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

• 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

• 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

• 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

• 3rd Chair-1973-1991—internist/psychiatrist

• Importance of family in psychiatric care

• A founder of CL psychiatry

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