The inspiration for this post comes from my reading the history
of psychiatry. That was not a particular interest of mine until I began researching
threads of knowledge going back into time. Then I started to look at how American
psychiatry evolved and the fact that it did not really exist at the same time
psychiatry existed in Europe. This is historically
confusing in the US, where certain movements try to connect psychiatry to historical
events where there are no connections.
The development of psychiatry in Europe is a complicated and interesting
story. The most striking feature is that
those early psychiatrists were trained in neuroanatomy, neuropathology, neurology,
and psychiatry. Freud was a Privadozent
in neuropathology. Adolph Meyer
emigrated to the US as a neuropathologist and eventually became the chairman of
psychiatry at Johns Hopkins eventually influencing a significant number of
American psychiatrists.
In reading about these early psychiatrists, some authors will refer to them as neurologists even though the person in question identified as a psychiatrist (examples include Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868)). Others like von Economo (1) were designated psychiatrists and neurologists. After graduating from medical school in 1901 von Economo spent a year working in an internal medicine clinic and over the next four years worked at various clinics in Europe with Marie, Kraepelin, Alzheimer, and Oppenheim learning psychiatry, neurology, and hypnosis. He returned to the University of Vienna in 1906 and was appointed Professor of Neurology and Psychiatry in 1921. This was an observation from his book Encephalitis Lethargica (2):
"Towards the end of 1916 the wards of the Vienna Psychiatric Clinic contained quite a number of patients with a strange variety of symptoms - cases which had apparently only one feature in common - a difficulty to fit into any known diagnostic scheme. They had been admitted under the most varied descriptions, such as meningitis, acute disseminated sclerosis, amentia, delirium &c. The patients all showed a slight influenza-like prodromal condition with trifling pharyngeal symptoms, a slight rise in temperature, soon followed by a variety of nervous symptoms, though generally one sign or another pointed to the midbrain as a source...."
From there von Economo goes on to describe encephalitis lethargica in great detail. He was subsequently nominated for the Nobel Prize in Medicine four times for this work. He also worked on neuroanatomy - where he made additional discoveries. His education and career contrasts well with current psychiatric education in the US where it seems that too little content is being spread over too many years - even more if you want to be certified in both neurology and psychiatry. He apparently got what he needed in 4 years while living in 4 different European cities. Places like the Vienna Psychiatric Clinic also do not exist today - where the only solid criteria for admission is dangerousness and all admissions need to be medically cleared by somebody (physician or extender) that may be oblivious to neurological and psychiatric presentations of acute illness.
More to
the point – they were probably neuropsychiatrists and that has relevance for the system
of board certification in the US. Prior
to board certification most psychiatrists in the US were neuropsychiatrists and
practiced neurology and psychiatry. That all changed in 1934 when the American
Board of Psychiatry and Neurology (ABPN) – made the rule that all psychiatrists
practicing both specialties must pass both board certification exams.
Reading the paper (3) about Bleuler was interesting because it
is an easy read that emphasizes several concepts in psychiatry that just repeat
if you don’t understand them. First
is the age-old debate about categorical versus dimensional diagnoses. The author’s conclude that Bleuler supported dimensional
diagnoses but it seems they are describing his process as one of detailed formulation
rather than dimensions. This was rooted in his method of clinical psychiatry. I suppose a four dimension scale could be envisioned based
on Bleuler’s “4 As” (see below) – but my interpretation is that he was looking
for detailed medical, family, social, and developmental history. He is described as a clinician who had close
contact with patients rather than an experimentalist – that is the data he was
interested in.
Second, the richness of the psychiatric landscape during Bleuler’s
time cannot be denied. The psychiatrists were writing and researching across
the spectrum of neurology, neuroscience, psychology, and theoretical
psychiatry. There was no shortage of ideas about describing clinical phenomena
or possible treatments. Bleuler had
contact with many prominent psychiatrists of his time and his opinions about
some of their theories was known.
Third, Bleuler’s
approach could be considered pluralistic to use today’s jargon. He was
clearly engaged in doing the subjective realm and individualized evaluations. He thought that schizophrenia could be an
exaggerated neurosis from psychological conflicts. He believed that the disease process had a
biological basis but he was focused on a psychological treatment. He also did not see schizophrenia as having a
uniformly deteriorating course. His thoughts about the biology of the disorder
were undoubtedly affected by the facts that he was not an experimentalist, there
were no useful biological treatments and despite many autopsy studies there were
no good gross anatomical or histological correlates of schizophrenia.
