David A. Casey, M. D. University Of Louisville

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  • David A. Casey, M.D.

  • University Of Louisville

  • Louisville, KY


Why care about the history of psychiatry?

  • Why care about the history of psychiatry?

  • Our discipline is controversial

  • We are relatively young and rapidly evolving

  • We have many critics with disparate points of view. Why don’t they like us?

  • We need to be able to critically view ourselves

  • Historical perspective locally as well as globally

  • An outline—not all inclusive



A pattern or model

  • A pattern or model

  • An organizing system of belief or set of assumptions underlying a scientific discipline

  • Paradigms can evolve, suddenly shift, overlap or even compete

  • The history of psychiatry can be viewed through its paradigms



Mental illness as a medical problem—problem originates within the individual

  • Mental illness as a medical problem—problem originates within the individual

  • Mental illness as a religious, spiritual or supernatural issue

  • Mental illness as a result of family dysfunction

  • Mental illness as a social issue

  • Problem of personal responsibility

  • Mind-body duality; nature of consciousness

  • These issues have been present throughout the history of psychiatry







Greece: cult of Asclepius

  • Greece: cult of Asclepius

  • Mental illness not clearly separate from physical illness

  • Individual out of favor with the gods; Hubris

  • The gods’ favor needs to be regained

  • A supernatural, but not necessarily moral, view of the origins of mental illness



Evolving view that mental illness represents an imbalance of the body rather than a supernatural event

  • Evolving view that mental illness represents an imbalance of the body rather than a supernatural event

  • Concept of melancholia and manic-depression



Rationalism

  • Rationalism

  • Plato’s (428-348 BC) views sometimes similar to modern ideas

  • Psychological importance of childhood trauma

  • The unconscious

  • Psychological importance of meanings people assign to events rather than events themselves



“Four humours”—Galen (ca. 129-200 AD)

  • “Four humours”—Galen (ca. 129-200 AD)

  • Phlegm-phlegmatic-winter, water, unemotional

  • Blood-sanguine—spring, air, fun-loving

  • Black bile-melancholic—autumn, earth, sadness

  • Yellow bile-choleric—summer, fire, passionate

  • Similar to the idea of “chemical imbalance”



Christianity---mental illness as a moral issue

  • Christianity---mental illness as a moral issue

  • Consequence of sinning

  • Demonic influence or possession

  • Jesus Casting Out a Demon (Mark 5:1-20)









Maimonides, Avicenna, others taught a rational rather than supernatural view

  • Maimonides, Avicenna, others taught a rational rather than supernatural view

  • Psychiatric wards of major hospitals in Islamic capitals

  • Psychiatric texts

  • Moises Maimonides

  • Avicenna







“The Rake’s Progress” 1735

  • “The Rake’s Progress” 1735

  • “Moral insanity”—mental illness as a result of immorality



Moral treatment—reformer of asylum approach

  • Moral treatment—reformer of asylum approach

  • Shackles to be removed

  • Phillipe Pinel (1745-1826) at the Saltpetriere in Paris

  • “Pinel Removing the Shackles”



  • Founder of APA

  • Signer of Declaration of Independence

  • American Enlightenment –moral treatment







Key ideas: the dynamic unconscious, internal conflicts, defense mechanism, early childhood experience, sexuality, drives, transference, stages of development

  • Key ideas: the dynamic unconscious, internal conflicts, defense mechanism, early childhood experience, sexuality, drives, transference, stages of development

  • Conscious, preconscious, unconscious: Topographical model

  • Id, ego, superego: Structural model

  • A system of psychology as well as treatment

  • Deterministic---challenges ideas of free will

  • Ongoing controversy yet many ideas have thoroughly imbued our culture





Collective unconscious

  • Collective unconscious

  • Archetypes—anima, animus, hero, etc.

  • Spirituality balancing rationality

  • Comparative religions, anthropology

  • Synchronicity

  • Analytic psychology

  • Conflict with Freud over importance of libido

  • Importance in art, literature

  • Controversies: antisemitism, Nazi collaboration



  • Ego Psychology: emphasis on defense mechanisms, unconscious fantasy; Hartmann, Anna Freud, Arlow

  • Object Relations: ego exists in relation to “objects”; internalized representations of self, others which generate affects; Winnicott, Fairbairn, Melanie Klein



Self Psychology: Idea of Self-object; emphasis on empathy as healing force

  • Self Psychology: Idea of Self-object; emphasis on empathy as healing force

  • Brief dynamic therapies: Davanloo, Malan, Sifneos, many others

  • Psychoanalytic ideas in social sciences, academic post-modernism







Kraeplin: illness model, nosology, categorical diagnosis

  • Kraeplin: illness model, nosology, categorical diagnosis

  • Alzheimer: correlating brain function and pathology with clinical diagnosis

  • Origins of biological psychiatry—the biomedical model



Harry Stack Sullivan

  • Harry Stack Sullivan

  • Mental Hygiene Clinic movement

  • Louisville Mental Hygiene Clinic eventually evolved into Bingham Child Guidance Center



Watson-classical conditioning

  • Watson-classical conditioning

  • “Little Albert” experiments

  • Skinner-operant conditioning

  • Black box paradigm

  • Observable inputs-outputs





  • 1st full-time U of L Chair (1932/1947-1963)

  • Opened ULH psychiatry unit

  • Groundbreaking psychiatric curriculum

  • Incorporated Louisville Mental Hygiene Clinic (predecessor of BCGC)



Barry Bingham, Sr (1906-1988) personally investigated CSH and ESH as owner-publisher of Courier-Journal

  • Barry Bingham, Sr (1906-1988) personally investigated CSH and ESH as owner-publisher of Courier-Journal

  • Courier-Journal: “They Can Be Cured” (1937)

  • Led to legislation and new standards here and nationwide

  • Bingham continued to promote mental health





Prefrontal leucotomy-- “lobotomy”

  • Prefrontal leucotomy-- “lobotomy”

  • Moniz—Nobel Prize 1949—a cautionary tale



  • Founder of Norton Psychiatric Clinic-among first general hospital psych units and academic-private partnerships— 1949

  • Medical Director NPC 1949-1975

  • 1st ECT in Kentucky 1949



OLOP-- 1950s-one of first and largest freestanding psychiatric hospitals in the US

  • OLOP-- 1950s-one of first and largest freestanding psychiatric hospitals in the US



MAOI

  • MAOI

  • TCA

  • Antipsychotics

  • Lithium

  • 1950s through present



  • 2nd U of L Chair (1963-1973)

  • WW II experience crucial in shaping psychiatry here and throughout US: growth of psychoanalysis and psychotherapy, groups, outpatient treatment











Within and outside psychiatry

  • Within and outside psychiatry

  • Michel Foucault

  • R.D. Laing, Thomas Szasz

  • Complete rejection (and suspicion) of medical model and psychiatry

  • Denial of reality of mental illness; romanticized psychosis

  • Belief in social causation

  • Faded but contributed to legislation limiting commitment, requiring individualized treatment plans rather than custodial treatment

  • L. Ron Hubbard and Scientology

  • Louisville Standard Gravure massacre 1989—the “Prozac trial”





State hospitals greatly deemphasized-1950s

  • State hospitals greatly deemphasized-1950s

  • CMHC established-1960s

  • KY one of first states to set up CMHC

  • CMHC never fully funded

  • Locally, River Region bankrupted and reorganized as Seven Counties Services—example of financial stresses

  • “Transinsitutionalization”- the “revolving door”



Psychiatry exclusions

  • Psychiatry exclusions

  • Nevertheless fueled stupendous growth in treatment

  • Explosion of medical school enterprise—faculty increased by orders of magnitude almost overnight

  • Tended to federalize financial responsibility for care of serious mental illness



James Grier Miller, M.D., Ph.D. (1916-2002)

  • James Grier Miller, M.D., Ph.D. (1916-2002)

  • “Living Systems”

  • President of U of L 1973--1980





George Engel, M.D.—internist working in psychosomatics

  • George Engel, M.D.—internist working in psychosomatics

  • Seminal works early-mid 1970s

  • University of Rochester, Univ. of Cincinnati

  • Counterpoint to biomedical model

  • Current dominant paradigm in psychiatry

  • More of a philosophical viewpoint than a true paradigm

  • Criticisms—eclecticism; additive rather than integrative









Attempt to standardize diagnosis

  • Attempt to standardize diagnosis

  • Explicit diagnostic criteria—a categorical approach

  • Attempt to establish validity and reliability of diagnosis

  • Evolved from need to standardize diagnosis for research

  • Multi-axial system adapted from biopsychosocial model

  • Largely embraced by profession, government, insurance industry

  • Field tested at NPC

  • Always controversial



  • U of L Genesis Center 1980s



A new paradigm for psychotherapy

  • A new paradigm for psychotherapy

  • Here and now, structured, pragmatic

  • Addresses symptoms, behaviors, dysfunctional thinking

  • Albert Ellis, Ph.D.--RET

  • Aaron Beck, M.D.

  • Jesse Wright, M.D., Ph.D.



  • Authorizations-cost controls, de facto rationing

  • Limits on care, especially hospital care

  • MD-limited to diagnosis, psychopharmacology



  • APA Vice-President; President AWP, AMWA

  • Women in psychiatry and medicine

  • Retired U of L Associate Chair



  • 4th Chair 1991-present

  • Past president APA

  • Editor “Psychiatry”



Supernatural paradigm-ancient world

  • Supernatural paradigm-ancient world

  • Moral/religious paradigm-1st century-present

  • Asylum era-middle ages-1900s

  • Psychoanalytic movement-1890s-present

  • Modern biological psychiatry-1900-present

  • Psychopharm revolution-1950-present

  • General hospital psychiatry-1940s-present ?

  • Private freestanding hospitals 1950s-present



Antipsychiatry-1960s-present

  • Antipsychiatry-1960s-present

  • Community mental health-1960s-present

  • Medicare and Medicaid- 1967-present

  • Biopsychosocial model-1977-present

  • CBT-1970s-present

  • DSM III -1980-present

  • Managed care-1980s-present



Incorporate new knowledge of brain plasticity and genomics

  • Incorporate new knowledge of brain plasticity and genomics

  • New appreciation of constant adaptation of brain to internal and external conditions

  • Limits of DSM IV and biopsychosocial model

  • Interaction of psychiatry, religion, politics

  • Boundaries of psychiatry and other disciplines




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