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A Brief History of Psychiatry: Evolving Paradigms David A. Casey, M.D. University Of Louisville Louisville, KY.

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Presentation on theme: "A Brief History of Psychiatry: Evolving Paradigms David A. Casey, M.D. University Of Louisville Louisville, KY."— Presentation transcript:

1 A Brief History of Psychiatry: Evolving Paradigms David A. Casey, M.D. University Of Louisville Louisville, KY

2 History of Psychiatry Why care about the history of psychiatry? Why care about the history of psychiatry? Our discipline is controversial Our discipline is controversial We are relatively young and rapidly evolving We are relatively young and rapidly evolving We have many critics with disparate points of view. Why dont they like us? We have many critics with disparate points of view. Why dont they like us? We need to be able to critically view ourselves We need to be able to critically view ourselves Historical perspective locally as well as globally Historical perspective locally as well as globally An outlinenot all inclusive An outlinenot all inclusive

3 Paradigm A pattern or model A pattern or model An organizing system of belief or set of assumptions underlying a scientific discipline An organizing system of belief or set of assumptions underlying a scientific discipline Paradigms can evolve, suddenly shift, overlap or even compete Paradigms can evolve, suddenly shift, overlap or even compete The history of psychiatry can be viewed through its paradigms The history of psychiatry can be viewed through its paradigms

4 Paradigms Mental illness as a medical problemproblem originates within the individual Mental illness as a medical problemproblem originates within the individual Mental illness as a religious, spiritual or supernatural issue Mental illness as a religious, spiritual or supernatural issue Mental illness as a result of family dysfunction Mental illness as a result of family dysfunction Mental illness as a social issue Mental illness as a social issue Problem of personal responsibility Problem of personal responsibility Mind-body duality; nature of consciousness Mind-body duality; nature of consciousness These issues have been present throughout the history of psychiatry These issues have been present throughout the history of psychiatry

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

6 Asclepius

7 Ancient World Greece: cult of Asclepius Greece: cult of Asclepius Mental illness not clearly separate from physical illness Mental illness not clearly separate from physical illness Individual out of favor with the gods; Hubris Individual out of favor with the gods; Hubris The gods favor needs to be regained The gods favor needs to be regained A supernatural, but not necessarily moral, view of the origins of mental illness A supernatural, but not necessarily moral, view of the origins of mental illness

8 Hippocrates (ca BC) 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 Concept of melancholia and manic-depression

9 Classical Greece Rationalism Rationalism Platos ( BC) views sometimes similar to modern ideas Platos ( BC) views sometimes similar to modern ideas Psychological importance of childhood trauma Psychological importance of childhood trauma The unconscious The unconscious Psychological importance of meanings people assign to events rather than events themselves Psychological importance of meanings people assign to events rather than events themselves

10 Rome Four humoursGalen (ca AD) Four humoursGalen (ca AD) Phlegm-phlegmatic-winter, water, unemotional Phlegm-phlegmatic-winter, water, unemotional Blood-sanguinespring, air, fun-loving Blood-sanguinespring, air, fun-loving Black bile-melancholicautumn, earth, sadness Black bile-melancholicautumn, earth, sadness Yellow bile-cholericsummer, fire, passionate Yellow bile-cholericsummer, fire, passionate Similar to the idea of chemical imbalance Similar to the idea of chemical imbalance

11 Late Roman Empire to Middle Ages Christianity---mental illness as a moral issue Christianity---mental illness as a moral issue Consequence of sinning Consequence of sinning Demonic influence or possession Demonic influence or possession Jesus Casting Out a Demon (Mark 5:1-20) Jesus Casting Out a Demon (Mark 5:1-20)

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13 Malleus Maleficarum The Witches Hammer Germany,

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

15 Islamic World 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 wards of major hospitals in Islamic capitals Psychiatric texts Psychiatric texts Moises Maimonides Moises Maimonides Avicenna Avicenna Maimonides

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17 Bethlehem Hospital Bedlam

