Women in Psychiatry

Women in Psychiatry
   Several of the women involved with psychoanalysis, such as Anna Freud and Melanie Klein, are familiar figures. Yet, the lives of many other women who also made distinguished contributions to the fields of psychoanalysis, psychiatry, and psychopharmacology are relatively unknown. Here follows a partial list, one that could be considerably expanded.
   Marie Asberg (1938–). Pioneer investigator in psychopharmacology, Asberg graduated in medicine in 1965 at the Karolinska Institutet in Stockholm. She trained in psychiatry at the "KI," becoming associate professor of psychiatry there in 1975, then professor of psychiatry in 1982, chair of the department of psychiatry in 1985, and chair of the department of clinical neuroscience in 1993. Asberg is associated with several important discoveries in biological psychiatry. Based on the finding of other Swedish researchers that, at the same dose, there are large genetically determined differences in blood levels of the antidepressant drug nortriptyline from patient to patient, in 1971 she discovered, along with co-workers, and published in the British Medical Journal, that the patients with higher blood levels tended to develop side effects. As she later put it, "The high concentrations were not only unpleasant for the patient, but also made them less likely to recover from their depression." This was an early contribution to pharmacogenetics. She then became interested in the relationship between levels of the neurotransmitter serotonin and depression, and by chance in 1976 made a quite important discovery: that depressed patients with low levels of a metabolite of serotonin (called 5-HIAA, or 5-hydroxy-indole-acetic acid) in their spinal fluid were much more likely to attempt suicide than equally depressed patients with a high level of the serotonin metabolite. Bearing the name of two co-investigators as well, this work was published in the Archives of General Psychiatry. She is, however, best known for a psychiatric rating scale for depression that she and English psychiatrist Stuart Montgomery published in 1979 in the British Journal of Psychiatry and called the Montgomery–Asberg Rating Scale for Depression, or MADRS, which became standard in treatment studies all over the world.
   Lauretta Bender (1897–1987). An early student of the biological approach in child psychiatry, Bender was born in Butte, Montana, into a lawyer’s family. After studying neuropathology in Europe, in 1926 she graduated with an M.D. from the University of Iowa. She trained in psychiatry at the Boston Psychopathic Hospital, then in 1929–1930 was a research associate at the Phipps Clinic at Johns Hopkins University. In 1930, she came on staff in the psychiatric department of Bellevue Hospital in New York City, becoming in 1934 the psychiatrist in charge of the children’s service, where she remained until becoming in 1956 director of research of the new children’s unit at Creedmoor State Hospital. As well, from 1941 to 1958 she was professor of psychiatry at the New York University College of Medicine, and after 1959, she was professor at the College of Physicians and Surgeons of Columbia University. In 1974, she moved to Annapolis, where she taught at the University of Maryland until her death.
   Bender is best known for her studies of childhood schizophrenia, for which she introduced in 1934 the Bender Visual Motor Gestalt Test and in 1938 described it in a book of that title. She soon became convinced that schizophrenia was an organic condition and during the years introduced a variety of biological approaches to it, controversial at the time because she shunned such concepts as "schizophrenogenic mother." Her influential 1956 book, Psychopathology of Children with Organic Brain Disorders, extended the "organic" concept to include childhood schizophrenia. In 1961, she became president of the Society of Biological Psychiatry. She had followed psychiatrist Paul Schilder to New York in 1930 and married him in 1936 after his divorce; Schilder was killed in 1940 in a traffic accident, leaving her with three small children.
   Paula Jean Clayton (1934–). One of the best-known members of the St. Louis school—and the first woman to chair a department of psychiatry in the United States—Clayton was born in St. Louis, Missouri, and earned her M.D. at Washington University in 1960. After training in psychiatry at Washington University, she joined the department in 1965, becoming full professor in 1976. In 1980, she became head of the department of psychiatry at the University of Minnesota, where she served until her retirement in 1999. In 1965, she and George Winokur wrote in Comprehensive Psychiatry a definitive paper on mania, and during the years she and other members of the St. Louis school laid the basis for studying the genetics of mania and other affective disorders. Beginning in 1968, she undertook, in an article in the American Journal of Psychiatry, what turned out to be a lifelong study of bereavement, initially in widows, later in children and others. She was also interested in the mortality of patients with mood disorders, and in 2002, together with Jules Angst of Zurich’s university psychiatric hospital and other researchers, she published in the Journal of Affective Disorders a landmark 38-year follow-up study of such patients.
