Book: Psychiatric Diagnosis and Classification

Book Title:

Psychiatric Diagnosis and Classification.

Author(s): Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor, and Norman Sartorius (Editors).

Year: 2002.

Edition: First (1st).

Publisher: Wiley-Blackwell.

Type(s): Hardcover and Kindle.

Synopsis:

This book provides an overview of the strengths and limitations of the currently available systems for the diagnosis and classification of mental disorders, in particular the DSM-IV and the ICD-10, and of the prospects for future developments. Among the covered issues are: The impact of biological research The diagnosis of mental disorders in primary care The usefulness and limitations of the concept of comorbidity in psychiatry The role of understanding and empathy in the diagnostic process The ethical, legal and social aspects of psychiatric classification Psychiatric Diagnosis & Classification provides a comprehensive picture of the current state of available diagnostic and classificatory systems in psychiatry and the improvements that are needed.

What is Major Depressive Disorder?

Introduction

Major depressive disorder (MDD), also known simply as depression, is a mental disorder characterised by at least two weeks of pervasive low mood. Low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause are common symptoms. Those affected may also occasionally have delusions or hallucinations. Some people have periods of depression separated by years, while others nearly always have symptoms present. Major depression is more severe and lasts longer than sadness, which is a normal part of life.

The diagnosis of MDD is based on the person’s reported experiences and a mental status examination. There is no laboratory test for the disorder, but testing may be done to rule out physical conditions that can cause similar symptoms. Those with MDD are typically treated with counselling and antidepressant medication. Medication appears to be effective, but the effect may only be significant in the most severely depressed. Types of counselling used include cognitive behavioural therapy (CBT) and interpersonal therapy, and electroconvulsive therapy (ECT) may be considered if other measures are not effective. Hospitalisation may be necessary in cases with a risk of harm to self and may occasionally occur against a person’s wishes.

The most common time of onset is in a person’s 20s and 30s, with females affected about twice as often as males. MDD affected approximately 163 million people (2% of the world’s population) in 2017. The percentage of people who are affected at one point in their life varies from 7% in Japan to 21% in France. Lifetime rates are higher in the developed world (15%) compared to the developing world (11%). The disorder causes the second-most years lived with disability, after lower back pain.

The term MDD was introduced by a group of US clinicians in the mid-1970s. The cause of MDD is believed to be a combination of genetic, environmental, and psychological factors, with about 40% of the risk related to genetics. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance abuse. It can negatively affect a person’s personal life, work life, or education as well as sleeping, eating habits, and general health. Those currently or previously affected with the disorder may be stigmatised.

Not to be confused with Depression (Mood).

Brief History

The Ancient Greek physician Hippocrates described a syndrome of melancholia as a distinct disease with particular mental and physical symptoms; he characterised all “fears and despondencies, if they last a long time” as being symptomatic of the ailment. It was a similar but far broader concept than today’s depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fear, anger, delusions and obsessions were included.

The term depression itself was derived from the Latin verb deprimere, “to press down”. From the 14th century, “to depress” meant to subjugate or to bring down in spirits. It was used in 1665 in English author Richard Baker’s Chronicle to refer to someone having “a great depression of spirit”, and by English author Samuel Johnson in a similar sense in 1753. The term also came into use in physiology and economics. An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in 1856, and by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function. Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and through the 19th century, became more associated with women.

Although melancholia remained the dominant diagnostic term, depression gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states.

Sigmund Freud likened the state of melancholia to mourning in his 1917 paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious, narcissistic process called the libidinal cathexis of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised. The patient’s decline of self-perception is revealed in his belief of his own blame, inferiority, and unworthiness. He also emphasized early life experiences as a predisposing factor. Adolf Meyer put forward a mixed social and biological framework emphasizing reactions in the context of an individual’s life, and argued that the term depression should be used instead of melancholia. The first version of the DSM (DSM-I, 1952) contained depressive reaction and the DSM-II (1968) depressive neurosis, defined as an excessive reaction to internal conflict or an identifiable event, and also included a depressive type of manic-depressive psychosis within Major affective disorders.

In the mid-20th century, researchers theorised that depression was caused by a chemical imbalance in neurotransmitters in the brain, a theory based on observations made in the 1950s of the effects of reserpine and isoniazid in altering monoamine neurotransmitter levels and affecting depressive symptoms. The chemical imbalance theory has never been proven.

The term unipolar (along with the related term bipolar) was coined by the neurologist and psychiatrist Karl Kleist, and subsequently used by his disciples Edda Neele and Karl Leonhard.

The term Major depressive disorder was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms (called the “Research Diagnostic Criteria”, building on earlier Feighner Criteria), and was incorporated into the DSM-III in 1980. The American Psychiatric Association added “major depressive disorder” to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), as a split of the previous depressive neurosis in the DSM-II, which also encompassed the conditions now known as dysthymia and adjustment disorder with depressed mood. To maintain consistency the ICD-10 used the same criteria, with only minor alterations, but using the DSM diagnostic threshold to mark a mild depressive episode, adding higher threshold categories for moderate and severe episodes. The ancient idea of melancholia still survives in the notion of a melancholic subtype.

The new definitions of depression were widely accepted, albeit with some conflicting findings and views. There have been some continued empirically based arguments for a return to the diagnosis of melancholia. There has been some criticism of the expansion of coverage of the diagnosis, related to the development and promotion of antidepressants and the biological model since the late 1950s.

Epidemiology

MDD affected approximately 163 million people in 2017 (2% of the global population). The percentage of people who are affected at one point in their life varies from 7% in Japan to 21% in France. In most countries the number of people who have depression during their lives falls within an 8-18% range. In North America, the probability of having a major depressive episode within a year-long period is 3-5% for males and 8-10% for females. Major depression is about twice as common in women as in men, although it is unclear why this is so, and whether factors unaccounted for are contributing to this. The relative increase in occurrence is related to pubertal development rather than chronological age, reaches adult ratios between the ages of 15 and 18, and appears associated with psychosocial more than hormonal factors. As of 2017, depression is the third most common worldwide cause of disability among both sexes, following low back pain and headache.

People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60. The risk of major depression is increased with neurological conditions such as stroke, Parkinson’s disease, or multiple sclerosis, and during the first year after childbirth. It is also more common after cardiovascular illnesses, and is related more to those with a poor cardiac disease outcome than to a better one. Studies conflict on the prevalence of depression in the elderly, but most data suggest there is a reduction in this age group. Depressive disorders are more common in urban populations than in rural ones and the prevalence is increased in groups with poorer socioeconomic factors, e.g. homelessness.

Signs and Symptoms

Major depression significantly affects a person’s family and personal relationships, work or school life, sleeping and eating habits, and general health. Its impact on functioning and well-being has been compared to that of other chronic medical conditions, such as diabetes.

A person having a major depressive episode usually exhibits a low mood, which pervades all aspects of life, and an inability to experience pleasure in previously enjoyable activities. Depressed people may be preoccupied with – or ruminate over – thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness or hopelessness. In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. Other symptoms of depression include poor concentration and memory (especially in those with melancholic or psychotic features), withdrawal from social situations and activities, reduced sex drive, irritability, and thoughts of death or suicide. Insomnia is common among the depressed. In the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. Some antidepressants may also cause insomnia due to their stimulating effect.

A depressed person may report multiple physical symptoms such as fatigue, headaches, or digestive problems; physical complaints are the most common presenting problem in developing countries, according to the World Health Organisation’s (WHO’s) criteria for depression. Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice that the person’s behaviour is either agitated or lethargic. Older depressed people may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements.

Depressed children may often display an irritable mood rather than a depressed one, and show varying symptoms depending on age and situation. Most lose interest in school and show a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as “normal moodiness.”

Associated Conditions

Major depression frequently co-occurs with other psychiatric problems. The 1990-1992 National Comorbidity Survey (US) reports that half of those with major depression also have lifetime anxiety and its associated disorders such as generalised anxiety disorder. Anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability and increased suicide attempts. There are increased rates of alcohol and drug abuse and particularly dependence, and around a third of individuals diagnosed with attention deficit hyperactivity disorder (ADHD) develop comorbid depression. Post-traumatic stress disorder and depression often co-occur. Depression may also coexist with ADHD, complicating the diagnosis and treatment of both. Depression is also frequently comorbid with alcohol abuse and personality disorders. Depression can also be exacerbated during particular months (usually winter) for those with seasonal affective disorder. While overuse of digital media has been associated with depressive symptoms, digital media may also be utilised in some situations to improve mood.

Depression and pain often co-occur. One or more pain symptoms are present in 65% of depressed patients, and anywhere from 5 to 85% of patients with pain will be suffering from depression, depending on the setting; there is a lower prevalence in general practice, and higher in specialty clinics. The diagnosis of depression is often delayed or missed, and the outcome can worsen if the depression is noticed but completely misunderstood.

Depression is also associated with a 1.5- to 2-fold increased risk of cardiovascular disease, independent of other known risk factors, and is itself linked directly or indirectly to risk factors such as smoking and obesity. People with major depression are less likely to follow medical recommendations for treating and preventing cardiovascular disorders, which further increases their risk of medical complications. In addition, cardiologists may not recognise underlying depression that complicates a cardiovascular problem under their care.

Depression often coexists with physical disorders common among the elderly, such as stroke, other cardiovascular diseases, Parkinson’s disease, and chronic obstructive pulmonary disease.

Cause(s)

The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression. The diathesis-stress model specifies that depression results when a pre-existing vulnerability, or diathesis, is activated by stressful life events. The pre-existing vulnerability can be either genetic, implying an interaction between nature and nurture, or schematic, resulting from views of the world learned in childhood.

Childhood abuse, either physical, sexual or psychological, are all risk factors for depression, among other psychiatric issues that co-occur such as anxiety and drug abuse. Childhood trauma also correlates with severity of depression, lack of response to treatment and length of illness. However, some are more susceptible to developing mental illness such as depression after trauma, and various genes have been suggested to control susceptibility.

Genetics

Family and twin studies find that nearly 40% of individual differences in risk for major depressive disorder can be explained by genetic factors. Like most psychiatric disorders, major depressive disorder is likely to be influenced by many individual genetic changes. In 2018, a genome-wide association study discovered 44 variants in the genome linked to risk for major depression. This was followed by a 2019 study that found 102 variants in the genome linked to depression.

The 5-HTTLPR, or serotonin transporter promoter gene’s short allele has been associated with increased risk of depression. However, since the 1990s, results have been inconsistent, with three recent reviews finding an effect and two finding none. Other genes that have been linked to a gene-environment interaction include CRHR1, FKBP5 and BDNF, the first two of which are related to the stress reaction of the HPA axis, and the latter of which is involved in neurogenesis. There is no conclusive effects of candidate gene on depression, either alone or in combination with life stress. Research focusing on specific candidate genes has been criticised for its tendency to generate false positive findings. There are also other efforts to examine interactions between life stress and polygenic risk for depression.

Other Health Problems

Depression may also come secondary to a chronic or terminal medical condition, such as HIV/AIDS or asthma, and may be labelled “secondary depression.” It is unknown whether the underlying diseases induce depression through effect on quality of life, of through shared aetiologies (such as degeneration of the basal ganglia in Parkinson’s disease or immune dysregulation in asthma). Depression may also be iatrogenic (the result of healthcare), such as drug-induced depression. Therapies associated with depression include interferons, beta-blockers, isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents such as gonadotropin-releasing hormone agonist. Drug abuse in early age is also associated with increased risk of developing depression later in life. Depression that occurs as a result of pregnancy is called postpartum depression, and is thought to be the result of hormonal changes associated with pregnancy. Seasonal affective disorder, a type of depression associated with seasonal changes in sunlight, is thought to be the result of decreased sunlight.

Pathophysiology

The pathophysiology of depression is not yet understood, but the current theories centre around monoaminergic systems, the circadian rhythm, immunological dysfunction, HPA axis dysfunction and structural or functional abnormalities of emotional circuits.

The monoamine theory, derived from the efficacy of monoaminergic drugs in treating depression, was the dominant theory until recently. The theory postulates that insufficient activity of monoamine neurotransmitters is the primary cause of depression. Evidence for the monoamine theory comes from multiple areas. Firstly, acute depletion of tryptophan, a necessary precursor of serotonin, a monoamine, can cause depression in those in remission or relatives of depressed patients; this suggests that decreased serotonergic neurotransmission is important in depression. Secondly, the correlation between depression risk and polymorphisms in the 5-HTTLPR gene, which codes for serotonin receptors, suggests a link. Third, decreased size of the locus coeruleus, decreased activity of tyrosine hydroxylase, increased density of alpha-2 adrenergic receptor, and evidence from rat models suggest decreased adrenergic neurotransmission in depression. Furthermore, decreased levels of homovanillic acid, altered response to dextroamphetamine, responses of depressive symptoms to dopamine receptor agonists, decreased dopamine receptor D1 binding in the striatum, and polymorphism of dopamine receptor genes implicate dopamine, another monoamine, in depression. Lastly, increased activity of monoamine oxidase, which degrades monoamines, has been associated with depression. However, this theory is inconsistent with the fact that serotonin depletion does not cause depression in healthy persons, the fact that antidepressants instantly increase levels of monoamines but take weeks to work, and the existence of atypical antidepressants which can be effective despite not targeting this pathway. One proposed explanation for the therapeutic lag, and further support for the deficiency of monoamines, is a desensitisation of self-inhibition in raphe nuclei by the increased serotonin mediated by antidepressants. However, disinhibition of the dorsal raphe has been proposed to occur as a result of decreased serotonergic activity in tryptophan depletion, resulting in a depressed state mediated by increased serotonin. Further countering the monoamine hypothesis is the fact that rats with lesions of the dorsal raphe are not more depressive than controls, the finding of increased jugular 5-HIAA in depressed patients that normalised with SSRI treatment, and the preference for carbohydrates in depressed patients. Already limited, the monoamine hypothesis has been further oversimplified when presented to the general public.

Immune system abnormalities have been observed, including increased levels of cytokines involved in generating sickness behaviour (which shares overlap with depression). The effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) and cytokine inhibitors in treating depression, and normalization of cytokine levels after successful treatment further suggest immune system abnormalities in depression.

HPA axis abnormalities have been suggested in depression given the association of CRHR1 with depression and the increased frequency of dexamethasone test non-suppression in depressed patients. However, this abnormality is not adequate as a diagnosis tool, because its sensitivity is only 44%. These stress-related abnormalities have been hypothesized to be the cause of hippocampal volume reductions seen in depressed patients. Furthermore, a meta-analysis yielded decreased dexamethasone suppression, and increased response to psychological stressors. Further abnormal results have been obscured with the cortisol awakening response, with increased response being associated with depression.

Theories unifying neuroimaging findings have been proposed. The first model proposed is the “Limbic Cortical Model”, which involves hyperactivity of the ventral paralimbic regions and hypoactivity of frontal regulatory regions in emotional processing. Another model, the “Corito-Striatal model”, suggests that abnormalities of the prefrontal cortex in regulating striatal and subcortical structures results in depression. Another model proposes hyperactivity of salience structures in identifying negative stimuli, and hypoactivity of cortical regulatory structures resulting in a negative emotional bias and depression, consistent with emotional bias studies.

Diagnosis

Clinical Assessment

A diagnostic assessment may be conducted by a suitably trained general practitioner, or by a psychiatrist or psychologist, who records the person’s current circumstances, biographical history, current symptoms, family history, and alcohol and drug use. The assessment also includes a mental state examination, which is an assessment of the person’s current mood and thought content, in particular the presence of themes of hopelessness or pessimism, self-harm or suicide, and an absence of positive thoughts or plans. Specialist mental health services are rare in rural areas, and thus diagnosis and management is left largely to primary-care clinicians. This issue is even more marked in developing countries. Rating scales are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose; these include the Hamilton Rating Scale for Depression, the Beck Depression Inventory[90] or the Suicide Behaviours Questionnaire-Revised.

Primary-care physicians and other non-psychiatrist physicians have more difficulty with under-recognition and undertreatment of depression compared to psychiatric physicians, in part because of the physical symptoms that often accompany depression, in addition to many potential patient, provider, and system barriers. A review found that non-psychiatrist physicians miss about two-thirds of cases, though this has improved somewhat in more recent studies.

Before diagnosing major depressive disorder, a doctor generally performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH and thyroxine to exclude hypothyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and a full blood count including ESR to rule out a systemic infection or chronic disease. Adverse affective reactions to medications or alcohol misuse are often ruled out, as well. Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men. Vitamin D levels might be evaluated, as low levels of vitamin D have been associated with greater risk for depression.

Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer’s disease. Cognitive testing and brain imaging can help distinguish depression from dementia. A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms. No biological tests confirm major depression. In general, investigations are not repeated for a subsequent episode unless there is a medical indication.

DSM and ICD Criteria

The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) and the WHO’s International Statistical Classification of Diseases and Related Health Problems (ICD) which uses the name depressive episode for a single episode and recurrent depressive disorder for repeated episodes. The latter system is typically used in European countries, while the former is used in the US and many other non-European nations, and the authors of both have worked towards conforming one with the other.

Both DSM-5 and ICD-10 mark out typical (main) depressive symptoms. ICD-10 defines three typical depressive symptoms (depressed mood, anhedonia, and reduced energy), two of which should be present to determine the depressive disorder diagnosis. According to DSM-5, there are two main depressive symptoms- a depressed mood and loss of interest/pleasure in activities (anhedonia). These symptoms, as well as five out of the nine more specific symptoms listed, must frequently occur for more than two weeks (to the extent in which it impairs functioning) for the diagnosis.

MDD is classified as a mood disorder in DSM-5. The diagnosis hinges on the presence of single or recurrent major depressive episodes. Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Unspecified Depressive Disorder is diagnosed if the depressive episode’s manifestation does not meet the criteria for a major depressive episode. The ICD-10 system does not use the term major depressive disorder but lists very similar criteria for the diagnosis of a depressive episode (mild, moderate or severe); the term recurrent may be added if there have been multiple episodes without mania.

Major Depressive Episode

A major depressive episode (MDE) is characterised by the presence of a severely depressed mood that persists for at least two weeks.

Episodes may be isolated or recurrent and are categorised as mild (few symptoms in excess of minimum criteria), moderate, or severe (marked impact on social or occupational functioning). An episode with psychotic features – commonly referred to as psychotic depression – is automatically rated as severe. If the patient has had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead. Depression without mania is sometimes referred to as unipolar because the mood remains at one emotional state or “pole”.

DSM-IV-TR excludes cases where the symptoms are a result of bereavement, although it is possible for normal bereavement to evolve into a depressive episode if the mood persists and the characteristic features of a MDE develop. The criteria were criticised because they do not take into account any other aspects of the personal and social context in which depression can occur. In addition, some studies have found little empirical support for the DSM-IV cut-off criteria, indicating they are a diagnostic convention imposed on a continuum of depressive symptoms of varying severity and duration. Bereavement is no longer an exclusion criterion in DSM-5, and it is now up to the clinician to distinguish between normal reactions to a loss and MDD. Excluded are a range of related diagnoses, including:

  • Dysthymia, which involves a chronic but milder mood disturbance;
  • Recurrent brief depression, consisting of briefer depressive episodes;
  • Minor depressive disorder, whereby only some symptoms of major depression are present; and
  • Adjustment disorder with depressed mood, which denotes low mood resulting from a psychological response to an identifiable event or stressor.

Three new depressive disorders were added to the DSM-5:

  • Disruptive mood dysregulation disorder, classified by significant childhood irritability and tantrums;
  • Premenstrual dysphoric disorder (PMDD), causing periods of anxiety, depression, or irritability in the week or two before a woman’s menstruation, and
  • Persistent depressive disorder.

Subtypes

The DSM-5 recognises six further subtypes of MDD, called specifiers, in addition to noting the length, severity and presence of psychotic features:

  • Melancholic depression:
    • This is characterised by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
  • Atypical depression:
    • This is characterised by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (comfort eating), excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
  • Catatonic depression:
    • This is a rare and severe form of major depression involving disturbances of motor behaviour and other symptoms.
    • Here, the person is mute and almost stuporous, and either remains immobile or exhibits purposeless or even bizarre movements.
    • Catatonic symptoms also occur in schizophrenia or in manic episodes, or may be caused by neuroleptic malignant syndrome.
  • Depression with anxious distress:
    • This was added into the DSM-V as a means to emphasize the common co-occurrence between depression or mania and anxiety, as well as the risk of suicide of depressed individuals with anxiety.
    • Specifying in such a way can also help with the prognosis of those diagnosed with a depressive or bipolar disorder.
  • Depression with peri-partum onset:
    • This refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth or while a woman is pregnant.
    • DSM-IV-TR used the classification “postpartum depression,” but this was changed in order to not exclude cases of depressed woman during pregnancy.
    • Depression with peripartum onset has an incidence rate of 10-15% among new mothers.
    • The DSM-V mandates that, in order to qualify as depression with peripartum onset, onset occur during pregnancy or within one month of delivery.
    • It has been said that postpartum depression can last as long as three months.
  • Seasonal affective disorder (SAD):
    • This is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring.
    • The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.

Differential Diagnosis

Refer to Differential Diagnoses of Depression.

To confirm MDD as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depression (sometimes referred to as double depression). Adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioural symptoms are significant but do not meet the criteria for a MDE. Bipolar disorder, also known as manic–depressive disorder, is a condition in which depressive phases alternate with periods of mania or hypomania. Although depression is currently categorised as a separate disorder, there is ongoing debate because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a mood disorder continuum. Further differential diagnoses involve chronic fatigue syndrome.

Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, medications, and substance abuse. Depression due to physical illness is diagnosed as a mood disorder due to a general medical condition. This condition is determined based on history, laboratory findings, or physical examination. When the depression is caused by a medication, drug of abuse, or exposure to a toxin, it is then diagnosed as a specific mood disorder (previously called substance-induced mood disorder in the DSM-IV-TR).

Screening and Prevention

Since 2016, the United States Preventive Services Task Force (USPSTF) has recommended screening for depression among those over the age 12; a 2005 Cochrane review found that the routine use of screening questionnaires has little effect on detection or treatment.

Preventive efforts may result in decreases in rates of the condition of between 22 and 38%. Eating large amounts of fish may also reduce the risk.

Behavioural interventions, such as interpersonal therapy and cognitive-behavioural therapy, are effective at preventing new onset depression. Because such interventions appear to be most effective when delivered to individuals or small groups, it has been suggested that they may be able to reach their large target audience most efficiently through the Internet.

However, an earlier meta-analysis found preventive programmes with a competence-enhancing component to be superior to behaviour-oriented programmes overall, and found behavioural programmes to be particularly unhelpful for older people, for whom social support programmes were uniquely beneficial. In addition, the programs that best prevented depression comprised more than eight sessions, each lasting between 60 and 90 minutes, were provided by a combination of lay and professional workers, had a high-quality research design, reported attrition rates, and had a well-defined intervention.

The Netherlands mental health care system provides preventive interventions, such as the “Coping with Depression” course (CWD) for people with sub-threshold depression. The course is claimed to be the most successful of psychoeducational interventions for the treatment and prevention of depression (both for its adaptability to various populations and its results), with a risk reduction of 38% in major depression and an efficacy as a treatment comparing favourably to other psychotherapies.

Management

The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice (over medication) for people under 18. The UK National Institute for Health and Care Excellence (NICE) 2004 guidelines indicate that antidepressants should not be used for the initial treatment of mild depression because the risk-benefit ratio is poor. The guidelines recommend that antidepressants treatment in combination with psychosocial interventions should be considered for:

  • People with a history of moderate or severe depression.
  • Those with mild depression that has been present for a long period.
  • As a second line treatment for mild depression that persists after other interventions.
  • As a first line treatment for moderate or severe depression.

The guidelines further note that antidepressant treatment should be continued for at least six months to reduce the risk of relapse, and that SSRIs are better tolerated than tricyclic antidepressants.

American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and patient preference. Options may include pharmacotherapy, psychotherapy, exercise, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all patients with severe depression unless ECT is planned. There is evidence that collaborative care by a team of health care practitioners produces better results than routine single-practitioner care.

Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition. A 2014 Cochrane review found insufficient evidence to determine the effectiveness of psychological versus medical therapy in children.

Lifestyle

Physical exercise is recommended for management of mild depression, and has a moderate effect on symptoms. Exercise has also been found to be effective for (unipolar) major depression. It is equivalent to the use of medications or psychological therapies in most people. In older people it does appear to decrease depression. Exercise may be recommended to people who are willing, motivated, and physically healthy enough to participate in an exercise programme as treatment.

There is a small amount of evidence that skipping a night’s sleep may improve depressive symptoms, with the effects usually showing up within a day. This effect is usually temporary. Besides sleepiness, this method can cause a side effect of mania or hypomania.

In observational studies, smoking cessation has benefits in depression as large as or larger than those of medications.

Besides exercise, sleep and diet may play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.

Talking Therapies

Talking therapy (psychotherapy) can be delivered to individuals, groups, or families by mental health professionals. A 2017 review found that cognitive behavioural therapy appears to be similar to antidepressant medication in terms of effect. A 2012 review found psychotherapy to be better than no treatment but not other treatments. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used. There is moderate-quality evidence that psychological therapies are a useful addition to standard antidepressant treatment of treatment-resistant depression in the short term.

Psychotherapy has been shown to be effective in older people. Successful psychotherapy appears to reduce the recurrence of depression even after it has been stopped or replaced by occasional booster sessions.

Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy (IPT) are preferred therapies for adolescent depression. In people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy. CBT has also been shown to reduce the number of sick days taken by people with depression, when used in conjunction with primary care.

The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviours. Research beginning in the mid-1990s suggested that CBT could perform as well as or better than antidepressants in patients with moderate to severe depression. CBT may be effective in depressed adolescents, although its effects on severe episodes are not definitively known. Several variables predict success for cognitive behavioural therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions. CBT is particularly beneficial in preventing relapse.

CBT and occupational programmes (including modification of work activities and assistance) have been shown to be effective in reducing sick days taken by workers with depression.

Variants

Several variants of CBT have been used in those with depression, the most notable being rational emotive behaviour therapy (REBT), and mindfulness-based cognitive therapy. Mindfulness-based stress reduction programmes may reduce depression symptoms. Mindfulness programmes also appear to be a promising intervention in youth.

Psychoanalysis

Psychoanalysis is a school of thought, founded by Sigmund Freud, which emphasizes the resolution of unconscious mental conflicts. Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression. A more widely practiced therapy, called psychodynamic psychotherapy, is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person’s immediate problems, and has an additional social and interpersonal focus. In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.

Antidepressants

Conflicting results have arisen from studies that look at the effectiveness of antidepressants in people with acute, mild to moderate depression. Stronger evidence supports the usefulness of antidepressants in the treatment of depression that is chronic (dysthymia) or severe.

While small benefits were found, researchers Irving Kirsch and Thomas Moore state they may be due to issues with the trials rather than a true effect of the medication. In a later publication, Kirsch concluded that the overall effect of new-generation antidepressant medication is below recommended criteria for clinical significance. Similar results were obtained in a meta-analysis by Fornier.

A review commissioned by the National Institute for Health and Care Excellence (UK) concluded that there is strong evidence that selective serotonin reuptake inhibitors (SSRIs), such as escitalopram, paroxetine, and sertraline, have greater efficacy than placebo on achieving a 50% reduction in depression scores in moderate and severe major depression, and that there is some evidence for a similar effect in mild depression. Similarly, a Cochrane systematic review of clinical trials of the generic tricyclic antidepressant amitriptyline concluded that there is strong evidence that its efficacy is superior to placebo.

A 2019 Cochrane review on the combined use of antidepressants plus benzodiazepines demonstrated improved effectiveness when compared to antidepressants alone; however, these effects were not maintained in the acute or continuous phase. The benefits of adding a benzodiazepine should be balanced against possible harms and other alternative treatment strategies when antidepressant mono-therapy is considered inadequate.

In 2014, the US Food and Drug Administration published a systematic review of all antidepressant maintenance trials submitted to the agency between 1985 and 2012. The authors concluded that maintenance treatment reduced the risk of relapse by 52% compared to placebo, and that this effect was primarily due to recurrent depression in the placebo group rather than a drug withdrawal effect.

To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50 to 75%, and it can take at least six to eight weeks from the start of medication to improvement. Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimise the chance of recurrence, and even up to one year of continuation is recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.

SSRIs are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants. People who do not respond to one SSRI can be switched to another antidepressant, and this results in improvement in almost 50% of cases. Another option is to switch to the atypical antidepressant bupropion. Venlafaxine, an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs. However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits, and it is specifically discouraged in children and adolescents.

For children, some research has supported the use of the SSRI antidepressant fluoxetine. The benefit however appears to be slight in children, while other antidepressants have not been shown to be effective. Medications are not recommended in children with mild disease. There is also insufficient evidence to determine effectiveness in those with depression complicated by dementia. Any antidepressant can cause low blood sodium levels; nevertheless, it has been reported more often with SSRIs. It is not uncommon for SSRIs to cause or worsen insomnia; the sedating atypical antidepressant mirtazapine can be used in such cases.

Irreversible monoamine oxidase inhibitors, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed. The safety profile is different with reversible monoamine oxidase inhibitors, such as moclobemide, where the risk of serious dietary interactions is negligible and dietary restrictions are less strict.

It is unclear whether antidepressants affect a person’s risk of suicide. For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both suicidal ideations and suicidal behaviour in those treated with SSRIs. For adults, it is unclear whether SSRIs affect the risk of suicidality. One review found no connection; another an increased risk; and a third no risk in those 25-65 years old and a decreased risk in those more than 65. A black box warning was introduced in the United States in 2007 on SSRIs and other antidepressant medications due to the increased risk of suicide in patients younger than 24 years old. Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.

Other Medications

There is some evidence that omega-3 fatty acids fish oil supplements containing high levels of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) are effective in the treatment of, but not the prevention of major depression. However, a Cochrane review determined there was insufficient high quality evidence to suggest omega-3 fatty acids were effective in depression. There is limited evidence that vitamin D supplementation is of value in alleviating the symptoms of depression in individuals who are vitamin D-deficient. There is some preliminary evidence that COX-2 inhibitors, such as celecoxib, have a beneficial effect on major depression. Lithium appears effective at lowering the risk of suicide in those with bipolar disorder and unipolar depression to nearly the same levels as the general population. There is a narrow range of effective and safe dosages of lithium thus close monitoring may be needed. Low-dose thyroid hormone may be added to existing antidepressants to treat persistent depression symptoms in people who have tried multiple courses of medication. Limited evidence suggests stimulants, such as amphetamine and modafinil, may be effective in the short term, or as adjuvant therapy. Also, it is suggested that folate supplements may have a role in depression management. There is tentative evidence for benefit from testosterone in males.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses. ECT is used with informed consent as a last line of intervention for major depressive disorder.

A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar. Follow-up treatment is still poorly studied, but about half of people who respond relapse within twelve months.

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anaesthesia. Immediately following treatment, the most common adverse effects are confusion and memory loss. ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.

A usual course of ECT involves multiple administrations, typically given two or three times per week, until the patient is no longer suffering symptoms. ECT is administered under anaesthesia with a muscle relaxant. Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT.

ECT appears to work in the short term via an anticonvulsant effect mostly in the frontal lobes, and longer term via neurotrophic effects primarily in the medial temporal lobe.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) or deep transcranial magnetic stimulation is a non-invasive method used to stimulate small regions of the brain. TMS was approved by the FDA for treatment-resistant major depressive disorder (trMDD) in 2008 and as of 2014 evidence supports that it is probably effective. The American Psychiatric Association the Canadian Network for Mood and Anxiety Disorders, and the Royal Australia and New Zealand College of Psychiatrists have endorsed TMS for trMDD.

Transcranial Direct Current Stimulation

Transcranial direct current stimulation (tDCS) is another non-invasive method used to stimulate small regions of the brain with the help of a weak electric current. Increasing evidence has been gathered for its efficiency as a depression treatment. A meta-analysis was published in 2020 summarising results across nine studies (572 participants) concluded that active tDCS was significantly superior to sham for response (30.9% vs. 18.9%, respectively), remission (19.9% vs. 11.7%) and depression improvement. According to a 2016 meta analysis, 34% of tDCS-treated patients showed at least 50% symptom reduction compared to 19% sham-treated across 6 randomised controlled trials.

Light Therapy

Bright light therapy reduces depression symptom severity, with benefit for both seasonal affective disorder and for non-seasonal depression, and an effect similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to the standard antidepressant treatment was not effective. For non-seasonal depression, where light was used mostly in combination with antidepressants or wake therapy, a moderate effect was found, with response better than control treatment in high-quality studies, in studies that applied morning light treatment, and with people who respond to total or partial sleep deprivation. Both analyses noted poor quality, short duration, and small size of most of the reviewed studies.

Other

There is insufficient evidence for Reiki and dance movement therapy in depression.

As of 2019 cannabis is specifically not recommended as a treatment.

Prognosis

Major depressive episodes often resolve over time whether or not they are treated. Outpatients on a waiting list show a 10-15% reduction in symptoms within a few months, with approximately 20% no longer meeting the full criteria for a depressive disorder. The median duration of an episode has been estimated to be 23 weeks, with the highest rate of recovery in the first three months.

Studies have shown that 80% of those suffering from their first major depressive episode will have at least one more depression during their life, with a lifetime average of 4 episodes. Other general population studies indicate that around half those who have an episode recover (whether treated or not) and remain well, while the other half will have at least one more, and around 15% of those experience chronic recurrence. Studies recruiting from selective inpatient sources suggest lower recovery and higher chronicity, while studies of mostly outpatients show that nearly all recover, with a median episode duration of 11 months. Around 90% of those with severe or psychotic depression, most of whom also meet criteria for other mental disorders, experience recurrence.

A high proportion of people who experience full symptomatic remission still have at least one not fully resolved symptom after treatment. Recurrence or chronicity is more likely if symptoms have not fully resolved with treatment. Current guidelines recommend continuing antidepressants for four to six months after remission to prevent relapse. Evidence from many randomised controlled trials indicate continuing antidepressant medications after recovery can reduce the chance of relapse by 70% (41% on placebo vs. 18% on antidepressant). The preventive effect probably lasts for at least the first 36 months of use.

People experiencing repeated episodes of depression require ongoing treatment in order to prevent more severe, long-term depression. In some cases, people must take medications for the rest of their lives.

Cases when outcome is poor are associated with inappropriate treatment, severe initial symptoms including psychosis, early age of onset, previous episodes, incomplete recovery after one year of treatment, pre-existing severe mental or medical disorder, and family dysfunction.

Depressed individuals have a shorter life expectancy than those without depression, in part because depressed patients are at risk of dying of suicide. They also have a higher rate of dying from other causes, being more susceptible to medical conditions such as heart disease. Up to 60% of people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and borderline personality disorder. About 2-8% of adults with major depression die by suicide, and about 50% of people who die by suicide had depression or another mood disorder. The lifetime risk of suicide associated with a diagnosis of major depression in the US is estimated at 3.4%, which averages two highly disparate figures of almost 7% for men and 1% for women (although suicide attempts are more frequent in women). The estimate is substantially lower than a previously accepted figure of 15%, which had been derived from older studies of hospitalised patients.

Major depression is currently the leading cause of disease burden in North America and other high-income countries, and the fourth-leading cause worldwide. In the year 2030, it is predicted to be the second-leading cause of disease burden worldwide after HIV, according to the WHO. Delay or failure in seeking treatment after relapse and the failure of health professionals to provide treatment are two barriers to reducing disability.

Depression may affect people’s ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) probably reduces sick leave by 15%, and leads to fewer depressive symptoms and improved work capacity, reducing sick leave by an annual average of 25 days per year. Helping depressed people return to work without a connection to clinical care has not been shown to have an effect on sick leave days. Additional psychological interventions (such as online CBT) leads to fewer sick days compared to standard management only. Streamlining care or adding specific providers for depression care may help to reduce sick leave.

Society and Culture

Terminology

The term “depression” is used in a number of different ways. It is often used to mean this syndrome but may refer to other mood disorders or simply to a low mood. People’s conceptualisations of depression vary widely, both within and among cultures. “Because of the lack of scientific certainty,” one commentator has observed, “the debate over depression turns on questions of language. What we call it – ‘disease,’ ‘disorder,’ ‘state of mind’ – affects how we view, diagnose, and treat it.” There are cultural differences in the extent to which serious depression is considered an illness requiring personal professional treatment, or is an indicator of something else, such as the need to address social or moral problems, the result of biological imbalances, or a reflection of individual differences in the understanding of distress that may reinforce feelings of powerlessness, and emotional struggle.

The diagnosis is less common in some countries, such as China. It has been argued that the Chinese traditionally deny or somatise emotional depression (although since the early 1980s, the Chinese denial of depression may have modified). Alternatively, it may be that Western cultures reframe and elevate some expressions of human distress to disorder status. Australian professor Gordon Parker and others have argued that the Western concept of depression “medicalises” sadness or misery. Similarly, Hungarian-American psychiatrist Thomas Szasz and others argue that depression is a metaphorical illness that is inappropriately regarded as an actual disease. There has also been concern that the DSM, as well as the field of descriptive psychiatry that employs it, tends to reify abstract phenomena such as depression, which may in fact be social constructs. American archetypal psychologist James Hillman writes that depression can be healthy for the soul, insofar as “it brings refuge, limitation, focus, gravity, weight, and humble powerlessness.” Hillman argues that therapeutic attempts to eliminate depression echo the Christian theme of resurrection, but have the unfortunate effect of demonising a soulful state of being.

Stigma

Historical figures were often reluctant to discuss or seek treatment for depression due to social stigma about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author Mary Shelley, American-British writer Henry James, and American president Abraham Lincoln. Some well-known contemporary people with possible depression include Canadian songwriter Leonard Cohen and American playwright and novelist Tennessee Williams. Some pioneering psychologists, such as Americans William James and John B. Watson, dealt with their own depression.

There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to creativity, a discussion that goes back to Aristotelian times. British literature gives many examples of reflections on depression. English philosopher John Stuart Mill experienced a several-months-long period of what he called “a dull state of nerves”, when one is “unsusceptible to enjoyment or pleasurable excitement; one of those moods when what is pleasure at other times, becomes insipid or indifferent”. He quoted English poet Samuel Taylor Coleridge’s “Dejection” as a perfect description of his case: “A grief without a pang, void, dark and drear, / A drowsy, stifled, unimpassioned grief, / Which finds no natural outlet or relief / In word, or sigh, or tear.” English writer Samuel Johnson used the term “the black dog” in the 1780s to describe his own depression, and it was subsequently popularised by depression sufferer former British Prime Minister Sir Winston Churchill.

Social stigma of major depression is widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly. In the UK, the Royal College of Psychiatrists and the Royal College of General Practitioners conducted a joint Five-year Defeat Depression campaign to educate and reduce stigma from 1992 to 1996; a MORI study conducted afterwards showed a small positive change in public attitudes to depression and treatment.

Elderly

Depression is especially common among those over 65 years of age and increases in frequency beyond this age. In addition, the risk of depression increases in relation to the frailty of the individual. Depression is one of the most important factors which negatively impact quality of life in adults, as well as the elderly. Both symptoms and treatment among the elderly differ from those of the rest of the population.

As with many other diseases, it is common among the elderly not to present with classical depressive symptoms. Diagnosis and treatment is further complicated in that the elderly are often simultaneously treated with a number of other drugs, and often have other concurrent diseases. Treatment differs in that studies of SSRIs have shown lesser and often inadequate effects among the elderly, while other drugs, such as duloxetine (a serotonin-norepinephrine reuptake inhibitor), with more clear effects have adverse effects, such as dizziness, dryness of the mouth, diarrhoea and constipation, which can be especially difficult to handle among the elderly.

Problem solving therapy was, as of 2015, the only psychological therapy with proven effect, and can be likened to a simpler form of CBT. However, elderly with depression are seldom offered any psychological treatment, and the evidence proving other treatments effective is incomplete. ECT has been used in the elderly, and register-studies suggest it is effective, although less so as compared to the rest of the population. The risks involved with treatment of depression among the elderly as opposed to benefits are not entirely clear.

Research

MRI scans of patients with depression have revealed a number of differences in brain structure compared to those who are not depressed. Meta-analyses of neuroimaging studies in major depression reported that, compared to controls, depressed patients had increased volume of the lateral ventricles and adrenal gland and smaller volumes of the basal ganglia, thalamus, hippocampus, and frontal lobe (including the orbitofrontal cortex and gyrus rectus). Hyperintensities have been associated with patients with a late age of onset, and have led to the development of the theory of vascular depression.

Trials are looking at the effects of botulinum toxins on depression. The idea is that the drug is used to make the person look less frowning and that this stops the negative facial feedback from the face. In 2015 results showed, however, that the partly positive effects that had been observed until then could have been due to placebo effects.

In 2018-2019, the US Food and Drug Administration (FDA) granted Breakthrough therapy designation to Compass Pathways and, separately, Usona Institute. Compass is a for-profit company studying psilocybin for treatment-resistant depression; Usona is a non-profit organisation studying psilocybin for major depressive disorder more broadly.

Animals Models

Models of depression in animals for the purpose of study include iatrogenic depression models (such as drug-induced), forced swim tests, tail suspension test, and learned helplessness models. Criteria frequently used to assess depression in animals include expression of despair, neurovegetative changes, and anhedonia, as many other criteria for depression are untestable in animals, such as guilt and suicidality.

On This Day … 24 January

People (Births)

  • 1850 – Hermann Ebbinghaus, German psychologist (d. 1909).
  • 1853 – Sigbert Josef Maria Ganser, German psychiatrist (d. 1931).

Hermann Ebbinghaus

Hermann Ebbinghaus (24 January 1850 to 26 February 1909) was a German psychologist who pioneered the experimental study of memory, and is known for his discovery of the forgetting curve and the spacing effect. He was also the first person to describe the learning curve. He was the father of the neo-Kantian philosopher Julius Ebbinghaus.

Early Life

Ebbinghaus was born in Barmen, in the Rhine Province of the Kingdom of Prussia, as the son of a wealthy merchant, Carl Ebbinghaus. Little is known about his infancy except that he was brought up in the Lutheran faith and was a pupil at the town Gymnasium. At the age of 17 (1867), he began attending the University of Bonn, where he had planned to study history and philology. However, during his time there he developed an interest in philosophy. In 1870, his studies were interrupted when he served with the Prussian Army in the Franco-Prussian War. Following this short stint in the military, Ebbinghaus finished his dissertation on Eduard von Hartmann’s Philosophie des Unbewussten (philosophy of the unconscious) and received his doctorate on 16 August 1873, when he was 23 years old. During the next three years, he spent time at Halle and Berlin.

Professional Career

After acquiring his PhD, Ebbinghaus moved around England and France, tutoring students to support himself. In England, he may have taught in two small schools in the south of the country (Gorfein, 1885). In London, in a used bookstore, he came across Gustav Fechner’s book Elemente der Psychophysik (Elements of Psychophysics), which spurred him to conduct his famous memory experiments. After beginning his studies at the University of Berlin, he founded the third psychological testing lab in Germany (third to Wilhelm Wundt and Georg Elias Müller). He began his memory studies here in 1879. In 1885 – the same year that he published his monumental work, Über das Gedächtnis. Untersuchungen zur experimentellen Psychologie, later published in English under the title Memory: A Contribution to Experimental Psychology – he was made a professor at the University of Berlin, most likely in recognition of this publication. In 1890, along with Arthur König, he founded the psychological journal Zeitschrift für Physiologie und Psychologie der Sinnesorgane (“The Psychology and Physiology of the Sense Organs'”).

In 1894, he was passed over for promotion to head of the philosophy department at Berlin, most likely due to his lack of publications. Instead, Carl Stumpf received the promotion. As a result of this, Ebbinghaus left to join the University of Breslau (now Wrocław, Poland), in a chair left open by Theodor Lipps (who took over Stumpf’s position when he moved to Berlin). While in Breslau, he worked on a commission that studied how children’s mental ability declined during the school day. While the specifics on how these mental abilities were measured have been lost, the successes achieved by the commission laid the groundwork for future intelligence testing. At Breslau, he again founded a psychological testing laboratory.

In 1902, Ebbinghaus published his next piece of writing entitled Die Grundzüge der Psychologie (Fundamentals of Psychology). It was an instant success and continued to be long after his death. In 1904, he moved to Halle where he spent the last few years of his life. His last published work, Abriss der Psychologie (Outline of Psychology) was published six years later, in 1908. This, too, continued to be a success, being re-released in eight different editions. Shortly after this publication, on 26 February 1909, Ebbinghaus died from pneumonia at the age of 59.

Sigbert Ganser

Sigbert Josef Maria Ganser (24 January 1853 to 04 January 1931) was a German psychiatrist born in Rhaunen.

He earned his medical doctorate in 1876 from the University of Munich. Afterwards he worked briefly at a psychiatric clinic in Würzburg, and later as an assistant to neuroanatomist Bernhard von Gudden (1824-1886) in Munich. In 1886, he became head of the psychiatric department at Dresden General Hospital. Among his students was neurologist Hans Queckenstedt (1876-1918).

Sigbert Ganser is remembered for a hysterical disorder that he first described in 1898. He identified the disorder in three prisoners while working at a prison in Halle. The features included approximate or nonsensical answers to simple questions, perceptual abnormalities, and clouding of consciousness. Ganser believed that these symptoms were an associative reaction caused by an unconscious attempt by the patient to escape from an intolerable mental situation. The disorder was to become known as Ganser syndrome.

On This Day … 22 January

People (Births)

  • 1913 – Henry Bauchau, Belgian psychoanalyst and author (d. 2012).
  • 1932 – Berthold Grünfeld, Norwegian psychiatrist and academic (d. 2007).

Henry Bauchau

Henry Bauchau (22 January 1913 to 21 September 2012) was a Belgian psychoanalyst, lawyer, and author of French prose and poetry.

He became a trial lawyer in Brussels in 1936 and was a member of the Belgian Resistance in the Ardennes during World War II.

Berthold Grunfeld

Berthold Grünfeld (22 January 1932 to 20 August 2007) was a Norwegian psychiatrist, sexologist, and professor of social medicine at the University of Oslo. He was also a recognised expert in forensic psychiatry, often employed by Norwegian courts to examine insanity defence pleas.

Grünfeld was born in Bratislava in what was then Czechoslovakia. In 1939, when he was seven, he and 34 other Jewish children were separated from their families in an attempt by Nansenhjelpen to rescue them from the early manifestations of the Holocaust. The group of children was sent by train to Norway via Berlin, after having been told they would never again see their parents.

Once in Norway, Grünfeld was first placed at the Jewish children’s home in Oslo, then lived as a foster child with a Jewish family in Trondheim before returning to the orphanage. During the occupation of Norway, Grünfeld avoided capture and deportation by fleeing with members of the Norwegian Resistance in 1942 to neutral Sweden, where he stayed until the war ended. He returned to the children’s home in 1946. The Jewish community funded his education.

Berthold Grünfeld earned his medical degree in 1960, when he also met his future wife Gunhild. He was awarded his doctorate in medicine in 1973 based on a dissertation on abortion. In 1993, he was made professor of social medicine at the University of Oslo.

Grünfeld was noted for his academic contributions within sexology, on the issues of abortion and euthanasia, and within forensic psychology. In addition to his advocacy and teaching, he acted as an expert witness in criminal cases, and as a consultant on human relations and sexology for Oslo Helseråd. His dissertation influenced the reform of abortion laws in Norway.

Grünfeld and his wife had three children and six grandchildren. In 2005, his daughter Nina Grünfeld made a film, Origin Unknown, about her efforts to research her father’s background and heritage. Among other things, she found that his mother had worked as a prostitute and was murdered in the death camp at Sobibor.

On This Day … 20 Janaury

People (Births)

People (Deaths)

  • 1944 – James McKeen Cattell, American psychologist and academic (b. 1860).
  • 2012 – Alejandro Rodriguez, Venezuelan-American paediatrician and psychiatrist (b. 1918).

Nikos Sideris

Nikos Sideris (Greek: Νίκος Σιδέρης; born 20 January 1952), is a Greek psychiatrist, translator, poet and writer.

Sideris studied medicine at the University of Athens. He then settled in Paris for his postgraduate studies (specializing in Psychiatry, History and Neuropsychology-Neurolinguistics). He is a PhD of Panteion University Psychology Department and teaching psychoanalyst, member of the Strasbourg School of Psychoanalysis (E.P.S.) and the European Federation of Psychoanalysis and Psychoanalytic School of Strasburg (FEDEPSY). He works as a psychiatrist, psychoanalyst and family therapist in Athens.

His book “Children do not need psychologists. They need parents!” (Τα παιδιά δεν θέλουν ψυχολόγο. Γονείς θέλουν) became a non-fiction best-seller in Greece.

James McKeen Cattell

James McKeen Cattell (25 May 1860 to 20 January 1944), American psychologist, was the first professor of psychology in the United States, teaching at the University of Pennsylvania, and long-time editor and publisher of scientific journals and publications, most notably the journal Science. He also served on the board of trustees for Science Service, now known as Society for Science & the Public (or SSP), from 1921-1944.

At the beginning of Cattell’s career, many scientists regarded psychology as, at best, a minor field of study, or at worst a pseudoscience such as phrenology. Perhaps more than any of his contemporaries, Cattell helped establish psychology as a legitimate science, worthy of study at the highest levels of the academy. At the time of his death, The New York Times hailed him as “the dean of American science.” Yet Cattell may be best remembered for his uncompromising opposition to American involvement in World War I. His public opposition to the draft led to his dismissal from his position at Columbia University, a move that later led many American universities to establish tenure as a means of protecting unpopular beliefs.

Alejandro Rodriguez

Alejandro Rodriguez (February 1918 to 20 January 2012) was a Venezuelan-American paediatrician and psychiatrist, known for his pioneering work in child psychiatry. He was the director of the division of child psychiatry at the Johns Hopkins University School of Medicine, and conducted pivotal studies on autism and other developmental disorders in children.

On This Day … 15 January

People (Births)

  • 1842 – Josef Breuer, Austrian physician and psychiatrist (d. 1925).
  • 1877 – Lewis Terman, American psychologist, eugenicist, and academic (d. 1956).
  • 1958 – Boris Tadić, Serbian psychologist and politician, 16th President of Serbia

Josef Breuer

Josef Breuer (15 January 1842 to 20 June 1925) was a distinguished physician who made key discoveries in neurophysiology, and whose work in the 1880s with his patient Bertha Pappenheim, known as Anna O., developed the talking cure (cathartic method) and laid the foundation to psychoanalysis as developed by his protégé Sigmund Freud.

He graduated from the Akademisches Gymnasium of Vienna in 1858 and then studied at the university for one year before enrolling in the medical school of the University of Vienna. He passed his medical exams in 1867 and went to work as assistant to the internist Johann Oppolzer at the university.

Breuer, working under Ewald Hering at the military medical school in Vienna, was the first to demonstrate the role of the vagus nerve in the reflex nature of respiration. This was a departure from previous physiological understanding, and changed the way scientists viewed the relationship of the lungs to the nervous system. The mechanism is now known as the Hering–Breuer reflex.

Independent of each other in 1873, Breuer and the physicist and mathematician Ernst Mach discovered how the sense of balance (i.e. the perception of the head’s imbalance) functions: that it is managed by information the brain receives from the movement of a fluid in the semicircular canals of the inner ear. That the sense of balance depends on the three semicircular canals was discovered in 1870 by the physiologist Friedrich Goltz, but Goltz did not discover how the balance-sensing apparatus functions.

Lewis Terman

Lewis Madison Terman (15 January 1877 to 21 December 1956) was an American psychologist and author. He was noted as a pioneer in educational psychology in the early 20th century at the Stanford Graduate School of Education. He is best known for his revision of the Stanford-Binet Intelligence Scales and for initiating the longitudinal study of children with high IQs called the Genetic Studies of Genius. He was a prominent eugenicist and was a member of the Human Betterment Foundation. He also served as president of the American Psychological Association. A Review of General Psychology survey, published in 2002, ranked Terman as the 72nd most cited psychologist of the 20th century, in a tie with G. Stanley Hall.

Boris Tadic

Boris Tadić (15 January 1958 to Present) is a Serbian politician who served as President of Serbia from 2004 to 2012. He was elected to his first term on 27 June 2004, when Serbia was part of Serbia and Montenegro, and re-elected for a second term on 03 February 2008, this time as president of independent Serbia. He resigned on 05 April 2012 in order to trigger an early election. Prior to his presidency, Tadić served as the last Minister of Telecommunications of the Federal Republic of Yugoslavia and as the first Minister of Defence of Serbia and Montenegro. He is a psychologist by profession.

Tadić finished Pera Popović Aga (today Mika Petrović Alas) elementary school and matriculated at the First Belgrade Gymnasium in Dorćol. During his teenage years he played water polo for VK Partizan, but had to quit due to injuries. He graduated from the University of Belgrade Faculty of Philosophy with a degree in psychology, specifically social psychology in the department of clinical psychology.

He was arrested during his studies in July 1982 for protesting the arrest of a group of students, arrested for protesting against martial law in Poland and in support of the Solidarity movement. Tadić spent one month in penal labour prison in Padinska Skela.

He worked as a journalist, military clinical psychologist and as a teacher of psychology at the First Belgrade Gymnasium. Until 2003, Tadić also worked at the Faculty of Dramatic Arts at the University of Arts in Belgrade as a lecturer of political advertising. He is a Senior Network Member at the European Leadership Network (ELN).

What is Anti-Psychiatry?

Introduction

Anti-psychiatry is a movement based on the view that psychiatric treatment is more often damaging than helpful to patients. It considers psychiatry a coercive instrument of oppression due to an unequal power relationship between doctor and patient, and a highly subjective diagnostic process. Wrongful involuntary commitment is an important issue in the movement. It has been active in various forms for two centuries. Anti-psychiatry originates in an objection to what some view as dangerous treatments.

In the 1960s, there were many challenges to psychoanalysis and mainstream psychiatry, where the very basis of psychiatric practice was characterised as repressive and controlling. Psychiatrists involved in this challenge included Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Silvano Arieti, and David Cooper. Others involved were L. Ron Hubbard (science fiction author & founder of scientology), Michel Foucault, Gilles Deleuze, Félix Guattari, and Erving Goffman. Cooper coined the term “anti-psychiatry” in 1967, and wrote the book Psychiatry and Anti-psychiatry in 1971. Thomas Szasz introduced the definition of mental illness as a myth in the book The Myth of Mental Illness (1961), Giorgio Antonucci introduced the definition of psychiatry as a prejudice in the book I pregiudizi e la conoscenza critica alla psichiatria (1986).

Contemporary issues of anti-psychiatry include freedom versus coercion, racial and social justice, effects of antipsychotic medications, mental illness unintentionally induced by medical therapy, personal liberty, social stigma, and the right to be different.

Examples of historically dangerous treatments include electroconvulsive therapy, insulin shock therapy, and brain lobotomy. A more recent concern is the significant increase in prescribing psychiatric drugs for children in the beginning of the 21st century. There were also concerns about mental health institutions. All modern societies permit involuntary treatment or involuntary commitment of mental patients.

Brief History

Precursors

The first widespread challenge to the prevailing medical approach in Western countries occurred in the late 18th century. Part of the progressive Age of Enlightenment, a “moral treatment” movement challenged the harsh, pessimistic, somatic (body-based) and restraint-based approaches that prevailed in the system of hospitals and “madhouses” for people considered mentally disturbed, who were generally seen as wild animals without reason. Alternatives were developed, led in different regions by ex-patient staff, physicians themselves in some cases, and religious and lay philanthropists. The moral treatment was seen as pioneering more humane psychological and social approaches, whether or not in medical settings; however, it also involved some use of physical restraints, threats of punishment, and personal and social methods of control. And as it became the establishment approach in the 19th century, opposition to its negative aspects also grew.

According to Michel Foucault, there was a shift in the perception of madness, whereby it came to be seen as less about delusion, i.e. disturbed judgment about the truth, than about a disorder of regular, normal behaviour or will. Foucault argued that, prior to this, doctors could often prescribe travel, rest, walking, retirement and generally engaging with nature, seen as the visible form of truth, as a means to break with artificialities of the world (and therefore delusions). Another form of treatment involved nature’s opposite, the theatre, where the patient’s madness was acted out for him or her in such a way that the delusion would reveal itself to the patient.

According to Foucault, the most prominent therapeutic technique instead became to confront patients with a healthy sound will and orthodox passions, ideally embodied by the physician. The cure then involved a process of opposition, of struggle and domination, of the patient’s troubled will by the healthy will of the physician. It was thought the confrontation would lead not only to bring the illness into broad daylight by its resistance, but also to the victory of the sound will and the renunciation of the disturbed will. We must apply a perturbing method, to break the spasm by means of the spasm…. We must subjugate the whole character of some patients, subdue their transports, break their pride, while we must stimulate and encourage the others (Esquirol, J.E.D., 1816). Foucault also argued that the increasing internment of the “mentally ill” (the development of more and bigger asylums) had become necessary not just for diagnosis and classification but because an enclosed place became a requirement for a treatment that was now understood as primarily the contest of wills, a question of submission and victory.

The techniques and procedures of the asylums at this time included “isolation, private or public interrogations, punishment techniques such as cold showers, moral talks (encouragements or reprimands), strict discipline, compulsory work, rewards, preferential relations between the physician and his patients, relations of vassalage, of possession, of domesticity, even of servitude between patient and physician at times”. Foucault summarised these as “designed to make the medical personage the ‘master of madness'” through the power the physician’s will exerts on the patient. The effect of this shift then served to inflate the power of the physician relative to the patient, correlated with the rapid rise of internment (asylums and forced detention).

Other analyses suggest that the rise of asylums was primarily driven by industrialization and capitalism, including the breakdown of the traditional family structures. And that by the end of the 19th century, psychiatrists often had little power in the overrun asylum system, acting mainly as administrators who rarely attended to patients, in a system where therapeutic ideals had turned into mindless institutional routines. In general, critics point to negative aspects of the shift toward so-called “moral treatments”, and the concurrent widespread expansion of asylums, medical power and involuntary hospitalisation laws, in a way that was to play an important conceptual part in the later anti-psychiatry movement.

Various 19th-century critiques of the newly emerging field of psychiatry overlap thematically with 20th-century anti-psychiatry, for example in their questioning of the medicalisation of “madness”. Those critiques occurred at a time when physicians had not yet achieved hegemony through psychiatry, however, so there was no single, unified force to oppose. Nevertheless, there was increasing concern at the ease with which people could be confined, with frequent reports of abuse and illegal confinement. For example, Daniel Defoe, the author of Robinson Crusoe, had previously argued for more government oversight of “madhouses” and for due process prior to involuntary internment. He later argued that husbands used asylum hospitals to incarcerate their disobedient wives, and in a subsequent pamphlet that wives even did the same to their husbands. It was also proposed that the role of asylum keeper be separated from doctor, to discourage exploitation of patients. There was general concern that physicians were undermining personhood by medicalising problems, by claiming they alone had the expertise to judge it, and by arguing that mental disorder was physical and hereditary. The Alleged Lunatics’ Friend Society arose in England in the mid-19th century to challenge the system and campaign for rights and reforms. In the United States, Elizabeth Packard published a series of books and pamphlets describing her experiences in the Illinois insane asylum, to which she had been committed at the request of her husband.

Throughout, the class nature of mental hospitals, and their role as agencies of control, were well recognised. And the new psychiatry was partially challenged by two powerful social institutions – the church and the legal system. These trends have been thematically linked to the later 20th century anti-psychiatry movement.

As psychiatry became more professionally established during the nineteenth century (the term itself was coined in 1808 in Germany, as “Psychiatriein”) and developed allegedly more invasive treatments, opposition increased. In the Southern US, black slaves and abolitionists encountered Drapetomania, a pseudo-scientific diagnosis for why slaves ran away from their masters.

There was some organised challenge to psychiatry in the late 1870s from the new speciality of neurology. Practitioners criticised mental hospitals for failure to conduct scientific research and adopt the modern therapeutic methods such as nonrestraint. Together with lay reformers and social workers, neurologists formed the National Association for the Protection of the Insane and the Prevention of Insanity. However, when the lay members questioned the competence of asylum physicians to even provide proper care at all, the neurologists withdrew their support and the association floundered.

Early 1900s

It has been noted that “the most persistent critics of psychiatry have always been former mental hospital patients”, but that very few were able to tell their stories publicly or to confront the psychiatric establishment openly, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In the early 20th century, ex-patient Clifford W. Beers campaigned to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions, publicizing the issues in his book, A Mind that Found Itself (1908). While Beers initially condemned psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility since he needed their support for reforms. In Germany there were similar movements which used the term “Antipsychiatrie”.

His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organisation he helped found, the National Committee for Mental Hygiene which eventually became the National Mental Health Association. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients who sought justice for abuses committed in psychiatric custody, and were aggrieved that their complaints were patronisingly discounted by the authorities, who were seen to value the availability of medicalised internment as a ‘whitewashed’ extrajudicial custodial and punitive process. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing “The Experiences of an Asylum Patient”. In the US, We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York, and continued to meet as an ex-patient group.

In the 1920s, extreme hostility to psychiatrists and psychiatry was expressed by the French playwright and theatre director Antonin Artaud, in particular, in his book on van Gogh. To Artaud, imagination was reality. Much influenced by the Dada and surrealist enthusiasms of the day, he considered dreams, thoughts and visions no less real than the “outside” world. To Artaud, reality appeared little more than a convenient consensus, the same kind of consensus an audience accepts when they enter a theatre and, for a time, are happy to pretend what they are seeing is real.

In this era before penicillin was discovered, eugenics was popular. People believed diseases of the mind could be passed on so compulsory sterilisation of the mentally ill was enacted in many countries.

Early 1930s

In the 1930s several controversial medical practices were introduced, including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (lobotomy). In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. But lobotomy was ultimately seen as too invasive and brutal.

Holocaust historians argued that the medicalisation of social programmes and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nazi programmes were called Action T4 and Action 14f13. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. For instance this idea of a Swiss psychiatrist: “A not so easy question to be answered is whether it should be allowed to destroy lives objectively ‘unworthy of living’ without the expressed request of its bearers. (…) Even in incurable mentally ill ones suffering seriously from hallucinations and melancholic depressions and not being able to act, to a medical colleague I would ascript the right and in serious cases the duty to shorten – often for many years – the suffering” (Bleuler, Eugen, 1936: “Die naturwissenschaftliche Grundlage der Ethik”. Schweizer Archiv Neurologie und Psychiatrie, Band 38, Nr.2, S. 206).

1940s and 1950s

The post-World War II decades saw an enormous growth in psychiatry; many Americans were persuaded that psychiatry and psychology, particularly psychoanalysis, were a key to happiness. Meanwhile, most hospitalised mental patients received at best decent custodial care, and at worst, abuse and neglect.

The psychoanalyst Jacques Lacan has been identified as an influence on later anti-psychiatry theory in the UK, and as being the first, in the 1940s and 50s, to professionally challenge psychoanalysis to re-examine its concepts and to appreciate psychosis as understandable. Other influences on Lacan included poetry and the surrealist movement, including the poetic power of patients’ experiences. Critics disputed this and questioned how his descriptions linked to his practical work. The names that came to be associated with the anti-psychiatry movement knew of Lacan and acknowledged his contribution even if they did not entirely agree. The psychoanalyst Erich Fromm is also said to have articulated, in the 1950s, the secular humanistic concern of the coming anti-psychiatry movement. In The Sane Society (1955), Fromm wrote “”An unhealthy society is one which creates mutual hostility [and] distrust, which transforms man into an instrument of use and exploitation for others, which deprives him of a sense of self, except inasmuch as he submits to others or becomes an automaton”…”Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of ‘unadjusted’ individuals, and not of a possible unadjustment of the culture itself”.

In the 1950s, new psychiatric drugs, notably the antipsychotic chlorpromazine, slowly came into use. Although often accepted as an advance in some ways, there was opposition, partly due to serious adverse effects such as tardive dyskinesia, and partly due their “chemical straitjacket” effect and their alleged use to control and intimidate patients. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to develop services in the community.

In the 1950s in the United States, a right-wing anti-mental health movement opposed psychiatry, seeing it as liberal, left-wing, subversive and anti-American or pro-Communist. There were widespread fears that it threatened individual rights and undermined moral responsibility. An early skirmish was over the Alaska Mental Health Bill, where the right wing protestors were joined by the emerging Scientology movement.

The field of psychology sometimes came into opposition with psychiatry. Behaviourists argued that mental disorder was a matter of learning not medicine; for example, Hans Eysenck argued that psychiatry “really has no role to play”. The developing field of clinical psychology in particular came into close contact with psychiatry, often in opposition to its methods, theories and territories.

1960s

Coming to the fore in the 1960s, “anti-psychiatry” (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. While most of its elements had precedents in earlier decades and centuries, in the 1960s it took on a national and international character, with access to the mass media and incorporating a wide mixture of grassroots activist organisations and prestigious professional bodies.

Cooper was a South African psychiatrist working in Britain. A trained Marxist revolutionary, he argued that the political context of psychiatry and its patients had to be highlighted and radically challenged, and warned that the fog of individualised therapeutic language could take away people’s ability to see and challenge the bigger social picture. He spoke of having a goal of “non-psychiatry” as well as anti-psychiatry.