18 Bedlam The Rakes Progress 1735 The Rakes Progress 1735 Moral insanitymental illness as a result of immorality Moral insanitymental illness as a result of immorality

19 Enlightenment Moral treatmentreformer of asylum approach Moral treatmentreformer of asylum approach Shackles to be removed Shackles to be removed Phillipe Pinel ( ) at the Saltpetriere in Paris Phillipe Pinel ( ) at the Saltpetriere in Paris Pinel Removing the Shackles Pinel Removing the Shackles

20 Benjamin Rush ( ) Founder of APA Founder of APA Signer of Declaration of Independence Signer of Declaration of Independence American Enlightenment –moral treatment American Enlightenment –moral treatment

21 Central State Hospital (1873) Lakeland

22 Sigmund Freud ( )

23 Freud and Psychoanalysis 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 Conscious, preconscious, unconscious: Topographical model Id, ego, superego: Structural model Id, 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 will Deterministic---challenges ideas of free will Ongoing controversy yet many ideas have thoroughly imbued our culture Ongoing controversy yet many ideas have thoroughly imbued our culture

24 Carl Jung ( )

25 Carl Jung Collective unconscious Collective unconscious Archetypesanima, animus, hero, etc. Archetypesanima, animus, hero, etc. Spirituality balancing rationality Spirituality balancing rationality Comparative religions, anthropology Comparative religions, anthropology Synchronicity Synchronicity Analytic psychology Analytic psychology Conflict with Freud over importance of libido Conflict with Freud over importance of libido Importance in art, literature Importance in art, literature Controversies: antisemitism, Nazi collaboration Controversies: antisemitism, Nazi collaboration

26 Psychoanalysis: Evolving Schools Ego Psychology: emphasis on defense mechanisms, unconscious fantasy; Hartmann, Anna Freud, Arlow 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 Object Relations: ego exists in relation to objects; internalized representations of self, others which generate affects; Winnicott, Fairbairn, Melanie Klein

27 Psychoanalysis: Evolving Schools 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 Brief dynamic therapies: Davanloo, Malan, Sifneos, many others Psychoanalytic ideas in social sciences, academic post-modernism Psychoanalytic ideas in social sciences, academic post-modernism

28 Emil Kraeplin ( )

29 Alois Alzheimer ( )

30 Biological Psychiatry The Biomedical Model Kraeplin: illness model, nosology, categorical diagnosis Kraeplin: illness model, nosology, categorical diagnosis Alzheimer: correlating brain function and pathology with clinical diagnosis Alzheimer: correlating brain function and pathology with clinical diagnosis Origins of biological psychiatrythe biomedical model Origins of biological psychiatrythe biomedical model

31 Social Psychiatry Harry Stack Sullivan Harry Stack Sullivan Mental Hygiene Clinic movement Mental Hygiene Clinic movement Louisville Mental Hygiene Clinic eventually evolved into Bingham Child Guidance Center Louisville Mental Hygiene Clinic eventually evolved into Bingham Child Guidance Center

32 John B. Watson B.F. Skinner Behaviorism Watson-classical conditioning Little Albert experiments Skinner-operant conditioning Black box paradigm Observable inputs-outputs

33 Adolf Meyer ( ) Psychobiology Psychobiology: view the patient in the context of their entire life experience-in Opposition to Kraeplins views on categorical diagnosis Predecessor of biopsychosocial model

34 Spafford Ackerly ( ) 1 st full-time U of L Chair (1932/ ) Opened ULH psychiatry unit Groundbreaking psychiatric curriculum Incorporated Louisville Mental Hygiene Clinic (predecessor of BCGC)

35 Media Scrutiny Barry Bingham, Sr ( ) personally investigated CSH and ESH as owner-publisher of Courier-Journal Barry Bingham, Sr ( ) personally investigated CSH and ESH as owner-publisher of Courier-Journal Courier-Journal: They Can Be Cured (1937) Courier-Journal: They Can Be Cured (1937) Led to legislation and new standards here and nationwide Led to legislation and new standards here and nationwide Bingham continued to promote mental health Bingham continued to promote mental health

