A-87 HIST Final Study Guide
UNIT ONE:
PINEL, TUKE, KIRKBRIDE, What was moral therapy? What did curing madness mean?
How is being mad related to being normal? Or is it? How were the ideals of moral
therapy translated into the practice of moral therapy and asylum management and design?
Pinel
Pinel came to Paris as a young doctor and was there before and during the French
Revolution.
Rational and scientific approaches interested him much more than the traditional
treatments of the insane (which included bloodletting, dunking, drugging, and chaining
people)
He removed the chains of patients at the Bicetre and the Salpetriere; people thought he
was crazydespite the national Revolutionary value of liberty, it did not seem to apply
to the insane.
He maintained that the insane were sick people, not guilty people; he paid attention to
them and started keeping case histories. He met with them, was caring, and took notes,
setting an example of hospital research.
He researched and wrote extensively, publishing articles and volumes of books.
He also trained other staff members in his methods of care (moral treatment) and
attention.
He believed, "The number of types of mental disease is limited (to mania, melancholia,
dementia, and idiocy), but their varieties can multiply indefinitely."
Disapproved of the methods of most physicians, thinking that instead those who care for
the insane should live with them, visit and converse frequently, study and record their
habits with objectivity, be authoritative but kind, etc.
Main Point: Pinel believed that locking up the mad was wrong and that instead moral
treatment and research should be implemented. He believed it was important to care
about patients, interact and converse with them, and keep records.
Samuel Tuke
Founder of the York Retreat in 1796:
Wanted a place of healing: stimulating physical well-being, orderliness and relaxation.
Wanted to allow patients a substantial degree of human dignity.
Based on the model of the family.
Moral Treatment
Moral Treatment, also known as Moral Therapy, was an approach to mental disorder
based on humane psychosocial care and moral discipline.
o Emerged in the late 18th century and came to the fore for much of the 19th
century, deriving partly from psychiatry or psychology and partly from religion or
moral concerns.
The movement was particularly associated with reform of the asylum system.
Principles of Moral Treatment
Conditional Kindness
Cultivation of self-esteem
Regular rhythm of rest and work
Fear
Tukes Beliefs of Moral Treatment
Based on overarching idea that madness can be controlled most, if not all, of the time.
Treatment depends on their conduct, and the patients are specifically told so as incentive
to behave.
o Believed that madness was largely a behavioral issue.
Tuke was disdainful of the way asylums did things using chains, etc when unnecessary.
Believed that the threat of fear should only be used when a necessary object cant
otherwise be obtained
Madmen should be treated much in the same way that children are treated
o Keep childs spirit easy, active and free
o Restrain him from many things he has a mind to
o Draw him to things which are uneasy to him
In terms of treatment, fear should be sparingly used, use mainly the desire of esteem
Believed in using a moral treatment that emphasized behaving properly in the terms of
society and religion.
Thomas Story Kirkbride and the Kirkbride Plan
Thomas Story Kirkbride
One of the thirteen founders of the Association of Medical Superintendents of American
Asylums for the Insane (now the American Psychiatric Association), founded in 1844.
Played a leading role in the profession and served as the associations secretary and
treasurer for 11 years. He also served as president from 1862 to 1870.
Headed a prestigious private hospital, the Pennsylvania Hospital for the Insane.
Wrote On the Construction, Organization and General Arrangements of Hospitals for the
Insane, which was the industry textbook for over thirty years.
Talked about therapeutic image in his Annual Reports.
o It was a marketing tool, and many people requested a brochure.
o He countered many misconceptions about the asylum, and many families of the
insane actually visited him for comfort. He also kept an audience in mind --- that
audience was composed of prospective patrons and patients families.
o It covered topics such as the cause and nature of insanity, financial statement,
statistical tables, etc. Its basically what we would see in a Please donate to this
cause brochure today.
Kirkbride defined insanity as a functional disease of the brain but left it at that.
o He took a non-judgmental tone and lessened the blame on the patient.
o Denied that heredity had any role in insanity.
Also cared about stating that everyone could be affected, not only the lower classes.
o Implied that the more cultured an individual, the more vulnerable he would be to
mental disease.
o This was because a high state of civilization would bring in its train a host of
ailments.
Said the principal causes of insanity were: ill health (majority of cases), loss of property,
grief, unemployment, etc. He even included masturbation.
o Insanity could be encompassed in a very few terms.
Needed to convince that families should treat their relatives in the hospital rather than the
home.
o Implied that a change of scenery was needed to treat the patient.
o Also said families waited too long to admit their relatives.
o Assured that prompt action would lead to a complete recovery.
o He even cited a statistic that 80% of asylum patients who were caught early
were completely healed!
o Even chronic cases should give the asylum a try!
Kirkbride Plan
Kirkbride thought that moral architecture was the most powerful method to build trust
in asylum treatment. Every detail (design of window frames to table settings) was not
overlooked to give off an image that patients would be cared for here.
Said patients were assigned based on their mental conditions and social traits. He also
said that the hospital would be a community made up of distinct and congenial families.
By putting them together, patients could help each other realize their own delusions. Of
course, the sexes were segregated. There would only be female attendants to help secure
the male patients with the humanizing influence of female society.
Wrote that he did not approve of a great variety of apparatus and believed that strong
chairs, muffs had a bad influence. This was reassuring.
Cared about the grounds on which the hospital was built.
o It must be outside of a city.
o It should be easily accessible by train and roads.
o It should be in a secluded area, and the soil should be tilled easily.
o It should also be interesting aesthetically.
The style should be simple and cost-effective. It should not resemble a prison. He was
anal-retentive, basically all the details mattered!
o The interior made as much of a difference as the exterior. Everything should feel
large and airy. Therefore, there should be tall ceilings, wide corridors, etc.
Kirkbride designed wings radiating off the center section so that each ward had proper
ventilation and unobstructed view of the grounds.
o It also allowed for undesirables to not mix. Also, the worst patients should be
farthest from the center on the first floor and the best patients should be on the top
floor, closer to the center.
o There were a lot of details to prevent suicide, violence, escape, etc. For example,
doors had to be open into the hallway. There should also be wickets so that food
could be given through a hole. There were also window guards, etc.
For the less destructive patients, the wards were made to be homelike as possible.
He made toilets exposed to view so that there couldnt be any possibility for vermin.
ZILBOORG, FOUCAULT, SCULL, ROTHMAN
Rothman, Scull, Foucault, Zilboorg
1. David J. Rothman (The Discovery of the Asylum: Social Order and Disorder in the New
Republic, 1971): The invention of the asylum in the U.S. was of a piece with the
invention of the prison and the poor house. Its function was not to offer compassionate
care to the mentally ill, but to discipline deviants and maintain social order.
a. Many people felt threatened by immigrants. People also did not know how the
rules would work.
2. Andrew Scull (Museums of Madness: The Social Organization of Insanity in Nineteenth
Century England, 1979): The function of the asylum in England was to ensure that those
who refused or were unable to participate in the new industrial economy were disciplined
and reeducated: Defective human mechanisms were to be repaired so they could once
more compete in the marketplace.
a. People who were not able to contribute to the marketplace needed to be taken out
of the system so that they could be fixed!
3. Michel Foucault (Madness and Civilization, 1961; English edition in 1965): His was
probably the most influential. The context was very different. The starting point for his
argument was philosophical. It had a foundation of deep discontent with the dominant
philosophy in France at the time Existentialism.
a. Existentialism stated that people were free to choose their own lives. The new
philosophers were saying that this was not true. We live in cultural and linguistic
contexts that are made up of structural elements (language, culture, etc.). These
elements regulate what we say, think, believe, etc. This was called structuralism.
There were philosophers such as Roland Barthes, Louis Althusser, Claude LeviStrauss and Jacques Lacan.
b. Important structuralist claim: meaning for societies and people emerges through a
sense of difference, and in particular of opposition; things are defined by
reference to what they are NOT, to their declared opposite. We get to know what
is cooked food by knowing what raw food is.
c. Foucault denied that he was a structuralist. He clearly was, however, inspired by
this field. He was influenced by the rule of opposites. He also did a degree in
psychology too. He had a discomfort while being at St. Anns Hospital for three
years for fieldwork.
d. Every French intellectual was Communist in the 1950s. Communism provided a
way to do that. Many were supportive of the USSRs experiment in Communism.
The Lysenko affair prompted people to think about the relationship between
science and politics. Madness and Civilization was Foucaults initial work to
think about the relationship between power and knowledge.
i. Trofim Lysenko: He was a geneticist who was also an agronomist. He
insisted that grain could be conditioned to sprout out of season or to grow
in inhospitable conditions. Those traits, he said, would then be inherited
by the next generation of crops. Coming to power in a time of failed govt
agricultural policies, Lysenko was made director of Soviet biology under
Stalin. Scientists who criticized his belief in the inheritance of acquired
traits were fired or imprisoned. Lysenko implemented his methods and
millions starved.
1. His ideas were already considered null in the international
scientific community.
Zilboorg, Gregory, A History of Medical Psychology (W.W. Norton & Co., 1941), pp. 319341
In the Midterm Study Guide that Kacey had already attached
_Salvador Pelayo_= TOMES, DWYER, Different people, different stories: How do we
understand the asylum from the perspectives of administrators, politicians, doctors,
attendants, communities, families, and patients? What sources help us hear these voices?
UNIT TWO:
Key Pathologies: Disorders of will and morality associated especially with supposed
degenerate blood lines, hysteria, GPI
I. Disorders of will/morality (degeneration)
Background Info
Started in the 1870s and lasted until WWI
Key figures: Cesare Lombroso, Henry Maudsley
Degeneration - caused by defective biology that is innate & therefore incurable
Degenerates are less than human and are biologically backwards/primitive
Degeneration theorists believed degeneration was on the rise and was responsible for the
increase in crime, suicide, squalid living conditions, prostitution, etc.
When degenerates married non-degenerates, they tainted/poisoned the pure blood &
spread the bad seed
o Degeneration gets worse and worse with each generation
The stigmata of degeneration were physical characteristics that indicated madness:
facial features, structure of cranium
Related to atavism, a term coined by Cesare Lombroso
Def: a throwback to a more primitive ancestral type
Prejudiced against:
Other races, which were called savages not as evolved as Caucasians
Children = evidence that humans are born savages and must evolve during their
lifetime (e.g. Lord of the Flies)
Women signs of their degeneration are masked by a faade of gentles & docility
through moral and religious training, but emerge during illness & childbirth
The poor lived in the breeding ground of madness; were dangerous & could act
collectively as a single madman (e.g. those who stormed the Bastille)
For further info, see:
Criminal Man According to the Classification of Cesare Lombroso, Gina LombrosoFerrero
Body and Will, Henry Maudsley
II. Hysteria
Generally considered to be a womans malady
Initially believed to be caused by restlessness in the uterus (uterine theory)
Characterized by problems with vision, paresis, paralysis, hallucinations, tics, convulsions
Famous case = Anna O., who was treated by Josef Breuer
Breuer mentioned there were two states: a normal and a hysterical one
o Hysterical state: happened during day; Anna was irresponsible & experienced
hallucinations
o Normal occurred at night; Annas mind was clear & lucid
Breuer claimed that using hypnosis enabled him to trace the causes of Annas hysteria
and cure it by bringing them out in the open
o Ex: hypnosis allowed Breuer to discover that seeing a woman letting a dog drink
out of a cup had caused Annas trauma of drinking water
Freud went on to develop his own theory independent of Breuer:
Rejected hypnosis as a treatment method
Seduction theory (1896): hysteria is caused by sexually traumatic events during
childhood
Revised the seduction theory later on: hysteria is caused by infantile sexual fantasies, not
actual events
For more info, see:
Studies on Hysteria (Anna O.), Josef Breuer & Sigmund Freud
Freuds Seduction Theory & its Rehabilitation: A Saga of One Mistake after Another,
Maurice L. McCullough
III. General Paralysis of the Insane (GPI)
Had close ties with the degeneration theory; GPI was thought to be caused by loss of morality &
lowlife living
Believed to be incurable
Works of key figures:
Acting upon general assumption that GPI was related to syphilis, Richard Freiherr von
Kraft-Ebbing (1884 ) injected paretics with infected blood (from syphilis patients) into
patients with GPI. This would prove that (since you can get syphilis only once), if the
patients got syphilis (and its characteristic sores), syphilis was not linked with GPI. No
one developed the sores, implying that syphilis and GPI were indeed related.
