New Biological Psychiatry

Question 1

In the 20th century, psychiatry was a biological field, with somatic treatments popular early in the century. Into and after the 1950s, while psychiatry was still a biological model, there were some massive changes happening, what were they?

Answer 1

Into and after the 1950s, the new biological psychiatry took place in the form of psychopharmacology: pills and medication became very popular.

Question 2

Chlorpromazine was one of the first medications to hit the market, what it is considered to be?

Answer 2

It’s known to be ‘the first drug that worked.’

Question 3

How is Chlorpromazine produced?

Answer 3

Coal tar produces crude oil, and a bi product of crude oil is Chlorpromazine.

Question 4

Who first created Chlorpromazine and what was it used for?

Answer 4

It was first created by Henri Laborit, a French physician/surgeon (not a psychiatrist). Chlorpromazine was first used as an anaesthetic to help reduce surgical shock, it was observed that the drug would make patients calm and indifferent.

Question 5

How was Chlorpromazine first tested, and what were the outcomes of these tests?

Answer 5

Chlorpromazine was first tested on rats, where the rats who received the drug didn’t react to receiving a shock. Henri Laborit was excited by these results so he called his friends, some of whom were psychiatrists – they thought the drug would benefit the mentally ill.

Question 6

While being using in mental hospitals, what else was Chlorpromazine used for?

Answer 6

To help people with severe insomnia, however, the dosage given to patients in mental hospitals was much higher than the dose used for insomnia.

Question 7

What was Chlorpromazine, as a drug for the mentally ill, first classified as and why?

Answer 7

It was considered a neuroleptic, which means it calms the nervous system and, because it was believed that the mentally ill, particularly those with schizophrenia, had over-active nervous systems.

Question 8

What type of patient was Chlorpromazine targeted at? And was it perceived to work?

Answer 8

It was targeted at patients with schizophrenia, and yes, it seemed to work. The patients with schizophrenia were no longer violent. They still had their delusions, but it was reported the voices (etc.) were quieter.

Question 9

What was the reaction of practitioners to Chlorpromazine? Who was it that noticed the biggest difference in mental hospitals?

Answer 9

Psychiatrists were completely blown away by the drug, it was considered miraculous. The glazier was one of the first to notice a big change in the mental hospitals, because the windows were no longer being smashed.

Question 10

Chlorpromazine was manufactured in France and shipped to the US, where it was widely advertised. What were the advertisements like?

Answer 10

They were dream-like, idealistic, made to seem like a miracle drug.

Question 11

Chlorpromazine was considered the equivalent of a somatic treatment. Because of this, was the name it was given?

Answer 11

‘Chemical Lobotomy’.

Question 12

Chlorpromazine was not initially considered a cure or a treatment… but what?

Answer 12

Symptom suppression.

Question 13

Chlorpromazine was widely used in mental hospitals from 1954 onwards, why? What was its effect on the hospital environment?

Answer 13

The drug made the work of attendants and therapists much easier, it was like a chemical restraint for violent or uncontrollable patients. Hospitals became less brutal.

Question 14

What must be remembered is that, no drug is perfect. What were some of the side-effects of chlorpromazine?

Answer 14

Extrapyramidal symptoms (EPS):

• ‘tardive dyskinesia’: involuntary movement of the muscles, such as a ‘smacking’ reflex (similar to gurning).
• Parkinson’s syndrome: involuntary movements all over the body.
• Akathisia: restlessness.

Question 15

Although there were side effects of Chlorpromazine, why were physicians not so worried about them, even looking for them?

Answer 15

Because the side-effects were thought to be a sign of the drugs effectiveness.

Question 16

The history of psychiatry tells that Chlorpromazine, and psychopharmacology in general, triggered deinstitutionalisation in the 1950s. While the drugs did work, it is a more complex situation, why?

Answer 16

Well, there are multiple factors:

1. There was optimism in American psychiatry after WWII, where many doctors who served on the frontlines became interested in psychiatry.
2. New therapies were being introduced into mental hospitals, such as occupational therapy and group therapy, where it was not just about warehousing patients but about giving them meaningful work.

These factors combined WITH psychopharmacology led to deinstitutionalisation.

Question 17

When doctors look back, they think that deinstitutionalisation was a result of psychopharmacology, is this true?

Answer 17

No, because in the hospitals that didn’t have new programs/therapies coming in BUT had the drugs, did not see as much effectiveness as in other places.

Question 18

Why was there such optimism in psychiatry after 1945/WWII? Was there any person in particular leading this?

