American Psychiatry Research Articles

Genes and Environment and the World of Psychiatry

Genes and Environment and the World of Psychiatry

A Premature Obituary

On March 4, 1878, at a meeting of the New York Neurological Society, Edward C. Spitzka delivers a blistering attack on psychiatry, basically dismissing all alienists as incompetent and indicating that "the study of insanity should be considered a subdivision of neurology." This address was published in the Journal of Nervous and Mental Disease in 1878 and reproduced in the current issue of the journal.Spitzka asserts that "nothing worthy of notice has proceeded from our insane asylums" and that asylum superintendents may be experts in many things, but they are not experts in the "diagnosis, pathology, and treatment of insanity." To ascertain whether or not Spitzka's characterizations were correct, I examined the medical and psychiatric literature published in English only in 1878.This review indicates that Spitzka was largely wrong. Research was not what it should have been, and the alienists (psychiatrists of that era) knew it. American alienists, however, were otherwise engaged in all manner of deliberations about important issues of the day relevant to the practice of psychiatry. In fact, to an absolutely remarkable degree, the issues of 1878 are the same as those of American psychiatry in the 21st century. That might say much more about psychiatry than Spitzka could ever have known 133 years ago.

The (Un)managed Self: Paradoxical Forms of Agency in Self-Management of Bipolar Disorder

Self-management of mental illness is a therapeutic paradigm that draws on a distinctly biomedical conceptualization of the isolability of personhood from pathology. This discourse posits a stable and rational patient/consumer who can observe, anticipate, and preside over his disease through a set of learned practices. But in the case of bipolar disorder, where the rationality of the patient is called into question, the managing self is elusive, and the disease that is managed coincides with the self. While humanist critiques of the biomedical model as applied to mental illness have argued that its logic fatalistically denies patients intentionality and effectiveness (Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry, 2000), biomedical proponents claim that psychiatry's way of envisioning the body as under the control of the intentional mind actually returns agency to the patient/consumer. Rose (The Psychiatric Gaze, 1999) remarks that biomedical models have the potential to "[open] that which was considered natural to a form of choice" (p. 37), and that techniques of medical self-control help constitute the free embodied liberal subject who is obliged to calculate and choose. Through an examination of clinical literature as well as the practices and narratives of members of a bipolar support group, this paper explores ethnographically the possibilities for subjectivity and agency that are conditioned or foreclosed by the self-management paradigm, which seems to simultaneously confer and deny rational selfhood to bipolar patients. To express their expertise as rational self-managers, patients/consumers must, paradoxically, articulate constant suspicion toward their present thoughts and emotions, and distrust of an imagined future self. I argue that through their self-management practices, bipolar support group members model provisional and distributed forms of agency based on an elusive, discontinuous, and only partially knowable or controllable self-revealing, perhaps, the limits of the contemporary reification and medicalization of both selfhood and disease.

Medicalized Psychiatry and the Talking Cure: A Hermeneutic Intervention

The dominance of the medical-model in American psychiatry over the last 30 years has resulted in the subsequent decline of the “talking cure”. In this paper, we identify a number of problems associated with medicalized psychiatry, focusing primarily on how it conceptualizes the self as a de-contextualized set of symptoms. Drawing on the tradition of hermeneutic phenomenology, we argue that medicalized psychiatry invariably overlooks the fact that our identities, and the meanings and values that matter to us, are created and constituted by our dialogical relations with others. While acknowledging the importance of medical and pharmaceutical interventions, we suggest that it is only by means of the dialogical interplay of the talking cure that the client can both recognize unhealthy and self-defeating ways of being and be opened up to the possibility of new meanings and self-interpretations.