Robert Koch discovered the bacillus for anthrax, tuberculosis, and cholera during the
late 1800s
Fritz Schaudinn discovered in 1905 that syphilis is caused by an infection
Hideyo Noguchi proved in 1911 that the same bacterium (treponema pallidum) that
causes syphilis is found in the brains of GPI patients. This led to the conclusion that GPI
was a form of syphilis.
Alexander Dubbs=_ Key Figures: Henry Maudsley and Cesare Lombroso (degeneration
theorists)
Jean-Martin Charcot and other neurologists (Wilhelm Griesinger, Paul Broca, Hughlings
Jackson, Theodor Meynert)
Paul Broca- localized articulate language in brain in 1861, patint was M. Leborgne or Tan, he
had interesting symptoms, lost ability to speak, could still swear, could understand and
comprehend, but not produce language, dies 3 days later, speech loss associated with small part
of brian on left temporal lobe, now called Brocas area, momentous moment b/c suggests that
highly complex processes and forms of human function might have seed in specific parts of
brian, implications for mad brain, implications in disordered speech as characteristic of mental
illness
John Hughlings Jackson- worked on epilepsy and speech loss, interested in mental disorder,
perspective informed by reflex and evolutionary theory, he saw that the brain had evolved as a
structure, need to integrate this with idea of behavior and experience driven by reflexes
1. Idea of basic reflexes in spine that b/c more complex as go higher up
2. Brain that functions as a higherarchy
3. Simple at bottom and complex and fragile at top
4. Top layers of brain, most recently involved, have job of inhibiting
lower level, more primitive processes, helps make sense of mental
disorders like epilepsy,
5. Strain, shock, lesion- first to go are the top levels b/c more vulnerable
and then release the lower levels to produce functions that are normaly
suppressed
6. Dissolution- like meltdown, saying symptoms of mental disorder
unmasked by lesions to the brain when higher level brain ruined and
lower level brain unmasked to run rampant (Jackson)
7. Political analogy- destroy governing body, and have anarchy of
uncontrollable people
Theodor Meynert - scientific development of psychiatry elevates it to the status of a science
that deals with causes.
Meynerts 1884- text called Psychiatrie: A clinical treatise on disease of the frontal lobe
(dicribes all mental disorders of frontal lobe)
As a student of therapeutic nihilism, he found that the method of curing the insane as utterly
useless, instead he devoted his time in psychiatry strictly for research. His research included
pioneer work in the microscopic structure o the brain and the spinal cord, as well as searching for
pathological lesions in those with neurosyphilis (rather revolutionary, because it connected
science to psychiatry - keep that in mind!). However, perhaps because of his therapeutic
nihilism, Meynert had no interest in patients and had terrible personal relationships with them. In
any case, Meynert began what Shorter calls the "last phase in the development of the first
biological psychiatry" which is a concentration on anatomy, instead of symptoms of a disease.
Wilhelm Griesinger
convincing part of medicine by belonging to a general hospital. So when Wilhelm Griesinger
(portrait of him on page 122 - potential ID!) became a professor of psychiatry at Charit hospital,
the medical view of psychiatry changed. Not only was Griesinger to become the single most
influential represenhtative of the first biological psychiatry, he established the modern model of
the department of psychiatry as dedicated to teaching and research rather than to custodialism.
Griesinger divided the Charit clinic into halves, one for the "usual nervous diseases," the other
for "nervous disease with a primarily psychiatric presentation". Alternating between them by
semester, he could hold clinical lectures on them. He encouraged his students to focus on
diagnosing these diseases. He emphasized that mental illness stemmed from illnesses of the
brain and brain, and therefore psychiatry needed to become medicalized.
Jean Charcot
Introducing Jean Martin Charcot, Europes leading neurologist, at the Salpetriere,
committed to the truth-telling power of the visual: the camera does not lie
a. (1825-1893) archetype and embodiment of this era of research, all about the diagnosis
rather than treatment, patient as experiment rather than to be cured and helped
b. method: clinico-anatomical method: look carefully at multiple instances of a disorder
to discern the underlying fundamental pattern of symptoms; compare what you find to
multiple anatomical preparations to discern the underlying fundamental pattern of the
causal pathology
c. matching exercise b/t symptoms and pathoanatomy
d. made him europes leading neurologist
e. career change- 1862- appointed one of two leading neurologists at Salpatriere (1st
image of asylum where 100 yrs before Pinel famously removed the chains of the
mentally ill) today it was also a general hospital for womenpeople with STDs,
dimentia, municiple and charity hospital for lower class, and huge place, almost 1
mill sq ft (mini city), almost 5,000 people mostly patients
f. goldmind, museum of living pathology waiting to be elucidated
g. 1862 he comes here and decides to make hysteria his special focus of study
h. hysteria insane or epileptics? Like epilepsy both have convulsions
i. Charcot asked how similar they really were and wanted to understand it
j. Anatomical investigations of the brains of hysterical patients produced no results
k. Charcot had luck- objectively-visible stigmata or permanent symptoms of hysteria
in Charcots neurological work
l. Innovations: the camera comes to Salpetriere: the photo plate is the scientists true
retina
m. THE CAMERA- true vision to search for signs, as crucial as use of microscope in
bio, camera did not lie
n.
Introducing hypnosis: how Charcot overcame a century of suspicion about this practice
and reinterpreted as a neurological research tool
a. Another tool- hypnosis
b. Hypnosis- idea of mesmerism as pop culture, emphasize occult powers, John
Elliotson mesmerism used as medical intervention in places like India, medical
mesmerism late 19th c eastern Europe
c. Charcot- decides to rehabilitate it, nothing to do with therapy, not reliable, but what
hypnosis was, he said, was a fantastically precise research tool to provoke the nervous
system of patients and used to create artificially induced hysterias, turn into
observational therapy
d. Neurologists- in france began using hypnosis, start of rise of hypnosis renaissance,
charcot the master, demonstrate lawful nature of hysterical attack
Charcot and his team at the Salptrire put a heavy emphasis on photographing their patients.
They compiled these findings into a three-volume work called Iconographie photographique de
la Salptrire. However, Charcot never attempted to analyze these cases or find cures for them .
Charcot became chief physician of the Salptrire in 1862, and was so intrigued by the
diversity of its population that he began to categorize it. Women diagnosed with epilepsy
or hysteria were placed in the same ward. In his interest to distinguish between epilepsy
and hysteria, Charcot became fascinated with the latter and studied it extensively from
the 1870s on. His study of hysteria is distinctive because he was so focused on being
objective. Visual observation (including photographs, paintings, and diagrams), he
thought, was the least biased and most reliable method of studying hysteria. Charcot
believed that the causes of mental illness were all hereditary; in his opinion, because the
root of these disorders were biological, listening to his patients verbal accounts was
unnecessary. Ironically, despite his obsession with being as objective as possible,
Charcot was completely subjective by dismissing his patients reports, which were
considered untrustworthy and unreliable.
Jennifer Anyaegbunam=_ the degenerates (especially women and the lower classes);
Hideyo Noguchi and J. W. Moore (who proved that the bacterium responsible for syphilis,
treponema pallidum, was in the brains of GPI patients)
Logan Ury=_ Key Ideas: The failure of the asylum, degeneration, biological determinism,
therapeutic nihilism (until GPI), _
Key Ideas: brain localization, clinical-anatomical method, the camera and scientific
objectivity, class/gender issues
I. Brain Localization (Information found in Shorter-The First Biological Psychiatry and
Lecture 6)
A. Brain localization or cerebral localization represents one of the three 19th
century
visions of the mad brain
1. The brain in a state of meltdown (framework: evolutionary theory and
reflex theory).
2. The lesioned frontal lobe (framework: cerebral localization and
evolutionary theory)
3. The bug in the brain (framework: germ theory)
B. Brain localization basically deals with the anatomy of the brain. The goal was
to discover which parts of the brain governed certain functions of the mind. Early
advances in the research of neuroanatomy include:
1. Paul Broca, who localized articulate language in the brain in 1861.
He arrived at this discovery by studying the brains of aphasic patients
(persons with speech and language disorders resulting from brain injuries),
particularly the brain of his first patient in the Bictre Hospital, Leborgne,
nicknamed "Tan" due to his inability to clearly speak any words other than
"tan".
2. Carl Wernicke and the 1874 localization of speech comprehension.
Shorter claims, The first biological psychiatry slid to an end with the
work of Carl Wernicke, narrowly balanced between neuromythology and
brain anatomy (129). Wernicke studied stroke patients, and discovered
that damage to a specific part of the brain would render them unable to
understand the spoken word and only able to speak incomprehensible
jargon. Later he investigated whether psychiatric symptom complexes
existed that might be localized in certain areas of the brain.
3. Phineas Gage was a railroad construction foreman who suffered a
traumatic brain injury when a tamping iron accidentally passed through his
skull, damaging the frontal lobes of his brain. This injury is supposed to
have negatively affected his emotional, social and personal traitsleaving
him in a temperamental and unsociable state, so much so that his friends
said he was "no longer Gage".
At the time of its report to the scientific community, Gage's condition led
to changes in the scientific perception of the function and
compartmentalization of the brain with regards to emotion and personality.
Gage's case is cited as among the first evidence suggesting that damage to
the frontal lobes could alter aspects of personality and affect socially
appropriate interaction. Before this time the frontal lobes were largely
thought to have little role in behavior. Gages doctor was J.M. Harlow.
Gage was fitful, irreverent, indulging at times in the grossest profanity
(which was not previously his custom), manifesting but little deference for
his fellows, impatient of restraint or advice when it conflicts with his
desires, at times pertinaciously obstinate, yet capricious and vacillating,
devising many plans of future operations, which are no sooner arranged
than they are abandoned in turn for others appearing more feasible. A
child in his intellectual capacity and manifestations, he has the animal
passions of a strong man. Previous to his injury, although untrained in the
schools, he possessed a well-balanced mind, and was looked upon by
those who knew him as a shrewd, smart businessman, very energetic and
persistent in executing all his plans of operation. In this regard his mind
was radically changed, so decidedly that his friends and acquaintances
said he was 'no longer Gage.