36 Electroconvulsive Therapy ECT (1938) Cerletti and Bini Ugo Cerletti ( )

37 Egas Moniz ( ) Walter Freeman ( ) Prefrontal leucotomy-- lobotomy Prefrontal leucotomy-- lobotomy MonizNobel Prize 1949a cautionary tale MonizNobel Prize 1949a cautionary tale

38 Ed Landis Founder of Norton Psychiatric Clinic-among first general hospital psych units and academic- private partnerships 1949 Medical Director NPC st ECT in Kentucky 1949

39 Private Asylums OLOP s-one of first and largest freestanding psychiatric hospitals in the US OLOP s-one of first and largest freestanding psychiatric hospitals in the US

40 Psychopharmacolgy Revolution 1950s-Present MAOI MAOI TCA TCA Antipsychotics Antipsychotics Lithium Lithium 1950s through present 1950s through present

41 Billy Keller 2 nd U of L Chair ( ) WW II experience crucial in shaping psychiatry here and throughout US: growth of psychoanalysis and psychotherapy, groups, outpatient treatment

42 Novel by Ken Kesey, movie by Michael Douglas Novel by Ken Kesey, movie by Michael Douglas Best picture Oscar Best picture Oscar State hospital as model of repressive society State hospital as model of repressive society

43 Foucault and Laing

44 Thomas Szasz (b. Hungary, 1920) (Published ca. 1962)

45 L. Ron Hubbard ( ) Pub Founder of Scientology

46 Antipsychiatry Movement Within and outside psychiatry Within and outside psychiatry Michel Foucault Michel Foucault R.D. Laing, Thomas Szasz R.D. Laing, Thomas Szasz Complete rejection (and suspicion) of medical model and psychiatry Complete rejection (and suspicion) of medical model and psychiatry Denial of reality of mental illness; romanticized psychosis Denial of reality of mental illness; romanticized psychosis Belief in social causation Belief in social causation Faded but contributed to legislation limiting commitment, requiring individualized treatment plans rather than custodial treatment Faded but contributed to legislation limiting commitment, requiring individualized treatment plans rather than custodial treatment L. Ron Hubbard and Scientology L. Ron Hubbard and Scientology Louisville Standard Gravure massacre 1989the Prozac trial Louisville Standard Gravure massacre 1989the Prozac trial

47 Community Mental Health Centers (1963-present)

48 Deinstitutionalization and Community Mental Health Movement State hospitals greatly deemphasized-1950s State hospitals greatly deemphasized-1950s CMHC established-1960s CMHC established-1960s KY one of first states to set up CMHC KY one of first states to set up CMHC CMHC never fully funded CMHC never fully funded Locally, River Region bankrupted and reorganized as Seven Counties Services example of financial stresses Locally, River Region bankrupted and reorganized as Seven Counties Services example of financial stresses Transinsitutionalization- the revolving door Transinsitutionalization- the revolving door

49 Medicare and Medicaid (1967) Psychiatry exclusions Psychiatry exclusions Nevertheless fueled stupendous growth in treatment Nevertheless fueled stupendous growth in treatment Explosion of medical school enterprisefaculty increased by orders of magnitude almost overnight Explosion of medical school enterprisefaculty increased by orders of magnitude almost overnight Tended to federalize financial responsibility for care of serious mental illness Tended to federalize financial responsibility for care of serious mental illness

50 Systems Theory James Grier Miller, M.D., Ph.D. ( ) James Grier Miller, M.D., Ph.D. ( ) Living Systems Living Systems President of U of L President of U of L

51 George Engel ( )

52 Biopsychosocial Model George Engel, M.D.internist working in psychosomatics George Engel, M.D.internist working in psychosomatics Seminal works early-mid 1970s Seminal works early-mid 1970s University of Rochester, Univ. of Cincinnati University of Rochester, Univ. of Cincinnati Counterpoint to biomedical model Counterpoint to biomedical model Current dominant paradigm in psychiatry Current dominant paradigm in psychiatry More of a philosophical viewpoint than a true paradigm More of a philosophical viewpoint than a true paradigm Criticismseclecticism; additive rather than integrative Criticismseclecticism; additive rather than integrative

