, but actually many consider Fulton the father
Fulton delivered speech at 2nd Neurological Congress from which Moniz got his idea
Fulton performed lobectomies on 2 chimps Becky and Lucy and this procedure turned Becky from wild and crazy to
docile
In the 30-40’s psychosurgery established as only treatment for severe chronic mental illness-the type of patient who is
doomed to an institution the rest of their life: 20000 operations done in 15 years around 30’s
Most people saw Fulton’s and assistant Jacobsen’s work on chimps the first step
Success at intellectual and social levels is necessary for medical innovation to go from laboratory research to clinical trial
Fulton was psychosurgery’s most significant patron- he was chair of Yale Dept. of Physiology- used the new and high
tech lab at Yale to transform neurophysiology- the generations leading authority on it
Fultons life work the construction of a coherent model of the nervous system- organized 1st US primate lab to help do so
at Yale
He collaborated with Carlyle Jacobsen( a psychologist) to do studies on Becky/Lucy
They found that the removal of frontal lobe tissue resulted in loss of specific faculties- frontal lobes integrate recent past
into current actions
Some of their post operative monkeys no longer worried- similar to human patiens w/ lobe damage: this excited the
human idea- these findings the neurophysiological rationale for lobotomy
Experimental neurosis- promised to unite animal psychology and human psychiatry
Sterling Extension at Yale labs- finest primate labs and neurophysiological equipment in country at time
Rockefeller Foundation gave much money to Fulton/Jacobsen in these years for the study of psychiatric issues
Fulton believed most lasting role would be as a teacher- he was James Watts’ teacher/mentor
Watts/ Freeman used the lobectomy of the chimps as part of justification to try lobotomies on humans
After 1st operation by Watts/ Freeman, Fulton very encouraging and pushed for them to give it a fair clinical trial
Fulton used his wide correspondent base in 1936 to tell everyone about potential of brain operations
Without this encouragement most psychiatrists/ surgeons like Harvard’s Harry Solomon would not have tried the
procedure b/c it was dangerous and bold
He realized that he would have to answer for any problems but he thought it was worth a trial
Fulton conveyed info of new operation on medical poster which won a prize, in his Sigma Xi Lecture Series, and in
magazines such as Science Service
He gave Watts/Freeman the support to make it through the 1st tough years when they met with muchopposition
He gave Kaempffert the info and support to write a science journal article on the procedure despite the negative remarks
from the NY Academy of Medicine
Kaempffert’s article in Saturday Evening Post resulted in calls for censure of Freeman/Watts, but Fulton said he would
stand by them and defeated the censure movement by himself
Medical publisher Thomas only published Watts monograph b/c Fulton said he should
He was so involved b/c 1) most of the inspiration came from his lab, 2) the treatment offered hope in a realm where
“despondency reigns”, 3) it was a stepaway from the static practices of neurology that had pervaded America for a
while
Fulton used Harvey Cushing Society(Watts a member) as his people to bring about neurological transformation- became
its 2nd president
Looked at every mental derangement as having an anatomical basis: thought Freud was off the mark with psychoanalysis
Believed that psychosurgery programs would be integrated into state hospitals and would severely reduce the crowding
and costs
Psychosurgery’s initial development followed typical pattern of successful medical practices: leading figures supported it
and there was a consensus that a scientific basis existed for the treatment- Fulton instrumental in both ways
Many people think that psychosurgery would not have held up to scrutiny of the time had Fulton not made it “uncritical
enthusiasm running rampant”
Why did so many scientists believe in it? 1) chimp experiments used to justify them came about in a specific institutional
context, 2)popular “Pavlovian model” of experimental neuroses provided intellectual context which united
physiological psychology, psychiatry and neurophysiology- thought to have direct bearing on psychiatric problems
Psychosurgery follows path of “today’s orthodoxy is tomorrow’s heresy”
Studies of failed technologies show us that what constitutes standard medical practice and belief does not stay fixed but
evolves
Week 7a
Hersey, John, “A Short Talk with Erlanger,” Life Magazine, (October 29, 1945)


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This article talks about narco-synthesis, a treatment used by the army during WWII to help psychiatric casualties
a.k.a. neuropsychiatric cripples (what does this mean?)
Details of the case history:
the patient has a problem with his leg and cannot walk as a result of a nearby explosion during the war. However, his
medical record revealed nothing physically wrong with him. The paralysis was a “hysterical conversion” – a device
contrived by the unconscious part of the mind.
Doctor wanted to “have a talk” with all the levels of the patient’s mind. He would get access to his unconscious by
injecting the patient with a barbiturate drug that would break down the patient’s emotional inhibitions and allow him
to pour out in their full intensity some of the terrible unconscious guilt and anxiety that were responsible for his
condition.
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

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The patient speaks: He recounts the stories that troubled him and were lurking in his unconscious, affecting this
mental and physical well-being. Among other things he mentions the fact that his mother didn’t want any sons after
his older brother was born and dressed him up like a girl. He suffered from the fact that he had a big body and yet he
was made fun of for being weak.
The doctors talks to him and tells him how his fears are irrational and that he has no reason for believing the things he
does. He tells him to use his leg, to walk. And the patient walks.
The author talks about many soldiers like Erlanger, admitted to hospitals as neuropsychiatric patients. More than 40%
of all army medical discharges had been NP cases. Lots of these patients were suffering from the so-called combat
fatigue.
Narcosynthesis:
treatment successful in severe anxiety states, acute depressions, psychosomatic disturbances, Erlanger’s hysterical
conversion symptom (physical failing for which there is not physical basis) etc. but not with psychotics.
Never used alone, in conjunction with other techniques of psychotherapy.
Not regarded as a cure, but as a help/short-cut.
Neill, John "Whatever became of the schizophrenogenic mother?" in American Journal of Psychotherapy (1990)
This article chronicles the rise and fall of the concept of “schiz. Mother”, which was popular in the psychotherapeutic
literature from the 1940s to the 1970s.
What the term meant:
- Women could “cause” schizophrenia in their children.
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Historical context:
- in mid 20th century psychiatry was dominated by an environmentalist bias in search for the roots of mental illness.
Psychoanalytic theory held that early childhood experiences determine the resultant adult personality. Classic
Freudian theory would say that it was all about the conflict between competing drives within the individual and how
this conflict was expressed in the environment.
- In 1940s, as psychiatry expanded its venue into the community, interest began to focus on the family and its role in
psychogenesis of pathology.
Harry Stack Sullivan and Washington School of Psychiatry: importance of child’s earliest interaction with the parents
and its major distorting influence as causing schizophrenia in particular. Central pathological construct was anxiety,
discomfort that child learns to feel in presence of significant adult, who uses this as a tool to train the child to abide by the
basic requirement of acculturation.
Frieda Fromm-Reichman: (1948) Distorted maternal relations are the cause of schizophrenia. Schizophrenic is
distrustful and resentful of other people due to the severe early warp and rejection he encountered in important people in
his infancy and childhood, mainly the mother.
David Levy studied a small series of cases that he thought were representative of the phenomena and concluded that
schizophrenogenic mother involved:
a) maternal overprotection – covertly rejective
b) maternal rejection – domineering, aggressive, rejecting, critical and overdemanding
Lidz et. al. at Yale:
- marital schism: paretns are ”emotionally divorced” from each other
- marital skew: one of the partners (usu. Mother) dominates family interaction
Murray Bowen: family systems theory > the greatest single influence on continuing the preoccupation with the schiz.
mother, idea that schizophrenia was the symptom manifestation of an active dynamic process that involved the entire family.
Treat family, not individuals.
Cultural changes after WWII drew public attention to the mother and the child:
- rising divorce rates, adolescent pregnancies, working moms who had to leave their children with nannies.
- In the 1950s and 1960s there was an unexplained misogyny in American culture: the mother was blamed for anything.
- Women seemed to be very powerful whereas men seemed to be weaker, emasculated.
Developments in psychiatric theory also played a part in empowering the mother. Child became the focus of psychological
study. Mother-child interactions during the earliest months of life were considered to be determinants of the child’s
personality and later psychopathology. Nurture was more important than nature.

This example of the schiz. mother remains deeply embedded in its cultural matrix.

By the 1970s, the concept of schiz. mother turned out to have been too elusive and not plausible but this blamelevelling concept, which had no basis in scientific fact, may have caused a lot of harm.
Week 7b
Strecker – Their Mother’s Sons
Mothers: raised physically and emotionally healthy sons who could joke about an injury or who were honorably “wounded”
by severe combat fatigue.
Moms: “women who have failed in the elementary mother function of weaning her offspring emotionally;” their sons were the
draft dodgers, those who couldn’t get into the military due to neuroses, and those who developed neuroses before even
reaching the battlefield.
Immaturity (emotional immaturity): a “Mama’s Boy;” comes from a mother who spoils her kid, by giving him excessive
“freedom of self-expression” she exerts her dominance over him because he will always need her protection; due to this, he is
unable to make successful connections with others even though he tries to seek them out.
Strecker asks: What is the difference between those who failed after the trauma of war and those who failed well before it?
Nothing, all of them are sick: it is the inner conflict of self-preservation and society’s ideals. Why did self-preservation
prevail in some and not others? Those who failed were “immature,” raised by their moms to be that way. Society is partly to
blame for encouraging the moms because (apparently) society is matriarchal. Strecker feels that the mom should receive part
of the blame for the children’s failures and delinquencies, but instead society “profoundly pities” the mom.
He also blames “progressive education,” which removed competition by doing away with punishment for failure, but in doing
this it also got rid of the incentive to succeed by not rewarding excellence. Progressive education was at its peak when that
generation of soldiers was in school, so he suggests that progressive education may have been a factor in the “psychoneuroticineffectiveness” displayed by those turned away from the military. Progressive education was similar to what mothers were
doing because they both produce “spurious maturity” by apparently encouraging self-expression while making the kid
dependant on that system.
Bateson – Toward a Theory of Schizophrenia
Theory of Logical Types: The class cannot be a member of itself nor can one of the members be the class. “Class” is a
different “level of abstraction” or Logical Type. Schizophrenics have trouble identifying the correct communicational mode
or Logical Type (literal, metaphor, etc.).
Double Bind: (damned if you do, damned if you don’t) the cause of schizophrenia – repeated experience involving two or
more people, one of which is the victim, where there arises a primary negative injunction (response required under threat of
punishment), a secondary injunction that conflicts with the first on a more abstract level (Logical Type thing), and a tertiary
injunction that prevents any escape from the first two. This must all be internalized until the victim sees a double bind in all
aspects of life. (and, voila!: schizophrenia)
The switch in mode occurs (to anyone, not necessarily a schizophrenic) when an individual finds himself in a situation where
he must respond to contradictory messages but is unable to comment on the contradictions. The person may respond to a
metaphorical question with a literal answer. (For an example, see Bateson pg 254, bottom left, employee example). Bateson
claims schizophrenics “habitually respond with a defensive insistence on the literal level” when they perceive a metaphorical
double bind, or vice versa, creating a metaphorical story to comment on something that happened and making it even more
exaggerated if the “metaphorical comment” is ignored, in an attempt to convey the fact that is was a metaphor. (Therapist is
late, makes up story about a man missing a boat, which turns into a trip to Mars if therapist isn’t getting it). Paranoid
schizophrenics respond to double bind by assuming there is a hidden meaning in every statement, hebephrenics by laughing at
it, and catatonics by ignoring it.
Description of the Schizophrenogenic Mother: Cold and Caring – has some problem with the child that causes her to feel
anxiety when the child shows affection, behaves overly loving in other aspects in order to compensate for this. This causes
the child to believe that either his interpretation of the meaning of her behavior is wrong or that his interpretations of his own
behaviors are wrong: the child withdraws from a mother who does not want a hug, she asks “Don’t you love me?” so that
either his interpretation of her unapproachable behavior was off (and she did want the hug) or his interpretation of his retreat
should actually have been that he didn’t love his mother not that he was backing away from someone who didn’t want to be
hugged. If he questions these mixed messages the mother will feel threatened and not respond or not validate his questioning.
Because of this, the schizophrenic never develops the ability to use the metacommunicative level to ask what is meant.
Fathers barely factored into this except to say that fathers were not able to support the child’s need for the validation of his
interpretations of the mother’s responses either because they were also in a sort of double bind with their wives or because
they were unavailable.
Pages 258 to the end give examples of schizophrenics and their mothers behavior towards them. There is an example of a
schizophrenia model where a smoker was continually offered cigarettes but not given any until the point where he did not
even remember being offered a cigarette and he created a reason for no longer wanting one.
According to the paper, their basis for this theory rested on interviews with psychotic patients and exactly TWO mothers and
one father. They say that they have not factored in all the dynamics of a family but they make it quite clear that the mother
will undoubtedly have something to do with the making of a schizophrenic even thought they have no data. This paper was
written in 1956 (Strecker’s in 1946) and it seemed to be assumed that mental illness was the mother’s fault. This was
happening right after the psychoanalysis phase where childhood experiences and the family were accepted as the sources of
mental illness, and also near the mental hygiene phase where people were encouraged to talk about their emotions. This was
clearly denied to the schizophrenics by the schizophrenogenic mothers.
Week 7b (Take Two)
Reading #1: Strecker, Edward A. Their Mothers' Sons (pp. 13-29, 160-168)
Summary: In Their Mothers' Sons, Strecker outlines his argument that “moms” -- which he defines as women who “failed in
the elementary mother function of weaning [their] offspring emotionally as well as physically” -- are responsible for the huge
number of neuropsychiatric casualties in World War II. Strecker notes that “war is a great leveler” that brings out both the
strengths and weaknesses of its participants. He describes the wide range in severity and symptoms of cases of
psychoneurosis and combat fatigue, finding as a commonality that even though there are no physical causes for the men's
ailments, “they were as honorably wounded as though they had been struck down by enemy fire.”
Strecker contrasts the neuropsychiatric casualties to the massive numbers of drafts dodgers (500,000), neurotics
rejected before enlistment due to screening (over 1.8 million), and even cases of psychoneuroses who had to be discharged
from the military (600,000). While all these men were sick from the same inner emotional conflict (“self-preservation versus
soldierly ideals), the men who fought bravely before breaking down and those who never reached the battlefield differed in
the amount of motivation and determination they had to fight. Strecker attributes a lack of determination and motivation to
immaturity.
Strecker notes that maturity “is the result of early background, environment, training, and unselfish parental love,”
and immaturity is therefore caused by the opposite – he damningly claims that “in the vast majority of case histories, a 'mom'
is at fault.” Such “moms” fail to wean their children emotionally, and, since “the vast majority of men and women are made
or broken before the first ten years of their lives have been completed, moms inflict irreversible psychological damage on their
children.
Strecker also claims that society as a whole fails to condemn these “moms,” and indeed even encourages or pities
them for their children's failings. Furthermore, progressive education contributes to the children's psychological damage by
actively encouraging them to express their (implicitly) immature feelings and eliminating competition wherever possible.
This elimination of competition in turn erases “the desire and incentive to achieve”
Relationship to Course Material: In the lecture corresponding to this reading (March 23rd), Professor Harrington described
Strecker as a World War I veteran who served as a military psychoanalyst in the Second World War. Strecker was concerned
by the fact that even though the military had rejected over 1,850,000 men for service due to psychological screening prior to
enlistment, there were still nearly 1 million psychiatric casualties between the United States' entry into the war in 1941 and the
war's conclusion in 1945. The number of war-related psychiatric casualties was such a burden that the National Institute of
Mental Health was founded in 1945 to provide federal funding to deal with cases of combat neurosis. Strecker faulted the
mental hygiene movement's “progressive education” for coddling children, and so-called “mom's” for their
overprotectiveness, which supposedly made the generation of Americans fighting in World War II more vulnerable to
psychiatric breakdown. The blaming of “moms” was quickly embraced by popular culture and served as a harbinger of the
idea
of
the
“schizophrenogenic
mother”
of
the
1950s.
Reading #2: Bateson, Gregory. “Toward a Theory of Schizophrenia.” Behavioral Sciences. (1956)
Summary: Bateson bases his ideas about schizophrenia on a part of communications theory called the Theory of Logical
Types, the central thesis of which “is that there there is a discontinuity between a class and its members.” In terms of human
communication, this essentially means that we communicate on different levels, either through different mediums (verbal
versus nonverbal), different uses of the same medium (using the same word to mean different things), or attaching different
meanings to the same medium (such as using the same word seriously in one instance and then sarcastically in a different
instance). Bateson hypothesizes that when a mother simultaneously communicates contradictory messages to her child on
different levels, the child's inability to decipher the multiple levels of communication lead to the pathology that we call
schizophrenia.
As an example of how this pathology occurs, Bateson outlines the idea of the double bind, which requires two or more
persons (the child and either the mother or the rest of the family as well) and repeated experience between the two people. A
double bind occurs when a mother gives a primary injunction (“if you do X, I will punish you” or “if you do not do X, I will
punish you”) and then contradicts her primary injunction either on a nonverbal level (through a gesture, etc.) or indirectly on a
verbal level (“don't think of me as someone who will punish you”). The double bind is completed by a meta-level injunction
that prevents the child from pointing out the contradiction. Bateson believes this occurs in families with mothers who are
uncomfortable both with loving displays by their child but also with their own ambivalence toward the child.
The double bind causes schizophrenia when repeated experiences prevent the child from ever determining what the
mother actually desires that he should do. This results in the child's confusing of literal and metaphoric elements, inability to
discuss what is asked of him with others, and other common schizophrenic symptoms. Bateson concludes the article by
noting that a psychotherapist could be successful treating schizophrenia by devising a series of “therapeutic double binds”
that force the patient to realize that the fault in his childhood lay not with his inability to decipher his mother's messages, but
her contradictory expression of them.
Relationship to Course Material: Professor Harrington discussed Bateson and the “double bind” on March 23rd – she
essentially outlined the double bind (in much simpler terms than Bateson himself did) as an example of a theory that
supported Frieda Fromm-Reichman's (who Bateson references in his article) idea of the “schizophrenogenic mother.” Bateson
and Fromm-Reichman are two of the clearest representatives of the neo-Freudian ethos in American psychiatry in the
immediate post-World War II era. Neo-Freudianism had a decreased focus on sexuality and fantasies and a correspondingly
increased focus on the quality of emotional experience and attachment in early childhood. In addition, the neo-Freudian
therapeutic rationale for psychoanalysis was that it not only offered insight into the source of mental illness, but that
“corrective emotional experiences” with a psychotherapist could help counteract negative childhood experiences. Thus,
psychoanalysis could benefit psychotics as well as neurotics – a striking divergence from Freud's own belief. This neoFreudian therapeutic sensibility is evident throughout Bateson's article.
WEEK 8A
Shorter 239-262
The Second Biological Psychiatry
In 1970’s biological psychiatry came back and replaced psychoanalysis. Went back to the themes present in the 19th
century. Emil Kraepelin had scientists work for him who believed the brain was the seat of psychiatric disease and had a
genetics lab trying to see the ties of disease to the brain and not to faulty mothering.
Genetic Strand – Genetics play a role in disorders. The 1st bio psychiatrists saw that but attributed it to “degeneration” so
the 2nd bio psychiatrists knew they needed solid data comparing sick patients to controls. Kraepelin and others saw that many
schizophrenics had a family history of the disease. To separate genetics from family inheritance twin studies and adoption
studies were adopted in the 1920s. Monozygotic twins are great since they share much of their genes and tend to fall sick at
the same time. 1928 – Luxenburger performed 1st large-scale survey of the area to see which ones had mental problems (211
ppl out of 16000 as one of a pair of twins and 106 cases of schizo amongst them) this showed the disease had a bio reason.
Rosanoff by 1930s had data from a huge twin study looking at state mental hospitals in California. Found out that there was a
genetic basis of disease. A great contribution to psychiatry during a time of psychoanalysis so not so well recognized.
Kallman did a study and when he presented his results in a conference in 1950 he caused a lot uproar from the psychoanalysts.
In 1968 Ketty looks @ adopted kids in Denmark, which kept amazing records on their citizens and showed that nature had
a big part to play. His research provoked more research using twins and adopted kids which was disheartening to
psychoanalysts. In 1970s studies showed that family wasn’t the only environmental factor
1st drug that worked – Drug therapy era began w/ inquiries into the brain. 1926 – acetylcholine discovered and used in
psychiatry. More physical treatments came in the 1930s. In France in 1951 Laborit after researching an antihistamine to lessen
the shock soldiers were in before operation, saw that they were relaxed and so he continued and found chlorpromazine. He
convinced colleagues to give it to patients who saw that it calmed down a manic patient. Delay and Deniker saw its uses in
psychiatry and made it popular in France. The drug was developed by Rhone-Poulenc for profit. In Canada in 1952 Dr.
Koeppe gave it to 25 patients who talked w/o anger and could sleep. Also in Canada, Lehmann decided to try it out in 1953
and saw “unique” results and he introduced it to the English-speaking world. Smith Kline got the rights to use it in the US
under the name of Thorazine and once doctors tried it they saw the tranquilizing effects and less side-effects than ECT. Smith
Kline got it into State Hospitals as a way to cost-saving tool where the patients that found no cure from psychoanalysis were.
Chlorpromazine took away the symptoms of disease and was called in the US as an antipsychotic.
The Cornucopia – this began the era of psychopharmacology (some drugs were just copies there to make $$, others were
toxic and soon withdrawn). In Australia Cade stumbled on Lithium that made subjects lethargic upon injection and in manic
patients the change was huge. He published his findings in 1949 but bad time for this because in US two cases of people dying
from Lithium were published. In 1952 Shou does a study using Lithium and sees the amazing results and his study brought
lithium to the world of psychiatry. It took some time to get popular and only in 1970 the FDA approved it. It took so long
because it had no industry backer and it was plentiful in nature
Depression is more common in the population and Kuhn was principal in finding a pharmacological cure for it. From
1952 until 1955 he experimented with drugs provided by Geigy and only then when given imipramine to depressed patients he
saw an amazing change. The name of the drug was decided by 1958 and then other companies marketed copies of it because
depression was so prevalent.
Psychiatrists were getting confident since they could make people better. This mix of luck and scientific preparation
helped to bring forth the biological psychiatric revolution and made psychiatry more effective.
Genetics are very important in mental disorders which is showed by twin studies and adoption studies
Psychoanalysis failed and psychopharmacology works
Chlorpromazine – the first widely used psychiatric drug that started off a revolution
Ostow – The New Drugs
A story of a woman who is anxious to the point she is helpless and is given electric shocks and insulin treatment; she got
better and 5 years later remised and given treatment by chlorpromazine. The drug is widely used not withstanding the sideeffects it is known as a tranquilizer. Its effect biologically is that it quells part of brain responsible for spontaneity. On psychic
level it lowers the libido and such instincts while not abating the instincts associated with death and destruction. Freud
predicted that chemicals would equilibrate mental energies. There is no data to be sure. The woman suffered a relapse and was
given shock therapy that resulted with her having big memory gaps. She did not respond to chlorpromazine. Author believes
that disorders stem from surplus or lack of libido and that either tranquilizers of energizers will help them. Drug therapy can’t
correct the root of the problem – psychoanalysis can.
Mental illness begins in childhood and it is provoked by: genetics (childhood experiences), current temptations and
frustrations and energetics. Author acknowledges that drugs helped the ones in hospitals and it helped cut down the costs for
the hospitals. We need to remember that these are just therapies and that we really don’t know what we are doing with them.
Drugs help but we must remember their limitations. Problem with treatment: toxic side effects, and unwise use.
A very psychoanalytic way of explaining why chlorpromazine worked.
Defends psychoanalysis
Crane – Clinical Psychopharmacology in its 20th year
Hospital beds replaced by community health centers thanks to drugs. Neuroleptic agents used more and more by the
doctors to control patients who cant go out into the community. In the last 15 years neuroleptic agents replaced most forms of
treatment. They really are not tranquilizers but these symptoms are just 2nd effects of lessening of psychopathology. Tries to
answer how many people are actually helped. There is a huge gap between the ones who get drugs and whether they go back
to institutions after one year but not so much after a period of several years. Author says that the success rates of drugs are
really not that spectacular and they are even prescribed in different doses. Doctors dismiss the possibility of a natural
remission and schizophrenia might be caused by other environmental factors. Hospitals are still needed to take care of the ill
but they lack funds so drugs seem to be the answer; especially since they did reduce the number of people in the institutions.
The drugs given over a long period to people who have schizophrenia might lead to side-effects (Parkinsonism is one,
blindness is another, and cardiac disorders and most of these are reversed once the administration of the drug is stopped.)
Tardive Dyskinesia (bizarre muscular activity all over body) is another symptom that results and can be quite common and
they don’t really know why it happens. Companies only after 1971 put more warnings on the labels of their drugs about this
disorder. Author says that use of drugs should be continued but be more regulated and that more funds should be used to find
out about this disorder that possibly occurs because of the use of neuroleptics. This is an example of “large-scale and
inefficient application of a potentially useful discovery without consideration for its long-term effects of the individual and his
environment.”
Criticizes the wide use of drugs without taking into account the side-effects.
Tardive dyskinesia – possibly caused by psychopsichiatric drugs that were kinda overlooked by companies and medical
professionals.
Week 8b
1. www.nmda.org - It's easier/more useful if everyone just visits the website, as opposed to my summarizing anything from it.
I think the idea is to get a feel for what this group is about.
2. Johnson, Dale. "Schizophrenia as a brain disease" pp. 553-555
 Families of persons with a mental illness hold that schizophrenia is a brain disease, especially those in NAMI (National
Alliance for the Mentally Ill).
 One reason is that the person changes so much that their families know the cause has to be basic. Another reason is that
parents often know when their child is “different.”
 The belief that schizophrenia is a brain disease is less stigmatizing than the idea that mental illness is caused by family
behaviors.
 This brain disease idea also offers hope for a cure and treatment. NAMI advocates research into mental illnesses. NAMI
emphasizes neuroscience.
 There is powerful statistical (e.g. twin studies) and scientific evidence (through brain imaging – MRI, PET etc.) that points
at a biological basis for schizophrenia.
 A more comprehensive model to schizophrenia’s etiology is necessary – one that also considers psychological and social
context – a.k.a. biopsychosocial model.
 As a disease is not progressive but marked by remissions and relapses (possibly due to stress).
 Treatment should not always be purely medical because some forms of the disease are based more on brain dysfunction than
others. However, neither medication nor psychotherapy are particularly helpful to many schizophrenics. Rehabilitation
centers emphasizing a calm environment are good places for treatment.
 If schizophrenia is a brain disease, it is necessary to assess the neuropsychological status of a patient.
 Research reflects a trend in collaboration between neuropsychiatrists and neuropsychologists.
 Weinberger (1987) provides a framework for new theory of schizophrenia as a brain lesion from early in life interacting
with normal maturational events. Understanding adolescence is therefore vital in understanding schizophrenia.
 NAMI is comprised of psychologists, family members and recovering mentally ill persons. Its main goal is to advocate for
more research funding and fight the stigma that goes with being mentally ill.
3. Kay Redfield Jamison, An Unquiet Mind
pp. 3-8: Prologue
 She describes boundless, restless energy and lack of good judgment associated with being manic.
 Within 3 months of appointment at UCLA (1974) she was ‘manic beyond recognition.’ She struggled for years with her
medication. She did not seek treatment for first 10 years.
 She describes the ups and downs of her youth and her understanding of herself as a person with moods. Knowing this
difficulty she wanted to help others.
 She resisted taking her medication despite knowing it was the best thing for her.
 She uses her experiences in her teaching, research and clinical practice. She had concerns about disclosing the truth of her
illness, but ultimately felt it’d be dishonest not to.
pp. 41-48
 Attended UCLA despite reservations. Was ultimately good because it had money to offer independent research. However,
she struggled all the way through college because of her shifting moods.
 Her mania was marked by intense creativity and energy but also by impulsive spending she could not afford. Schoolwork
was easy while she was manic. While depressed however, she considered dropping out of college, was plunged into deep
despair and agitated by awful thoughts. She hints at her father having bipolar disorder (“my father’s black and
unpredictable moods.”
 She ended up becoming a research assistant in one of her psych professor’s labs and fell in love with research. She took a
year off to study at St. Andrews in Scotland.
pp. 65-136
 Describes being unsure as to who she really is – manic or depressed?
 Wasn’t initially interested in working with mood disorders. Being well for a while lulled her into thinking she was ok.
 Her marriage fell apart – partly because she wanted kids and he didn’t, but mostly because with the spiraling madness she
craved excitement/adventure.
 While manic she spent a LOT of money (+$30,000 during two major manic episodes). The bills she received for these
spending sprees afterwards added to her depression.
 Her brother helped her out a lot – especially by organizing her bills and paying them for her.
 She had vivid and frightening hallucinations. The man she was seeing, a psychiatrist, told her she might have manicdepressive illness and encouraged her to take lithium.
 She describes realizing she was insane in a single moment.
 She describes her psychiatrist as being unusually kind and committed to psychotherapy. He convinced her she was manicdepressive and would need lithium for life.
 She describes how lithium prevented her illness but psychotherapy actually healed her.
 For years she resisted taking lithium, partly because she didn’t want to believe she had a real disease. She felt she should be
able to deal with her problems without medicine. And losing her moods, something so human, also made her feel like she
was losing who she was. Being “normal” was very restrictive. She still misses the highs. She also resisted lithium because
she had a higher dose than she does now and had side effects – nausea, vomiting, trembling, slurred speech. The effects she
really hated however were being unable to read (due to blurred vision) and understand what she’d read. When off lithium,
her depressive episodes were increasingly suicidal.
 She describes a patient of hers with manic-depression who refused to take lithium once he felt better and relapsed into worse
episodes. This is common in manic-depressives. He eventually died.
 Kay herself tried to commit suicide via a lithium overdose. She was very violent while ill. She found that she was less
accepted when manic than when depressed because of society’s ideas about what women should be like.
 She started an outpatient clinic at UCLA that specialized in treating mood disorders. She emphasized medication and
therapy as a course of treatment. She aimed to educate about the positive aspects of mania – creativity, energy etc. – and
how they were difficult for people to give up. All of her work resulted in her finally getting tenure. Even at this time
though few people knew of her illness.
pp. 177-184
 She describes the harm done by societal labels for people with mental illness.
 She debates the accuracy of the label – “bipolar disorder” for what she considers “manic-depressive illness”. She thinks
there are merits to both names. “bipolar disorder” is useful in de-stigmatizing the illness but in her mind can be misleading.
Week 9 b
The Antidepressant Era—The Discovery of Antidepressants pp. 43-77
by David Healy
The general idea of this piece is that the creation/discovery/acceptance of the first antidepressants cannot be attributed to
single people. Deciding who had the greatest contribution in the effort toward creating and marketing successful
antidepressants is a rather contentious and ambiguous subject.
 After recognizing the effects of chlorpromazine on schizophrenia, Roland Kuhn, a German, attempted to find similar
psychotropic drugs. The pharmaceutical company Geigy gave Kuhn a substance that will later come to be known as
imipramine, the first of the tricylcics. Kuhn first tested it on patients with schizophrenia, but they began to
deteriorate and became agitated and often hypomanic.
 However, because of this “high,” Kuhn decided to try the drug as an antidepressant in a study in 1955. Although the
study was not a stringent, double-blind trial that is standard today, the subjective effects were noticeable enough to
report the success to Geigy. He made particular note that the drug seemed to help the “vital” depressed cases, those
who seem to have a deep depression of no specific cause and likely more biological roots (today known as
endogenous depression).
 Questions arose about why the drug took so long to show effects because chlorpromazine worked immediately. Kuhn,
following the European trend, was very theoretical, but ironically made his imipramine conclusions based on
empirical observation. Like Kramer in Listening to Prozac, he began to write about how imipramine and other drugs
could potentially help researchers learn more about the human mind.
 An American contemporary of Kuhn was Nathan Kline. He was very different from Kuhn in that he was a very
flamboyant, outgoing, and a psychodynamic empiricist. He is credited for discovering the antidepressant effect of
iproniazid, the first of the MAOIs. Kline, being a psychodynamic thinker, labeled iproniazid as a “psychic elevator”
that basically boosted one’s id and suppressed the ego.
 Many others, including George Crane, Saunders, and Al Zeller, claimed that Kline was not the first discoverer of such
effects of the substance. Kline was chairman of the Committee on Research for the APA and very prominent in the
media, so his story of his findings in 1957 gave him the notoriety.
 The demise of psychoanalysis and the rise of the medical model along with severe side-effects noted in MAOIs
caused Kuhn’s views and imipramine to ultimately be the most widely-accepted solution to depression from 1960 to
1990. The World Health Organization officially endorsed imipramine as its antidepressant.
 The author points out that the first antidepressants, despite the controversies, were discovered using observation and
somewhat unscientific trial and error experimentation. Contrast that to the careful construction of Prozac and the
rigorous double-blind randomized placebo-controlled trials used for scientific verification of results today. Today, it is
more about the data than the ability of researchers to market their results through charisma.
Week 10a Greenslit, Healy (179-224)
Greenslit Reading:
Prozac marketed as antidepressant, Sarafem marketed as treatment for Premenstrual Dysphoric Disorder (PMDD),
manufactured by same drug company, same active ingredient, different packaging
Rebranding – product of DTC
- different colors for medicine to prevent “symbolic mistakes”
Sarafem not antidepressant – not because of chemical makeup but because of its brand
Branding drugs differently sustains conceptual apartness of different illnesses
Controversy over DTC and Sarafem
- Empowering consumers or tricking them by not giving them complete information?
DSM – put under “needing further research”
Arguments about PMDD:
- negative view of women’s physiology
- bad medicine to deny women effective treatment because culture has negative views of female physiology
Sarafem put on market around time genetic fluoxetine infringed on Prozac’s market
Was PMDD created to market Sarafem? Or is Sarafem just a name for the Prozac women are already taking to treat PMDD?
Women – may change relationship to same drug, rather than being prescribed a new drug
Politics, not science, translate debates over Sarafem marketing
Boundary disputes – gynecology vs. psychiatry
DTC makes drugs more than chemicals – texts to be consumed socially, culturally, and personally
Twisted Thoughts and Twisted Molecules: Healy
Discovery of LSD contributed to 2 ideas:
Notion of the receptor: small concentrations of LSD produced large effects
Transmethylation hypothesis as the cause of schizophrenia
Transmethylation Hypothesis: instabilities of the methylation process of metabolites may contribute to schizophrenia
- proposed a mechanism as the source of the clinical features of psychosis and schizophrenia
- has yet to be further researched
1963: dopamine hypothesis of schizophrenia
- argued backwards from the efficacy of treatment to what may be the cause of the disorder
- used by the pharmaceutical industry to sell drugs
LSD – perceived as agent of counter-culture which alarmed political establishment, experiments using LSD required strict
oversight due to possible use by military
Transmethylation hypothesis swept away with LSD experiments in psychiatry
Receptors and neurotransmitters discovered in the brain:
Dopamine Receptor Hypothesis of Schizophrenia
Discovery of opiate receptors – meant there are naturally occurring opioids in the body
Dopamine receptor hypothesis – common language for psychiatry and pharmaceutical industry, advertising power of industry
to support mainstream psychiatry 70s
Research on other receptors done
2 views of science:
- evolves by theories checked by experiments (transmethylation)
- evolves when there are new technological developments (dopamine receptor hypothesis)
- this requires pharmaceutical companies to produce compounds and establish how they work
Companies – businesses – happy if compounds reveal things about human nature, but if compounds do not sell or are proven
to treat a specific disease that occurs with sufficient frequency in community to warrant its production
Drugs would not be developed if has marginal clinical utility or unfavorable political profile
Week 10b
Week 10bDain, Szasz reading
Dain. Critics and Dissenters: Reflections on ‘Antipsychiatry’ in the United States
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Hostility to psychology actually predates its establishment as a profession in 1844
The novel aspect of it, however, is the organization of ex-mental patients themselves
During the past three decades, a number of forces – religious, legal, scientific and intellectual developments, internal
contradictions, new approaches to patient care and mental disorder, and the rise of a new social activism and the
patients’ rights movement – converged to place psychiatry on the defensive
The new psychiatry was problematical for two powerful social institutions, the church (transformed sin and crime into
insanity) and the legal system (bad, punishable behavior was curable and transient)
Psychiatrists claimed that mental hospital patients could, if motivated, be brought to exercise some control over their
actions and were therefore partly responsible agents. On the other hand, prominent psychiatrists maintained in legal
proceedings that the mere fact of a defendant being declared insane should free him or her from responsibility
(claiming their inability to know right from wrong was at fault) - Contradiction
In the 1920s and 1930s practice in private offices and then also in community agencies became more attractive and
more lucrative than practice in hospitals where conditions discouraged physicians who wanted to work effectively and
build careers
20th century psychiatry, Freud included, continued to believe in an ultimately physical etiology of insanity while their
practice, in the absence of proof of such etiology and of some potent somatic therapies, stressed nonsomatic elements
– Contradiction
Move to private offices: 20th c. tendency of psychiatry to abandon the “psychotic” hospital patient in favor of treating
less disturbed people, a trend further confirmed by the rise of new community mental health centers
Mass deinstitutionalization of the 1960s and 70s was the conviction that community mental health centers would
serve as inexpensive yet more effective alternatives to mental hospitals
The expatient movement is the newest and most interesting component of recent anti-psychiatry manifestations. Until
now very few would have the courage to tell their stories publicly or openly confront psychiatry
Failure to cultivate and involve a deeply, personally interested constituency characterized all reform efforts until our
own day. Movements appealed for support not from the victims of mental disorder/hospitals but from elite groups in
positions of power or having access to those in power.
A good deal of attention was given to physical mistreatment (electroshock, lobotomy, chemotherapy). One argument
against it was that the heavy reliance on chemicals would continue to produce drug-induced disorders in patients
Voluntarism vs. involuntary commitment: voluntarism inhibits the formulation of programs to reach all mentally
troubled people, which means that only those who seek help will get it – HUGE shortcoming, left out the chronically
ill, the criminally insane, and the mentally ill who had been transmitted out of the hospitals
In 1985 an APA conference constituted official recognition of the challenge presented by the ex-patient movement
State legislatures and the courts have made it much more difficult to hospitalize involuntarily any but the so called
dangerous mentally ill, and the courts, responding to arguments on behalf of patient rights, have upheld restrictions on
both involuntary commitment and involuntary treatment
The Szaszian critique of psychiatry is the imposition of an erroneous concept of illness and treatment upon misfits
that serves to justify neglect and impoverishment in the name of freedom and self-reliance. Fear of the unwarranted
power of psychiatry
Szasz. The Myth of Mental Illness
 When a person claims to be ill, he usually means firstly that he suffers from an abnormality or malfunctioning of his
body and, secondly, that he wants or is at least willing to accept medical help for it – this does not work with
psychiatry
 While medical diagnoses are the names of genuine diseases, psychiatric diagnoses are stigmatizing labels
 Szasz’s Thesis: Mental illness is a myth, psychiatric intervention is a type of social action, and involuntary
psychiatric therapy is not treatment but torture
 Psychiatry as a pseudo-science like astrology, “only talking,” points to the unbridgeable gap between what most
psychotherapists/analysts do in practice and what they say about it
 We remain shackled to a scientifically outmoded conceptual framework and its terminology
 Prediction is a legitimate concern of psychiatry
 Historicism: a doctrine according to which historical prediction is essentially no different from physical prediction.
Historical events are viewed as fully determined by their antecedents.
 The failure of historicism is that the prediction of a social event itself may cause it to occur or lead to its prevention
(self-fulfilling prophecy)
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The paradox that is psychoanalysis: consisting on the one hand of a historicist theory and on the other of an antihistoricist theory
Week 11a
* TUESDAY April 25th *
Laing, R.D.: The Politics of Experience (pp. 100 – 130 Sourcebook II)
Chapter 5. The Schizophrenic Experience
Main Key Terms:
(1): R.D. Laing – Scottish psychiatrist noted for his views on the experience of schizophrenia/psychosis, influenced by
existential philosophy, which went against the psychiatric orthodoxy of the time (60s) by taking the expressions/experiences
of the patient as representing valid reality rather than some separate disorder.
(2): double-bind – (Bateson) refers to the communication paradox described in families with a schizophrenic member. The
victim of the double-bind receives contradictory emotional messages; no metacommunication is possible; the victim cannot
leave the communication field (family); failing to fulfill the contradictory injunctions is punished; double-bind was first
described as part of the etiology of schizophrenia
*(Laing’s main point: schizophrenia is a natural ‘trip’ that should be embraced and a journey into an inner world that
therapists/families try to stop and frustrate)
*(Laing is writing in the 1960s):
>Begins with a dialogue between 2 schizophrenics > we may ask why do these people have to be so incomprehensible?
>Most psychiatrists believe that people they call ‘schizophrenic’ suffer from an inherited predisposition to behave
incomprehensibly, due to some unknown genetic factor.
In general interactions between patient and doctor, the psychiatrist as ipso facto (by the very fact is) sane, shows that the
patient is out of contact with him; the fact that he (the doctor) is out of contact with the patient shows that there is something
wrong with the patient, but not the psychiatrist.
>The process of therapy, the encounter between the schizophrenic patient and doctor, consists of the patient abandoning his
‘false subjective perspectives’ for the therapist’s objective ones > the essence is that the therapist understands what is going on
and the patient does not (Laing is criticizing this process of devaluing the schizophrenic’s experience).
>The research of Erving Goffman (who developed the idea of ‘total institutions’ which supported Michel Foucault’s theories)
is mentioned here; Goffman spent 1 year as an assistant physical therapist in a mental hospital fraternizing with patients in a
way that upper staff could not; he observed the following > that no clearcut line can be drawn between normal people and
mental patients – ‘a community is a community’; a large part of his thoughts detail how a person, in being put into the role of
patient, tends to become defined as nonagent, as a nonresponsible object, and begins to regard himself in this way (the
connection here with Foucault, total institutions and schizophrenics as nonagents).
>Laing moves to the ‘double-bind’ hypothesis whose chief architect was Gregory Bateson > under the double-bind theory
(1956), schizophrenics suffer under a ‘can’t win’ situation of paradoxical internal communication patterns specific to the
family of the schizophrenic, destructive to the self-identity of the patient > he cannot make a move, or make no move,
without being beset by contradictory pressures and demands, pushes and pulls, both internally from himself, and externally
from those around him; he is in position of checkmate.
>The position of ‘double-bind’ as described by Laing is impossible to see by studying the different people in it singly; the
social system, not single individuals extrapolated from it, must be the object of study.
>Laing begins to get closer to his main point (that schizophrenia is a journey to be embraced, a sort of 60s “trip”) in stating
that schizophrenia is merely a label, and schizophrenics are the behavioral expressions of an experiential drama > but
therapists see this drama in a distorted form that their efforts distort even further; the outcome is the frustration of what Laing
considers a ‘natural’ process, that psychiatrists do not allow to happen, i.e. schizophrenic behavior is put to a stop and not
allowed its natural expression.
>Laing tries to characterize the sequence of events of the subjective experience that splits us between ‘inner’ and ‘outer’
worlds, where the schizophrenic finds himself lost in the ‘inner’ one; Laing says we are alienated from both worlds but
perhaps are more knowledgeable of the outer world; when the “fabric of reality bursts” (the schizophrenic’s first episode
occurs) and one falls into the inner world, one is considered pathological by others, according to Laing, they are also lost and
to try to retain their bearings they often happen to compound their confusion by applying inner meanings to the outer world
(thus, the very strange talk that comes from schizophrenics) and introjections (importing outer categories into the inner).
>Laing defends the voyage of the schizophrenic by arguing that we as humans honor and admire the journeys of Columbus,
the mountain climber of Mount Everest and do not consider them pathological, so why do we consider the journeyer, the
schizophrenic pathological too?
>Laing believes that the journey into schizophrenia is healing process, which we degrade, a ceremonial process in fact; what
our society needs is a ceremonial initiation process through which the person will be guided with full social support into the
inner world > psychiatrically, this would appear as ex-patients helping future patients go mad.
>This process would entail:
 a voyage from outer to inner
 from life to a kind of death
 from going forward to going back
 from outside to back into the womb
and the return voyage would be the exact opposite of the above (a voyage of inner to outer, etc.); but ending with an
existential rebirth (as Laing is coming from an existential background)
>Laing believes this could occur in a ‘truly sane’ society
*TUESDAY April 25th*
Showalter, Elaine: Women, Madness and the Family: R.D. Laing and the Culture of Anti-Psychiatry (pp. 220-247 Sourcebook
II)
Main Key Terms:
(1): R.D. Laing -- Scottish psychiatrist noted for his views on the experience of schizophrenia/psychosis, influenced by
existential philosophy, which went against the psychiatric orthodoxy of the time (60s) by taking the expressions/experiences
of the patient as representing valid reality rather than some separate disorder; the movement of anti-psychiatry.
(2): Anti-Psychiatry – refers to approaches that fundamentally challenge the practice of mainstream psychiatry and criticizes it
as using medical concepts and tools inappropriately, by treating patients against their will, is over dominant, etc. Believes in
placing emphasis on the social context of mental illness.
>R.D. Laing writes Sanity, Madness, and the Family (1964) which chronicles and studies 11 cases of women who had not had
brain surgery, were chronic schizophrenics, and had not received more than 150 ECT treatments; these dramatized female
plots demonstrated that the signs and symptoms of schizophrenia could be caused by the patient’s unlivable situation in the
home and primarily the mother’s attacks on the patient’s attempts at independence; these failed struggles of sick women to
free themselves from ‘puritanism’ and ‘hypocrisy’ was only an exaggeration faced by normal women everywhere, not just
schizophrenics, as the story of their own lives – the book struck a chord.
>’Anti-psychiatry’ (coined by David Cooper, a colleague of Laing’s) was the name of the new movement, and was connected
with an attack on psychiatric power in institutions, on the hierarchical authority structure in doctor-patient relationships, on
psychosurgery and shock treatments; anti-psychiatry was an attempt to reverse the rules of the ‘psychiatric game’, countering
medical power as embodied in the diagnosis with ‘attentive non-interference’; according to the new anti-psychiatrists, mental
illness had to be examined in terms of social contexts: emotional dynamics of the family and the institution of psychiatry
itself.
>London became the Vienna of the 1960s, the place of the anti-psychiatry movement.
>For women, anti-psychiatry offered new ways of conceptualizing the relationship between madness & femininity; Laingian
theory interpreted female schizophrenia as the product of women’s repression and oppression within the family.
>Schizophrenia could be seen as a protest against the female role; Laingian therapy not only listened to women’s words (as
Freudian psychoanalysis had done) but also to her social circumstances.
>In his 2nd book The Politics of Experience (1967) (which was released the same year at the Beatles’ Sergeant Pepper’s
Lonely Hearts Club Band – indicative of the times), Laing argues that schizophrenia, far from being a form of mental illness,
is a form of insight and prophecy; that in a generally supportive environment, the schizophrenic would pass through the acute
phase of his ‘journey’; this concept had many sources: shamanism and initiation rituals, hallucinogenic drug experiences, and
the 60s fascination with “trips”.
>The author of this article relates a few female case studies where Laing fails to make the feminist connection (e.g. female
oppression, anger towards husband), but rather is more interested in existential topics and applying them towards his patients,
leaving theses patients unheard.
>The author of the article then continues to point out that many times, Laingian models fail to make connections between
schizophrenic women/femininity and anti-psychiatry; that over and over again, Laing’s women are modern day Ophelias and
Cassandras, the women of anti-psychiatry whose voices are in fact silenced and whose cases become interchangeable rather
than unique.
>The successes of anti-psychiatry did not last past the 1960s.
>Eventually Laing became anti-Laingian in the 1970s, separating from left-wing politics, drugs, mysticism, attacks on the
family, even ati-psychiatry, admitting he “never recommended madness”.
>At first, for a whole generation of women, Laing’s work was a significant validation of perceptions that had little social
support elsewhere; but in retrospect, the representations of women’s suffering by anti-psychiatry really had no coherent
analysis to offer women – it really doesn’t address itself to women’s problems.
Week 11b
Zeidner, Lisa [review of “Cuckoo’s Nest”], “Rebels Who Were More Angry Than Mad: The originality of Milos Forman lies
in his rejection of too much easy drama,” New York Times (Nov 26, 2000) pp. AR11-12
The article reviews how the timeless movie translates through the generations, as well as points out the art of its subtleties.
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The article traces the history of the making of the movie, and how it almost wasn’t made due to lack of interest.
o First a book, then a play, then a movie
o Movie producers didn’t see the appeal in a movie about an asylum; believed they wouldn’t have an audience
Became the 7th highest grossing movie ever
o More than $320 million worldwide
o Sweden ran it in theaters for 11 straight years
o Swept 5 top Oscars (including best picture)
“Continues a line of American movies celebrating the romance of rebellion” (pg. AR 11)
Article points out other successful movies with the above similar theme: i.e. “Five Easy Pieces”, “King of Hearts”,
“Rebel Without a Cause”
“Cuckoo’s Nest” became a sort of “baby-boomer counterculture bible”
What was the appeal of an “‘objective’ film about madness?”
o The movie director changed many parts of the novel to have it translate better to the screen and to audiences
 Rejected disturbing images of shock treatment; patients, although they look crazy, are not “static nut
cases”; the head nurse is not depicted in the movie as evil as she is in novel; any racist comments are
eliminated
 This also helped the movie translate across generations
“Cuckoo’s Nest” was at the same time that radical changes were being made in psychiatric treatment
Shot on location at the Oregon State Mental Hospital in Salem.
o Patients were put on payroll as assistants to the film crew
 One patient permanently lost his stutter as a result of the empowering feeling of the responsibility
“The brilliance of the film is precisely that its subtle” (pg. AR 12)
Lehmann-Haupt, Christopher, “Ken Kesey, Author of 'Cuckoo's Nest,' Who Defined the Psychedelic Era, Dies at 68,” New
York Times ( Nov 11, 2001), pg. A47
This is an article about the death of Ken Kesey, who was the author of the “Cuckoo’s Nest. It also discusses how he
was the subject of the book “The Electric Kool-Aid Acid Test,” which was about LSD and the new psychedelic era. Kesey
used to throw big parties – the so-called “Acid Tests” complete with music and strobe lights and LSD infused Kool Aid. He
would then challenge his guests “not to freak out.” Basically, he was one of the leaders of the 70s era, who “brewed the
cultural mix that permeated everything from psychedelic art to acid-rock groups.”
Kesey then volunteered to be a paid subject of new drugs that induced “psychosis.” He took a job as a night ward at a
psychiatric hospital. This was the inspiration for his book.
 He thought the patients were locked into a system that was “anything but therapeutic”
 He would write while under the influence of the drugs, and then “cut out the junk” when he became sober.
 His book was widely popular when it came out in 1962. Film was even more successful.
The rest of the article basically just follows his biography. Typical story: athletic guy, grew up and went to college in Oregon
and grad school at Stanford, moved to the hippy section of town, and started experimenting with drugs. He continued taking
LSD until the end of his life.
Week 12a
On Being Sane in Insane Places
D.L. Rosenham
- Experiment (1972) involving “pseudo-patients”, 2 parts
1) 8 healthy individual gained admission to 12 different hospitals claiming auditory hallucinations and
admitted with a diagnosis of schizophrenia
2) Told doctors and staff that there were potential imposters, 41 people were suspected, little agreement
between clinicians and staff. In reality none were imposters.
- In the first part, patients claimed to hear a voice say “empty”, “hollow” or “thud” (common existential themes). No
one was questioned about these voices.
- Once they were admitted, no one was questioned (although some of the patients were suspicious)
- Also the pseudo-patients were able to comment on behind the scene treatment (beatings, lack of attention) in the
mental hospitals
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Point of the study= suggest problems in health care system as well as diagnostic criteria. Also, suggest that the
difference between the sane and insane may depend on the situation
Criticism of Rosenhan:
- no reason to question the voices they heard
- they were also on voluntary status and able to leave whenever
Rosenhan made assumptions about staff from the point of view of the patient, no evidence from clincians
- There are also malingerers and liars in medical field, don’t deny them treatment, especially when there is no physical
diagnostic test to question the diagnosis
DSM-III and the Transformation of American Psychiatry: A History
Mitchell Wilson, M.D.
- Traces history of the development of DSM-III
- publication of DSM-III represented a shift from clinically based biopsychosocial model to a research-based medical
model
- WWII brought together different strains of psychiatric thinking.
- Two problems that hurt psychiatry’s cause:
1) Homosexuality being voted out of DSM-II embarrassed psychiatry
2) Rosenhan (1973) study
- created task force, aggregate data
- need for diagnostic criteria that were descriptive, explicit, and rule-driven so that the assessment could be done
reliably.
- Worked closely with WHO and consistent with ICD.
- Got rid of word “neurosis”= signified break with Freud and psychoanalysis, marked a new era/focus for psychiatry.
- Story of DSM-III is a story of changing power base (government census, insurance companies) and changing
knowledge base
DSM-IV
American Psychiatric Association
- Purpose= to provide helpful guide to clinical practice.
- Must provide nomenclature applicable for a wide diversity of context.
- Was the product of 13 working groups
- Coordinated efforts with ICD-10, mutual influence
- Influenced by Adolf Meyer’s psychological, social, and biological factors (introduced in DSM-I)
- Literature reviews to provide comprehensive and unbiased information and to ensure that DSM-IV reflects the best
available clinical and research literature.
- Used systematic computer searches and critical reviews done by large groups of advisors to ensure that the literature
coverage was adequate and that the interpretation of the results and justified.
- Each of the mental disorders is conceptualized “as a clinically significant behavioral or psychological syndrome or
pattern that occurs in an individual and that is associated with present distress (e.g. painful symptom) or disability (i.e.
impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death,
pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an
expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.”
- The section also provides a classification index, it might be useful to skim through it to get a feel for it but otherwise I
doubt that anything specific from the index will be asked on the test.
Week 12b
Interview with Dr. Judith Lewis Herman, field: psychology of women, child abuse and domestic violence, and posttraumatic disorders.
-Herman claims that trauma endured by children and mothers extends beyond them to victims of political torture, to war
veterans, and so on--argues people will respond in the same way to trauma weather it is political, familial, or from an
accident.
-According to DSM IV, traumatic events are those that instill a feeling of terror and helplessness. These have to be “events
outside the realm of ordinary human experience”. However, according to Herman this is not always a good differentiation,
because if you're living in a war zone or you're living in a country emerging from dictator or that's experienced dictatorship,
these are not out-of-the-ordinary experiences, unfortunately, but experiences that instill helplessness and terror. And terror
turns out to be different from fear.
-Fear is something we're biologically wired to experience when we're in danger. Fight or flight doesn't work in conditions of
terror and helplessness. So biological rewiring happens, even after the danger is over, the person continues to respond to both
specific reminders and to generally threatening situations as though this terrifying event were still occurring
- you have the hyper-activation of the fear system. You have a kind of re-experiencing of the trauma that takes the form of
flashbacks, nightmares, and so forth.
-numbing or withdrawal or symptoms of PTSD.
-So hyper-arousal, re-experiencing, numbing is the triad.
-Herman proposes that there are three elements needed to help people get over PTSD: These include providing them with a
zone of safety. Then having them remember and tell their story. And then, very importantly, they helping them reconnect with
the environment around them.
- Herman believes that there is an essential interconnection between biological, psychological, social, and political dimensions
of trauma.
“Famous psychiatrist L.R. Mosher resigns from the American Psychiatric Association in disgust”
- APA reflects, and reinforces, in word and deed, our drug dependent society.
- in his view, psychiatry has been almost completely bought out by the drug companies, psychiatrists have become the
minions of drug company promotions.
- APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation.
Influence seen because:
- drug company exhibits and industry sponsored symposia draw crowds with their various
enticements while
the serious scientific sessions are barely attended.
- Psychiatric training: the most important part of a resident curriculum is the art and
quasi-science of dealing
drugs, i.e., prescription writing.
- No longer do we seek to understand whole persons in their social contexts rather we are there to realign our patients'
neurotransmitters.
--condone and promote the widespread overuse and misuse of toxic chemicals that we know have serious long term effects:
tardive dyskinesia, tardive dementia and serious withdrawal syndromes
-biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine is a
matter of fashion, politics, connection, money.
- APA has entered into an unholy alliance with NAMI, such that the two organizations have adopted similar public belief
systems about the nature of madness.
- APA is supporting non-clients, the parents, in their wishes to be in control, via legally enforced dependency, of
their mad/bad offspring.
- NAMI, APA approval, has set out a pro-neuroleptic drug and easy commitmentinstitutionalization agenda
that violates the civil rights of their offspring.
- “psychiatry of oppression and social control”
- Biologically based brain diseases are convenient for families and practitioners alike.
-no responsibility for problematic individuals (like syphillus as an example)
- we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real
relationships, with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers
- DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general, but no more a political than
scientific document.
- DSM IV has become a bible and a money making best seller
- confines and defines practice, but it isn’t factually accurate because there are no
external validating criteria
for psychiatric diagnoses. There is neither a blood test nor
specific anatomic lesions for any major psychiatric disorder.
- APA has bought into a theoretical hoax. Is psychiatry a hoax, as practiced today?
Recommends to APA for the future:
1.. let us be ourselves. Stop taking on unholy alliances without the members' permission.
2.. Get real about science, politics and money. Label each for what it is - that is, be honest.
3.. Get out of bed with NAMI and the drug companies. APA should align itself with the true consumer groups, i. e., the expatients, psychiatric survivors etc.
4.. Talk to the membership; I can't be alone in my views.
- We seem to have forgotten a basic principle: the need to be patient/client/consumer satisfaction oriented
Are Psychiatrists Betraying Their Patients?
- Mosher’s “unholy alliance" between psychiatrists and drug companies?
- substantial number of cases of misdiagnosis and fraud support his view that patient care may be in jeopardy.
- not everyone agrees: Frederick Goodwin, counters that volumes of research and thousands of real-life stories long ago
confirmed the value of prescription drugs for psychological problems.
"I Want No Part of It Anymore" Loren R. Mosher, M.D.
- conducted a controversial study: where newly diagnosed schizophrenic patients lived medication-free with a young,
nonprofessional staff trained to listen to and understand them and provide companionship. The idea was that schizophrenia
can often be overcome with the help of meaningful relationships, rather than with drugs: Over the initial six weeks, patients
recovered as quickly as those treated with medication in hospitals.
- but project lost its funding and the facility was closed, also faced an investigation into his behavior as chief of the National
Institute of Mental Health's Center for Studies of Schizophrenia and was excluded from prestigious academic events.
- By 1980 removed from his post altogether because of his strong stand against the overuse of medication and disregard for
drug-free, psychological interventions to treat disorders
- the doctors-for-hire tell only half the story: Prozac and its successor antidepressants cause sexual dysfunction in as many as
70% of people taking them
- press is catching on to how pharmaceutical companies use cash incentives to encourage doctors to prescribe their drugs
- Columbia University has been cashing in: Office of Clinical Trials generates about $10 million a year testing new
medications--much of which is granted to the Columbia Psychiatric Institute for implementing these tests.
- The director of the institute was being paid $140,000 a year by various drug companies to tour the country
promoting their drugs.
.- practices aggressively promote reliance on prescription drug use -- so much so that many people think drugs should be
forced on those who refuse to take them.
- The APA supports the National Alliance for the Mentally Ill, which believes that mentally ill patients should be coerced to
take medication.
The Other Side:
"Safe and Effective Drugs Have Improved the Lives of Millions”
A Response by Frederick Goodwin, M.D, former director of National Institute of Mental Health.
- availability of safe and effective psychoactive drugs has dramatically improved the lives of millions of individuals with
major mental disorders such as schizophrenia, bipolar illness, clinical depression, obsessive-compulsive disorder and panic
disorder.
- the overwhelming majority of mental health professionals know that effective medication makes it possible for psychosocial
interventions to work
- It is now so well-established that illnesses such as schizophrenia and bipolar disorder generally require medication, that
many countries no longer allow a placebo group in clinical trials
- is effective:
- schizophrenic following treatment with a new, atypical neuroleptic drug, is able to hold a job for the first time, to
form meaningful relationships, in short, to reconnect to life
- social workers, psychologists and psychiatrists who work with the seriously mentally ill every day know from their
own experience that without medications, their patients could
not engage with them in the difficult psychological work of
recovery.
- Today small fraction of mentally ill require involuntary hospitalization because of modern medications.
- development of novel drugs will continue to be essential to improving treatment options.
- Pharmaceutical innovation depends on lively competition in the industry, adequate capitalization of what is a high-risk
business and, most importantly, a close working relationship between industry, government and academia. The procedures
and safeguards needed to ensure the integrity of this process require continued discussion
A Response by the American Psychiatric Association:
"We Advocate For the Patient and For Quality Treatment"
-James Thompson, M.D., issue of commercial influence on medical education.
- The APA has a careful review and monitoring process, sessions supported by the pharmaceutical industry at our meetings
present solid scientific information in an unbiased manner
-We control all aspects of this process: choose the topics and the speakers,
control the
logistics and
evaluation.
-These sponsored sessions represent only a small percentage of the program and are scientific and lack bias.
-Companies are charged a fee (though not "rent," as the writer indicates), much of which covers the cost of reviewing and
monitoring the presentations.
-No advertising is permitted and the company's name is mentioned as required
-APA recommends psychotherapy and other nonmedication-based treatments, and continues to recommend psychotherapy
training for residents.
- APA supports the use of a wide variety of therapeutic options geared toward the needs of the particular patient and
continues, above all, to advocate for the patient and quality treatment.
-A Response by the National Institute of Mental Health:
"The Time for Helplessness And Bitterness Is Past"
- Steven E. Hyman, M.D., is the director of the National Institute of Mental Health.
- we now have a variety of safe and effective medications and psycho-therapies for mental illnesses.
-The National Institute of Mental Health, with public funds, has overseen this quiet revolution and has funded its own studies
to make sure that the new mood stabilizers, antidepressants and antipsychotics work for Americans with mental illness.
A Response by the National Alliance for the Mentally Ill:
"All People Should Have The Right to Make Their Own Decisions"