4. In the1880s Paul Flechsig laid down the basic map of what regions of the
cerebral cortex are responsible for what functions, and Eduard Hitzig established
that the brain responds to electrical stimulation (128).
II. The Clinical Anatomic Method and the Camera/Scientific Objectivity (Found in Daphne de
Maurneffe-Looking and Listening: The Clinical construction of Charcot and Freud)
A. The method was employed by Jean Martin Charcot, who ran the Salpetriere in
the late 19th century. Charcots main point of study was hysteria. Charcots
famed
clinicoanatomic method involved the meticulous description, analyzation, and categorization of
clinical phenomena into pathological archetypes. De
Maurneffe states, The means by
which Charcot examined his patients and carried
out his research was the celebrated
clinicoanatomic method, developed in France
during the late eighteenth and early
nineteenth centuries. Through his use of this method, Charcot analyzed and categorized clinical
phenomena into "archetypes,"
fully developed examples of the disease, and analyzed
these further to detect their anatomical bases.' The differentiation of an archetype from its
"variants" emerged from the careful observation of numerous cases (73).
B. Charcot believed that scientific objectivity was best achieved by using a
camera
to document symptoms and phenomena. Only a phenomenon that Charcot could physically
observe could qualify as scientifically acceptable. Photography thus became a useful tool to
capture the characteristic symptoms of
both hysteria and the hypnotic condition. Every
aspect of hysteria or hypnosis
captured on film translated into increasing scientific
plausibility in the mind of
Charcot. Daphne de Marneffe states, Photography was thus
established as a
more perfect extension of the clinicians eye, a means of recording
objective truth
and knowledge (de Marneffe 79).
III. Class/Gender Issues
A. In terms of class issues, I think they are talking about psychiatric Darwinism.
Showalter writes, The rhetoric of heredity, inheritance, and degeneracy which
appears obsessively in the medical literature of the time is also closely linked to class
prejudice and to ideas of race superiority. The rich and the well educated, although they were
increasingly vulnerable to the neuroses of modern civilizationwere essentially seen as a
reservoir of mental health, while the poor and disreputable were the breeding ground of
madness. While the moral managers had hoped that the insane poor could be cured, the
Darwinians thought that they could only be segregatedphysicians hinted their inferiority
could be
reduced through stricter immigration laws and selective breeding (75).
B. In terms of gender issues, the theme of women being more susceptible to
mental
illness can be found in Showalter and de Maurneffe.
1. Showalter: CS Lombroso and Henry Maudsley provide aesthetic
criteria for the identification of women who were potentially degenerate.
She states, In women, physical signs of mental disorder were thought to
be especially striking (74).
2. de maurneffe shows gender issues seen in the work of Charcot and
Freud. Essentially, Charcot studied hysteria only in women, holding with
the tradition that the disease was feminine. De Maurneffe explains,
hysteria is of continuing interest to feminists, because of both its
historical association with women and its enigmatic status as an actual or
socially constructed illness. The term "hysteria" itself derives from the
Greek word hystera, meaning uterus, and early Greek and Egyptian
medicine attributed the hysterical woman's emotional instability to the
"wandering" of her womb. This idea has had surprising resilience
throughout medical history (85).
Key Pathologies: Hysteria, neurasthenia, shellshock
Hysteria, Neurasthenia, Shellshock
Hysteria had been the despair of the medical profession
Doctors did not understand it: too many unstable symptoms (may cause paralysis, vision
problems, ticks, convulsions)
Old explanation: a gynecological disorder (hysteria is the Latin for uterus)
By first decades of 19th century, people began to look elsewhere, old theory lost
credibility
o Perhaps a lot of faking, lingering, acting out? (attacks only happened in public, by
a couch, etc.)
o Treatment: pouring water over patients head
By mid-19th: unclear, annoyed, frustrated
In the 1870s, people began to turn around: hysteria has been redeemed and it is a real
neurological disorder, because of the work of Jean Martin Charcot
Hysteria vs neurasthenia:
Main difference had to do with stigma
Hysteria still tended to be associated with neuropathic weakness and degeneracy
Neurasthenia associated with weak nerves; overworked nerves that just collapsed
Cases of neurasthenia were in sharp rise in the late 19th century
Explained it because modern life and society was so stimulating and fast paced that the
delicate and refined nervous systems simply couldn't cope
George Beard: what happens when you overload circuits of electric lights (analogy to
neurasthenia)
"Rest Cure": Weir Mitchell (guy that came in and criticized superintendents); dominate
treatment for private patient population
o Primarily used with women: put to bed and fed with rich diet
o Men: need to go into primitive raw nature and would reconnect with their natural
manly roots
Charcot impressed by beirs ideas: presented multiple cases of neurasthenia
Shellshock
Began to appear after the onset of World War I
First industrialized war: Tanks, Gas, and Heavy Artillery
Soldiers complaining of sensory disturbances, motor disturbances, twitching, inability to
focus, crying and shaking uncontrollably
Believed that artillery landed near the body and shocked the nervous system
This theory disproved after soldiers not on the battlefield began to show symptoms
Officers showed it as well: got better treatment than the average soldier
Often people believed it was simply due to cowardice; soldiers were in disgrace
W.H.R. Rivers: Believed that Freud might be the key to understanding dreams of
shellshocked soldiers
o -Repression is not helpful for dealing with the trauma of war
Lewis Yealland: tried an intensive treatment to cure shellshock; need to give them a
strong idea that they can get well;
o -Took out a scary looking electric generator and shocked the parts of the body
that werent working; I expect you to be the hero I know you really are; had
short-term success but cure was not long-lasting
Key Figures: Charcot; middle class and wealthy neurotics; Sigmund Freud, Josef Breuer,
and Anna O (Bertha Pappenheim)
Charcot: Charcot was a psychiatrist at the Salpetriere, an asylum in France, during the late
1800s. He is well known for his study of hysteria. Charcot worked with poor female patients, so
he did not have to show them much respect. His relationship to his patients was that of scientist
to research subjects. He favored looking (and taking photographs of the various states of the
mentally ill) over listening to the patient. Charcot tried to be objective and used the clinicalanatomical method (looking at multiple instances of a disorder to discern the underlying
fundamental pattern of symptoms).
Middle class and wealthy neurotics: Middle class and wealthy neurotics changed the way
doctors treated patients and played an important role in the birth of psychoanalysis. Since
Freuds and Breuers patients had a high status in society, these psychiatrists could not
completely dismiss what their patients were saying.
Sigmund Freud: Freud was an Austrian psychiatrist and the father of psychoanalysis. He
developed several theories about the causes of hysteria and neurosis. He claimed that people had
an unconscious mind and repressed their traumatic memories. The role of the psychiatrist was to
assist the patient in recovering the repressed memories (through free association, dream
analysis, etc). Freud blamed sexual fantasies and experiences (especially those during
childhood) for mental illness. He revolutionized the relationship between the doctor and the
patient; he focused on helping the patient instead of on the science of mental illness.
Josef Breuer: Breuer was Freuds colleague and a pioneer of psychoanalysis. He favored the
talking cure and claimed that he successfully treated Anna O with it.
Anna O (Bertha Pappenheim): Anna O was Breuers case study in psychoanalysis. Unlike later
cases of psychoanalysis, this one made no mention of sexual experiences or fantasies. In later
years, Freud claimed that Breuer had concealed the true, sexual nature of Anna Os case. After
her role as Anna O, Bertha Pappenheim went on to be a social activist.
W.H.R. Rivers, Lewis Yealland, and shell-shocked soldiers (officers and enlisted)
W.H.R. Rivers, Lewis Yealland, and Shellshock
Shellshock was first described by C.S. Myers in 1915
o Left men blinded, deaf, dumb, semi-paralyzed, in a state of stupor
o Took doctors by surprise and no one knew how symptoms were created
Largely attributed to technological advances in warfare
Because officers suffered from shellshock, therewas no talk of degenerates or weaklings
o One-sixth of shellshock patients were officers, although at the front, the ratio was
1:30
Asylum doctors were unhelpful because of preconceived notions of degeneracy and
inferiority
At first, the treatment options were discipline, physical exercise, isolation, rest, unfocused
massage, and electrical stimulation of muscles
Edgar Douglas Adrian and Louis Yealland believed that weakness of the will and
intellect led to the hysterical mind
o They believed psychoanalysis would be too slow
o They gave patients electricity and orders to motivate them to get better
Success occurred in cases of deafness, dumbness, and paralysis in a limb
Arthur Hurst was also successful with shellshock
o He first used suggestion under hypnosis and electricity
o Then he simply talks to patients
o Created atmosphere for cure at his own shellshock hospital
Patients told of doctors miraculous records, primed by nurses, shown the
castaway crutches etc.
Maghull Hospital in Liverpool was also important
o Superintedent was Ronald Rows
o Army sent many bright academic psychologists and doctors
o Focused on self-belief and therapeutic optimism
o Maghull had to send soldiers back to the front, because it was a military hospital
William Rivers
o Started at Maghull in 1915 and then went to Craiglockhart in 1916
Craiglockhart is specialized for nerve-shattered officers
Rivers worked well with intelligent, educated officers
o Rivers liked Freuds idea of analyzing dreams
Disagreed with Freuds idea that neurosis was produced by sexual factors
o Some doctors told patients to forget their war memories
Rivers wanted patients to confront their memories and accept that
o He became good friends with Sigfried Sassoon and Sassoon wrote about him in
his memoirs
This is why Rivers is so famous today
o Rivers wrote The Repression of War Experience, which detailed his methods of
curing shellshock
Key Issues: The talking cure, looking versus listening, class/gender issues (again), the
importance of the erotic, trauma and fantasy
The "talking cure."
See October 19th lecture (Hysteria: From Charcot to Freud) and "Anna O" reading in
sourcebook
The birth psychoanalysis. Josef Breuer and Freud pioneered the talking cure in the late 1800s.
This happened in the historic case of the hysteric woman Anna O. Breuer and Freud were able
to cure Anna O through talking: they hypnotized her required her to search her memory to the
point when each of her strange symptoms began. Once Anna O got to the bottom of each
symptom and talked it through, the symptom disappeared. They found that each symptom began
with a trauma. For example, Anna O was unable to drink after she saw a dog drink out of a glass
(schwaa?). Freud concluded that hysterics suffer from reminiscences, and that the road to a cure
is reclaiming those bad memories.
Looking vs. listening.
See October 9th lecture and the online DeMaurneffe reading
Charcot (who did the looking) and Freud (who did the listening) are the main players here. Both
of these men worked with hysterics; also, both were especially interested in the "sexual trauma"
as experienced by their female patients and how it was related to their symptoms. However,
Charcot and Freud went about their work with hysteric patients very differently.
Charcot was very big into categorizing symptoms by just looking at the patient. He thought that
the most objective way to study hysteria was by photographing it. He described the camera as
"true retina" that "did not lie." Ironically, Charcot's looking method was extremely subjective.
He posed his (female) patients erotically in the photos he took, and even touched up the photos
with paint. Also, Charcot used hypnosis (medical mesmerism) to induce the hysterical
symptoms he would observe and photograph. Charcot didn't bother to listen or speak with the
patients.