53 John Schwab 3 rd Chair internist/psychiatrist 3 rd Chair internist/psychiatrist Importance of family in psychiatric care Importance of family in psychiatric care A founder of CL psychiatry A founder of CL psychiatry

54 Biological Psychiatry and Measurement 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)

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56 DSM III (1980) and DSM IV (1994; TR 2000) Attempt to standardize diagnosis Attempt to standardize diagnosis Explicit diagnostic criteriaa categorical approach Explicit diagnostic criteriaa categorical approach Attempt to establish validity and reliability of diagnosis Attempt to establish validity and reliability of diagnosis Evolved from need to standardize diagnosis for research Evolved from need to standardize diagnosis for research Multi-axial system adapted from biopsychosocial model Multi-axial system adapted from biopsychosocial model Largely embraced by profession, government, insurance industry Largely embraced by profession, government, insurance industry Field tested at NPC Field tested at NPC Always controversial Always controversial

57 Joel Elkes Behavioral Medicine U of L Genesis Center 1980s U of L Genesis Center 1980s

58 Cognitive-Behavioral Therapy CBT A new paradigm for psychotherapy A new paradigm for psychotherapy Here and now, structured, pragmatic Here and now, structured, pragmatic Addresses symptoms, behaviors, dysfunctional thinking Addresses symptoms, behaviors, dysfunctional thinking Albert Ellis, Ph.D.--RET Albert Ellis, Ph.D.--RET Aaron Beck, M.D. Aaron Beck, M.D. Jesse Wright, M.D., Ph.D. Jesse Wright, M.D., Ph.D.

59 Managed Care Psychiatry: A Paradigm of Clinical Services Authorizations-cost controls, de facto rationing Authorizations-cost controls, de facto rationing Limits on care, especially hospital care Limits on care, especially hospital care MD-limited to diagnosis, psychopharmacology MD-limited to diagnosis, psychopharmacology

60 Leah Dickstein APA Vice-President; President AWP, AMWA APA Vice-President; President AWP, AMWA Women in psychiatry and medicine Women in psychiatry and medicine Retired U of L Associate Chair Retired U of L Associate Chair

61 Allan Tasman 4 th Chair 1991-present 4 th Chair 1991-present Past president APA Past president APA Editor Psychiatry Editor Psychiatry

62 Timeline Supernatural paradigm-ancient world Supernatural paradigm-ancient world Moral/religious paradigm-1 st century-present Moral/religious paradigm-1 st century-present Asylum era-middle ages-1900s Asylum era-middle ages-1900s Psychoanalytic movement-1890s-present Psychoanalytic movement-1890s-present Modern biological psychiatry-1900-present Modern biological psychiatry-1900-present Psychopharm revolution-1950-present Psychopharm revolution-1950-present General hospital psychiatry-1940s-present ? General hospital psychiatry-1940s-present ? Private freestanding hospitals 1950s-present Private freestanding hospitals 1950s-present

63 Timeline Antipsychiatry-1960s-present Antipsychiatry-1960s-present Community mental health-1960s-present Community mental health-1960s-present Medicare and Medicaid present Medicare and Medicaid present Biopsychosocial model-1977-present Biopsychosocial model-1977-present CBT-1970s-present CBT-1970s-present DSM III present DSM III present Managed care-1980s-present Managed care-1980s-present

64 Future Psychiatry Paradigms 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 New appreciation of constant adaptation of brain to internal and external conditions Limits of DSM IV and biopsychosocial model Limits of DSM IV and biopsychosocial model Interaction of psychiatry, religion, politics Interaction of psychiatry, religion, politics Boundaries of psychiatry and other disciplines Boundaries of psychiatry and other disciplines


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