Answer 18

William Menniner was a doctor on the frontlines of the war. Him, like many other doctors, noticed that it was important to treat injured soldiers immediately, even in the trenches. He brought this philosophy back to psychiatry, where it was believed that treating early is incredibly important. Menninger became president of the psychiatric association, where he pushed for more psychoanalysis. Except, he made it simpler, he made it about strengthening the ego to meet the challenges of everyday life.
He, and others, strongly believed in therapeutic intervention and community intervention.

Question 19

Did the new drugs trigger the optimism in psychiatry? Or did the changes happening in American psychiatry make the drugs work?

Answer 19

It was mainly that the positive changes happening in psychiatry helped the drugs to work, although it worked both ways.

Question 20

List four reasons as to why was there such optimism in psychiatry after WWII/1945.

Answer 20

• therapeutic interventionism.
• scientific prestige.
• social and community psychiatry
• the beginnings of ‘deinstitutionalisation’.

Question 21

The handling of drugs before WWII was quite different to after WWII, what was the change?

Answer 21

Before WWII, drugs were given to anyone to see if they worked. There were no trials, or studies etc. That all changed after WWII when double blind trials were introduced, new regulations surrounding drugs and prescriptions were needed.

Question 22

During the optimistic changes in psychiatry after WWII, the field became a lot more community based, what were the two main therapies being introduced, what was the ideal type of treatment believed to be, AND what was this based on?

Answer 22

The two main therapies introduced were group therapy, and occupational therapy, the ideal type of treatment was treatment within the community, and this was based on optimism, psychoanalysis and the mental hygiene movement.

Question 23

Chlorpromazine, also known as Thorazine, was initially marketed in America as… what? And then what did it change to? What prompted this change?

Answer 23

It was initially marketed as a neuroleptic, to being called an ‘antipsychotic’. The change was mainly a marketing strategy to make the drug sound like a cure.

Question 24

What kind of conditions were drug companies more interested in?

Answer 24

Drug companies are interested in the chronic conditions that require prolonged periods of medication (if not lifetime usage of medication), as this provides more funding. One off illnesses have less financial benefits.

Question 25

What was happening in the relationships between pharmaceutical companies and doctors?

Answer 25

There was a close relationship forming between pharmaceutical companies and doctors, who were pressured, or paid, to promote certain drugs to patients. Also, the advertisement of side-effects became less prominent.

Question 26

In 1961 there was a randomised controlled trial on Chlorpromazine that showed, what?

Answer 26

The trial showed NO side effects, improvement on apathy and no restraint of movement… a strange, and misleading result.

Question 27

What is the ‘rotating door’ phenomenon?

Answer 27

It is when someone feels good after taking a drug, but they eventually start to have bad side effects, OR they want to go off the drug they have been on for so long. After doing so… they will need treatment again. Just shows that these drugs are certainly no ‘cure’.

Question 28

Who invented Lithium? What was it considered a treatment for?

Answer 28

Lithium was an Australian invention by John Cade in 1949. It was and still is used to treat Bipolar disorder.

Question 29

What type of drug is Lithium classified as? Who owns it?

Answer 29

It is classified as a mood stabiliser, and because it is an element that exists in nature, nobody can patent it – so, it is cheap.

Question 30

After medications became available, mental hospitals became very different places. What were some of the positive effects on the mentally toward mental illness?

Answer 30

Less people were admitted or kept in mental hospitals, and the stigma toward mental illness lessened.

Question 31

After the introduction of medications, along with other measures, less people were admitted to mental hospitals and eventually they were deinstitutionalised altogether. Why is this not necessarily a good thing?

Answer 31

Because there are still people who need care in the community, such as half-way houses, etc. That exists to a certain extent, but there is not enough support in the community.

Question 32

Pretty much all the successes of psychiatry is ascribed to medication, BUT even if medication proved great results for psychiatry, it is not always fantastic for the patient. What are some negative consequences for those taking medication?

Answer 32

Many people did not like the drugs or how it made them feel, and some will have a life-long dependency.

Question 33

Are medication became heavily used and seen as successful, what were some subsequent effects in the field of psychiatry?

Answer 33

There was increasing impetus for genetic research and a perception that mental illness is purely medical and can be treated as such. Modern research strategies were brought into psychiatry and there was an alliance with pharmaceutical companies.

Question 34

In psychiatry, the 1910s was considered the ‘decade of the ___’, and the 1990s was considered the ‘decade of ___’?

Answer 34

The 1910s was considered the ‘decade of the brain’, and the 1990s was considered the ‘decade of genetics.’

Question 35

What problem were researchers coming up against when trying to study mental illness? And what was the solution?

Answer 35

There was a lack of consistency between diagnoses and diagnostic criteria. The solution was to create rigid diagnostic criteria that happened with the DSM-3.

