theory, diagnosis, and treatment in psychiatric practice across ... theories of mental health and illness separated ... focal infection in the abdomen, the teeth, etc.
Psychiatry Richard Noll DeSales University, U.S.A.
Psychiatry is one of the oldest specialty professions in medicine, arising after 1800 in small communities of European, British, and American physicians who were physically, socially, and professionally isolated in separate institutions for the care and management of persons suffering from severe disturbances of thought, emotion, and behavior. Over the past two centuries such persons have been referred to as the insane, mad, lunatic, mentally alienated, distracted, feeble-minded, demented, mentally diseased, or psychotic. Dementia praecox (after 1896) and schizophrenia (after 1908, but particularly after 1922 in Europe and 1927 in the United States) became the dominant labels for inexplicable, incurable madness in institutionalized patients (Noll, 2011). Throughout history, and still true today, general practice physicians have always treated a sizable proportion of patients suffering from less chronic or disabling conditions. Between 1880 and 1930 some began specializing in what were then called “nervous and mental diseases,” although identifying oneself publicly as a specialist was considered unethical professional behavior in Europe, Britain, and the United States until the early twentieth century. In the United States and Britain psychiatrists shifted their focus to the social problems of populations living in communities outside asylum walls after the creation in the United States of the National Committee for Mental Hygiene in 1909 and the Eugenics Records Office in 1910. American psychiatrists promoted the creation of new “psychopathic hospitals” with outpatient clinics, social work, and psychological testing services, and short-term transitional inpatient units (Grob, 1983). Similar “university clinics” had already existed
in Germany since the late 1870s (Engstrom, 2003). This shift in mission also paved the way for the creation of child guidance clinics, the expansion of outpatient psychotherapy and psychiatry, and eventually the inspiration for new professions such as clinical psychology (Grob, 1991). Patients treated or evaluated in such settings were often referred to as nervous, neurasthenic, neurotic, psychoneurotic, constitutionally inferior, psychopathic, simple or latent schizophrenic, or maladjusted. Today, the generic term for all psychiatric conditions is “mental disorder.” German, Austrian, and Swiss physicians and researchers dominated the field from the mid 1800s until World War II, and their word for their specialty—psychiatry—has been universally adopted (Shorter, 2005). The term was coined in 1808 by Johann Christian Reil (1759–1813), a physician and professor of medicine in Halle, and the term “psychiatrist” (psychiater) became widely used to refer to asylum physicians in German-speaking countries by the 1840s. French physicians made most of the earliest contributions to the specialty in the early 1800s, referring to themselves as “alienists” (alienistes) because they practiced “mental medicine” on insane patients suffering from “mental alienation.” From the mid nineteenth century, doctors who worked in asylums, state hospitals, and sanitariums Great Britain and the United States referred to themselves as “asylum physicians” or “alienists” (following the French tradition), and their field was variously referred to as “asylum medicine,” “alienism” (the two preferred terms in the U.S.A.), or “psychological medicine” (preferred in Great Britain). The general usage of the terms “psychiatry” and “psychiatrist” evolved slowly in the United States after the 1903 founding of the elite New York Psychiatrical Society, with “psychiatrist” and “psychiatry” (or, sometimes, “neuropsychiatrist” and “neuropsychiatry”) replacing
The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc. DOI: 10.1002/9781118625392.wbecp427
2 PSYCHIATRY “alienist” and “alienism” after 1917 (Grob, 1973; Noll, 2011). Psychiatry has always occupied a marginal place with respect to the beliefs, practices, and higher social status of other physicians. Its fragile connection to the larger medical profession only became more apparent after the rise of scientific, laboratory-driven medicine and the creation of new biologically grounded specialty professions by the last third of the nineteenth century. The failure of this laboratory revolution to solve essential diagnostic and treatment issues in psychiatry stood in stark contrast to the successes of the new biomedical disciplines of the twentieth century. Due to its international dominance in the post-World War II era, particularly after 1980, the history of psychiatry in the United States provides an illustration of several epistemological and historical tensions that inform current theory, diagnosis, and treatment in psychiatric practice across the globe. Of all the European influences on American medicine in the last third of the nineteenth century and, beginning in 1896, American psychiatry, the doctrine of disease specification was the most powerful. The new notion that diseases were natural entities existing outside their appearance in the unique bodies and experiences of individual men and women, and not to be interpreted as a unique consequence of place and person, led to our current medical belief that diseases have typical signs and symptoms, typical courses, typical outcomes, and specifiable biological mechanisms underlying them all. This principle of biological disease specificity was at the heart of the psychiatric perspective of German psychiatrists Karl Kahlbaum (1828–99) and Emil Kraepelin (1856–1926), perhaps the most influential figure in the history of psychiatry. Beginning with the fifth edition of his textbook, Psychiatrie (1896), Kraepelin offered a classification of mental diseases that was based on longitudinal research spanning many years. From his observations he noticed typical patterns of course and outcome and made new diagnostic groupings based on this evidence. He assumed that
