Psychiatry, Insane Asylums, Mental Illness, ECT, Lobotomies, Freud & Jung | Lex Fridman Podcast #502

Andrew Scull is a historian of psychiatry. Thank you for listening ❤ Check out our sponsors: https://lexfridman.com/sponsors/ep502-sb See below for timestamps, transcript, and to give feedback, submit questions, contact Lex, etc.

• The following is a conversation with Andrew Scull, a historian of psychiatry and mental health. He has authored many books that I highly recommend including Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine and Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness. Andrew Scull has spent decades studying how societies have understood madness, how psychiatry rose to authority, and how often that authority was used with false confidence and catastrophic consequences. In this conversation we’ll trace the long arc from the asylum era to eugenics, from lobotomy and insulin coma therapy to electroconvulsive therapy, psychoanalysis, antipsychotics, antidepressants and the modern crisis of mental health. It is in part a story about the terrifying history of bad ideas in medicine but it is also about the fascinating mystery of the human mind and about the difficult journey to understand it.

This is a Lex Fridman podcast. To support it please check out our sponsors in the description where you can also find links to contact me, ask questions, give feedback and so on. And now dear friends here’s Andrew Scull. Is it fair to characterize your view on psychiatry and mental illness as that there’s a crisis in modern psychiatry? We have made some progress- - Yes - …

over the past century but mostly we still are not good at treating mental illness either via the drugs or talk therapy meaning psychopharmacology or psychotherapy or as you put it the brain or the mind route. So let’s start at the end of our story. Let’s start at where we stand before we go into the rich history that you so eloquently write about. - So psychiatry is a profession that tries to deal with an enormously complicated thing. The human mind, the human emotions, the human ability to attempt to understand the world and in particular obviously it focuses on people where our common sense approach to the world seems to break down.

People whose emotional life is filled with turmoil, people whose ability to relate to others is badly damaged, people who see things in the world that the rest of us simply think aren’t there. They’re illusions, they’re hallucinations, they’re delusions and this is a subject that has occupied some very clever minds over the years and there’s no question that in the course of at least the last three quarters of a century there has been some limited progress in dealing with the problems that mental illness creates. Some of that is confined to the milder forms of mental distress; the more serious forms of psychosis and breakdown of emotional control those are areas where I think again there’s been some progress but it’s easy to overstate how much of that there’s been. As we’ll see probably later in our conversation today the advent of modern psychopharmacology which occurred in the early nineteen fifties was a serendipitous event. It wasn’t planned for.

It happened almost by accident and it did mark in some ways an advance over some of the things that psychiatry had engaged in before that and no question for some people that revolution and a parallel revolution in the psychotherapeutic realm have created some advance for patients and we should not minimize that. What we have available to us are symptomatic treatments not cures. We don’t have a psychiatric penicillin for any of the conditions we’re gonna be talking about. That doesn’t mean we can’t do some things that help but the help is quite limited and it’s important to understand both the ways in which we have progressed and the limits of that progress and also to understand that when we treat something sometimes we create new problems what we call iatrogenic problems, things caused by the interventions that we use. That’s true of some psychotherapeutic interventions and most certainly true of the drugs we use to treat mental illness these days.

So for example in treating PTSD we often get patients to confront the episode — the trauma which provoked their distress and that is often a very, very fraught process and for many patients it actually makes things worse. For some patients it makes them better. So that’s a situation where you could see problems With both antipsychotics and antidepressants, the two main classes of psychotropic drugs that we use, um, they’re at best partially effective and they don’t work for a significant fraction of patients who are given them and one of the big problems psychiatry faces is that psychiatrists don’t know in advance who’s going to respond well to the drugs, who’s going to respond badly, for which group of patients in the middle the side effects and the main effects, if that’s what we want to call them, the therapeutic effect are finely balanced and making those judgment calls about what to do are very, very difficult. Now in terms of the crisis psychiatry faces at the moment as I see it there are a number of strands that point to this. Psychiatry’s diagnostic system, that is still used — I mean, the fundamental basis of, of psychiatric diagnosis today was really first formulated in 1980 with the third edition of The Diagnostic and Statistical Manual of a profession — - DSM-III - …

DSM-III and then there’s been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM 5. Finally not with a Roman numeral but with with an Arabic numeral. So they thought with DSM 5 when they needed to modify it it would be like a piece of software. You have Windows 10, Windows 11, and so on right? Now that diagnostic system came into being because psychiatrists had a very hard time agreeing with one another about what was wrong with somebody, and that became embarrassingly clear in — first in the professional literature which outsiders didn’t read and then via a very famous study that’s a scientific fraud by David Rosenhan called On Being Sane in Insane Places where he claimed to have sent in pseudo patients to the hospital and they all were diagnosed as schizo.

All but one of them diagnosed as schizophrenic the other as somebody with bipolar disorder and they were fake patients. So almost in a panic after that study appeared in Science and because there was an abundant professional literature from the 1960s showing the same thing that diagnosis was a very erratic process. The DSM-III task force led by Robert Spitzer who was then at Columbia was explicitly set up to try to create a sort of tick the boxes approach to deciding which box a patient belonged in. Were you schizophrenic? Were you this type of schizophrenic or that type of schizophrenic?

Were you manic depressive or bipolar? Did you have various forms of depression? And to construct those boxes what they relied upon was a list of symptoms and if you had more than a certain number If you had more than six of ten Six or ten or more symptoms of a certain sort you could be diagnosed with major depression for example. So that system came into being. It was partially embedded because it appealed to drug companies who were developing drugs to treat these various disorders.

It appealed to insurance companies ‘cause it gave them a stable base to look at. It appealed to, as diagnosis always does to patients and their families who are scrambling to deal with these enormous upsets in the mental life of either themselves or a family member. So provided some sense of certainty around diagnosis. But that was always based simply on symptoms in the way an eighteenth century doctor might diagnose dropsy or diagnose, Some other kind of disor--- Fever for example well fever and other diseases they talked about in the eighteenth century are really