Question 36

Where does the idea of diagnostic criteria stem from?

Answer 36

From the type of scientific classification that Carl Linnaeus defined when he categorised all plants and animals based on their appearance. His theory was that in doing so, researchers can understand how different things are related to one another.

Question 37

What is medical nosology?

Answer 37

A classification of similar cases in medicine, to best understand how to treat illness.

Question 38

Who is considered the father of classification in psychiatry? What did he do?

Answer 38

Emil Kraepelin, a disciple of Wundt, is considered the father of classification in psychiatry. Instead of focusing on the brain as the source of mental illness, he looked at symptoms over the life course. By doing so, he made the distinction between dementia (which increasingly gets worse), and bipolar (which goes up and down).

Question 39

In the course of a disease, there is the aetiology, then the pathology, and then the symptoms. How did psychiatry view and classify mental illness initially, and what did Emil Kraepelin do to change that perception?

Answer 39

At first, psychiatrists just looked at the symptoms, but Emil Kraepelin worked from left to right, by understand aetiology first to then classify an illness.

Question 40

The DSM-3 was radically different from the previous editions. What changes did it make in terms of disease classification?

Answer 40

It was a retreat to the medical model with symptom checklists and disorders grouped based on their symptoms, as a way to guide research.

Question 41

In the DSM-3, psychiatry followed the medical model approach to diagnosis. How did Adolf Meyer and other psychoanalysts differ in their approach?

Answer 41

Meyer, and other analysts, kept a dynamic model. They believed that illness is individual, and people cannot be classified like plants are. He said that symptoms are deceptive because they change so much over time. Treatment should be in reaction to their symptoms at one point in time, and there is a continuity/spectrum between normal and abnormal.

Question 42

Biological psychiatry around the time of the DSM-3 had a very different approach to Meyer, or the theorists around dynamic mental illness. What was the approach?

Answer 42

Diagnosis is the first step, and it is based on symptoms. Disease is specific and normal vs. abnormal behaviour does not lie on a spectrum. The assumption is that mental illness is a brain disease, and therefore requires pharmacological, somatic treatment.

Question 43

What was the great classification crisis in psychiatry?

Answer 43

Well, it was when experiments were done to see if the classification of disease in psychiatry was reliable. The experiments showed little reliability. In 1949, 3 psychiatrists interviewing the same patient at the same time completely agreed on diagnosis less than 20% of the time. In 1970, a US-UK project showed that US psychiatrists diagnose schizophrenia 5x more than in the UK.

Question 44

What were 7 external critiques/challenges to psychiatry?

Answer 44

• philosophical critiques.
• political critiques.
• the anti-psychiatry movement.
• feminist and gay rights protests.
• psychology and other mental health professionals questioned the medical monopoly.
• the regulation of drugs meant no prescription without a diagnosis.
• insurance companies demanded no pay without a diagnosis.

Question 45

Why was the DSM-3 seen to be a revolution in psychiatry?

Answer 45

Because it gave symptom checklists and focused on reliability, claimed to be ‘theory-neutral’ and was seen to unite a fragmented profession. Claimed to be based on the best empirical research.

Question 46

What were some of the subsequent effects of the DSM-3 on the field of psychiatry?

Answer 46

An explosion in research, often funded by drug companies. There was new scientific credibility for mental health workers. New popular language surrounding mental illness (OCD, GAD, etc.), it legitimised psychopharmacology, gave medical respectability to psychiatry.

Question 47

What was the political critique of the DSM-3?

Answer 47

Certain powerful individuals had control over what went into the manual. The diagnoses reflected gender and cultural biases. Was a way to blame the victim. Highlights the influence of big pharma, was questioned whether it was actually a scientific text, or a marketing tool.

Question 48

What were the scientific critiques of the DSM-3?

Answer 48

The rhetoric surrounding its reliability masks its poor and questionable results. It included diagnoses that supposedly reflect clinical ‘consensus’, but are not well supported by research data. The trial data and empirical bases of the DSM are not publicly available for scrutiny.

Question 49

What are the philosophical critiques of the DSM-3?

Answer 49

Has a weak definition of disorders, has a problem with pathologizing normal response. Reliability does not guarantee validity, meaning that we might all be wrong.

Question 50

In terms of important periods for psychopharmacology, which eras were most important?

Answer 50

The 1950s was when psychopharmacology took off, the 1980s was when drugs such as Ritalin and Prozac became popular.

Question 51

What does ‘an epidemic of suggestion’ mean?

Answer 51

It questions whether the ‘suggestion’ of a type of mental illness might cause a lot of people to identify with that illness and subsequently take prescription drugs, or get help for something that is somewhat normal.