In January 1973, the journal Science published an article entitled “How to be sane in crazy places”. Its author, psychologist David Rosenhan, described how he and seven other healthy people went to different psychiatric hospitals on their own, claiming to hear voices that uttered strange words such as” thump “or”empty.” All were diagnosed with either schizophrenia or manic-depressive psychosis. Once inside the mental hospital, they immediately stopped the simulation. On average, after 19 days, all participants were discharged with a diagnosis of “schizophrenia in remission”.
The management of one of the hospitals, after hearing about the study, said that their specialists can not be so easily deceived. The chief medical officer challenged Rosenhan to send malingerers to him. The man quickly agreed, but did not do so. However, the hospital said that forty-one malingerers were identified and sent home.
Psychiatrists at the time seemed unable to recognize either healthy people or people with mental disorders. Diagnostic criteria for mental disorders did not allow us to accurately separate the norm from the pathology. Rosenhan’s research uncovered much of what went wrong in twentieth-century psychiatry, at a time when doctors, psychoanalysts, and sociologists were fighting for supremacy in understanding the human psyche and its disorders.
In a highly simplified form, the history of psychiatry over the past 150 years can be represented as a struggle between “biologizers” and “psychologizers”. From the point of view of biologizers, the main factors in the development of mental disorders are internal factors — various disorders in the brain or in the body. Most doctors who hold this view agree that the mind and brain are one. Psychologizers have a different view of the problem — mental disorders are the product of bad influence of society, family, internal beliefs and character of a person, but not a pathology of the nervous system (it should be dealt with by neurologists, and the soul — psychologists). Biologically preferred to use pharmacotherapy, psychologically — psychotherapy. In any case, the dispute was reduced to the famous psychophysiological problem of the relationship of the soul (psyche) and the body, their mutual influence, and so on.
The described positions are radical opposites, built on a serious simplification and leading to the vulgarization of ideas about the human psyche, in a word, to reductionism. Reducing the complex and multi-faceted to the simple and one-sided is a fatal cognitive distortion of psychiatrists and neuroscientists, which probably most hindered progress in these areas.
Psychiatry almost always had a “psychologizing” bias, which greatly influenced its development and conceptual framework. Its orientation was not affected by the invention of antipsychotics and antidepressants, nor by the introduction of neuroimaging methods and other technical innovations. Most psychiatrists and psychotherapists are still held hostage by the “brain vs. psyche” dichotomy, which forces them to accept one of two extreme, reductionist points of view.
The history of the biological approach in psychiatry began long before the invention of the first psychopharmacological drugs. In the nineteenth century, neurosyphilis was one of the most common and deadly forms of degenerative mental illness ever known in medicine. Many practitioners of the time considered patients with progressive paralysis, often with symptoms of psychosis (hallucinations and delusions), people with poor heredity, “weak character” or “morally fallen”. Fortunately, everything changed in 1913, when Japanese bacteriologist Hideyo Noguchi, who worked at Rockefeller University in new York, found traces of Treponema pallidum (pale Treponema)-a spiral — shaped bacterium responsible for syphilis — in the brains of deceased people suffering from progressive paralysis. At that time, one-third of patients in psychiatric hospitals had symptoms that can now be clearly described as manifestations of neurosyphilis.
In 1887, the Russian scientist Sergey Korsakov published his doctoral dissertation “on alcoholic paralysis”. This disorder was manifested by fixation amnesia, that is, the inability to remember current events with partial retention of memory for the past, as well as complete disorientation in space and memory deceptions. Korsakov wrote that the main cause of alcohol paralysis is a disorder of the associative apparatus of the brain. In addition, symptoms of alcoholic paralysis were often accompanied by involuntary eye movements and impaired coordination of movements, which the German psychoneurologist Karl Wernicke (1848-1905) associated with damage to the oculomotor nerve and cerebellum. Thus, another mental illness, and one associated with alcoholism, was reduced to disorders in the brain.
A little later, a large number of cases of lethargic encephalitis after world war I prompted the study of the role of the intermediate brain in the emotional sphere. In the late 1930s, there were numerous publications that patients with hallucinations, mood changes, obsessions, and outbursts of anger post mortem were found to have damage to the intermediate brain.
