Tuesday, May 09, 2006

Freud set back Psychiatry 100 years

[Rant posted by Roy]

Okay, it was his birthday last week and all, but I think Sigmund Freud single-handedly stalled the progress of psychiatry for nearly a century.

Look at some of the thought leaders in psychiatry in the early 2oth century. Kraepelin. Bleuler. Alzheimer. It was around 1905 when it was found that syphilis could cause a type of psychotic illness, called general paresis of the insane. Most "psychiatrists" were actually neurologists then, and the field was decidedly heading in the what's-wrong-with-their-brain direction. Fifty years later, the first antipsychotic drug was introduced. What happened in those first 50 years, and in the 50 years since?

The locus of pathology switched from the brain to the mind, from the individual neuron to the individual person. We were just starting to realize that psychiatric illness could occur through no fault of one's own (okay, maybe unprotected sex, but you see where I'm going), and then Dr. Freud comes along and we start looking at the mother or the father or Uncle Pete as the source.

And the treatment? Lie on a couch and talk. About whatever comes to mind. Four times per week. For seven years.

The result? Worsening of stigma. Marginalization of Psychiatry from Medicine. Diversion of research interest and resources from the cell to the self. The "psychiatric reduction" and non-parity in health insurance coverage. (The "psychiatric reduction" was Medicare's discriminatory practice of requiring outpatients with psychiatric illnesses to pay 50% out-of-pocket, while all other illnesses cost you 20%. This sham is still on the books today, despite bipartisan efforts to end this anachronism.) Tom Cruise.

So now, with the Decade of the Brain a recent memory, we have now entered the Century of the Genome. We are discovering more and more about how the brain cell is put together, which protein does what, and what goes wrong when the blueprint goes awry. About time.

The damage is fading. People are getting more comfortable to talking about having an illness, less worried about folks wondering about the "dirty little secrets" which have tripped them up.

Don't get me wrong. We learned some things in the process about human psychosocial development... about transference... about id. After all, understanding psychiatric illness cannot be boiled down to neurons and receptors any more than diabetes can be boiled down to insulin and sugar. But we have had a long and winding detour. Time to blow out the candles and get this party started.


Dinah said...

Roy, Wow, what a rant. How did that make you feel???

Anonymous said...

Well said. Reminds me of one of my favorite stories about my Dad. Back in the 1970's he was taking some graduate psychology classes and sitting in on group therapy with some psychiatry residents. He would come home all excited about what the psych residents had taught him about "schizophrenigenic parents". After explaining the theory he said, "Goes to show you what little I know. I just thought there was something wrong with their brains!"

Dr. Deb said...

Congrats on your blog. Come by and visit mine.

Though I disagree on the contributions of Freud, modern psychoanalysis is an excellent treatment form. Many who criticize are often those who have never experienced the treatment.

Dave_MSW said...

Welcome to the blogosphere! Come by and check out mine. I will read your blog with interest. But I take exception with your comments about Freud.

It may well be true that the preoccupation of psychiatry with development sapped virtually all of it's creative energy and likely delayed the early development of psychotropic medications. And it's true the stigma of mental illness was exacerbated by psychiatry's stepchild status within the medical fraternity.

But to blame Freud for stigma is entirely too simplistic. The moralistic culture simply couldn't tolerate a challenge to the idea that a person's value to the world is predetermined. And to assert that psychiatry was set back for 100 years is blaming the primary victim of stigma within the profession for it's puritanistic detractors.

Anonymous said...

Deborah and Dave are correct in stating that it isn't actually Freud's fault that stigma and stilted academic progress resulted from his theories. (And thank you for stopping by to read!)

Granted, the title and first sentence of my Freud rant both belie the complex sociologic and academic forces which shaped the direction in psychiatry for many years. To state that it is all his fault is absurd. Reductio ad absurdum. Nonetheless, he is the archetype at whose feet I lay most of the blame.

While I agree with DaveMSW that the pendulum has swung too far in the other direction (where is the humanism?), let's see how far we can go with the idea of putting the mind back into the brain. Like Freud, we can dare to dream.