90th Birthday Finds Pioneer Undertaking New Challenges

90th Birthday Finds Pioneer Undertaking New Challenges

Contested Jurisdictions: Psychiatry, Psychoanalysis, and Clinical Psychology in the United States, 1940–2010

American psychiatry on the eve of Pearl Harbor was a small, stigmatised, and isolated specialty, for the most part confined as surely inside the high walls of its barrack-asylums as the patients over whom it exercised near-autocratic powers. The number of mentally ill patients incarcerated in state and county mental hospitals had grown sharply, from 150,000 at the turn of the century to 445,000 in 1940. The fiscal crisis of the states that accompanied the Great Depression had produced a steady deterioration of conditions in these institutions, a deterioration that would intensify as a result of the exigencies of total war. In the immediate aftermath of that prolonged conflict, conditions had degenerated to such a parlous state that a number of outside observers compared America's asylums to Nazi death camps.

The Sabshin Legacy of Hope

Back to table of contents Previous article Next article From the PresidentFull AccessThe Sabshin Legacy of HopeJohn Oldham, M.D.John OldhamSearch for more papers by this author, M.D.Published Online:1 Jul 2011https://doi.org/10.1176/pn.46.13.psychnews_46_13_7Ironically, I was on my way to a "Blue Sky" meeting chaired by APA's CEO and Medical Director, Jay Scully, M.D., when I received an e-mail that former APA Medical Director Mel Sabshin, M.D., had died. It might have brought a smile to Mel's face to learn that this news was communicated to the APA senior staff and its president, immediate past president, and president-elect as we gathered for an annual meeting convened by Jay to do some blue sky, out-of-the-box thinking about how best to serve the organization that Mel loved and led for 23 years. I won't even try to summarize Mel's many accomplishments throughout his remarkable career, but his near-legendary stature and his importance as a forceful leader in the field of psychiatry are not in dispute. And Mel was, through and through, a visionary thinker, wisely watching the world change day by day, while passionately promoting psychiatry's growing importance in that changing world. Some time ago, I put together my own "big picture" chronology of the changing face of psychiatry, to use when talking to patients and families at The Menninger Clinic. The chronology looks like this: Some of these are my own designations, and some are the National Institute of Mental Health's (NIMH) designations. The current decade has been referred to in NIMH postings as the Decade for Psychiatric Disorders, as shown, but I also applied my own label, the Decade for Integrated Care. As many of you have heard me say, I believe that integrated, collaborative, patient-centered care is today's biopsychosocial model of health care—a systems version of the country doctor of simpler times. We must be active members of teams of experts working efficiently together, in partnership with our patients and their families. In our Blue Sky meeting, we spent time talking about the implementation of parity, the changing nature of health care in this country, the move away from fee-for-service models, workforce issues, membership issues, and scope-of-practice concerns. We talked about reducing stigma in many forms, including within the medical profession itself—for example, by taking a leadership role to sunset the term "international medical graduate." We reviewed the expanding range of CME opportunities within APA and the rapid transformation from print to electronic publishing. We discussed the new APA Web site that is well along in construction, and we thought about ways to involve our MITs and ECPs in order for them to teach us better ways to communicate using new technologies. We reviewed the many research programs being carried out under the leadership of the American Psychiatric Institute for Research and Education, including an extensive discussion about DSM-5. And we talked at length about how to partner with allied organizations both at home and abroad. Finally, of course, we studied what the budget looks like and how to prioritize what we need to do. One theme throughout the day was that the good work being carried out by APA staff in the Association's many divisions and departments needs to be better integrated with the work of the councils and components. Ultimately, we want all of our systems, large and small, to serve the goal of strengthening scientific progress, leading to better prevention and treatment for our patients, a goal to which Mel Sabshin devoted his long and fruitful career. In his wonderful 2008 book Changing American Psychiatry, Mel said that one of his motives in accepting the position of APA medical director was "to assist in a transition from an ideologically oriented profession to one that developed and maintained a genuine scientific base." He went on to say that "psychiatry needs to be a stronger advocate of understanding the relevance of biopsychosocial factors to normal human development and resilience as well as to psychopathology. The 21st century will include a strong surge in this direction. The next period of a changing American psychiatry will include a newly emerging group that wishes to see psychological hypotheses integrated systematically with social and biological variables. Academic psychiatry ... will ultimately need to support this new generation of empiricists who must also fully comprehend the fundamental importance of neuroscience." Mel's spirit was with us during our Blue Sky meeting, and I believe that he would be pleased at the tone of teamwork, optimism, and future-thinking that characterized the day—a day that could be described as right down Mel's alley. ISSUES NewArchived

Naming the problem that has no name: creating targets for standardized drugs

Many of the most common types of mental health problems that are found in outpatient psychiatric and general medical practices are diffuse, undifferentiated, and amorphous. Before the 1970s this lack of specificity did not conflict with the dominant theories and treatments of the American psychiatric profession or the demands of third party insurers and regulators. However, since that time the legitimacy and solvency of the psychiatric profession has come to depend on the perception that it treats specific disease entities. The establishment of the DSM-III in 1980 provided American psychiatry with many standardized disease entities that could be precisely measured, quantified, and abstracted from their particular contexts. In the late 1980s, these entities became the targets of the new class of psychoactive drugs, the Selective Serotonin Reuptake Inhibitors. Professional, political, economic, and cultural forces that arose in a particular historical era account for the standardization of mental illnesses.

Parasomnias, Violence and the Law

In this review, we trace the parallel development of scientific understanding of parasomnias and the jurisprudence of violent behavior during sleep. Before sleep physiology was studied, it was generally self-evident that sleeping persons would not be criminally responsible. Though the problem of malingering was acknowledged in early American forensic psychiatry, the defendant with sleepwalking or sleep drunkenness was treated leniently. Over the past half century, sleep physiology has been examined and there is a developing nomenclature for sleep disorders. Though there is no clear-cut correlation between violence and sleep, several parasomnias have been implicated. We discuss contemporary concepts of parasomnias and suggest how expert witnesses might apply this knowledge to the difficult matter of assessing criminal intent and responsibility.

Autism Spectrum Disorders According to DSM-IV-TR and Comparison With DSM-5 Draft Criteria: An Epidemiological Study

The latest definitions of autism spectrum disorders (ASDs) were specified in DSM-IV-TR in 2000. DSM-5 criteria are planned for 2013. Here, we estimated the prevalence of ASDs and autism according to DSM-IV-TR, clarified confusion concerning diagnostic criteria, and evaluated DSM-5 draft criteria for ASD posted by the American Psychiatry Association (APA) in February 2010. This was an epidemiological study of 5,484 eight-year-old children in Finland, 4,422 (81%) of them rated via the Autism Spectrum Screening Questionnaire by parents and/or teachers, and 110 examined by using a structured interview, semi-structured observation, IQ measurement, school-day observation, and patient records. Diagnoses were assigned according to DSM-IV-TR criteria and DSM-5 draft criteria in children with a full-scale IQ (FSIQ) ≥50. Patient records were evaluated in children with an FSIQ <50 to discover diagnoses of ASDs. The prevalence of ASDs was 8.4 in 1,000 and that of autism 4.1 in 1,000 according to DSM-IV-TR. Of the subjects with ASDs and autism, 65% and 61% were high-functioning (FSIQ ≥70), respectively. The prevalence of pervasive developmental disorder not otherwise specified was not estimated because of inconsistency in DSM-IV-TR criteria. DSM-5 draft criteria were shown to be less sensitive in regard to identification of subjects with ASDs, particularly those with Asperger's syndrome and some high-functioning subjects with autism. DSM-IV-TR helps with the definition of ASDs only up to a point. We suggest modifications to five details of DSM-5 draft criteria posted by the APA in February 2010. Completing revision of DSM criteria for ASDs is a challenging task.

Book review: Kelley Winters: Gender Madness in American Psychiatry: Essays from the Struggle for Dignity. United States: GID Reform Advocates, 2009. 220 pp., $17.99, ISBN: 9781439223888 (pbk)

Book review: Kelley Winters: Gender Madness in American Psychiatry: Essays from the Struggle for Dignity. United States: GID Reform Advocates, 2009. 220 pp., $17.99, ISBN: 9781439223888 (pbk)

There is potential for cultural and social bias in DSM-V.

