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Saturday, May 22, 2010

The Evolving Face of Psychiatry: Demons, Molecules, and Genes

By Barton J. Blinder, M.D, PhD
This year’s APA meeting, with its presentations of cutting-edge science and discussions about the many aspects of psychiatry has inspired me to reflect on the history of our field. For the past few years, I have had the pleasure and opportunity of teaching the history of psychiatry to our residents at the University of California-Irvine. The long historical struggle to change attitudes toward mental illness, from contempt, superstition and stigma to compassion, understanding and a true medical approach, has been hard-won and littered with pitfalls. The greatest deterrents to progress have come from theories of mental illness that failed to include the complexities of human development, the multiplicity of biopyschosocial factors, and the heterogeneous forces of culture and various spiritual traditions. As knowledge of mental illness progressed from the terror of supposed demon possession to the belief in a theory of bodily humors to the absurdity of mesmerism and phrenology and, in recent years, the parent-bashing of “refrigerator” mothers, we have often endured long periods of stagnation.

The era of asylums and state hospitals has given way to community-based psychiatry, which has been characterized by great accomplishments as well as continued challenges and disappointments. Advances in neuropharmacology have lessened the suffering from psychosis, mood disorders, anxiety, and cognitive impairments. Yet pharmaceutical treatments, for all their usefulness, have not eliminated the need to continue to address the mind and life of each patient in a comprehensive and truly effective manner. The need to integrate the autobiographical complexity of each patient, their adversities and strengths and their biological and genetic vulnerabilities into a meaningful diagnosis and treatment plan must continue to be a hallmark of our specialty.

Doing away with the mind-brain controversy and integrating psychotherapy with pharmacotherapy should be an important future goal. LeDoux (2002) has stated this eloquently, writing, “nature and nurture speak the same language--they both ultimately achieve their mental and behavioral effect by shaping the systematic organization of the brain. The particular pattern of synaptic connection in an individual’s brain and the information encoded by these connections are the keys to who the person is.” Achieving psychotherapeutic goals (gaining insight, experiencing emotional modulation and enjoying decreased conflict in interpersonal relations) depends on some degree of modification to the perceptions, memory, and emotions that work throughout and enduringly in the brain.

The rapidly progressing field of brain imaging studies may help define attentional and memory processes that are significant in human relationships. Brain imaging may also have important implications for the development of a science-based and rational psychotherapy. Combined medications and psychotherapy may drive change by promoting consolidation of the individual and combined effects on the underlying biology. Both negative stressors and positive changes in behavior can cause alterations in gene expression, which may produce structural changes in the brain. Brain imaging studies in the future may aid in diagnosing chronic states of conflict and may advance the practice of psychotherapy.

Even though we still have major challenges to overcome, our specialty has a very bright future. This means there is all the more reason to overcome the problems of access to care, the integration of psychiatry within the medical field, and adequate recognition and funding of our critical and effective care of patients.

Dr. Blinder is clinical professor from the Department of Psychiatry at University of California-Irvine.

LeDoux JE. The self: clues from the brain. Ann N Y Acad Sci. 2003;1001:295-304.

Blinder BJ. Psychodynamic Neurobiology. In: Beitman B, Blinder B, Thase M, Riba M, Safer D, eds. Integrating Psychotherapy andPharmacotherapy. New York, NY: Norton; 2003:161-180.

Blinder BJ. The Autobiographical Self: Who We Know and Who We Are. Psychiatric Annals 37:4. April 2007: 276-284.

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