- William Emmet is the chief operating officer of the National Alliance for the Mentally Ill.
- National Alliance for the Mentally Ill (NAMI) focuses primarily on ensuring access to adequate, appropriate treatment
within the American health care system.
- some individuals with brain disorders such as schizophrenia and bipolar disorder may at times, due to their illness, lack
insight or good judgment about their need for medical treatment.
- Involuntary treatment of any kind should be used only as a last resort and only when it is believed to be in the best interest of
the individual, following a court hearing in which due process has been provided
Listening to Prozac
Chapter 1:
This chapter sets up the rest of the book by introducing the story of a patient, Tess, who was given Prozac to treat her
depression. Tess was born into poor parents (father alcoholic, mother depression) and grew up the eldest of 10 children. She
was abused both physically and sexual as a child. Tess grew and developed a business career where she helped turn around
struggling companies by addressing issues of organization and employee moral. Tess was not a social individual, the only man
she was involved with , Jim, was a married man who eventually left Tess for his wife. She was first treated with imiramine,
the oldest available antidepressant. Tess claimed to be more comfortable. She was sleeping and eating normally. She stated “I
am better… I am myself again.” However, her psychiatrist was not satisfied. She began to have minor problems at work, and
she was still emotionally unstable (ex. bust into tears at the mention of Jim’s name). Psychiatrist decided to put her on Prozac.
She responded well, more energetic and happy. She developed a strong social life, going out on three days each weekend. Her
work became more satisfying and she was more confident.
Tess went off the medication after 9 months and she continued to do well, until 8 months after going off the meds. She
was slipping and said, “I am not myself.” She felt that she needed the medicine to help her achieve high levels of success. The
psychiatrist felt torn: should he give prozac to someone who is not depressed? The rest of the chapter goes on to talk about
using prozac to alter personality and what that means for society. The question of whether of not a drug should make global
effects versus small effects is raised. The term “cosmetic psychopharmacology” is introduced to describe patients who take
drugs, but lack the symptoms of the disease in order to achieve desired personality effects.
Chapter 2:
The case of Julia is discussed. Julia suffers from being “a perfectionist” but she does not have enough of the symptoms of
OCD to receive a diagnosis. She has a personality disorder that affects her marriage, relationship with her children and her
daily life. Her psychiatrist prescribed her prozac, which reports to be effective in treating OCD. The first week on the
medicine, Julia reported was like “day and night.” The children behaved, her husband cooperative, and she had more energy.
However, the euphoria wore off, however she remained moderately improved as compared to her state before prozac. Her
dose was raised, and she reported steady modest improvement in her mood and ability to tolerate messiness. There were ups
and downs, where some weeks Julia reported having been nervous with her children and yelling excessively. These were often
linked with stressors. Overall Julia felt as though her life had been transformed. She was even planning on getting a dog. She
started working out of the home and taking jobs that were more challenging.
They lowered the dose of medicine and two weeks later, Julia called in to say she fell back into her normal routine and
personality. After 3 weeks, she resumed taking the higher dose. Within 5 weeks she was feeling better, and “almost there
again.” She went out of her way to show her psychiatrist that she was much better on prozac. Her husband fully supported her
taking prozac.
The social worker that Julia was seeing felt that the prozac solved Julia’s problems by making her more assertive.
Although the drugs had accomplished what psychotherapy could not (improved family dynamics) this change came about
without any increased self-knowledge on Julia’s part.
Question raised about whether or not Julia had OCD. Julia heard about psychiatrist in a magazine article about Tess. She
related with her because Tess was hard-working and paid attention to detail. Two different pathways to take:
1. stretch the scope of illness to encompass character traits.
2. say we have found a medication that can affect personality, perhaps in even in
the absence
of illness.
Either way is edging toward “medicalization of personality.”
Chapter goes on to discuss whether or not Tess and Julia were truly suffering from disease. (pg. 42 discusses the
history of diagnostic categories) Lithium started the trend that medication response can determine diagnosis. The thrust of
biological psychiatry has been to bolster the discrete-disease model of mental deviance and to undermine the spectrum
concept.
Chapter 9:
Debate about prozac started by Robert Aranow
- Challenged colleagues to consider the ethical implications of “mood brighteners”: brighten mood of those who are down, but
not clinically depressed. Furthered this by addressing “conservation of mood.” Elevated moods result in a crash- no shortcuts
to happiness
Response by Richard Schwartz: suggested that mood brighteners interfere with a person’s relationship to reality in a
way that traditional antidepressants do not. Schwartz focuses on the result, not the means of the treatment.
- central idea of “affect tolerance:” to stand to feel what you feel. Contribution of Elizabeth Zetzel; considered the capacity
for emotional growth to be grounded in the capacity to bear anxiety and depression. A mood brightener fails to induce the
capacity to bear depression, and stunts emotional growth
- mood brighteners have the ability to reinforce oppressive cultural expectations
Response by Randolph Nesse: criticized mood brighteners from the viewpoint of evolutionary biology: negative
feelings may not but signs of family or developmental dysfunction bit of adaptive mechanisms appropriate to a different
environment, presumably mankind’s hunter-gatherer phase. This point of view can be a relief to patients.
Response by Mark Sullivan: suggests “autonomy” as a way to test the risk benefit. Ask whether it promotes or retards
a person’s capacity to run his or her own life. Takes into consideration the question of addiction.
Arguments by Kramer: Inherent abstract concept “mood brighteners” which fails to take into account the
characteristics of any actual drug that might affect an actual brain. But Prozac does something different: it lends people
courage and allows them to choose life’s ordinarily risky undertakings.
Response to Schwartz: Prozac starts the precondition for tragedy, namely participation. Does not rob life of the edifying
potential for tragedy. “Affect tolerance” is ambiguous – allows for more profundity of feeling and for more resilience
Response to Zetzel: What happens to people in psychotherapy in similar to what happens when they take prozac. They are
more experience-tolerant, not better at tolerating the most excruciating emotions.
Schwartz’s argument has has been called pharmacological Calvinism: cure by pill is seen as dehumanizing when
compared with psychotherapy.
Both Schwartz and Nesse worry about the capacity of medication to diminish a person’s experience of sadness. Prozac
raises an alternative possibility; a mood brightener that moves people form one common human state to another.
Should we use drugs for pleasure?
Brock’s property of conscious experience theory: engage in actions for the pleasure they bring. Drugs not only give
pleasure, but enhance it. Prozac is different- it induces pleasure in part by freeing people to enjoy activities that are social and
productive. It does so without being experiences as pleasurable in itself and without inducing distortions of people.
Prozac is not a cause of up or down, but of same or other. Has the power to transform the whole person, illness and
temperament. When you take it, you risk widespread change. Because of this, Prozac seems to create two different
personalities.
-Prozac highlights our culture’s preference for certain personality types. (i.e “curing” women of traditional passive feminine
traits)
-The concern Prozac raises regarding social coercion to take on new personalities (ex. steroids and athletes, and breast job and
female fashion models).
- Walter Percy’s concerns over Heavy Sodium: objects to technological attenuation of ordinary suffering, thinks it is tied to
production of art, give insight
- but “wounds of most artists are mild” and no evidence that drugs decrease or stifle creativity
- Percy says guilt and self-consciousness, and sadness are important signals of whats wrong with us, links us to awareness of
original sin
- psychoanalysis: to lose pain without quest or struggle is to lose the self
- drug is somehow morally wrong—“medical theological damnation” for takers
- to Percy, patient who is anxious and troubled has an authentic existence, more than those that are complacent and
tranquilized, to take drugs is a form of pretending
-but for the highly afflicted, it restores the self!
- descriptive psychiatry—diagnosis centered psychiatry, that traces its roots to Kraeplin’s differentiation of schizo from
manic-depression, and had changed in response to observation that patients with differing conditions respond to same
medications
- different diseases responding to same meds presents problem to descriptive psych…so many syndromes, how to
categorize or group together?
- return of “neurosis”?—disorder encompassing effects of heredity and trauma, risk and stress
- ideal modern psychiatrist will understand drugs and help patients grow in self-understanding
- Prozac can be negative, makes some feel phony
- psychotherapy as most helpful technology for treatment of minor depression and anxiety
- “compulsion is a basis for moral action”—perhaps diminishing pain cal dull the soul
- our cultures preference for stimulation over contemplation
- Prozac’s moral consequence: changes sort of evidence we attend to, changes sense of constraints on human behavior,
changing the observing self
Rothman, David. Shiny Happy People: The problem with “cosmetic psychopharmacology. The New Republic.
February 14, 1994.
Rothman criticizes Peter Kramer, the writer of Listening to Prozac, for promoting and practicing cosmetic
psychopharmacology. Prozac was first put on the market in 1987 as an anti-depressant. Between 1980 and 1989 there was an
over 50% increase in anti-depressant prescriptions, which can be mostly attributed to Prozac.
Kramer embraces cosmetic psychopharmacology. Kramer confesses that many of his patients on Prozac are not ill by
standard psychiatric classifications.
The reason why physicians are so eager to prescribe Prozac is because it is the first anti-depressant and mood
elevating drug that demonstrated efficacy with low side effects. Physicians assume that since the drug seems to be safe, then it
is safe. Side effects occur in 20-30% of patients and include nausea and diarrhea, and sometimes sexual dysfunction. These
however are outweighed by the effect of restoring confidence, improving self-image, and raising energy that the drug brings
as well as social benefits.
Rothman also has a problem with Kramer’s claim that the drug restores patients to “their original, biological self.
However, Rothman claims that we don’t have the means to distinguish between our biological selves and our social selves.
Rothman also thinks that Prozac is too fast acting (2-3 weeks compared to years of psychotherapy), does not depend on
patient insight, and brings benefits that are not “earned”.
Phrase “cosmetic pharmacology” implies a gender bias towards women. Two thirds of psychiatric/depressed patients
are women. He hints that cultural norms of the society probably play a more important role than the biology. Kramer argues
that the drug is liberating and empowering. However, feminists would criticize Prozac as a drug that enforces societal values
on women. As a result, Prozac can be seen as a male-gendered drug.
WEEK 13
“Neuroscience, Genetics, and the Future of Psychiatric Diagnosis”
Steven E. Hyman
Introduction
- despite DSM, diagnosis remains problematic
o b/c primitive understanding of brain and behavior and pathophysiology of mental illness
o brain is most complex organ
- but problems not insurmountable as scientific understanding advances
Genes and Environment
- some diseases (e.g. schizophrenia, ADHD, alcoholism) known to be genetic
- twin studies show heredity
- Single gene Mendelian inheritance
o Rare, only a few disorders (e.g. Rett’s disorder, early-onset Alzheimer’s)
- Most disorders are complex genetic traits – multiple genes
o Environment also factors involved
o Neural plasticity
 brain not genes proximate to control behavior
 dependent on neural circuits
 shaped by gene-envir interactions over lifetime
o risk of common illness is not from deleterious mutations producing defective protein but from common
genetic variants
- mental disorders represent quantitative phenotypes (continuum)
- sharp cut-offs for DSM disorders are arbitrary
- risk of common diseases from alleles shared across all groups of humans, so they must have already existed in
ancestral African populations
Psychiatric diagnosis
- Robins and Guze on the establishment of diagnostic validity
o Follows program of research that began w/ careful clinical description, lab studies, and clear delineation of
disorders
o Validation through longterm follow-up studies and family studies
- But Robines and Guze don’t converge on valid diagnoses
o Various reasons including shared genetic vulnerability of anxiety and mood disorders, clinical symptom
clusters that don’t breed true, eetc
- No lab markers for mental disorders except polysomnography and IQ tests
- Reliability (agreement by different raters) of DSM, but not validity (naturally right)
- DSM politically separated into two axes (science and psychoanalytical)
- Problems
o Doesn’t talk about existence of different levels of evidence for different diagnoses
o No developmental perspective across lifespan (overlap of childhood diagnoses)
o Conceptual incoherence between Axis II in DSM3, and DSM4
o Confounded symptoms and impairments
o Arbitrary thresholds of diagnosis
 Somewhat socially constructed
- Need to remove biological-psychological splits
- Danger of separating Axis I and II in preserving different practice patterns
Conclusion
- purposes of classification
o research, communication, clinical utility, calculation of disease burden, forensic purposes, access to benefits,
reimbursement for provides
o may conflict
- should not change diagnostic criteria too much
o may change apparent prevalence of disorders
o confound family and longitudinal studies
o alter treatment development by regulatory agencies (FDA)
o require expensive changes in forms and records for reimbursement
Themes: classification, role of biology, conception of mental illness
DSM IV Entries
The general layout of an entry for each disorder is:
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Diagnostic features
Subtypes
Recording Procedures
Associated Features and Disorders
Specific Culture, Age, and Gender Features
Prevalence
Course
Familial Pattern
Differential Diagnosis
Finally, a chart with diagnostic criteria neatly laid out
Besides some familiarity with how the DSM is laid out (above), we are not expected to know the actual details listed in each
disorder’s entry. Nonetheless, some short descriptions from the “diagnostic features” for each disorder are given below so
that we’re all at least familiar with the disorders in this reading:
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Attention-Deficit/Hyperactivity Disorder: “The essential feature of Attention-Deficit/Hyperactivity Disorder is a
persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically
observed in individuals at a comparable level of development.”
Major Depressive Disorder: “The essential feature of Major Depressive Disorder is a clinical course that is
characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic
Episodes.”
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Borderline Personality Disorder: “The essential feature of Borderline Personality Disorder is a pervasive pattern of
instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early
adulthood and is present in a variety of contexts.”
Key term:
Differential diagnosis: Determination of which one of two or more diseases with similar symptoms is the one from which the
patient is suffering.
LECTURES
Lecture, Feb 2: The intro lecture. Getting oriented
This was the first lecture, so there wasn’t much substantive stuff in it.
Questions we ask when studying hist of psych… Why do we care? Why does this history keep getting rewritten?
Containing Madness
Institutions- madhouses, asylums, mental hospitals
Science of Madness
Moralizing biology, racism
-Evolution + degeneration- ideas of “primitive people” – gender, racial, age issues
-hysteria, late 19th c.- 1. psychoanalysis, unconscious
2. psychiatry and war
3. psychiatry in dialogue with mainstream madness/germ theory
a. paralysis -> syphilis of the brain (bacterial)
ii. Classification of science
1. diagnostic/statistical
2. manual of mental disorders: DSM
b. Treatment of Madness
i. Treatment/mental hygiene/social work
ii. Psychopharmacology
iii. Psychoanalysis/therapeutics
c. Madness and its Discontents
i. Legitimacy
ii. Civil rights etc.
d. Madness and Medicine Today
Psychiatry is an unstable form of medicine, always changing.
e.g.- after 9/11 the psychiatric community was widely mobilized, but no such response after Pearl Harbor.
Andrea Yates – retrial 1/8/06- Reveals an unstable boundary between madness (person is not responsible) and badness
(person is responsible)
Saw the Tom Cruise and Matt Lauer video. It was pretty funny.
So why do historians of psych rewrite history?
-Up until 40 years ago, it was a celebration of the triumph over the cruel treatment of the ill. Freudian psychiatry was
dominant.
- late 1960s/70s everybody was skeptical of The Man. Was psych an instrument of
social control?
-1990s: realizing suffering/dysfunction; reinvention as a biological process; Shorter
explores modern drugs,
neuroscience, biology.
Lecture, Feb 7: Origin stories. The birth of psychiatry and of the asylum
How does psychiatry see the story of its own birth?
Fleury’s “Pinel freeing the insane painting” (1887) shows the clear contrast of liberation with earlier treatment of insane like
animals.
Madness understood before as a disease (imbalances of bodily humors). Secular-moral understanding (that is, not religious)
as a result of immorality.
Hogart’s “Bedlam” (1735) shows the Bethlehem Royal Hospital, a refuge for those who couldn’t care for themselves, mostly
dominated by mad people.
Ladies of society would come to look at the mad. It was an attraction.
Shift to public duties of what used to be private (taking care of mad family member, also undertakers)
1774 Madhouse Act- Now madhouse admissions require a “doctor’s note”, though the doctors are there to manage, not to
cure. Used lots of gadgets, chains,
bloodletting, etc.
First Hero of movement- Pinel removes the chains and frees the insane.
Psychiatry sees itself as going from Bad old medicine >> good new asylum
Second hero- William Tuke, a Quaker tea merchant who reinforces humanitarian message. Starts York Retreat, where they
use “Moral Treatment” for behavioral shaping. Mad will reform themselves because they want to impress director. They are
like little children, and the retreat is like a family.
Moral Treatment Principles: conditional kindness, regular work on the grounds, cultivation of “self-esteem”, psychological
methods if there were problems (“The Eye”)
Psychiatry wanted the birth of psychiatry to have to do with this birth of the asylum, though there’s nothing truly medical in
nature here.
Lecture 3: Th, Feb 9: The radical critics: Michel Foucault, Marxism, and new origin stories
Getting oriented: the history of psychiatry, from intellectual backwater to impassioned focus of scholarship and controversy
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1940s, 1950s – the “old-fashioned” histories – ignored
All of that changed – went from sleep, self-satisfied to edgy, hot topic
Became mainstream, rich in lessons for present day
Today: why did this happen, and what happened?
all written by psychiatrists themselves
tells self-satisfied story of psychiatry’s progress from barbarianism to rationality
Introducing the radical historians: Michel Foucault, David Rothman, Andrew Scull
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1965 Madness and Civilization – Michel Foucault
1971 The Discovery of the Asylum – David Rothman
1979 Museums of Madness – Andrew Scull
Set agenda for new way to think about history of psychiatry
Instinct to question the humanitarian and therapeutic assumptions of the old-fashioned historians; look at the birth of
psychiatry (from madhouse to asylum)
questioning whether it’s the whole story
o The new asylums: who did they really serve? Did they really look after the mad, or did they have another
function?
o Moral Treatment: what was it really for? Is it really just behavioral treatment?
o Had social agendas, not serving patients but serving society
They lived in a time where scrutinizing everything
Also “radical psychiatrists”
o Thomas Szasz
o R.D. Laing
o Questioned that psychiatry was a medical discipline: do these aberrant people actually have a disease?
Erving Goffman, Asylums: Essays ont eh Social Situation of Mental Patients and Other Inmates 1961
o “total institutions” – stripped inmates of all autonomy, civil rights, and “selfhood”
o convents, army, prisons
o most pernicious is the asylum
 the identity they create is so dehumanizing – the mad person, unreasonable
 any acts of rebellion are seen only as further evidence that you belong there
at same time, Foucault published a history of madness
o see sinister trajectory of humane treatment to the oppressive total institutions
o relevance of psychiatry’s past seemed immediate
Putting the new history in context: why was it happening?
Spotlight on Foucault
o
Background and catalysts: the personal and the political
 Madness and Civilization was his doctoral thesis – psychology and philosophy
 hovered in psychiatric hospital – not staff
 joined Communist party in 1950
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o
at first his attitude toward psychiatry was apolitical, just unease
as a young person, he had negative experience with psychiatry
he was homosexual
quotes – all his works are on basis of his own experience
1950s, Communist party experienced big shock: Lysenko affair
Trofim Lysenko – rejected LaMarcke’s theory
Plant geneticist, thought he could train grain to grow in inhospitable environments
His policies became basis of USSR agricultural policies, millions starved
People who disagreed with him were put into gulag
Lysenko taught people that you need to subject science to the same questions in society as other institutions,
science was before thought to be non-ideological
 Foucault’s Madness and Civilization was a response to Lysenko affair: power and knowledge
 “Couldn’t the interweaving of effects of power and knowledge be grasped with greater certainty in the case of a
science as ‘dubious’ as psychiatry?”
“Experiencing” Madness and Civilization: a storytelling interlude
 Starting premise: the importance for societies of having some “other” – some group of specially marked people
who serve symbolically as the antithesis of values which societies hold dear
 What if heterosexuals need the homosexuals to know that they’re okay?
 What if societies need the mad to tell them that they are sane, rational, and okay?
 What if it turned out that reason needs to create this concept of madness to know itself? It needs to dominate over
and denigrate unreason.
 The argument: I define you as such, and then damn and punish you for being what I defined you as.
 Tells history of madness from Shakespeare and Hogarth to modern times (what we did on Tuesday)
 Starts with lepers in medieval and Renaissance European society – tainted “others” – damned and unclean
 Not just public health measure – they were important b/c they served as signs of God’s wrath
 Served as antithesis of all that’s good
 Isolation decreased numbers of lepers
 Society lost the “other,” but gained the idea that a good way of marking the “other” is to lock them up
 At this time, madness roams free
 They were respected as having dangerous, sacred truths
o Shakespeare – the fool tells King Lear what nobody else dare speak
o “Ship of Fools” – alighted port to port to tell people their truths
 Enlightenment changed things – saw invention of the madhouse (rise of the new professional class)
o Foucault links rise of madhouse to the valuation of reason
o Every society to protect the value of reason needs to create the “other,” unreason
o Put unemployed, foolish, vagrants, criminals, and mad people together
o Why has reason condemned all these people?
o Foucault’s answer: all of them didn’t work – idleness was at the heart of their unreasonableness
o Put them into confinement so they could be forced to work (cultural memory of confining the
lepers)
o Era of prisons, workhouses
o Not explicitly for the mad
o But then mad became a problem in these institutions, disrupted the reform programs
o Led to further exclusion of the mad from these other kinds of people
o Birth of Madhouse – animals chained
 Rise of doctors
o Cultural memory of the lepers – fear of houses of confinement, doctors palliate this anxiety
o Pinel, Tuke – still the story of society condemning, locking up, and annihilating of its antithesis,
but it calls the annihilation as “curing”
o This is what Foucault sees as the moral treatment
o Now madness is your fault, something you can control
o Moral treatment is to persuade the mad that their truths were false, the mad’s task is to silence his
truths
o Chains took off b/c moral treatment caused the mad to internalize its madness
o Why do we still need a doctor in the house?
 Not b/c we have a new medical understanding of madness
 Doctors then had the moral authority priests used to have
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Real nature of doctor’s power has been obscured, doctor is police hidden behind medical
practices
 Transformed bodies and minds of all of us to what they tell us
 “juridicial space” – quote
even in 1998, they condemned psychiatry in the name of Foucault
After Foucault: what Rothman said, what Scull said
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Rothman
o we don’t want to say that asylums serve as social control
o asylum relieves anxiety over the loss of social control
Andrew Scull
o asylum turns out bourgeoise, capitalist workers again
Legacies and taking stock: what was this radical history (and maybe Foucault in particular) really trying to do?
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80s – step back, are these people just as biased?
Are Foucault’s facts right?
Did Ship of Fools even exist?
What was the larger point of Foucault?
He was catalytic; Foucault’s whole point was that getting your facts right can never protect you anyway from bias
The workings of knowledge and power can not be avoided
Andrew Scull – 1970s – try to reverse what the system orders us to do
February 14th Lecture
After the beginning: Visiting the 19th-century asylum
19th-Century American Asylums:
- seen as institutions of social control or humanitarian reform
- asylum directors beginning to become more concerned with the outer appearance of buildings than with diagnosing
patients
- moral architecture: majesty and tranquility of the outer appearance of asylums functioned as a form of therapy for moral
treatment. Goal was to maximally facilitate the recovery of patients through comfortable, pretty, pleasant, and cheerful
asylums.
- Kirkbride Plan: 1867 plan for the Ohio State Mental Hospital, in which the sickest patients were placed on the ground
floors, the staff lived near the center, and the best patients were placed in the top-floor wards (closer to the center). Nature
played a large role in recovery, such that male patients worked in the fields while women did domestic work as forms of
therapeutic treatment. The superintendent had absolute control of the asylum, and he hired intelligent and educated staff
members.
Thomas Kirkbride:
- one of the founders of the current APA in 1844, and one of the leading figures in asylum construction and management –
said moral architecture and moral order of asylums were the most powerful means for treatment
- reached out to patients’ families and friends to provide them with clear answers to all their questions pertaining to the
asylum
- said the more cultivated someone was, the more vulnerable he/she was to mental illness – so, mental illness did not only
affect the lower class
- regardless of Kirkbride’s vision of the ideal asylum, hospitals were overcrowded, had poor ventilation, and were vermininfested
Marketing 19th-Century Asylums:
- wanted to persuade patient families and communities that they were designed not only for the patients, but also for their
families so that the families would not have to take care of the patients
- wanted to be seen as institutions the communities should be proud of – civic pride
- one of the reasons for improving the appearance of asylums was not truly for the patients’ benefits, but to attract families
and the outside communities
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portrayed image of “madness is charming”
“Problem” of Black and Irish Patients:
- madness was not level in terms of class
- whites could not live with blacks – blacks were put in cottages behind all-white institutions
- slavery still existed at the time, so black patients usually did not receive treatment, unless their slave owners agreed to pay
for them
- after emancipation, colored asylums were built in the South (not much is known about them)
- John Galt (a VA asylum superintendent) argued that mental illness was rare among blacks because slavery acted as a
“buffer” against mental illness
- there were a large number of Irish immigrants who flooded into America as a result of the potato famine, and many of
them had mental illnesses
- many female Irish immigrants had been seduced, cheated, deluded., etc.  they became mad
Asylum Becomes Cultural Fixture
- tax dollars went to asylums, which became a reality of daily life
- the fact that asylums were beginning to dominate in the community unnerved people – where were all these crazy people
coming from?
- IRONY = if moral treatment was getting better, then why was the number of mentally ill patients increasing???
February 16th Lecture
Bad Biology: Madness as Degeneration
1880’s: Pessimism of Asylums:
- due to the unchecked growth of mental illness, people began to ask questions
- asylums lowered the social tolerance for mental illness
- moral treatment became a management tactic
- asylum doctors realize that moral treatment has failed, and treatment cannot just be about acting kind towards patients
- Degeneration theory: stemmed from 1880’s pessimism of asylums and biological, Darwinian thinking. Said that humans
were animals, and thus the dark seeds of our origins would eventually erupt, causing us to fall backwards into savagery 
madness
o those who are more primitive than others are more likely to succumb to degeneration because they never climbed
up the social ladder – thus, they have less power to stay up
o degeneracy is hereditary and worsens from one generation to the next  eventually will become sterile
Darwinian Thinking:
- humans come from lower animals, and hence, we have a fundamental instability in morals and rationality (children and
women are examples of our inner savageries)
- animals symbolize everything humans fear, yet animal origins lurk in all of us
- children are an example of our savagery since infants have outbursts like madmen
- “blood poisoning”: when virtuous women have sex with degenerate men
- Eugenics: efforts to actively eliminate degenerate “germ lines” with the purpose of secluding degenerates from the rest of
society
- asylum’s role now to seclude degenerates not because they can be cured, but to prevent them from reproducing and
worsening society --- psychiatrists act as policemen rather than doctors
Cesare Lombroso:
- believed in atavism: some people are just born with the potential to be mad based on their physical features – these people
are lazy and lack inhibition
- noted the small difference between savages and criminals
Henry Maudsley:
- noted that moral treatment had failed that that scientists were needed to do research
- 2 themes: physical basis of all mental illness (ugly and deformed features) and hereditary origins of mental weakness
(inescapable and can’t change)
- degeneration is necessary and natural – some more primitive than others and will degenerate quicker
- need to focus on diagnosis rather than treatment of illnesses, since the mentally ill cannot be cured
Lecture Feb 16
Bad Biology: Madness and Degeneration
Rise of moral treatment  larger percentage of people sent to asylums instead of cared for at home. Perception of a cure 
increase in diagnosis (like ADHD today).
1870’s, 80’s: moral treatment no longer successful for therapy, just a management tactic  father figure “superintendent”
becomes just a manager
Compassion for mentally ill fades. Rise of pessimism in psychiatry.
 return of physical restraints
Degeneration theory: a pessimistic theory for a pessimistic time
- blames the problems of disadvantaged groups on defective biology
- this defective is increasing and spreading (degeneration in place of evolution)
- this accounts for rising rates of mental illness, suicides, criminals, poverty, prostitution, perverse sexuality
The “pervert” is created as one who exhibits moral debauchery
Considered Cubism, jazz as signs of degeneracy
Nazi’s showed degenerate art so Germans could be morally warned
Degeneracy theory was a pessimistic view of the trends of 1900s
- claims to be a theory of “biology”
- pressures of modern life are bringing seeds to fruition
- price paid for modernity and boundless ambition, hard to cope
- derangement, perversity, squalidness, madness
Second half of 19th century  Darwinism threatening
- suggested fundamental instability in our capacity for moral behavior
- we come from animals, animals are beasts  are we?
- Darwin, “M notebook,” 1838
-“The Devil under form of Baboon is our grandfather.”
- Mind of man degenerate because beastly
“Savages” in Victorian imagination:
-now in colonies in Africa, India, etc.
-“clearly” came from lower animals, not as evolved as whites
- Darwin’s travel notebooks show irrational/crazy behavior of savages
- Savages illustrated our lowly origins  clearly incapable of ruling themselves
-Kipling: “White man’s burden,” “Half devil and half child.”
Children:
- lurking savagery in children as well (ex. Lord of the Flies)
-ex., if baby were more powerful, would be worse than a madman
- perhaps madmen just stay as children
Lack of development includes lower classes and women, who are considered less developed than men. They are therefore
more likely to succumb to mental illness.
“Statistical” evidence: More women and poor in asylums than rich and men
When lower classes gathered in mass became “savages.” Crowd mentality is considered savage. Ex. Storming of the Bastille
in 1789, crowd decapitated king. We consider this a response to injustice, psychiatrists considered it biologically
degenerate.
“a return to the unstable nature of their barbarous ancestors”
Motherhood:
- Women not in crowds, but have an alleged “affinity” for madness
- Motherhood is not “sweet,” it is a façade
- Childbirth brought out the crude side of women. Behavior during labor, post-partum was inculpating. Seen for the first
time b/c rise of male doctors instead of midwives at scene of childbirth. Explosions during childbirth seen as brutish.
- Religious and moral principles alone strengthen women’s minds
Degeneracy as a family affair:
- Inherited: kids worse than parents
- Upper class man who masturbates, a lower class man who drinks, all “alter” hereditary template and weaken it
-Next generation even more susceptible
- Next generate has epileptics, demented, the next has imbeciles
- Sins of the father passed on to the kids
Blood poisoning: Sex with a degenerate brings down your children
- ex. Emile Zola’s Germinal
- Good women accidentally marry degenerate men
- ex. Nazis considered Jews to be a degenerate race trying to poison Christian blood
- Count Dracula: blood poisoning
- Degenerate not because parents are immoral. Just born bad.
Cesare Lombroso: Sometimes degenerationist processes erupt for no reasons. Some are just born bad. Don’t know why.
Just know they can be identified.
- Atavists: throwback to a more primitive ancestral type.
- Can recognize them because they have physical marks
(big ears, large jaws, recessed foreheads, high cheek bones,
etc.)
Psychiatrists become policemen/detectives of degeneracy
- New role of asylum: seclusion of degenerates to cut of their germ line
- “Eugenics” – efforts to actively eliminate degenerate germ lines
Borderland: where seeds of epilepsy, imbecility begin to sprout.
February 21 Lecture: MADNESS AND THE BRAIN
This lecture outlines the beginning of psychiatry moving into the realm of science and out of moral treatment. A common
thread throughout this period is a call to science and research, using patients as case materials. This is seen in Henry
Maudsley’s hospital, which used patients as research subjects. Other medical professionals, like Silas Weir Mitchell, were
becoming upset at psychiatry’s lack of scientific principles. Visions of the brain began to take biology into effect. Phineas
Gage, whose frontal lobe was damaged in a mining accident, showed irritability and irrationality after the accident. This
provided evidence to the biological interpretation of madness. In addition, Broca and Wernicke began to link brain defects,
language, and mental illness.
This lecture links with the previous in that it sets the stage for the beginning of the end of the moral treatment era. It links
with the following in that it provides a basis for the biological interpretation of madness as a result of the study of brain
defects.
Notes:
Henry Maudsley
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Married into a family of asylum directors
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Was a proponent of degeneration theory
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Came to detest asylums
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In 1907 offered money to construct a new institution that was staffed by scientists and focuses on research and
teaching medical students
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“The Maudsley Hospital” – first alternative to the traditional asylum
Silas Weir Mitchell
 Neurologist and guest of honor at the 1894 hospital superintendents meeting
 In his speech, he attacked other superintendents for failing to act like scientists
William Griesinger and Theodor Meynert
 Started journals linking psychiatry and neurology
 Interested in brains after death
19th century visions of madness and the brain
 Still charged with elements of “moral treatment”
 “hierarchies of function” – meltdown of higher functions, vision of the brain as a pyramid
 “localization principle” - madness as a dysfunction of the frontal lobes
 Broca and Wernicke, studied speech problems
 Phineas Gage – frontal lobe damage made him irrational
February 23 Lecture: HYSTERIA: FROM CHARCOT TO FREUD
This lecture serves as an overview of the causes of hysteria. The GPI/Syphilis cause is first considered. This disease fit into
degeneration theory. The link between GPI and Syphilis was proven by von Kraft-Ebbing. Others who studied hysteria
included Charcot, who focused photographs and anatomically measurable characteristics; Bernheim suggested that hypnosis
did not work because it failed to induce biological changes; Freud believed that hysteria was folk understanding); and Breur
believed hysteria was caused by trauma.
This lecture links with the previous in that it considers GPI and hysteria from different perspectives, showing how
degeneration theory was on the way out in favor of a biological approach. This lecture links with the next in that it introduces
Freud.
Notes:
Patient with GPI
 Poster-child disease for degeneration believers
 GPI had an association with fast, loose living
 Was an archetypal degenerative disease, was progressive
 Might be a link to syphilis
Richard Freiher von Kraft-Ebbing
 Conducted an experiment transferring syphilis to patients, proved GPI/Syphilis link
 Need to look at things from a new, biological perspective
Other thoughts
 Robert Koch – many diseases have infectious roots
 Fritz Shandinn – GPI is caused by some sort of worm – madness caused by bugs in the brain
 Paul Ehrlich – treated syphilis with a drug
Hysteria
 Was something “other than it seemed”, a pseudo-disorder, attention-seeking?
o Symptoms seemed to be “strategic”, always fainted near a couch…etc
 Womb was thought to move through the body
Jean-Martin Charcot – “Napoleon of the Neuroses”
 Studied the symptoms clinically and anatomically
 Recorded objectively visible “stigmata”
 Used hypnosis as a “behavioral prod”
Sigmund Freud – “Nerve doctor”
 Higher class people go to the nerve doctor instead of the asylum
 “Neurasthemia” – exhaustion of the nerves
 Used portable electricity machines to stimulate “weak” nerves
 Offered support through listening
Hippolyte Bernheim
 Hypnosis is a state of heightened suggestibility, nothing biological going on
Josef Breuer
 Studied “Anna O.”
 Treats using hypnosis to get her to talk, could remember things linked to trauma
 Symptoms disappear after she talked about them
 Hysteria caused by traumatic memories
FEB 28th - Freud in the trenches: from hysteria to shellshock
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Theoretical nihilism has been replaced by therapy; Freud realizes hypnosis is more powerful that interpreting
dreams/free association sessions
Fought against Bruer who rejected sex theory of hysteria. Freud also suggests most sex trauma are fictitious and are
created, but they are nevertheless the root of the patients problems
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Psychosexual stages model emerges – infants go through developmental stages, and are later dysfunctional if
progression does not occur naturally
Shellshock (range of symptoms like stuttering speech, deaf, dumb, imagined immovability of limbs) emerges – name
due to incorrect initial belief that disorder was due to physical effects of nearby but not direct exploding shells
Shepard reading empathizes with these embarrassed patients who envied the honorable suffering of their physically
wounded compatriots.
Then thought to be due to weak hereditary, cowardice personality (James Farr brought to firing squad for acting
cowardly when faced with enemy) Military sought to make training and selection more rigorous and stringent
But because even officers got shellshock, military and doctors had to admit environmental trauma influence – could
be seen as a hysteria epidemic
Shellshock was Freudian in the sense of latent hidden problems causing hysteria, but many of the cases were not
related to sex (in this sense, it fit the early Freudian understand that Frued himself had moved beyond and away from)
Treatment involved psychological methods- psychoanalysis may help, but hypnosis can bring out problem if patient is
unwilling to reveal it. Also, suggestion/bad memory modification and techniques like Yealland’s instistence on
healthiness (forcing the patient to raise allegedly paralyzed arm instead of asking him) are employed.
Rivers (Army psychiatrist at Craiglockheart Army Hospital) was instructed to cure WW1 patients in the sense of
making them fit to return to battle
Pat Barker’s novel Regeneration documents Rivers and suggests that he often acted more like an instrument of control
than what a doctor is supposed to act like: a curer and improver of human lives. In a way he was silencing a voice
protesting the war by silencing the hysterics assigned to his care.
In fact, many patients created great war poems about their experiences – these poems both had a therapeutic effect and
showed the extent to which war pervaded these afflicted souls.
In the end, the best treatment was Rivers’ middle course. For some patients, a tough rejection of ailment was best.
For others, an explanation of why their cowardice was completely human and acceptable was used. He rejected both
an immediate banishment of all painful memories as well as contestant dwelling on the painful past characteristic of
some patients.
Key tensions: curing/silencing discrepancy, hysteria as sexual early memories/recent trauma, and best curative
strategies for shellshock
March 2nd - Schizophrenia, between Freud and biology
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Frued defines Nuerosis as disorders resulting from efforts by a patient to “defend” himself against becoming aware of
threatening fantasies and memories. Examples: hysteria, anxiety, narcissism, and obsessive- compulsive disorder
He defines Psychosis as when neurotic defenses break down, and the person is “overwhelmed” by the fantasies and
needs of his or her unconscious. Examples are paranoia, mania, and schizophrenia.
“Find out all about dreams, and you will have found out all about insanity.“
– John Hughlings Jackson (madness now seems not so distant for sanity…our dreams are not so different from the
experience of madness)
Case of Daniel Shreber – Freud analyzed him w/o ever meeting him. He interpreted his book and the references
within it to feminization represented Shreber’s repressed sexual urges towards his father. These urges extended
towards his doctor. His irregular father relationship leads him to find a new father figure, according to Frued, who
was God. Shreber did believe he communicated with God, and God implanted a female genital organ in him.
(Shreber was one of the first in line of patient authors - Memoirs of My Nervous Illness, 1903)
Frued’s ideas were interesting, but were not useful in the asylum. In fact, Freud did not care much for asylums and
did not focus too much on curative strategies.
Dementia Praecox – name coined by Kraeplin to cover paranoia (delusion), catatonia (stiff muscles/mental blocks
to fluidity), and hebephrenia (childlike behavior)
Kraeplin coined term after exhaustive prognosis, classification, and analysis of “patient cards” in his retreat house.
He was very systematic, and believed in a longitudinal analysis of illness. He likened himself to a detective.
Bleuler was more personal, more loving of his Swiss patients, and changed the name of Krapelin’s disorder to
schizophrenia based on the fact that many cases did not have dementia ( a progressively worsening condition) or
praecox (affliction occurring early in life)
He was said to integrated biology and Freud
The Four "A"s in Bleuler's concept of schizophrenia:
1. Association: associations among thoughts are disturbed; they are rambling, incoherent, lacking associative
connectivity, rapidly changing,
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2. Affect: emotional responses are flattened, extreme, or otherwise inappropriate.
3. Ambivalence: people hold conflicting feelings simultaneously, such as loving and hating someone at the same
time.
4. Autism: cross-checking between inner experience and outer reality is no longer effective; there is a
withdrawal into a fantasy world
Carl Gustav Jung worked under him temporarily – he came to believe the mad in a very humane life, believing the
madness to have a logic to it that if we simply tried to understand we would completely appreciate and acknowledge
similar hopes, fears, and worries within ourselves.
Lecture Notes for March 9, 14, 16
March 9, 2006 Lecture Notes
Prevention as Best Medicine: The Rise of “Mental Hygiene”
1. Moving into a new unit of the course: 20th Century
2. Mental Hygiene
a. Hygiene is on the a deliberate effort to connect its mission to another important development in mainstream
medicine, the rise of public health
i. Public hygiene program: prevent people from becoming sick in the first place, preventative form of
medicine
ii. Campaigns to encourage widespread mass vaccination of children, improve sanitary systems, get
people to wash their hands, etc.
b. “Mental hygiene is the last word in preventative medicine… Mental hygiene is primarily addressed to
preventing such failures (asylums, etc.) whenever possible.” –William White, 1917
c. Principles shaped more by the insight of Freud than the neurologists
d. For the first time in our history, a big innovation of psychiatry is being spearheaded by Americans
e. The broader context: the reformist impulses of the progressive era
i. United states emerging as a world power, and it full of plans and projects to improve life for citizens
3. Adolf Meyer: Intellectual visionary behind mental hygiene movement
a. Most influential psychiatrist of his generation
b. Swiss-born neurologist who had trained with the best of the European schools, and brought the best of
European psychiatry to American shores
i. Knew and respected the works of Kraepelin
c. “Maladjustment”
i. People lacked ability to adjust themselves to the pressures of life in the modern world
ii. Most of the cases resulted from bad habits, generally learned in early childhood
1. You can teach a person better habits
4. Meyer Setup the National committee on Mental Hygiene in 1909
a. Clifford Beers was their poster child
i. Former asylum patient
ii. Found asylum experience distressing and oppressive, and wrote a book that told public how bad
asylum system was and that it should be reformed
b. Primary focus on prevention
5. The Public Education campaign of the Mental Hygiene Movement
a. What were the messages?
i. Messages would seem Freud-like to us
ii. Talk about your feelings, fantasies, fears
iii. Conflict between parents and children is normal
iv. Emotionally stable childhood is an important foundation for mental health in adult life
b. Who were the target audiences?
i. Families, parents (importance of early childhood)
ii. Schools, young people themselves
c. What were the strategies for dissemination?
i. Mental hygiene advice literature, self-help books
ii. Radio shows, lectures, poster campaigns, film (especially after WWII)
6. Mental hygiene and the new helping professions of psychiatry
a. What happens when education isn’t enough?
b. Identify people who are showing signs of maladjustment, and direct them to psychiatrists
c. Psychiatric social work, evolved directly out of mental hygiene movement
i. Brings feminized sensibility of social work into psychiatry
ii. Raises the status of social work more broadly
d. Other: Child guidance centers, Truant officers
7. Not clear that mental hygiene kept people out of asylums
a. Mental hygiene did help to create a new sensibility of American culture that wasn’t there before
b. Psychiatry wasn’t just for mentally ill people
i. People who behave badly are really more troubled than bad, and they need therapy rather than
discipline
c. The invention of the “juvenile delinquent”
i. By the time we reached the middle decades of the 20th century, perspective of troubled kid became so
widely accepted that it served as the basis for West-Side Story: “Office Krupke”
d. Mental hygiene kicked into motion a social process that turned middle class American society into a
therapeutic society
8. The problem of the incurably maladjusted
a. What about the subset of the American population that were incurably mal-adjusted?
b. Sterilization: Try to keep them from reproducing their own kind
i. Would happen if they were diagnosed by trained psychiatrist as feeble-minded
ii. First legislation passed in 1909
iii. By 1924 more than 3,000 people had been involuntarily sterilized
iv. Carrie Buck, 1924: her mom is in asylum, she’s pregnant and sent to an asylum; evidence that the
baby daughter is sub-normal
1. Three generations of sub-normality
2. Carrie should be sterilized under new VA state law
3. Did it violate 14th Amendment?
a. She was made a test case for the constitutionality of the law – decided in favor of the
law
March 14, 2006 Lecture Notes
First Somatic Therapies: Fever and Shock
1. People in the top of the field were starting private practices and going to universities instead of to asylums
a. The tools of asylum psychiatry, 1920s: straitjackets, cell belts, chains and restraining baths
b. No one was being kept out asylums because of mental hygiene
2. 1917-1937: Four somatic therapies developed so that the first time in more than three generations the asylum can
claim that it is once again a therapeutic institution; each treatment left its own legacy
3. Introduction to the group of therapies
a. Malaria fever treatment, introduced in 1917
i. Pacemaker, treatment wasn’t hopeless
b. Insulin-coma treatment, 1927
i. First treatment for schizophrenia
ii. Reminded psychiatrists that they were doctors after all
c. Metrazol-induced convulsive treatment, 1934
d. Electroconvulsive shock treatment (ECT), introduced in 1937
i. Only one that we still use today
e. Treatments that involved subjecting patients to life-threatening treatments
4. How do we think about these histories?
a. Suggestion one: focus on process of discovery (how did these treatments come into being? What can we
learn from their origin stories?)
i. Science is not an important player in these histories
b. Suggestion two: focus on therapeutic rationales (why were the treatments developed? Why were they
embraced?)
i. Psychiatrists were operating under certain kinds of imperatives
1. What kind of liberties can I take on behalf of the patient? How desperate is the situation?
ii. Anything that holds out hope should be tried
1. Compare it with situation today of cancer treatment
c. Suggestion three: focus on outcomes (in what ways was psychiatry different after the developments of the
treatments?)
i. Did any of these treatments really have discernable effects?
1. Questions of outcome that were sociological
ii. Effect of these treatments on the doctor-patient relationship
1. Once doctors could help their patients (GPI example) they started talking about them better
and treating them better
iii. Political outcome of somatic treatments
5. Story one: malaria fever therapy
a. Person: Julius Wagner-Jauregg, 1857-1940
b. If his patients became sick with an infection, their psychosis seemed to have abated
c. GPI (general paralysis of the insanse) became his focus for trying out this hunch because GPI patients were
considered hopeless cases anyway
d. Drew blood from a shell-shock patient with malaria and injected it into the arms of patients with GPI
i. Patients who had been given the infected blood got acute malaria, and he let the disease run its course
before he gave them quinine
ii. Reported 6/9 patients for whom he gave this treatment were much better mentally, 3/9 were later at
work
iii. When injected into frontal lobes, reported success rates were 80%
e. By 1920s, American asylum psychiatrists adopted this method
f. In 1927, he received the Nobel Prize in Physiology or Medicine Treatment, only Nobel Prize awarded for
psychiatry in our time
g. Even after salvarsan, patients of GPI continued to crowd into the asylums
6. Story two: insulin coma therapy
a. Key person: Manfred Sakel; Disease: schizophrenia
b. Upshot: deemed first successful treatment ever for schizophrenia, brought a new “medical” feel to the work of
the asylum, widely used through the 1950s
c. Banting and Best, heroic discoverers of insulin, which is one of the great success stories of mainstream
modern medicine
d. Manfred Sakel (1900-1957) became interested in wider uses for insulin
i. Begins giving insulin to patients: makes the calmer, dampens their pain, prevents them from losing
weight
ii. Gave a morphine addicted actress too much and sent her into hypoglycemic shock
1. She seemed to have lost all her morphine cravings, and became a much better patient
iii. Maybe a state of conditions that for one disease had been a serious side effect could be reinvented as
a therapy for its own right
iv. Gave it to schizophrenic patients, and they demonstrated bouts of lucidity that we hadn’t seen in years
7. Story three: convulsive shock therapy
a. Story in two parts
b. Begins with Ladislas Meduna, 1896-1964
i. Theory that epilepsy and schizophrenia were diseases that existed in an antagonistic relationship to
each other
ii. Concluded that metrazol was the best
1. Reported fantastic results
2. Cheaper and faster than ICT
iii. Problem with metrazol was that it was also dangerous
1. Convulsions were so severe that they produced spinal fracture
c. Ugo Cerletti, 1877-1963
i. Switch from chemical means to an electrical means
ii. Modeled on technologies that he saw being used in slaughterhouses for pigs
March 16, 2006 Lecture Notes
Frontal Lobotomies (psychosurgery)
1. ECT: the rest of the story
a. The treatment that ECT was meant to replace was sidelined quickly
b. Bring ECT into the routinized techniques, joining ICT in the small arsenal of treatments psychiatrists could
give to their patients
c. Invented as a treatment for schizophrenia, but turned into treatment for depression
d. Used as a treatment of last resort, often in conjunction with psychotherapy
e. ECT is the only treatment of this era of somatic treatments that is still in use today
2. Frontal Lobotomies: changing the brain through surgery
a. Performed to bring about psychological changes in the patient
i. Psychosurgery as opposed to neurosurgery
b. Tempting to cast it as an aberrant chapter in the history of psychiatry, but it was supported by some of the
most prestigious psychiatrists
3. Stage-setting
a. Theodor Meynert wrote a Clinical Treatise on Diseases of the Forebrain [frontal lobes], 1884
b. Evolution of understanding of our brain after WWI
i. Machine gun: lots of soldiers with discrete bullet wounds in brain
c. Neurologists reported that patients who suffered damage to the frontal lobe area also suffered cognitive
deficits
d. Surgeons now feel capable of operating on the brain
e. Surgeons realized that operating on the frontal lobes was not a straightforward matter
i. Cost-benefit analysis when doing frontal lobe surgery
f. A new site: the animal laboratory in the 1920s, 1930s
4. A chimpanzee named “Becky”
a. An experimental animal who changes the course of psychiatric history and leads to the rise in psychosurgery
b. “The face that lopped 10,000 lobes.”
c. Story begins in 1935 at a conference on the functions of the frontal lobe that include a presentation by John
Fulton and Carly (?)
i. Delayed Response Test
1. After removing large parts of the frontal lobe area, the chimpanzees could no longer
remember where treat was
d. Before the operation, Becky had been a difficult chimp to handle, afterwards it seemed like she had joined a
happiness cult
e. Egas Moniz, a portugese
i. Thought there might be a foundation for introducing a surgical treatment to the repertoire of
psychiatry treatments
ii. Moniz decides not to do any experiments on animals
iii. Chose patients who suffered from anxiety, and who he thought would benefit from Becky-style peace
of mind
iv. Drill two holes in the skulls of his patients and inject alcohol that would kill the nerve tissue where it
was injected
v. The leucotomoe: showing the retracting wire loop used to cute the “core”
1. Called a prefrontal leucotomy
2. Thought he was damaging the white matter of the brain
f. Walter Freeman got his hands on a copy of the monogram from Moniz that explained the operation, and
followed Moniz’s work in 1935-1936
g. Mrs. A. H.
i. Before: Frantic nervous housewife, anxious about growing old, mental breakdowns
ii. After: none of her old fears, doesn’t remember what she was afraid of, husband thought she was more
normal than she had ever been
h. Standard Freeman-Watts lobotomy procedure
i. Instead of carving cores, you insert a knife into an area of the brain so that it severs the connection
between the frontal lobe area and the thalamus
1. Sever communication link between frontal lobes and thalamus, known as the emotional
center
i. In the beginning, Freeman, like Moniz, did not operate on schizophrenics
i. Didn’t think it should be used on the truly insane, but he begins to change his mind with
consequences that are quite significant
j. Even more important is the recognition that some chronically disturbed schizophrenic patients can be returned
to resorted citizenship
k. Effective citizenship should be a chief goal of mental health and psychiatry (Remembering the creed of Adolf
Meyer)
5. How do we explain the scope of this kind of treatment?
a. Between 1940s-1950s, 4,000 lobotomies peformed in US
b. In 1960s, 50,000 lobotomies performed. Why?
i. Technical: Freeman develops the Transorbital lobotomy – “ice-pick” surgery
ii. Turns major surgery into a 10-15 minute office surgery
iii. Patients given quick jolt of ICT, then device was inserted through eye socket, into the brain, then
quickly twisted
iv. Procedure that anyone could learn
6. There were always critics of all this
a. Called in foolhardy, said it was mutilation not therapy
b. These kind of protests would only gain force when there is an alternative to treatment
i. 1955, approval of Chlorpromazine
Movie – 4/6/06 – Madness and the Brain – NOVA
Highlights of interviews with schizophrenic patients and information about the disease:
 paranoid thoughts
 inappropriate mood
 voices are often critical
 prognostic categories for schizophrenics:
o 1/3 will get well and not get sick again
o 1/3 will get sick off and on
o 1/3 are chronic schizophrenics
 considered a disorder of the highest, most human functions of the brain
 schizophrenic argues with doctors and mother about whether he will stay at mental institution
 Freud did not think schizophrenia was appropriately treated with psychoanalysis
 There’s no evidence that schizophrenia is caused by early childhood experiences
 Man’s mother says “you adopt a stranger who looks like your son and sometimes acts like your son”
 Stress plays a big role in the lives of patients
 Some forms of schizophrenia have a genetic component – some families have a history of the disease running through
generations
 Doctor describes when drugs first came over from Paris – how amazing it was that they could now talk to patients as
calm people
 Sedative drugs used to calm anxiety before surgery has positive applications in schizophrenics as well
 One common belief is that schizophrenics have an excess of dopamine – thus, some drugs block effects of
neurotransmitter dopamine
Lecture – 4/11/06
Jamison memoir – an unquiet mind – written by Kay Jamison who was both a textbook author as well as a manic depressive
woman herself
We are in an age of biological focus with the rise of psychopharmacology
Manic-depression: getting oriented
 Emil Kraeplin – engaged in diagnostic focus
o Identified dementia praecox and manic depression as 2 categories of psychosis
o Dementia praecox was related to disorders of thinking
o Manic depressive – emotional disorders/mood disorders
 Manic depressive disorder had been largely neglected during the hayday of psychoanalytic thinking
 The improbable story of lithium – 1949-1970
o Effects of lithium for manic-depressive patients were just as amazing as effects of chlorpromazine on
schizophrenics
o But there was a great reluctance to prescribe and use lithium – evidence:
 It took 21 years between discovery and its approval by FDA for legal treatment for manic depression
 For chlorpromazine, the same time stretch was only 2 years
Lithium is not a manufactured substance – it is a natural metallic element
 Supposed to be helpful against gout and intestinal disorders
 Many drinks were marketed based on their high lithium content
o Lithium Chloride – marketed as a salt substitute for hypertensive patients in 1940s
 Scandal broke out in 1949 – a family physician published letter in AMA journal – patients using salt
substitute had tremors and even fatalities associated with the salt substitute
 FDA eventually issued a warning against Lithium Chloride
o John Cade – found that Lithium had an effect on his depressive patients
 speculated that if there was a toxin involved in disorder, there should be a toxin in urine
 Urine was injected into abdomen of guinea pigs – all pigs died
 But he thought that something else was involved in the urine of manic patients that made
poisonous effects of urea more toxic for pigs
 Cade injected lithium urate with urea which weakened the toxic effects of urea
 He then injected lithium chlorate into pigs and they become lethargic
 Cade gave lithium to manic patients – it had a profound effect on symptoms of mania
o Even after Cade made this discovery – no one listened
 Cade was in Australia – people were not used to looking to Australia for developments in psychiatry
o Morgens Schou – discovers Cade’s article and tests the results
 he declines to rely on expert opinion of the doctors
 Schou uses the clinical trial
 Blinded doctors and patients as to who was in each group
 Schou’s trial on the efficacy of Lithium was the first use of the randomized placebo-controlled double
blind trial
 Schou shows conclusively that the Lithium did have the beneficial effect
o If some pharmapseudical company had “stepped up to bat” to approve the Lithium, it might have been
approved
 No company would want to do this however since Lithium is natural and widely available – it
couldn’t be patented and so would never be profitable
o Pfizer finally steps in and offers 3 Lithium compounds as treatment for manic-depressive disorder and the
FDA approves them
The rise of the “celebrity patient” and its his her role in the new patient advocacy movements
o Joshua Logan – appeared on TV with his psychiatrist
 told American audiences that he was manic depressive
 told audiences about how effective he had found Lithium treatment
 Logan was Tony-award winning director of plays
 Millions of people soon learned about the positive effects of Lithium
o This was first time a celebrity was used to promote awareness and treatment audiences for a psychiatric
disorder
o Patient Advocacy Groups Concerned with Mood Disorders – on the rise:
 National Depressive and Manic Depressive Association
 National Foundation for Depressive Illness
 Depression and Related Affective Disorders Association
Manic-depression: the “creative person’s psychosis”
o Patient advocacy groups go to great lengths to highlight the positive aspects of the individuals suffering from
manic-depression
o There was a push to say that the famous, distinguished individuals who had mental disorder were not
successful and particularly creative in spite of their disorder, but partly because of it
o Jamison’s work:
 did a study of artists and writers and argued that there was a correlation between high creativity and
manic-depression
 concerned that getting rid of the genes of the manic-depression might mean a loss of some of the
unique creativity in society
 appreciated the illness because she says that she has “felt more things, more deeply had more
experiences, more intensely; loved more, and been more loved, laughed more often for having cried
more often:
o she writes, “Which of my feelings are real? Which of the me’s is me?”
o


