The Practical Psychiatrist

History of Psychiatry Part II; The Asylum ctd. - The Dawn of Asylum Medicine

The Dawn of Asylum Medicine

Asylum – A place of retreat and security

Prior to theories of Darwin and the extrapolations of Spencer, insanity was considered by most physicians to be a permanent state of mind. Insanity was all encompassing, all consuming, and never-ending. Insanity was an amorphous blob into which the unfortunate and the immoral fell, never to re-emerge. The life of a person with mental illness was, as a rule, brutal and short. In the medieval period, when day to day survival often depended on every member of a community contributing in some way to the wellbeing of the whole, a mentally ill person who consumed resources but produced nothing might tip the balance of that community into starvation. People with mental illness were left to wander the streets and countryside until they died of disease, violence, or exposure. Most people with mental illness found shelter in prisons and almshouses where they were chained to walls and tied to trees. Different religious orders began to establish hospitals and eventually began accepting patients with mental illness.

Things began to change in Florence, Italy in the 1770s when Pietro Leopoldo, the Grand Duke, sought to improve the treatment of the mentally ill. In 1774, the “legge sui pazzi” or law on the insane was introduced. This law allowed steps to be taken to hospitalize people thought to be insane. In 1788, a young physician by the name of Vincenzo Chiarugi was appointed director of the public hospital for the insane in Florence (Bonifacio Hospital). There he introduced a set of rules which prescribed the appropriate care of mentally ill patients, as well as setting down rules for the conduct of staff, admission of patients and record keeping. At his prior post, the Santa Dorotea hospital, he had outlawed the use of chains. The “Regolamento” that Chiarugi instituted at Bonifacio stated “The patient is to be treated with respect; not put to work…no physical pain to be inflicted under any circumstance…restraints must be applied in accord with humanitarian and hygienic practices.” He also allowed the patients to have access to the hospital grounds where they could walk, play, or exercise.

In 1793, Philippe Pinel began work as a physician at Bicetre Hospital. During this period of time he developed his ideas about moral treatment. By the time he became the chief physician at Salpetriere, he was ready to implement these ideas on a large scale. While he still relied on the straitjacket and seclusion for folks who got out of line, he did not restrain people indefinitely. He actually talked to his patients and would attempt to dissuade them from their delusions. He felt that many of the problematic behaviors of patients could be relieved by providing space, kindness, consolation, hope, and humor. He believed that recovered patients should be employed by the institution due to their ability to empathize with patients. Pinel believed that heads of hospitals should be “devoted to the concept of order without violence”. These were radical ideas for the time!

In England, from 1795-1797, William Tuke worked with his personal physician and fellow Quaker meeting-goers (Friends?) to develop plans for an asylum based on moral principles of care similar to those of Pinel. This asylum came to be known as the York Retreat and served as the basic template for asylums in England, Europe and the US for years to come. The York Retreat was a place where the mentally ill could be sheltered from the cares of the world, where they would be given a healthy diet, where they would participate in enjoyable pass-times, and where they would be safe. The facility itself was designed to be visually pleasing rather than imposing, as were most hospitals and poor houses of the era.

The intended purpose of the insane asylum was not to construct a building in which the mentally ill would be warehoused, neglected and abused, but rather to create an environment in which the stressors associated with the outside world would be minimized and the afflicted individual would reside in safety and security. In such an environment, with removal of the aggravating factors of the insanity, the brain might heal itself and restore its owner to his productive place in society. With excellent care and time to heal, these people would leave their cocoon, physically and mentally healthy, never to return. There is no doubt that this approach was paternalistic and gave the patient little control over his treatment or recovery, but at the time, this was certainly an improvement over previous treatment approaches.

You’ll notice that a discussion of the medical treatment of mental illness is conspicuously lacking. That’s because the psychiatric formulary for your basic 18^th century psychiatric hospital was conspicuously lacking as well. Other than opium, bella donna, mild stimulants, and a few other nasty potions, mental illness wasn’t treated with medications. It was treated with bleeding, blistering, cauterizations, dunking in cold water baths, emetics, laxatives, etc.