Spiritual Emergency said...

Clearly, beauty is in the eye of the beholder. Freud started out studying neurology and switched to psychopathology. I don't like him near as much as Jung and I'm not fond of Tom Cruise either, unless he's in a bang-up action flick.

As far as "what's wrong with their brain" direction, it must be borne in mind that there is still no test that can determine, for instance, whether or not an individual actually has schizophrenia. Meanwhile, all the drugs available to treat the disorder carry heavy side-effects, including the atypical anti-psychotics which the CATIE study revealed were not superior to the older neuroleptics.

As for modern-day psychiatrists, when they can produce these kind of results with their schizophrenic clients, I'll give them a standing ovation...

"...85% of our clients (all diagnosed as severely schizophrenic) at the Diabasis center not only improved, with no medications, but most went on growing after leaving us."

- John Weir Perry

"Ongoing research shows that over 80% of those treated with the approach return to work and over 75% show no residual signs of psychosis. Official government statistics comparing 22 health districts in Finland found that Dr. Seikulla's district was the only one not to have any new chronic hospital patients in a two year period."

- Jaakko Seikkula

Among those who went through the OPT program, incidence of schizophrenia declined substantially, with 85% of the patients returning to active employment and 80% without any psychotic symptoms after five years. All this took place in a research project wherein only about one third of clients received neuroleptic medication.

- Jaakko Seikkula

At 2 years post-admission, Soteria treated subjects were working at significantly higher occupational levels, were significantly more often living independently or with peers, and had fewer readmissions; 571/16 had never received a single dose of neuroleptic medication during the entire 2-year study period.

- Loren Mosher

Each of those psychiatrists rely heavily on various forms of "talk therapy" or "being with" the client during their schizophrenic process. They currently are or did produce astounding results with their schizophrenic clients simply be responding to them as human beings.

Forget about Freud setting back psychiatry, look to Eli Lily as the culprit and the accompanying assumption that a human being who has been through a traumatic process can be healed with a pill.

As for me, I went through a schizophrenic break on my own four years ago. I have had no hospitalizations, no therapy, and no form of psychiatric drugs. Ihave been working for three years, my relationships are all stable, and I have still had no form of psychiatric medication.

My experience was literally a textbook case of what Jungian, John Weir Perry, refers to as the psychotic-visionary episode. This is a self-healing function of the psyche in response to the trauma of ego disintegration. If left to run its course, it lasts about six weeks and does not return.

If you want to learn more, I have two blogs devoted to the subject. If you don't want to learn more, there is nothing I can do or say to make you. In the interim, I'm not capable of being impressed with the current success rates of psychiatry when it comes to their most wounded and complex patients. And no, I'm not a Scientologist. I don't even know any.

Anonymous said...

For what it's worth, I argued evidence-based medicine with the late Dr. Mosher in 2002, and it turned into an "Area 51" sort of discussion. He railed at the pharmaceutical manufacturers as agents actively "preventing" his information from being diseminated, solely for monoply and financial gain. He would not even entertain medication as "adjunctive" to the Soteria model. This, I believe reasonably, stopped me in my tracks. Nevertheless, from what he and his wife (who met him at NIMH) showed me, Soteria, and others modeled on Soteria, were moderately successful with middle-class, late adolescent- early adult Caucasians. Our discussion did not include the chronically, persistently mentally ill. The black and white film he used in his presentations was hardly convincing: young "residents" were free to draw on the walls, roller skate indoors, move freely between each other's rooms, all in what seemed to be a continuous background of near- deafening 60's acid rock. Obviously, Soteria has evolved, but the model strikes me as insular, skewed, and limited. This would explain to me their "success rates." Medicine is not practiced by anecdote.

Spiritual Emergency said...

This would explain to me their "success rates."

And what of Perry and Seikuula, or persons such as myself? How do you explain (or dismiss), not only their success rates but also the success rates of other cultures and countries?

