From the Editor
The transient truths of medical ‘progress’
There is a widespread notion that today’s medical practices and advances—including in psychiatry—are superior to the tools and therapies of the...
Disruptive breakthroughs
Several are notable:
• National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to generate knowledge about the causes, treatment, course, and prevention of mental illness. No other country has spent as much on psychiatric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
• Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clinical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
• Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
• Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds promise for preventing medical disorders, including psychiatric illness.
• Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several techniques have been approved by the FDA, including transcranial magnetic stimulation, vagus nerve stimulation, and deep brain stimulation, to supplement, and perhaps eventually supplant, ECT.
Legal intrusiveness
No other medical specialty has been subject to laws governing clinical practice as psychiatry has been. Progressive intrusion of laws (ostensibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admission and then often harm themselves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semiconscious myocardial infarction patients when they are admitted to a hospital.
Distortions of the anti-psychiatry movement
The antipsychiatry movement preceded the Baby Boomer era by a century but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which portrayed psychiatry in a purely negative light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness persists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.
Gender and sexuality
• Gender distribution of psychiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been documented in other medical specialties. At least one-half of psychiatry residents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
• Acceptance and depathologization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treatment. That year, membership of the American Psychiatric Association voted to remove homosexuality from DSM-II and to no longer regard it as a behavioral abnormality. This was a huge step toward de-pathologizing same-sex orientation and love, and might have been the major impetus for the progressive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.
The DSM paradigm shift in psychiatric diagnosis
• DSM-III. Perhaps the most radical change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.
The move toward more operational and reliable diagnostic requirements began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete paradigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diagnostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
• Recognizing PTSD. Develop-ment of posttraumatic stress disorder (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosology. At last, the old terms—shell shock, battle fatigue, neurasthenia—were legitimized as a recognizable syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated substantial clinical and research interest in identifying how serious psychopathology can be triggered by life events.