these patterns might reflect underlying natural disease entities, and by making a diagnosis using the patient information he provided in his manual he asserted that psychiatrists could now make a diagnosis that indicated what the probable prognosis of the patient would be; this was a first for psychiatry, but already well known in other branches of scientific medicine (Berrios, 1996; Berrios & Porter, 1995). Although Kraepelin’s first love was his work in experimental psychology, his continual revisions of his textbook and his leadership of multidisciplinary, dual-purpose clinical and research clinics in Heidelberg and Munich until his death made him a pivotal figure in the psychiatric profession’s effort to rejoin general medicine. In America, Swiss émigré neurologists Adolf Meyer (1866–1950) and August Hoch (1868–1919) were the first to introduce Kraepelinian classification and mental disorders such as dementia praecox and manic depressive insanity after 1896, but both turned toward psychosocial theories after 1903 and retreated from Kraepelin’s quest for biological disease specificity in psychiatry. However, around 1910 the published psychiatric literature on both sides of the Atlantic began to be dominated by articles on discrete categories of mental diseases and evidenced a decline in articles on “insanity” as a general condition. A compensatory embrace of psychosocial theories of mental health and illness separated psychiatry further from biomedicine in the United States and United Kingdom from about 1910 until the late 1970s. Adolph Meyer used his political power of patronage to dominate the institutions of American psychiatry from 1900 to 1940, promoting a holistic “psychobiology” perspective which viewed all mental disease as resulting from maladaptive reactions to an individual’s unique biopsychosocial history of stressors (Pressman, 1998). Meyer’s reliance upon induction and the documenting of an extensive case history detailing the unique life situation of the patient, and the patient’s habitual style of reaction to his or her unique life situation, was all that mattered. Unique situations were not generalizable,
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hence in his opinion categorical diagnostic concepts and conclusions drawn from biological and psychological laboratory research were of limited value. Since Meyer regarded each patient as a unique “experiment of life” and a “type” of one, he was critical of all attempts at classification, generalization, or statistical quantification in psychiatry. After 1903 he rejected most biologically specifiable disease concepts for psychiatry, preferring instead the looser language of “reactions” or “reaction types.” The psychoanalytic theories and treatments of Austrian neurologist Sigmund Freud (1858–1939) blended seamlessly with the maladjustment model of Meyer and rapidly eclipsed it. With the continual failure of biomedical efforts to solve the riddle of severe mental diseases such as dementia praecox, manic depressive insanity, and schizophrenia, by default Freud became a culturally idealized “god of the gaps” between the 1920s and 1980s. Freudian mental mechanisms, not biological mechanisms, became the dominant discourse of psychiatry (Ellenberger, 1970; Shorter, 1997). After 1918 there was a movement in the United States to have a uniform system of statistical record-keeping in institutions for the insane (including a standard set of 22 classifications for mental diseases) and early attempts were made at epidemiological studies of mental diseases inspired by the public health movement in medicine. By the mid 1920s, with significant encouragement by Rockefeller-family philanthropy, psychiatry slowly began its embrace of quantification methods from the social sciences, particularly the new statistical and biometric methods of Karl Pearson (1857–1936), Ronald A. Fisher (1890–1962), and Raymond Pearl (1879–1940). These new methods were first applied at the Boston Psychopathic Hospital between 1925 and 1934 and at the Worcester State Hospital between 1927 and 1946. At Worcester a multidisciplinary schizophrenia research project led by endocrinologist Roy Hoskins (1880–1964) developed psychiatry’s first operationalized research diagnostic
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criteria for subject selection based on the collaboration of biometrician E. M. Jellinek (1890–1963) and psychologist David Shakow (1901–81) (Cautin, 2008). The absence of biomedical breakthroughs in psychiatry, especially its lack of objective, quantitative biological diagnostic tests for mental diseases/disorders, led to its increasing reliance upon statistical methods (and psychologists) to solve problems such as the reliability of diagnosis, which was not even recognized as a problem by physicians who trusted their five senses and subjective, experience-based medical opinions. Unable to solve the medical and social catastrophe of the institutionalized mentally ill, psychiatrists left the hopelessness of the asylums for clinic and private practice in the community and turned their attention to prevention through psychotherapy, psychoanalysis, and mental hygiene education. The migration was slow between 1900 and 1930, accelerated to the point that only two thirds of American psychiatrists still worked in institutions in 1942, and then peaked after the war. Those who remained in institutions experimented with somatic treatments such as surgery (removal of ovaries, portions of the thyroid gland, or suspected sources of focal infection in the abdomen, the teeth, etc.), organotherapy (injection with gland extracts), prolonged drug-induced sleep, chemical and electroshock therapies, insulin coma treatment, induced fever therapies, and psychosurgery of the brain. The serendipitous discovery of the antimanic and antipsychotic effects of lithium (1949) and chlorpromazine (1952) led to a pharmacological revolution in psychiatry that challenged psychoanalytic and other psychotherapeutic treatments in psychiatry. Neurotransmitters and genes replaced psychosocial maladjustments and mothers as the suspected origins of mental disorders and as the rationales for treatment and research. In the 1970s “neo-Kraepelinian” psychiatrists in America led a movement to create a new diagnostic manual which reasserted
4 PSYCHIATRY the medical cognition of Kraepelin. They were influenced by advances in biochemistry, genetics, and brain science and disdainful of the dominant Meyerian and Freudian assumptions of pure psychosocial causation and a fluid dimensional concept of health and illness that did not distinguish between severe and disabling disorders such as schizophrenia and everyday problems with depression and anxiety. When the American Psychiatric Association published DSM-III in 1980 it ignited a backlash against Freudism and psychoanalysis in psychiatry and rationalized a turn to biological psychiatry (Decker, 2013). Since the 1980s psychiatry has attempted to reassert its place in medicine as a strictly “biological psychiatry,” but in order to do so treatment has shifted to an almost exclusive reliance on psychopharmacology (Grob, 1991; Healy, 2002, 2012). Psychotherapeutic treatment by psychiatrists has almost completely disappeared. Whether psychiatry will survive as a separate specialty in twenty-first century biomedicine remains an open question, since conditions which have been traditionally under the jurisdiction of psychiatrists may increasingly be treated by primary care physicians or other allied professions such as clinical nurse specialists and clinical psychologists who have the legal authority for the limited prescription of medications. Perhaps the diagnosis and treatment of many mental disorders may eventually be transferred to the jurisdiction of other medical specialties (such as endocrinology, immunology, or virology) that may use serum biomarkers as the basis of systemic or “whole-body” disease models that extend beyond the current psychiatric obsession with the brain. Perhaps because of its uniquely marginal status in medicine as a healing profession that crosses biological, social, moral, and psychological boundaries as it continually renegotiates cultural norms of abnormal behavior, the literature on the history of psychiatry is enormous. For the European and British background the reader is referred to the works of Shorter
(1997, 2005), Berrios (1996), Berrios and Porter (1995), Engstrom (2003), and Ellenberger (1970). For the history of psychiatry in the United States, the works of Grob (1973, 1983, 1991), Pressman (1998), Noll (2011), and Decker (2013) are recommended. For the rise of psychopharmacology, and a critique, see the works of David Healy (2002, 2012). SEE ALSO: DSM-I and DSM-II; DSM-III and DSM-III-R; DSM-IV; DSM-5; Fisher, Ronald A. (1890–1962); Kraepelin, Emil (1856–1926); Meyer, Adolf (1866–1950); Neo-Kraepelinians; Schizophrenia; Shakow, David (1901–81)
References Berrios, G. E. (1996). The history of mental symptoms: Descriptive psychopathology since the nineteenth century. Cambridge: Cambridge University Press. Berrios, G. E., & Porter, R. (1995). A history of clinical psychiatry: The origin and history of psychiatric disorders. London: Athlone Press. Cautin, R. L. (2008). David Shakow and schizophrenia research at the Worcester State Hospital: The roots of the scientist-practitioner model. Journal of the History of the Behavioral Sciences, 44, 219–237. Decker, H. (2013). The making of DSM-III: A diagnostic manual’s conquest of American psychiatry. New York: Oxford University Press. Ellenberger, H. F. (1970). The discovery of the unconscious: The history and evolution of dynamic psychiatry. New York: Basic Books. Engstrom, E. J. (2003). Clinical psychiatry in Imperial Germany: A history of psychiatric practice. Ithaca, NY: Cornell University Press. Grob, G. N. (1973). Mental institutions in America: Social policy to 1875. New York: Free Press. Grob, G. N. (1983). Mental illness and American society, 1875-1940. Princeton, NJ: Princeton University Press. Grob, G. N. (1991). From asylum to community: Mental health policy in modern America. Princeton, NJ: Princeton University Press. Healy, D. (2002). The creation of psychopharmacology. Cambridge, MA: Harvard University Press. Healy, D. (2012). Pharmageddon. Berkeley, CA: University of California Press.
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Noll, R. (2011). American madness: The rise and fall of dementia praecox. Cambridge, MA: Harvard University Press. Pressman, J. (1998). Last resort: Psychosurgery and the limits of medicine. Cambridge: Cambridge University Press. Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of prozac. New York: John Wiley and Sons. Shorter, E. (2005). A historical dictionary of psychiatry. New York: Oxford University Press.
Further Reading Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. New York: Blue Rider Press. Lamb, S. (2014). Pathologist of the mind: Adolf Meyer, psychobiology and the Phipps Psychiatric Clinic at the Johns Hopkins Hospital, 1908-1917. Baltimore: Johns Hopkins University Press (forthcoming).
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