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Not so fun facts about psychiatry...

Out of all the medical disciplines psychiatry may arguably have the worst reputation. Unfortunately, this view is not entirely undeserved; the first two Nobel Prizes awarded to psychiatrists were for the discovery that infecting patients with malaria - a form of pyrotherapy - could cure certain psychotic disorders (a consequence of syphilis, and the induced fevers either killed the pathogen - or the patient) and the invention of lobotomy, in which lesioning neural connections, or basically, scraping out pieces of the frontal lobes, made aggressive patients complacent. While much easier to manage afterwards, these patients also lacked any recognizable personality. In all fairness, while these approaches were both literal and metaphorical stabs into the dark, unknown realm of mental illness, terrible treatments such as pyrotherapy and lobotomy were the only alternatives to a lifetime shuttered away in an asylum.  Unfortunately, these institutions were often overcrowded, typically poorly maintained psychiatric hospitals with the main purpose of preventing patients from doing damage to themselves or society because no cures were available.

It is until the middle of the last century that Freud’s legacy firmly controlled the discipline of psychiatry in the United States. It was a widely held belief that all psychiatric illness stemmed from unresolved conflicts of the subconscious that simply needed to be uncovered and discussed to resolve the condition.  Though a neurologist by training, Freud’s approach was not based on biological data but rather on the interpretation of patient case studies fueled by theoretical considerations, many of which when judged by today’s standards appear to be based upon idiosyncratic convictions. For example, today we know that autism is not caused by “frigid mothers” and schizophrenia is not a consequence of obscure inner conflicts.

Initial attempts to classify neuropsychiatric illness in the United States grew out of the 1840 census.  The first Diagnostic and Statistical Manual (DSM) was a medical document which emerged from the assessment of soldiers during World War II. While some biological aspects of mental illness had been considered by this time, a major step forward was the development of the DSM-III, the first guidebook to facilitate the diagnosis of psychiatric illness in a systematic way, based on data rather than on purely Kraepelinian views or Freudian anecdotes. DSM-III was published in 1980(!) as a response to public frustration over inconsistent diagnoses and treatments in psychiatry. The practitioners realized that in order to maintain public trust in psychiatry, insurance coverage for psychiatric procedures, and to find actual cures for devastating illnesses such as depression, bipolar disorder and schizophrenia, a data-based approach was indispensable.

Now, almost 40 years and two DSM versions later, we have a variety of psychopharmacological treatment options. We have also realized that neither pharmacological treatment nor psychotherapy alone can solve the big problems in neuropsychiatric illness, and that combined, these approaches are only a small step towards actually understanding and curing the most devastating disorders. Even with our most advanced neuroimaging technology it is still painstakingly difficult to advance our knowledge. But, taking the history of treatment into perspective along with our evolving  understanding of mental illness, at least we no longer infect patients with malaria or blindly poke around in the frontal lobes of patients suffering from psychoses. We are still a long way from general, reliable solutions but psychiatric illness is no longer a life sentence to an asylum.



Sources/Further Reading:

Lieberman, J., Ogas, O., (2015). Shrinks: the Untold Story of Psychiatry. London: Weidenfeld and Nicolson.

Jamison, Kay Redfield, (1995). An Unquiet Mind. New York: Knopf.

Decker, Hannah, (2013). The making of DSM-III. Oxford: Oxford University Press.


Schematic of a transorbital lobotomy:

Source: https://www.theparisreview.org/blog/2017/04/18/the-art-of-the-lobotomy-and-other-news/

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