The Evolving Face of Psychiatry

Demons, Molecules, and Genes

For the past several years, I have had the pleasure and opportunity of teaching the history of psychiatry to our residents at UCI. The long struggle from society’s view of mental illness emerging from contempt, superstition, and stigma to compassion, understanding, and medical research has been hard won and littered with pitfalls and cul-de-sacs. The greatest deterrents to progress have come from unitary theories of causation and treatment that denied or avoided the complexities of human development, the multiplicity of biopyschosocial determinants, and the force of cultural and spiritual heterogeneity. From terror of demonology, the elusiveness of bodily humors, the absurdity of mesmerism and phrenology and in recent years, the parent bashing of the “schizophrenic” and “refrigerator” mothers we have endured long periods of stagnation.

The era of asylums and state hospitals has evolved into psychiatry in the community with great accomplishments as well as continued challenges and disappointments. Advances in neuropharmacology have lessened suffering from psychosis, mood, anxiety, and cognitive impairments yet challenged us to continue to address the mind and life of each patient in a comprehensive and truly effective manner.

How to integrate the autobiographical complexity of each patient, his or her adversities, and strengths, and biogenetic vulnerabilities into a meaningful diagnostic formulation and treatment plan must continue to be a hallmark of our specialty and never relinquished.

Dissolving the mind-brain barrier and integrating psychotherapy and pharmacotherapy should be an important future goal.
LeDoux (2002) has stated this eloquently “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 (insight, affect modulation, decreased relational conflict depends on there being some degree of modification to the perceptions, memory, and emotional systems that work ambiently and enduringly in the brain.

Neurobiological studies have discovered that human attachment, empathy, social bonding, mentalization, and mirroring of actions and intention are complex phenomena mediated by specific brain structures (e.g. orbital frontal cortex) and neurochemical modulations (e.g. opioid mediation of separation distress).

Imaging studies may help define attentional and memory processes significant in human relationships with important implications for informing a rational psychotherapy. Pharmacotherapy and psychotherapy may be synergistic for change by promoting consolidation of the biological substrate of their individual and combined effects.

Both negative stressors and positive changes in behavior elicit alterations in gene expression, which may produce structural changes in the brain (epigenetic effect). Brain imaging studies in the future may aid in diagnosing enduring conflict states and the progress of psychotherapy.

Our specialty has a very bright future—all the more reason to vigorously overcome the challenges to access to care, integration to our medical base, and adequate recognition and funding of our critical and effective services to patients.

Blinder BJ. “The Autobiographical Self: Who We Know and Who We Are.” Psychiatric Annals. 2007 April;37(4):276-284.
Blinder BJ. “Psychodynamic Neurobiology.” Beitman B, Blinder B, Thase M, Riba M, Safer D, eds. Integrating Psychotherapy and Pharmacotherapy: Dissolving The Mind-Brain Barrier. New York, NY: Norton; 2003:161-180.
LeDoux JE. “The Self: Clues From the Brain.” Ann NY Acad Sci. 2003 Oct;1001:295-304.

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