Lecture – 4/13/05
Depression & the Anti-depressants
Lauren Slater – discusses existential disorientation she experienced when she became “normal” after taking Prozac
Centrality of the pharmaceutical industry – marketing has played a huge role
From melancholy to major depression – a brief guided tour:
 once considered a disorder of solitary people – of people who read to many heavy philosophical books and are thus
weighed down by their thoughts
 Kraepelin – “manic-depressive insanity includes one the one hand the whole domain of so-called periodic and circular
insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not
inconsiderable number of cases of confusional insanity.”
 Freud – “Melancholy is in some way related to an unconscious loss of a love object, in contrast to mourning, in which
there is nothing unconscious about the loss, in grief the world becomes poor and empty in melancholia it is the ego
itself that becomes poor and empty.”
 1953 – Karl Leonhard – disaggregating Kraepelin’s monolithic affective disorders category: the establishment of
depression as a “unipolar” mood disorder and its contrast with the “bipolar” mood disorder which Kraepelin had
called “manic-depression” - major depression would be today’s analogous to unipolar mood disorder
 Distinguishing “major” (endogenous, vital) depression from psychoneurotic (“reactive”) depression
o Major Depression (unipolar disorder): rare, associated with debilitating loss of energy, sleep disorder,
depressed mood, suicidal thoughts, assumed to be endogenous (biological)
o Reactive depression – relatively common, often consistent with continued if impaired functioning . . .
 Major depression – the new image
o “no longer fashionable to be depressed” – Nathan Kline, psychiatrist
o psychotherapy was not clearly effective
 understandings of depression, 1960’s – a spontaneously remitting disorder – opinions of experts in the 1960’s:
o placebo induced improvement rate is high
o most depressions terminate in spontaneous remission
The anti-depressants: a story in three chapters and with three “protagonists”:
1. Monoamine Oxidase Inhibitors (MAOIs)
o Drug developed for TB was found in a stimulant – patients became hyperactive and energized
o Nathan Kline – suggested that these drugs are like a “psychic energizer”
o Drug came out as Marsidil
o Turned out to not be very safe – ex: liver damage was sometimes observed
o So other safer alternatives to Marsilid were developed
2. Tricyclics
 Developed from the antihistamine family which make you sleepy
 Antihistamines had been source for the development of chlorpromazine
 Roland Kuhn – tests Imipramine (structurally similar to Chlorpromazine) on schizophrenics
o Drug was then given to individuals with major depression and the effects were “miraculous”
o “patients become more lively, more communicative, crying came to and end”
 Imipramine rivals the MAOIs
 They do have side effects – nausea, headaches, sleep difficulties
Interlude one: from anti-depressants to new biochemical theories of depression
 Reserpine – laboratory animals became inactive and immobile
 Monoamines and tricyclics both act on the synapse but by very different mechanisms
 Belief developed that depression might be caused by a deficit in neurotransmitter – antidepressants caused
raising of neurotransmitter levels to normal levels
 many experts believed that the real situation was more complex
Interlude two: Not so rare after all? The rise of the depression as an under-diagnosed disorder
 Richard Ayd – “Recognizing the depressed patient” – Merck drug company bought 50,000 copies of his
book and distributed it to doctors and families
 1974 – “at least one hundred million people in the world untreated” (depressed individuals)
3. Chapter 3 – the selective serotonin reuptake inhibitors (SSRIs)
 Fluoxetine – blocked reuptake site of 1 neurotransmitter – serotonin
o Marketed as Prozac
o Marketed as alternative to medications previously taken by those with other types of depression
o New SSRI variants were then developed
Lecture: 4/18/06
Marketing Drugs, Marketing Illness
EVERYONE has heard of Prozac
DTC (Direct to Consumer) advertising – magazine ads, commercials
Before DTC, there was DTC!
Before legislation passed by FDA in 30s, people could sell “medication” as long as didn’t contain narcotics/poison
In 20s and 30s, rise of consumer interest groups
1937 – company sold a drug, active ingredient some version of anti-freeze killed many children
1983 Food, Drug, and Cosmetic Act – can’t exaggerate claims, list ingredients, required proposed drugs demonstrated to be
safe before coming to market
- had profound effects on nature of pharmaceutical companies
- pharmaceutical R and D
40s and 50s – pivotal to pharmaceutical industry – proliferation of new drugs and required development practice
New marketing practices
Physician-directed ads
Before DTC: Physician-directed advertising: advertising promotions not aimed at entire American population
Public Relations
- pharmaceutical industry selling very idea of itself
During 50s and 60s – marketing changed ways neuroscientists worked
Healy – Receptor Theories
- concepts of antipsychotics and antidepressants not chemical nor pharmacological, but social constructs
- chlorpromazine – marketed as “Largactil”: “LARGe range of ACTions”
Chlorpromazine: dopamine receptor theory vs. transmethylation hypothesis
The Rise of DTC (Part I)
- American consumer movements and the paradigm of birth control
- Mandated consumer safety and medical information
- Taken by healthy people – different from other medications – anticipates entire consumer-driven health movement –
consumer empowerment, education
- Patient Package Inserts (PPI) – late 60s early 70s
- Coincides with consumer empowerment movements in general in American culture
- Physician’s Desk Reference (PDR) available to public – late 70s early 80s
- FDA-requester moratorium (82-85) of DTC
- Rise of print advertising – 85-95
- 95 – pro DTC advertising movement begins within FDA
- Until 95, FDA director was very anti DTC, allowed print, resisted TV
- 97 – emergence of TV advertising, blew up
- Newspaper – reports on DTC
- DTC American phenomenon, New Zealand allows TV ads too, no other countries allow TV ads
The new Cultural Lives of Psychopharmaceuticals
Prozac and Sarafem
Sarafem Website:
Physicians – initially developed and marketed as antidepressant
Patients – same active ingredient as Prozac
Drug branded identity can separate illnesses
Sarafem “trivialized seriousness of PMDD”
Mid 80s – PMDD included in new DSM?
Debating PMS in the DSM – politics, not science
End – “other and unspecified special symptoms or syndromes”, needed further research
April 18th Lecture : Drug Marketing (Theme that appears: How do you classify psychiatric disorders?)
 Direct Consumer Advertising (DTC)
o 1930s, over 90% aimed at the public
o
o
o
o
o
o
1970, over 90% aimed at doctors exclusively
W hat led to this shift?
Before certain legislation by the FDAs in the 30s, anyone could concoct a medication, as long as it did not contain
narcotics. (Brief TimeLine)
 1930s, led to the rise of consumer interest groups.
 These groups reacted to deleterious practices on the part of companies that made dangerous medicines
 1937, a company sold a drug that had antifreeze
 1938, Food, Drug and Cosmetics Act
 companies to add a list of ingredients to drugs and demonstrate safeness.
 this act made companies have to analyze and test all these chemical companies, this led to labs becoming
part of this chemical companies
 led to pharmaceutical research today
 40s and 50s
 After the FDA regulation, companies decided to advertise directly to physicians and consolidate their
markets
 No longer aimed at the American population anymore.
 During the 1950s, companies still communicated to the people with Public Relations
 the industry started selling the idea of psychiatric medicine as a public good.
o advertise the drugs as an idea instead of advertising the drugs itself.
o They showed that companies were concerned with well-being and utilized sciences.
 1950s and 60s
 marketing changed the way that neuroscientists begin to explore scientific regulation
 David Healey – talks about how, it created the belief that drugs should have a specific treatment goals
which is influenced by the market. E.g. prozac
o Claims that prozac has always affected sexual drive pretty reliably, and it’s hard to show that it
affects anti-depressants.
o There is no market for a drug that reduces sex drive
o So prozac is marketed as an anti-depressant with sexual side effects.
 Also, competing theories on science are settled by how marketable they are. Markets affected
classification of disorders
o Healey talks about chlorpromazine, during which there was a debate on receptor theory vs.
transmethylation.
o The latter was based on results with unpatentable substances, so the pharmaceutical industry
began to support the receptor theory.
o Zoloft commercials have a focus on receptor theories.
o There is no mention of psychiatry, nothing specifically psychiatric anymore.
What Led to the Rise of DTC?
The Rise of DTC
 Birth Control pills were the first prescription product that the FDA mandated medical information to the
consumers when they got their pills.
 Birth Control pills were taken by healthy people and this anticipates a consumer driven health movements.
 Creation of patient-package inserts (late 60s and early 70s)
Physicians Desk Reference (PDR)
 Now available to all.
First DTC ads, for Rufen and Pneumovax.
 The act of advertising these drugs to the consumers triggers a new debate.
 FDA requests a moratorium (1982 – 1985)
 FDA declared that the restriction that was applicable to physician ads would also be there for consumers
(side-effects)
 Rise of Print advertising (1985 – 1995)
 Side-effects easier to advertise in print
 1995 pro-television advertising shift by the FDA
 director left, which led to this shift
 1997, rise of TV advertising
 risks were supposed to be present
 This has led to a blow up in TV advertising
o
o
 This is an American phenomenon, New Zealand also allows director consumer advertising
The New Cultural Lives of Psychopharmaceuticals since DTC
 Parody videos shows that psycho-pharmaceuticals have become cultural objects
The social lives of drugs (disorder classified by the presence of different drugs)
 Prozac – was white and green, anti-depressants vs. Serafem – pink and lavender, offered as a treatment for
PMDD (premenstrual dysophria Disorder) for women
 Different information for physician and patient
o physician information : fluoxetine initially marketed as prozac (communicates same drugs)
o Patient told: Sarafem contains the same active ingredient found as prozac (communicates diff
drugs)
 Drug banded identity parses illnesses into separate identities but they are treated with the same drugs
 Varying conditions that prozac appears to treat might suggest that all the disorders might be the same thing,
because one drug counteracts them.
 Rise of generic drugs.
 Drug Company says that medication with a different colour and shape may be unsettling or cause
concern.
The Rise of PMDD (the development of a new disorder)
 Some ads on PMDD rejected by FDA, reasons given:
o Because PMDD was not separated from PMS
o PMDD was trivialized
 This reflected institutional struggles about PMDD
o There was a belief that PMDD among gynecologists and psychiatrists should be different from PMS
 PMDD in the making in the mid 80s
o Should a pre-menstrual disease be included in the DMS?
o Polarized quickly
 Some said PMDD would pathologize all pre-menstrual symptoms and pathologize women
 Other wanted Unique recognition of women suffering
 Complicated because the DSM-III was supposed to be a decisive break by being more scientific and
more neo-Kraeplinian with a symptoms checklist
 IN the end, it was placed in a special appendix of the DSM that was created for disorders that required
further research
o “Other and Unspecified Special Symptoms or Syndromes, Not Elsewhere Classified”
 1987, Prozac hits the market.
 Created a treatment for its symptoms
 Early 90s DMS-IV is being made (society affects debate of disorder)
 This time it was claimed that there was bad science surrounding PMS.
 Others belief that to deny treatment to women because our culture has a negative view of female
physiology is bad science
 Both sides use science in the name of women to advance a political argument.
o
Introduces Robbie
 A gender-ambiguous individual.
 Administered depovera / progesterone, makes her feel very emotional
 Serafem rescues her belief that she was gender ambiguous
 Interesting because, Serafem talks about a return to femaleness but she returned to her gender ambiguous
identity
Lecture April 20th
Anti-Psychiatry and its Discontents