“In the 1960s fresh voices mounted a new challenge to the pretensions of psychiatry as a science and the mental health system as a successful humanitarian enterprise. These voices included: Ernest Becker, Erving Goffman, R.D. Laing; Laing and Aaron Esterson, Thomas Scheff, and Thomas Szasz. Their writings, along with others such as articles in the journal The Radical Therapist, were given the umbrella label “antipsychiatry” despite wide divergences in philosophy. This critical literature, in concert with an activist movement, emphasized the hegemony of medical model psychiatry, its spurious sources of authority, its mystification of human problems, and the more oppressive practices of the mental health system, such as involuntary hospitalisation, drugging, and electroshock”.
The psychiatrists R D Laing (from Scotland), Theodore Lidz (from America), Silvano Arieti (from Italy) and others, argued that “schizophrenia” and psychosis were understandable, and resulted from injuries to the inner self-inflicted by psychologically invasive “schizophrenogenic” parents or others. It was sometimes seen as a transformative state involving an attempt to cope with a sick society. Laing, however, partially dissociated himself from his colleague Cooper’s term “anti-psychiatry”. Laing had already become a media icon through bestselling books (such as The Divided Self and The Politics of Experience) discussing mental distress in an interpersonal existential context; Laing was somewhat less focused than his colleague Cooper on wider social structures and radical left wing politics, and went on to develop more romanticised or mystical views (as well as equivocating over the use of diagnosis, drugs and commitment). Although the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Lidz and Arieti never became involved in the latter. Franco Basaglia promoted anti-psychiatry in Italy and secured reforms to mental health law there.

Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities including Kingsley Hall, where staff and residents theoretically assumed equal status and any medication used was voluntary. Non-psychiatric Soteria houses, starting in the United States, were also developed as were various ex-patient-led services.

Psychiatrist Thomas Szasz argued that “mental illness” is an inherently incoherent combination of a medical and a psychological concept. He opposed the use of psychiatry to forcibly detain, treat, or excuse what he saw as mere deviance from societal norms or moral conduct. As a libertarian, Szasz was concerned that such usage undermined personal rights and moral responsibility. Adherents of his views referred to “the myth of mental illness”, after Szasz’s controversial 1961 book of that name (based on a paper of the same name that Szasz had written in 1957 that, following repeated rejections from psychiatric journals, had been published in the American Psychologist in 1960). Although widely described as part of the main anti-psychiatry movement, Szasz actively rejected the term and its adherents; instead, in 1969, he collaborated with Scientology to form the Citizens Commission on Human Rights. It was later noted that the view that insanity was not in most or even in any instances a “medical” entity, but a moral issue, was also held by Christian Scientists and certain Protestant fundamentalists, as well as Szasz. Szasz was not a Scientologist himself and was non-religious; he commented frequently on the parallels between religion and psychiatry.

Erving Goffman, Gilles Deleuze, Félix Guattari and others criticised the power and role of psychiatry in society, including the use of “total institutions” and the use of models and terms that were seen as stigmatizing. The French sociologist and philosopher Foucault, in his 1961 publication Madness and Civilization: A History of Insanity in the Age of Reason, analysed how attitudes towards those deemed “insane” had changed as a result of changes in social values. He argued that psychiatry was primarily a tool of social control, based historically on a “great confinement” of the insane and physical punishment and chains, later exchanged in the moral treatment era for psychological oppression and internalized restraint. American sociologist Thomas Scheff applied labelling theory to psychiatry in 1966 in “Being Mentally Ill”. Scheff argued that society views certain actions as deviant and, in order to come to terms with and understand these actions, often places the label of mental illness on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behaviour to fulfil them.

Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts.

Since 1970

New professional approaches were developed as an alternative or reformist complement to psychiatry. The Radical Therapist, a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan “Therapy means change, not adjustment.” It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, counselling and self-help and clinical psychology developed and sometimes opposed psychiatry.

Psychoanalysis was increasingly criticised as unscientific or harmful. Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The psychoanalytically trained psychiatrist Szasz, although professing fundamental opposition to what he perceives as medicalisation and oppressive or excuse-giving “diagnosis” and forced “treatment”, was not opposed to other aspects of psychiatry (for example attempts to “cure-heal souls”, although he also characterises this as non-medical). Although generally considered anti-psychiatry by others, he sought to dissociate himself politically from a movement and term associated with the radical left-wing. In a 1976 publication “Anti-psychiatry: The paradigm of a plundered mind”, which has been described as an overtly political condemnation of a wide sweep of people, Szasz claimed Laing, Cooper and all of anti-psychiatry consisted of “self-declared socialists, communists, anarchists or at least anti-capitalists and collectivists”. While saying he shared some of their critique of the psychiatric system, Szasz compared their views on the social causes of distress/deviance to those of anti-capitalist anti-colonialists who claimed that Chilean poverty was due to plundering by American companies, a comment Szasz made not long after a CIA-backed coup had deposed the democratically elected Chilean president and replaced him with Pinochet. Szasz argued instead that distress/deviance is due to the flaws or failures of individuals in their struggles in life.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses.

The gay rights movement continued to challenge the classification of homosexuality as a mental illness and in 1974, in a climate of controversy and activism, the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of “sexual orientation disturbance” and then “ego-dystonic homosexuality,” which was deleted in 1986, although a wide variety of “paraphilias” remain. The diagnostic label gender identity disorder (GID) was used by the DSM until its reclassification as gender dysphoria in 2013, with the release of the DSM-5. The diagnosis was reclassified to better align it with medical understanding of the condition and to remove the stigma associated with the term disorder. The American Psychiatric Association, publisher of the DSM-5, stated that gender nonconformity is not the same thing as gender dysphoria, and that “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” Some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender. It has been noted that gay activists in the 1970s and 1980s adopted many of Szasz’s arguments against the psychiatric system, but also that Szasz had written in 1965 that: “I believe it is very likely that homosexuality is, indeed, a disease in the second sense [expression of psychosexual immaturity] and perhaps sometimes even in the stricter sense [a condition somewhat similar to ordinary organic maladies perhaps caused by genetic error or endocrine imbalance]. Nevertheless, if we believe that by categorising homosexuality as a disease we have succeeded in removing it from the realm of moral judgement, we are in error.”

Increased legal and professional protections, and a merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Anti-psychiatry came to challenge a “biomedical” focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalised alienation regarding those categorised as mentally ill. An emerging consumer/survivor movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalised within psychiatry, and to a lesser extent within the wider mental health community.

Three authors came to personify the movement against psychiatry, and two of these were practising psychiatrists. The initial and most influential of these was Thomas Szasz who rose to fame with his book The Myth of Mental Illness, although Szasz himself did not identify as an anti-psychiatrist. The well-respected R.D. Laing wrote a series of best-selling books, including The Divided Self. Intellectual philosopher Michel Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term “anti-psychiatry” was coined by David Cooper in 1967. In parallel with the theoretical production of the mentioned authors, the Italian physician Giorgio Antonucci questioned the basis themselves of psychiatry through the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli and the liberation – and restitution to life – of the people there secluded.

Challenges to Psychiatry

Civilisation as a Cause of Distress

In recent years, psychotherapists David Smail and Bruce E. Levine, considered part of the anti-psychiatry movement, have written widely on how society, culture, politics and psychology intersect. They have written extensively of the “embodied nature” of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and financial interest in modern Western society. They argue that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to their situation in society. Even psychotherapy, they suggest, can only change feelings in as much as it helps a person to change the “proximal” and “distal” influences on their life, which range from family and friends, to the workplace, socio-economics, politics and culture.

R.D. Laing emphasized family nexus as a mechanism by which individuals become victimized by those around them, and spoke about a dysfunctional society.

Inadequacy of Clinical Interviews Used to Diagnose ‘Diseases’

An aetiology common to bipolar spectrum disorders has not been identified. Patients cannot be identified just by clinical interviews. A neurobiological basis of bipolar disorder has not been discovered. In making a bipolar spectrum disorder diagnosis based solely on a clinical interview, a false positive cannot be avoided.

Psychiatrists have been trying to differentiate mental disorders based on clinical interviews since the era of Kraepelin, but now realise that their diagnostic criteria are imperfect. Tadafumi Kato writes, “We psychiatrists should be aware that we cannot identify ‘diseases’ only by interviews. What we are doing now is just like trying to diagnose diabetes mellitus without measuring blood sugar.”

Normality and Illness Judgements

In 2013, psychiatrist Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”.

Reasons have been put forward to doubt the ontic status of mental disorders. Mental disorders engender ontological scepticism on three levels:

  • Mental disorders are abstract entities that cannot be directly appreciated with the human senses or indirectly, as one might with macro- or microscopic objects.
  • Mental disorders are not clearly natural processes whose detection is untarnished by the imposition of values, or human interpretation.
  • It is unclear whether they should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them.

In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). Common hybrid views argue that the concept of mental disorder is objective but a “fuzzy prototype” that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.

One remarkable example of psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. In the US prior to the American Civil War, physicians such as Samuel A. Cartwright diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape. By classifying such a dissident mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and unhealth. This example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs.

It has been argued by philosophers like Foucault that characterizations of “mental illness” are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely defined qualities that distinguish a “healthy” mind from a “sick” one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

Psychiatric Labelling

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, the American Psychiatric Association created its own classification system, DSM-I. The definitions of most psychiatric diagnoses consist of combinations of phenomenological criteria, such as symptoms and signs and their course over time. Expert committees combined them in variable ways into categories of mental disorders, defined and redefined them again and again over the last half century.

The majority of these diagnostic categories are called “disorders” and are not validated by biological criteria, as most medical diseases are; although they purport to represent medical diseases and take the form of medical diagnoses. These diagnostic categories are actually embedded in top-down classifications, similar to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether the shape of leaves or fruiting bodies were the main criterion for classifying plants. Since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews.

Experiments Admitting “Healthy” Individuals into Psychiatric Care

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders.

Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. It is now realised that the psychiatric diagnostic criteria are not perfect. To further refine psychiatric diagnosis, according to Tadafumi Kato, the only way is to create a new classification of diseases based on the neurobiological features of each mental disorder. On the other hand, according to Heinz Katsching, neurologists are advising psychiatrists just to replace the term “mental illness” by “brain illness.”

There are recognised problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal and controlled circumstances and even more so in routine clinical practice (McGorry et al.. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent. Some psychiatrists who criticise their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely defined or changeable boundaries between what psychiatrists claim are distinct illness states.

There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernised, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians, and men more than women. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the biomedical model.

Tool of Social Control

According to Franco Basaglia, Giorgio Antonucci, Bruce E. Levine and Edmund Schönenberger whose approach pointed out the role of psychiatric institutions in the control and medicalisation of deviant behaviours and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. According to Mike Fitzpatrick, resistance to medicalisation was a common theme of the gay liberation, anti-psychiatry, and feminist movements of the 1970s, but now there is actually no resistance to the advance of government intrusion in lifestyle if it is thought to be justified in terms of public health.

In the opinion of Mike Fitzpatrick, the pressure for medicalisation also comes from society itself. As one example, Fitzpatrick claims that feminists who once opposed state intervention as oppressive and patriarchal, now demand more coercive and intrusive measures to deal with child abuse and domestic violence. According to Richard Gosden, the use of psychiatry as a tool of social control is becoming obvious in preventive medicine programmes for various mental diseases. These programmes are intended to identify children and young people with divergent behavioural patterns and thinking and send them to treatment before their supposed mental diseases develop. Clinical guidelines for best practice in Australia include the risk factors and signs which can be used to detect young people who are in need of prophylactic drug treatment to prevent the development of schizophrenia and other psychotic conditions.

Psychiatry and the Pharmaceutical Industry

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment in contemporary society is primarily or overwhelmingly shaped by profit prerogatives, echoing a common criticism of general medical practice in the United States, where many of the largest psychopharmaceutical producers are based.

Psychiatric research has demonstrated varying degrees of efficacy for improving or managing a number of mental health disorders through either medications, psychotherapy, or a combination of the two. Typical psychiatric medications include stimulants, antidepressants, anxiolytics, and antipsychotics (neuroleptics).

On the other hand, organisations such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists believe individuals are not given balanced information, and that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts; and psychiatric drugs not only fail to correct measurable chemical imbalances in the brain, but rather induce undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they can also develop abnormal movements such as tics, spasms and other involuntary movements. This has not been shown to be directly related to the therapeutic use of stimulants, but to neuroleptics. The diagnosis of attention deficit hyperactivity disorder on the basis of inattention to compulsory schooling also raises critics’ concerns regarding the use of psychoactive drugs as a means of unjust social control of children.

The influence of pharmaceutical companies is another major issue for the anti-psychiatry movement. As many critics from within and outside of psychiatry have argued, there are many financial and professional links between psychiatry, regulators, and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organisations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, Sharkey, and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organisations.

There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 concludes: “The influence of the pharmaceutical industry is such that it dominates clinical practice” and that there are serious regulatory failings resulting in “the unsafe use of drugs; and the increasing medicalisation of society”. The campaign organisation No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice. The ghostwriting of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding.

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilisers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales. As a solution to the apparent conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

John Read and Bruce E. Levine have advanced the idea of socioeconomic status as a significant factor in the development and prevention of mental disorders such as schizophrenia and have noted the reach of pharmaceutical companies through industry sponsored websites as promoting a more biological approach to mental disorders, rather than a comprehensive biological, psychological and social model.

Electroconvulsive Therapy

Psychiatrists may advocate psychiatric drugs, psychotherapy or more controversial interventions such as electroshock or psychosurgery to treat mental illness. Electroconvulsive therapy (ECT) is administered worldwide typically for severe mental disorders. Across the globe it has been estimated that approximately 1 million patients receive ECT per year. Exact numbers of how many persons per year have ECT in the United States are unknown due to the variability of settings and treatment. Researchers’ estimates generally range from 100,000 to 200,000 persons per year.

Some persons receiving ECT die during the procedure (ECT is performed under a general anaesthetic, which always carries a risk). Leonard Roy Frank writes that estimates of ECT-related death rates vary widely.

  • The lower estimates include:
    • 2-4 in 100,000 (from Kramer’s 1994 study of 28,437 patients);
    • 1 in 10,000 (Boodman’s first entry in 1996);
    • 1 in 1,000 (Impastato’s first entry in 1957); and
    • 1 in 200, among the elderly, over 60 (Impastato’s in 1957).
  • Higher estimates include:
    • 1 in 102 (Martin’s entry in 1949);
    • 1 in 95 (Boodman’s first entry in 1996);
    • 1 in 92 (Freeman and Kendell’s entry in 1976);
    • 1 in 89 (Sagebiel’s in 1961);
    • 1 in 69 (Gralnick’s in 1946);
    • 1 in 63, among a group undergoing intensive ECT (Perry’s in 1963–1979);
    • 1 in 38 (Ehrenberg’s in 1955);
    • 1 in 30 (Kurland’s in 1959);
    • 1 in 9, among a group undergoing intensive ECT (Weil’s in 1949); and
    • 1 in 4, among the very elderly, over 80 (Kroessler and Fogel’s in 1974-1986).

Political Abuse of Psychiatry

Psychiatrists around the world have been involved in the suppression of individual rights by states in which the definitions of mental disease have been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined and abused in mental institutions. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.

Under the Nazi regime in the 1940s, the “duty to care” was violated on an enormous scale. In Germany alone 300,000 individuals that had been deemed mentally ill, work-shy or feeble-minded were sterilized. An additional 200,000 were euthanised. These practices continued in territories occupied by the Nazis further afield (mainly in eastern Europe), affecting thousands more. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia, as well as in Western European countries, such as Italy. An example of the use of psychiatry in the political field is the “case Sabattini”, described by Giorgio Antonucci in his book Il pregiudizio psichiatrico. A “mental health genocide” reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was later attributed to the People’s Republic of China.

K. Fulford, A. Smirnov, and E. Snow state: “An important vulnerability factor, therefore, for the abuse of psychiatry, is the subjective nature of the observations on which psychiatric diagnosis currently depends.” In an article published in 1994 by the Journal of Medical Ethics, American psychiatrist Thomas Szasz stated that “the classification by slave owners and slave traders of certain individuals as Negroes was scientific, in the sense that whites were rarely classified as blacks. But that did not prevent the ‘abuse’ of such racial classification, because (what we call) its abuse was, in fact, its use.” Szasz argued that the spectacle of the Western psychiatrists loudly condemning Soviet colleagues for their abuse of professional standards was largely an exercise in hypocrisy. Szasz states that K. Fulford, A. Smirnov, and E. Snow, who correctly emphasize the value-laden nature of psychiatric diagnoses and the subjective character of psychiatric classifications, fail to accept the role of psychiatric power. He stated that psychiatric abuse, such as people usually associated with practices in the former USSR, was connected not with the misuse of psychiatric diagnoses, but with the political power built into the social role of the psychiatrist in democratic and totalitarian societies alike. Musicologists, drama critics, art historians, and many other scholars also create their own subjective classifications; however, lacking state-legitimated power over persons, their classifications do not lead to anyone’s being deprived of property, liberty, or life. For instance, a plastic surgeon’s classification of beauty is subjective, but the plastic surgeon cannot treat his or her patient without the patient’s consent, so there cannot be any political abuse of plastic surgery.

The bedrock of political medicine is coercion masquerading as medical treatment. In this process, physicians diagnose a disapproved condition as an “illness” and declare the intervention they impose on the victim a “treatment,” and legislators and judges legitimate these categorisations. In the same way, physician-eugenicists advocated killing certain disabled or ill persons as a form of treatment for both society and patient long before the Nazis came to power.

From the commencement of his political career, Hitler put his struggle against “enemies of the state” in medical rhetoric. In 1934, addressing the Reichstag, he declared, “I gave the order… to burn out down to the raw flesh the ulcers of our internal well-poisoning.” The entire German nation and its National Socialist politicians learned to think and speak in such terms. Werner Best, Reinhard Heydrich’s deputy, stated that the task of the police was “to root out all symptoms of disease and germs of destruction that threatened the political health of the nation… [In addition to Jews,] most [of the germs] were weak, unpopular and marginalized groups, such as gypsies, homosexuals, beggars, ‘antisocials’, ‘work-shy’, and ‘habitual criminals’.”

In spite of all the evidence, people ignore or underappreciate the political implications of the pseudotherapeutic character of Nazism and of the use of medical metaphors in modern democracies. Dismissed as an “abuse of psychiatry”, this practice is a controversial subject not because the story makes psychiatrists in Nazi Germany look bad, but because it highlights the dramatic similarities between pharmacratic controls in Germany under Nazism and those that have emerged in the US under the free market economy.

The Swiss lawyer Edmund Schönenberger claims that the strongholds of psychiatry are instruments of domination and have nothing to do with care, the law, or justice.

“Therapeutic State”

The “therapeutic state” is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the “therapeutic state”, a system in which disapproved actions, thoughts, and emotions are repressed (“cured”) through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that “we must guard against charges of nanny statism”. The “nanny state” has turned into the “therapeutic state” where nanny has given way to counsellor. Nanny just told people what to do; counsellors also tell them what to think and what to feel. The “nanny state” was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive – and even more authoritarian. According to Szasz, “the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion”.

Faced with the problem of “madness”, Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and non-members of the group from the temptation to worship false gods or goods. A secularisation of God and the medicalisation of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason – that is, madness.

Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilisation. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the State.

“Total Institution”

In his book Asylums, Erving Goffman coined the term ‘total institution’ for mental hospitals and similar places which took over and confined a person’s whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organisations, orphanages, and monasteries. In Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone ‘dull, harmless and inconspicuous’; it in turn reinforces notions of chronicity in severe mental illness.

Law

While the insanity defence is the subject of controversy as a viable excuse for wrongdoing, Szasz and other critics contend that being committed in a psychiatric hospital can be worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment. Moreover, while a criminal imprisonment has a predetermined and known time of duration, patients are typically committed to psychiatric hospitals for indefinite durations, an unjust and arguably outrageous imposition of fundamental uncertainty. It has been argued that such uncertainty risks aggravating mental instability, and that it substantially encourages a lapse into hopelessness and acceptance that precludes recovery.

Involuntary Hospitalisation

Critics see the use of legally sanctioned force in involuntary commitment as a violation of the fundamental principles of free or open societies. The political philosopher John Stuart Mill and others have argued that society has no right to use coercion to subdue an individual as long as he or she does not harm others. Mentally ill people are essentially no more prone to violence than sane individuals, despite Hollywood and other media portrayals to the contrary. The growing practice, in the United Kingdom and elsewhere, of Care in the Community was instituted partly in response to such concerns. Alternatives to involuntary hospitalisation include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide what was argued to be a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, similar establishments are presently flourishing in Europe, especially in Sweden and other North European countries.

The physician Giorgio Antonucci, during his activity as a director of the Ospedale Psichiatrico Osservanza of Imola, refused any form of coercion and any violation of the fundamental principles of freedom, questioning the basis of psychiatry itself.

Psychiatry as Pseudoscience and Failed Enterprise

Many of the above issues lead to the claim that psychiatry is a pseudoscience. According to some philosophers of science, for a theory to qualify as science it needs to exhibit the following characteristics:

  • Parsimony, as straightforward as the phenomena to be explained allow (see Occam’s razor);
  • Empirically testable and falsifiable (see Falsifiability);
  • Changeable, i.e. if necessary, changes may be made to the theory as new data are discovered;
  • Progressive, encompasses previous successful descriptions and explains and adds more; and
  • Provisional, i.e. tentative; the theory does not attempt to assert that it is a final description or explanation.

Psychiatrist Colin A. Ross and Alvin Pam maintain that biopsychiatry does not qualify as a science on many counts.

Psychiatric researchers have been criticised on the basis of the replication crisis and textbook errors. Questionable research practices are known to bias key sources of evidence.

Stuart A. Kirk has argued that psychiatry is a failed enterprise, as mental illness has grown, not shrunk, with about 20% of American adults diagnosable as mentally ill in 2013.