Freud rejected Charcot's methods for an entirely different approach. Freud cared deeply about
what his patients had to say, and believed that this was the only meaningful way to curing them
(see "talking cure"). By cultivating a trusting doctor/patient relationship, Freud believed in the
therapeutic power of honest conversation between the doctor and patient (psychoanalysis).
Class and gender issues (again)
See Oct 9th lecture and DeMaurneffe
Hysteria was depicted in a very misogynistic light (the term is derived from Latin "uterus").
Early theories described hysteria as being caused by the stress of the uterus pressing up against
other organs. Later, the theory was that hysterical women were basically just acting out for
attention. Especially in Charcot's hyper-sexualized photographs, hysteria was portrayed as a
very female disorder.
The hysteric patients being photographed by Charcot in the Salpetiere were mostly lower-class
women (dumped in a hospital and considered incurable), versus the patients seen in Freud's
private practice who were more well-to-do.
Mmmmm... the Importance of the erotic, trauma, and fantasy
See Oct 11th lecture and "Theory transformed" Freud letter in sourcebook
Basically it's all about sex. The erotic, trauma, and fantasy were all themes running through
Freud's mind between the Anna O case and the formation of psychoanalysis. The Anna O case
taught Freud that past traumas were at the root of hysteria, and he hypothesized that the traumas
buried in the unconscious were sexual in nature. (This is something that Breur and Freud
disagreed upon... Remember the little scandal between Breuer and Anna O?)
Freud claimed that all cases of hysteria are caused by childhood "seduction" (traumatic sexual
encounters as children) and that fathers were often the cause.
Freud ended up renouncing this theory, because actual cases of fathers sexually abusing their
kids didn't seem common enough to explain the prevalence of hysteria. While he still believed
that sex was at the root of hysteria, he no longer believed that real life events/traumas were
involved, but rather fantasies of sex and seduction... for example, children having forbidden
erotic feelings for their parents. This conceptual shift transcended just hysteria, and became part
of a universal theory of human development (Oedipus complexes, oral phase, anal phase, phallic
phase, penis envy, all that good stuff!).
Key Pathologies: Dementia praecox/schizophrenia, manic-depression, Key Figure: Emil
Kraepelin
Key Pathologies: Dementia praecox/schizophrenia, manic-depression
Key Figure: Emil Kraepelin
Time period: late 19th century
Key Text: Edward Shorters The First Biological Psychiatry (note: there are two different
sections of this text found in the first course pack)
Major contributions to psychiatry:
I.
New diagnostic strategies, new paradigm for understanding mental illness
a. Kraepelinian model emphasized that patients should be diagnosed based on their
medical history and current symptoms- he followed the course of illness across
the years to determine its nature
b. This was a new vertical way of seeing illness, trying to understand the patients
problems in the context of his or her lifetime history
c. Shift from earlier days of this biological psychiatry in which the tendency was to
try to correlate the symptoms with neurological findings and with brain findings
postmortem
II.
Key word: prognosis
a. Kraepelinian model brought psychiatric treatment back to the patients, whereas in
biological psychiatry, the emphasis had been on the research
b. He used patient data to identify natural disease entities
c. Emphasis on classifying illness in a way that would let one predict outcome
d. According to Kraepelin, the doctors first task at the bedside is being able to
form a judgment about the probable further course of the case (i.e. the prognosis)
III.
New classifications of psychotic illnesses: manic-depression and dementia praecox
(schizophrenia); Differences in prognosis
a. Kraepelin splits the vast world of psychotic illnesses without an obvious organic
cause into two neat camps:
i. Illnesses involving an affective component (meaning a mood componentthink symptoms of depression, mania, anxiety)
ii. Illnesses without an affective component
b. Manic-depressive illness and prognosis
i. Diagnosis given to patients who were psychotic with an affective
component (ex: if patients were melancholic or euphoric, ried all the time,
were always tired without a cause, or displayed any of the other signs of
depression or mania)
ii. Prognosis: patients would go through a circular disorder that naturally
would improve
c. Dementia Praecox (later renamed schizophrenia by Bleuler)
i. Diagnosis given to patients who were psychotic in the absence of an
affective component
ii. Prognosis: Kraepelin was very pessimistic; he believed patients with
d.p. would deteriorate into what he considered to be dementia---i.e. he
understood the disease we know as schizophrenia to be incurable and
degenerative
III.
Kraepelins legacy
a. The only way to truly diagnosis disease is to track it over time. Natural history
(course) and prognosis (expected outcome)
b. The bifurcation of the psychoses into two types: manic-depression and dementia
praecox
c. Interpretation of mental symptoms had been dethroneda rejection of
Wernickes emphasis on observing a patients symptoms to determine the nature
of his/her illness
d. Content of psychosis no longer mattered
e. Precise symptoms that the patient evidenced were unremarkable unless they gave
evidence of the cause
f. *Being Kraepelinian meant that one operated within a medical model rather
than a biopsychosocial model
Key Figures: Eugen Bleuler, Freud, Paul Schreber and other psychotic patients
FREUD: private nerve doctor and the father of psychoanalysis. His theories changed overtime
from the trauma/seduction theory to that hysteria is the result of bodys repression of childhood
trauma abuse theory to the unconscious/fantasy theory.
He says the hysteria is the result of the repression of these experiences and he treats them
through the talking cure (talking and listening) to his patients to bring these repressed memories
into consciousness.
He rejects the therapeutic nihilism of the time (unlike Charcot), perhaps partly due to his position
as a private doctor dealing with wealthy, middle class patients (a more equal patient-doctor
relationship).
EUGENE BLEULER:
Swiss psychiatrist most famous for his contribution to understanding and naming schizophrenia
(dementia praecox). He recognized Freud for his interpretations of the dreams.
Bleuler placed more emphasis on the experience and psychology of the schizophrenia patient. He
would probably think that schizophrenia is curable (whereas Kraeplin would say no).
DANIEL SHREBER:
German judge suffering from paranoid schizophrenia in adulthood. He described his conditions
in his memoir memoirs of my nervous illness. Freud read it and interpreted Schrebers dream
to be turned into a woman as his desire to be the sexual object of God (who represented
Schrebers father).
This represents how Freud uses dreams of the insane to understand their deeper structure of the
unconscious mind. Freud used Schreber to testdrive his psychoanalysis and interpretation of
dreams of the psychotic (this is a very bold step) . Freud then concludes that the dream reveals
Schrebers repressed homosexuality and latent feelings for his dad
Key Issues: Classification, longitudinal clinical method, the four As of Bleulers new
category of schizophrenia
Classification:
Henry Goddard was the director of the Vineland Training School for Feeble-Minded Girls and
Boys from 1906-1918. He argued that feeble-mindedness was inherited, and he wanted to
differentiate between them and normal children. He developed a new classification system for
the feeble-minded by mental competency:
1) Moron (competency of a 8-12 year old)
2) Imbecile (competency of a 3-7 year old)
3) Idiot (competency of less than a 3 year old)
4 A's of Bleuler's New Category of Schizophrenia:
1) Association: associations among thoughts are disturbed; incoherent and changing rapidly
2) Affect: emotional responses are flattened, extreme, or otherwise inappropriate
3) Ambivalence: conflicting feelings (such as loving/hating at the same time)
4) Autism: cannot cross-check between inner and outer reality
Feminist Critiques: Elaine Showalter on Maudsley (degeneration and the masculinzation of
psychiatry); Daphne de Marneffe on Charcot and Freud (photography, power, and the
aesthetics of objectivity vs. subjective science and collaboration; gender and class, The
View from Here: Edward Shorter on the neurologists (first steps towards a scientific
psychiatry)
DaphnedeMarneffeonCharcotandFreud(photography,power,andtheaestheticsof
objectivityvs.subjectivescienceandcollaboration;genderandclass)
TheViewfromHere(?):EdwardShorterontheneurologists(firststepstowardsa
scientificpsychiatry)
Feminist Critiques:
Henry Maudsley and the Darwinians encouraged the masculinzation of psychiatry by 1)
criticizing the domestic faade of the asylums and stimulating a new management style of mental
illness and 2) by targeting women as being particularly susceptible or responsible for mental
illness. The excerpt On the Borderland from Elaine Showalters book, On the Borderland,
provided a lot of description in regards to the Darwinian view on mental illness and how they felt
the mentally ill should be treated. The Darwinian era of psychiatry came about as a result of the
failure of the domestic asylum: Critics of the asylum increasingly charged that the domestic
facades and homely activities of the mammoth institutions were simply deceits (102).
Furthermore, the position of the superintendent was becoming less and less popular in large part
because it did not seem that medical treatments were an important or efficacious part of their
jobs (103). Their job appeared to be that of a baby sitter or family friend, but the Darwinians
felt that these close relationships compromised the importance of their position.
Darwinians emphasized the hereditary disposition to madness and the congenital
inferiority of the insane, (104) says Showalter, and that meant that they sought to extend their
professional beliefs beyond the walls of the mental hospital; the Darwinians moved into the
courtroom, where they used physical characteristics as a means for criminal profiling, or in the
bedroom where they tried to define acceptable sexual behavior. A large basis of the mental
hygiene movement came from the efforts of what the Darwinians were doing.
Showalter then goes into a discussion of the borderland, defined by the Darwinians as
the shadowy territory between sanity and madness in which they felt lurked many individuals on
the verge of mental illness. Will, self restraint, and self-control were still considered the
ultimate development of mental healthinsanity thus represented an evolutionary reversal, a
regression to a lower nature (106). Weve come to recognize this definition as degeneration.
These individuals were classified as being on the borderland based on physical appearance,
social behavior, as well as economic status. Those that were most often seen on the borderland
were women and the poor. Henry Maudsley, one of the leaders of the degeneration movement,
particularly singled out women and children as individuals prone to degeneracy, and he could tell
simply by looking at them. Maudsley urged prospective husbands to scrutinize their future
wives for physical signswhich betray degeneracy of stock any malformations of the head,
face, mouth, teeth, and ears. He didnt warm women to look out for the same malformations in
their future husbands.
The belief that women were not only predispositioned for madness but that they also
were responsible for dirivng men mad reached a ridiculous point when Furneaux Jordan, a
surgeon at Queens College, Birmingham, that women with delicate skin, thin eyebrows, convex
spine, and sharp tongue had the hereditary disposition that made it impossible for men to resist
hitting them. Whether it was a poor woman who was murdered or a rich woman appearing in
Divorce Court, heredity was responsible for their domestic violence.
Showalter particularly criticized Maudsley not simply because of how degeneration
targeted women, but also because of his own curmudgeon and antisocial personality. Maudsley
was unlike the doctors of previous generations, those domestic men that ran the asylum as a
home. Maudsley and his colleagues were conspicuously and aggressively masculine in their
interests, attitudes, and goals (117). They sought personal success through private consulting,
spent much of their free time playing billiards and being athletic instead of reading up on the
leading psychiatric innovations or caring for a lunatic family in the asylum. Rational, not
emotional, deliberate rather than impulsive and he criticized his father in law, in the memoir he
wrote for him, for being the opposite. Maudsley ultimately was not well liked and upon his
retirement, Showalter explains, [he] could not bring himself to admit the possibility that his own
character, rather than evil fortune, incurable lunatics, or unregenerate humanity, had robbed him
of the satisfactions of his career.
