From the Editor
July, 2014. As we progress down the road of personalized medicine, individualized treatment planning is at an interesting place in time—a whole new place, yet one that has brought us full circle. In the early years of my career, individualized psychodynamically informed case formulation was the name of the game, and treatment planning was built on meticulous history-taking and fact-finding that explored early development, family dynamics, and symptom formation. A patient’s life story was sketched out, in order to fit the parts into a theory-based template shaped by clinical experience, to help explain what we understood to be anxiety-fueled “neurotic” distress, in the colors of depression, conversion, dissociation, obsession, compulsion, other conditions, and anxiety itself. This process took time, of course, but then we had time in those days. And I could tell you in vivid detail about many patients I treated over the years who, based on such formulations and treatment plans, worked hard with me to get better and did so. Did their improvement and relief from distress derive from our psychodynamic formulations at the time? Today I would say probably a lot, but not as exclusively as we thought then. We might use terms today like epigenetics or stress/vulnerability or risk factors or disruptions in attachment, and we should. But these concepts do not invalidate all of our previous theorybased assumptions—in fact, in very interesting ways, today’s neuroscience is providing scientific validation for many things that lived in the realm of theory in the past.
One of the ways that we have come full circle is the returning emphasis in personalized medicine on careful individualized assessment and treatment planning. New technology promises that future tools, such as brain imaging and genomic sequencing, will guide us as we tailor a given patient’s treatment based on the person’s individual biomarkers—data, not theory and clinical experience alone, to add to the treatment formulation. While not yet ready for prime time, the focus on the individual, not just the diagnostic criteria, is close at hand.
In this issue of the Journal, Clemens considers psychoanalysis from a historical perspective and then from the perspective of modern medical neurobiology. He cites recent advances in our knowledge about the plasticity of the brain and its capacity for repair, enrichment, and neurogenesis, and notes that “revising significant, long-standing neuronal patterns requires repeated experience over months or years,” a central feature of psychoanalysis and of most forms of psychotherapy. And a growing evidence base informs us in detail about indications for pharmacotherapy. Preskorn and McMahon present, in this issue’s Psychopharmacology column, the results of a very interesting survey concerning what medical students know about information in the “package insert” for FDA-approved medications—another source of information to guide treatment planning. In the future, as we learn more, we hope to identify specific patterns of brain structure and functioning that correlate with specific treatments, preferentially guiding us in the type of psychotherapy or medication to recommend for each patient.