The patterns and themes noted in this paper run throughout
the history of psychiatry. Since
psychiatry became the default profession for treating severe mental illnesses,
there have been hypotheses about the nature of the illnesses, how to medically evaluate
them, and how to treat them. As illustrated on this blog, there are often
critics outside of the field who seem to ask these questions as if no
psychiatrist has ever thought about them in the past.
In many ways the intellectual landscape of turn of the century
psychiatry was richer than it is today. We currently have a refined product in
terms of classification, but many of the questions relevant of psychopathology
and neuroscience remain open. The basic problem of biological complexity is not
easily answered and it is only recently being approached. Biological and psychotherapy options appear
to have been maxed out by heterogeneity problem. From a historical perspective, what is most
alarming to me is that there has not been a synthesis of these questions and
approaches to bring current psychiatrists and trainees up to speed. Much of the time seems to be spent on the
same research techniques and critiquing endless clinical trials.
At a global level, the intellectual landscape of the field seems constricted. The board certification process has certainly been part of that as well as the general goals of standardization. There has been an enormous effort on standardizing nomenclature at the cost of de-emphasizing psychopathology. Clinical practice has been standardized largely based on settings and administrative codes. Documentation has been standardized by the same codes and electronic health records. Much of the documentation is essentially worthless in describing patient progress or the unique features of the individual and is essentially there to satisfy business administrators. The training of new psychiatrists is standardized in some areas - but there are very few specifics in terms of what trainees need to see in order to be good psychiatrists. For example, there is an apparent assumption that if you spend a month or two in a neurology clinic - you will have adequate exposure to accurately assess neurological problems presenting as psychiatric problems and make the correct triage or treatment decisions.
I don’t think expanding
the intellectual landscape for residency programs would take much. It will take a bit of integration. The sanctioning bodies of medical education
have made the task harder than it should be by not specifying all of the important
educational topics and letting the programs each sort it out on their own. That means residents will see certain concepts
inconsistently if at all, presentations and seminars will depend on the
availability, interest, and quality of the teaching staff, and even then,
topics are likely to be followed too rigidly.
The first question is what exactly should that landscape be? Residency requirements by the ACGME
are surprisingly vague. They are focused
primarily on clinical experiences based on clinical populations and settings,
availability of supervision, and overriding goals of excellence, motivation,
and interest on the part of the teaching faculty. There are some broad technical
markers of specific experiences by psychiatric subspeciality or skill (eg.
psychotherapy, managing drug interactions, etc). I know that the residency directors meet frequently
and it would not surprise me to find out that there are more detailed approaches
shared among them – but if that occurs, I do not know where to access it.
My suggested approach at integration would be teaching the historical
controversies and concepts that are still relevant all at once. There are several integrative papers in the
literature already. There are also still
some big concepts that need formulation and discussion like the biological
diversity and heterogeneity issues that run throughout all of medicine. A
potential academic model for this approach already exists and I suggest it is
in the Voet, Voet, and Pratt - Fundamentals of Biochemistry - 6th edition. One of the issues that frequently arises
during discussions of this nature is how much philosophy needs to be included.
My reading of the literature suggests that if anything there has been an excess
of philosophy being applied to psychiatry.
At times psychiatry is made to seem like psychiatrists themselves have
never considered the obvious questions. Teaching residents about psychiatry and
the way that psychiatrists have attempted to formulate and solve problems seems
like as good a place to start as any to me.
It can start with the names in this paper.
Pattern matching also needs to be reemphasized. The reason a psychiatrist can diagnose bipolar disorder is that they have seen many cases and many variations - not because they have read the DSM. The same is true for all of the mimics of bipolar disorder including neurological conditions. I am concerned about the level of exposure that residents have to acute neurological problems, especially now that many inpatient neurology services have been replaced by hospitalists with neurology consultants. There is a long list of acute neurological presentations that every psychiatrist must see and diagnose in training and distance from our neurology colleagues makes that more difficult.
George Dawson, MD, DFAPA
References:
1: Kaya Y, Uysal H, Akkoyunlu G, Sarikcioglu L. Constantin von Economo (1876-1931) and his legacy to neuroscience. Childs Nerv Syst. 2016 Feb;32(2):217-20. doi: 10.1007/s00381-015-2647-0. Epub 2015 Feb 24. PMID: 25707481.
2: von Economo C. Encephalitis Lethargica. Oxford University Press, London. 1929. page B.
3: Heckers S. Bleuler and the neurobiology of schizophrenia. Schizophr Bull. 2011 Nov;37(6):1131-5. doi: 10.1093/schbul/sbr108. Epub 2011 Aug 26. PMID: 21873614; PMCID: PMC3196934.
Open Access <-you can read this paper
Supplementary:
