Descriptive Psychopathology: The Signs and Symptoms of ...

334 Section 3: Examination domainsThe superego represented internalized social prohibitions modulating the instinctiveimpulses. The ego was also hypothesized as an arbitrator between the id andsuperego. Too much id or superego, or too fragile an ego, was said to causepersonality deviation and, when extreme, neurosis or even psychosis. The balanceor imbalance evolved over several psychosexual stages in childhood. Psychoanalysiswas envisioned as the process that would reveal the patient’s id, ego and superegorelationships and the reasons for them. Through an understanding of interactionswith the therapist that mirrored the patient’s relationships with parental figures(transference), the patient would gain emotional insight and subsequent personalitychange. Freud’s contemporaries such as Jung and Adler, 7 and the “neo-Freudians”such as Karen Horney, Harry Stack Sullivan, Erich Fromm, and Erik Erikson spreadpsychoanalytic notions, but did not influence psychiatric classification.In 1909, Freud gave a series of lectures at Clark University in Worcester,Massachusetts, introducing psychoanalysis to the USA. No individual in the twentiethcentury had a greater influence on American psychiatry and culture. For thenext 50 years, psychoanalytic thought dominated psychiatric research and treatmentin the USA, and psychoanalysts dominated training programs. From the endof WWII until the 1970s, almost all academic chairs in psychiatry were fully trainedpsychoanalysts. Despite few current psychiatrists in the USA considering themselvespsychoanalysts, the psychoanalytic movement still influences accreditation guidelinesfor psychiatric residency training programs and DSM and ICD formulations.Pop culture, literature, the visual and performing arts also consistently presenta psychoanalytic view of reality and of human nature. Modern actors “analyze”their “character” searching for “motivations” for the character’s actions, a directlink to Freudian theory. Shakespeare, by contrast, indicates no interest in hischaracters’ motivations, yet he is first among Western playwrights and is said tohave “invented” by demonstration the modern person. Elizabethan actors playedparts not characters. 8Learning theory and biologyThe most serious early challenge to the Freudian view of human nature camefrom learning theorists, who proposed that much of human behavior, includingabnormal behavior, was learned and therefore could be unlearned. 9 They documentedthe poor efficacy of psychoanalytic-based treatments, 10 and offeredclassical and operant conditioning paradigms as processes underlying phobiasand other neurotic disorders. 11 Behavior therapy, based on learning theories, wasquickly shown to be effective for phobias, and in the late 1970s, after years ofacrimonious debate, became the standard treatment for those conditions. 12The introduction of cognitive behavior therapy further narrowed the perceivedindications for psychoanalysis. 13