History of psychiatry

Abstract

Purpose of review

The present review examines recent contributions to the evolving field of historical writing in psychiatry.

Recent findings

Interest in the history of psychiatry continues to grow, with an increasing emphasis on topics of current interest such as the history of psychopharmacology, electroconvulsive therapy, and the interplay between psychiatry and society. The scope of historical writing in psychiatry as of 2007 is as broad and varied as the discipline itself.

Summary

More than in other medical specialties such as cardiology or nephrology, treatment and diagnosis in psychiatry are affected by trends in the surrounding culture and society. Studying the history of the discipline provides insights into possible alternatives to the current crop of patent-protected remedies and trend-driven diagnoses.

Introduction

Interest in the history of psychiatry continues to grow, shifting from curiosity about the history of psychoanalysis and Freud’s Vienna to the history of psychopharmacology, electroconvulsive therapy (ECT) and neuroscience, subjects more in the forefront today. Yet the scope of historical writing in psychiatry is as broad as the discipline itself, and the history of psychiatry in 2007 has tumbled into many variegated nooks and crannies.

History of psychopharmacology

Among senior figures in psychopharmacology, Thomas A. Ban, emeritus professor of psychiatry at Vanderbilt University, has applied himself most consistently to the discipline’s history over the years. In 2006, Ban [1^••] described the relationship among diagnosis, pharmaceutical industry, and clinical trials, postulating that ‘development of a pharmacologically valid psychiatric nosology with a “nosological matrix” would provide the pharmaceutical industry with the necessary feedback to develop clinically selective drugs in mental illness and to break the impasse of progress in “translational research” in psychiatry’ (p. 429). Ban also wrote a history of the Collegium Internationale Neuro-Psychopharmacologicum [2^•].

Klein [3^•], another senior psychopharmacologist, has described his early experiences with antipsychotics, ending with thoughts about regulatory changes needed today. Emil Kraepelin, the founder of modern psychiatric nosology, now excites great interest, and a team of German and English scholars, using published sources, has chronicled his early psychopharmacological research [4].

Finally, Turner [5], a consultant psychiatrist in London with a long track record of publication in the history of psychiatry, looks at the discovery of chlorpromazine (Thorazine, Largactil) in 1952 as ‘a kind of psychic penicillin’ that opened the therapeutics of psychosis.

Psychiatry and bioethics

The accent here is usually on the Nazi years. Notable is the work of a team of scholars at the Max Planck Institute for Psychiatric Research in Munich on the relationship between intellectual giftedness and psychiatric illness [6^••]. A Spanish–English team, López-Munoz et al. [7], gives us a quick overview of Nazi medicine in the Holocaust as well, drawing appropriate present-day parallels.

Autobiography/biography/obituaries

A subject of perennial interest in psychiatry is that the lives of important psychiatrists have the capacity to inspire – sometimes to repel – and to capture the human drama of the discipline’s way forward. Among the notable contributions is McGlashan and Carpenter’s [8] commemoration of the late Wayne Fenton’s contribution to schizophrenia studies.

Jerome Frank at Johns Hopkins University is remembered for, among other things, introducing the concept of demoralization, a useful term deserving of revival. De Figueiredo [9^•] at Yale University, a former student of Frank, reminds us of this accomplishment.

For linguistic reasons, the life of Sergey Korsakov, who described the alcoholic polyneuritis that was later named after him, has been largely inaccessible to scholarly inquiry. A step towards filling this gap is a brief biography by two Russian clinicians, Ovsyannikov and Ovsyannikov [10] placing Korsakov in context.

Kerr and Kay [11^•] have given us a beautifully written appreciation of the life and achievements of the late Sir Martin Roth, one of the leading figures in twentieth century British – and world – psychiatry.

Hilton [12^•] has written an exhaustively researched account of the life of the Maudsley’s Felix Post, one of the founders of geriatric psychiatry, as well as commemorating an important figure; the memorial gives an insight into British psychiatry in the postwar era.

An absolutely charming memoir of psychiatry’s institutional past is the account of the Worcester State Hospital in Massachusetts in the 1940s by Callaway [13^••], where he was a resident.