Such discoveries have strengthened the position of specialists who are convinced that mental disorders are associated with the brain. Unfortunately, the weakness of medical ethics, and indeed the legal system at that time, made it possible to use rather crude methods of treatment, such as malaria infection, tooth extraction (such treatment was proposed by the infectious theory of mental disorders), or “therapeutic” lobotomy — partial destruction of the frontal lobes. These sad episodes in the history of medicine cast a dark shadow over the biological direction of psychiatry.
The Nazi eugenic experiments [7] reinforced the antipathy of most American and European psychologists to biological psychiatry. By the 1950s, psychoanalysts, i.e. representatives of one of the psychologizing schools, occupied a dominant position in the departments of psychiatry in the United States. At the same time, the theory of social constructivism began to gain strength, saying that all differences between people are caused only by social processes. Mental disorders in this theory were considered as a consequence of the unfavorable social situation under capitalism.
In the 1960s, sociologists became the third influential force to team up with psychoanalysts on the alleged role of “toxic” families in causing mental disorders (see the Chapter on schizophrenia). Proponents of social constructivism faced a negative reaction from professional communities and families, who were blamed for the illnesses of relatives.
The division between psychiatry and neurology that took shape in the first half of the twentieth century dramatically affected the development of medical science. Psychiatrists engaged in the description of psychopathology and the study of how different symptoms are combined with each other through illnesses. Neurologists took over the nervous system and work to identify the relationship between a clinical symptom and a lesion of a certain part of the nervous system. Both of them subsequently tried to enter foreign territory as rarely as possible, protecting the division of pathology into mental diseases and diseases of the nervous system.
It must be admitted that not only psychiatry, but also neurology deals with disorders that do not lend themselves to precise classification. On the one hand, neurologists deal with well-biologically characterized conditions, such as stroke or Huntington’s disease [8]. But on the other hand, they take up the treatment of disorders of an indefinite nature, such as dissociative disorders, in which psychological experiences are expressed through physical symptoms (partial paralysis, convulsions, vision problems, tics, etc.) without objective reasons for their development.
An outdated name for dissociative disorders is hysteria. The outstanding French psychoneurologist Jean-Martin Charcot (1825-1893) made an invaluable contribution to the systematization of such conditions. Charcot mistakenly believed that the origins of hysteria lie in the violation of the peripheral nervous system. Joseph Babinsky (1857-1932), a pupil of Charcot, came to the conclusion that hysteria is a kind of deception — a psychological disorder that hides under neurological symptoms. He suggested dropping the term “hysteria “and replacing it with the term” pitiatism”, meaning a condition caused by persuasive suggestion and eliminated in the same way.
As a result, science has recognized hysteria as a mental problem that causes a patient to behave as if they are physically ill. Neurosyphilis, meanwhile, has been recognized as a brain disease that simulates mental illness. Both disorders were considered “copycats” of other diseases, including each other. Some cases of syphilis have almost certainly been misdiagnosed as hysteria, and Vice versa. But more importantly, one of the main places in the experiences of patients with hysteria and neurosyphilis was occupied by sex. Freud’s time was a time of syphilis. Freud and his followers focused on repressed sexual fantasies and psychotraumas, because the specter of syphilis, a disease with a complex reputation, overshadowed almost every sexual encounter.
Neurosyphilis has shifted psychiatry towards biological reductionism. Everyone wanted to find the same simple solution for schizophrenia, depression, dementia, and other mental disorders. Many scientists wanted to reduce diseases to the scheme “factor X always causes mental disorder Y”. The study of hysteria, on the contrary, encouraged the desire to psychologize the suffering of patients with mental disorders. Hence, there are many sad cases when the real disease was interpreted as a “somatized disorder” or simply “psychosomatic”, which led to underdiagnosis with complications up to a fatal outcome.
None of biologization or psychologization wasn’t right. Simple ways did not solve the problem of diagnosis and treatment of mental disorders. There is no genetic mutation or typical schizophrenic situation in the family that is guaranteed to lead to schizophrenia. Both biological and environmental factors are involved in the development of mental disorders to varying degrees. Psychopathology is a complex interweaving of heterogeneous causes and effects.
Historically, psychiatry has always tended toward psychologization. Doctors, like most people, had dualistic views, dividing body and soul (“physically you are all right, all your problems are in your head”). It is understandable why the shift of attention to biological factors was perceived by many as a new turn in the treatment of mental disorders.
Historian mark Micale decided to find out what events in psychiatry after 1945 can be called the most important. His own knowledge and the opinions of his colleagues were not enough. Analyzing the frequency of certain topics in PubMed databases didn’t help either. Then he started making the top 10 events in psychiatry in a different way.
