A Brief History of A Brief History of Psychiatry:Psychiatry:

Evolving ParadigmsEvolving Paradigms

David A. Casey, M.D.David A. Casey, M.D.

University Of LouisvilleUniversity Of Louisville

Louisville, KYLouisville, KY

History of PsychiatryHistory of Psychiatry

Why care about the history of psychiatry?Why care about the history of psychiatry? Our discipline is controversialOur discipline is controversial We are relatively young and rapidly evolvingWe are relatively young and rapidly evolving We have many critics with disparate points We have many critics with disparate points

of view. Why don’t they like us?of view. Why don’t they like us? We need to be able to critically view We need to be able to critically view

ourselvesourselves Historical perspective locally as well as Historical perspective locally as well as

globallyglobally An outline—not all inclusiveAn outline—not all inclusive

ParadigmParadigm

A pattern or modelA pattern or model An organizing system of belief or set An organizing system of belief or set

of assumptions underlying a of assumptions underlying a scientific disciplinescientific discipline

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

The history of psychiatry can be The history of psychiatry can be viewed through its paradigmsviewed through its paradigms

ParadigmsParadigms Mental illness as a medical problem—Mental illness as a medical problem—

problem originates within the individualproblem originates within the individual Mental illness as a religious, spiritual or Mental illness as a religious, spiritual or

supernatural issuesupernatural issue Mental illness as a result of family Mental illness as a result of family

dysfunctiondysfunction Mental illness as a social issueMental illness as a social issue Problem of personal responsibilityProblem of personal responsibility Mind-body duality; nature of consciousnessMind-body duality; nature of consciousness These issues have been present throughout These issues have been present throughout

the history of psychiatrythe history of psychiatry

Good and Evil: A Good and Evil: A Question Of Brain Question Of Brain Function or ChoiceFunction or Choice

AsclepiusAsclepius

Ancient WorldAncient World

Greece: cult of AsclepiusGreece: cult of Asclepius Mental illness not clearly separate Mental illness not clearly separate

from physical illnessfrom physical illness Individual out of favor with the gods; Individual out of favor with the gods;

HubrisHubris The gods’ favor needs to be regained The gods’ favor needs to be regained A supernatural, but not necessarily A supernatural, but not necessarily

moral, view of the origins of mental moral, view of the origins of mental illnessillness

HippocratesHippocrates(ca. 460-370 BC) (ca. 460-370 BC)

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

Concept of melancholia and manic-Concept of melancholia and manic-depressiondepression

Classical GreeceClassical Greece

RationalismRationalism Plato’s (428-348 BC) views sometimes Plato’s (428-348 BC) views sometimes

similar to modern ideassimilar to modern ideas Psychological importance of childhood Psychological importance of childhood

traumatrauma The unconsciousThe unconscious Psychological importance of meanings Psychological importance of meanings

people assign to events rather than people assign to events rather than events themselvesevents themselves

RomeRome

““Four humours”—Galen (ca. 129-200 AD)Four humours”—Galen (ca. 129-200 AD) Phlegm-phlegmatic-winter, water, Phlegm-phlegmatic-winter, water,

unemotionalunemotional Blood-sanguine—spring, air, fun-lovingBlood-sanguine—spring, air, fun-loving Black bile-melancholic—autumn, earth, Black bile-melancholic—autumn, earth,

sadnesssadness Yellow bile-choleric—summer, fire, Yellow bile-choleric—summer, fire,

passionatepassionate Similar to the idea of “chemical imbalance”Similar to the idea of “chemical imbalance”

Late Roman Empire to Late Roman Empire to Middle AgesMiddle Ages

Christianity---mental illness as a moral issueChristianity---mental illness as a moral issue Consequence of sinningConsequence of sinning Demonic influence or possessionDemonic influence or possession

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

Malleus MaleficarumMalleus Maleficarum“The Witches Hammer”“The Witches Hammer”

Germany, 1486-1487

St Joan of Arc Burning at St Joan of Arc Burning at the Stake (1431)the Stake (1431)

Islamic WorldIslamic World

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

Psychiatric wards of major hospitals Psychiatric wards of major hospitals in Islamic capitalsin Islamic capitals

Psychiatric textsPsychiatric texts Moises MaimonidesMoises Maimonides AvicennaAvicenna

Maimonides 1135-1204

Bethlehem HospitalBethlehem Hospital“Bedlam”“Bedlam”

