A Brief History of Psychiatry
Biology and psychology wrestle for the upper hand.
Posted Oct 20, 2014
Psychiatry got its name as a medical specialty in the early 1800s. For the first century of its existence, the field concerned itself with severely disordered individuals confined to asylums or hospitals. These patients were generally psychotic, severely depressed or manic, or suffered conditions we would now recognize as medical: dementia, brain tumors, seizures, hypothyroidism, etc. As was true of much of medicine at the time, treatment was rudimentary, often harsh, and generally ineffective. Psychiatrists did not treat outpatients, i.e., anyone who functioned even minimally in everyday society. Instead, neurologists treated "nervous" conditions, so named for their presumed origin in disordered nerves.
Around the turn of the 20th century, the neurologist Sigmund Freud published theories on the unconscious roots of some of these less severe disorders, which he termed psycho-neuroses. These disorders impaired relationships and work, or produced odd symptoms such as paralysis or mutism that could not be explained medically. Freud developed psychoanalysis to treat these "neurotic" patients. However, psychiatry, not neurology, soon became the specialty known for providing this treatment. Psychoanalysis thus became the first treatment for psychiatric outpatients. It also created a split in the field, which continues to this day, between biological psychiatry and psychotherapy.
Psychoanalysis was the dominant paradigm in outpatient psychiatry for the first half of the 20th century. In retrospect it overreached, as dominant paradigms often do, and was employed even for conditions where it appeared to do little good. Empirical evidence of its efficacy was scarce, both because psychoanalysts largely shunned experiments, and because analytic interventions and outcomes are inherently difficult to study this way. Nonetheless, many case reports alleged the benefits of psychoanalysis, and subsequent empirical research has tended to support this.
By the late 1950s and early 1960s, new medications began to change the face of psychiatry. Thorazine and other first generation anti-psychotics profoundly improved institutionalized psychotic patients, as did newly developed antidepressants for the severely depressed. (The introduction of lithium for mania is more complicated; it was only available in the U.S. starting in 1970.) State mental hospitals rapidly emptied as medicated patients returned to the community (the "deinstitutionalization movement"). Although a well-funded community mental health system never materialized as promised, psychiatric patients with varying levels of symptoms and dysfunction were now treated as outpatients, often with both medication and psychodynamic psychotherapy, i.e., less intensive psychotherapy based on psychoanalytic principles.
In 1980, the Diagnostic and Statistical Manual (DSM) of Mental Disorders, published by the American Psychiatric Association, was radically revised. Unlike the prior two editions which included psychoanalytic language, DSM-III was symptom-based and "atheoretical," i.e., it described mental disorders without reference to a theory of etiology (cause). This was intended to provide a common language so that biological and psychoanalytic psychiatrists could talk to each other, and to improve the statistical reliability of psychiatric diagnosis. Patients were thereafter diagnosed by "meeting criteria" for one or more defined disorders. One result of this shift was that psychoanalysis and psychodynamic therapies were increasingly seen as nonspecific and unscientific, whereas pharmaceutical research took off in search of drugs that could improve discrete symptoms to the point that patients would no longer meet criteria for a DSM-III disorder.
The push for pharmaceutical innovation paid off. A new class of antidepressants called SSRIs ("selective serotonin reuptake inhibitors") were better tolerated and medically safer than prior antidepressants. The first of these, Prozac, was released in 1987. Shortly thereafter, new anti-psychotics were released: "atypical neuroleptics" such as Risperdal and Zyprexa. Heavily promoted and with apparent advantages over their predecessors, these medications were widely prescribed by psychiatrists, and later by primary care physicians and other generalists. Psychiatry was increasingly seen as a mainstream medical specialty (to the relief of APA leadership), and public research money strongly shifted toward neuroscience and pharmaceutical research. The National Institute of Mental Health (NIMH) declared the 1990s the Decade of the Brain "to enhance public awareness of the benefits to be derived from brain research." DSM-IV was published in 1994, further elaborating criterion-based psychiatric diagnosis. Biological psychiatry appeared to have triumphed.
Meanwhile, clinical psychologists championed the use of cognitive and cognitive-behavioral psychotherapies. Coming from an experimentalist tradition (the "rats in mazes" stereotype of academic psychology), clinical psychologists empirically validated the use of cognitive-behavioral therapy (CBT) for depression, anxiety, and other named disorders. Standardized therapy could be conducted by following a treatment manual; targeted symptom improvement documented success or failure. This empiricism meshed well with the "evidence based medicine" movement starting in the 1990s, to the further detriment of analytic and dynamic therapies. Whether treated by a psychiatrist with a prescription pad or a psychologist with a CBT manual (or both), emotional complaints were first categorized and diagnosed, and then treated by sharply focusing on the specific defining symptoms of the diagnosis.
Notwithstanding the Decade of the Brain and lavish public and private investment, pharmaceutical innovation dried up in the 2000s. No new classes of medication or blockbuster psychiatric drugs were discovered. Moreover, previously unrecognized or under-appreciated side-effects of widely used medications hit the headlines. SSRIs were implicated in increased suicidal behavior, and some patients reported severe "discontinuation syndromes" when stopping treatment. Atypical neuroleptics were associated with a "metabolic syndrome" of weight gain, increased diabetes risk, and other medical complications. Adding insult to injury, the millions spent on basic brain research led to no advancement in our understanding of psychiatric etiology, nor to novel biological treatments. And to top it off, pharmaceutical companies were fined repeatedly and for huge sums for promoting powerful, expensive psychiatric medications for unapproved uses.
The release of DSM-5 in 2013 garnered much controversy. Dr. Allen Frances, chair of the APA task force that oversaw the prior edition, criticized the new effort for its medical/biological bias, and for expanding the scope of psychiatric disorders in ways that shrink the range of normality. Thousands of mental health clinicians and researchers signed petitions opposing the new edition for similar reasons. The NIMH declared it would no longer use DSM diagnoses in its research, because DSM definitions were products of expert consensus, not experimental data. Like psychoanalysis before it, the new dominant paradigm, psychiatry as a "neurobiological" specialty, had also overreached.
Psychiatry's reputation suffered for it. Once the doctors for society's hopeless and forgotten, later the subtle explorers of individual psyches, office-based psychiatrists are now too often viewed as mere technicians, attacking emotional symptoms with one prescription after another. Getting to know the person behind the symptoms is left to non-psychiatric therapists, obscuring the often close connection between medication response and psychology.
Healing the rift between biological psychiatry and psychotherapy was foreshadowed in the 1970s by George L. Engel's biopsychosocial medical model and by Eric R. Kandel's laboratory work on the cellular basis of behavior. (Kandel's classic 2001 paper is well worth reading.) Even at the height of the medicalization of psychiatry in the 1980s and 90s it was recognized that unconscious dynamics affect the doctor-patient relationship, and that interpersonal factors strongly influence whether patients feel helped with treatment. It is time again to acknowledge that many outpatients, probably most, seek treatment not for discrete symptoms but for diffuse dissatisfaction, stormy relationships, unwitting self-sabotage, dissociative reactions, and other misery that cannot readily be reduced to DSM diagnostic criteria. The convenient fiction that people's feelings can be distilled into a "problem list" is not so convenient after all.
The future of psychiatry can be neither "brainless" nor "mindless." History points to many conditions once thought to be "mental" (general paresis, cretinism, senility, seizures, etc.) that are now known to be medical. Brain research is essential, as more such examples are sure to come. It is equally clear that we are nowhere near analyzing and treating human psychology at the neural level. That may be possible someday, but for now any such claims are absurdly premature. The distinction between medical and psychological will likely become less sharp in the years ahead, as certain genetic or other biological differences will be linked to psychological vulnerabilities. Nonetheless, the uneasy tension between biological and psychological psychiatry will not end soon; we are better off embracing it instead of choosing sides. A robust psychiatry of the future will surely claim a wide purview, from the cellular basis of behavior, to individual psychology, to family dynamics, and finally to community and social phenomena that affect us all.
©2014 Steven Reidbord MD. All rights reserved.