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A Brief History of Psychiatry: Evolving Paradigms

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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?
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

3 Paradigm 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

4 Paradigms 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

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

6 Asclepius

7 Ancient World 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

8 Hippocrates (ca BC) Evolving view that mental illness represents an imbalance of the body rather than a supernatural event Concept of melancholia and manic-depression

9 Classical Greece Rationalism
Plato’s ( 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

10 Rome “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”

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


13 Malleus Maleficarum “The Witches Hammer”

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

15 Islamic World Maimonides, Avicenna, others taught a rational rather than supernatural view Psychiatric wards of major hospitals in Islamic capitals Psychiatric texts Moises Maimonides Avicenna Maimonides


17 Bethlehem Hospital “Bedlam”

18 Bedlam “The Rake’s Progress” 1735
“Moral insanity”—mental illness as a result of immorality

19 Enlightenment Moral treatment—reformer of asylum approach
Shackles to be removed Phillipe Pinel ( ) at the Saltpetriere in Paris “Pinel Removing the Shackles”

20 Benjamin Rush (1745-1813) Founder of APA
Signer of Declaration of Independence 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 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

24 Carl Jung ( )

25 Carl Jung 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

26 Psychoanalysis: Evolving Schools
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

27 Psychoanalysis: Evolving Schools
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

28 Emil Kraeplin ( )

29 Alois Alzheimer ( )

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

31 Social Psychiatry Harry Stack Sullivan Mental Hygiene Clinic movement
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 (1866-1950) Psychobiology
Predecessor of biopsychosocial model Psychobiology: view the patient in the context of their entire life experience-in Opposition to Kraeplin’s views on categorical diagnosis

34 Spafford Ackerly ( ) 1st 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 Courier-Journal: “They Can Be Cured” (1937) Led to legislation and new standards here and nationwide Bingham continued to promote mental health

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

37 Egas Moniz (1874-1955) Walter Freeman (1895-1972)
Prefrontal leucotomy-- “lobotomy” Moniz—Nobel Prize 1949—a cautionary tale

38 Ed Landis Founder of Norton Psychiatric Clinic-among first general hospital psych units and academic-private partnerships— 1949 Medical Director NPC 1st ECT in Kentucky 1949

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

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

41 Billy Keller 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

42 Novel by Ken Kesey, movie by Michael Douglas
Best picture Oscar 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. 1950 Founder of Scientology

46 Antipsychiatry Movement
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”

47 Community Mental Health Centers (1963-present)

48 Deinstitutionalization and Community Mental Health Movement
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”

49 Medicare and Medicaid (1967)
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

50 Systems Theory James Grier Miller, M.D., Ph.D. (1916-2002)
“Living Systems” President of U of L

51 George Engel ( )

52 Biopsychosocial Model
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

53 John Schwab 3rd Chair-1973-1991—internist/psychiatrist
Importance of family in psychiatric care 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)


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

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

58 Cognitive-Behavioral Therapy CBT
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.

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

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

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

62 Timeline 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

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

64 Future Psychiatry Paradigms
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

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