According to a 2014 meta-analysis, psychiatric treatment is no less effective for psychiatric illnesses in terms of treatment effects than treatments by practitioners of other medical specialties for physical health conditions. The analysis found that the effect sizes for psychiatric interventions are, on average, on par with other fields of medicine.

Diverse Paths

Szasz has since (2008) re-emphasized his disdain for the term anti-psychiatry, arguing that its legacy has simply been a “catchall term used to delegitimise and dismiss critics of psychiatric fraud and force by labelling them ‘antipsychiatrists'”. He points out that the term originated in a meeting of four psychiatrists (Cooper, Laing, Berke and Redler) who never defined it yet “counter-label[led] their discipline as anti-psychiatry”, and that he considers Laing most responsible for popularising it despite also personally distancing himself. Szasz describes the deceased (1989) Laing in vitriolic terms, accusing him of being irresponsible and equivocal on psychiatric diagnosis and use of force, and detailing his past “public behaviour” as “a fit subject for moral judgment” which he gives as “a bad person and a fraud as a professional”.

Daniel Burston, however, has argued that overall the published works of Szasz and Laing demonstrate far more points of convergence and intellectual kinship than Szasz admits, despite the divergence on a number of issues related to Szasz being a libertarian and Laing an existentialist; that Szasz employs a good deal of exaggeration and distortion in his criticism of Laing’s personal character, and unfairly uses Laing’s personal failings and family woes to discredit his work and ideas; and that Szasz’s “clear-cut, crystalline ethical principles are designed to spare us the agonising and often inconclusive reflections that many clinicians face frequently in the course of their work”. Szasz has indicated that his own views came from libertarian politics held since his teens, rather than through experience in psychiatry; that in his “rare” contacts with involuntary mental patients in the past he either sought to discharge them (if they were not charged with a crime) or “assisted the prosecution in securing [their] conviction” (if they were charged with a crime and appeared to be prima facie guilty); that he is not opposed to consensual psychiatry and “does not interfere with the practice of the conventional psychiatrist”, and that he provided “listening-and-talking (“psychotherapy”)” for voluntary fee-paying clients from 1948 until 1996, a practice he characterises as non-medical and not associated with his being a psychoanalytically trained psychiatrist.

The gay rights or gay liberation movement is often thought to have been part of anti-psychiatry in its efforts to challenge oppression and stigma and, specifically, to get homosexuality removed from the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders. However, a psychiatric member of APA’s Gay, Lesbian, and Bisexual Issues Committee has recently sought to distance the two, arguing that they were separate in the early 70s protests at APA conventions and that APA’s decision to remove homosexuality was scientific and happened to coincide with the political pressure. Reviewers have responded, however, that the founders and movements were closely aligned; that they shared core texts, proponents and slogans; and that others have stated that, for example, the gay liberation critique was “made possible by (and indeed often explicitly grounded in) traditions of antipsychiatry”.

In the clinical setting, the two strands of anti-psychiatry – criticism of psychiatric knowledge and reform of its practices – were never entirely distinct. In addition, in a sense, anti-psychiatry was not so much a demand for the end of psychiatry, as it was an often self-directed demand for psychiatrists and allied professionals to question their own judgements, assumptions and practices. In some cases, the suspicion of non-psychiatric medical professionals towards the validity of psychiatry was described as anti-psychiatry, as well the criticism of “hard-headed” psychiatrists towards “soft-headed” psychiatrists. Most leading figures of anti-psychiatry were themselves psychiatrists, and equivocated over whether they were really “against psychiatry”, or parts thereof. Outside the field of psychiatry, however – e.g. for activists and non-medical mental health professionals such as social workers and psychologists – ‘anti-psychiatry’ tended to mean something more radical. The ambiguous term “anti-psychiatry” came to be associated with these more radical trends, but there was debate over whether it was a new phenomenon, whom it best described, and whether it constituted a genuinely singular movement. In order to avoid any ambiguity intrinsic to the term anti-psychiatry, a current of thought that can be defined as critique of the basis of psychiatry, radical and unambiguous, aims for the complete elimination of psychiatry. The main representative of the critique of the basis of psychiatry is an Italian physician, Giorgio Antonucci, the founder of the non-psychiatric approach to psychological suffering, who posited that the “essence of psychiatry lies in an ideology of discrimination”.

In the 1990s, a tendency was noted among psychiatrists to characterize and to regard the anti-psychiatric movement as part of the past, and to view its ideological history as flirtation with the polemics of radical politics at the expense of scientific thought and enquiry. It was also argued, however, that the movement contributed towards generating demand for grassroots involvement in guidelines and advocacy groups, and to the shift from large mental institutions to community services. Additionally, community centres have tended in practice to distance themselves from the psychiatric/medical model and have continued to see themselves as representing a culture of resistance or opposition to psychiatry’s authority. Overall, while antipsychiatry as a movement may have become an anachronism by this period and was no longer led by eminent psychiatrists, it has been argued that it became incorporated into the mainstream practice of mental health disciplines. On the other hand, mainstream psychiatry became more biomedical, increasing the gap between professionals.

Henry Nasrallah claims that while he believes anti-psychiatry consists of many historical exaggerations based on events and primitive conditions from a century ago, “antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care”.

A criticism was made in the 1990s that three decades of anti-psychiatry had produced a large literature critical of psychiatry, but little discussion of the deteriorating situation of the mentally troubled in American society. Anti-psychiatry crusades have thus been charged with failing to put suffering individuals first, and therefore being similarly guilty of what they blame psychiatrists for. The rise of anti-psychiatry in Italy was described by one observer as simply “a transfer of psychiatric control from those with medical knowledge to those who possessed socio-political power”.

Critics of this view, however, from an anti-psychiatry perspective, are quick to point to the industrial aspects of psychiatric treatment itself as a primary causal factor in this situation that is described as “deteriorating”. The numbers of people labelled “mentally ill”, and in treatment, together with the severity of their conditions, have been going up primarily due to the direct efforts of the mental health movement, and mental health professionals, including psychiatrists, and not their detractors. Envisioning “mental health treatment” as violence prevention has been a big part of the problem, especially as you are dealing with a population that is not significantly more violent than any other group and, in fact, are less so than many.

On 07 October 2016, the Ontario Institute for Studies in Education (OISE) at the University of Toronto announced that they had established a scholarship for students doing theses in the area of antipsychiatry. Called “The Bonnie Burstow Scholarship in Antipsychiatry,” it is to be awarded annually to an OISE thesis student. An unprecedented step, the scholarship should further the cause of freedom of thought and the exchange of ideas in academia. The scholarship is named in honour of Bonnie Burstow, a faculty member at the University of Toronto, a radical feminist, and an antipsychiatry activist. She is also the author of Psychiatry and the Business of Madness (2015).

Some components of antipsychiatric theory have in recent decades been reformulated into a critique of “corporate psychiatry”, heavily influenced by the pharmaceutical industry. A recent editorial about this was published in the British Journal of Psychiatry by Moncrieff, arguing that modern psychiatry has become a handmaiden to conservative political commitments. David Healy is a psychiatrist and professor in psychological medicine at Cardiff University School of Medicine, Wales. He has a special interest in the influence of the pharmaceutical industry on medicine and academia.

In the meantime, members of the psychiatric consumer/survivor movement continued to campaign for reform, empowerment and alternatives, with an increasingly diverse representation of views. Groups often have been opposed and undermined, especially when they proclaim to be, or when they are labelled as being, “anti-psychiatry”. However, as of the 1990s, more than 60% of ex-patient groups reportedly support anti-psychiatry beliefs and consider themselves to be “psychiatric survivors”. Although anti-psychiatry is often attributed to a few famous figures in psychiatry or academia, it has been pointed out that consumer/survivor/ex-patient individuals and groups preceded it, drove it and carried on through it.

Criticism

A schism exists among those critical of conventional psychiatry between radical abolitionists and more moderate reformists. Laing, Cooper and others associated with the initial anti-psychiatry movement stopped short of actually advocating for the abolition of coercive psychiatry. Thomas Szasz, from near the beginning of his career, crusaded for the abolition of forced psychiatry. Today, believing that coercive psychiatry marginalises and oppresses people with its harmful, controlling, and abusive practices, many who identify as anti-psychiatry activists are proponents of the complete abolition of non-consensual and coercive psychiatry.

Criticism of antipsychiatry from within psychiatry itself object to the underlying principle that psychiatry is by definition harmful. Most psychiatrists accept that issues exist that need addressing, but that the abolition of psychiatry is harmful. Nimesh Desai concludes: “To be a believer and a practitioner of multidisciplinary mental health, it is not necessary to reject the medical model as one of the basics of psychiatry.” and admits “Some of the challenges and dangers to psychiatry are not so much from the avowed antipsychiatrists, but from the misplaced and misguided individuals and groups in related fields.”

On This Day … 14 January

People (Deaths)

Harry Stack Sullivan

Herbert “Harry” Stack Sullivan (21 February 1892 to 14 January 1949) was an American Neo-Freudian psychiatrist and psychoanalyst who held that “personality can never be isolated from the complex interpersonal relationships in which [a] person lives” and that “[t]he field of psychiatry is the field of interpersonal relations under any and all circumstances in which [such] relations exist”.

Having studied therapists Sigmund Freud, Adolf Meyer, and William Alanson White, he devoted years of clinical and research work to helping people with psychotic illness.

Early Life

Sullivan was a child of Irish immigrants and grew up in the then anti-Catholic town of Norwich, New York, resulting in a social isolation which may have inspired his later interest in psychiatry. He attended the Smyrna Union School, then spent two years at Cornell University from 1909, receiving his medical degree in Chicago College of Medicine and Surgery in 1917.

Work

Along with Clara Thompson, Karen Horney, Erich Fromm, Otto Allen Will, Jr., Erik H. Erikson, and Frieda Fromm-Reichmann, Sullivan laid the groundwork for understanding the individual based on the network of relationships in which they are enmeshed. He developed a theory of psychiatry based on interpersonal relationships where cultural forces are largely responsible for mental illnesses (see also social psychiatry). In his words, one must pay attention to the “interactional”, not the “intrapsychic”. This search for satisfaction via personal involvement with others led Sullivan to characterise loneliness as the most painful of human experiences. He also extended the Freudian psychoanalysis to the treatment of patients with severe mental disorders, particularly schizophrenia.

Besides making the first mention of the significant other in psychological literature, Sullivan developed the idea of the “Self System”, a configuration of the personality traits developed in childhood and reinforced by positive affirmation and the security operations developed in childhood to avoid anxiety and threats to self-esteem. Sullivan further defined the Self System as a steering mechanism toward a series of I-You interlocking behaviours; that is, what an individual does is meant to elicit a particular reaction.

Sullivan called these behaviours Parataxical Integrations and he noted that such action-reaction combinations can become rigid and dominate an adult’s thinking pattern, limiting their actions and reactions toward the world as the adult sees the world and not as it really is. The resulting inaccuracies in judgment Sullivan termed parataxic distortion, when other persons are perceived or evaluated based on the patterns of previous experience, similar to Freud’s notion of transference. Sullivan also introduced the concept of “prototaxic communication” as a more primitive, needy, infantile form of psychic interchange and of “syntactic communication” as a mature style of emotional interaction.

Sullivan’s work on interpersonal relationships became the foundation of interpersonal psychoanalysis, a school of psychoanalytic theory and treatment that stresses the detailed exploration of the nuances of patients’ patterns of interacting with others.

Sullivan was the first to coin the term “problems in living” to describe the difficulties with self and others experienced by those with mental illnesses. This phrase was later picked up and popularised by Thomas Szasz, whose work was a foundational resource for the antipsychiatry movement. “Problems in living” went on to become the movement’s preferred way to refer to the manifestations of mental disturbances.

In 1927, he reviewed the controversial, anonymously published The Invert and his Social Adjustment and in 1929 called it “a remarkable document by a homosexual man of refinement; intended primarily as a guide to the unfortunate sufferers of sexual inversion, and much less open to criticism than anything else of the kind so far published.”

He was one of the founders of the William Alanson White Institute, considered by many to be the world’s leading independent psychoanalytic institute, and of the journal Psychiatry in 1937. He headed the Washington, DC School of Psychiatry from 1936 to 1947.

In 1940, he and colleague Winfred Overholser, serving on the American Psychiatric Society’s committee on Military Mobilisation, formulated guidelines for the psychological screening of inductees to the United States military. He believed, writes one historian, “that sexuality played a minimal role in causing mental disorders and that adult homosexuals should be accepted and left alone.” Despite his best efforts, others included homosexuality as a disqualification for military service.

Beginning on 05 December 1940, Sullivan served as psychiatric adviser to Selective Service director Clarence A. Dykstra, but resigned in November 1941 after General Lewis B. Hershey, who was hostile to psychiatry, became the director. Sullivan then took part in establishing the Office of War Information in 1942. Beginning in 1927, Sullivan had a 22-year relationship with James Inscoe Sullivan, known as “Jimmie”, who was 20 years younger than Sullivan.

Although some contemporaries and historians have regarded Inscoe as an unofficially adopted son, and Sullivan as closeted, one should remember that to be open about it would have made his professional interest in the area and further research very difficult. His colleague Helen Swick Perry’s biography of Sullivan mentions the relationship and it is clear his close friends were well aware they were partners.

Writings

Although Sullivan published little in his lifetime, he influenced generations of mental health professionals, especially through his lectures at Chestnut Lodge in Rockville, Maryland, outside Washington, DC. Leston Havens called him the most important underground influence in American psychoanalysis. His ideas were collected and published posthumously, edited by Helen Swick Perry, who also published a detailed biography in 1982 (Perry, 1982, Psychiatrist of America).

Works

The following works are in Special Collections (MSA SC 5547) at the Maryland State Archives in Annapolis: Conceptions of Modern Psychiatry, Soundscriber Transcriptions (February 1945 to May 1945); Lectures 1-97 (begins 02 October 1942); Georgetown University Medical School Lectures (1939); Personal Psychopathology (1929-1933); The Psychiatry of Character and its Deviations-undated notes.

His writings include:

  • The Interpersonal Theory of Psychiatry (1953).
  • “The Psychiatric Interview” (1954).
  • Conceptions of Modern Psychiatry (1947/1966).
  • Schizophrenia as a Human Process (1962).

Associates

After Sullivan’s death, Saul B. Newton and his wife Dr. Jane Pearce (a psychiatrist who studied with Sullivan in the late 1940s) established the Sullivan Institute for Research in Psychoanalysis in New York City.

On This Day … 12 January

People (Births)

  • 1896 – David Wechsler, Romanian-American psychologist and author (d. 1981).
  • 1914 – Mieko Kamiya, Japanese psychiatrist and psychologist (d. 1979).
  • 1941 – Fiona Caldicott, English psychiatrist and psychotherapist.

David Wechsler

David Wechsler (12 January 1896 to 02 May 1981) was a Romanian-American psychologist. He developed well-known intelligence scales, such as the Wechsler Adult Intelligence Scale (WAIS) and the Wechsler Intelligence Scale for Children (WISC). A Review of General Psychology survey, published in 2002, ranked Wechsler as the 51st most cited psychologist of the 20th century.

Biography

Wechsler was born in a Jewish family in Lespezi, Romania, and emigrated with his parents to the United States as a child. He studied at the City College of New York and Columbia University, where he earned his master’s degree in 1917 and his Ph.D. in 1925 under the direction of Robert S. Woodworth. During World War I, he worked with the United States Army to develop psychological tests to screen new draftees while studying under Charles Spearman and Karl Pearson.

After short stints at various locations (including five years in private practice), Wechsler became chief psychologist at Bellevue Psychiatric Hospital in 1932, where he stayed until 1967. He died on 02 May 1981.

Intelligence Scales

Wechsler is best known for his intelligence tests. He was one of the most influential advocates of the role of non-intellective factors in testing. He emphasized that factors other than intellectual ability are involved in intelligent behaviour. Wechsler objected to the single score offered by the 1937 Binet scale. Although his test did not directly measure non-intellective factors, it took these factors into careful account in its underlying theory. The Wechsler Adult Intelligence Scale (WAIS) was developed first in 1939 and then called the Wechsler-Bellevue Intelligence Test. From these he derived the Wechsler Intelligence Scale for Children (WISC) in 1949 and the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) in 1967. Wechsler originally created these tests to find out more about his patients at the Bellevue clinic and he found the then-current Binet IQ test unsatisfactory. The tests are still based on his philosophy that intelligence is “the global capacity to act purposefully, to think rationally, and to deal effectively with [one’s] environment” (cited in Kaplan & Saccuzzo, p. 256).

The Wechsler scales introduced many novel concepts and breakthroughs to the intelligence testing movement. First, he did away with the quotient scores of older intelligence tests (the Q in “I.Q.”). Instead, he assigned an arbitrary value of 100 to the mean intelligence and added or subtracted another 15 points for each standard deviation above or below the mean the subject was. While not rejecting the concept of general intelligence (as conceptualised by his teacher Charles Spearman), he divided the concept of intelligence into two main areas: verbal and performance (non-verbal) scales, each evaluated with different subtests.

Mieko Kamiya

Mieko Kamiya (神谷 美恵子, Kamiya Mieko, 12 January 1914 to 22 October 1979) was a Japanese psychiatrist who treated leprosy patients at Nagashima Aiseien Sanatorium. She was known for translating books on philosophy. She worked as a medical doctor in the Department of Psychiatry at Tokyo University following World War II. She was said to have greatly helped the Ministry of Education and the General Headquarters, where the Supreme Commander of the Allied Powers stayed, in her role as an English-speaking secretary, and served as an adviser to Empress Michiko. She wrote many books as a highly educated, multi-lingual person; one of her books, titled On the Meaning of Life (Ikigai Ni Tsuite in Japanese), based on her experiences with leprosy patients, attracted many readers.

Fiona Caldicott

Dame Fiona Caldicott, DBE, FMedSci (12 January 1941 to Present) is a psychiatrist and psychotherapist and, previously, Principal of Somerville College, Oxford. She is the present National Data Guardian for Health and Social Care in England.

Caldicott was born on 12 January 1941 in Troon, daughter of barrister Joseph Maurice Soesan and civil servant Elizabeth Jane (née Ransley). Her paternal grandparents were greengrocers who were unenthusiastic about education; her father left school in his mid-teens, but subsequently completed a chemistry degree at night school and a law degree by correspondence. Caldicott was educated at City of London School for Girls, then studied medicine at St Hilda’s College, Oxford, qualifying BM BCh in 1966.

Career

She was a Pro Vice-Chancellor, Personnel and Equal Opportunities, of the University of Oxford and chaired its Personnel Committee. She retired from her 10-year term as Chair at the Oxford University Hospitals NHS Trust in March 2019, and was a past President of the British Association for Counselling and Psychotherapy. She was the first woman to be President of the Royal College of Psychiatrists (1993–96) and its first woman Dean (1990-1993). From 2011 to 2013 she was Chair of the National Information Governance Board for Health and Social Care.

Caldicott Committee

A review was commissioned by the Chief Medical Officer of England and Wales owing to increasing concern about the ways in which patient information is used in the NHS of England and Wales and the need to ensure that confidentiality is not undermined. Such concern was largely due to the development of information technology in the service, and its capacity to disseminate information about patients rapidly and extensively. In 1996, guidance on “the protection and use of patient information” was promulgated and there was a need to promote awareness of it at all levels in the NHS. It did not affect Scotland originally but they have recently adopted it. A main committee was set up under Caldicott’s Chair and there were four separate working groups; the committee was known as the Caldicott Committee.

The Caldicott Committee … was [responsible] to review all patient-identifiable information, which passes from NHS organisations to other NHS or non-NHS bodies for purposes other than direct care, medical research, or where there is a statutory requirement for information. The committee was to consider each flow of patient-identifiable information and was to advise the NHS Executive whether patient identification was justified by the purpose and whether action to minimise risks of breach of confidentiality was desirable – for example, reduction, elimination, or separate storage of items of information.

The Caldicott Report was published in December 1997. Today, every NHS trust has a ‘Caldicott Guardian’, to make sure standards of patient confidentiality and the Caldicott principles are upheld.

National Data Guardian for Health and Social Care

Caldicott became the UK’s first National Data Guardian for Health and Social Care in November 2014. In December 2018 the Health and Social Care (National Data Guardian) Act 2018 passed into law, and in April 2019 she was appointed as the first statutory position holder by the Secretary of State for Health and Social Care.

Awards and Honours

  • Honorary fellow at Somerville College, Oxford.
  • Dame Commander of the Order of the British Empire, 15 June 1996..
  • Lifetime Achievement Award from the Royal College of Psychiatrists, November 2018.

What is Psychology?

Introduction

Psychology is the science of mind and behaviour. Psychology includes the study of conscious and unconscious phenomena, as well as feeling and thought. It is an academic discipline of immense scope. Psychologists seek an understanding of the emergent properties of brains, and all the variety of phenomena linked to those emergent properties, joining this way the broader neuro-scientific group of researchers. As a social science, it aims to understand individuals and groups by establishing general principles and researching specific cases. Not to be confused with psychiatry.

In this field, a professional practitioner or researcher is called a psychologist and can be classified as a social, behavioural, or cognitive scientist. Psychologists attempt to understand the role of mental functions in individual and social behaviour, while also exploring the physiological and biological processes that underlie cognitive functions and behaviours.

Psychologists explore behaviour and mental processes, including perception, cognition, attention, emotion, intelligence, subjective experiences, motivation, brain functioning, and personality. This extends to interaction between people, such as interpersonal relationships, including psychological resilience, family resilience, and other areas. Psychologists of diverse orientations also consider the unconscious mind. Psychologists employ empirical methods to infer causal and correlational relationships between psychosocial variables. In addition, or in opposition, to employing empirical and deductive methods, some – especially clinical psychologists and counselling psychologists – at times rely upon symbolic interpretation and other inductive techniques. Psychology has been described as a “hub science” in that medicine tends to draw psychological research via neurology and psychiatry, whereas social sciences most commonly draws directly from sub-disciplines within psychology.