There is potential for cultural and social bias in DSM-V.

Two views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

Two views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

Where do classifications come from? The DSM-III, the transformation of American psychiatry, and the problem of origins in the sociology of knowledge

When something serves a function, it is easy to overlook its origins. The tendency is to proceed directly to function and retroactively construct a story about origin based on the function it fills. In this article, I address this problem of origins as it appears in the sociology of knowledge, using a case study of the publication of the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. The manual revolutionized American psychiatry and the treatment of mental illness, because it served the function of classification that had become critical to the field of mental health by this time. But this function must be bracketed in order to reveal the “extra-functional” origins of the DSM-III. Using field theory, I argue that the manual was necessary for reasons other than the function it filled as a classification. Specifically, its origin lies in a series of conflicts among psychiatrists, psychoanalysts, and clinical psychologists within the field of mental health, which followed in the wake of the collapse of psychoanalysis as the dominant treatment type for mental illness. I reveal the generative formula behind the production of the DSM-III, capturing a variety of social processes that influenced the format of the manual and made it a useful classification, but which are not reducible to function. In this way, I reproduce its raison d’etre in a manner similar to how the DSM-III appeared for the people who produced it. This focus on generative formulas offers the sociology of knowledge a way to capture the epistemic importance of a range of different social processes. Most importantly, it avoids the functional fallacy of reducing origin to function, and ignoring the idea that innovations might appear necessary even without clear recognition of their functional consequences.

F. Scott Fitzgerald and American Psychiatry: A New Letter

A previously unpublished four-page letter written by F. Scott Fitzgerald to one of his readers in the spring of 1936 reveals a considerable lack of confidence in psychotherapy. The reader, Joan Tyson, had come upon two of Fitzgerald’s now-famous Crack-Up essays in Esquire magazine and had written to him suggesting that he seek psychiatric help. Fitzgerald’s wife, Zelda Sayre, had been undergoing treatment for mental illness since 1930, but without much progress, and Fitzgerald had lost confidence in such therapy. In his response to Mrs. Tyson he writes of psychoanalysts: “I would never consider trusting myself to what passes for psychology-psychiatry in this country. How could someone not up to your ankles in intelligence + character help you. By some miracle? some act of God?”

CS05-01 - Interpersonal therapy

Interpersonal therapy of depression was created and established in American psychiatry in the 80ties. At that time european and especially german psychiatry was still dominated by the concept of endogenous depression, which suggested a somehow biologically determined aetiology which was not very likely to be influenced by psychotherapeutic access.However, the empiric approach to evaluate therapy regardless of aetiology, which is very typical for IPT, produced strong evidence for the effectiveness of IPT in unipolar depression and many other psychiatric disorders.On this basis, a diversity of biological studies became possible which aimed to the elucidation of neurobiological mechanisms of psychotherapy.The first data indicate that biological state markers change when the patient responds, regardless if he received Psycho- or pharmacotherapy. However, no empirical findings suggested, how IPT might be linked to neurobiological phenomena.We followed the suggestion by E. Kandel, that the phosphorylation of cAMP-responsive-binding-protein (pCREB) could be a crucial factor in the process of psychic improvement. Therefore we studied pCREB in human T-lymphocytes under different treatment conditions in unipolar depression. The results will be presented.