Summary of the reading from the midterm study guide infused with some feminist points:
Daphne de Marneffes article provides a feminist critique during a similar time period but
focused the on techniques of Jean-Martin Charcot and Sigmund Freud. The psychiatric theory in
question was hysteria, primarily in women, and the methods by which each man classified,
analyzed, and presented the details of hysteria to the rest of the psychiatric world. Charcot and
his team at the Salptrire put a heavy emphasis on photographing their patients. They compiled
these findings into a three-volume work called Iconographie photographique de la Salptrire.
However, Charcot never attempted to analyze these cases or find cures for them. Recalling the
analysis we did in section on the photograph A Clinical Lesson with Doctor Charcot at the
Salpetriere, 1887 (Andrew Brouillet), it isnt always clear whether Charcots hypnotic methods
were actually working, or if the women were in some way mimicking the behavior they were
expected to exhibit. The picture on the wall in the back of the room of the portrait implies this
conflicting belief. Female sexuality became the foundation for hysteria; mental illness was
caused by early sexual trauma in the womans life.
Charcot and Freud were similar in that they both studied mainly the sexual trauma of
their women patients, but their methods were vastly different. Freud, by contrast published his
Studies on Hysteria with Breuer based on verbal accounts by the patients themselves, whereas
Charcot focused on hypnosis and photography; he avoided listening to his patients.
Charcot became chief physician of the Salptrire in 1862, and was so intrigued by the
diversity of its population that he began to categorize it. Women diagnosed with epilepsy or
hysteria were placed in the same ward. In his interest to distinguish between epilepsy and
hysteria, Charcot became fascinated with the latter and studied it extensively from the 1870s on.
His study of hysteria is distinctive because he was so focused on being objective. Visual
observation (including photographs, paintings, and diagrams), he thought, was the least biased
and most reliable method of studying hysteria. Charcot believed that the causes of mental illness
were all hereditary; in his opinion, because the root of these disorders were biological, listening
to his patients verbal accounts was unnecessary. Much like Maudsley, Charcot allowed his
masculinity to govern the way in which he worked with female patients. Ironically, despite his
obsession with being as objective as possible, Charcot was completely subjective by dismissing
his patients reports, which were considered untrustworthy and unreliable. He felt that the
women were chronically dishonest, and had no trouble photographing them in a manner that
placed the created photographs that could easily be assessed under a sexual context, in many
ways forcing the belief that female sexuality was the cause of these womens illnesses.
Freud greatly admired Charcot for being the leading neurological expert on hysteria at the
time, but between the late 1880s and early 1890s, his approach came to be completely different
than his former idols. He relied completely on verbal communication with his patient, believing
that trustworthy, dependable information could be obtained through a healthy relationship
between a doctor and his patient. Through discussions with patients, Freud initially came to
believe that hysteria was caused by sexual trauma during childhood (namely, sexual abuse of
girls by their fathers). Later, this idea was replaced by another: hysteria was caused by repressed
sexual fantasies during childhood (i.e. the Oedipus complex). In this aspect, his opinion varied
enormously to that of Charcot, who dismissed the idea of sexuality playing a role in the onset of
hysteria. Yet another difference between the two mens beliefs is that Freud thought Charcots
methods of hypnosis as a neurological treatment (to induce hysterical symptoms) were
ineffective.
The View from Here with Edward Shorter: First steps toward a scientific psychiatry
Summary of the reading from the midterm study guide:
The First Biological Psychiatry
Shorter, Edward, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac
(New York: John Wiley & Sons, 1998), pp. 69-81
Shorter gives a brief overview of the medical movement towards biological psychiatry and away
from Kirkbride's "moral therapy". However, this biological psychiatry should not be confused
with degeneration. Instead of using physical traits to distinguish and outcast those with the
potential chance of developing mental illness, psychiatrists at this time shift to researching a
relationship between the mind and brain at universities and institutesnot asylums.
Shorter explains that this need for a greater relationship between psychiatry and science is due to
a greater demand in psychiatric education for medical doctors and scientific curiosity of the age.
For contemporaries, it was important that medical doctors to be able to understand the brain and
the central nervous system in order to treat mental illness. He then moves on to briefly describe
the contributions made by several significant German psychiatrists.
Early efforts to teach psychiatry to medical students were inefficient because medical schools
lacked a nearby department of psychiatry (asylums were the only sources) that would admit
patients whose illnesses the professors wanted to demonstrate in lecture and that could make
psychiatry a convincing part of medicine by belonging to a general hospital. So when Wilhelm
Griesinger (portrait of him on page 122 - potential ID!) became a professor of psychiatry at
Charit hospital, the medical view of psychiatry changed. Not only was Griesinger to become the
single most influential represenhtative of the first biological psychiatry, he established the
modern model of the department of psychiatry as dedicated to teaching and research rather than
to custodialism.
Griesinger divided the Charit clinic into halves, one for the "usual nervous diseases," the other
for "nervous disease with a primarily psychiatric presentation". Alternating between them by
semester, he could hold clinical lectures on them. He encouraged his students to focus on
diagnosing these diseases. He emphasized that mental illness stemmed from illnesses of the
brain and brain, and therefore psychiatry needed to become medicalized.
The reading also mentions Theodor Meynert (also mentioned in lecture). As a student of
therapeutic nihilism, he found that the method of curing the insane as utterly useless, instead he
devoted his time in psychiatry strictly for research. His research included pioneer work in the
microscopic structure o the brain and the spinal cord, as well as searching for pathological
lesions in those with neurosyphilis (rather revolutionary, because it connected science to
psychiatry - keep that in mind!). However, perhaps because of his therapeutic nihilism, Meynert
had no interest in patients and had terrible personal relationships with them. In any case, Meynert
began what Shorter calls the "last phase in the development of the first biological psychiatry"
which is a concentration on anatomy, instead of symptoms of a disease.
Shorter goes on to mention several other significant names in biological psychiatry, including
Paul Flechsig (portrait on page 128, also potential ID), who laid down the basic map of what
regions of the cerebral cortex are responsible for what functions ("cerebral localization"), as well
as Eduard Hitzig who established that the brain responds to electrical stimulation (also
mentioned in lecture). Both these men were also terrible to their patients, which leads Shorter to
the conclusion that as research into brain anatomy and brain physiology accelerated, the first
biological psychiatry became nihilistic about the possibilities of clinical care.
Quotes from lecture 6 that characterizes the movement toward a scientific understanding of
mental illness and away from clinical treatment or cures:
The more that psychiatry seeks, and finds, its scientific basis in a adeep and finely grained
understanding of the anatomical structure [of the brain], the more it elevates itself to the status of
a science thatdeals with causes. Meynert, 1890
Why think when you can experiment? Claude Bernard, French medical physiologists in
1876.
A doctor who visited the hospital [ in Vienna] told me he saw a party of students sounding a
woman who was dying of pleurisy or pneumonia, in order that they might hear the crepitation in
her lungs as her last moments approached. She expired before they left the ward. He said
something about treatment in another case to the professor who was lecturing these young men.
The reply was, Treatment, treatment, that is nothing; it is the diagnosis that we want.
UNIT THREE:
Mental Hygiene, Adolf Meyer, Clifford Beers, Progressivism, National Committee on
Mental Hygiene (NCMH), maladjustment, juvenile delinquents
Madness and Medicine Final Exam Study Guide
Unit Three
Mental Hygiene: mental illness is a result of poor development of the personality. As childhood
is a key time for this development, schools ought to focus on personality development rather than
any other form of education. Mental hygiene should be an every day health concern just as
physical health is. Mental illness is caused by environmental causes such as bad habits, family
life, and communites that shape peoples minds in early childhood. There was a need for
intervention and education. Mental Hygiene was based on the the idea of prevention and youth.
Adolf Meyer 1866-1950; visionary behind mental hygiene. Worked with Kraepelin but was
more interested in environmental factors than neurology. He focused less on defective
mechanisms in the brain and more on the defective mismatch btw personality type and
environment. Started the NCMH
Clifford Beers- the poster child for the NCMH; wrote a book a mind that found itself (1908)
explaining how terribly asylums are and how treatment needs to be improved to overcome the
stigma of mental illness
Progressivism- an American movement (referred to as the Progressive Era). It was a time of
social fervent driven by a larger belief in the power of expterts to intervene in peoples lives for
the better. Mental Hygine was the psychiatric side of the procressive movement. It was also
when the US was first emerging as a world power (specifically in the automobile industry,
success of the Spanish-American war, the assembely line, etc). There was a larger quest for
efficiency and nation building, the root of which was in a sound mind/body. Nationalistic, unity,
optimism
National Committee on Mental Hygiene (NCMH)- Founded in 1909, by 1920 it had expanded
its initially small-scale investigation of institutionalized mental illness into a large-scale push to
prevent mental illness. Crucially, Mental illness was not a disease of the brain or of the
nervous system but a personality disorder, one that grew gradually, with the foundation for
illness or health formed childhood. Focused on revamping the role of education. Hygienists
targeted 1) failure 2) academic subject-matter-centered curriculum and 3) disciplinary
procedures, each of which damaged the childs adjustment. Misbehaving children were now
those who were healthily rebelling. The shy, shut-in ones were those who were problems: they
showed symptoms of maladjustment. All this put enormous pressure and responsibility on the
teacher. By 1950s NCMH had pretty much run its course and mental hygiene was a firmly
emedded part of the national consciousness and education.
Maladjustment- Meyers idea of where mental illness comes frompeople who cant adjust to
their environment; you must express your emotions, because if you keep emotions bottled up,
you will eventually explode
Juvenile Delinquents-before the turn of the century kids were tried as adults. Then, with the
progressive era came the new idea that if you are a young person who commits a crime you
should go to reform school/readjusmtnet institution (not prison) because you are simply
maladjusted and dont know any better. The youth were still saveable
-The 1922 Program for the Prevention of Delinquency provided visiting teachers to educate
parents and teachers and provided psychiatric aid for children in need.
