by Bruce Hershfield, MD, David Goodman, MD, and Donn Teubner-Rhodes, MD
[Spring 1999; Vol.26 No.1]
On November 13 and 14, 1998, distinguished scientists from the U.S.A. and the U.K. addressed an audience of more than 300 who had convened to honor Dr. Paul McHugh at The Johns Hopkins University, School of Medicine. On the previous day, the Paul R. McHugh Chair in Psychiatry had been dedicated and Dr. Edward Miller, Dean of the School of Medicine, had informed Dr. McHugh that Johns Hopkins' Board of Trustees had awarded him the rare honor of naming him "University Distinguished Services Professor." The McHugh Chair is to be dedicated to research with the emphasis on ·motivated behaviors". By the time that the symposium opened, $1.75 million had been raised for its endowment. In conjunction with the symposium, Drs. McHugh and Slavney's The Perspectives of Psychiatry was released in a second edition.
Drs. John Breitner and Phillip Slavney of Johns Hopkins began the first day's activities by describing Dr. McHugh's influence on a generation of students. "This man saves lives," was Dr. Breitner's comment. "He's the best teacher I've ever had," said Dr. Slavney, who himself has taught many of the Hopkins-trained psychiatrists who were present. Dr. Slavney also gave the first talk of the day, exploring the "mind-brain continuum -- the greatest mystery in psychiatry." This continuum cannot be completely integrated or completely separated; attempts have been made by psychiatric educators to abolish it, finesse it, or ignore it. Dr. Slavney commented on how DSM III ignored the issue, on today's "superficial eclecticism" and about how Dr. McHugh and he had described the "disease model, dimensions, behaviors, and life stories" in The Perspectives of Psychiatry.
The first visitor from the U.K., Gerald F. M. Russell, addressed "Clinical Science in Psychiatry." He touched on several interesting points about the correlation between personality disorders and Axis I, the centrality of patients in the clinical sciences, and the classification of treatments as "general" and "specific," concluding that there are new treatments and that we are learning more about the nature of illness. He was followed by Cornell University's Gerard Smith, MD, who lectured on "Satiation and Pleasure" and who reminded the audience of Dr. Curt Richter's work on the "shame-feeding rat" and of the finding that food-seeking behavior can be eliminated by experimental damage to the brain. Next up Hopkins' Timothy H. Moran, PhD, spoke about satiety issues, including an endogenous reaction that depends on a hormone released by the intestine in response to food.
After a break for lunch, Dr. Edward Miller, Dean of the School of Medicine, told the delighted audience of the Board of Trustees' decision to name Dr. McHugh a University Distinguished Services Professor.
The rest of the afternoon's talks centered on Geriatric Psychiatry and then on Psychiatric Genetics. Richard Mindham, MD of the University of Leeds, spoke about "Psychiatry of the Elderly." He reviewed data from the 1930s-1950s that showed that a substantial proportion of the elderly psychiatrically ill do recover. He predicted that we may eventually see the "very elderly" in the same way that the "younger over-65s" were seen in the 1940s. Dr. Peter Rabins then described Hopkins' geriatric psychiatry services. Few of the elderly were receiving any outpatient psychiatric treatment in the early 1980s, he commented. However, more recently, a study of the residents of an East Baltimore building revealed that only about 40% of those who were psychiatrically ill were getting any treatment for their problems at all.
Dr. Susan Folstein of the New England Medical Center began the talks about genetics--"Autism at Johns Hopkins and Beyond". She described Dr. Leo Kanner's 1943 criteria for autism, reviewed various statistics concerning the disorder, and went on to the features of the parents of autistic youngsters. Autistics have fewer friends, more difficulty with narrative discourse, and difficulty with "language pragmatics" . She was followed by Hopkins' Dr. Christopher Ross, who talked about Huntington's disease. He described the triad of movement disorders, cognitive changes, and affective changes that characterize the disorder. He explained the "expanding triplicate repeats" on chromosome 4; at least 36 of these repeats are necessary for the disorder to appear. The mechanism of the neuronal degeneration with glial sclerosis that is seen in the disorder is unknown, he said, but, injecting the IT-15 protein that is found in Huntington's into mice leads to the death of the animals, with the same microscopic changes that characterize the disease. J. Raymond De Paulo, Jr., MD finished the first day's lectures with a talk concerning bipolar disorder, personality traits, and alcoholism. Some of the points he made were: 1) DRD4 polymorphism is associated with "novelty-seeking" and polymorphism in the serotonin transport gene with "introversion," 2) Emil Kraepelin not only wrote in 1895 that manic-depression disease is genetic but he also did a twin study to support this concept, and 3) genes are best considered "risk factors" for phenotypic illnesses, but they don't determine that illnesses will appear all by themselves.
A reception followed the close of the day's activities. The lectures resumed on November 14th, with Joseph V. Brady, PhD talking about the motivational functions of drugs. He spoke about the model of drug abuse switching from "passive" to "motivated" behavior. He went on to describe a mobile treatment methadone program. Johns Hopkins' Dr. Glenn Treisman then captivated the audience with a lecture about "The Four Perspectives of AIDS Psychiatry", concentrating on extroversion/introversion and reward-directed and punishment-avoiding behaviors. "Treat the co-morbid disorders," he advised; this will yield better compliance and better outcome for AIDS patients.
Sir David Goldberg and Dr. William Breakey then concluded the morning's lectures. Dr. Goldberg, from the Maudsley Hospital, University of London, talked about "Biological Medicating Variables in Common Mental Disorder." He speculated that depression may be related to an imbalance between different serotonin systems and he listed six factors for vulnerability to this disorder. Dr. Breakey, from Johns Hopkins, told the audience about "Psychiatry on the Streets." A study of the homeless showed 35-40% had major mental illnesses, but their biggest problem is substance abuse. These people need engagement; help to transition back into the "world of other people," housing, rehabilitation services, and case management. "The problem remains," he concluded.
All that was left for the symposium to cover following lunch on the second day was a fine series of lectures about Neuropsychiatry, beginning with Dr. Fred Plum's talk about how Dr. McHugh went from Neurology to Psychiatry. From that starting point, Dr. Plum turned his attention to "words without mind"--verbalizations that occur in a vegetative state. He presented an interesting case of a woman who had suffered a severe CVA and who occasionally muttered profanity even though the words meant nothing to her because of her condition. Marshal Folstein, MD of the New England Medical Center then lectured about the "Noncognitive Symptoms of Dementia". He talked about depression and mania in Alzheimer's and he cautioned that the mania is often missed because the patients tend to be agitated and not classically euphoric. (They are more likely to be dysphoric and irritable.) Godfrey Pearlson, MB then talked about neuroimaging in schizophrenia. The greater the reduction in the volume of the superior temporal gyrus, he explained, the more pronounced the "positive" symptoms of the disorder. "Why does schizophrenia have its onset in late adolescence?"--a question that has struck psychiatrists for many years-may have its answer in the myelinization and pruning of neurons that continue well into this period of life.
Dr. Laura Marsh's lecture, "The Application of Epilepsy to the Study of Schizophrenia," described how the indications of pathology in the temporal lobes -- more often on the left side of the brain-- usually characterize "schizophrenia" in patients who have epilepsy. This is not a rare combination; 4-10% of epileptic patients also meet the criteria for the other disorder.
The last lecture of the day was delivered by Robert Robinson, MD, Chairman of Psychiatry at the University of Iowa, who pioneered the concept of post-stroke depression when he had been on the Hopkins faculty. He talked about the relatively robust response that these patients have to nortriptyline (compared to fluoxetine or to placebo) and about the greater risk for depression in patients whose CVAs are in the left frontal regions.
It was fitting that Dr. McHugh concluded the symposium's events with some remarks of his own. He has always focused on the "3 Ds" as Chairman--"discourse, discussion, and direction." As to the psychological theories, he emphasizes "facts first and hypotheses second." The audience responded with a standing ovation.