BedlamBedlam

““The Rake’s Progress” 1735The Rake’s Progress” 1735 ““Moral insanity”—mental illness as a Moral insanity”—mental illness as a

result of immoralityresult of immorality

EnlightenmentEnlightenment

Moral treatment—reformer of Moral treatment—reformer of asylum approachasylum approach

Shackles to be removedShackles to be removed Phillipe Pinel (1745-1826) at the Phillipe Pinel (1745-1826) at the

Saltpetriere in ParisSaltpetriere in Paris ““Pinel Removing the Shackles”Pinel Removing the Shackles”

Benjamin RushBenjamin Rush(1745-1813)(1745-1813)

Founder of APAFounder of APA Signer of Declaration of IndependenceSigner of Declaration of Independence American Enlightenment –moral treatmentAmerican Enlightenment –moral treatment

Central State Hospital Central State Hospital (1873)(1873)

“Lakeland”“Lakeland”

Sigmund Freud (1856-Sigmund Freud (1856-1939)1939)

Freud and Freud and PsychoanalysisPsychoanalysis

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

Conscious, preconscious, unconscious: Conscious, preconscious, unconscious: Topographical modelTopographical model

Id, ego, superego: Structural modelId, ego, superego: Structural model A system of psychology as well as treatment A system of psychology as well as treatment Deterministic---challenges ideas of free willDeterministic---challenges ideas of free will Ongoing controversy yet many ideas have Ongoing controversy yet many ideas have

thoroughly imbued our culturethoroughly imbued our culture

Carl Jung (1875-1961)Carl Jung (1875-1961)

Carl JungCarl Jung

Collective unconsciousCollective unconscious Archetypes—anima, animus, hero, etc.Archetypes—anima, animus, hero, etc. Spirituality balancing rationalitySpirituality balancing rationality Comparative religions, anthropologyComparative religions, anthropology SynchronicitySynchronicity Analytic psychologyAnalytic psychology Conflict with Freud over importance of libidoConflict with Freud over importance of libido Importance in art, literatureImportance in art, literature Controversies: antisemitism, Nazi Controversies: antisemitism, Nazi

collaborationcollaboration

Psychoanalysis: Evolving Psychoanalysis: Evolving SchoolsSchools

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

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

Psychoanalysis: Evolving Psychoanalysis: Evolving SchoolsSchools

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

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

Psychoanalytic ideas in social Psychoanalytic ideas in social sciences, academic post-modernismsciences, academic post-modernism

Emil Kraeplin (1856-Emil Kraeplin (1856-1926)1926)

Alois Alzheimer (1864-Alois Alzheimer (1864-1915)1915)

Biological PsychiatryBiological PsychiatryThe Biomedical ModelThe Biomedical Model

Kraeplin: illness model, nosology, Kraeplin: illness model, nosology, categorical diagnosiscategorical diagnosis

Alzheimer: correlating brain Alzheimer: correlating brain function and pathology with clinical function and pathology with clinical diagnosisdiagnosis

Origins of biological psychiatry—the Origins of biological psychiatry—the biomedical modelbiomedical model

Social PsychiatrySocial Psychiatry

Harry Stack SullivanHarry Stack Sullivan Mental Hygiene Clinic movementMental Hygiene Clinic movement Louisville Mental Hygiene Clinic Louisville Mental Hygiene Clinic

eventually evolved into Bingham eventually evolved into Bingham Child Guidance CenterChild Guidance Center

John B. Watson B.F. John B. Watson B.F. SkinnerSkinner

BehaviorismBehaviorismWatson-classical conditioningWatson-classical conditioning

““Little Albert” experimentsLittle Albert” experiments

Skinner-operant conditioningSkinner-operant conditioning

Black box paradigmBlack box paradigm

Observable inputs-outputsObservable inputs-outputs

Adolf Meyer (1866-1950)Adolf Meyer (1866-1950)PsychobiologyPsychobiology

Psychobiology: view the patient in the context of their entire life experience-inOpposition to Kraeplin’s views on categorical diagnosis

Predecessor of biopsychosocial model

Spafford Ackerly (1895-Spafford Ackerly (1895-1981)1981)

11stst full-time U of L Chair (1932/1947-1963) full-time U of L Chair (1932/1947-1963)

Opened ULH psychiatry unitOpened ULH psychiatry unit

Groundbreaking psychiatric curriculumGroundbreaking psychiatric curriculum

Incorporated Louisville Mental Hygiene Incorporated Louisville Mental Hygiene Clinic (predecessor of BCGC)Clinic (predecessor of BCGC)

Media ScrutinyMedia Scrutiny

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

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

Led to legislation and new standards Led to legislation and new standards here and nationwidehere and nationwide

Bingham continued to promote mental Bingham continued to promote mental healthhealth

Electroconvulsive Electroconvulsive TherapyTherapy

ECT (1938)ECT (1938)Cerletti and BiniCerletti and Bini

Ugo Cerletti (1877-1963)

Egas Moniz (1874-1955) Egas Moniz (1874-1955) Walter Freeman (1895- Walter Freeman (1895-

1972)1972) Prefrontal leucotomy-- “lobotomy”Prefrontal leucotomy-- “lobotomy”

Moniz—Nobel Prize 1949—a cautionary Moniz—Nobel Prize 1949—a cautionary taletale

Ed LandisEd Landis

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

Medical Director NPC 1949-1975Medical Director NPC 1949-1975

11stst ECT in Kentucky 1949 ECT in Kentucky 1949

Private AsylumsPrivate Asylums

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

Psychopharmacolgy Psychopharmacolgy RevolutionRevolution

1950s-Present1950s-Present MAOIMAOI TCATCA AntipsychoticsAntipsychotics LithiumLithium 1950s through present1950s through present

Billy KellerBilly Keller

22ndnd U of L Chair (1963-1973) U of L Chair (1963-1973)

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

Novel by Ken Kesey, movie by Michael Novel by Ken Kesey, movie by Michael DouglasDouglas

Best picture OscarBest picture Oscar State hospital as model of repressive societyState hospital as model of repressive society

Foucault and LaingFoucault and Laing

Thomas Szasz Thomas Szasz (b. Hungary, 1920)(b. Hungary, 1920)

(Published ca. 1962)

L. Ron Hubbard (1911-L. Ron Hubbard (1911-1986)1986)

Pub. 1950Founder of Scientology

Antipsychiatry MovementAntipsychiatry Movement Within and outside psychiatryWithin and outside psychiatry Michel FoucaultMichel Foucault R.D. Laing, Thomas SzaszR.D. Laing, Thomas Szasz Complete rejection (and suspicion) of medical model and Complete rejection (and suspicion) of medical model and

psychiatrypsychiatry Denial of reality of mental illness; romanticized psychosisDenial of reality of mental illness; romanticized psychosis Belief in social causationBelief in social causation Faded but contributed to legislation limiting commitment, Faded but contributed to legislation limiting commitment,

requiring individualized treatment plans rather than requiring individualized treatment plans rather than custodial treatmentcustodial treatment

L. Ron Hubbard and ScientologyL. Ron Hubbard and Scientology Louisville Standard Gravure massacre 1989—the “Prozac Louisville Standard Gravure massacre 1989—the “Prozac

trial”trial”

Community Mental Community Mental Health Centers (1963-Health Centers (1963-

present)present)

Deinstitutionalization and Deinstitutionalization and Community Mental Health Community Mental Health

MovementMovement State hospitals greatly deemphasized-1950sState hospitals greatly deemphasized-1950s CMHC established-1960sCMHC established-1960s KY one of first states to set up CMHCKY one of first states to set up CMHC CMHC never fully fundedCMHC never fully funded Locally, River Region bankrupted and Locally, River Region bankrupted and

reorganized as Seven Counties Services—reorganized as Seven Counties Services—example of financial stressesexample of financial stresses

““Transinsitutionalization”- the “revolving Transinsitutionalization”- the “revolving door”door”

Medicare and Medicaid Medicare and Medicaid (1967)(1967)

Psychiatry exclusionsPsychiatry exclusions Nevertheless fueled stupendous Nevertheless fueled stupendous

growth in treatment growth in treatment Explosion of medical school enterpriseExplosion of medical school enterprise

—faculty increased by orders of —faculty increased by orders of magnitude almost overnightmagnitude almost overnight

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

Systems TheorySystems Theory

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

““Living Systems”Living Systems” President of U of L 1973--1980President of U of L 1973--1980

George Engel (1913-George Engel (1913-1999)1999)

Biopsychosocial ModelBiopsychosocial Model

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

Seminal works early-mid 1970sSeminal works early-mid 1970s University of Rochester, Univ. of CincinnatiUniversity of Rochester, Univ. of Cincinnati Counterpoint to biomedical modelCounterpoint to biomedical model Current dominant paradigm in psychiatryCurrent dominant paradigm in psychiatry More of a philosophical viewpoint than a More of a philosophical viewpoint than a

true paradigmtrue paradigm Criticisms—eclecticism; additive rather than Criticisms—eclecticism; additive rather than

integrativeintegrative

John SchwabJohn Schwab

33rdrd Chair-1973-1991—internist/psychiatrist Chair-1973-1991—internist/psychiatrist Importance of family in psychiatric careImportance of family in psychiatric care A founder of CL psychiatryA founder of CL psychiatry

Biological Psychiatry and Biological Psychiatry and MeasurementMeasurement

“Where measurement begins, science enters in…”J. Willis Hurst, M.D.