   Helene Rosenbach Deutsch (1884–1982). Celebrated for applying psychoanalytic concepts to the lives of women, Helene Rosenbach was born in Przemysl, Galicia, Austria (later Poland), into a prominent lawyer’s family. She finished her medical studies at the University of Vienna in 1912, then trained in psychiatry under Julius Wagner von Jauregg at the university clinic until 1919, becoming the first woman to serve as an assistant (albeit without the formal title) in that clinic. In 1918–1919, she did a training analysis with Sigmund Freud and quickly became part of his inner circle. In 1924, based on her experience with the Berlin psychoanalytic institute 1 year previously, she became founding director of the new training institute of the Vienna Psychoanalytic Society. In 1912, she married Felix Deutsch (1884–1964) (who later became Freud’s personal physician), and in 1935 Helene Deutsch and her son emigrated to the United States, followed by Felix a year later. The family settled in Boston, where Helene Deutsch joined the teaching staff of the Boston Psychoanalytic Institute; she was president of the Boston Psychoanalytic Society from 1939 to 1941.
   She is known for her psychoanalytic explorations of various phases of the life cycle of women, writing in 1925 Zur Psychoanalyse der weiblichen Sexualfunktionen (translated into English in 1991 as Psychoanalysis of the Sexual Functions of Women) and then The Psychology of Women: A Psychoanalytic Interpretation (2 vols., 1944–1945). She is also remembered for having postulated a kind of "as if" personality style in accounting for what she believed was a female tendency to be "imitatively suggestible," as her biographer Paul Roazen puts it. Given that Boston then was a stronghold of psychoanalysis, she supervised training analyses of many later influential figures in American psychiatry, including John C. Whitehorn (1894–1973), later head of the Phipps Clinic at Johns Hopkins University (from 1941 to 1960), and Erich Lindemann (1900–1974), who succeeded Stanley Cobb (1887–1968) as head of psychiatry at Massachusetts General Hospital. (On Lindemann, see Barbiturates: Narcotherapy; Posttraumatic Stress Disorder: acute grief [1944].)
   Charmian Elkes (1919–1995). Responsible for one of the earliest controlled clinical trials in psychopharmacology, Elkes was born in London, the daughter of Aleck Bourne, a noted gynecologist. She read medicine at King’s College Hospital, graduating in 1942. The following year, she married Joel Elkes and followed him to Birmingham, where she first worked as a family physician, then from 1949 to 1952 trained in psychiatry at All Saints Hospital; she served there as senior medical officer until 1957. In 1957, she and her husband moved to the United States. Joining the intramural program of the National Institute of Mental Health in 1959—and then as a staff psychiatrist at Johns Hopkins Medical School—from 1960 to 1968 she developed a pioneering program to train mental health counselors. Later, she was founding chief of psychiatry at a hospital in Columbia, Maryland, until her retirement in 1978. In Birmingham, from 1945 until 1951, she and Joel were involved in drug trials for schizophrenic catatonia; then, from 1952 to 1954, in Birmingham at the Winson Green Hospital, she led the first controlled trial of chlorpromazine, publishing the results together with her husband in 1954 in the British Medical Journal. (It was a crossover study, using the patients as their "own controls" by shifting them on and off placebo at various points during the trial.) She also ran a controlled trial of the Rauwolfia alkaloids including reserpine at the All Saints Hospital on chronic psychotic patients, noting that "The change in ward atmosphere brought about by reserpine is striking" (Journal of Mental Science, 1957, p. 473).
   Barbara Fish (1920–). A pioneer of pharmacotherapy in child psychiatry, especially in childhood schizophrenia, Fish was born in New York, her father an engineer, and graduated with an M.D. from New York University in 1945. A student of Lauretta Bender (see above), she trained in pediatrics and psychiatry at Bellevue Hospital, then served during the 1950s in various hospital and university appointments in New York. In 1960, she became psychiatrist in charge of the children’s service of the psychiatry division of Bellevue, and in 1972 she became professor of psychiatry at the University of California in Los Angeles, where she was emerited in 1991.
   She was a prominent student of the neurological antecedents of childhood schizophrenia, and as an investigator in the Children’s Psychopharmacological Research Unit of the New York University School of Medicine, she helped to open up the pharmacotherapy of the illness. She is especially known for the first long-term followup study of the children of schizophrenic mothers—following some of them to age 30—which she began at Bellevue Hospital in 1952. On the basis of early neurological development, she was able to predict which adults would develop schizotypal (schizophrenia-like) traits. See among other publications her article in the American Journal of Psychiatry in 1962. As one biographer says, "Her conception of schizophrenia as a neurobiological disorder met with hostility from the psychiatric community in the 1950s, when notions of castrating mothers and bungled toilet training were more popular as explanations for mental illnesses" (Halcomb, Women Making It, p. 216).
   Karen Horney (pronounced [HORN-eye]) (1885–1952). The initiator of feminist psychoanalysis, Horney was born Karen Danielsen in the wealthy Hamburg suburb of Blankenese, the daughter of a socially prominent sea captain’s family. She began medical studies first at Freiburg—where she was one of the first female medical students, then completed her state exam in Berlin in 1911 (having married in Berlin a fellow Freiburg student, Oscar Horney [1882–1948]). In 1911, she joined the newly founded (1910) Berlin Psychoanalytic Institute. She quickly had two daughters, then received her M.D. degree in 1915. After training in psychiatry (she had earlier undergone some psychoanalytic sessions, either for training or for personal therapy), she served in a military hospital during the First World War, and in 1919 opened a psychoanalytic private practice in the suburb of Zehlendorf. In 1920, she commenced a training analysis with Hanns Sachs (1881–1947) and later became director of training of the institute.
   As early as 1923 she began publishing on what became for her lifelong themes, such as the psychology of femininity and women’s sexuality and relationship to men; see particularly an article on the "female castration complex" in the International Journal of Medical Psychoanalysis (Internationale Zeitschrift für [ärztliche] Psychoanalyse) (the adjective "medical" was removed from the German title in 1920). In 1932, she emigrated to the United States as director of training of fellow Berliner Franz Alexander’s just-founded Chicago Institute of Psychoanalysis. Two years later, in 1934, she moved to New York to teach at the New School for Social Research and open a private practice. Because she ended up denying such theories as "penis envy"—believing women’s problems are much more a consequence of their oppression—some observers have hesitated even to call her a psychoanalyst (she never knew Freud and owed little to the Vienna circle). Indeed, the radical nature of her views about the constancy of change in the personality led to her expulsion, together with a like-minded group, in 1941 from the New York Psychoanalytic Institute, whereupon she organized her own Association for the Advancement of Psychoanalysis and an associated teaching institute.
   As a member of the "second generation" of analysts following Freud, Horney adopted a number of unconventional views, particularly in regard to women. She saw "women’s neuroses" more as a product of women’s position in the culture than of psychic development. She saw personality change as constant and ongoing rather than being cast in concrete at the end of infantile development. Among her books, translated in numerous languages and continuously reprinted, are The Neurotic Personality of Our Time (1937)—a book that rejected many of the key concepts of psychoanalysis— New Ways in Psychoanalysis (1939), and Our Inner Conflicts, A Constructive Theory of Neurosis (1945). Her collected essays, published posthumously in 1967 as Feminine Psychology, were influential in feminist theory.
   Eve Johnstone (1944–). An innovator in biological studies of schizophrenia, Johnstone grew up in Glasgow, her father a dental surgeon, and read medicine at the University of Glasgow (M.B. in 1967). From 1968 to 1972, she trained in psychiatry in various Glasgow hospitals, then began lecturing at the university. Early in her medical studies, she became curious about patients with schizophrenia: "I was fascinated by them. I could not believe that so little was known about this disease which so cruelly transformed, and indeed destroyed people who were the age that I was then." From 1974 to 1989, at the instigation of Timothy Crow, she served as a member of the scientific staff of the Medical Research Council’s clinical research center at Northwick Park Hospital in Harrow. In 1989, she returned to Scotland as chair of psychiatry at the University of Edinburgh.
   In 1976, with the MRC group at Harrow, she led the first team to discover brain abnormalities in schizophrenia with the aid of computerized tomography. (See NEUROIMAGING; SCHIZOPHRENIA: RECENT CONCEPTS [1976].) Published in the Lancet, this was the first finding of structural change in schizophrenia involving controls. It was in 1976 as well that Johnstone published an important but little noted paper in Psychopharmacologia on biochemical predictors of response to the antidepressant drug phenelzine (slow "acetylators" of the drug do better because they keep more of it on board). This was one of the first papers to identify a "polymorphic," meaning probably genetic, marker of drug response in psychopharmacology. In other work, Johnstone and colleagues did a controlled trial of real vs. sham ECT, discovering the real version to be more effective (reported in the Lancet in 1980). In research published in the British Journal of Psychiatry in 1986, she, Crow, and others determined that schizophrenic patients treated early with antipsychotics had a better prognosis, a finding that turned out to be of much interest.