-an example of Juvenile delinquency can be seen in the song Gee Officer Krupkee in West
Side Story
Neo-Freudianism, /Let There Be Light (movie), /Freida Fromm-Reichmann and the
schizophrenogenic mothers
Frieda Fromm-Reichmann
$
psychiatrist at Chestnut Lodge under Harry Stack Sullivan in the 1940s
$
Chestnut Lodge used intense psychoanalytic treatments, no psychosomatic or ECT
$
Reichmann thought that schizophrenia was created because of a hurt from the world, so
her treatment mostly consisted of listening to her patients with compassion and treating
them like valid human beings; she would accept their gifts (sometimes disgusting like
feces)
$
she was a follower of Freud, but he believed the schizophrenics were beyond help, while
she believed in the power of empathy
Schizophrenogenic Mothers
$
Edward Strecker wrote on Moms in 1946he said that maturity is key to preventing
mental illness, but Moms in America use their power and subversive authority to keep
their children immature and dependent; our lazy culture supports this Mom behavior,
with the result of weak men
$
Trude Tietze in 1949 interviewed the mothers of 25 schizo patients; she characterized
them as cold, falsely ingratiating, and attempted to dominate situations by faking
submission; these mothers left no room for their childs rebellion, and then rejected
their children when they became schizophrenic
$
Tietzes work quickly became common sense, in part because this was occurring on a
backdrop of post-WWII gender anxieties where middle class women were continuing to
work and disrupting traditional family dynamics
$
other psychiatrists compared mothers to totalitarian dictators and SS guardsthe F-scale
test of authoritarian personalities tested mothers for Fascist qualities
Let There Be Light
$
directed by John Huston, 1946 at New Yorks George Mason Hospital
$
2 minutes before the premier of the film, two military policeman confiscated the filma
piece of failed and potentially dangerous propaganda in the eyes of the government
$
treatments shown in the movie are individual psychotherapy and group therapy
injections of the drug sodium amytal are used to provide a shortcut to the unconscious
to help the patients uncover suppressed memories
$
the soldiers in the film are diagnosed with psychoneurosis, a neo-Freudian concept to
explain shellshock
$
unlike WWI, where shellshock was viewed as the result of battle trauma and suppressed
war memories, by WWII, psychiatrists had decided that battle was a traumatic event that
triggered the real source of neurosischildhood development issues and sexual fantasies
$
we see in the film that psychoanalysis is centered on patients early childhood trauma and
their relationships with mothers and lovers and not their war experience
$
mantraevery man has his breaking point
$
side notethe hospital was not as racially integrated as it is portrayed in the filmalso, the
black soldier is portrayed as the most educated, and perhaps this was part of the problem
that the US government had with the film
Neo-Freudians
$
Harry Stack Sullivan, Franz Alexander, Eric Fromm, Karen Horneythey were a
psychoanalytic school that fled Germany in 1933 and came to US
$
focuspersonality is shaped by families, and psychotherapy as a tool to provide nurturing
patient lacked in childhood
$
idea of personality also emerged in 1930s, as something that could be studied
scientifically with personality tests
$
Freuds open-ended, and richly literary/philosophical ideas were very easily adapted by
and influential for later schools of psychology, as well as becoming synthesized into
common sense understandings of psychology
Gregory Bateson and the double-bing, Dr. Spock, /Madness and the Brain (Nova
Movie), /National Alliance on Mental Illness (NAMI)
Gregory Bateson- Toward a Theory of Schizophrenia
The paper details results of a research study examining the effects of a double-bind scenario
created in familial relationships, and how this can lead to development of schizophrenia.
-The double bind is a situation in which no matter what the individual does he cant win.
-Person stuck in the double bind will develop schizophrenic tendencies.
-Discontinuity in the communications between a mother and child will cause symptoms
of schizophrenia.
-Schizophrenic has faulty ego function which serves to evaluate the meaning (literal
and underlying) and/or the mode (humor, sarcasm, expected outcome) of a message
-Difficulty interpreting messages: misses the implied underlying message
-Difficulty assigning proper mode of communication in messages to others
-Difficulty assigning correct mode to internal, personal thoughts
-Double-bind creates a universe that fosters and instills the inability to properly utilize
modes of communication.
-Ingredients necessary for double bind:
-Victim and Influence (Mother or entire Family)
-Repeated occurrence
-Primary negative injuction: Act a certain way or will be punished
-Secondary injuction, conflicting with first but still enforced through punishment:
Child asked to do something, child acts, mother still appears angry.
-Schizophrenic begins to speak in metaphors to convey fact. Because they are unsure
about what the message actually means (since they cannot interpret) they speak in
metaphors that do not directly address the idea at hand to test the waters.
-Unknown meaning leads to three types of reception: literal (face value) or inventive
(assume implied message) or complete ignorance (to avoid any response)
Hypothesis for Family Situation of Schizophrenic:
-Mother who feels anxiety about contact with child, but feels bad about that and
overcompensates with overt demonstrations of emotion that do not imply
affection. Child has no one to intervene.
-If child realizes mothers misleading action and criticizes, she manipulates thoughts:
You dont really mean that. And gives child the Guilt Trip
-Thus child lacks intimacy with mother because he will either be punished for 1)making
her uncomfortable, or 2) withdrawing.
-Therapeutic hypothesis: Psychiatrist can form double-bind relationship with
schizophrenic patient to mimic original cause and then slowly guide him out, teaching
and re-teaching proper communicational interpretation.
Dr. Benjamin Spock: The Common Sense Book of Baby and Child Care (1946)
-Book quickly became a bestseller
-Popularity demonstrated the turn to professional help for proper rearing guidelines
-Tried to present psychoanalytical observations with a Common Sense basis
-It is natural for young children to be curious about their sexuality
-Children will compete for attention from parent of the opposite sex
-Children will develop envy for opposite sex attributes (ie, Female penis envy)
-Dr. Spock appeared in 1950s Peanuts comic strip: representation of the common attempt to
show psychiatric tension through childish medium and point of view
Nova: Madness and the Brain (1987)
-The video depicted the feelings a schizophrenic patient might feel from symptoms of the
disorder.
-Not having taken his pills for a few days, the patient is hearing sounds and has blurred vision
and lagged hearing, as well as slow comprehension of things said.
-The patient is waiting for approval of a prescription and begins to suffer from what appear to be
hallucinations, but might be events that appear so because of slow reaction time.
-The video depicts stereotypical symptoms of a schizophrenic patient
National Alliance of Mental Illness ( www.nami.com)
-NAMI (the National Alliance on Mental Illness) is the nations largest grassroots mental health
organization dedicated to improving the lives of persons living with serious mental illness and
their families. Founded in 1979, NAMI has become the nations voice on mental illness, a
national organization including NAMI organizations in every state and in over 1100 local
communities across the country who join together to meet the NAMI mission through advocacy,
research, support, and education.
-NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality
of life of all whose lives are affected by these diseases.
Dedicated NAMI members, leaders, and friends work tirelessly across all levels to meet a shared
-NAMI mission of support, education, advocacy, and research for people living with mental
illness through various activities.
Eugenics, Buck vs. Bell, Feeblemindedness
The mental hygiene movement began in the 1920s, after the failure of the Treaty of Versailles
led Americans to look towards new methods of reform, not legal, but psychological. After the
success of psychiatrists in treating shell-shock, it seemed the best method of attacking mental
disorders in the general population would be somewhat similar to war therapeutics. Emotions
and personality were now seen as the root of mental disorders, not biology, as biological research
had been largely stalled in the early part of the 20th century. Mental hygienists especially hoped
to motivate those in contact with young people - namely teachers - to attempt to effect positive
change in their mental state. The force of the mental hygiene rested on two assumptions, the first
being that emotions and personality were malleable, and the second being that youth was the best
time in life to attempt to remedy personality defects.
Sol Cohen, "The Mental Hygiene Movement"
Cohen studies the emergence of "mental hygiene" as a as a popular concept from the 1920s
through the '60s. The term "personality development" in particularly representative of this field,
as its use encapsulated the belief that personality was individual, could be molded, and should be
molded in young people through the education system. Much like one would be taught math or
English, students should be taught proper psychological maintenance of their selves. The
National Committee on Mental Hygiene, established in 1909, was the first manifestation of the
increasing importance of psychiatric knowledge in popular culture. At first, general pessimism
regarding psychiatric therapeutics prevented the NCMH from doing much more than
disseminating information on the prevalence of personality disorders and attempting to improve
institutional conditions. However, with the emergence of Freudianism, soon the concept of
personality and emotions being at the heart of most disorders gained momentum, as well as the
concept that certain emotional maintenance could prevent these disorders. Furthermore, the onset
of the first World War and the increasingly important role of psychiatrists in treating shell-shock
gave these doctors a new professional identity, that of a treater of personality disorders. WWI
allowed doctors to move out of the asylums and treat broader, more common forms of mental
illness.
The best place, mental hygienists argued, to effect change was in the classroom. This was
because each child had to attend school, and would be under the influence of a teacher during a
particularly malleable part of their lifetimes. Students were therefore analyzed for potential
personality defects, and teachers were urged to treat "maladjusted" children, especially quiet,
withdrawn ones, in order to prevent mental illness. Academic rigor was criticized, and instead
the "attitude" of students was supposed to be the focus on teachers. The NCMH worked to instill
these beliefs on the importance of mental hygiene in schools throughout the psychiatric
profession, in hopes that they would trickle down to teachers and guidance counselors. Soon the
movement would pass through the elementary schools into high schools, and various teacher
education books were published on the topic of running a classroom in which mental hygiene
was part of the curriculum.
Cohen argues that in a time of instability the mental hygiene movement was an outlet for the
desire to control human behavior. After the failure of the Treaty of Versailles, people were
anxious to put faith in a new manner of reform, mainly that of personality maintenance and
adjustment to form healthy, productive members of society.
Frankwood Williams "Community Responsibility in Mental Hygiene"
Williams writes an emotional testament to the large number of American youths who will
eventually succumb to mental illness. He does not so much propose a remedy as lament their
fate. It is more an attempt to raise awareness of the effect mental illness has on American
society than a call to action, although he does insist that something should be done to prevent
their falling in in order to maintain a healthy community. As noted in the Cohen reading, the
operative themes of the mental hygiene movement are emotions and personality defects, all of
which may be changed through "hygiene", and not biological explanations.
Buck v. Bell
In 1927, Carrie Buck brought her case against John Bell to the Supreme Court. Buck was a
minor who had been sent to the Virginia State Colony of Epileptics and Feeble Minded, and was
going to be involuntarily sterilized for the "health of the state". Buck argued that the severing of
the fallopian tubes to induce sterility - termed a salpingectomy - violated her rights as termed
under the Fourteenth Amendment which guaranteed her right to the life and enjoyment of her
own body. Bell, the superintendent of the Colony, argued that as a minor, and furthermore with
a "congenital mental defect", the plaintiff was not in a position to determine what was in her own
best interests. In addition, it was argued that as a occupant of the Colony she would be unable to
procreate, but if the surgery were performed she could be released and be of benefit to society.
The court agreed with Buck, stating that there was nothing inherently unconstitutional in either
the surgery itself or the process by which it was decided who deserved to be sterilized. "Three
generations of imbeciles are enough," concluded Judge Holmes, who wrote the decision. The
verdict of the Supreme Court safeguarded the involuntary sterilization of the residents of mental
institutions until 1974.
_
Morgan Mary Wainwright Jessee=_ Somatic Therapies, Julius Wagner-Jauregg (malaria fever);
Manfred Sakel (insulin coma); Ugo Cerletti (ECT)
_
Where do new therapies come from? How do new theoretical understandings of mental illness emerge
and spread? What is the relationship between therapeutic and theoretical shifts in psychiatry?
The development of the somatic therapies and the initial development of drugs were not driven by theory
and did not immediately cause any shift in the dominant theoretical understandings within psychiatry.
How do we understand, then, the gradual shift from a predominantly Freudian framework in psychiatry to
a predominantly biological framework?
Most of the new therapies in the 1900s were discovered by almost pure chance.
Ex. Malaria-fever therapy was discovered by a chance observation
Ex. Insulin coma therapy was originally used to treat morphine addicts, but they happened to
realize it calmed the patients down afterwards
Therapeutic and theoretical shifts are deeply interconnected, sometimes with therapeutic shifts driving
theoretical shifts, other times with theoretical shifts driving therapeutic shifts. In the 1900s, it seems more
a case of therapeutic shifts driving theoretical shifts. Some of the therapies that were developed were not
even understood theoretically, but were just seen to be therapies that worked. Only after
Carlyle Jacobsen, John Fulton, Egas Moniz, James Watts, and Walter Freeman
(psychosurgery); trans-orbital lobotomy
Madness in Medicine Study Guide
History of Psychosurgery
Unlike the other psychotherapy treatments we have seen, psychosurgery was the only
procedure used by asylums at the time that had been based on laboratory research, theories about
relations between thinking and feeling in the brain, and general ways of assessing acceptable
therapeutic benefit for certain kinds of patients.
