How and When Psychiatrists Became “Real Doctors”
The single most notable figure in psychiatric history was Emil Kraepelin–a German psychiatrist who identified two major psychiatric diagnoses that persist to this day.
Kraepelin was the presiding doctor at a German asylum in the late 19th century, and in the course of this practice he studied the patients who were admitted and discharged from his hospital. Some patients presented with disorganized thought and behavior, along with auditory hallucinations and paranoid delusions. Their disease course was typically poor, with chronic deterioration of their thought and behavior, and little likelihood of improvement. He called this disorder dementia praecox, which eventually came to be known as schizophrenia. Another group of patients presented with either depressed moods with prominent psychomotor slowing; or with grandiose delusions, agitation, and hyperactivity, along with diminished need for sleep. These patients often alternated between these two emotional states, and hence were labeled by Kraepelin as manic-depressive insanity–which is now called bipolar I disorder.
Kraepelin’s aim in distinguishing these two patient populations was not so much to guide treatment decisions, because there were few treatment options available to him. What drove him to differentiate these populations was the aim of determining the patient’s likely outcome, so he could inform the patient's family what to expect from their treatment. He also noted that there were patients who presented mixed symptoms from both maladies, now identified as schizoaffective disorder. He was the first psychiatrist to formulate three diagnostic entities that remain valid to this day.
For a large part of the 20th century, psychiatric treatment was dominated by the psychoanalytic model of care proposed by Sigmund Freud–talk therapy, with little if any introduction of medications into outpatient treatment. Psychiatry then was far removed from the medication-based practice of other specialties, and its current treatment model. My own father was initially enraged at my choice of specialty–yelling at me, “I wanted you to be a real doctor!” A number of my peers experienced similar confrontations.
The movement of psychiatric treatment toward biological treatments like electroconvulsive therapy and psychoactive medications was not only motivated by scientific advances. It was also driven by the desire of psychiatrists themselves to be regarded as “real doctors.” This wish was at last finally made true by the “neo-Kraepelinian” movement that emerged in the 1970s, under the intellectual guidance of academic psychiatrists affiliated with Washington University in St. Louis. These true believers held that only empirical psychiatric research with a strong focus on biology would improve the treatment of psychiatric disorders, despite the profound limits that we had in understanding how the brain worked. Many of those limits in our knowledge persist to this day, in our inability to credibly explain thought. But the movement nonetheless moved forward, culminating in the overwhelmingly biological model of psychiatric treatment that we see today.
The tenets of this movement were delineated as a neo-Kraepelinian credo intent upon redefining psychiatry’s professional identity and purpose, and read as follows:
1. Psychiatry is a branch of medicine.
2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.
3. Psychiatry treats people who are sick and who require treatment for mental illnesses.
4. There is a boundary between the normal and the sick.
5. There are discrete mental illnesses. Mental illnesses are not myths. There is not one but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis, and treatment of these mental illnesses.
6. The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.
7. There should be an explicit and intentional concern with diagnosis and classification.
8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate such criteria by various techniques. Further, departments of psychiatry in medical schools should teach these criteria and not depreciate them, as has been the case for many years.
9. In research efforts directed at improving the reliability and validity of diagnosis and classification, statistical techniques should be utilized.
Despite its stated intentions, it was clearly motivated by forces that have nothing whatsoever to do with true science–such as:
1) Psychiatry is a branch of medicine.
It’s number one on their wish list, but has nothing to do with the actual science or treatment of mental illness. It was clearly motivated by our desire for professional prestige, income, and the respect of our medical peers.
3) Psychiatry treats people who are sick and who require treatment for mental illness.
Is a person who nowadays presents with mild anxiety, and is placed on a benzodiazepine to help them sleep, truly “sick”? What if there are psychosocial circumstances that are contributing to their distress, such as a divorce in process?
4) There is a boundary between the normal and the sick.
This is perhaps the most grossly unscientific contention on this wish list. I think every one of us knows that people can be mildly depressed, intermittently anxious, somewhat dysfunctional, or even a little bit crazy. This dictum declares that there is a clear boundary between “us” and “them.” My 40 years of psychiatric practice and 70 years of living tell me that this is an arrogantly subjective statement that has nothing to do with either science or medical compassion.
5) There are discrete mental illnesses. Mental illnesses are not myths. There is not one but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis, and treatment of these mental illnesses.
A myth is defined as a “widely held but false belief or idea,” “invention,” “fabrication,” or “exaggerated or idealized conception” of a thing–usually part of a shared belief system. Psychiatric diagnoses are not discovered in laboratories, but negotiated in committee meetings by our trade association. They are not valid diagnoses of illness because the vast majority lack identified causation. They are fabricated in extensive meetings, where psychiatrists get together and negotiate the definitions thereof with the support and assistance of business interests. They are, in fact, a manifestation of communal faith.
6) The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.
Focusing “particularly on the biological aspects of mental illness” clearly suggests that we should ignore the psychological aspects of mental illness. But after 45 years of neo-Kraepelinian psychiatry, the biological nature of psychiatric disorders is still unknown.
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Our neo-Kraepelinian psychiatrists drop the word “science” as their ally whenever they can, but habitually neglect that scientific vacuum in which we’re still operating. How much natural understanding of the brain can psychiatry have if we don’t actually know how the brain generates thought, or saves memory?
Rather than acknowledge our crippling ignorance of its target organ, psychiatry has deleted nearly all references to the mind and thought from its scientific literature. The result is a pseudoscientific facade of brain literature that is focused on the use of available technologies to fill medical journals–distracting ourselves, and the world around us, from acknowledging our pig ignorance of the brain’s most notable functions. Undaunted by our crippling inability to explain the nature of thought and behavior, we grasp at any facts that we come upon to lend us credibility–like this decade's fatuous bum-rush to cite “neuroplasticity” as an explanation for everything.
Regardless of its original intentions, the Neo-Kraepelinian credo did not lead us to scientifically discover psychiatric disorders, or to follow that process to wherever nature leads us. It has instead driven psychiatrists to invent diagnoses independent of any actual scientific understanding of their biological nature–so that we can talk like real doctors, prescribe medications like real doctors, and even be recognized as real doctors by our peers in a manner that we never could before. And it also greatly facilitates our profitable relationship with the pharmaceutical industry, which continues to pay off in a manner that we never could have anticipated. Mission accomplished!
It’s quite likely that Kraepelin has been spinning in his grave for the past fifty years or so, watching his name being abused to dignify a corporate sellout. In his later years, he actually became captivated with the advent of psychology as a science in the early 20th century.
But that was a long time ago.