While psychological knowledge is often applied to the assessment and treatment of mental health problems, it is also directed towards understanding and solving problems in several spheres of human activity. By many accounts, psychology ultimately aims to benefit society. The majority of psychologists are involved in some kind of therapeutic role, practicing in clinical, counselling, or school settings. Many do scientific research on a wide range of topics related to mental processes and behaviour, and typically work in university psychology departments or teach in other academic settings (e.g. medical schools, hospitals). Some are employed in industrial and organizational settings, or in other areas such as human development and aging, sports, health, and the media, as well as in forensic investigation and other aspects of law.

Etymology and Definitions

The word psychology derives from Greek roots meaning study of the psyche, or soul (ψυχή psychē, “breath, spirit, soul” and -λογία -logia, “study of” or “research”).The Latin word psychologia was first used by the Croatian humanist and Latinist Marko Marulić in his book, Psichiologia de ratione animae humanae in the late 15th century or early 16th century. The earliest known reference to the word psychology in English was by Steven Blankaart in 1694 in The Physical Dictionary which refers to “Anatomy, which treats the Body, and Psychology, which treats of the Soul.”

In 1890, William James defined psychology as “the science of mental life, both of its phenomena and their conditions”. This definition enjoyed widespread currency for decades. However, this meaning was contested, notably by radical behaviourists such as John B. Watson, who in his 1913 manifesto defined the discipline of psychology as the acquisition of information useful to the control of behaviour. Also since James defined it, the term more strongly connotes techniques of scientific experimentation. Folk psychology refers to the understanding of ordinary people, as contrasted with that of psychology professionals.

Brief History

The ancient civilizations of Egypt, Greece, China, India, and Persia all engaged in the philosophical study of psychology. In Ancient Egypt the Ebers Papyrus mentioned depression and thought disorders. Historians note that Greek philosophers, including Thales, Plato, and Aristotle (especially in his De Anima treatise), addressed the workings of the mind. As early as the 4th century BC, Greek physician Hippocrates theorised that mental disorders had physical rather than supernatural causes.

In China, psychological understanding grew from the philosophical works of Laozi and Confucius, and later from the doctrines of Buddhism. This body of knowledge involves insights drawn from introspection and observation, as well as techniques for focused thinking and acting. It frames the universe as a division of, and interaction between, physical reality and mental reality, with an emphasis on purifying the mind in order to increase virtue and power. An ancient text known as The Yellow Emperor’s Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation, includes theories of personality based on yin-yang balance, and analyses mental disorder in terms of physiological and social disequilibria. Chinese scholarship focused on the brain advanced in the Qing Dynasty with the work of Western-educated Fang Yizhi (1611-1671), Liu Zhi (1660-1730), and Wang Qingren (1768-1831). Wang Qingren emphasized the importance of the brain as the centre of the nervous system, linked mental disorder with brain diseases, investigated the causes of dreams and insomnia, and advanced a theory of hemispheric lateralisation in brain function.

Distinctions in types of awareness appear in the ancient thought of India, influenced by Hinduism. A central idea of the Upanishads is the distinction between a person’s transient mundane self and their eternal unchanging soul. Divergent Hindu doctrines, and Buddhism, have challenged this hierarchy of selves, but have all emphasized the importance of reaching higher awareness. Yoga is a range of techniques used in pursuit of this goal. Much of the Sanskrit corpus was suppressed under the British East India Company followed by the British Raj in the 1800s. However, Indian doctrines influenced Western thinking via the Theosophical Society, a New Age group which became popular among Euro-American intellectuals.

Psychology was a popular topic in Enlightenment Europe. In Germany, Gottfried Wilhelm Leibniz (1646-1716) applied his principles of calculus to the mind, arguing that mental activity took place on an indivisible continuum – most notably, that among an infinity of human perceptions and desires, the difference between conscious and unconscious awareness is only a matter of degree. Christian Wolff identified psychology as its own science, writing Psychologia empirica in 1732 and Psychologia rationalis in 1734. This notion advanced further under Immanuel Kant, who established the idea of anthropology, with psychology as an important subdivision. However, Kant explicitly and notoriously rejected the idea of experimental psychology, writing that “the empirical doctrine of the soul can also never approach chemistry even as a systematic art of analysis or experimental doctrine, for in it the manifold of inner observation can be separated only by mere division in thought, and cannot then be held separate and recombined at will (but still less does another thinking subject suffer himself to be experimented upon to suit our purpose), and even observation by itself already changes and displaces the state of the observed object.” In 1783, Ferdinand Ueberwasser (1752-1812) designated himself Professor of Empirical Psychology and Logic and gave lectures on scientific psychology, though these developments were soon overshadowed by the Napoleonic Wars, after which the Old University of Münster was discontinued by Prussian authorities. Having consulted philosophers Hegel and Herbart, however, in 1825 the Prussian state established psychology as a mandatory discipline in its rapidly expanding and highly influential educational system. However, this discipline did not yet embrace experimentation. In England, early psychology involved phrenology and the response to social problems including alcoholism, violence, and the country’s well-populated mental asylums.

The Beginning of Experimental Psychology

Gustav Fechner began conducting psychophysics research in Leipzig in the 1830s, articulating the principle (Weber-Fechner law) that human perception of a stimulus varies logarithmically according to its intensity. Fechner’s 1860 Elements of Psychophysics challenged Kant’s stricture against quantitative study of the mind. In Heidelberg, Hermann von Helmholtz conducted parallel research on sensory perception, and trained physiologist Wilhelm Wundt. Wundt, in turn, came to Leipzig University, establishing the psychological laboratory which brought experimental psychology to the world. Wundt focused on breaking down mental processes into the most basic components, motivated in part by an analogy to recent advances in chemistry, and its successful investigation of the elements and structure of material. Paul Flechsig and Emil Kraepelin soon created another influential psychology laboratory at Leipzig, this one focused on more on experimental psychiatry.

Psychologists in Germany, Denmark, Austria, England, and the United States soon followed Wundt in setting up laboratories. G. Stanley Hall who studied with Wundt, formed a psychology lab at Johns Hopkins University in Maryland, which became internationally influential. Hall, in turn, trained Yujiro Motora, who brought experimental psychology, emphasizing psychophysics, to the Imperial University of Tokyo. Wundt’s assistant, Hugo Münsterberg, taught psychology at Harvard to students such as Narendra Nath Sen Gupta – who, in 1905, founded a psychology department and laboratory at the University of Calcutta. Wundt students Walter Dill Scott, Lightner Witmer, and James McKeen Cattell worked on developing tests for mental ability. Catell, who also studied with eugenicist Francis Galton, went on to found the Psychological Corporation. Wittmer focused on mental testing of children; Scott, on selection of employees.

Another student of Wundt, Edward Titchener, created the psychology program at Cornell University and advanced a doctrine of “structuralist” psychology. Structuralism sought to analyse and classify different aspects of the mind, primarily through the method of introspection. William James, John Dewey and Harvey Carr advanced a more expansive doctrine called functionalism, attuned more to human-environment actions. In 1890, James wrote an influential book, The Principles of Psychology, which expanded on the realm of structuralism, memorably described the human “stream of consciousness”, and interested many American students in the emerging discipline. Dewey integrated psychology with social issues, most notably by promoting the cause progressive education to assimilate immigrants and inculcate moral values in children.

A different strain of experimentalism, with more connection to physiology, emerged in South America, under the leadership of Horacio G. Piñero at the University of Buenos Aires. Russia, too, placed greater emphasis on the biological basis for psychology, beginning with Ivan Sechenov’s 1873 essay, “Who Is to Develop Psychology and How?” Sechenov advanced the idea of brain reflexes and aggressively promoted a deterministic viewpoint on human behaviour.

Wolfgang Kohler, Max Wertheimer and Kurt Koffka co-founded the school of Gestalt psychology (not to be confused with the Gestalt therapy of Fritz Perls). This approach is based upon the idea that individuals experience things as unified wholes. Rather than breaking down thoughts and behaviour into smaller elements, as in structuralism, the Gestaltists maintained that whole of experience is important, and differs from the sum of its parts. Other 19th-century contributors to the field include the German psychologist Hermann Ebbinghaus, a pioneer in the experimental study of memory, who developed quantitative models of learning and forgetting at the University of Berlin, and the Russian-Soviet physiologist Ivan Pavlov, who discovered in dogs a learning process that was later termed “classical conditioning” and applied to human beings.

Consolidation and Funding

One of the earliest psychology societies was La Société de Psychologie Physiologique in France, which lasted 1885-1893. The first meeting of the International Congress of Psychology sponsored by the International Union of Psychological Science took place in Paris, in August 1889, amidst the World’s Fair celebrating the centennial of the French Revolution. William James was one of three Americans among the four hundred attendees. The American Psychological Association (APA) was founded soon after, in 1892. The International Congress continued to be held, at different locations in Europe, with wider international participation. The Sixth Congress, Geneva 1909, included presentations in Russian, Chinese, and Japanese, as well as Esperanto. After a hiatus for World War I, the Seventh Congress met in Oxford, with substantially greater participation from the war-victorious Anglo-Americans. In 1929, the Congress took place at Yale University in New Haven, Connecticut, attended by hundreds of members of the APA. Tokyo Imperial University led the way in bringing new psychology to the East, and from Japan these ideas diffused into China.

American psychology gained status during World War I, during which a standing committee headed by Robert Yerkes administered mental tests (“Army Alpha” and “Army Beta”) to almost 1.8 million soldiers. Subsequent funding for behavioural research came in large part from the Rockefeller family, via the Social Science Research Council. Rockefeller charities funded the National Committee on Mental Hygiene, which promoted the concept of mental illness and lobbied for psychological supervision of child development. Through the Bureau of Social Hygiene and later funding of Alfred Kinsey, Rockefeller foundations established sex research as a viable discipline in the U.S.[41] Under the influence of the Carnegie-funded Eugenics Record Office, the Draper-funded Pioneer Fund, and other institutions, the eugenics movement also had a significant impact on American psychology; in the 1910s and 1920s, eugenics became a standard topic in psychology classes.

During World War II and the Cold War, the US military and intelligence agencies established themselves as leading funders of psychology – through the armed forces and in the new Office of Strategic Services intelligence agency. University of Michigan psychologist Dorwin Cartwright reported that university researchers began large-scale propaganda research in 1939-1941, and “the last few months of the war saw a social psychologist become chiefly responsible for determining the week-by-week-propaganda policy for the United States Government.” Cartwright also wrote that psychologists had significant roles in managing the domestic economy. The Army rolled out its new General Classification Test and engaged in massive studies of troop morale. In the 1950s, the Rockefeller Foundation and Ford Foundation collaborated with the Central Intelligence Agency (CIA) to fund research on psychological warfare. In 1965, public controversy called attention to the Army’s Project Camelot – the “Manhattan Project” of social science – an effort which enlisted psychologists and anthropologists to analyse foreign countries for strategic purposes.

In Germany after World War I, psychology held institutional power through the military, and subsequently expanded along with the rest of the military under the Third Reich. Under the direction of Hermann Göring’s cousin Matthias Göring, the Berlin Psychoanalytic Institute was renamed the Göring Institute. Freudian psychoanalysts were expelled and persecuted under the anti-Jewish policies of the Nazi Party, and all psychologists had to distance themselves from Freud and Adler. The Göring Institute was well-financed throughout the war with a mandate to create a “New German Psychotherapy”. This psychotherapy aimed to align suitable Germans with the overall goals of the Reich; as described by one physician: “Despite the importance of analysis, spiritual guidance and the active cooperation of the patient represent the best way to overcome individual mental problems and to subordinate them to the requirements of the Volk and the Gemeinschaft.” Psychologists were to provide Seelenführung, leadership of the mind, to integrate people into the new vision of a German community. Harald Schultz-Hencke melded psychology with the Nazi theory of biology and racial origins, criticising psychoanalysis as a study of the weak and deformed. Johannes Heinrich Schultz, a German psychologist recognised for developing the technique of autogenic training, prominently advocated sterilisation and euthanasia of men considered genetically undesirable, and devised techniques for facilitating this process. After the war, some new institutions were created and some psychologists were discredited due to Nazi affiliation. Alexander Mitscherlich founded a prominent applied psychoanalysis journal called Psyche and with funding from the Rockefeller Foundation established the first clinical psychosomatic medicine division at Heidelberg University. In 1970, psychology was integrated into the required studies of medical students.

After the Russian Revolution, psychology was heavily promoted by the Bolsheviks as a way to engineer the “New Man” of socialism. Thus, university psychology departments trained large numbers of students, for whom positions were made available at schools, workplaces, cultural institutions, and in the military. An especial focus was paedology, the study of child development, regarding which Lev Vygotsky became a prominent writer. The Bolsheviks also promoted free love and embraced the doctrine of psychoanalysis as an antidote to sexual repression. Although paedology and intelligence testing fell out of favour in 1936, psychology maintained its privileged position as an instrument of the Soviet Union. Stalinist purges took a heavy toll and instilled a climate of fear in the profession, as elsewhere in Soviet society. Following World War II, Jewish psychologists past and present (including Lev Vygotsky, A.R. Luria, and Aron Zalkind) were denounced; Ivan Pavlov (posthumously) and Stalin himself were aggrandised as heroes of Soviet psychology. Soviet academics was speedily liberalised during the Khrushchev Thaw, and cybernetics, linguistics, genetics, and other topics became acceptable again. There emerged a new field called “engineering psychology” which studied mental aspects of complex jobs (such as pilot and cosmonaut). Interdisciplinary studies became popular and scholars such as Georgy Shchedrovitsky developed systems theory approaches to human behaviour.

Twentieth-century Chinese psychology originally modelled the US, with translations from American authors like William James, the establishment of university psychology departments and journals, and the establishment of groups including the Chinese Association of Psychological Testing (1930) and the Chinese Psychological Society (1937). Chinese psychologists were encouraged to focus on education and language learning, with the aspiration that education would enable modernisation and nationalisation. John Dewey, who lectured to Chinese audiences in 1918-1920, had a significant influence on this doctrine. Chancellor T’sai Yuan-p’ei introduced him at Peking University as a greater thinker than Confucius. Kuo Zing-yang who received a PhD at the University of California, Berkeley, became President of Zhejiang University and popularised behaviourism. After the Chinese Communist Party gained control of the country, the Stalinist Soviet Union became the leading influence, with Marxism-Leninism the leading social doctrine and Pavlovian conditioning the approved concept of behaviour change. Chinese psychologists elaborated on Lenin’s model of a “reflective” consciousness, envisioning an “active consciousness” (pinyin: tzu-chueh neng-tung-li) able to transcend material conditions through hard work and ideological struggle. They developed a concept of “recognition” (pinyin: jen-shih) which referred the interface between individual perceptions and the socially accepted worldview (failure to correspond with party doctrine was “incorrect recognition”). Psychology education was centralized under the Chinese Academy of Sciences, supervised by the State Council. In 1951, the Academy created a Psychology Research Office, which in 1956 became the Institute of Psychology. Most leading psychologists were educated in the United States, and the first concern of the Academy was re-education of these psychologists in the Soviet doctrines. Child psychology and pedagogy for nationally cohesive education remained a central goal of the discipline.

Disciplinary Organisation

Institutions

In 1920, Édouard Claparède and Pierre Bovet created a new applied psychology organisation called the International Congress of Psychotechnics Applied to Vocational Guidance, later called the International Congress of Psychotechnics and then the International Association of Applied Psychology. The IAAP is considered the oldest international psychology association. Today, at least 65 international groups deal with specialized aspects of psychology. In response to male predominance in the field, female psychologists in the US formed National Council of Women Psychologists in 1941. This organisation became the International Council of Women Psychologists after World War II, and the International Council of Psychologists in 1959. Several associations including the Association of Black Psychologists and the Asian American Psychological Association have arisen to promote non-European racial groups in the profession.

The world federation of national psychological societies is the International Union of Psychological Science (IUPsyS), founded in 1951 under the auspices of UNESCO, the United Nations cultural and scientific authority. Psychology departments have since proliferated around the world, based primarily on the Euro-American model. Since 1966, the Union has published the International Journal of Psychology. IAAP and IUPsyS agreed in 1976 each to hold a congress every four years, on a staggered basis.

The International Union recognises 66 national psychology associations and at least 15 others exist. The American Psychological Association is the oldest and largest. Its membership has increased from 5,000 in 1945 to 100,000 in the present day. The APA includes 54 divisions, which since 1960 have steadily proliferated to include more specialties. Some of these divisions, such as the Society for the Psychological Study of Social Issues and the American Psychology-Law Society, began as autonomous groups.

The Interamerican Society of Psychology, founded in 1951, aspires to promote psychology and coordinate psychologists across the Western Hemisphere. It holds the Interamerican Congress of Psychology and had 1,000 members in year 2000. The European Federation of Professional Psychology Associations, founded in 1981, represents 30 national associations with a total of 100,000 individual members. At least 30 other international groups organize psychologists in different regions.

In some places, governments legally regulate who can provide psychological services or represent themselves as a “psychologist”. The APA defines a psychologist as someone with a doctoral degree in psychology.

Boundaries

Early practitioners of experimental psychology distinguished themselves from parapsychology, which in the late nineteenth century enjoyed great popularity (including the interest of scholars such as William James), and indeed constituted the bulk of what people called “psychology”. Parapsychology, hypnotism, and psychism were major topics of the early International Congresses. But students of these fields were eventually ostracised, and more or less banished from the Congress in 1900-1905. Parapsychology persisted for a time at Imperial University, with publications such as Clairvoyance and Thoughtography by Tomokichi Fukurai, but here too it was mostly shunned by 1913.

As a discipline, psychology has long sought to fend off accusations that it is a “soft” science. Philosopher of science Thomas Kuhn’s 1962 critique implied psychology overall was in a pre-paradigm state, lacking the agreement on overarching theory found in mature sciences such as chemistry and physics. Because some areas of psychology rely on research methods such as surveys and questionnaires, critics asserted that psychology is not an objective science. Sceptics have suggested that personality, thinking, and emotion, cannot be directly measured and are often inferred from subjective self-reports, which may be problematic. Experimental psychologists have devised a variety of ways to indirectly measure these elusive phenomenological entities.

Divisions still exist within the field, with some psychologists more oriented towards the unique experiences of individual humans, which cannot be understood only as data points within a larger population. Critics inside and outside the field have argued that mainstream psychology has become increasingly dominated by a “cult of empiricism” which limits the scope of its study by using only methods derived from the physical sciences. Feminist critiques along these lines have argued that claims to scientific objectivity obscure the values and agenda of (historically mostly male) researchers. Jean Grimshaw, for example, argues that mainstream psychological research has advanced a patriarchal agenda through its efforts to control behaviour.

Major Schools of Thought

Biological

Psychologists generally consider the organism the basis of the mind, and therefore a vitally related area of study. Psychiatrists and neuropsychologists work at the interface of mind and body. Biological psychology, also known as physiological psychology, or neuropsychology is the study of the biological substrates of behaviour and mental processes. Key research topics in this field include comparative psychology, which studies humans in relation to other animals, and perception which involves the physical mechanics of sensation as well as neural and mental processing. For centuries, a leading question in biological psychology has been whether and how mental functions might be localised in the brain. From Phineas Gage to H.M. and Clive Wearing, individual people with mental issues traceable to physical damage have inspired new discoveries in this area. Modern neuropsychology could be said to originate in the 1870s, when in France Paul Broca traced production of speech to the left frontal gyrus, thereby also demonstrating hemispheric lateralisation of brain function. Soon after, Carl Wernicke identified a related area necessary for the understanding of speech.

The contemporary field of behavioural neuroscience focuses on physical causes underpinning behaviour. For example, physiological psychologists use animal models, typically rats, to study the neural, genetic, and cellular mechanisms that underlie specific behaviours such as learning and memory and fear responses. Cognitive neuroscientists investigate the neural correlates of psychological processes in humans using neural imaging tools, and neuropsychologists conduct psychological assessments to determine, for instance, specific aspects and extent of cognitive deficit caused by brain damage or disease. The biopsychosocial model is an integrated perspective toward understanding consciousness, behaviour, and social interaction. It assumes that any given behaviour or mental process affects and is affected by dynamically interrelated biological, psychological, and social factors.

Evolutionary psychology examines cognition and personality traits from an evolutionary perspective. This perspective suggests that psychological adaptations evolved to solve recurrent problems in human ancestral environments. Evolutionary psychology offers complementary explanations for the mostly proximate or developmental explanations developed by other areas of psychology: that is, it focuses mostly on ultimate or “why?” questions, rather than proximate or “how?” questions. “How?” questions are more directly tackled by behavioural genetics research, which aims to understand how genes and environment impact behaviour.

The search for biological origins of psychological phenomena has long involved debates about the importance of race, and especially the relationship between race and intelligence. The idea of white supremacy and indeed the modern concept of race itself arose during the process of world conquest by Europeans. Carl von Linnaeus’s four-fold classification of humans classifies Europeans as intelligent and severe, Americans as contented and free, Asians as ritualistic, and Africans as lazy and capricious. Race was also used to justify the construction of socially specific mental disorders such as drapetomania and dysaesthesia aethiopica – the behaviour of uncooperative African slaves. After the creation of experimental psychology, “ethnical psychology” emerged as a subdiscipline, based on the assumption that studying primitive races would provide an important link between animal behaviour and the psychology of more evolved humans.

Behavioural

Psychologists take human behaviour as a main area of study. Much of the research in this area began with tests on mammals, based on the idea that humans exhibit similar fundamental tendencies. Behavioural research ever aspires to improve the effectiveness of techniques for behaviour modification.