Occurred in the 60s and early 70s
Broad-based challenge to psychiatry’s authority, in some cases a challenge to mental illness itself.

Where did it come from?
Edward Shorter is surprised!
o early 1960s was a time when psychiatry had quite a few successes under its belt.
o
Drugs seemed to have made mental illness tranquil, Freudian thinking had established itself in elite and popular culture
Discontents with Medicine: rise of post war consumer movements and the idea of patient rights
 Greenslit talks about this in his lecture
o He claims this led to the strengthening of rules by the FDA for full-disclosure and truth in labeling
 They challenged the paternalistic doctor-patient relationship.
o The doctor didn’t always have your best interest at heart.
 Asked for a patient-bill of rights.
 They created a term for a new style of thinking in one’s relationships to one’s doctor, as a consumer.
 Something else happened that made the anti-psychiatry movements possible.
o A perception that the class of patients that are looked after by psychiatrists are disenfranchised
o Especially in mental hospitals where they lost control of their life choices.
o Newspapers at the time criticized:
 E.g. Albert Maisel.
 In 1946 he published Bedlam, 1946 in Life Magazine
 He drove home the neglect, forced labour, restraint, nakedness in the asylum.
Big Player: Szasz
 1961, Thomas Szasz published the book: The myth of mental illness
 he is the most distinguished face in the anti-psychiatric movement
 He was a Hungarian, who immigrated to the uS.
o Identified himself as a libertarian
 A philosophy that values the right to individual autonomy
 Opposes government interference in the lives of individual and the working of the market place
 People can do whatever they like so long as they don’t harm somebody else.
 If you do… then you need to be prepared
 Myth of Mental Illness
o He looks at psychiatry’s history, but he’s not interested in the origins of the asylum.
o He’s interested in the moment when Charcot interpreted hysteria as a disease of the mental system.
o He believed that medicine committed itself to physicalism, the belief that there is no disease with a physiological
malfunction.
o He said Charcot had to show a defect in the nervous system in order to show that hysteria was a disease and bring
psychiatry to the ranks of medicine
o Even Freud agrees that Charcot gave authority to psychiatrists
o Szazs believes that CHarcot had no proof, but hysteria continued to known as a disease and hysteric was a patient.
o It was an act of narcotization
 The hysteric is not sick, but is using such behaviour to avoid responsibility for her actions and to complain for
her social situation.
o Szazs made an objection for neurosyphillis and he more recently concedes alzheimers disease because of the biological
basis. (Psychiatry as a science is questioned again)
 He, however, states that when they found evidence for neuro-syphills and alzheimers, they were now neurology
and no more psychiatry
 Psychiatry continues to reign over fake diseases.
o He says that people might still need help, but it was not medical in nature and voluntary.
o Therefore nobody should be absolved for their actions, for the basis that they are mentally ill, he is against the insanity
defence.
o Example given of Harvey Milk – openly gay man who held political office.
 He was murdered by a police officer, White.
 During the trial a psychiatrist said that White had diminished responsibility because he had been eating too much
twinkies and this had produced a chemical imbalance in his brain that made his temporarily unstable
Proponents of Anti Psychiatry
Ex-patient
 They wanted their rights much like the blacks, women and gays had had theirs.
 Ex-patients took to the streets to protest psychiatry’s oppression of them; they modeled themselves after the civil
rights protests.
 They believed in peer-led alternative treatment centers or help centers.