The great Spanish psychiatrist Juan López Ibor coined the term ‘vital anxiety’, borrowing from Kurt Schneider’s ‘vital depression’. López Ibor introduced the German tradition into Spanish psychiatry, and Lidesmo-Jimeno [14] gives an overview of his life.

Famous patients

Along with studies of famous psychiatrists are those of famous patients, once called ‘pathographies’ when written by physicians. In this year’s collection of reviews, there are no formal pathographies, yet of interest is a Swiss group’s extensively documented reanalysis of the symptoms of French novelist Gustav Flaubert, concluding that he might have had a tic disorder [15^•].

Drawing upon the resources of St Elizabeths Hospital in Washington, District of Columbia, formerly the mental hospital of the Public Health Service, researcher Kleiman [16^••] studies the records of Stanley McCormick, a member of the International Harvester dynasty, whose clinician was William Alanson White.

Shawn [17^•], son of New Yorker magazine’s legendary editor William Shawn, has written an account of his own phobic illness that journalist Malcolm [18^•], a frequent New Yorker contributor, engagingly noticed in the New York Review of Books. Literary-minded readers will appreciate both the memoir and the review.

Lerner [19^••], professor of medicine at Columbia University and veteran historian of medicine, has analyzed various accounts of Franklin Roosevelt’s terminal illness with the aid of archival sources, including the question of the president’s mental competency at the time of the Yalta agreements (fully competent is the answer).

Psychoanalysis

The decline of interest in Freud’s doctrines among clinicians has been matched by that among historians. Yet, so vast was the previous curiosity about the history of psychoanalysis that in relative terms, a considerable volume of literature persists.

The tragic emigration abroad of German–Jewish psychiatrists in the Nazi years has been often chronicled. The story of Hans Erich Haas, the first psychoanalyst in the German city of Cologne, and his emigration to Birmingham (where he also was the first psychoanalyst) is now recounted in detail by Schultz-Venrath [20].

Firmly archive based is the study of the stay of Freud’s father in Leipzig in 1859 by Schröter and Tögel [21^•], which originally appeared in German.

Given the ongoing closure of collections in the Freud archives in the Library of Congress and elsewhere, archive-based findings in the Freud world are few and far between, the literature consisting mainly of endless reinterpretations of well known texts and collection of letters. Yet, not all are without interest, for example, the study of Anna Freud’s role in the Hampstead War Nurseries by Midgley [22^•].

The ‘Schreber case’ continues to fascinate, as Martin [23], at the School of Education of the University of Birmingham, adds Tourette’s syndrome to the growing list of possible illnesses that Daniel Paul Schreber, whose published memoirs crystallized Freud’s thinking about paranoia, might have had (neurosyphilis seems the most likely candidate to the present reviewer). Freud adepts who miss nothing will not want to miss the review of how Freud came to some of his ideas, including free association, by Brenner [24], based on Freud’s works and several references from the second generation of analysts.

Psychiatry and neuroscience

Psychiatry and neuroscience is an important area of psychiatric history that was poorly reviewed in 2007, and only a single article, albeit an important one, need be cited, as interest in the history of neuroendocrinology and neuroimmunology starts to develop. Irwin and Miller [25] at the University of California Los Angeles Cousins Center for Psychoneuroimmunology give us an overview of 20 years of progress in ‘depressive disorders and immunity’, concluding that a ‘cytokine model of depression’ offers ‘drug targets for further development’ (p. 374).

Psychiatry and society

More than disciplines such as cardiology or nephrology, psychiatric treatment and diagnosis are affected by the surrounding culture and society. Witness the inability of psychiatry to protect itself from various fads, such as the current vogue for ‘pediatric bipolar disorder’, that sweep back and forth. This is not to say that other medical specialties are immune to faddish thinking, but merely that the problem is worse in psychiatry because, in the absence of a good model of pathophysiology, psychiatry is unable to prove faddish new ideas wrong. Apropos of the above, Bendersky [26^•], professor of German and intellectual history at Virginia Commonwealth University, reviews the impact of Gustav Le Bon’s thinking about ‘panic’ on US military psychology during the Second World War. Le Bon was the father of social psychology, and his 1895 book, The Crowd, had a major impact on understanding mass behavior.