To digress a bit, imagine the 17^th century psychiatrist on rounds, standing beside the bed of a poor unhealthy looking fellow, barely clinging to life. The psychiatrist says,  “Nurse, since this patient’s admission, we’ve applied the leeches to his temples, irrigated his bladder, cupped and cauterized him twice, opened his veins and drained a couple of liters of blood, completely immersed his body repeatedly in ice water, gave him a good blistering, starved him, whipped him about the waist with reeds, made him puke continuously for 3 days, then gave him a couple of high colonic enemas. Has his melancholia improved?” The nurse replies, “I don’t know about his depression Doc, but he’s confessed to being a heretic, a witch, and a French spy!”

Next: Psychiatry – American Style!

History of Psychiatry Part II; The Asylum

Let’s return to the roots of my profession and examine the soil from which it sprang.

Darwin, Spencer, and Evolutionary Psychiatry

The mid to late nineteenth century was an exiting time to be a scientist. Charles Darwin’s work had only recently been published, but his theories of evolution caught like wildfire in the scientific community. Up to that point, scientists had placed all the world’s species of living organisms into little cubby holes where each was expected to stay for eternity. Darwin’s finches and tortoises dumped this biologic cabinet of cubby holes onto the floor and gave the species wings and legs on which to journey toward adaptive perfection.

Darwin’s theories became the omnipotent force driving the evolution of science.  Herbert Spencer, a largely self trained political theorist who lived in England, applied Darwin’s principles to biology, sociology, psychology, religion, and politics. (He is also credited with coining the term “survival of the fittest”.) Some of his ideas regarding the evolution of the human mind served as basic building blocks for the foundation of what would become modern psychiatry and psychology.

The early concept of evolution allowed for the rapid adaptation of organisms, literally within one or two generations, in response to the external evolutionary forces. Another tenant of early evolutionary theory suggested that just as organisms evolve, that when exposed to adverse evolutionary forces, they might de-evolve. In other words, rather than adhering to the evolutionary version of the Peter Principle, where organisms rise to a certain level of development and get stuck there and quietly fade away (consider Neanderthal man), it is possible for an organism to squander its previous evolutionary success and backslide to a cruder or simpler state of development. (If you think about it, this might actually represent a form of adaptation in which the devolution from complex to simple organization results in a better chance of survival for the organism. I haven’t had the chance to dig deeper and see if this was a consideration.)

 

The Diathesis Stress Model of Insanity

In the late 19^th century, a diathesis-stress model for the causation of mental illness gained popularity. This model proposed that an individual has a pre-disposing factor to mental illness. This diathesis might be genetic, characterologic, traumatic, or disease related. When such a diathesis exists or is created, mental illness can be triggered by a precipitating factor, such as an emotional shock, a physical illness or trauma, the use of substances such as alcohol or narcotics, etc. The mental illness would then could be propagated by aggravating factors (stressors) such as difficult life circumstances (hunger, poverty, abuse), or conversely, a chronically bacchanalian lifestyle, chronic physical illness, marital or employment difficulties, etc.. 

 

The Evolution/De-Evolution of the Mind

The early psychiatrist postulated that though the human mind was much more complex than a bird, it WAS a dynamic biologic entity and subject to the same evolutionary forces which shaped Darwin’s finches. As such, even in the presence of an insane diathesis, if you controlled the external forces which shaped the mind, exposing it to all that was  healthy and balanced, and sheltering it from worldly nastiness, it would evolve more quickly and more completely than it might have done otherwise. This evolution to a more perfect and adapted state would be reflected not only by an ever-increasing level of intelligence, but also by an increasingly higher level of morality. Men would learn to resolve their conflicts peacefully. Wars would cease. Education, eradication of pain and suffering, and service to fellow-man would be the focus of the evolved society. On the other hand, if that same vulnerable mind was exposed to unhealthy, diseased, stressful, and toxic forces, it would slip back into the primordial gutter from whence it first crawled.

Next - The History of Psychiatry, Part II; The Asylum -
The Dawn of Asylum Medicine

Bipolar Disorder Is Associated With Significant Burden Of Medical Illness

In a study from the Journal of Psychiatric Research (J Psychiatr Res, 2008" 42; 956-961) Isabella Soreca and colleagues assessed 111 patients with bipolar disrder using the Cumulative Illness Rating Scale. They found that in this study population with a mean age of 42.7 years and a duration of bipolar illness of 22.4 years, the burden of medical illness was signicant, with, on the average, more than three major organ systems being affected. The most frequently endorsed categories were cardiovascular and endocrine.

