A Brief History of Psychiatry
Biology and psychology wrestle for the upper hand.
Posted October 20, 2014 | Reviewed by Ekua Hagan
THE BASICS
• What Is Psychiatry?
• Find a therapist near me
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 the
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.
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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.
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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.