   Veronica Murphy Pennington (1894–1986). A pioneer psychopharmacologist, she was born in Lansing, Iowa, and graduated with an M.D. from the University of Iowa in 1919 as the only woman in her class. After training in psychiatry at state hospitals in Cherokee, Iowa, and Peter, Minnesota, in 1928 she founded with her husband, Dr. Elree Pennington, a private psychiatric sanatorium in South Bend, Indiana, which they maintained until 1943. After further service at state hospitals in Indiana, Georgia, and Texas, in the mid-1950s she became senior staff psychiatrist at Whitfield Hospital in Mississippi. From that vantage point, she became part of the U.S. delegation to the Second World Congress of Psychiatry in Zurich in 1957, giving a paper on her various controlled trials, which had begun with reserpine in 1954 and chlorpromazine in 1955. At Whit-field, she further studied a whole series of drugs, the results of which endorsed some innovative combination therapies (which shortly, and perhaps unjustly, were to go out of style). (See her article in the American Journal of Psychiatry, 1962, summarizing this work, beginning with trials of reserpine in 1953 and continued through the 1950s with a host of antipsychotic agents.) She told the Congress that she had abandoned electroconvulsive therapy: "I now believe chemotherapy to be the most efficacious and safest treatment for neuropsychiatric patients" (Kline, Frontiers, p. 166).
   In the 1960s, Pennington shifted to the Veterans Administration hospital in Jackson, Mississippi, where she became part of the network of VA hospital trialists studying psychoactive drugs. Also in the 1960s, she authored or co-authored several key articles on psychotropic compounds just being introduced, especially a 1966 article in the Journal of the American Medical Association on the differential effect of various drugs in depression, which she co-wrote with John Overall (1929–), a psychologist–statistician at the University of Texas Medical Branch at Galveston (who had just moved there from a VA hospital in Kansas), and Leo Hollister (1920–2000) at the Veterans Administration hospital in Palo Alto, California.*
   Judith Livant Rapoport (1933–). A pioneer of biological child psychiatry, Rapoport was born in New York City, her parents Louis and Minna Livant Rapoport. She graduated with an M.D. from Harvard University in 1959, then trained in psychiatry at the Massachusetts Mental Health Center in Boston and at St. Elizabeths Hospital in Washington, D.C. After a postdoctoral fellowship at the Karolinska Hospital in Stockholm, in 1964 she became a National Institute of Mental Health fellow in child psychiatry at Children’s Hospital in Washington and remained associated with NIMH for the remainder of her career, serving simultaneously as a lecturer (later professor) in pediatric psychiatry at Georgetown University in Washington. In 1984, she became chief of the child psychiatry branch of NIMH’s division of intramural (meaning on-campus) research programs.
   Rapoport is known for her bestselling book, The Boy Who Couldn’t Stop Washing (1989), which placed obsessive-compulsive disorder (OCD) for children on the map. She and her group developed the first animal model for studying OCD. This work gave research on OCD a scientific basis and raised awareness of the disorder, so that currently there are about 500 treatment clinics specifically for OCD across the United States. She also helped found the discipline of pediatric psychopharmacology and in general was an early investigator of biological aspects of severe childhood psychiatric disorders, studied with magnetic resonance imaging.
   Hannah Steinberg (ca. 1926–). A pioneer of experimental psychopharmacology, Steinberg was born in Vienna; her father was a lawyer who practiced only briefly, thereafter helping Hannah’s mother in her wholesale pelt business. Hannah Steinberg came to London in 1939 in a Kindertransport—child Holocaust survivors who were brought by the British Jewish Refugee Committee, without their parents, out of Austria, Germany, Poland, and Czechoslovakia to Great Britain. After finishing high school in Putney, in 1948 she earned an undergraduate psychology degree at University College London (UCL), going on to a Ph.D. in the subject in 1954. After a postdoctoral fellowship in psychology, she began lecturing in psychopharmacology at UCL, where in 1970 she became professor of psychopharmacology, the first such professorship in the world. (She was emerited in 1989.)
   Working with Ruth Rushton and Michael Besser, she showed in 1963 in the British Journal of Pharmacology that—as she put it later—"combinations of amphetamines and a barbiturate could induce spectacular hyperactivity in rodents. It was much greater than any activity obtainable with any dose of the separate drugs and also greater than the sum of the activity induced by the separate ingredient drugs. We also showed comparable effects in volunteers." (See ANTIDEPRESSANT: first-generation antidepressants.) On the basis of this and similar research on the drug clenbuterol and the benzodiazepines, she received a lifetime achievement award from the British Association of Psychopharmacology that stated, "Only now are we beginning to realise that Hannah was tapping into the effects of drug combinations on neuronal second messenger systems, or beyond, and that understanding the interactions of drugs with receptors is merely the first step in explaining their effects on behaviour." Steinberg’s later research on the positive effects on mood of regular exercise also aroused a good deal of interest (see European Psychologist, 1998).
   * Hollister and Overall were among the most prominent of the early psychopharmacologists; it was in these years that they were developing computer-assisted assessment of patients. In 1962, Overall and Donald R. Gorham (1903–) at the Veterans Administration Central Neuropsychiatric Research laboratory, proposed the Brief Psychiatric Rating Scale [BPRS] in Psychological Reports, a test of psychopathology.

Edward Shorter. 2014.

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