Inpatient Care in the 21st Century: We Need More Evidence

Back to table of contents Next article Taking IssueFull AccessInpatient Care in the 21st Century: We Need More EvidenceHoward H. Goldman, M.D., Ph.D., Howard H. GoldmanSearch for more papers by this author, M.D., Ph.D., editor, Psychiatric ServicesPublished Online:1 Feb 2011AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This issue of Psychiatric Services includes an Open Forum, “Inpatient Psychiatric Care in the 21st Century,” written by three distinguished psychiatrists, Ira Glick, Steven Sharfstein, and Harold Schwartz. Many will consider their vision of inpatient psychiatry a sensible guide to practice and policy, but others will find it controversial. We have yet to resolve the role of inpatient care in the range of psychiatric services.In 1894, S. Weir Mitchell, eminent neurologist and novelist, criticized American psychiatry in an invited address on the occasion of the 50th anniversary of the organization that became the American Psychiatric Association. Among other criticisms he asserted, “You have for too long maintained the fiction that there is some mysterious therapeutic influence to be found behind your walls and locked doors. We hold the reverse opinion. … Your hospitals are not our hospitals; your ways are not our ways.” He argued forcefully for the integration of psychiatric hospital care into the medical centers and academic centers of the time. In the 20th century, general hospitals expanded their psychiatric services dramatically and brought scientific psychiatry to patients. The inpatient setting rarely eliminated its locked doors, and inpatient psychiatry rarely shed its role in confinement. As outpatient care expanded and became more effective, the residual role of the hospital was confinement. The principal indication for hospitalization became an issue of safety to prevent harm to the person or to society. The focus on confinement reintroduces the question of what is the most appropriate and effective locus for that role.Deinstitutionalization and the growth of community care further challenged the role of the hospital. At the time, in response to a series of studies focused on length of hospital stay and alternatives to inpatient care, we asked, “If less is more, is none optimal?” The appropriate answer at the time was “No,” but the optimal form of 24-hour care was anything but clear. It is not clear that “your hospitals” should be “our hospitals,” unless patients need the intensive, high-technology environment of the modern general hospital. Some people with acute mental disorders require a general hospital setting. Not all patients who need 24-hour supervision or confinement, however, need that level of care. For some patients, freestanding psychiatric hospitals, affiliated with academic centers, are a more appropriate, lower-cost alternative to the general hospital. For many others, 24-hour alternatives may be more appropriate than the acute care hospital.Research on inpatient care has almost disappeared. The Open Forum in this issue provides clinical guidance for inpatient psychiatry. It also reopens many of the key questions that remain unanswered. It is time for more empirical evidence to guide policy and practice. FiguresReferencesCited byDetailsCited byDeterminants of Length of Stay in a Psychiatric Ward: a Retrospective Chart Review21 December 2019 | Psychiatric Quarterly, Vol. 91, No. 2Factors associated with length of psychiatric hospitalizationComprehensive Psychiatry, Vol. 55, No. 3 Volume 62Issue 2 February 2011Pages 117-117 Metrics PDF download History Published online 1 February 2011 Published in print 1 February 2011

Iraqis' Visit Turns Into Mutual Learning Experience

Iraqis' Visit Turns Into Mutual Learning Experience

Dalla crisi del paradigma neokraepeliniano verso una nuova nosografia psichiatrica. Il DSM-5

With this article we intend to outline the story of American psychiatry starting at the end of the 19th century until the present time, describing the cultural, political and economic context which culminated in the development and diffusion of biological psychiatry and its nosography. The diffusion of psychoanalysis and of A. Meyer’s psychological psychiatry, beginning at the end of the Second World War until the end of the Sixties, determined such as an enlargement of psychiatric diagnosis which no longer allowed one to distinguish a sane individual from an ill individual. This “dimensional” model caused a slow process of de-medicalization of psychiatry which removed consent and legitimacy from the discipline. The answer was the publication in 1980 of DSM III, the work of a small number of psychiatrists known as the “Neo-Kraepelinians”. The new nosography based on a categorial diagnostic system, emphasized what is directly observable and therefore measurable, and not what is clinically significant. Whit DSM III and the successive versions the interest of the psychiatrists moved from the clinical to the epidemiological research. In the attempt to take psychiatry back to one of the medical sciences DSM III has in reality continued the process of undermining started whit Meyer and psychoanalysis. And now with the forthcoming publication of DSM V, psychiatry will be confused ever more with neurosciences.

The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatryby GhaemiS. Nassir . Baltimore, Johns Hopkins University Press, 2010, 253pp., $50.00.

The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatryby GhaemiS. Nassir . Baltimore, Johns Hopkins University Press, 2010, 253pp., $50.00.