For several years, he went to conferences and visited hospitals. As a result, he interviewed about 200 people, including psychiatrists, doctors of other specialties, psychologists, psychoanalysts, social workers, hospital administrators, etc. The survey was conducted only in North America, but among the respondents were people who grew up outside the United States and Canada. Based on the results of a 2014 survey, Mikale compiled a list of the most important changes that have occurred in psychiatry since 1945.
- The Psychopharmacological revolution of the 1950s (the discovery of the first psychotropic drugs: imipramine, chlorpromazine).
- Deinstitutionalization and reduction of the number of patients in hospitals.
- The Weakening of the influence of psychoanalysis (includes the weakening of the popularity of Freudianism in culture, in universities, the growth of non-Freudian psychotherapy schools, the rejection of such concepts of psychoanalysis as”the unconscious”).
- The use of psychotherapy in practice, not only doctors, but also specialists without medical education.
- the Emergence of large-scale scientific programs in the field of neurochemistry and neurobiology of mental disorders.
- Introduction of a new generation of antidepressants (for example, prozac).
- Growing influence of the pharmaceutical industry in psychiatry.
- Increasing influence of the American classification of mental disorders DSM [11].
- the Emergence of a large number of new diagnoses.
- Removing homosexuality from the list of mental disorders.
Half of the respondents believed that biological psychiatry offers too narrow a view of the psyche. However, the new wave of biological psychiatry overcame many of the shortcomings that usually provoked criticism of this direction. Improving technologies have changed our understanding of mental disorders and freed biological psychiatry from many of its early shortcomings. Modern psychiatry analyzes the dynamic work of neural networks, distinguishes several levels of description, and takes into account all the contexts in which the symptom exists, while being aware of its methodological, theoretical, and therapeutic limitations. The confrontation of biologization and psychologization today is losing relevance.
The very term “biological psychiatry” refers to the original duality of “brain vs psyche” and implies that there is another psychiatry — non-biological, dealing with the psyche and not the brain. There are no other medical specializations where there is the same split, fixed at the academic level. In the medical literature, such phrases as “biological cardiology”, “biological dentistry” or “biological proctology”are not possible. The only conceptual division adopted in medicine for ease of communication is the separation of the fundamental and clinical levels of study of the subject. Biological psychiatry is psychiatry, there can be no other psychiatry.
Famous neuroscientist Robert Sapolsky in the book ” Who are we? Genes, our body, society” (2005) precisely defined what modern psychiatry does. Sapolsky writes that genes, hormones, and neurotransmitters rarely trigger certain emotions, thoughts, or behaviors. They are only responsible for the tendency to react to the environment in a certain way. Therefore, any psychological phenomenon, from the point of view of biology, exists only in the context of the external environment acting on a person. Modern psychiatry and neuroscience investigate how the world around us affects the brain and how the brain of people with mental disorders functions in this world.
In human science, there is always a danger of exaggerating one or another aspect of the observed phenomena. The history of psychiatry is a perfect example of an imbalance, of throwing oneself from one extreme to the other. Exaggerating the significance of one factor was accompanied by downplaying or ignoring other aspects of the psyche. Turning to the chronology of psychiatric science helps to understand the meaning of current concepts and imagine how this field of medicine will develop in the future.
As an epigraph for the book “the Logic of scientific research” (1934) Karl Popper chose the words of John Acton, which are well suited to define the purpose of the book you are holding in your hands: “there Is nothing more necessary for a man of science than its history and the logic of scientific research… – ways to detect errors, use hypotheses and imagination, methods of verification.” In the logic of psychiatric research, one of the most intriguing moments is the plot with the introduction to the foreground of a specific organ, a material object located inside the skull — the brain.
It can be very difficult for a person, especially a dreamer, to accept materialism. It seems that the world of the Ideal cannot be described in terms of lifeless nature. Something beautiful, like the human mind with its whole palette of feelings, cognitive abilities, free will, social connections, language and culture, cannot be reduced to something physical. The cold material side of the psyche is more often frightening than attractive. The soulless simplification of the entire multi-faceted personality of a person to the interaction of neurons in the brain is like a disregard for Ideals, a desecration of “sanctity”. Biological psychiatry has the same effect as Charles Darwin’s writings on Christian Europe. However, whether we like it or not, modern science tells its own story about the amazing and yet incomprehensible world of neurobiology of mental disorders.