Although studies had shown a possible association between behavior and the frontal
lobes (see lecture 12 Meynert, Phineas Gage, etc.), John Fulton (1899-1960) and Carlyle
Jacobsens (a psychologist at Yale interested in frontal lobe function) experiment on the effects
of a bilateral amputation of monkeys frontal lobe on the monkeys cognitive functions became a
pivotal point in psychology. The experiment was held at the Yerkes Primate Research Center in
collaboration with John Fultons physiology laboratory at Yale University in the 1930s. Results
of the experiment showed after the bilateral amputation, the monkey subjects were unable to
perform the delayed response test unlike before, proving that removal of frontal lobe tissue
would result in the loss of a specific brain function.
Aside from the results, what the two researchers found most remarkable was the change
in the behavior of one particular primate test subject, Becky the monkey. Among the rest of the
monkey test subjects, Becky appeared to be the most temperamental. However, after the
experiment, she became more significantly complacent. Effectively, this finding joined
neurosurgery, neurophysiology, physiological psychology, and psychiatry together. The
significance of this motivated John Fulton to muse if removing bits of the frontal lobe in
humans in order to cure their anxieties. Argumentatively, Fultons efforts to spread his
hypothesis may have been the catalyst for the widespread use of psychosurgery in the U.S. (since
he was at some point a mentor of James Watts and had convinced Watts to perform the
procedure).
Based on Fulton and Jacobsens experiment, Egas Moniz (1874-1955), a Portuguese
neurologist, was the first to perform the procedure on humans. However, instead of severing the
frontal lobes (lobectomy), Egas Moniz cut small, discrete bores in the frontal lobes (leucotomy).
Results of the procedure caused patients to become more complacent afterwards. The success of
the leucotomy became a sensation. Over the next 15 years, psychosurgery became established as
the only significant treatment available for cases of severe chronic mental illness. In fact, Egas
Moniz becomes the first and only psychiatrist to receive Nobel Peace Prize for performing
psychosurgery. Published accounts of the procedure were spread all over the world, inciting
similar trials in other regions.
Walter Freeman (1895-1972) and James Watts (1904-1994) were two of many
neurologists that had adopted the practice in the U.S. The first psychosurgery procedure was
performed by them in 1937 at George Washington University. Walter Freeman was a
psychiatrist known for his advocacy in radical treatments such as psychosurgery. For him,
psychosurgery served as an excellent treatment for anxious patients, who may be suffering from
an over-active emotional connection in their brains. By cutting off the connection between
emotion and reason sections of the brain via psychosurgery, patients can become more normal.
Together with the surgeon, James Watts, Freeman created the Standard Freeman Watts
lobotomy procedure which cuts between the hypothalamus and prefrontal cortex of the brain.
Oddly enough, lobotomies were received well by the public as can be seen Walter
Kaempfferts article in the Saturday Evening Post (see course pack). Psychosurgery quickly
became popular until the early 1970s. At a certain point, Freeman decided to use the procedures
on schizophrenias as well, arguing that the procedure would change these tax eaters to tax
payers by making them more capable of handling menial jobs such as making beds or wait
tables, although originally he insisted the procedure was specifically for the anxious.
Since the Freeman Watts lobotomy procedure required surgery, Freeman created a new
form of lobotomy that only required an ice pick. This trans-orbital lobotomy or ice-pick
surgery was a much quicker procedure that allowed Freeman to embark on a national campaign
in his van which he called his "lobotomobile" to demonstrate the procedure to surgeons working
at state-run institutions; Freeman would show off by icepicking both of a patient's eyesockets at
one time - one with each hand. His patients included Rosemary Kennedy, and Howard Dully,
whose NPR account can be found on the course website.
Psychopharmacology, Henri Laborit, and Pierre Deniker
The first drug marketed explicitly for mental illness was chlorpromazine. Clinical tests
in 1952 indicated therapeutic effects on schizophrenics, and by 1954, the drug was approved by
the FDA in the US for psychiatric use (marketed as Thorazine). Other major tranquilizers
followed, as did minor tranquilizers (Miltown [1955], Valium [1963]). A pharmaceutical
treatment for manic-depressive disorder also emerged at this time, lithium, but its path from
discovery in 1949 to FDA approval as a treatment for symptoms in 1970 and as a prophylactic
treatment in 1974 was rockier, in part because it is a natural element, without much support from
pharmaceutical companies. Another new class of drugs, antidepressants, were developed in
the 1950s as well the MAOIs (Monoamine oxidase inhibitors), first marketed in 1957
(iproniazid), and the Tricyclics, also emerging in 1957 (imipramine) after two years of clinical
tests. These drugs, both of which had significant side effects, were initially intended for patients
suffering from major unipolar depression, also sometimes called vital depression, a disease
category thought to afflict a relatively small number of people and characterized by not being
related to any external events in the sufferers lives. This form of depression was contrasted with
reactive depression, which was a reaction to external events and was thought to be best treated
with psychotherapy. By the early 1970s, this distinction had for the most part collapsed, and the
singular category of depression was increasingly thought to be the most common of all mental
illnesses, a worldwide epidemic that could be treated with drugs. Depression expanded again
with the introduction of a third class of antidepressants, the SSRIs (selective serotonin reuptake
inhibitors) in 1987 (fluoxetine Prozac). Viewed as a relatively clean drug (no serious side
effects), the success of the SSRIs also stemmed from the collapse of the large minor tranquilizer
market in the late 70s, when the addictive properties of these drugs became widely publicized
and the introduction of a new marketing strategy by pharmaceutical companies direct to
consumer advertisements (DTC ads) which were officially allowed by the FDA in 1985.
Chlorpromazine was originally intended to be an anti-vomit medication. The French
pharmaceutical company Rhone-Poulenc gave Paris surgeon Henri Laborit a sample to try out
on his patients. Laborit hoped the drug would reduce surgical shock in his patients, which it did.
However, chlorpromazine also had a calming effect on anxious patients. He mentioned a
possible application for this drug in psychiatry but at the time, the psychiatric community did not
pay attention. Laborit did his own test in a schizophrenic patient and found it was effective. He
asked around to find out if a psychiatrist would pursue the study further. Eventually, psychiatrist
Pierre Deniker decided to do a study with Chlorpromazine on schizophrenic patients. With
Jean Daley, Deniker did a study on 38 schizophrenic patients and found that the drug was very
effective.
Nikolas Weissmller_=John Case, Joshua logan and Ronald Fieve, Kay Redfield Jamison,
Prozac, Sarafem
Joshua Logan:
Joshua Logan (October 5, 1908- July 12, 1988) was a stage and film director and writer. The
early 1970s introduced the celebrity patient or glorious figure as a new actor in the field
of psychiatry. Josuha Logan was the first of the celebrity patient (who directed Camelot,
South Pacific, and Paint Your Wagon among others).
Ronald Fieve:
Dr. Ronald R. Fieve (MD), a psychopharmacologist, is a leading world expert in diagnostic
evaluation and biological treatment of Bipolar I, Bipolar II, manic depression, depression, panic,
anxiety disorders and ADHD (attention deficit hyperactivity disorder)
(http://www.fieve.com/meet.htm). Dr. Fieve helped introduce and coin the term of chemical
imbalance in the brain as cause for mental illness, as described in his book: Moodswing, 1974.
Kay Redfield Jamison:
Kay Redfield Jamison (born June 22, 1946) is an American clinical psychologist and writer who
is one of the foremost experts on bipolar disorder (then known as manic depression). She is
Professor of Psychiatry at Johns Hopkins University School of Medicine and the author of: An
Unquiet Mind, (in which she shares her experiences of manic depression throughout her life: she
emphasizes her incredible creativity and energy because of the disease, which helped her
in her life: to get her first assistant position at UCLA for example). In Touched with Fire: ManicDepressive Illness and the Artistic Temperament, she shows how bipolar disorder can run in
artistic or high-achieving families. Jamison claims, that a world without manic depression would
be much blander. She furthermore, her books fuel the ongoing debate on whether the personality
changing effects of psychoactive drugs are moral/humane/desired?
Prozac:
Fluoxetine hydrochloride (Prozac) is an antidepressant of the selective serotonin reuptake
inhibitor (SSRI) class. Fluoxetine is approved for the treatment of clinical depression (including
pediatric depression), obsessive-compulsive disorder (in both adult and pediatric populations),
bulimia nervosa, panic disorder. (http://en.wikipedia.org/wiki/Prozac). The work which
eventually led to the discovery of fluoxetine began at Eli Lilly in 1970 as a collaboration
between Bryan Molloy and Robert Rathburn. Fluoxetine made its appearance on the Belgian
market in 1986 and was approved for use by the FDA in the United States in December 1987.
Fluoxetine was the fourth SSRI to make it to market, after indalpine, zimelidine and
fluvoxamine. However, the first two were withdrawn due to the side effects, and a vigorous
marketing campaign by Eli Lilly made sure that in the popular culture fluoxetine has been
perceived as a scientific breakthrough and associated with the title of the first SSRI. Eli Lilly's
patent on Prozac (fluoxetine) expired in August, 2001, prompting an influx of generic drugs onto
the market. In 1974, the WHO (World Health Organization) published a study in which
according to the Hamilton Scale (Scale that rates depression) that 100 million people in the
world are amenable to treatment for depressive disorder -> increased investigation. In 1987,
65,000 prescription of Prozac were written per month. 1990s depression became kind of
fashionable (see book: Prozac Nation by Elizabeth Wurtzel).
Sarafem:
The WHO study in 1974 also showed that women statistically were more prone to depression
than men. Sarafem is an example of strategic drug advertisement, targeting especially women.
Sarafem also is Fluoxetine which is Prozac, but the pill was pink as opposed to blue (Prozac). To
avoid the stigma of the disease (depression) the drug was marketed as Sarafem -> the identity of
the drug plays a role in the perception of its social status.
Thorazine, anxiety, Valium "Mother's Little Helper", reserpine, dopamine, seratonin,
Accounting for new voices. By the 1980s, we must consider the interests of a wide array of
actors in order to understand psychiatry. Besides psychiatrists and patients, whose
experiences have become increasingly prominent and accessible, research scientists, patient
families, legislators, celebrities, mass culture/media, and pharmaceutical corporations are
all active participants in contemporary psychiatric debates. How do we make sense of these
different voices and their interactions?
Key Terms:
Thorazine, anxiety, Valium, "Mother's Little Helper", Reserpine, dopamine, serotonin
Key Questions:
By the 1980s, we must consider the interests of a wide array of actors in order to understand
psychiatry. Besides psychiatrists and patients, whose experiences have become increasingly
prominent and accessible, research scientists, patient families, legislators, celebrities, mass
culture/media, and pharmaceutical corporations are all active participants in contemporary
psychiatric debates. How do we make sense of these different voices and their interactions?