Early behavioural researchers studied stimulus-response pairings, now known as classical conditioning. They demonstrated that behaviours could be linked through repeated association with stimuli eliciting pain or pleasure. Ivan Pavlov – known best for inducing dogs to salivate in the presence of a stimulus previously linked with food – became a leading figure in the Soviet Union and inspired followers to use his methods on humans. In the United States, Edward Lee Thorndike initiated “connectionism” studies by trapping animals in “puzzle boxes” and rewarding them for escaping. Thorndike wrote in 1911: “There can be no moral warrant for studying man’s nature unless the study will enable us to control his acts.” From 1910-1913 the American Psychological Association went through a sea change of opinion, away from mentalism and towards “behaviouralism”, and in 1913 John B. Watson coined the term behaviourism for this school of thought. Watson’s famous Little Albert experiment in 1920 demonstrated that repeated use of upsetting loud noises could instil phobias (aversions to other stimuli) in an infant human. Karl Lashley, a close collaborator with Watson, examined biological manifestations of learning in the brain.

Embraced and extended by Clark L. Hull, Edwin Guthrie, and others, behaviourism became a widely used research paradigm. A new method of “instrumental” or “operant” conditioning added the concepts of reinforcement and punishment to the model of behaviour change. Radical behaviourists avoided discussing the inner workings of the mind, especially the unconscious mind, which they considered impossible to assess scientifically. Operant conditioning was first described by Miller and Kanorski and popularised in the US by B.F. Skinner, who emerged as a leading intellectual of the behaviourist movement.

Noam Chomsky delivered an influential critique of radical behaviourism on the grounds that it could not adequately explain the complex mental process of language acquisition. Martin Seligman and colleagues discovered that the conditioning of dogs led to outcomes (“learned helplessness”) that opposed the predictions of behaviourism. Skinner’s behaviourism did not die, perhaps in part because it generated successful practical applications. Edward C. Tolman advanced a hybrid “cognitive behavioural” model, most notably with his 1948 publication discussing the cognitive maps used by rats to guess at the location of food at the end of a modified maze.

The Association for Behaviour Analysis International was founded in 1974 and by 2003 had members from 42 countries. The field has been especially influential in Latin America, where it has a regional organization known as ALAMOC: La Asociación Latinoamericana de Análisis y Modificación del Comportamiento. Behaviourism also gained a strong foothold in Japan, where it gave rise to the Japanese Society of Animal Psychology (1933), the Japanese Association of Special Education (1963), the Japanese Society of Biofeedback Research (1973), the Japanese Association for Behaviour Therapy (1976), the Japanese Association for Behaviour Analysis (1979), and the Japanese Association for Behavioural Science Research (1994). Today the field of behaviourism is also commonly referred to as behaviour modification or behaviour analysis.

Cognitive

Cognitive psychology studies cognition, the mental processes underlying mental activity. Perception, attention, reasoning, thinking, problem solving, memory, learning, language, and emotion are areas of research. Classical cognitive psychology is associated with a school of thought known as cognitivism, whose adherents argue for an information processing model of mental function, informed by functionalism and experimental psychology.

Starting in the 1950s, the experimental techniques developed by Wundt, James, Ebbinghaus, and others re-emerged as experimental psychology became increasingly cognitivist – concerned with information and its processing – and, eventually, constituted a part of the wider cognitive science. Some called this development the cognitive revolution because it rejected the anti-mentalist dogma of behaviourism as well as the strictures of psychoanalysis.

Social learning theorists, such as Albert Bandura, argued that the child’s environment could make contributions of its own to the behaviours of an observant subject.

Technological advances also renewed interest in mental states and representations. English neuroscientist Charles Sherrington and Canadian psychologist Donald O. Hebb used experimental methods to link psychological phenomena with the structure and function of the brain. The rise of computer science, cybernetics and artificial intelligence suggested the value of comparatively studying information processing in humans and machines. Research in cognition had proven practical since World War II, when it aided in the understanding of weapons operation.

A popular and representative topic in this area is cognitive bias, or irrational thought. Psychologists (and economists) have classified and described a sizeable catalogue of biases which recur frequently in human thought. The availability heuristic, for example, is the tendency to overestimate the importance of something which happens to come readily to mind.

Elements of behaviourism and cognitive psychology were synthesized to form cognitive behavioural therapy, a form of psychotherapy modified from techniques developed by American psychologist Albert Ellis and American psychiatrist Aaron T. Beck.

On a broader level, cognitive science is an interdisciplinary enterprise of cognitive psychologists, cognitive neuroscientists, researchers in artificial intelligence, linguists, human-computer interaction, computational neuroscience, logicians and social scientists. The discipline of cognitive science covers cognitive psychology as well as philosophy of mind, computer science, and neuroscience.[citation needed] Computer simulations are sometimes used to model phenomena of interest.

Social

Social psychology is the study of how humans think about each other and how they relate to each other. Social psychologists study such topics as the influence of others on an individual’s behaviour (e.g. conformity, persuasion), and the formation of beliefs, attitudes, and stereotypes about other people. Social cognition fuses elements of social and cognitive psychology in order to understand how people process, remember, or distort social information. The study of group dynamics reveals information about the nature and potential optimisation of leadership, communication, and other phenomena that emerge at least at the microsocial level. In recent years, many social psychologists have become increasingly interested in implicit measures, mediational models, and the interaction of both person and social variables in accounting for behaviour. The study of human society is therefore a potentially valuable source of information about the causes of psychiatric disorder. Some sociological concepts applied to psychiatric disorders are the social role, sick role, social class, life event, culture, migration, social, and total institution.

Psychoanalysis

Psychoanalysis comprises a method of investigating the mind and interpreting experience; a systematised set of theories about human behaviour; and a form of psychotherapy to treat psychological or emotional distress, especially conflict originating in the unconscious mind. This school of thought originated in the 1890s with Austrian medical doctors including Josef Breuer (physician), Alfred Adler (physician), Otto Rank (psychoanalyst), and most prominently Sigmund Freud (neurologist). Freud’s psychoanalytic theory was largely based on interpretive methods, introspection and clinical observations. It became very well known, largely because it tackled subjects such as sexuality, repression, and the unconscious. These subjects were largely taboo at the time, and Freud provided a catalyst for their open discussion in polite society. Clinically, Freud helped to pioneer the method of free association and a therapeutic interest in dream interpretation.

Swiss psychiatrist Carl Jung, influenced by Freud, elaborated a theory of the collective unconscious – a primordial force present in all humans, featuring archetypes which exerted a profound influence on the mind. Jung’s competing vision formed the basis for analytical psychology, which later led to the archetypal and process-oriented schools. Other well-known psychoanalytic scholars of the mid-20th century include Erik Erikson, Melanie Klein, D.W. Winnicott, Karen Horney, Erich Fromm, John Bowlby, and Sigmund Freud’s daughter, Anna Freud. Throughout the 20th century, psychoanalysis evolved into diverse schools of thought which could be called Neo-Freudian. Among these schools are ego psychology, object relations, and interpersonal, Lacanian, and relational psychoanalysis.

Psychologists such as Hans Eysenck and philosophers including Karl Popper criticised psychoanalysis. Popper argued that psychoanalysis had been misrepresented as a scientific discipline, whereas Eysenck said that psychoanalytic tenets had been contradicted by experimental data. By the end of 20th century, psychology departments in American universities mostly marginalised Freudian theory, dismissing it as a “desiccated and dead” historical artefact. However, researchers in the emerging field of neuro-psychoanalysis today defend some of Freud’s ideas on scientific grounds, while scholars of the humanities maintain that Freud was not a “scientist at all, but … an interpreter”.

Existential-Humanistic Theories

Humanistic psychology developed in the 1950s as a movement within academic psychology, in reaction to both behaviourism and psychoanalysis. The humanistic approach sought to glimpse the whole person, not just fragmented parts of the personality or isolated cognitions. Humanism focused on uniquely human issues, such as free will, personal growth, self-actualisation, self-identity, death, aloneness, freedom, and meaning. It emphasized subjective meaning, rejection of determinism, and concern for positive growth rather than pathology. Some founders of the humanistic school of thought were American psychologists Abraham Maslow, who formulated a hierarchy of human needs, and Carl Rogers, who created and developed client-centred therapy. Later, positive psychology opened up humanistic themes to scientific modes of exploration.

The American Association for Humanistic Psychology, formed in 1963, declared:

Humanistic psychology is primarily an orientation toward the whole of psychology rather than a distinct area or school. It stands for respect for the worth of persons, respect for differences of approach, open-mindedness as to acceptable methods, and interest in exploration of new aspects of human behaviour. As a “third force” in contemporary psychology, it is concerned with topics having little place in existing theories and systems: e.g., love, creativity, self, growth, organism, basic need-gratification, self-actualization, higher values, being, becoming, spontaneity, play, humour, affection, naturalness, warmth, ego-transcendence, objectivity, autonomy, responsibility, meaning, fair-play, transcendental experience, peak experience, courage, and related concepts.

In the 1950s and 1960s, influenced by philosophers Søren Kierkegaard and Martin Heidegger and, psychoanalytically trained American psychologist Rollo May pioneered an existential branch of psychology, which included existential psychotherapy: a method based on the belief that inner conflict within a person is due to that individual’s confrontation with the givens of existence. Swiss psychoanalyst Ludwig Binswanger and American psychologist George Kelly may also be said to belong to the existential school. Existential psychologists differed from more “humanistic” psychologists in their relatively neutral view of human nature and their relatively positive assessment of anxiety. Existential psychologists emphasized the humanistic themes of death, free will, and meaning, suggesting that meaning can be shaped by myths, or narrative patterns, and that it can be encouraged by an acceptance of the free will requisite to an authentic, albeit often anxious, regard for death and other future prospects.

Austrian existential psychiatrist and Holocaust survivor Viktor Frankl drew evidence of meaning’s therapeutic power from reflections garnered from his own internment. He created a variation of existential psychotherapy called logotherapy, a type of existentialist analysis that focuses on a will to meaning (in one’s life), as opposed to Adler’s Nietzschean doctrine of will to power or Freud’s will to pleasure.

Themes

Personality

Personality psychology is concerned with enduring patterns of behaviour, thought, and emotion – commonly referred to as personality – in individuals. Theories of personality vary across different psychological schools and orientations. They carry different assumptions about such issues as the role of the unconscious and the importance of childhood experience. According to Freud, personality is based on the dynamic interactions of the id, ego, and super-ego. In order to develop a taxonomy of personality constructs, trait theorists, in contrast, attempt to describe the personality sphere in terms of a discrete number of key traits using the statistical data-reduction method of factor analysis. Although the number of proposed traits has varied widely, an early biologically-based model proposed by Hans Eysenck, the 3rd mostly highly cited psychologist of the 20th Century (after Freud, and Piaget respectively), suggested that at least three major trait constructs are necessary to describe human personality structure: extraversion–introversion, neuroticism-stability, and psychoticism-normality. Raymond Cattell, the 7th most highly cited psychologist of the 20th Century (based on the scientific peer-reviewed journal literature) empirically derived a theory of 16 personality factors at the primary-factor level, and up to 8 broader second-stratum factors (at the Eysenckian level of analysis), rather than the “Big Five” dimensions. Dimensional models of personality are receiving increasing support, and a version of dimensional assessment has been included in the DSM-V. However, despite a plethora of research into the various versions of the “Big Five” personality dimensions, it appears necessary to move on from static conceptualisations of personality structure to a more dynamic orientation, whereby it is acknowledged that personality constructs are subject to learning and change across the lifespan.

An early example of personality assessment was the Woodworth Personal Data Sheet, constructed during World War I. The popular, although psychometrically inadequate Myers-Briggs Type Indicator sought to assess individuals’ “personality types” according to the personality theories of Carl Jung. Behaviourist resistance to introspection led to the development of the Strong Vocational Interest Blank and Minnesota Multiphasic Personality Inventory (MMPI), in an attempt to ask empirical questions that focused less on the psychodynamics of the respondent. However, the MMPI has been subjected to critical scrutiny, given that it adhered to archaic psychiatric nosology, and since it required individuals to provide subjective, introspective responses to the hundreds of items pertaining to psychopathology.

Unconscious Mind

Study of the unconscious mind, a part of the psyche outside the awareness of the individual which nevertheless influenced thoughts and behaviour was a hallmark of early psychology. In one of the first psychology experiments conducted in the United States, C.S. Peirce and Joseph Jastrow found in 1884 that subjects could choose the minutely heavier of two weights even if consciously uncertain of the difference. Freud popularised this concept, with terms like Freudian slip entering popular culture, to mean an uncensored intrusion of unconscious thought into one’s speech and action. His 1901 text The Psychopathology of Everyday Life catalogues hundreds of everyday events which Freud explains in terms of unconscious influence. Pierre Janet advanced the idea of a subconscious mind, which could contain autonomous mental elements unavailable to the scrutiny of the subject.

Behaviourism notwithstanding, the unconscious mind has maintained its importance in psychology. Cognitive psychologists have used a “filter” model of attention, according to which much information processing takes place below the threshold of consciousness, and only certain processes, limited by nature and by simultaneous quantity, make their way through the filter. Copious research has shown that subconscious priming of certain ideas can covertly influence thoughts and behaviour. A significant hurdle in this research is proving that a subject’s conscious mind has not grasped a certain stimulus, due to the unreliability of self-reporting. For this reason, some psychologists prefer to distinguish between implicit and explicit memory. In another approach, one can also describe a subliminal stimulus as meeting an objective but not a subjective threshold.

The automaticity model, which became widespread following exposition by John Bargh and others in the 1980s, describes sophisticated processes for executing goals which can be selected and performed over an extended duration without conscious awareness. Some experimental data suggests that the brain begins to consider taking actions before the mind becomes aware of them. This influence of unconscious forces on people’s choices naturally bears on philosophical questions free will. John Bargh, Daniel Wegner, and Ellen Langer are some prominent contemporary psychologists who describe free will as an illusion.

Motivation

Psychologists such as William James initially used the term motivation to refer to intention, in a sense similar to the concept of will in European philosophy. With the steady rise of Darwinian and Freudian thinking, instinct also came to be seen as a primary source of motivation. According to drive theory, the forces of instinct combine into a single source of energy which exerts a constant influence. Psychoanalysis, like biology, regarded these forces as physical demands made by the organism on the nervous system. However, they believed that these forces, especially the sexual instincts, could become entangled and transmuted within the psyche. Classical psychoanalysis conceives of a struggle between the pleasure principle and the reality principle, roughly corresponding to id and ego. Later, in Beyond the Pleasure Principle, Freud introduced the concept of the death drive, a compulsion towards aggression, destruction, and psychic repetition of traumatic events. Meanwhile, behaviourist researchers used simple dichotomous models (pleasure/pain, reward/punishment) and well-established principles such as the idea that a thirsty creature will take pleasure in drinking. Clark Hull formalised the latter idea with his drive reduction model.

Hunger, thirst, fear, sexual desire, and thermoregulation all seem to constitute fundamental motivations for animals. Humans also seem to exhibit a more complex set of motivations – though theoretically these could be explained as resulting from primordial instincts – including desires for belonging, self-image, self-consistency, truth, love, and control.

Motivation can be modulated or manipulated in many different ways. Researchers have found that eating, for example, depends not only on the organism’s fundamental need for homeostasis – an important factor causing the experience of hunger – but also on circadian rhythms, food availability, food palatability, and cost. Abstract motivations are also malleable, as evidenced by such phenomena as goal contagion: the adoption of goals, sometimes unconsciously, based on inferences about the goals of others. Vohs and Baumeister suggest that contrary to the need-desire-fulfilment cycle of animal instincts, human motivations sometimes obey a “getting begets wanting” rule: the more you get a reward such as self-esteem, love, drugs, or money, the more you want it. They suggest that this principle can even apply to food, drink, sex, and sleep.

Development

Mainly focusing on the development of the human mind through the life span, developmental psychology seeks to understand how people come to perceive, understand, and act within the world and how these processes change as they age. This may focus on cognitive, affective, moral, social, or neural development. Researchers who study children use a number of unique research methods to make observations in natural settings or to engage them in experimental tasks. Such tasks often resemble specially designed games and activities that are both enjoyable for the child and scientifically useful, and researchers have even devised clever methods to study the mental processes of infants. In addition to studying children, developmental psychologists also study aging and processes throughout the life span, especially at other times of rapid change (such as adolescence and old age). Developmental psychologists draw on the full range of psychological theories to inform their research.

Genes and Environment

All researched psychological traits are influenced by both genes and environment, to varying degrees. These two sources of influence are often confounded in observational research of individuals or families. An example is the transmission of depression from a depressed mother to her offspring. Theory may hold that the offspring, by virtue of having a depressed mother in his or her (the offspring’s) environment, is at risk for developing depression. However, risk for depression is also influenced to some extent by genes. The mother may both carry genes that contribute to her depression but will also have passed those genes on to her offspring thus increasing the offspring’s risk for depression. Genes and environment in this simple transmission model are completely confounded.

Experimental and quasi-experimental behavioural genetic research uses genetic methodologies to disentangle this confound and understand the nature and origins of individual differences in behaviour. Traditionally this research has been conducted using twin studies and adoption studies, two designs where genetic and environmental influences can be partially un-confounded. More recently, the availability of microarray molecular genetic or genome sequencing technologies allows researchers to measure participant DNA variation directly, and test whether individual genetic variants within genes are associated with psychological traits and psychopathology through methods including genome-wide association studies.

One goal of such research is similar to that in positional cloning and its success in Huntington’s: once a causal gene is discovered biological research can be conducted to understand how that gene influences the phenotype. One major result of genetic association studies is the general finding that psychological traits and psychopathology, as well as complex medical diseases, are highly polygenic, where a large number (on the order of hundreds to thousands) of genetic variants, each of small effect, contribute to individual differences in the behavioural trait or propensity to the disorder. Active research continues to understand the genetic and environmental bases of behaviour and their interaction.

Applications

Psychology encompasses many subfields and includes different approaches to the study of mental processes and behavior:

Mental Testing

Psychological testing has ancient origins, such as examinations for the Chinese civil service dating back to 2200 BC. Written exams began during the Han dynasty (202 BC-AD 200). By 1370, the Chinese system required a stratified series of tests, involving essay writing and knowledge of diverse topics. The system was ended in 1906. In Europe, mental assessment took a more physiological approach, with theories of physiognomy – judgement of character based on the face – described by Aristotle in 4th century BC Greece. Physiognomy remained current through the Enlightenment, and added the doctrine of phrenology: a study of mind and intelligence based on simple assessment of neuroanatomy.

When experimental psychology came to Britain, Francis Galton was a leading practitioner, and, with his procedures for measuring reaction time and sensation, is considered an inventor of modern mental testing (also known as psychometrics). James McKeen Cattell, a student of Wundt and Galton, brought the concept to the United States, and in fact coined the term “mental test”. In 1901, Cattell’s student Clark Wissler published discouraging results, suggesting that mental testing of Columbia and Barnard students failed to predict their academic performance. In response to 1904 orders from the Minister of Public Instruction, French psychologists Alfred Binet and Théodore Simon elaborated a new test of intelligence in 1905-1911, using a range of questions diverse in their nature and difficulty. Binet and Simon introduced the concept of mental age and referred to the lowest scorers on their test as idiots. Henry H. Goddard put the Binet-Simon scale to work and introduced classifications of mental level such as imbecile and feebleminded. In 1916 (after Binet’s death), Stanford professor Lewis M. Terman modified the Binet-Simon scale (renamed the Stanford–Binet scale) and introduced the intelligence quotient as a score report. From this test, Terman concluded that mental retardation “represents the level of intelligence which is very, very common among Spanish-Indians and Mexican families of the Southwest and also among negroes. Their dullness seems to be racial.”

Following the Army Alpha and Army Beta tests for soldiers in World War I, mental testing became popular in the US, where it was soon applied to school children. The federally created National Intelligence Test was administered to 7 million children in the 1920s, and in 1926 the College Entrance Examination Board created the Scholastic Aptitude Test to standardise college admissions. The results of intelligence tests were used to argue for segregated schools and economic functions – i.e. the preferential training of Black Americans for manual labour. These practices were criticised by black intellectuals such a Horace Mann Bond and Allison Davis. Eugenicists used mental testing to justify and organise compulsory sterilisation of individuals classified as mentally retarded. In the United States, tens of thousands of men and women were sterilised. Setting a precedent which has never been overturned, the US Supreme Court affirmed the constitutionality of this practice in the 1907 case Buck v. Bell.

Today mental testing is a routine phenomenon for people of all ages in Western societies. Modern testing aspires to criteria including standardisation of procedure, consistency of results, output of an interpretable score, statistical norms describing population outcomes, and, ideally, effective prediction of behaviour and life outcomes outside of testing situations.

Mental Health Care

The provision of psychological health services is generally called clinical psychology in the US The definitions of this term are various and may include school psychology and counselling psychology. Practitioners typically includes people who have graduated from doctoral programs in clinical psychology but may also include others. In Canada, the above groups usually fall within the larger category of professional psychology. In Canada and the US, practitioners get bachelor’s degrees and doctorates, then spend one year in an internship and one year in postdoctoral education. In Mexico and most other Latin American and European countries, psychologists do not get bachelor’s and doctorate degrees; instead, they take a three-year professional course following high school. Clinical psychology is at present the largest specialisation within psychology. It includes the study and application of psychology for the purpose of understanding, preventing, and relieving psychologically based distress, dysfunction or mental illness and to promote subjective well-being and personal development. Central to its practice are psychological assessment and psychotherapy although clinical psychologists may also engage in research, teaching, consultation, forensic testimony, and program development and administration.

Credit for the first psychology clinic in the United States typically goes to Lightner Witmer, who established his practice in Philadelphia in 1896. Another modern psychotherapist was Morton Prince. For the most part, in the first part of the twentieth century, most mental health care in the United States was performed by specialised medical doctors called psychiatrists. Psychology entered the field with its refinements of mental testing, which promised to improve diagnosis of mental problems. For their part, some psychiatrists became interested in using psychoanalysis and other forms of psychodynamic psychotherapy to understand and treat the mentally ill. In this type of treatment, a specially trained therapist develops a close relationship with the patient, who discusses wishes, dreams, social relationships, and other aspects of mental life. The therapist seeks to uncover repressed material and to understand why the patient creates defences against certain thoughts and feelings. An important aspect of the therapeutic relationship is transference, in which deep unconscious feelings in a patient reorient themselves and become manifest in relation to the therapist.

