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? 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 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 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 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” 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 Novel by Ken Kesey, movie by Michael Douglas Best picture Oscar State hospital as model of repressive society 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 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 3rd Chair-1973-1991—internist/psychiatrist Importance of family in psychiatric care A founder of CL psychiatry 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 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 Dostları ilə paylaş:
