Some years ago, while rummaging around in a room full of psychiatric hospital records from the 1920s, I ran across the verbatim typescript of a memorable case conference. During this period two perspectives on understanding patients were actively competing. Psychoanalytic ideas were still relatively new and attempting to explain all sorts of phenomena that had previously been explained biologically. At the same time new biological treatments were infusing biologically oriented psychiatrists with new confidence. At this hospital the ambitious medical director had recruited a number of young clinicians from each of these perspectives. The case presented on that day was a middle aged man who had been treated with mercury some ten years earlier for symptoms of general paresis of the insane. Now he was admitted to the hospital for symptoms of depression with some suspicion that his general paresis had returned. In the days before penicillin, general paresis, which is a form of tertiary syphilis was a common frightening cause of madness and death. Its early psychiatric manifestations were quite variable, though most often they were mood related--mania and depression. While severe dementia eventually dominated the clinical picture, symptoms of dementia were, in the early stages, often subtle and easy to miss.
Why was this man depressed? The medical director posed this question to his young new staff somewhat in the manner of a professor presenting a question to a class. A lively discussion broke out. The biologically oriented psychiatrists noted that mood symptoms were common in such cases of general paresis. The psychoanalytically oriented psychiatrists argued that the sexual nature of the disorder ws producing guilt and that was leading to the symptoms of depression. The discussion went on for some time without resolution since the two perspectives were incommensurable. Eventually the medical director asked that they simply review the facts of the case. After some further discussion, he pointed out that ten years earlier the patient had thought himself cured of syphilis and free from the possibility of general paresis. Now, perhaps, the patient was able to subtle signs of dementia in himself and understood what was in store for himself. "Isn't that," the medical director concluded, "reason enough to be depressed."
Reading that case many years ago, I thought about how ideological arguments have the power to distract psychiatrists from what is staring them in the face. Over the years that I have practiced psychiatry, i have often had occasion to recall the lesson of that case conference.