HO for Biology of Mental Disorders (BCS 246)

Lecture 6 (9/24)

Issues from last class:

Today's Handout:

• "Enlightenment" 18th century, age of reason, details in last week's ho, brief overview:
• Treatment of insane based on belief that these people had incurable illness whose causes were unknown
• Best approach to insane was through use of cruelty: intimidation and threats, meager diet, whipping, lowering treatments (into water I believe), and chaining
• Witnessed by public for a price
• Cullen and use of term neurosis
• Hysteria and other mental disorders included in this category
• Reforms of treatment of insane (Asylum treatment that is)
• Pinel most famous and promoted occupational therapy, exercise, entertainment, good food, attractive surroundings, regular meetings with attendants and groups of patients, and unchaining
• Much of above may have been due to French Enlightenment ideas and the Declaration of Rights in 1789
• Benjamin Rush (1745-1815) considered the father of American psychiatry
• Was half into the moral treatment camp, even arguing for elimination of stigma, but also used many traditional methods of treatment (physical restraint, chastisement, whirling in a rotary chair)
• Franz Anton Mesmer (1734-1815), Austrian physician
• Believed mentally ill could be cured by "mesmerism", which was based on belief that animal magnetism ("subtle fluid") caused problems and could be normalized by placing of hands and channeling this fluid into the air. Braid termed this neuro-hypnosis which later was shortened to hypnosis.
• Joseph Gall (1758-1828) German physician; founder of Phrenology
• Studied animal and human brains, states first to that that psychic structure and brain structure were related (? semantics here, others felt brain was major player)
• 37 organs in brain, each with different function, and mapped to surface of scalp
• Student Johann Spurzhiem (1776-1858) furthered this approach, very popular!!!
• 19th century French contributions
• Increasing number of physicians devoted their careers to working with psychiatric patients, with psychiatry separating from medicine somewhat, with its own professional organization and journals. French contributed most in first half of century, Germans most in 2nd half
• Esquirol (1782-1870) "most eminent psychiatrist of his time", successor of Pinel. Advanced " moral treatment" with involvement in law as well as developing the first course of clinical instruction in psychiatry in France (maybe the world). Trained physicians to specialize in Asylum practice. Contributed writings on hallucinations, partial insanity (paranoia) vs. general insanity
• J. Moreau de Tours (1804-1884) first psychiatrist to experience and write about drug induced psychosis (hashish)
• Benedict-Augustin Morel (1809-1873) wrote extensively and theorized on the cause of mental illness being inherited mental degeneration, with worsening of syndrome from generation to generation (again, a pattern noted recently and being looked at more closely)
• 19th century English contributions
• Samuel Tuke (1784-1857; grandson of William Tuke, earlier developed York Retreat) and John Conolly
• Influential in pushing "moral treatment" in England, including laws governing institutions and development of Acts of Parliament that directed each county to provide an Asylum, with a central inspecting agency
• James Prichard (1786-1848), one of the Commissioners of Lunacy described moral insanity, a type of madness not seen in asylums, but characterized by impulsive antisocial actions
• 19th century United States contributions
• Inspired by Pinel, superintendents of asylums began organizing a group, the Association of Medical Superintendents of American Institution for the Insane (to become American Psychiatric Association in 1921)
• Lay influences also, including Dorothy Dix (1802-1887) who dedicated her life to exposing the maltreatment of psychiatric patients, affecting legislation and practice
• 19th century German contributions
• Built more asylums than France, with moral treatment practiced in "some"
• Two opposing schools formed (organic vs. psychological again)
• Mental illness caused by "somatic" factors
• Mental illness caused by "psychic" factors
• Psychic school
• Johann Reil (1759-1813) considered founder of rational psychotherapy and promoted occupational therapy, music, and psychodrama in treatment, and founded the first psychiatric journal
• Johann Henroth (1773-1843) wrote book considered the first systematic textbook establishing a clinical system of psychotherapy
• Somatic school
• Wilhelm Griesinger (1817-1868) wrote Mental Pathology and Therapeutics, arguing that psychological phenomena affect the brain and cause alterations, making the distinction between somatic and psychic cause irrelevant (both result in anomalies of the brain). Became chair of academic department of Neuropsychiatry and argued that psychiatry and neurology are but one specialty. Shifted the focus of psychiatric work from the asylum to the university (an institution of treatment, teaching, and research)
• Griesinger the "prototype" of the university psychiatrist
• Second half of 19th century and into 20th century (School of Brain Psychiatry, with proponents being Theodor Meynert and Carl Wernicke)
• Kraepelin (1855-1926)
• Studied histories of thousands of patients, critical of current classification, and wrote numerous editions of Textbook of Psychiatry
• Very focused on longitudinal course and accurate clinical description, resulted in definition of new disorders as well as distinguishing disorders that had been "lumped" together
• Most known for dividing psychoses into "manic-depressive" and "dementia praecox", the first being cyclical with resolution of symptoms typically between episodes, with the latter being chronic with deterioration to dementia
• He divided dementia praecox into two forms that deteriorated: hebephrenia and catatonia (previously described by Hecker and Kahlbaum) and one form that did not deteriorate, dementia paranoia
• Textbook used extensively, with this classification enduring, and he founded the Research Institute of Psychiatry in Munich (advances in organic brain disease and heredity of psychiatric illnesses made here)
• Eugen Bleuler (1857-1939) wrote about dementia praecox and coined the term "schizophrenia" which meant the splitting of the mind's functions (more poor coordination, not split personality!!). Saw dementia praecox as many syndromes and was influenced later by Freud.
• Alzheimer's disease described as well as general paresis, with organic causes eventually found
• Moral treatment deteriorated into what is now called custodialism, due to the great increase in institutions and loss of the moral treatment attitude in many. Conditions became poor with overcrowding, unsanitary conditions, and little therapeutic contact
• Clifford Beers, in 1908 published his own account of three hospitalizations in mental institutions, being the "most influential expose" of asylums yet published. Helped usher in the era of Mental Hygiene, and the inclusion of other professionals in treating the mentally ill (social workers etc.)
• Adolf Meyer (1866-1950) at Johns Hopkins University became the dominant figure in American psychiatry for much of his career. Emphasized psychobiology, a commonsense psychiatry, and was influenced greatly by Freud
• Neurasthenia, as a syndrome of physical and mental exhaustion, described (1868) by George Beard (1839-1882), with cure being his "rest cure". Became prevalent and "fashionable" in middle class America then Europe.
• Charcot, a French neurologist, showed that many symptoms of hysteria could be produced by hypnosis and declared the hypnotized state to be a pathological state
• Rational psychotherapy, as a reaction to hypnosis, developed by Paul Dubois (1848-1918), which attempted to persuade the neurotic patient that his or her thoughts an behavior were irrational (cognitive/behavioral precursor)
• Hughling Jackson (1835-1911) influenced by Darwinian theory and showed how more recently developed areas inhibit the earlier areas of the brain. Speculated that in pathological states, the more recently developed are affected more, allowing the older brain areas to act "uninhibited". Also described in neurologic and psychiatric disorders "positive" and "negative" symptoms (excessive vs. deficient activity of "normal" behaviors) revised recently in schizophrenia research
• Ian Pavlov (1849-1936) studied reflexes of digestion (Nobel Prize in 1904) and went on to propose how reflex learning may influence thought and result in different personality forms
• Sigmund Freud (1856-1939) "no individual in the history of psychiatry has had more influence"

Case vignettes:

• Major depressive disorder
  
  
• Bipolar disorder, mania