Psychiatry and Primary Care

I, along with other Birmingham public psychiatrists, attended a discussion recently with primary care physicians, nurse practitioners, and other primary care providers in our community. This meeting was a follow-up to the Alabama Department of Mental Health's Psychiatric/Primary Care Institute in April. The purpose of these ongoing discussions is to foster improved communication between psychiatrists and primary care providers, and to improve access for our clients to services in both areas of these areas of medicine.

As I discussed in my post last week, (The History of Psychiatry Part I; The First Psychiatrists) the specialization of psychiatry occurred in the mid-19th century and represented the birth of specialization in medicine. Psychiatry struggled to define itself in the late 19th and early 20th century. There were conflicts between psychiatry and neurology based on diagnostic schema and different views in psychopathology. Psychiatry was also viewed as "institutional medicine" rather than a clear cut specialty, based on its' strong association with the asylum.

At the beginning of the early 20th century, psychoanalytic theory became the  definitive paradigm in psychiatry. This therapeutic trend gave the specialty a niche, but also pulled it away from its' medical base. While the rest of medicine was finding the histopathologic, endocrinologic, and environmental pathogenises of their respective diseases, psychiatry took a decidedly non-biologic approach in the study of psychopathology.

With the discovery of somewhat effective antipsychotic and antidepressant medications in the 1950's, psychiatry began moving back toward its medical roots. However, a wide gulf still reamins between psychiatry and the rest of medicine. Part of this is due to the stigma associated with the illnesses themselves. Just as they are scary to the average Joe, there are a lot of Docs who feel very uncomfortable  in dealing with our clients. This reluctance on the part of primary care providers (PCP) is a major barrier for our patients. They often have a hard time getting in to see a PCP. When they do, the PCP often doesn't see past the mental illness.

Another more complex factor is the fact that the diagnostic schema of psychiatry, the DSM IV, the most popular system for diagnosis in the field, still has no biologic basis. It reflects years of observing symptom clusters in large populations, rather than what might be found on the microscope slide or on radiologic images. This nebulous approach to diagnosis is difficult for primary care docs to comprehend (just as it is difficult for most psychiatrists to get their brain around). For the most part, psychiatrists and PCPs don't even speak the same language. Medical school does little to prepare most physicians when it comes to diagnosing and treating psychiatric patients.

Very little time is spent in psychiatric training programs preparing young psychiatrists to communicate effectively with physicians in other specialties. Psychiatrists have to go through a standard medical school or osteopathic training program prior to starting a four year psych residency. Then they do an internship which usually includes six months of primary care and neurology rotations. But as training and then psychiatric practice proceed, psychiatrists often become less and less connected to the medical education which started their career.

I sometimes get the sense that this is a point of pride with psychiatrists. It is not uncommon among psychiatrists to hear "I ONLY write for PSYCHOTROPICS". This implies that the psychiatrist will not write for medications used in the treatment of "medical" disorders, like diabetes or hypertension. While this is probably a good idea considering the amount of experience most psychiatrists have in dealing with the medically ill, it represents the cubbyhole in which most psychiatrists live. Another related issue is that psychiatrists and PCP's just don't talk. We fail to get on the phone and call the patient's PCP to ask questions about their medical illnesses or we fail to even check for elevated blood pressures or blood sugars. PCPs don't call psychiatrists to inquire about the new medications we've started, or to inform us about worsening symptoms they might observe.

In recent years, I've been forced to come out of my cubbyhole and start practicing medicine. Newer antipsychotics are associated with a host of side effects which can lead to medical problems (hyperlipidemia, hyperglycemia, etc.) In public psych clinics, we have started regularly checking weights, blood pressures, blood sugars, and other studies when called for. I have a special program on my PDA for calculating body mass indexes. I've had to go back to my basic medical texts to refresh my memory on the dyslipidemias and diabetes. I've gone to several primary care conferences to update myself on the newer medications used in the treatment of some of these medical illnesses. I am finding more acute medical problems in patients because I look for the physical signs and symptoms and try to take a good medical history. I attempt to contact a patient's PCP to talk about medications, medical issues, psychiatric symptoms, and the interplay of the different illnesses. If the patient doesn't have a PCP, we do our best to do an appropriate referral, then follow up to make sure they followed thru. On several occasions I've had to temporarily provide primary care services for patients who were unable to obtain it elsewhere

This approach to psychiatric practice is beneficial to the patients because they are receiving services which are more comprehensive, organized, and "seamless". It is certainly safer and, hopefully, more likely to result in improvement in their overall quality of life. It has given me more confidence in my ability to practice medicine.

I would encourage my colleagues in the psychiatric community who haven't already done so to establish relationships with local PCPs, to update their primary care knowledge base, and to "come out of the cubbyhole." We are physicians first and psychiatrists second. We can't forget from whence we came.

History of Psychiatry Part I: The First Psychiatrists

The persona of the psychiatrist is so common in popular culture that it seems he's been around since the dawn of time.

Og the caveman, arrow sticking out of his head, stumbles into the cave of Dr. Oop, Stoneage Psychiatrist. Dr. Oop, perusing the situation carefully, remarks to Og, "I know that must hurt badly, but how does it REALLY make you feeeeel?"

Adam, recently tossed out of the Garden of Eden on the couch; his psychiatrist sitting close by says, "You know, all we've really talked about is your father. Isn't it time we brought your mother into the picture?"

The Bible recounts an episode in the life of Jesus Christ which may have represented a "psychiatric healing";

1 They came to the other side of the sea, to the country of the Gerasenes. 2 And when he had come out of the boat, there met him out of the tombs a man with an unclean spirit, 3 who lived among the tombs; and no one could bind him any more, even with a chain; 4 for he had often been bound with fetters and chains, but the chains he wrenched apart, and the fetters he broke in pieces; and no one had the strength to subdue him. 5 Night and day among the tombs and on the mountains he was always crying out, and bruising himself with stones. 6 And when he saw Jesus from afar, he ran and worshiped him; 7 and crying out with a loud voice, he said, "What have you to do with me, Jesus, Son of the Most High God? I adjure you by God, do not torment me." 8 For he had said to him, "Come out of the man, you unclean spirit!" 9 And Jesus  asked him, "What is your name?" He replied, "My name is Legion; for we are many." 10 And he begged him eagerly not to send them out of the country. 11 Now a great herd of swine was feeding there on the hillside; 12 and they begged him, "Send us to the swine, let us enter them." 13 So he gave them leave. And the unclean spirits came out, and entered the swine; and the herd, numbering about two thousand, rushed down the steep bank into the sea, and were drowned in the sea. 14 The herdsmen fled, and told it in the city and in the country. And people came to see what it was that had happened. (The Holy Bible, RSV Catholic Edition)

To digress a bit, I've always wondered about the poor pig herder in the story. Can you imagine him trying to explain the situation to his boss? "Well, I was sittin' there, mindin' my own business, watchin the pigs walllowing in the mud, when this long haired hippie looking dude with a beard rides up in a boat with his whole entourage. He gets out and right away, crazy old Akmed (you know the guy who calls himself Legion) starts yelling at him. The dude with the long hair says something to Akmed, then he points at the pigs and all of a sudden the pigs jump up and run into the ocean! Mass Porcine Suicide! Drowned! Every single one of them! It was the craziest thing you ever.... Alright! Alright! I'm leavin! Don't call security! I'll pick up my paycheck on the way out!

It's hard to believe that psychiatry, as a specialty, is a relatively new concept. The evolution of this specialty started with the recognition that some folks seemed to have problems that everyone else didn't have. People with mental illness were regarded with suspicion and fear. Mental illness was thought to be caused by spiritual possession of the individual by evil spirits, or by perverse behaviors which the afflicted had engaged in prior to the illness. The mentally ill were a problem relegated to the clergy and physicians had no role in their care.

People with severe mental illness were the pariahs of society. Bizzarre behaviors associated with the mental illness tended to cause the mentally ill to be ostracized and most wound up chained in attics or barns, living in almshouses, jails, and prisons, or burned at the stake on charges of witchcraft. (Sometimes I wonder how much progress we've actually made in this modern age. Large numbers of mentally ill are homeless or incarcerated even today. We continue to excute people with mental illness for crimes which occurred when they were actively psychotic). Toward the end of the middle ages in Europe, institutions, which were loosely referred to as hospitals, were established by churches to provide care for the indigent insane. These instituions didn't really provide a lot of care. Most of the inmates were chained to their bed (if they had one) or to the wall. The idea was to keep the folks off the streets and out of everyones hair. The inhabitants of these institutions were viewed and treated as animals. Often, these hospitals charged entrance fees to the general public to come in and view the denizens for entertainment purposes.

In the late 18th century, a French physican by the name of Philippe Pinel was hired to head a hospital for insane women in Paris. He was shocked by the conditions in the hospital. He shocked the community by releasing these women from their chains and treating them as human beings. This marked the beginning of what became known as the Moral Treatment of the Insane. This philosophy was based on the belief that through decent care and appropriate treatment, the mentally ill might be cured.

In the United States, the Quakers (a religious sect dedicated, among other things, to the care of the poor) adopted a similar philosophy in caring for the mentally ill and several hospitals were established in the Northeast to provide moral treatment. The movement was fueled by its association with religous responsibility, and by the middle of the 19th century, there were about 35 hospitals for the mentally ill in the US.

Since people with mental illness tended to have poorer health, most required intensive medical attention. Hospitals for the insane were staffed by physicians who lived on the hospital grounds. The physicians not only attended to the medical needs of the patients but handled the administrative duties of the instituion as well. They were called the superintendents of the institution.

Even back then, physicians liked to get together and share common experiences in order to learn better ways of doing things (and to drink a lot, eat a lot, get loud, and act stupid), so a group  of these superintendents got together in 1845 and called themselves he Association of Medical Superintendents of American Institutions for the Insane (AMSAII). This was the beginning of what we now know as the medical specialty of psychiatry. Psychiatry was actually the FIRST specialty. No other physicians, up to that point, had formed an association for the purpose of gaining a deeper knowledge for the care of a specific group of patients. The AMSAII would evolve into what we now call the American Psychiatric Association the largest modern professional association for psychiatrists.

Next Week: History of Psychiatry Part II: The Asylum - "Well, It seemed like a good idea at the time!"

Commonsense Psychiatry

The subtitle of this blog may sound a little tongue-in-cheek, but it is written in all sincerity. If you view my website, you will see that I have been practicing psychiatry for a while. Almost universally, whenever I meet someone and tell them I am a psychiatrist, its almost as if a wall goes up. Part of this, I'm sure, is because of the stigma associated with the illnesses I treat. Psychiatric illnesses and their consequences can be pretty scary. People are frightened of mental illness and they are sometimes frightened by those who suffer with it. They are also pretty suspicious of the folks who treat it.

This suspiciousness is not unfounded. I know of few professions, even in medicine, associated with so much controversy. Psychiatrists have been known to inflict some pretty bizarre and, frankly, vicious treatments on their patients. Along with the mistakes made by the profession through the years, there are many myths, misconceptions, and untruths floating around about mental illness and its' treatment. There are a fair number of critics out there who don't even believe that mental illness exists and that psychiatry has actually created this concept in order to justify its own existence.

Finally, if you've ever been around a group of psychiatrists, they can be pretty weird. I include myself in this sweeping generalization. You can't do what I do, day after day, without being a little "tetched" as my grandmother used to say. Don't get me wrong, I have a passion for what I do, and I love my patients, but what I see as acceptable behavior probably differs from what the general public would deem as normal. Now this statement implies that psychiatrists are strange because of the company they keep, but the truth of the matter is that most of us start out that way. I felt comfortable the day I first set foot on a psychiatric unit. This tells me something.

All kidding aside, God has given me the opportunity to work with folks who most people won't associate with, and this is the greatest gift he could have bestowed upon me. I learn more from my patients than I ever learned in school. I have more respect for my patients than for most of the "normal" people I have to deal with on a daily basis. No one can imagine the strength that someone suffering with a serious and persistent mental illness has to dredge up every single day, sometimes just to survive. God put me right where I needed to be.

Through this blog, and through my website, I hope to pass on useful information about mental illness and psychiatry to folks who might not hear about it otherwise. I would like to communicate this information in such a way that just about anyone can understand it. Most psychiatrists have trouble communicating exactly what it is they do and just why it is they do it, but I am going to take a good crack at it.

The internet is a pretty anonymous place, so you don't have to worry about being judged by me or by anyone else. I welcome questions about any issues related to psychiatry. I am not an expert in most areas of my profession, but I have a good general knowledge, I love to learn, and I love to try to find answers to difficult questions. I am not perfect and I have been known to forget details, and ad lib on answers to questions I don't know the answer to, but I will try to keep that to a minimum. I am always open to correction if I am wrong about something. I will provide NO treatment through this blog or my website, but I hope to be able to explain different treatment options. I also welcome questions from colleagues in my profession, other medical specialties, family members of folks who have mental illness, or members of the general public.