In Demystifying Psychiatry: A Resource for Patients and Families, Washington University School of Medicine psychiatrists Charles F. Zorumski, MD, the Samuel B. Guze Professor and head of the Department of Psychiatry, and Eugene H. Rubin, MD, PhD, professor of psychiatry, offer a straight-forward description of the specialty. The authors recently shared some of their thoughts on the field’s history, the many changes it has gone through in recent decades, and where the future may lead.
The Department of Psychiatry at Washington University School of Medicine (WUSM) played a major role in shifting the field of psychiatry from an emphasis on Freudian psychoanalysis to evidence-based medicine. Why was WUSM such fertile ground to nurture this change?
Zorumski: The answer to that goes back to the late 1940s. Ed Gildea, the head of what was already a research-oriented department, recruited an enthusiastic group of physicians and gave them the intellectual ground to pursue their research. Those new faculty — Eli Robins, Sam Guze, George Winokur, to name a few — approached Gildea about taking over the teaching of the residents and medical student clerkships. They wanted to move the department toward becoming a much heavier research-based department, one in which all residents would do research when they came here to train. Gildea had the foresight to let them go ahead; they then became the driving force in recruiting like-minded others and pushing the department forward.
Rubin: It was a very conscious effort, led by Eli Robins as the intellectual head in terms of his energy, with the idea that “Psychiatry is in a terrible state, we want to change the field.” How was this core of people able to effect a tremendous transformation of an entire field in a 10-year period? I don’t have a good answer; it was just a matter of the right personalities with the right persistence.
Zorumski: They all came to Washington University with different expertise. Eli was not only a psychiatrist, but also a neurochemist, and Guze came out of internal medicine. So these new faculty brought their different backgrounds into psychiatry with a different way of thinking about problems.
When you say “psychiatry was in a terrible state,” what does that mean?
Rubin: There was no research done; the Diagnostic and Statistical Manual of Mental Disorders (DSM) at that time was not criteria-based. More importantly, although only about 10 to 20 percent of psychiatrists considered themselves psychoanalysts, they controlled just about every department of psychiatry in the country. One or two other departments were reacting to this, but by far our department — because of the personalities — reacted most strongly against it, favoring the medical model.
Zorumski: I also think the fact that they were in St. Louis, unencumbered by the trends of the coasts, played a role. They were free to pursue what they wanted. They had a kindred spirit as well: European and British psychiatry in particular had a tradition that was moving toward empirical medicine, so this department had a natural affection for their approach. That became their fertile intellectual ground more than anywhere else in the United States.
Rubin: From about the mid-1950s on, all training in the WUSM psychiatry program was structured to get people thinking about and being friendly toward research, even though they couldn’t get any grant funding at that time. The faculty would meet weekly to discuss different illnesses, diagnoses, and how to set up criteria, all based on literature review and expert opinion. As chief resident, John Feighner took the notes at these meetings and so penned the original draft of the department’s paper on diagnostic criteria. The 1972 Feighner paper and one written after that by Robert Spitzer and colleagues at Columbia University were the precursors that led to the development of the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III), which was a tremendous change in how psychiatry was seen in terms of diagnosis.
With today’s emphasis on research, it’s odd to learn that until relatively recently it was not really a part of the field.
Rubin: In the past 10 to 20 years, psychiatry has become a very research-intensive field, but many of the training directors of psychiatric residency programs still are not of the same mindset as researchers. There are those who think the field has morphed in a bad direction. They feel that by leaning toward the biologic, researchers aren’t thinking about the complexity of human behavior. But the scientific method does acknowledge the complexity of human behavior and feels as angered by the oversimplification of “give a pill and you’re better” as it does by the belief that everything goes back to your childhood and that psychoanalysis can correct the underlying causes of disorders.
Would you say the field represents more of a blend of the two approaches now? You wouldn’t say analysis has gone by the wayside?
Rubin: No, not at all. I would say that evidence-based talk therapies are very important (i.e., cognitive behavioral therapy, interpersonal therapy). There is a new breed of psychodynamic psychiatrist, people who use the concepts of psychoanalysis and are putting those concepts into testable form in ways that are very good and medical model-oriented. What’s interesting is that the definition of psychodynamics is not the same as old-school psychoanalysis. It’s more and more changing to an approach of psychologically working with someone during a defined and limited number of sessions. So there’s been a convergence.
How can psychiatrists know that they are treating the whole person and not just focusing on treating problems?
Rubin: Psychiatry, at least the way we envision it, is really dealing with people who have disabling problems and trying to help them. We try to understand what is going on in the brain in psychiatric illness, how it develops and how we can help people get better.
Zorumski: It’s an interesting thing what psychiatric illnesses actually are. Some illnesses seem to be real breaks with normality, such as someone who develops severe psychotic illness and is hearing voices or believes that strange things are controlling them. That is a discrete disorder that probably is distinct from the way the normal population functions. But many other behavioral traits — an example would be obsessive thinking — are distributed relatively normally in the population, and maybe some of the psychiatrically ill individuals are just at the far end of the extreme. There are no cures for psychiatric illnesses, and they’re not coming in the foreseeable future. What we are doing is controlling symptoms and helping individuals to develop healthy strategies to live more productive lives.
With the potential for genomics and a fuller understanding of neuroscience, are we moving toward more and more individualized medicine?
Rubin: The Human Connectome Project, an effort that is mapping brain connections, is very exciting. In children they’re finding that in a five-minute scan you may be able to determine if someone’s brain is developing in an incorrect manner or too slowly, almost like is done for developmental milestones such as height or weight. I think in 10 years there will be five-minute brain scans that will highly predict whether someone is developing autism or other psychiatric illnesses, which will allow us to use interactive therapies to help these children’s brains while they are at their most plastic. We also know now that the brain is able to continually change by adding cells and making new connections between cells, even in adulthood. So another approach to care would be the combination of psychological and somatic treatments. For instance, if a psychologist is working with a patient with a fear of heights and, at the same time, the patient is given a medicine that influences the ability of the brain to be more plastic, the chances for that patient experiencing a lasting change may be improved. One other point: Researchers may change the whole structure of how diagnoses are made when we understand brain networks better.
Zorumski: We’re only now just beginning to touch the surface of understanding how brain networks actually function and develop. Many psychiatric illnesses are developmental problems, with the brain on a developmental trajectory based on how connectivity networks develop from early in life to maturity in the 20s. The question is, can you then target strategies to correct that and correct the defects that they’re having in brain network function to lead to a personalized medicine. I think there’s a probability that will happen in the next 10 to 20 years because technology is advancing, and science in connectivity mapping is advancing at an incredible pace. We wrote our latest book (to be published June 2011), Psychiatry and Clinical Neuroscience: A Primer to introduce these concepts to the clinical and scientific communities. We’re lucky to be at Washington University, not only because of all that happened from the 1950s to the 1970s, but because we are here now for the Human Connectome Project. This is what we believe is the future of psychiatry going forward: treatments to heal the networks. It will be personalized medicine, I think, at the highest level.