I think we misunderstand schizophrenia in this culture, to our detriment. Is there a neurological or genetic factor involved. No doubt, there is. Whether it's falling in love, preparing dinner, or negotiating for a raise -- what human activity doesn't produce a wave of change in our biochemical make-up?

Our discussion did not include the chronically, persistently mentally ill.

There are some who ponder whether or not the treatment delivered in industrialized nations might not be responsible for creating that chronicitiy. I'm one of them, even as I allow that neurochemistry may play a significant role, for some more than others. But so too will environment, nutrition, personality, age, education, poverty, and yes, even families.

I can't help but feel that in the west, the schizophrenic experience is primarily approached with one tool -- antipsychotics. And I want to know too, when these studies are being done that reveal changes in the brains of those with schizophrenia, were those individuals taking neuroleptic medication?

Mosher states -- and perhaps this was the basis of his argument with you...

"The Germans, who invented neuropathology, looked at the brains of thousands of schizophrenics before there were any neuroleptics. And they were never able to find anything. They never reported increased ventricular volume, which at postmortem you can measure quite easily. And they also never reported any specific cellular pathology, and they studied many, many, many brains." He adds that "there are a whole lot of people who don't have schizophrenia and also have enlarged ventricles. And there are people who have other psychiatric conditions who have enlarged ventricles, and there are a number of known causes of enlarged ventricles that are not schizophrenia. So, yes, there is a statistical difference, but it is not specific."

"On the other hand," Mosher continues, "there are studies that have shown that people treated with neuroleptics have changes in brain structure that are at least associated with drug treatment, dosage, and duration -- and have been shown to increase over time as drugs are given." He cites one "horrific study" of children between the ages of 10 and 15 in which the researchers measured the volumes of the kids' cortexes. "The cortex is what you think with, the part on the outside," Mosher explains. Over time, "They watched the cortical volume of these young people decline, while the cortical volume of the nonschizophrenic controls was expanding because they were adolescents and still growing." The researcher concluded that their schizophrenia had caused the decrease in the subjects. "And yet every single one was taking neuroleptic drugs," Mosher says. [Source]

We live in a culture in which our emotional responses are increasingly being attributed to biochemisty, and hence, amended and "fixed" by pharmaceutical methods. I feel this is blinding us to other possibilities of treatment, even cure.

More than anything, I feel I should not be an anamoly and I still hurt for those like me who are not yet recovered, and may never be... in this culture.

Steve & Barb said...

It's all biochemistry and wiring, when you get right down to it. A skilled psychotherapist becomes good at helping to alter one's wiring and chemistry to the good, as does a skilled psychopharmacologist. Unfortunately, both approaches are fraught with error and imprecision.

Anonymous said...

I'm certainly late on commenting on this, but I have recently been reading a lot on psych issues and just came across this. I'm wondering your opinion on this. I have read opinions by others that Freud's psychoanalytic model was the most important aspect in the reemergence of the biological model of mental disease. The reason being that before Freud, psychiatrists focused much more on schizophrenia, bipolar disorder, and other disorders that are associated with "asylum psych" (I have no formal training outside of psych100 about 8 years ago, so excuse the weird terms). However, because the psychoanalytic model treated just about everybody with a problem that wanted tx and could pay for it somehow, it opened the door to an expanded biological model, outside of the asylum psyche barriers, and the massive increase in the DSM from II to III.

Anonymous said...

You are correct to point out that Freud massively set back psychiatry. The great work done by psychiatrists such as Alzheimer was discarded as the profession was hijacked by Freudian psychoanalytically oriented psychiatrists.

No longer are patients given deductive differential diagnoses. They are currently assigned a pseudoscientific DSM label based on negative social bias, which does absolutely nothing to identify the cause of their difficulties, let alone treat them.

I must respectfully disagree with Dr Serani's opinion that modern psychoanlysis is an excellent treatment programme for mental disorders. It can do nothing to treat those patients whose illnesses have a physical cause. Just like Pellagra, Schizophrenia and Autism before it, Depression is now overwhelmingly shown to be linked to medical caused. Psychiatry in its modern incarnation appears determined to ignore this fact as long as it can.