Three Giants Of The First Half Of The 20th Century

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The three pioneers who set the stage for thinking throughout the modern phase of 20th-century psychiatry were Emil Kraepelin (1855-1926) in Germany, Sigmund Freud (1856-1939) in Austria, and Adolph Meyer (1866-1950) in America. The influence of Kraepelin's perspective, derived from the successes of German neurology, has been most pervasive, yielding a lasting influence on our conceptualization of what a comprehensive psychiatry should look like. Kraepelin, now widely regarded as the titular father of biological psychiatry, started his academic work at Dorpat University at the edge of the German empire of medical science (now the University of Tartu, Estonia), where he wrote the first edition of his seminal Textbook of Psychiatry, which went through nine editions between 1883 and 1927. That contribution propelled him to Heidelberg and ultimately to Munich as the implicit leader of German psychiatry. Recognition of his seminal diagnostic and pathophysiological thinking remained widespread from the latter half of the 19th century until World War I shattered the vigorous beginnings of biological psychiatry.

Still, Kraepelin had laid the essential foundations, and his approach continues to symbolically represent how scientific psychiatry should proceed [his influence is still especially clear in Axis I diagnostics of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV)]. He recognized that progress had to be based on systematic cross-sectional and longitudinal clinical observations, leading to diagnostic systematics. He recruited all possible varieties of objective measures including behavioral and cognitive as well as neurological and biochemical, to achieve the most comprehensive understanding possible in his day. Through his desire to reach a full appreciation of the organic underpinnings of pathological processes, Kraepelin gathered around him a remarkable group of talented neuroscientists who also became luminaries, such as Alois Alzheimer, Korbinian Brodmann, and Franz Nissl.

Concurrently, Sigmund Freud was abandoning his early emphasis with neurological approaches to the mind, including experimentation with drugs such as cocaine for the treatment of opiate addiction, and was setting in motion a dynamic depth psychology that eventually captivated American psychiatry. Unfortunately, Freud's psychodynamic approach, which revolutionized our views of how the mind operates with many unconscious "instinctual" dimensions and urges, did not foster a robust scientific movement to properly evaluate his own blossoming ideas. That, of course, would have been impossible in his day. Initial theory was built upon rather limited clinical observations, and then theoretical constructs were built upon other theoretical constructs, with no clear empirical operationalization or organic foundations. In the opinion of many, the resulting structure ultimately resembled a Tower of Babel, where one could not readily sift the good ideas from the bad. Freud's thesis that most psychiatric problems arose simply from psychological causes has now been largely abandoned in psychiatry, even though it is accepted that childhood trauma is a powerful neurobiological factor in disrupting mental homeostasis (Chapter 4; Heim and Nemeroff, 1999). Pathogenesis is now more commonly discussed in strictly organic terms, or at the very least in terms of psychological factors that are linked to neural substrates (Chapters 6, 7, and 8).

A new chapter in modern psychiatry opened when Adolf Meyer came to America from Switzerland in 1894, moving to Johns Hopkins School of Medicine in 1910, where, under his leadership, the university became the leading psychiatric training center in the world. He established a utilitarian psychobiological tradition in American psychiatry, which consisted of a multidimensional and systematic confrontation with patient's lives. He helped revolutionize the careful documenting of life histories and acknowledged the many psychological and biological themes that must go into the treatment of each emotionally troubled person. He emphasized the fact that all patients are unique and that one should consider all aspects of their lives in a careful workup of the individual's psychological status. His analysis of case studies led to the recognition that the systematic harvesting of certain types of personal information could make a real difference in the care and prognosis of patients. He aspired to recruit all relevant aspects into multimodal treatment approaches that suited individuals' abilities and aspirations. This holistic approach set the stage for the emergence of a uniquely American psychiatry.

The intersecting ideas and approaches of these giants permeated 20th-century psychiatry, but their different viewpoints also led to cross currents that remain to be resolved in a satisfactory synthesis to the present day. Partly this is due to the discovery of potent and highly effective drug therapies that swept most other approaches from the scene. However, with the gradual recognition that these remarkable pharmacological advances are not the comprehensive, long-term panaceas they initially seemed to be, a consensus is once again emerging that complex systems such as the brain/mind require multiple avenues of study. One aim of this text is to promote that consensus and to help forge a greater recognition that a neuroscientific understanding of the fundamental nature of affect is an essential ingredient for future progress in psychotherapeutic practice and drug development. The brain does contain an evolved mental apparatus, and future progress will depend on how well we penetrate into the functional tangle of the nervous system (Chapter 20). We now know this will require a judicious blend of human and animal behavioral, brain, and mind sciences.

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