Howie the Harp, an ex-patient , introduces the theme of pride and self assertion.
 Asserted that those who were mentally insane could still be smart and creative
Group of organizations establish themselves, e.g. Insane Liberation Front, Network against Psychiatrist Assault etc.
Civil Rights Legal Teams
o Szazs brought the court-room, primarily by Bruce Ennis
 He believes that Szazs was right in his claim that involuntary commitments was infringements of the right of the
mentally ill.
 He publishes prisoner’s of psychiatry and Szazs writes the preface for the book.
 He and his colleagues engage in tactics to test civil rights issues.
 Famous Cases 1: 1974 – 1975 Lessard Case in Wisconsin
 It concludes that patients “accused” of mental illness should be afforded the same protections from their
potential loss of civil liberties.
 You had to prove that you were a danger now.
 Famous Cases 2: 1980 Richard Roe Case in Massachusses
 It concludes that even if it is determined that you are not competent, that your civil right to refuse treatment
is not null and void.
 In such case, that you are competent, the courts would step in to make the decision that they believe you
would have made.
Scientology
 Tom Szasz has had an alliance with the church of Scientology in 1969.
 He and L. Ron Hubbard established the Citizen’s commission for human rights.
 Scientology hates psychiatry.
4/25 Lecture Notes: Anti-Psychiatry, Part II
“Radical pscychiatry” and R.D. Laing
Continued from Szasz’s anti-psychiatry, who denies that mental illness is a medical illness–>medical fraud. Szasz’s form is a
complete rejection of psychiatry.
Laing’s form still denies disease approach (similar to Szasz) but SHIFT in anti-psychiatry b/c believes that even so,
psychiatry, reconceived, still has role. Psychiatry as part of SOLUTION–tool for liberation, instead of oppression
Key term 1: “The Radical Psychiatry Manifesto” (1968)–Claude Steiner (a radical psychiatrist). Written to disrupt APA
meeting that year
-elucidates sentiments of R.D. Laing and new anti-psychiatrist movement suggesting psychiatry should play “soul
healing” role (become advocates for mad)
-condemns psychiatry for being laden w/ “irrelevant medical concepts and term”, for being neutral and thus part of
oppressive forces-denies madness relation to biochemistry and genes (against degeneration)
Key term 2: R.D. Laing. Cultural Phenomenon–> “pop-shrink, rebel, yogi, philosopher-king?”. Had charisma–>perceived
relevance to times gave charisma
-context: Vietnam and anti-war movements...lots of protests, sit-ins, etc. Psychiatry also labeled oppressor b/c
trauma/reported atrocities labeled as mental illness symptoms/schizophrenia (see 5/4 lecture)
LSD and the “politics of consciousness”–drug culture
-Albert Hoffman (Key term 3)–chemist/synthesizer of LSD, “my problem child” in 1938. Employed by Sandoz
pharmaceutical co. (Swiss) to research as circulatory stimulus (medical value). Profound psychological effects
discovered accidently (inhaled–>psychedelic effects)
-began LSD journey: CIA (weapon, interrogation aid)–>research labs (artificial mental illness)–>therapeutic
applications. WAS LEGAL during time...tested on college students!–>carried into COUNTER-CULTURE
(made own...reinterpreted as sacrament for peace, not tool for war)
-Ken Kesey (Key term 4)–was one of these college students exposed to LSD. Author of “One Flew Over the
Cuckoo’s Nest”
-drug “opened mind to hypocrisy and oppressiveness” of psychiatric institute and research–>wrote Cuckoo’s
Nest
-decided drug needed to be taken out of lab and into larger culture: Founded “The Merry Pranksters”–> “acid
test” challenges. Wanted to transform consciousness of American people. Hoped could stop “coming end of
world”–> “deadly serious business”
Laing’s writings (ever-present resource and inspiration of times. Way of framing larger effort of 60s)
-positions evolved over 1960s–>increasingly more radical. (Different than Szasz who laid down basic arguments in
The Myth of Mental Illness)
-Began with The Divided Self: schizophrenia as “ontological insecurity” and the collapse of “bad faith”. Book
inspired from work in low budget psychiatric institution (found oppressive). Was training in psychoanalysis (liked
ethic of engaging w/psychotic experience). Got permission to set up “rumpus room” (I think)–“hopeless” female
schizos. Treated humanely (not like patients)–>released to families (w/in year, returned...return to for later book).
Important first point is what happens when treat as people...schizo not medical disorder but existential crisis.
“Divided self” from W. James book about saints as divided selves (similar to schizo experience). Present masks to
world–>feel like spectator to own life–>schizo behavior–> “partial voices”, “ inauthentic selves” (symptoms
psychiatrists’ see)
Jean-Paul Sartre–existential philosopher Laing influenced by–“man is condemned to be free”
-Laing says “schizophrenia is final collapse of strategies of ‘bad faith’ which all of us struggle”. Really radical move
is when includes psychiatry in practices of bad faith–pin label of schizophrenia to avoid “existential terror”
themselves
-message: stop being objective/medical–psychiatry needs to feel own existential terror
Next Laingian book Sanity, Madness and the Family (theme we know well–blaming family (psychoanalysis))
-schizos returned to hospital b/c returned to families–where double bind begins
-radicalizes double-bind b/c implicates psychiatry as well
-from “good to bad to mad”. (good–don’t tell terrible truth, bad–tell truth, mad–tell terrible truths) Psychiatry elects
truth-speaker as mad (authenticates, medicalizes)–>political act
Leads to last book The Politics of Experience
-mental patient as hero (truth-tellers). Similar to LSD culture prophets
-on a journey of exploration. Need to be validated, not pathologized. Exploring consciousness
-normal people=products of family, social system–teach us to conform–>induced false consciousness, etc.–> “so,
who’s mad, and who isn’t?” (Anti-war sentiments)
1968 Dialectics of Liberation Conference organized by Laing. Where “anti-psychiatry” term coined. Lots of liberal
important people attended (Ginsberg, etc.)
Kingsley Hall (Laing’s radical hospital–>therapeutic community), Mary Barnes (this era’s model patient) and feminist
critiques of Laing
Mary Barnes–(as described by Showalter (feminist critic))
-read Laing and thought he could help, went to Kingsley Hall. Painted w/feces, regressed often, psychiatrist
Berke gave oil paint–>artist. Wrote book w/Berke Journey Through Madness. Made into play, translated in
many languages, big press coverage (people very interested)
Showalter’s feminist critique of Laing
-still couldn’t escape patriarchal assumptions of day. Didn’t recognize all his schizophrenic patients were
women and why–patriarchal society!! Missed implications of gender roles and Barnes’ struggles w/own role
-Showalter extended tradition of feminist critique of Chester who implicates patriarchal society in Women
and Madness
Laing now–deradicalized (partly b/c psychiatry pushes back...teaser for next lecture)
5/2 Lecture Notes: Making of the DSM
Psychiatry of our time
-mental illness not a myth
-few deny psychiatry as medical discipline
How did we get here?
-fundamental reassertion/orientation of psychiatry as biological/medicine/science
DSM -IV (1994)-making of this book-how became important subject of lecture. Szasz helped catalyze psychiatry today
60s-no one interested in issue of diagnostics (Spitzer). Why not?
-interested instead in maladaptation/adaptation
-defenses, repression, unconscious were greater interests
-what’s behind symptom–big question/psychiatry’s goal at time (Karl Menninger)
-Meyerian legacy of psychosocial, unitary vision of mental illness important
2 studies showing worthlessness of diagnosis back then: Ash (1949)– 3 psychiatrists agreed on diagnosis 20% of time. Beck
(1962)–32-42% of time
The DSM before 1970s–getting oriented in history “nobody cared about”
-1st DSM asked for by US Gov for census bureau info (NOT psychiatry) b/c they are publicly funded institutions.
Wanted to know numbers and what’s wrong
-(1880-1913) 7 diagnostic categories–mania, melancholia, monomania, paresis, dementia, dipsomania,
epilepsy
-became less confident in criteria and categorization–>went to APA for help
-1913 set up committee- 1918 came out with Statistical Manual for the Use of Institutions for the Insane
(Key Term 1). 22 categories of mental illness (including different types of mental retardation)
-WWII and making of 1st DSM
-inkling more at stake in getting classification right b/c influx of military psychiatric casualties–
>Classification is EVERYONE’S business
-1st Stat. Manual useless for 90% of diseases trying to classify b/c made for chronically, severely
disordered. Not what’s wrong with soldiers (relate back to shell shock readings). Different branches
of military invent own manual–>APA decides to do something–>sets up committee
-1952 DSM-I (Key term 2) published. It’s different
1. Diagnostic manual (not just statistical, for census purposes)
2. Recognized 3 classes of mental disorder:
1. Major psychotic disorders
2. Disorders of mental deficiency and retardation
3. Fundamental (neurotic), personality, and “reaction” disorders–dominated by “anxiety” and
various “defenses” against it (very psychoanalytic)
-100 some illnesses categorized
-DSM-II 1968–>updated b/c agreement w/WHO to maintain for international purposes
The 1970s and how everything began to change
-Anti-psychiatry and economic/fiscal recession drive DSM to forefront
-Key term 3: “On Being Sane in Insane Places”- Rosenhan
-sentiment: psychiatry about prejudices
-experiment: 8 sane people went into mental hospital and complained of hearing voices (heard “hollow” or
“thud” in head). Everything else truthful–all admitted with schizophrenia, manic depression. Patients
stopped acting once admitted–sanity not recognized–>behavior interpreted as insane
-published in Science journal (why?)–>HUGE humiliation
-mental illness just a label? Do we know how to diagnose?
-same year: 2nd crisis: validity of “mental disorder” of homosexuality
-gay activism: 1969 highly publicized police raid of gay bar in Grenwich Village–>Stonewall riots, radicalism
for gay community
-stop apologizing for lifestyle, take pride, want liberation too. One way to liberate–>demand not to
be pathologized. Show up at APA meetings where discussing aversion therapy for homosexuals
(shock if aroused). Protest is violent
-1971 invited members to meeting.
-1972 APA meeting–Key Term 4: Dr. H Anonymous (revealed to be John Fryer), gay psychiatrist
speaks–says there are a lot of gay psychiatrists who “pass”. When finished speaking given standing
ovation. Destablilizing moment–if many of own members gay, how can it be a disorder?
-APA voted in 1973 to remove homosexuality from DSM (not how real medicine works–
embarrassing to psychiatry). Robert Spitzer wanted to treat distress caused by
homosexuality (compromise)
-economic recession in 70s–>NIMH budget cut for psychiatry b/c unclear–don’t know how money is spent.
Insurance companies questioning if should fund, pressure from congress and pharmaceutical companies too. Must
undergo clinical trial–>needs psychiatry to specifically diagnose to work. All roads point to Spitzer’s DSM (Spitzer
revised 1st DSM)
Spitzer recognizes and calls for “palace revolt”–return to Kraepelin
-reorienting psychiatry away from expansive, intuitive style–>medical, diagnostic style of Kraepelin. 1978 Spitzer’s
colleague, Gerald Klerman publishes A Neo-Kraepelin “manifesto”–interesting b/c has to DEFEND field as
SCIENCE (legit)–reflects battlescars
-Realizing the vision, Part I: Out with Freud! The excision of psychosocial and psychoanalytic language from
new DSM
-“atheoretical”, simply descriptive in approach (didn’t explicitly say excise Freud). Bigger deal than
effect of drugs on psychiatry
-reactive disorders, etc. excised b/c built in theories
-Part II: “Reliability” as new gold standard
-rooted in checklists, precise sensibility. Intuitive wisdom gone–>more robust.
-reliability vs. validity–>agreement …reality (e.g. phrenology reliable but not real). But have to start
somewhere (must 1st agree)–>DSM having implicit research agenda–>Promise to become more
researched, real medicine
-striking fact: growth in numbers of diagnostic categories. DSM-I: 106 diseases, DSMIV
307–suggest efforts to integrate w/rest of evidence based medicine just as complicated as
everything else for psychiatry
Notes 4/27: One Flew Over the Cuckoo’s Nest: Worksheet
Themes:
1) Idea of so-called mad as rebels, truth-tellers and heroes of an repressed and sick society:
–Randle McMurphy (Jack Nicholson) as likeable rebel–hero of ward (all the other mad people like him,
audience is made to sympathize with him and hate annoying Nurse Ratchett who doesn’t let him watch the
World Series, etc.). Chief as hero–hero of basketball game. McMurhpy applauds for his deception act
2) Idea of mental hospital or asylum as a “total institution”
-when McMurphy gets handcuffs taken off he is elated but director takes long look at asylum indicating it is
even more trapping than physical cuffs. Also, McMurhpy’s increasing frustration that he can’t leave. Also,
patients have no freedom–MUST take medicine, can’t switch up routine of ward (always adhere to that damn
Nurse Ratchett!)
3) Idea of diagnosis of a mental illness as a political labeling act
-scene where the crazies take the boat out–convince the boat owner that they are doctors and he doesn’t ask
any questions...says they can’t get in trouble b/c everyone thinks they’re crazy anyways! (If anyone can think
of something better feel free to email out)
4) Idea of different psychiatric treatments as a series of repressive measures designed to subjugate and silence those
deemed mentally ill
–medication (MUST take)–>psychoanalytic meetings led by nurse ratchett (power trip instead of real
healing–>belittling)–>Electric shock therapy (hold down, make put thing in mouth so won’t bite tongue)
because started scuffle–>lobotomy b/c tried to kill nurse ratchett (that horrible woman)
Characters and their interactions:
1. How are women represented as characters (including those not seen)?
-Nurse Ratchett and Billy Bibbit’s mother (the stutterer) are abusive authority figures on power trips.
Ratchett is cool, calculating, unemotional. In contrast are the wild and free (especially sexually) “friends” of
McMurphy who are accepting of the mad people. They seem like the morally correct ones except by society
(i.e. the doctors and nurse ratchett)
2. How are men represented variously as characters, especially the range of male patients in the hospital?
-they are all initially afraid to break routine/oppose nurse ratchett. There is a divide between the intelligible
patients and the really insane ones (as evident in the World Series vote which Nurse Rachett includes “them”
in). Idea of macho male plays a role (Harding ridiculed for his homosexuality), Billy is a hero when he
finally scores, McMurphy is ultimate hero (rebellious uber-male).
3. How do male-female relations operate in this film?
-women try to control men (billy’s mother, nurse ratchett) or are their sexual objects/conquests and not much
more. Idea of power dynamics important (not equal)
4. How are relations between the “inside world” of the hospital and the “outside world” of normalcy represented?
-inside world is own little community, goal becomes to “get out”–outside world is idealized through nature
(fishing trip, wanting to move to canada).
5. How are relations between representatives of psychiatric authority and those deemed mentally ill represented?
-all thoughts of mentally ill are illegitimized b/c of label. Nurse Ratchett has unquestioned authority. Also
note conversation of psychiatrists and nurse ratchett where they deem that McMurphy is not “mad” but he is
“dangerous” and so stays in the ward
Lecture 5/4
Themes: psychiatry in relationship to mainstream medicine
The DSM III:
- Shorter: lauds DSM III as “closing the book on Freud”
- Harrington: Shorter’s book is the only history that takes us up through today, but she argues with the idea that
psychiatry is making its way slowly but smoothly into mainstream medicine
- Examining three narratives:
o Malpractice lawsuit 1979
o Creation of PTSD and its inclusion in the DSM III
o Kramer’s Listening to Prozac
-
-
-
1979 Lawsuit
o Physician Osheroff suffered from anxious depression
o His situation deteriorated and he voluntarily admitted himself to Chestnut Lodge, where psychoanalysis
reigned
o Diagnosed with Narcissistic Personality Disorder and treated accordingly=no meds, only psychoanalysis
o Osheroff deteriorates even more and asks for antidepressants, which the doctors at Chestnut Lodge refuse to
give.
o Leaves Chestnut Lodge and goes to Silver Hill, where he is diagnosed with depression, given tricyclics,
improves.
o Osheroff sues Chestnut Lodge for negligence in diagnosis (because their diagnosis not in the DSM III) and
treatment.
o Responses:
 Gerald Klerman: wrote Neo-Kraepelinian manifesto saying clinicians have an ethical obligation to
administer scientifically proven treatments
 Alan Stone: psychoanalytic perspective, links even Osheroff’s improvement to narcissism (he had
asked for the tricyclics, so once he got his way he improved to spite the people at Chestnut)
o Suit eventually settled out of court, Chestnut pays Osheroff loads of cash
 General consensus: victory for Kraepelin over Freud.
PTSD = Post-Traumatic Stress Disorder
o 1969 young social worker (Haley) in Veteran’s hospital does an intake interview that shocks her: veteran
relates story of watching his platoon kill innocent women and children. This massacre has been reported in
Australia but no one believed the few vets who dared tell of it in US.
o Diagnosis of the hospital: paranoid schizophrenia
o Finally people come out with the story: Hugh Thompson testifies 1969
o Haley becomes more activist as she sees more similar stories, writes “When the patient reports atrocities”
1974
o Spitzer, who is heading up DSM III, is urged by activists to include a category of experiential trauma, which
becomes PTSD.
 Complicated because in the midst of the DSM III it’s an oasis of psychoanalysis. There are symptoms
caused by bad things, not just bad biology; to recover from trauma you must speak about it.
o Rapid mainstreaming of PTSD: domestic abuse.
Listening to Prozac
o Kramer: maybe you don’t need any courage to heal. Maybe you just need Prozac (counterargument to PTSD)
o Story of Lucy: mother murdered by manservant when @ age 10
 Showed no immediate symptoms
 In adulthood, had crippling oversensitivity= a prime candidate for PTSD.
 Goes on an SSRI and within a couple of weeks she shows vast improvement
 Think about trauma as something that becomes biological.
o
Kramer’s unease: are we just fixing health problems or are we on the verge of cosmetic psychiatry (using
drugs to not just make people well, but to make them more popular, actually changing their personality in the
process)?
 We need to believe that our mental distress has some meaning, but Prozac threatens that
understanding.
From these 3 perspectives, psychiatry looks much less like a nearly medicalized field and more like a divided soul.
5/12/2006
Key themes:
The DSM III and what preceeded it
The genetic component of mental illness
Psychiatry and its relationship to mainstream medicine
Problems faced by psychiatry
-
-
-
-
-
-
-
-
pre-DSM III: the approach to diagnosis was very inconsistent
o seemed that there were 2x as many cases of schizophrenia in US than UK, but it actually was a result of
diagnostic issues
methods of disease classification
o clinical similarity
o etiology (risk genes, environmental factors)
o pathophysiology (disease process going on, in this case in the brain, or underlying cognitive/affective
processes in psycho)
 endophenotype: looking, instead of at symptoms, a measurable trait that is intermediate between
pathophysiology and clinical disorder. (e.g. amount of grey matter in the brain)
o by treatment response: a dangerous way of doing things
different classes of illness
o categorical/taxon: where there is normal and abnormal, clearly. Not a continuum. (e.g. pneumonia)
o quantitative/dimensional (e.g. blood pressure, depression) everyone has some degree of blood pressure, but
it’s on a continuum and we decide what is healthy and what isn’t based on what we’ve seen correlate. **the
vast majority of psych disorders are this.
Foundation of DSM
o Psych has “medicine envy.” Wants to be recognized as legit.
o 1970 (Robins and Guze): Reliable and valid diagnoses come from clinical description, laboratory studies,
delineation of one disorder from another (reactionary to Freudian thought), follow-up studies (check later for
long-term validity of diagnosis), family studies.
o 1980 (Spitzer): took
 reliability- people agree
 validity- picking out something real in the world
o now, it seems that there is little long-term validity; a large number of people meet criteria for multiple
disorders
genome link?
o Mood and anxiety disorders may have overlapping genetic vulnerability:
o Looking at families with schizophrenia: often bipolar individuals as well.
o Trouble in the DSM: people get lots of diagnoses. It’s uncommon for someone who has a personality disorder
only to have a single personality disorder.
How did people originally think about disease?
o One of the first diseases to be understood were those caused by a single mutation (cystic fibrosis, e.g.).
o Other psych problems seemed to be somewhat hereditary. But actually Mendelian disorders of behavior are
rare and severe.
Polygenic Model: for most diseases the genetic diseases they are not single-gene, but are determined by a group of
genes, along with environmental factors and other factors. But for a lot of them, the genetic risk factors are not even
the same, even if it’s a very heritable disease. These as well seem to exist on a continuum: there is a degree of
direness of the disease.
Behavioral genetic manipulation (e.g. not having schizophrenics have kids) is not only morally repugnant, but
scientifically unsound.
Ultimately, it is our BRAINS, not our GENES that control behavior.
-
-
-
-
o Neural circuits are shaped by gene-environment interactions over a lifetime.
o But there are antecedent risk factors too.
If genes are important but don’t act alone, there’s not a single disorder where genes act alone (twin studies). Genotype
does not predict phenotype.
o Reveals that some things are shared, some not shared.
Looking at non-mental disorders: there are a lot of diseases that we classify as “real diseases” that also seem to exist
on a continuum. Example: breast cancer- it appears that there are distinct variations in causes and that they may
require different treatments.
For mental disorders, it’s a much bigger challenge because of the complexity of the brain and the complex
relationship between neural circuits and behavior.
Problems psychiatry faces:
o Difficult genetics, neurobiology, psychology: psychiatric science is still in its early stages
o Questions of behavior phenotype: which are closest to the pathophysiology?
o Etiological heterogeneity
o Problem of multiple common risk factors; missing of symptoms.
What does this mean for the classification?
1. The science is not far enough along to begin tinkering with lots of diagnostic criteria. When you change the
diagnostic criteria you change the pop’n count.
2. Want to begin to start experiments working on dimensions: recognizing depression, autism, etc. as a
continuum.
a. Right now, ability to get treatment requires DSM-recognized diagnosis
b. Risk factors: Shouldn’t we study what things portend for the future a la blood pressure?
c. Begin to chip away at the strange political-seeming anomalies. Personality disorders are separated on
a separate axis because there was a political truce between medically-oriented psychiatrists and
psychoanalytically-oriented psychiatrists, which means there are two classifications of the disorders.
There is a stigma attached to personality disorders.
d. Above all, we need to use these criterion sets for clinical communication, communicating with
patients, other caregivers, family, selecting treatments, but not reifying provisional diagnoses that
don’t actually seem to map in a real way.
e. An important trap: when you give something a name and a set of criteria, in some sense you have
made it real even if it is not “real in nature” (it doesn’t map onto what genes and risk factors do to a
brain to create a set of symptoms/dysfunctions). If you then need to use those definitions of a
diagnosis to study the disease, then you’re always going to be stuck with these heterogeneous grabbags. We need to extract DSM diseases- find a way to undercut the way in which the DSM reifies
these sets of diagnoses.
3. Why are we moving on to the DSM V? What are we gaining?
a. The DSM makes a lot of money. Moral hazard involved.
b. Becomes a cottage industry because of the academic work done. We need to resist some of the
pressures of producing a DSM V that has barely changed.
c. It’s easy to make fun of the book, but remember how important it is to have a common ground from
which to diagnose/study.
OTHER STUDY MATERIALS
15 Possible Important Terms
1. Phillipe Pinel (1745-1826)

