A History of Medical Psychology, Part III: ENTER THE BIOLOGISTS

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A History of Medical Psychology, Part IIIENTER
THE BIOLOGISTS

• Douglas Lehrer, M.D.
• Director of Medical Education
• Twin Valley Behavioral Healthcare

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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?)

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The First Biological Psychiatry

• Attempted to answer what is mental illness? by
  studying the anatomy of the brain

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Wilhelm Greisinger (1817-1868)

• Father of Biological Psychiatry
• Taught and practiced in general hospital
• Inaugurated university-based psychiatry devoted
  to study of brain

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The First Biological PsychiatryThe Great
Neuropathologists

• Theodor Meynert (Vienna)
• Neuropathologist Freuds teacher
• Brain cytoarchitecture syphilitic lesion
• Paul Flechsig (Leipzig)
• Basic map of cerebral localization

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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)

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The First Biological PsychiatryOther 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

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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

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The Classifiers

• By 1880s, many classifications, of little help
  to clinicians
• Too complex too many
• Emphasis on cross-sectional view

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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

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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

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Emil Kraepelin (1856-1926)

• Gathered best researchers (Nissl, Alzheimer)
• Published his ideas in his textbooks, starting in
  1883
• Agnostic regarding cause of illness

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Emil Kraepelin (1856-1926)

• Built on Karlbaum and Heckers description of
  malady of psychosis, disorientation in young
  patients with progressive course
• Dementia Praecox

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Emil Kraepelin (1856-1926)

• The other principal psychosis he termed Manic
  Depressive illness
• Followed description of circular insanity by
  Falret and Baillarger (at Salpetriere)

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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.

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Emil Kraepelin (1856-1926)

• The doctors 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.

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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

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The Second Biological Psychiatry

• Fever Therapies
• Insulin Coma
• Convulsive Therapy
• Psychosurgery
• Early Pharmacotherapies
• Modern Pharmacotherapy

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Neurosyphilis

• Growing epidemic since days of Columbus
• Bleeding, purging, vesicants, diuretics
• Mid-1800s Mercurials

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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

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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 thattertian or
  quartan agues have cured this disease.

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Therapeutic Use of Fever

• Julius Wagner von Jauregg (Vienna)
• Observed remission of insanity after erysipelas
  infection

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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

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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

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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

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Therapeutic Use of Fever

• Awarded Nobel Prize in Medicine and Physiology in
  1927

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Insulin Coma

• 1921 Banting and Best discovered insulin
• 1927 Manfred Sakel injected insulin into addicts

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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.

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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

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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

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Convulsive Therapy

• Metrazol-induced convulsions Ladislaus von
  Meduna, 1934
• Mistakenly thought there was biological
  antagonism between schizophrenia and epilepsy

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Convulsive Therapy

• Tested several compounds
• Camphor
• Strychnine
• Thebain
• Pilocarpine
• Pentylenetetrazol Metrazol

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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 40s with advantages of
  ECT

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Convulsive Therapy

• Electroconvulsive Therapy (ECT) Ugo Cerletti,
  1937
• Wanted less dangerous alternative to metrazol

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Convulsive Therapy

• Had seen electroshock used to anesthetize pigs
  before being butchered

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Convulsive Therapy

• Retrograde amnesia was an unforeseen advantage
  over metrazol
• More reliable, controllable
• Less injurious

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Convulsive Therapy

• Orthopedic risks
• Curare, 1940
• Succinlycholine, 1952
• Methohexital
• Widely used in US, Europe

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Psychosurgery

• Surgical Approach to insanity as old as medical
  psychology
• Archaeological evidence 40,000 years old

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Psychosurgery

• Trepanning done to liberate demons or bad
  spirits

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Psychosurgery

• Medieval quack doctors extracted the stone of
  madness, purported to cause mental illness

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Psychosurgery

• Egas Moniz
• Cerebral angiography
• Learned of effects of frontal ablation on chimp
  behavior
• 1935-6 Moniz Lima did 20 frontal
  leucotomies

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Psychosurgery

• Awarded Nobel Prize in Medicine and Physiology in
  1949

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Psychosurgery

• Walter Freeman
• With Watts, popularized lobotomy (1936)
• 1946 Developed transorbital lobotomy
• Traveled all over U.S.

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Psychosurgery

• White matter in frontal lobes disrupted
• Used ice pick-like instrument and hammer
• Local anesthetic

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Psychosurgery

• Effectively reduced tension, agitation, violence
• Adverse effects apathy impaired drive,
  initiative, emotional expression, socially cued
  behaviors, planning

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Psychosurgery

• By 1955, 40,000 done in U.S.
• Used on children, anyone with disruptive behavior
• Decline due to introduction of neuroleptics

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Early Pharmacotherapies

• Pre-19th century
• Laxatives
• Opiates
• Hellebore (purgative)

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Early Pharmacotherapies

• Morphine
• Solanaceae and belladonna alkaloids
• Hyoscyamine, hyoscine, scopolamine, atropine
• Chloral Hydrate (1832)
• Apomorphine

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Early Pharmacotherapies

• Bromides
• Mid-late 1800s Use as general sedative
• Bromide sleep

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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

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Modern Pharmacotherapy

• 1954 Chlorpromazine introduced
• 1960 Imipramine chlordiazepoxide introduced
• 1971 lithium salts introduced