“Statistical significance is not the same as clinical significance”David Healy, M.D. (paraphrase)

DSM III (1980) and DSM DSM III (1980) and DSM IV (1994; TR 2000)IV (1994; TR 2000)

Attempt to standardize diagnosisAttempt to standardize diagnosis Explicit diagnostic criteria—a categorical approachExplicit diagnostic criteria—a categorical approach Attempt to establish validity and reliability of Attempt to establish validity and reliability of

diagnosisdiagnosis Evolved from need to standardize diagnosis for Evolved from need to standardize diagnosis for

researchresearch Multi-axial system adapted from biopsychosocial Multi-axial system adapted from biopsychosocial

modelmodel Largely embraced by profession, government, Largely embraced by profession, government,

insurance industryinsurance industry Field tested at NPCField tested at NPC Always controversialAlways controversial

Joel ElkesJoel ElkesBehavioral MedicineBehavioral Medicine

U of L Genesis Center 1980s U of L Genesis Center 1980s

Cognitive-Behavioral Cognitive-Behavioral TherapyTherapy

CBTCBT A new paradigm for psychotherapyA new paradigm for psychotherapy Here and now, structured, Here and now, structured,

pragmaticpragmatic Addresses symptoms, behaviors, Addresses symptoms, behaviors,

dysfunctional thinking dysfunctional thinking Albert Ellis, Ph.D.--RETAlbert Ellis, Ph.D.--RET Aaron Beck, M.D.Aaron Beck, M.D. Jesse Wright, M.D., Ph.D.Jesse Wright, M.D., Ph.D.

Managed Care Managed Care Psychiatry: A Paradigm Psychiatry: A Paradigm

of Clinical Servicesof Clinical Services

Authorizations-cost controls, de facto Authorizations-cost controls, de facto rationingrationing

Limits on care, especially hospital careLimits on care, especially hospital care MD-limited to diagnosis, psychopharmacology MD-limited to diagnosis, psychopharmacology

Leah DicksteinLeah Dickstein

APA Vice-President; President AWP, AMWAAPA Vice-President; President AWP, AMWA Women in psychiatry and medicineWomen in psychiatry and medicine Retired U of L Associate ChairRetired U of L Associate Chair

Allan TasmanAllan Tasman

44thth Chair 1991-present Chair 1991-present Past president APAPast president APA Editor “Psychiatry”Editor “Psychiatry”

TimelineTimeline

Supernatural paradigm-ancient worldSupernatural paradigm-ancient world Moral/religious paradigm-1Moral/religious paradigm-1stst century-present century-present Asylum era-middle ages-1900sAsylum era-middle ages-1900s Psychoanalytic movement-1890s-presentPsychoanalytic movement-1890s-present Modern biological psychiatry-1900-presentModern biological psychiatry-1900-present Psychopharm revolution-1950-presentPsychopharm revolution-1950-present General hospital psychiatry-1940s-present ?General hospital psychiatry-1940s-present ? Private freestanding hospitals 1950s-presentPrivate freestanding hospitals 1950s-present

TimelineTimeline

Antipsychiatry-1960s-presentAntipsychiatry-1960s-present Community mental health-1960s-Community mental health-1960s-

presentpresent Medicare and Medicaid- 1967-presentMedicare and Medicaid- 1967-present Biopsychosocial model-1977-presentBiopsychosocial model-1977-present CBT-1970s-presentCBT-1970s-present DSM III -1980-presentDSM III -1980-present Managed care-1980s-presentManaged care-1980s-present

Future Psychiatry Future Psychiatry ParadigmsParadigms

Incorporate new knowledge of brain Incorporate new knowledge of brain plasticity and genomicsplasticity and genomics

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

Limits of DSM IV and biopsychosocial Limits of DSM IV and biopsychosocial modelmodel

Interaction of psychiatry, religion, politicsInteraction of psychiatry, religion, politics Boundaries of psychiatry and other Boundaries of psychiatry and other

disciplinesdisciplines