Humanitarian hospital worker during the French Revolution
Napoleon’s private physician

Released patients from chains at the Bicetre despite warnings from Bodin (state) and Couthon (church), gave
each his own bed, then went to
Salpetriere

“Rather than guilty people, the mentally ill are sick people who deserve consideration.”

Opposed to bloodletting, ducking, indiscriminate drugs; force only when kindness fails; neither indulgence
nor harshness

Introduced case histories and case records


“Pinel Freeing the Insane” Fleury 1887
Zilboorg’s Great Man Theory of History
2. Industrial Revolution (19th Century)

Mad become state responsibility  madhouses with “mad doctors”

Doctors needed because of the concern about abuse, and considered places of contagion

Chains and gadgets
3. Degeneration Theory (late 1800s – early 1900s)

Failure of moral treatment and unchecked growth in asylums

Self control and moral sense are last things acquired evolutionarily so are first to go; elitism

Science justifies eugenics and colonialism (e.g., Nazi degenerate art 1937)

“Dark seeds of our origin,” tumble back down the tree of life, “devil baboon”

Women and lower classes = natural affinity for madness (statistics to reinforce view that people already had)

Degenerates trying to plant their seed (e.g., Dracula)  reproductive isolation  eugenics

Atavism – square jaws, recessed foreheads, low ears
4. Michel Foucault (1926-1984)

Communist philosophy student, gay in the 40s and 50s

Questioned political function of science following the Lysenko Affair (teaching wheat)

“Power is knowledge”

Society creates and confines an “other” in order to define what is normal (e.g., lepers in Renaissance)

Mad people respected as having a truth of their own (e.g., Ship of Fools, Shakespeare) which changed during
Enlightenment

Idea of “antithesis”

Moral Treatment = internalizing chains

(1) Silence to humiliate, (2) Recognition by mirror, and (3) Perpetual judgment with no appeal
5. Freud (1856-1939)

Katharina, uncle, sexual causes become traumatic later Hysteria is a language of symptoms trying to
communicate distress of something pushed down into the unconscious

“The truth will set you free”

1st renunciation – rejection of hypnosis as truth-finding

Conceptual shift – it’s all about sex

2nd renunciation – no longer exclusively about actual events  Universal Theory of Human Psychosexual
Development, forbidden fantasies

Free association and dreams

“Find out all about dreams and you will have found out all about insanity.” – John Hughlings Jackson

Neurosis (defending from repressed feelings, hysteria, narcissism, OCD, anxiety) vs. Psychosis (lost the battle
to unconscious, paranoia,
schizophrenia, mania)
6. Shellshock

Industrial war

Term coined by CS Myers

1. Damaged nervous system due to nearby exploding shells  others?

2. Degenerates  officers?

3. Cowards

Conflict between duty and survival

Important but complicated vindication of psychoanalysis

Force them to remember or allow them to forget? (some too painful)

Stuck poor soldiers into asylums and thought these people were inferior, complaining and acting like
children, prompt treatment important
7. Mental Hygiene Movement (1920s-1950s or so)

Period of optimism and social zeal (Progressive Era); mental illness was the most serious social evil

Catalyzed by WWI and shellshock… some people had an incapacity to make adjustments

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Mental illness redefined as a personality disorder rather than a brain disorder
Relied on malleability of personality
Parents and teachers/schools (role changes) responsible for personality development – “prevention as the only
cure,” stress as a major factor
National Committee for Mental Hygiene (NCMH)
William White – people in asylums and jails have already failed
Adolf Meyer – influential psychiatrist, Freudian influence,
maladjustments, this is fixable!
Clifford Beers – delusional Yalie who recovers and then works with Meyer to bring about asylum reform,
muckraking
*Remember educational video – boy was told to talk about his feelings
“Helping professions” of psychiatry (truant officers, guidance counselors,
social workers) and the
“juvenile delinquent” (West Side Story)
People could be incurably maladjusted for biological reasons
Led to immigration and sterilization laws (Buck vs. Bell), IQ tests
8. Malaria Fever Therapy (1917)

Also Insulin Coma Treatment (1927), Metrazol-Induced Convulsive Treatment (1934), and
Electroconvulsive Therapy (1937)

Treated General Paralysis of the Insane (GPI) caused by syphilis

Julius Wagner-Jauregg (1927 Nobel Prize) drew malaria blood and injected it into patients

Reliable fever used to fight disease, also seen as morally cleansing (still a moral component), people left
“completely changed”; used
quinine to bring them out of it

Led to fever cabinets, and convulsions produced by other means

De-emphasis on actual “science”… if it works, use it (no randomized clinical trials)

Willingness to experiment showed level of desperation

Led to doctors being journalistic heroes, feeling like they could do
something, and liking their patients
more (seemed healthier
because they could withstand fevers, etc.)

Patients began to have a say in their treatment, and families began to talk
about syphilis rather than
covering it up

Insanity is curable!!
9. Psychosurgery (1940s)

Not the same as neurosurgery (supposed to bring about mental change)

Began with John Fulton’s primate (Becky and Lucy) lobectomy in 1935, Moniz’s leukotomies on humans, or
possibly as far back as WW1
(holes through soldier’s heads)

Extremely rapid implementation (US 1937)

Ultimately redefined use of the laboratory for psychological problems (e.g., Primate Research Center)

Watts and Freeman performed many frontal lobotomies, mainstream but always controversial

Realized that patients lost some “sparkle,” but thought it was worth it

Results in useful members of society, i.e., maids, janitors, bus-drivers (like Howard Dully)

By 1950, procedure was used for schizophrenics

Operation Ice-Pick – anyone could perform transorbital surgery
10. Schizophrenogenic Mother (1940s-1970s)

Nurture over nature bias (as opposed to during Degeneracy Era)

“Blame the Mother Ideology” supported by Frieda Fromm Reichman, Edward Strecker, Gregory Bateson
(double-bind theory for
schizophrenia)

Moms could be over or under nurturing… need for professional advice on
parenting

American fear that strong women over weak men was what had led to Fascism (“Rosie, go home!”)

Idea that Progressive Education had swung too far left and was producing
people less mature for war
(shouldn’t be a “fortress” between a child and the consequences of his actions)

Neo-Freudian idea that mental problems come from bad childhoods

“Refrigerator mothers” (rejecting and cold) produced autistic children who chose to hide in their own worlds
11. Antidepressants and Antipsychotics (1950s – 1970s or so)
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Gave them to a wide range of patients because they weren’t sure who would respond
Sometimes terrible side-effects – tardive dyskinesia, blindness,
immobility, etc.
1950s – Chlorpromazine/Thorazine (Charpentier, Laborit, Deniker and Delay), Imipramine (Kuhn, Geigy)
Still not randomized, double-blind clinical trials, but clinical impressions
1960s – Librium, Valium, Miltown
Return of biological psychiatry, no longer faulty child-rearing or environmental stress (twin studies, etc.)
BUT a spirit of accommodation towards Freud until the 1980s (Ostow = psychoanalyst excited by new
drugs). . . “tranquilizers” affect the underlying energy of anxiety
Major and minor tranquilizers even addressed gender issues (“Mother’s Little Helpers”)
Theme of liberation again, this time from inner torments
12. Thomas Szasz (1920 – present)

Antipsychiatry movement

Mental illness is a myth and an institution of social control; psychiatry and state should be separated, insanity
defense should be abolished

Problem with mental illness is that when you fake it, it is still mental illness

Lack of good evidence (exceptions are GPI/syphilis and Alzheimers)

Labeling makes problems worse
13. RD Laing (1927-1989)

Calls on psychiatry to change/radicalize (doesn’t want to abolish entirely)

Psychiatrists should be guides for the mentally ill, who are undergoing a natural process of healing

Mental illness should be embraced, journey into “inner world”

Ken Kesey – Merry Pranksters, acid tests, LSD, etc.

Schizophrenia – family is dangerous to individual; return of environmental factors

Backtracked on many of his theories later in life
14. Direct To Consumer (DTC) Advertising

Began with patient package inserts in birth control pills in 60s and 70s

Much debate

Today, may be differences in patient vs. doctor info

Medicines  disorders rather than disorders  medicines (e.g., Eli Lilly’s marketing of Sarafem (pink) vs.
Prozac (green and white) for Pre-Menstrual Dysphoric Disorder (PMDD) … both sides have feminist arguments

“Receptor Theories” are social constructs, not pharmacological (e.g., Zoloft ad)

Symbolism of drugs, overlap of politics and science, science as controlling or liberating, etc.
15. Diagnostic and Statistical Manual (DSM)

Classification can be traced back to Kraepelin
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A disorder is anything with an efficacious treatment
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Influence of Army and Navy in creating a standardized language for diagnoses
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Reliability as new “gold standard”
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Connection with FDA and drug companies… conflict of interest
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Excised Freud more effectively than new drugs
Possible Key Terms
DSM
Diagnostic Statistical Manuel, the APA’s publication which was originally done for government census, and has recently been
needed to have more unified diagnosis and effective treatment (although this can be discussed as you might be able to tell if
you went to Hyman’s lecture). 3rd edition was revolutionary way to categorize and recognize symptoms for the different
disorders with a gold standard of reaserch and criteria. It was very neo-Kreapelinian, for it was a way to categorize madness
which in turn enabled it to become “more scientific.” The DSM III was a way for psychiatry to fight back the anti-psychiatry
movements, and embarrassments of homosexuality and the Rosenhan article.
Lectures:
May 2 Psychiatry fights back: writing the DSM, the new "Bible" of mental illness
May 12  Hyman’s guest lecture mentioned it, but it was not that important, just have some nice thoughts of how the DSM is
also pejorative for mental illness should not be seem as categorical but instead dimensional
Readings:
Wilson, Mitchell, "DSM and the Transformation of American Psychiatry; A History," American Journal of Psychiatry 150:3
(March 1993), pp. 399-410
(to find out what it is and how it changed things, the Rosenhan article is good to see the reasons why it changed to the DSM
III
RD Laing
An anti-psychiatrist who saw schizophrenia as more of an existential crisis than a disorder, where the symptoms they were
feeling were indeed valid just a different way to perceive reality, a way that is more true to one self but devoid of social masks
and personalities. He praised disorder for the stigmitzation was a political act, and it was the upbringing of the people in such
a false environment that made them become psychotic. He had his own hospital policy which was a huge shift from that of
psychiatry of that time and he shifted the blame back to the families. He was a cultural phenomenon in the 60’s, and whose
vision of alternate psychology caught on and gave problems to psychiatry and was one more thing that psychiatry had to prove
itself to.
Lectures:
April 25 "Anti-psychiatry," part two: the counter-culture and the "psychedelics" of madness”
(the part one given on the 20th is good for other anti-psychiatry especially Szasz and his theory that psychiatry did not exist
which also gave the same or similar historical effects as Laing)
Readings:
Laing, R.D., The Politics of Experience (Ballantine Books, 1967) pp. 100-130
Showalter, Elaine, "Women, Madness and the Family: R.D. Laing and the Culture of Anti-Psychiatry," in The Female
Malady (Pantheon Books, 1985), pp. 220-247
Lithium
The most well known cure for manic-depression. The medical uses for the compound were discovered in 1949 by John Cade,
who not only tested the effects and saftey on mice, but also on himself. An intresting point, is that the FDA only approved
lithium for medical use in 1970. This shows two things, one was the fear of the people, since in the 40’s lithium was seens a s
atoxic chemical (for LiCl gave tremors when used as salt substitute), as well as the power of the pharmaceutical companies,
for lithium, being a natural occurring metal could not be patended as a formula, so would not be as profitable, thus since it was
not backed up by any powerful company, it took a lot of research (first blind placebo trials were run on it) and a lot of very
fine tuned trials in order for the FDA to approve it. It was only when patients, especially famous patients, started to speak out
about the drug that it got recognition, so this drug shows how political the entire process is, and its not all about the science.
Lectures:
April 11  Manic-depression and lithium: managing the highs and lows of the "other" psychosis
Readings:
There isn’t really any truly about Li, Jamison’s book talks about the love-hate relationship of those with lithium and the fear
that it would take a person’s personality away from them, which could also be important, but not about the discovery or
history.
Schizophrenigenic mother
Also known as “mom.” The type of mother that causes schizophrenia in her children, especially her sons. She is totalitarian
and by being at the same time overly involved and distant. . She would usually put then in a double bind situation (conflict of
dependence and independence) and thus because of her own problems she would make her children go psychotic. It is a
change back into blaming the situation and also moved to attack mothers, so it moved away from the selfless notion that was
there before. It was also after the Second World War and there was seen to have an American masculinity crisis, thus mothers
were a clear culprit for during the war matriarchal houses were the dominant ones.
Lectures:
March 23  “Blame it on your mother:” schizophrenia as a family affair
Readings:
Neill, John "Whatever became of the schizophrenogenic mother?" in American Journal of Psychotherapy, vol. XLIV, No.
4, (1990) pp.499-505
Strecker, E., Their Mothers' Sons, (J.B. Lippincott Co., 1946), pp. 13-29, 160-168
Double bind
According to Gregory Bateson it was the cause for schizophrenia, which was part of the movement of blaming the family and
especially the mother for mental disorder (at a time when biology had fallen out of favor). It is having two options, both
which conflict with each other, but neither of which can be ignored, thus a person cannot deal with the constraints imposed
and become psychotic over time. It was what the “mom’s” created and the actual reason that there was not only psychosis but
the masculine crisis.
Lectures:
March 23  “Blame it on your mother:” schizophrenia as a family affair
Readings:
Bateson, Gregory et al. "Toward a Theory of Schizophrenia" Behavioral Sciences, vol. 1 (1956), pp. 251-264
NOTE: this term and the one above are very similar, and they correlate for it was a schizophrenogenic mother that would
create the double bind on the child, so one was who was to blame and the other is how they supposedly caused their damage.
Dementia preacox
Emil Kraepelin first described it as one of the two major mental disorders. The name of this disorder means “premature
dementia” for that is how Kraepelin saw the disease, for he saw it as a disease that began in childhood and had a terrible
prognosis. It was Bleuler that renamed the disease schizophrenia for he thought the term was misleading. This diagnosis
showed a shift from the Freudian ideas that it was events that caused mental illness in a variety of forms, but to a more
scientific one. By using thousands of case studies he came up with this, and he also followed the disorder over time so in a
way organized it form the millions that were present before to two.
Lectures:
Thurs. March 2  The making of schizophrenia: madness of our time
Readings:
Kraepelin, Emil "Dementia Praecox and Paraphrenia (1919) and "Introductory Lectures on Clinical Psychiatry (1906), and
"Dementia Praecox", in C. Thompson, ed. The Origins of Modern Psychiatry (John Wiley & Sons, 1987) pp. 225-243
(the rest of the reading for the week describe just the rise of biology and categorization (Shorter) or the other view of
schizophrenia (Bleuler)
Buck vs. Bell case
Landmark case in 1927 where Carrie Buck was ordered to be compulsorily sterilized because of mental defect, according to
the supreme court it was for being “feeble-minded.” It was this case where the notion of three “generations of imbeciles [was]
enough” (said by Oliver Wendell Holmes), for both Carrie’s mother and daughter were also “feeble-minded.” This was
important historically for it gave power to the eugenics and sterilization movement where sterilization numbers steadily rose
for about 20 years, it was part of the mental hygiene movement seeing prevention of the creation of imbeciles and psychosis
as the best medicine. So this was the nasty side of mental hygeiene, beyond the educating and reforming the maladjusted, for
the feebleminded were streliziled (after this case it went from 3000 people in 20 years to 60000).
Lectures:
March 9  Prevention is the best treatment: the rise of mental hygeine
Readings:
Buck versus Bell, 1927 http://www.crimetheory.com/Archive/BvB/index.html
(the other readings of that day are good in order to see what the mental hygiene movement was all about, and in a way shows
the background to why this decision was made, to see it as a community issue and one that all has to deal with)
PTSD
Post-traumatic stress disorder, the disorder that was spearheaded by Vietnam veterans to help explain the troubles experiences
by themselves and their comrades after the horrors they witnessed. It was included in the DSMIII after much debate and an
important part of this disease is that it is not just biological as the other diseases in the current DSM are. PTSD has to follow a
traumatic event, so something in the environment has to trigger the rise of this disorder, it cannot just be biology, which seems
to go against what the new “second biological psychiatry” (term used by Edward Shorter) stands for. However the veterans
used similarities between survivors of concentration camps, natural disasters, and other traumatic events to show that this was
not just a war neurosis but a real disorder. It was a disorder with a range of symptoms, and with the a very psychoanalytical
approach to diagnosis, it was one of the ways the family was placed back into the spotlight (with notions of familial abuse
from the 80’s and 90’s affecting women and children)
Lectures:
May 4 Ambivalent legacies: psychiatry today, between PTSD and Prozac
Readings:
Conversation with Judith Herman, M.D.: The Case of Trauma and Recovery," September 21, 2000,
http://globetrotter.berkeley.edu/people/Herman/herman-con0.html
(also this is seen by some as the same thing as shell shock in the world war’s, so then you could try to compare the symptoms
by looking at shellshock (Feb 28 lecture), or may be even the movie Let There Be Light shown on (March 21 lecture) and the
readings following those two lectures)
SSRIs
Selective serotonin reuptake inhibitors are a class of antidepressants for treating depression, anxiety disorders and some
personality disorders since the 1980’s. These drugs are designed to allow the available serotonin to be utilized more efficiently
by blocking its reuptake, which aids with depression. They have no or only weak effects on other monoamine transporters,
thus having little direct influence on the level of other neurotransmitters. That distinguishes them from the older tricyclic
antidepressants, which is why they are “selective”, they are also the most recent of the antidepressants. They are part of the
biological psychiatry as well as the strength of the pharmaceutical companies to come up with more cures.
Lectures:
April 13 Depression and its drugs: from psychic “energizers” to Prozac
Readings:
Healy, David, “The Discovery of the Antidepressants,” The Anti-Depressant Era. Cambridge: Harvard University Press, 1997,
pp. 43-77 (does not fit directly but shows the general movement and how they came to be)
Tardive dyskinesia
A serious neurological disorder caused by the long-term and/or high-dose use of dopamine antagonists, such as first
antipsychotics for serious psychiatric disorders (schizophrenia). It is a disorder of abnormal movements that occurs after
some time has elapsed following initial administration of the neuroleptic drug. Tardive dyskinesia is characterized by
repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip
smacking, puckering and pursing of the lips, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also
occur. Some estimates suggest that it occurs in 15-30% of patients receiving treatment with antipsychotic neuroleptic
medications for 3 months or longer. It is important for it shows the problems that the drug movement had to face at first, for
these very strong side-effects had to be dealt with by the pharmaceutical companies and also pushed for other drugs to be
made.
Lectures:
April 4 Drugs for schizophrenia: from “major tranquilizers” to “anti-psychotics”
Readings:
Crane, George, "Clinical psychopharmacology in its 20th Year: late, unanticipated effects of neuroleptics may limit their use
in psychiatry," Science 181 (1973), pp. 124-128
MAOIs
A class of antidepressants prescribed for the treatment of depression since the 1950’s. Due to potentially serious dietary and
drug interactions they are used less frequently than other classes of antidepressant drugs. However, in some cases where
patients are unresponsive to other treatments they are tried, often with a marked success. They are particularly effective in
treating atypical depression. MAOIs act by inhibiting the activity of monoamine oxidase preventing the breakdown of
monoamine neurotransmitters and so increasing the available stores. They are also part of the huge wave that were the
different drugs in the 1950’s,, and those with the strongest side effects, but they were part of the medicalization of patients.
Lectures:
April 13 Depression and its drugs: from psychic “energizers” to Prozac
Readings: Healy article again
Tricyclics
From the 1950’s it is the oldest class of antidepressants, it is generally thought that tricylic antidepressants work by inhibiting
the re-uptake of the neurotransmitters by nerve cells. Although this pharmacologic effect occurs immediately, often the
patient's symptoms do not respond for several weeks For many years they were the first choice for pharmacological
treatment of depression. Although still considered effective, they have been increasingly replaced by SSRIs and other newer
drugs. They are not considered addictive and are preferable to the MAOIs.
Imipramine was, in the late 1950s, the first tricyclic antidepressant to be developed (by Ciba-Geigy). Initially, it was tried
against psychotic disorders (e.g. schizophrenia), but proved insufficient. During the clinical studies its antidepressant qualities,
unsurpassed until today, became evident. Subsequently it was extensively used as standard antidepressant and later served as a
prototypical drug for the development of the later released tricyclics. It is not as commonly used today but sometimes used to
treat major depression as a second-line treatment. The historical implications were very similar to all of the past, showing
how important the medicalization of psychiatry was, and also the new power of the pharmaceutical company (which began
after their inception).
Lectures:
April 13 Depression and its drugs: from psychic “energizers” to Prozac
Readings: Healy (very similar to the ones above)
Chlorpromazine
The first antipsychotic drug, used during the 1950s and 1960s. Today, chlorpromazine is considered a typical antipsychotic.
The drug was being sold as an antiemetic when its other use was noted. Smith-Kline was quick to encourage clinical trials and
in 1954 the drug was approved in the US for psychiatric treatment. Over 100 million people were treated but the popularity of
the drug fell from the late 1960s as the severe extrapyramidal side effects and tardive dyskinesia became more of a concern.
Its effects on mental state were first reported by the French doctor Henri Laborit as sedation without narcosis.It was first used
for psychiatric patients by Pierre Deniker and Jean Delay in 1953. Drug treatment with Chlorpromazine went beyond simple
sedation with patients showing improvements in thinking and emotional behavior. Chlorpromazine substituted and eclipsed
the old therapies of electro- and insulin shocks and other methods such as psychosurgical means (lobotomy) causing
permanent brain injury. It showed a shift from the older ways of treating patients to new, more “scientific” ways of treating
them with medication.
Lectures:
April 4 Drugs for schizophrenia: from “major tranquilizers” to “anti-psychotics”
Readings:
Ostow, Mortimer "The New Drugs" The Atlantic Monthly (1961) pp.92-96
Ken Kesey
American author, best known for his novel, One Flew Over the Cuckoo's Nest. Kesey enrolled in the creative writing program
at Stanford University, where in 1959, Kesey volunteered to take part in a study at the Menlo Park Veterans Hospital on the
effects of psychoactive drugs. These included LSD, among others Kesey wrote many detailed accounts of his experiences
with these drugs, both during the study and in years of private experimentation that followed. He left school and then
frequently had parties he called "Acid Tests" involving music, black lights, fluorescent paint, strobes, and other "psychedelic"
effects, and of course LSD. The inspiration for Kesey's first novel, One Flew Over the Cuckoo's Nest came from his work at
the Menlo Park Veterans Hospital on the night shift. There, Kesey often spent time talking to the patients, and believed that
these patients were not insane, but that society had pushed them out because they did not fit the conventional ideas of how
people were supposed to act and behave. One Flew Over the Cuckoo's Nest was adapted into a successful stage play and film.
That book and the subsequent movie added great fuel to the anti-psychiatry fire, so then psychiatry had to face all of the
problems that it had (which some say it did with the DSM). According to Edward Shorter it was the distance between doctor
and patient that fueled such criticism, but that was just part of the biological psychiatry.
Lectures:
April 25 "Anti-psychiatry," part two: the counter-culture and the "psychedelics" of madness
Readings:
Zeidner, Lisa [review of “Cuckoo’s Nest”], “Rebels Who Were More Angry Than Mad: The originality of Milos Forman
lies in his rejection of too much easy drama,” New York Times (Nov 26, 2000) pp. AR11-12
Lehmann-Haupt, Christopher, “Ken Kesey, Author of 'Cuckoo's Nest,' Who Defined the Psychedelic Era, Dies at 68,” New
York Times ( Nov 11, 2001), pg. A47
Mental hygiene
The mental hygiene movement of the late 19th and early 20th centuries was an attempt by Progressive-era reformers to
control vice, and disseminate sexual education through the use of scientific research methods and modern media techniques.
Many reformers were also exponents of eugenics. Inspired by Charles Darwin's theory of natural selection, they argued for the
sterilization of certain groups, even racial groups, in society. Social hygiene as a profession grew alongside social work and
other public health movements of the era. It was seen that prevention was the best treatment for medicine, those that were
seen as having problems were said to be “maladaptive” and it was that which lead to illness. It was during this time that terms
such as “juvenile delinquient” were established because there was a great need to reform children, instead of punishing them.
There was the idea that through education and with the help of the family (for they were often the root of illness) that all
would be well. This is historically significant for it shows the movement away from biology and back into blaming the family
(it also speared many programs known today).
Lectures:
March 9 Prevention is the best treatment: the rise of mental hygiene legacies: psychiatry today, between PTSD and Prozac
Readings:

Cohen, Sol, “The Mental Hygiene Movement, the Development of Personality and the School: The Medicalization of
American Education ,” History of Education Quarterly, Vol. 23, No. 2. (Summer, 1983), pp. 123-149
Williams, Frankwood, "Community Responsibility in Mental Hygiene," Mental Hygiene 7 (1923), pp. 496-508
Osheroff case
Osheroff suffered from anxious depression. He was a difficult patient and didn’t comply with his treatment so he voluntarily
committed himself to the Chestnut Lodge where psychoanalysis was still used primarily; he was then diagnosed as suffering
from narcissistic personality disorder. He wasn’t given antidepressants even though he asked for them, the psychoanalysts
refused because the drugs would be distracting from the real work that needed to be done. He left Chestnut Lodge after 7
months when he was getting worse, went to another hospital where he was given antidepressants because he was diagnosed as
having psychotic depression, was better within 3 weeks. Sued Chestnut Lodge for negligence because in the 7 months he lost
his job and his wife left him. In the case the psychiatrist testifying for him (Klerman) said that psychiatrists had the ethical
duty to prescribe treatment that had been scientifically tested and that patients had a right to effective treatment. The
psychiatrist testifying for Chestnut Lodge (Alan Stone) said that Osheroff was not a compliant patient, that he suffered from
transference and resisted the doctors at Chestnut Lodge, and that his remission at the second hospital was a further revolt
against his first doctors. The case was settled out of court, Chestnut Lodge paid Osheroff and the case was seen as Freud vs.
Kraepelin with Kraepelin having won. In 1997 Chestnut Lodge put out a new mission statement allowing for medication as a
way for the patient to become psychologically available (a.k.a. they caved). According to some this was the end of
psychoanalysis and that now it paved the way for biological view and science to rule in psychiatry.
Lectures:
May 4 Ambivalent legacies: psychiatry today, between PTSD and Prozac
Readings:
Not really any readings fit
Possible Essay Questions
1. In what ways did the popularization of pharmacological treatment change the conception of mental illness?
 It cemented the fact that there are organic – somatic – causes to mental illness. It reinforced the fact that psychiatry is
part of medicine, because there are underlying biological causes, and as a result, biological answers.

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It caused a major transformation within psychiatry about Freud’s work. Because there was now a proven biological
root, Freud’s ideas about neuroses, focusing on the childhood, and finding trauma seemed less applicable. Psychiatry
shifted from a Freudian to a neo-Kraeplinian perspective.
It changed the role of psychiatrist, such that their primary responsibility became writing prescriptions, whereas social
workers and psychologists were supposed to handle therapy.
It made treatment, and the broader field of psychiatry responsible, not only to patients, families, and the broader
community, but also to pharmaceutical companies.
It made psychiatry into the mainstream, and made mental illness less of a taboo, because it is just another medical
problem.
Also a backlash, though. Some psychopharmacological medicines change a persons’ conception of self. If drugs are
changing whom a person actually is – their personality -- what is the root of illness, and ethically, should doctors
prescribe pills that change the very core of people? (Kramer talks about this in ‘Listening to Prozac’)
2. In the history of psychiatry, there have been numerous times when there has been a call for psychiatry to return to
medicine. At present, where is psychiatry in relation to the rest of medicine?
 With the success of drugs like Valium, lithium, and most recently, Prozac, psychiatry is looking incredibly similar to
other more somatically based medical specialties. Many illnesses can be alleviated with medicine, pointing to an
organic cause and an organic solution.
 With the advent of the DSM, psychiatrists can look for specific symptoms, and diagnose mental illness, using the
same kind of diagnostic measures used throughout the rest of the field of medicine.
 However, because mental illness involves malfunctions in the brain – the most complicated structure in the human
body – diagnosing mental illness cannot be a concretely scientific venture, in the way diagnosing liver disease can be.
Mental illnesses are often associated with somatic symptoms, and psychological ones as well. Because this is the
case, psychiatry will always be a much more subjective science.
 Kramer highlights the fact that the distinction between mental diseases is often incredibly blurry – specifically
mentioning OCD and compulsive personality disorder. Many different illnesses display incredibly similar symptoms,
and can be treated using the same medicine. This makes diagnosis far more difficult, making psychiatry distinct from
other sub-specialties within medicine.
 At this point, though, psychiatry does seem to have answered the call to return to medicine – more receptively than
ever before. With the DSM and medications that are effective, psychiatry looks like other medicinal specialties more
than it ever has before.
3. Movements within psychiatry have not always proved to be positive or beneficial. Give an example of a movement within
psychiatry that had negative effects at a broader social level, and within the field of psychiatry, itself.
 The mental hygiene movement, in the early 20th century focused on personality, not organic, problems at the root of
mental illness.
 Hygienists blamed maladjustment in childhood – not being raised in the proper environment, not talking enough about
problems, etc. – for later psychiatric problems.
 However, they offered a solution. By education parents and teachers, the mental hygiene movement preached that
mental illness could be prevented. They distributed books, pamphlets, and had exhibits, aimed at teaching people
how to prevent madness.
 However, this movement shifted the emphasis from biology to personality, something that drew psychiatry far away
from the rest of medicine.
 In addition, this movement, and its failures, made society look at those people for whom prevention was not an
option. Because the numbers of mentally ill did not decrease, people began to look at those people – hereditarily
tainted people – who were beyond salvation.
 The mental hygiene movement showed that some people were irreparably maladjusted, and the only way to prevent
this type of irreparable damage seeping into the rest of the population was to isolate, or sterilize those individuals.
 And so, on the heels of the mental hygiene movement, eugenics erupted, targeting the mentally ill among other
groups. Thousands were sterilized, so that their bloodline would be cut off, and in doing so, their incurable
maladjustment would not continue to burden future generations.