Psychiatric psychotherapy blurred the distinction between psychiatry and psychology, and this trend continued with the rise of community mental health facilities and behavioural therapy, a thoroughly non-psychodynamic model which used behaviourist learning theory to change the actions of patients. A key aspect of behaviour therapy is empirical evaluation of the treatment’s effectiveness. In the 1970s, cognitive-behaviour therapy arose, using similar methods and now including the cognitive constructs which had gained popularity in theoretical psychology. A key practice in behavioural and cognitive-behavioural therapy is exposing patients to things they fear, based on the premise that their responses (fear, panic, anxiety) can be deconditioned.

Mental health care today involves psychologists and social workers in increasing numbers. In 1977, National Institute of Mental Health director Bertram Brown described this shift as a source of “intense competition and role confusion”. Graduate programmes issuing doctorates in psychology (PhD or PsyD) emerged in the 1950s and underwent rapid increase through the 1980s. This degree is intended to train practitioners who might conduct scientific research.

Some clinical psychologists may focus on the clinical management of patients with brain injury – this area is known as clinical neuropsychology. In many countries, clinical psychology is a regulated mental health profession. The emerging field of disaster psychology (see crisis intervention) involves professionals who respond to large-scale traumatic events.

The work performed by clinical psychologists tends to be influenced by various therapeutic approaches, all of which involve a formal relationship between professional and client (usually an individual, couple, family, or small group). Typically, these approaches encourage new ways of thinking, feeling, or behaving. Four major theoretical perspectives are psychodynamic, cognitive behavioural, existential-humanistic, and systems or family therapy. There has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of issues regarding culture, gender, spirituality, and sexual orientation. With the advent of more robust research findings regarding psychotherapy, there is evidence that most of the major therapies have equal effectiveness, with the key common element being a strong therapeutic alliance. Because of this, more training programmes and psychologists are now adopting an eclectic therapeutic orientation.

Diagnosis in clinical psychology usually follows the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook first published by the American Psychiatric Association in 1952. New editions over time have increased in size and focused more on medical language. The study of mental illnesses is called abnormal psychology.

Education

Educational psychology is the study of how humans learn in educational settings, the effectiveness of educational interventions, the psychology of teaching, and the social psychology of schools as organizations. The work of child psychologists such as Lev Vygotsky, Jean Piaget, and Jerome Bruner has been influential in creating teaching methods and educational practices. Educational psychology is often included in teacher education programmes in places such as North America, Australia, and New Zealand.

School psychology combines principles from educational psychology and clinical psychology to understand and treat students with learning disabilities; to foster the intellectual growth of gifted students; to facilitate prosocial behaviours in adolescents; and otherwise to promote safe, supportive, and effective learning environments. School psychologists are trained in educational and behavioural assessment, intervention, prevention, and consultation, and many have extensive training in research.

Work

Industrialists soon brought the nascent field of psychology to bear on the study of scientific management techniques for improving workplace efficiency. This field was at first called economic psychology or business psychology; later, industrial psychology, employment psychology, or psychotechnology. An important early study examined workers at Western Electric’s Hawthorne plant in Cicero, Illinois from 1924-1932. With funding from the Laura Spelman Rockefeller Fund and guidance from Australian psychologist Elton Mayo, Western Electric experimented on thousands of factory workers to assess their responses to illumination, breaks, food, and wages. The researchers came to focus on workers’ responses to observation itself, and the term Hawthorne effect is now used to describe the fact that people work harder when they think they are being watched.

The name industrial and organisational psychology (I-O) arose in the 1960s and became enshrined as the Society for Industrial and Organisational Psychology, Division 14 of the American Psychological Association, in 1973. The goal is to optimise human potential in the workplace. Personnel psychology, a subfield of I-O psychology, applies the methods and principles of psychology in selecting and evaluating workers. I-O psychology’s other subfield, organisational psychology, examines the effects of work environments and management styles on worker motivation, job satisfaction, and productivity. The majority of I-O psychologists work outside of academia, for private and public organisations and as consultants. A psychology consultant working in business today might expect to provide executives with information and ideas about their industry, their target markets, and the organisation of their company.

Military and Intelligence

One role for psychologists in the military is to evaluate and counsel soldiers and other personnel. In the US, this function began during World War I, when Robert Yerkes established the School of Military Psychology at Fort Oglethorpe in Georgia, to provide psychological training for military staff military. Today, US Army psychology includes psychological screening, clinical psychotherapy, suicide prevention, and treatment for post-traumatic stress, as well as other aspects of health and workplace psychology such as smoking cessation.

Psychologists may also work on a diverse set of campaigns known broadly as psychological warfare. Psychological warfare chiefly involves the use of propaganda to influence enemy soldiers and civilians. In the case of so-called black propaganda the propaganda is designed to seem like it originates from a different source. The CIA’s MKULTRA programme involved more individualised efforts at mind control, involving techniques such as hypnosis, torture, and covert involuntary administration of LSD. The US military used the name Psychological Operations (PSYOP) until 2010, when these were reclassified as Military Information Support Operations (MISO), part of Information Operations (IO). Psychologists are sometimes involved in assisting the interrogation and torture of suspects, though this has sometimes been denied by those involved and sometimes opposed by others.

Health, Well-Being, and Social Change

Medical facilities increasingly employ psychologists to perform various roles. A prominent aspect of health psychology is the psychoeducation of patients: instructing them in how to follow a medical regimen. Health psychologists can also educate doctors and conduct research on patient compliance.

Psychologists in the field of public health use a wide variety of interventions to influence human behaviour. These range from public relations campaigns and outreach to governmental laws and policies. Psychologists study the composite influence of all these different tools in an effort to influence whole populations of people.

Black American psychologists Kenneth and Mamie Clark studied the psychological impact of segregation and testified with their findings in the desegregation case Brown v. Board of Education (1954).

Positive psychology is the study of factors which contribute to human happiness and well-being, focusing more on people who are currently healthy. In 2010, Clinical Psychological Review published a special issue devoted to positive psychological interventions, such as gratitude journaling and the physical expression of gratitude. Positive psychological interventions have been limited in scope, but their effects are thought to be superior to that of placebos, especially with regard to helping people with body image problems.

Research Methods

Quantitative psychological research lends itself to the statistical testing of hypotheses. Although the field makes abundant use of randomised and controlled experiments in laboratory settings, such research can only assess a limited range of short-term phenomena. Thus, psychologists also rely on creative statistical methods to glean knowledge from clinical trials and population data. These include the Pearson product-moment correlation coefficient, the analysis of variance, multiple linear regression, logistic regression, structural equation modelling, and hierarchical linear modelling. The measurement and operationalisation of important constructs is an essential part of these research designs.

Controlled Experiments

A true experiment with random allocation of subjects to conditions allows researchers to make strong inferences about causal relationships. In an experiment, the researcher alters parameters of influence, called independent variables, and measures resulting changes of interest, called dependent variables. Prototypical experimental research is conducted in a laboratory with a carefully controlled environment.

Repeated-measures experiments are those which take place through intervention on multiple occasions. In research on the effectiveness of psychotherapy, experimenters often compare a given treatment with placebo treatments, or compare different treatments against each other. Treatment type is the independent variable. The dependent variables are outcomes, ideally assessed in several ways by different professionals. Using crossover design, researchers can further increase the strength of their results by testing both of two treatments on two groups of subjects.

Quasi-experimental design refers especially to situations precluding random assignment to different conditions. Researchers can use common sense to consider how much the non-random assignment threatens the study’s validity. For example, in research on the best way to affect reading achievement in the first three grades of school, school administrators may not permit educational psychologists to randomly assign children to phonics and whole language classrooms, in which case the psychologists must work with pre-existing classroom assignments. Psychologists will compare the achievement of children attending phonics and whole language classes.

Experimental researchers typically use a statistical hypothesis testing model which involves making predictions before conducting the experiment, then assessing how well the data supports the predictions. (These predictions may originate from a more abstract scientific hypothesis about how the phenomenon under study actually works.) Analysis of variance (ANOVA) statistical techniques are used to distinguish unique results of the experiment from the null hypothesis that variations result from random fluctuations in data. In psychology, the widely used standard ascribes statistical significance to results which have less than 5% probability of being explained by random variation.

Other Forms of Statistical Inference

Statistical surveys are used in psychology for measuring attitudes and traits, monitoring changes in mood, checking the validity of experimental manipulations, and for other psychological topics. Most commonly, psychologists use paper-and-pencil surveys. However, surveys are also conducted over the phone or through e-mail. Web-based surveys are increasingly used to conveniently reach many subjects.

Neuropsychological tests, such as the Wechsler scales and Wisconsin Card Sorting Test, are mostly questionnaires or simple tasks used which assess a specific type of mental function in the respondent. These can be used in experiments, as in the case of lesion experiments evaluating the results of damage to a specific part of the brain.

Observational studies analyse uncontrolled data in search of correlations; multivariate statistics are typically used to interpret the more complex situation. Cross-sectional observational studies use data from a single point in time, whereas longitudinal studies are used to study trends across the life span. Longitudinal studies track the same people, and therefore detect more individual, rather than cultural, differences. However, they suffer from lack of controls and from confounding factors such as selective attrition (the bias introduced when a certain type of subject disproportionately leaves a study).

Exploratory data analysis refers to a variety of practices which researchers can use to visualize and analyse existing sets of data. In Peirce’s three modes of inference, exploratory data analysis corresponds to abduction, or hypothesis formation. Meta-analysis is the technique of integrating the results from multiple studies and interpreting the statistical properties of the pooled dataset.

Technological Assays

A classic and popular tool used to relate mental and neural activity is the electroencephalogram (EEG), a technique using amplified electrodes on a person’s scalp to measure voltage changes in different parts of the brain. Hans Berger, the first researcher to use EEG on an unopened skull, quickly found that brains exhibit signature “brain waves”: electric oscillations which correspond to different states of consciousness. Researchers subsequently refined statistical methods for synthesizing the electrode data, and identified unique brain wave patterns such as the delta wave observed during non-REM sleep.

Newer functional neuroimaging techniques include functional magnetic resonance imaging and positron emission tomography, both of which track the flow of blood through the brain. These technologies provide more localised information about activity in the brain and create representations of the brain with widespread appeal. They also provide insight which avoids the classic problems of subjective self-reporting. It remains challenging to draw hard conclusions about where in the brain specific thoughts originate – or even how usefully such localisation corresponds with reality. However, neuroimaging has delivered unmistakable results showing the existence of correlations between mind and brain. Some of these draw on a systemic neural network model rather than a localized function model.

Psychiatric interventions such as transcranial magnetic stimulation and drugs also provide information about brain-mind interactions. Psychopharmacology is the study of drug-induced mental effects.

Computer Simulation

Computational modelling is a tool used in mathematical psychology and cognitive psychology to simulate behaviour. This method has several advantages. Since modern computers process information quickly, simulations can be run in a short time, allowing for high statistical power. Modelling also allows psychologists to visualise hypotheses about the functional organisation of mental events that could not be directly observed in a human. Computational neuroscience uses mathematical models to simulate the brain. Another method is symbolic modelling, which represents many mental objects using variables and rules. Other types of modelling include dynamic systems and stochastic modelling.

Animal Studies

Animal experiments aid in investigating many aspects of human psychology, including perception, emotion, learning, memory, and thought, to name a few. In the 1890s, Russian physiologist Ivan Pavlov famously used dogs to demonstrate classical conditioning. Non-human primates, cats, dogs, pigeons, rats, and other rodents are often used in psychological experiments. Ideally, controlled experiments introduce only one independent variable at a time, in order to ascertain its unique effects upon dependent variables. These conditions are approximated best in laboratory settings. In contrast, human environments and genetic backgrounds vary so widely, and depend upon so many factors, that it is difficult to control important variables for human subjects. There are pitfalls in generalizing findings from animal studies to humans through animal models.

Comparative psychology refers to the scientific study of the behaviour and mental processes of non-human animals, especially as these relate to the phylogenetic history, adaptive significance, and development of behaviour. Research in this area explores the behaviour of many species, from insects to primates. It is closely related to other disciplines that study animal behaviour such as ethology.[198] Research in comparative psychology sometimes appears to shed light on human behaviour, but some attempts to connect the two have been quite controversial, for example the Sociobiology of E.O. Wilson. Animal models are often used to study neural processes related to human behaviour, e.g. in cognitive neuroscience.

Qualitative and Descriptive Research

Research designed to answer questions about the current state of affairs such as the thoughts, feelings, and behaviours of individuals is known as descriptive research. Descriptive research can be qualitative or quantitative in orientation. Qualitative research is descriptive research that is focused on observing and describing events as they occur, with the goal of capturing all of the richness of everyday behaviour and with the hope of discovering and understanding phenomena that might have been missed if only more cursory examinations have been made.

Qualitative psychological research methods include interviews, first-hand observation, and participant observation. Creswell (2003) identifies five main possibilities for qualitative research, including narrative, phenomenology, ethnography, case study, and grounded theory. Qualitative researchers sometimes aim to enrich interpretations or critiques of symbols, subjective experiences, or social structures. Sometimes hermeneutic and critical aims can give rise to quantitative research, as in Erich Fromm’s study of Nazi voting or Stanley Milgram’s studies of obedience to authority.

Just as Jane Goodall studied chimpanzee social and family life by careful observation of chimpanzee behaviour in the field, psychologists conduct naturalistic observation of ongoing human social, professional, and family life. Sometimes the participants are aware they are being observed, and other times the participants do not know they are being observed. Strict ethical guidelines must be followed when covert observation is being carried out.

Program Evaluation

Program Evaluation is a systematic method for collecting, analysing, and using information to answer questions about projects, policies and programmes, particularly about their effectiveness and efficiency. In both the public and private sectors, stakeholders often want to know whether the programmes they are funding, implementing, voting for, receiving or objecting to are producing the intended effect. While programme evaluation first focuses around this definition, important considerations often include how much the programme costs per participant, how the programme could be improved, whether the programme is worthwhile, whether there are better alternatives, if there are unintended outcomes, and whether the programme goals are appropriate and useful.

Contemporary Issues in Methodology and Practice

Metascience

The field of metascience has revealed significant problems with the methodology of psychological research. Psychological research suffers from high bias, low reproducibility, and widespread misuse of statistics. These finding have led to calls for reform from within and from outside the scientific community.

Confirmation Bias

In 1959, statistician Theodore Sterling examined the results of psychological studies and discovered that 97% of them supported their initial hypotheses, implying a possible publication bias. Similarly, Fanelli (2010) found that 91.5% of psychiatry/psychology studies confirmed the effects they were looking for, and concluded that the odds of this happening (a positive result) was around five times higher than in fields such as space- or geosciences. Fanelli argues that this is because researchers in “softer” sciences have fewer constraints to their conscious and unconscious biases.

Replication

Over the subsequent few years, a replication crisis in psychology was identified, where it was publicly noted that many notable findings in the field had not been replicated and with some researchers being accused of outright fraud in their results. More systematic efforts to assess the extent of the problem, such as the Reproducibility Project of the Centre for Open Science, found that as many as two-thirds of highly publicised findings in psychology had failed to be replicated, with reproducibility being generally stronger in studies and journals representing cognitive psychology than social psychology topics, and the subfields of differential psychology (including general intelligence and Big Five personality traits research), behavioural genetics (except for candidate gene and candidate gene-by-environment interaction research on behaviour and mental illness), and the related field of behavioural economics being largely unaffected by the replication crisis. Other subfields of psychology that have been implicated by the replication crisis are clinical psychology, developmental psychology (particularly cognitive and personality development), and a field closely related to psychology that has also been implicated is educational research.

Focus on the replication crisis has led to other renewed efforts in the discipline to re-test important findings, and in response to concerns about publication bias and p-hacking, more than 140 psychology journals have adopted result-blind peer review where studies are accepted not on the basis of their findings and after the studies are completed, but before the studies are conducted and upon the basis of the methodological rigor of their experimental designs and the theoretical justifications for their statistical analysis techniques before data collection or analysis is done. In addition, large-scale collaborations between researchers working in multiple labs in different countries and that regularly make their data openly available for different researchers to assess have become much more common in the field. Early analysis of such reforms has estimated that 61% of result-blind studies have led to null results, in contrast to an estimated 5% to 20% in earlier research.

Misuse of Statistics

Some critics view statistical hypothesis testing as misplaced. Psychologist and statistician Jacob Cohen wrote in 1994 that psychologists routinely confuse statistical significance with practical importance, enthusiastically reporting great certainty in unimportant facts. Some psychologists have responded with an increased use of effect size statistics, rather than sole reliance on p-values.

WEIRD Bias

In 2008, Arnett pointed out that most articles in American Psychological Association journals were about US populations when US citizens are only 5% of the world’s population. He complained that psychologists had no basis for assuming psychological processes to be universal and generalizing research findings to the rest of the global population. In 2010, Henrich, Heine, and Norenzayan reported a systemic bias in conducting psychology studies with participants from “WEIRD” (western, educated, industrialized, rich and democratic) societies. Although only 1/8 people worldwide live in regions that fall into the WEIRD classification, the researchers claimed that 60-90% of psychology studies are performed on participants from these areas. The article gave examples of results that differ significantly between people from WEIRD and tribal cultures, including the Müller-Lyer illusion. Arnett (2008), Altmaier and Hall (2008), and Morgan-Consoli et al. (2018) saw the Western bias in research and theory as a serious problem considering psychologists are increasingly applying psychological principles developed in WEIRD regions in their research, clinical work, and consultation with populations around the world. In 2018, Rad, Martingano & Ginges showed that nearly a decade after Henrich et al.’s paper, over 80% of the samples used in studies published in the journal, Psychological Science, were from the WEIRD population. Moreover, their analysis showed that several studies did not fully disclose the origin of their samples, and the authors offer a set of recommendations to editors and reviewers to reduce the WEIRD bias.

From an anthropological perspective, scholars applied the WEIRD model to European history, arguing that a powerful Christian Church forced a radical change away from incest and cousin marriages that undermined the role of clans and created individualism in Europe by 1500 CE. They argue that a distinctive Western psychology thus emerged that valued agency, autonomy, and kindness towards strangers. Historians were not involved in that study, and have stated that it contains historical fallacies regarding an all-powerful Church at too early a point in time and a rejection of cousin marriage that did not happen.

Unscientific Mental Health Training

Some observers perceive a gap between scientific theory and its application – in particular, the application of unsupported or unsound clinical practices. Critics say there has been an increase in the number of mental health training programs that do not instil scientific competence. Practices such as “facilitated communication for infantile autism”; memory-recovery techniques including body work; and other therapies, such as rebirthing and reparenting, may be dubious or even dangerous, despite their popularity. In 1984, Allen Neuringer made a similar point[vague] regarding the experimental analysis of behaviour. Psychologists, sometimes divided along the lines of laboratory vs. clinic, continue to debate these issues.

Ethics

Ethical standards in the discipline have changed over time. Some famous past studies are today considered unethical and in violation of established codes (the Canadian Code of Conduct for Research Involving Humans, and the Belmont Report).

The most important contemporary standards are informed and voluntary consent. After World War II, the Nuremberg Code was established because of Nazi abuses of experimental subjects. Later, most countries (and scientific journals) adopted the Declaration of Helsinki. In the US, the National Institutes of Health established the Institutional Review Board in 1966, and in 1974 adopted the National Research Act (HR 7724). All of these measures encouraged researchers to obtain informed consent from human participants in experimental studies. A number of influential studies led to the establishment of this rule; such studies included the MIT and Fernald School radioisotope studies, the Thalidomide tragedy, the Willowbrook hepatitis study, and Stanley Milgram’s studies of obedience to authority.

Humans

University psychology departments have ethics committees dedicated to the rights and well-being of research subjects. Researchers in psychology must gain approval of their research projects before conducting any experiment to protect the interests of human participants and laboratory animals.

The ethics code of the American Psychological Association originated in 1951 as “Ethical Standards of Psychologists”. This code has guided the formation of licensing laws in most American states. It has changed multiple times over the decades since its adoption. In 1989, the APA revised its policies on advertising and referral fees to negotiate the end of an investigation by the Federal Trade Commission. The 1992 incarnation was the first to distinguish between “aspirational” ethical standards and “enforceable” ones. Members of the public have a five-year window to file ethics complaints about APA members with the APA ethics committee; members of the APA have a three-year window.

Some of the ethical issues considered most important are the requirement to practice only within the area of competence, to maintain confidentiality with the patients, and to avoid sexual relations with them. Another important principle is informed consent, the idea that a patient or research subject must understand and freely choose a procedure they are undergoing. Some of the most common complaints against clinical psychologists include sexual misconduct, and involvement in child custody evaluations.

Other Animals

Current ethical guidelines state that using non-human animals for scientific purposes is only acceptable when the harm (physical or psychological) done to animals is outweighed by the benefits of the research. Keeping this in mind, psychologists can use certain research techniques on animals that could not be used on humans.

  • An experiment by Stanley Milgram raised questions about the ethics of scientific experimentation because of the extreme emotional stress suffered by the participants.
    • It measured the willingness of study participants to obey an authority figure who instructed them to perform acts that conflicted with their personal conscience.
  • Comparative psychologist Harry Harlow drew moral condemnation for isolation experiments on rhesus macaque monkeys at the University of Wisconsin-Madison in the 1970s.
    • The aim of the research was to produce an animal model of clinical depression.
    • Harlow also devised what he called a “rape rack”, to which the female isolates were tied in normal monkey mating posture.
    • In 1974, American literary critic Wayne C. Booth wrote that, “Harry Harlow and his colleagues go on torturing their nonhuman primates decade after decade, invariably proving what we all knew in advance – that social creatures can be destroyed by destroying their social ties.”
    • He writes that Harlow made no mention of the criticism of the morality of his work.