A History of Medical Psychology_ Part III ENTER THE BIOLOGISTS

A History of Medical Psychology, Part III: ENTER THE BIOLOGISTS Douglas Lehrer, M.D. Director of Medical Education Twin Valley Behavioral Healthcare The First Biological Psychiatry • Germany: World leaders in psychiatry in 19th century • Early 19th century Germany dominated by Romantics • By end of century, biological psychiatrists held dominion (sound familiar?) The First Biological Psychiatry Attempted to answer “what is mental illness?” by studying the anatomy of the brain Wilhelm Greisinger (1817-1868) • “Father of Biological Psychiatry • Taught and practiced in general hospital • Inaugurated university-based psychiatry devoted to study of brain The First Biological Psychiatry The Great Neuropathologists Theodor Meynert (Vienna) • Neuropathologist; Freud’s teacher • Brain cytoarchitecture; syphilitic lesion Paul Flechsig (Leipzig) • Basic map of cerebral localization The First Biological Psychiatry The Great Neuropathologists Carl Wernicke (1848-1904) • Alcoholic disease; Aphasic states • Attempted to localize mental symptoms to brain areas Franz Nissl (1860-1919) Aloys Alzheimer (1864-1915) The First Biological Psychiatry Other Early Pioneers: France Antoine-Laurent Bayle • Attributed sx of neurosyphilis to definite organic lesion (inflammed meninges) Benedict-Auguste Morel: • Mental illness due to “degeneration” • Demence Precoce The Classifiers • 19th century preoccupation with nosology • Especially Germany • Reports of clinical descriptions as well as classifications proliferated • Ex: Karl Kahlbaum (1828-1899): described hebephrenia, catatonia, cyclothymia The Classifiers • By 1880’s, many classifications, of little help to clinicians • Too complex; too many • Emphasis on cross-sectional view Emil Kraepelin (1856-1926) • Shorter: “The central figure in the history of psychiatry” • Could not pursue neuropathology due to eye problem • Quit work with Flechsig in disgust Emil Kraepelin (1856-1926) • Avid reader of psychology, eg, Wundt • Became asylum physician for $ to marry • Fascinated with course of illness • Started keeping cards on every patient Emil Kraepelin (1856-1926) • Gathered best researchers (Nissl, Alzheimer) • Published his ideas in his textbooks, starting in 1883 • Agnostic regarding cause of illness Emil Kraepelin (1856-1926) • Built on Karlbaum and Hecker’s description of malady of psychosis, disorientation in young patients with progressive course • “Dementia Praecox” Emil Kraepelin (1856-1926) • The other principal psychosis he termed “Manic Depressive illness” • Followed description of “circular insanity” by Falret and Baillarger (at Salpetriere) Emil Kraepelin (1856-1926) • “As long as we are unable clinically to group illnesses on the basis of causes, our views about etiology will necessarily remain unclear and contradictory.” Emil Kraepelin (1856-1926) • “The doctor’s first task at the bedside is being able to form a judgment about the probably course of the case. People always ask him this. The value of a diagnosis for the practical activity of the psychiatrist consists of letting him give a reliable look at the future.” Emil Kraepelin (1856-1926) • 1899: Classification totaled 13 groups • Dementia Praecox: poor prognosis (in 3/4) • Manic-Depressive Illness: favorable px • Other categories: neurosis, febrile psychosis, MR, etc The Second Biological Psychiatry • • • • • • Fever Therapies Insulin Coma Convulsive Therapy Psychosurgery Early Pharmacotherapies “Modern” Pharmacotherapy Neurosyphilis • Growing epidemic since days of Columbus • Bleeding, purging, vesicants, diuretics • Mid-1800s: Mercurials Neurosyphilis • 1910: Salvarsan (Ehrlich): “Compuond 606” • Introduction of salvarsanized serum into CSF – – – – – lumbar puncture subdural space via trephine opening lateral ventricles cisterna magna via occipito-atlantoid puncture spinal drainage Therapeutic Use of Fever • Hippocrates: noted “convulsions (may) …cease if a quartan supervene.” • Galen cited case of mental illness cured by a quartan fever • Boerhaave: “when all remedies have been tried in vain, it has sometimes happened that…tertian or quartan agues have cured this disease.” Therapeutic Use of Fever • Julius Wagner von Jauregg (Vienna) • Observed remission of insanity after erysipelas infection Therapeutic Use of Fever • Speculated that psychosis could be treated with fever • Turned his attention to neurosyphilis • Injected tuberculin into neurosyphilitics • Good responses, but toxic Therapeutic Use of Fever • 1917: von Jauregg innoculated nine patients with the blood of a malarial soldier – complete recovery in four – improvement in two more • Developed protocol of malarial serum, followed by quinine, then salvarsan • 83% success rate Therapeutic Use of Fever • Tried in other disorders without desired effect • Cumbersome, dangerous, reliant on serum from matched blood type and malarial type (tertian) • Replaced by antibiotics Therapeutic Use of Fever • Awarded Nobel Prize in Medicine and Physiology in 1927 Insulin Coma • 1921: Banting and Best discovered insulin • 1927: Manfred Sakel injected insulin into addicts Manfred Sakel (1900-1957) “My supposition was that some noxious agent weakened the resilience and the metabolism of the nerve cells ... a reduction in the energy spending of the cell, that is in invoking a minor or greater hibernation in it, by blocking the cell off with insulin will force it to conserve functional energy and store it to be available for the reinforcement of the cell.” Insulin Coma • • • • • • Treated schizophrenic patients Infusion sufficient to cause coma Patient often convulsed Coma lasted 20-120 minutes Glucose infusion to recover patient Effects seen after 10-20 comas Insulin Coma • Schizophrenic patients showed marked improvement • 70% per Sakel • 63% per US study – 11%: Prompt and total recovery – 27%: Greatly improved – 26%: Some improvement Convulsive Therapy • Metrazol-induced convulsions: Ladislaus von Meduna, 1934 • Mistakenly thought there was “biological antagonism” between schizophrenia and epilepsy Convulsive Therapy Tested several compounds • Camphor • Strychnine • Thebain • Pilocarpine • Pentylenetetrazol = Metrazol Convulsive Therapy • Spinal fractures in up to 42% of patients • Horrible pre-ictal anxiety, dysphoria; vomiting • Later combined with curare and scopolamine • Discontinued in mid-late 40’s with advantages of ECT Convulsive Therapy • Electroconvulsive Therapy (ECT): Ugo Cerletti, 1937 • Wanted less dangerous alternative to metrazol Convulsive Therapy • Had seen electroshock used to anesthetize pigs before being butchered Convulsive Therapy • Retrograde amnesia was an unforeseen advantage over metrazol • More reliable, controllable • Less injurious Convulsive Therapy • Orthopedic risks • Curare, 1940 • Succinlycholine, 1952 • Methohexital • Widely used in US, Europe Psychosurgery • Surgical Approach to insanity as old as medical psychology • Archaeological evidence 40,000 years old Psychosurgery • Trepanning done to “liberate” demons or bad spirits Psychosurgery • Medieval “quack” doctors extracted the “stone of madness,” purported to cause mental illness Psychosurgery • Egas Moniz • Cerebral angiography • Learned of effects of frontal ablation on chimp behavior • 1935-6: Moniz & Lima did 20 frontal “leucotomies” Psychosurgery • Awarded Nobel Prize in Medicine and Physiology in 1949 Psychosurgery • Walter Freeman • With Watts, popularized “lobotomy” (1936) • 1946: Developed transorbital lobotomy • Traveled all over U.S. Psychosurgery • White matter in frontal lobes disrupted • Used ice pick-like instrument and hammer • Local anesthetic Psychosurgery • Effectively reduced tension, agitation, violence • Adverse effects: apathy; impaired drive, initiative, emotional expression, socially cued behaviors, planning Psychosurgery • By 1955, >40,000 done in U.S. • Used on children, anyone with disruptive behavior • Decline due to introduction of neuroleptics Early Pharmacotherapies • Pre-19th century: • Laxatives • Opiates • Hellebore (purgative) Early Pharmacotherapies • Morphine • Solanaceae and belladonna alkaloids – Hyoscyamine, hyoscine, scopolamine, atropine • Chloral Hydrate (1832) • Apomorphine Early Pharmacotherapies Bromides: • Mid-late 1800’s: Use as general sedative • “Bromide sleep” Early Pharmacotherapies • • • • • Barbiturates: Barbital synthesized in 1903 (VeronalR) Dozens followed in next two decades Deep sleep treatment with barbiturates Standard of sedative/hypnotic treatment until benzodiazepines Modern Pharmacotherapy • 1954: Chlorpromazine introduced • 1960: Imipramine & chlordiazepoxide introduced • 1971: lithium salts introduced