A triumph of linking clinical psychiatry to surrounding social trends is The Loss of Sadness by Horwitz and Wakefield [27^••], a highly readable and well informed indictment of the Diagnostic and Statistical Manual of Mental Disorders and of psychiatry’s ties to the pharmaceutical industry. The book has attracted much media attention and provides sobering reading for clinicians.

2007 has been a year of assaults on trendy diagnoses, including a scathing review of ‘social anxiety disorder’ by Lane [28^••], a medical historian at Northwestern University.

Transcultural psychiatry belongs par excellence in the rubric ‘psychiatry and society’ because its premise is that the surrounding culture changes the presentation of psychiatric illness as well as attitudes towards it. Littlewood et al. [29^•] examine the cross-national stigmatization of serious psychiatric illness using an ‘ethnographically grounded questionnaire’ on seven cultures from England to India to the Caribbean and West Africa.

Interest among medical historians in the history of shell shock and combat fatigue in wartime has been considerable. US psychiatrist Harry Stack Sullivan developed a questionnaire to screen out the ‘unfit’ in World War II, and Wake [30^••], an assistant professor in science history at Michigan State University, examines this story in the context of the history of military psychiatry. Despite being homosexual himself, by ‘unfit’ Sullivan seems to have meant primarily gay men.

France has always been distinctive in psychiatric history, having, for example, the world’s highest rate of consumption of benzodiazepines. Psychiatrist Verdoux [31] in Bordeaux examines the excessive emphasis on institutional care in France and the corresponding under-development of community services (often called ‘sectorization’). Interestingly, France has one of the largest numbers of psychiatrists in the world (many of them still given to psychoanalysis).

Psychiatric epidemiology in historical perspective

The enormous deployment of resources that epidemiology requires means that, in historical epidemiology as well, only determined groups with considerable resources are able to make a mark. Of these, the historical psychiatry group led by David Healy in Bangor, North Wales, has made several important contributions over the years. Of note in 2007 was their comparison of patients with manic-melancholic syndromes admitted to the North Wales asylum from 1875 to 1924 and to the North West Wales mental health services between 1995 and 2005. The authors found a significant decline in the incidence of postpartum psychoses, although the occurrence of melancholia as a whole remained stable. The authors further suggest that the concept of ‘manic-melancholic disorder’ by Rafaelsen [32] in 1974 might well replace ‘major depression’ [33^•].

Electroconvulsive therapy

Given the revival of interest of ECT in psychiatry, its history is also receiving renewed attention. Passione [34^••], a medical historian at the University of Bologna, has written a comprehensive biography of Ugo Cerletti, the originator of ECT, reviewing his complex relationship with Mussolini’s regime as well as the scientific story. As for utilization, one Danish study finds ECT stable over the last 15 years; its indications, however, shift from bipolar and schizoaffective disorders to unipolar depression [35]. Yet, the use of ECT has always been high in Denmark, so a failure to rise even further might not be entirely typical. Indeed, Shorter and Healy [36^••], in the first comprehensive history of ECT, do find that in the US, the use of ECT has recently been on the rise, a result of lessening the often horrendous stigmatization to which the procedure was subject from the 1960s to the 1980s. (Given this reviewer’s coauthorship, it is embarrassing to flag the book with double stars, yet it does offer a comprehensive overview – the first ever written – of the history of shock therapy from the 1930s to our own times.)

Conclusion

The history of psychiatry should be a fundamental part of resident training. More than a mere grab bag of historical curiosities for the diversion of established clinicians, psychiatric history offers insights into treatments and diagnoses that once flourished and now, perhaps unfairly, have been crowded from the stage to the advantage of patent-protected remedies and trendy diagnoses. There is much of benefit in psychiatry’s past – safe and effective therapeutic agents and diagnoses that cut nature at the joints perhaps even better than the current crop. Psychiatrists in training as well as senior practitioners should become aware of the historical existence of alternative therapies and diagnoses.