Key Lectures:
Lecture 17: Depression and Anti-depressants
Lecture 18: Marketing Drugs, marketing mental illness (Guest lecture, Dr. Nathaniel Greenslit)
Lecture 22: Untidy Endings: psychiatry and its history today
Key Readings:
Peter Kramers 1993 book, Listening to Prozac
Kay Redfield Jamisons memoir, An Unquiet Mind (1995)
Thorazine brand name for chlorpromazine in the US, the first antipsychotic drug (approved by
FDA in 1954; licensed to Smith Kline & French). Its principal use is in the treatment of
schizophrenia, though it has also been used to treat hiccups and nausea. Chlorpromazine works
on a variety of receptors in the central nervous system; these include anticholinergic,
antidopaminergic and antihistamine effects as well as some antagonism of adrenergic receptors.
Developed by French chemists at Rhne-Poulenc in 1950, it was first used as an antihistamine
and antiemetic. Its effects on mental state were first reported by the French doctor Henri Laborit
in 1951 as sedation without narcosis. It became possible to cause 'artificial hibernation' in
patients, if used as a cocktail together with pethidine and hydergine. The drug was credited for
emptying psychiatric hospitals in the US and its effect has been compared to that of penicillin in
the treatment infectious diseases; over 100 million people were treated. From chlorpromazine a
number of other similar neuroleptics were developed (e.g. triflupromazine, trifluoperazine).
Valium - benzodiazepine derivative drug commonly used for treating anxiety, insomnia,
seizures, alcohol withdrawal, and muscle spasms. It possesses anxiolytic, anticonvulsant,
sedative, skeletal muscle relaxant and amnestic properties. Also known as Diazepam, it was the
second benzodiazepine to be invented by invented by Polish chemist Leo Sternbach of
Hoffmann-La Roche, and was approved for use in 1963. From the early 60's to the early 80's
Valium was one of the most heavily prescribed drugs in the US and Europe and was used by
many housewives, earning it the nickname, Mothers Little Helper.
"Mother's Little Helper" nickname for Valium, after the title of a song by The Rolling
Stones. Written by Mick Jagger and Keith Richards, "Mother's Little Helper" and recorded in
December 1965, the sheds a light on the darker perspective of the widespread use of the
prescription drug Valium, especially among housewives.
Life's just much too hard today / I hear ev'ry mother say / The pursuit of happiness just
seems a bore / And if you take more of those / you will get an overdose / No more
running for the shelter / of a mother's little helper.
Reserpine an indole alkaloid antipsychotic and antihypertensive drug; rarely used today
because of its numerous side-effects. Isolated in 1952 from the dried root of Rauwolfia
serpentina (Indian snakeroot). Reserpine blocks the uptake of norepinephrine (i.e. noradrenaline)
and dopamine into synaptic vesicles. Notably, it was highly influential in promoting the
biogenic-amine hypothesis of depression (hypothesis that abnormalities in the physiology and
metabolism of biogenic amines are involved in the development of certain psychiatric illnesses).
Dopamine a neurotransmitter discovered by Arvid Carlsson and Nils-ke Hillarp in 1952.
Named Dopamine because it is a monoamine, and its synthetic precursor was 3,4dihydroxyphenylalanine (L-DOPA). Arvid Carlsson was awarded the 2000 Nobel Prize in
Physiology or Medicine for discovering the neurotransmitter. Abnormally high dopamine action
has also been strongly linked to psychosis and schizophrenia. Evidence comes partly from the
discovery of a class of drugs called the phenothiazines (which block D2 dopamine receptors) that
can reduce psychotic symptoms, and partly from the finding that drugs such as amphetamine and
cocaine (which are known to greatly increase dopamine levels) can cause psychosis. Because of
this, most modern antipsychotic medications, for example, Risperidone, are designed to block
dopamine function to varying degrees.
Serotonin neurotransmitter isolated and named in 1948 by Maurice M. Rapport. Low levels of
serotonin may be associated with several disorders, namely clinical depression, obsessivecompulsive disorder (OCD), migraine, bipolar disorder and anxiety disorders. Selective
serotonin reuptake inhibitors (SSRIs) are a class of antidepressants used in the treatment of
depression, anxiety disorders, and some personality disorders; SSRIs work by inhibiting
serotonin reuptake into the presynaptic cell, increasing the level of serotonin available to bind to
the postsynaptic receptor. The MAOIs prevent the breakdown of monoamine neurotransmitters
(including serotonin), and therefore increase concentrations of the neurotransmitter in the brain.
Many recreational drugs innately modulate the serotonin receptor system to produce alterations
in perception, emotional response, and thought process. These include psilocin/psilocybin, DMT,
mescaline, LSD, MDMA (ecstasy), MDA, MDEA and ibogaine.
Contemporary psychiatric debates
More players, more opposing viewpoints, more media attention in recent years. Much attention is
focused on prescription drugs and their supposed overuse.
-
The 1980s benzodiazepine dependency scandal
o Concerns about overprescription
o Media unease over the Prozac phenomenon arises after concerns about a link
between Prozac and increased suicide risk
"The cloud over bottled sunshine ..."; (Doyle, 1994)
With millions taking Prozac, a legal drug culture arises (Rimer, 1993)
"Escape Capsule ..." (Bracewell, 1993)
"The Personality Pill..." (Toufexis, 1994)
-
The DTC (direct to consumer advertising) debate should the pharmaceutical industry be
allowed to advertise prescription drugs to the general public, or should advertising be
directed only at physicians and other health care professionals?
o In September 1982, the Commissioner of FDA issued a formal request to the
pharmaceutical industry for a voluntary moratorium on DTC advertisements, to
allow FDA time to research the issue of legalization; three years later the FDA
decided to legalize DTC advertising of prescription drugs.
o Concerns: does DTC increase unnecessary spending on prescription drugs? Are
they effective in educating the consumer about different options? Are
consumers well informed enough to make choices about prescription drugs?
-
Cosmetic psychopharmacology and Listening to Prozac as described by Peter
Kramer in Listening to Prozac (1993) should people be allowed to take prescriptions if
not diagnosed with an illness?
o Who was I to withhold from her the bounties of science? Peter Kramer, on
deciding to write Tess a prescription for Prozac, even though she did not meet
DSM criteria for clinical depression
o Since you only live once, why not do it as a blonde; and why not as a peppy
blonde? Kramer, Listening to Prozac
-
Tom Cruise and Scientology
o example of celebrities who have a very public viewpoint about mental illness
-
Recent newspaper headlines on mental health problems in soldiers fighting in Iraq
o Flashback to Vietnam War era PTSD (post-traumatic stress disorder)
Where do new therapies come from? How do new theoretical understandings of mental
illness emerge and spread? What is the relationship between therapeutic and theoretical
shifts in psychiatry? The development of the somatic therapies and the initial development
of drugs were not driven by theory and did not immediately cause any shift in the
dominant theoretical understandings within psychiatry. How do we understand, then, the
gradual shift from a predominantly Freudian framework in psychiatry to a predominantly
biological framework?
Where do new therapies come from? How do new theoretical understandings of mental illness
emerge and spread? What is the relationship between therapeutic and theoretical shifts in
psychiatry?
The development of the somatic therapies and the initial development of drugs were not driven
by theory and did not immediately cause any shift in the dominant theoretical understandings
within psychiatry. How do we understand, then, the gradual shift from a predominantly Freudian
framework in psychiatry to a predominantly biological framework?
Most of the new therapies in the 1900s were discovered by almost pure chance.
Ex. Malaria-fever therapy was discovered by a chance observation
Ex. Insulin coma therapy was originally used to treat morphine addicts, but they
happened to realize it calmed the patients down afterwards
Therapeutic and theoretical shifts are deeply interconnected, sometimes with therapeutic shifts
driving theoretical shifts, other times with theoretical shifts driving therapeutic shifts. In the
1900s, it seems more a case of therapeutic shifts driving theoretical shifts. Some of the therapies
that were developed were not even understood theoretically, but were just seen to be therapies
that worked. Only after
Psychiatry and normal life. How have psychiatrists and psychiatric ideas influenced
understandings of normal behavior and experiences, from mental hygiene to the
marketing of modern antidepressants?
Psychiatry and normal life.
Major Trends
No longer considered to be part of a lower class in society.
Everyone has a breaking point.
Much less stigma to be mentally ill; or to seek help from a psychiatrist.
The field of psychiatry focused more on curing the patient as oppose to study the illness.
(remember: therapeutic nihilism)
Can be treated: antidepressants etc (Good or bad? Listening to Prozac)
Specifcs
Psychotherapy for the normal
We should turn our attention to the great numbers of near happy people, the
almost effective; the people for whom life has lost its savor but who plod along
holding their discontent as tightly as they can to themselves; the people who
struggle for control but lose it tragically at critical moments; the quietly desperate
people who cannot realize their own lives and who add much to the uncertainty
and unhappiness of others. (Dr. Nicholas Hobbs 1948 Conference of Mental
Hygiene and the problems of Exceptional Children)
Personality testing/Interpersonal Psychotherapy
1. focus on patients present day interpersonal relationships rather than childhood
fantasies.
2. focus on the patients personality rather than on unconscious drives
3. emphasis on the therapeutic value of the doctor-patient relationship, which was
supposed to be warm, emotionally intimate, and nurturing
4. allowed for a wide-ranging give-and-take between doctor and patient
5. Fritz Perls Gestalt Therapy; Carl Rogers Person-Centered Therapy; Eric Bernes
Transactional Analysis; Joseph Wolpes Behavior Therapy; Aaron Becks
Cognitive Therapy; Rorshach test; Myers Brigg Type Indicator; Scientific Dating
Self-help and advice literature
What we have to decide is not whether we want to go on having advice columns.
That is already settled. The question for us is whether we are prepared to take
over and help to direct these columns, so that they
will be run competently and responsibly; or whether we are to leave the many
thousands of people who seek help in that way at the mercy of the untrained and
the unqualified. (Psychiatrists 1950 editorial in Marriage and Family Living)
Popular culture
The most significant of the Ten bests this yearis delving underneath the bank
accounts, the handsome exteriorsseeking the Ten Best-Adjusted
Americans.It just goes to show how far psychiatrists have penetrated into our
folklore. (The Washington post 1950)
Movies: Hamlet; The Manchurian Candidate; The Snake Pit; Spellbound; Psycho
Depression as a fashionable disorder
"It seemed that suddenly, sometime in 1990, I ceased to be this freakishly
depressed person who had scared the hell out of people for most of my
life with my mood swings and tantrums and crying spells, and I instead
became downright trendy. This private world of loony bins and weird
people that I had always felt I occupied had suddenly been turned inside
out so that it seemed like this was one big Prozac Nation, one big mess of
malaise.
--Elizabeth Wurtzel, Prozac Nation
Drugs:
1. the good:
The patients became generally more lively; their low depressive voices
sound stronger. The patients appear more communicative, the
yammering and crying come to an end. If the depression had manifested
itself in a dissatisfied, plaintive, or irritable mood, a friendly, contented
and accessible spirit comes to the fore. Hypochondriacal and
neurasthenic complaints recede or disappear entirely. (Roland Huhn
Antihistamine 1955)
At least one hundred million people in the world suffer from
depressive disorders amenable to treatment (World Health
Organization 1974)
2.
Who are we to say what is normal and what makes others happier?
The drugs can adversely and permanently change someones intrinsic personality.
Also, unhealthy addictions can be created through use of such drugs.