The term ‘schizophrenia’ has led to much confusion about the nature of the illness, but Bleuler had intended it to replace the older, even more misleading term of ‘dementia praecox’ (‘dementia of early life’). This older term had been championed by the eminent German psychiatrist Emil Kraepelin, who mistakenly believed that the illness only occurred in young people and that it inevitably led to mental deterioration. Bleuler disagreed on both counts and, in an attempt to clarify matters, changed the name of the illness to ‘schizophrenia’. Bleuler believed that, contrary to mental deterioration, schizophrenia led to a heightened consciousness of memories and experiences.
It is as common as it is unfortunate to hear the adjective ‘schizophrenic’ being bandied about to mean ‘changeable’ or ‘unpredictable’. This usage should be discouraged because it perpetuates people’s misunderstanding of the illness and contributes to the stigmatization of schizophrenia sufferers. Even used correctly, the term ‘schizophrenic’ does little more than label a person according to an illness, implicitly diminishing him or her to little more than that illness. For this reason, I have dropped the term ‘schizophrenic’ from my books and articles in favour of ‘schizophrenia sufferer’. A person is not a ‘schizophrenic’ any more than he or she is a ‘diabetic’ or suffering with toothache.
Who ‘discovered’ schizophrenia?
Although Kraepelin had some mistaken beliefs about the nature of schizophrenia, he was the first person to distinguish the illness from other forms of psychosis, and in particular from the ‘affective psychoses’ that occur in mood disorders such depression and manic-depressive illness (bipolar affective disorder). His classification of mental disorders, the Compendium der Psychiatrie, is the forerunner of the two most influential classifications of mental disorders, the International Classification of Diseases 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders 4th revision (DSM-IV). Today these classifications are principally based on scientific research and expert opinion and, particularly in the case of ICD-10, on international consultation and consensus. As well as listing mental disorders, they provide operational definitions and diagnostic criteria that doctors use to reach a diagnosis of schizophrenia.
Kraepelin first isolated schizophrenia from other forms of psychosis in 1887, but this is not to say that schizophrenia—or ‘dementia praecox’, as he called it—had not existed long before Kraepelin’s day. The oldest available description of an illness closely resembling schizophrenia can be found in the Ebers papyrus, which dates back to the Egypt of 1550 BC. And archaeological discoveries of Stone Age skulls with burr holes drilled into them (presumably to release ‘evil spirits’) have led to speculation that schizophrenia is as old as mankind itself.
How was schizophrenia thought of in antiquity?
In antiquity, people did not think of ‘madness’ (a term that they used indiscriminately for all forms of psychosis) in terms of mental illness, but in terms of divine punishment or demonic possession. Evidence for this comes from the Old Testament and most notably from the First Book of Samuel, according to which King Saul became ‘mad’ after neglecting his religious duties and angering God. The fact that David used to play on his harp to make Saul better suggests that, even in antiquity, people believed that psychotic illnesses could be successfully treated.
But the spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him … And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him. —1 Samuel 16.14, 16.23 (KJV)
When did people first start thinking of schizophrenia as an illness?
In Greek mythology and the Homerian epics, madness is similarly thought of as a punishment from God—or the gods—and it is in actual fact not until the time of the Greek physician Hippocrates (460-377 BC) that mental illness first became an object of scientific speculation. Hippocrates thought that madness resulted from an imbalance of four bodily humors and that it could be cured by rebalancing these humors with such treatments as special diets, purgatives, and blood-lettings. To modern readers, Hippocrates’ ideas may seem far-fetched, perhaps even on the dangerous side of eccentric, but in the fourth century BC they represented a significant advance on the idea of mental illness as a punishment from God. The Greek philosopher Aristotle (384-322 BC) and later the Roman physician Galen (129-216) expanded on Hippocrates’ humoral theories and both men played an important role in establishing them as Europe’s dominant medical model.
Only from the brain springs our pleasures, our feelings of happiness, laughter and jokes, our pain, our sorrows and tears … This same organ makes us mad or confused, inspires us with fear and anxiety… —Hippocrates, The Holy Disease
It is perhaps worth noting that not everybody in antiquity invariably thought of ‘madness’ as a curse or an illness. In Plato’s Phaedrus, the Greek philosopher Socrates (470-399 BC) says,
Madness, provided it comes as the gift of heaven, is the channel by which we receive the greatest blessings … the men of old who gave things their names saw no disgrace or reproach in madness; otherwise they would not have connected it with the name of the noblest of arts, the art of discerning the future, and called it the manic art … So, according to the evidence provided by our ancestors, madness is a nobler thing than sober sense … madness comes from God, whereas sober sense is merely human.
In Ancient Rome, the physician Asclepiades and the statesman and philosopher Cicero (106-43 BC) rejected Hippocrates’ humoral theories, asserting, for example, that melancholia (depression) resulted not from an excess of ‘black bile’ but from emotions such as rage, fear, and grief. Unfortunately, in the first century AD the influence of Asclepiades and Cicero began to decline, and the influential Roman physician Celsus reinstated the idea of madness as a punishment from the gods—an idea to be later reinforced by the rise of Christianity and the collapse of the Roman Empire.
In the Middle Ages, religion became central to cure and, alongside the mediaeval asylums such as the Bethlehem in London, some monasteries transformed themselves into centres for the treatment of mental illness. This is not to say that the humoral theories of Hippocrates had been forgotten, but merely that they had been incorporated into the prevailing Christian beliefs, and the purgatives and blood-lettings continued alongside the prayers and confession.
How did beliefs change?
The burning of the so-called heretics—often people suffering from psychotic illnesses such as schizophrenia—began in the early Renaissance and reached its peak in the fourteenth and fifteenth centuries. First published in 1563, De praestigiis daemonum (The Deception of Demons) argued that the madness of ‘heretics’ resulted not from divine punishment or demonic possession, but from natural causes. The Church forbade the book and accused its author, Johann Weyer, of being a sorcerer.
From the fifteenth century, scientific breakthroughs such as those of the astronomer Galileo (1564-1642) and the anatomist Vesalius (1514-1584) began challenging the authority of the Church, and the centre of attention and study gradually shifted from God to man and from the heavens to the Earth. Unfortunately, this did not immediately translate into better treatments, and Hippocrates’ humoral theories persisted up to and into the eighteenth century.
Empirical thinkers such as John Locke (1632-1704) in England and Denis Diderot (1713-1784) in France challenged this status quo by arguing, very much as Cicero had done, that reason and emotions are caused by nothing more or less than sensations. Also in France, the physician Philippe Pinel (1745-1826) began regarding mental illness as the result of exposure to psychological and social stressors. A landmark in the history of psychiatry, Pinel’s Medico-Philosophical Treatise on Mental Alienation or Mania called for a more humane approach to the treatment of mental illness. This so-called ‘moral treatment’ included respect for the person, a trusting and confiding doctor-patient relationship, decreased stimuli, routine activity, and the abandonment of old-fashioned Hippocratic treatments. At about the same time as Pinel in France, the Tukes (father and son) in England founded the York Retreat, the first institution ‘for the humane care of the insane’ in the British Isles.
How did beliefs evolve in the 20th century?
The founder of psychoanalysis, the Viennese psychiatrist Sigmund Freud (1856-1939), influenced much of twentieth century psychiatry. As a result of his influence, by the second half of the twentieth century the majority of psychiatrists in the USA (although not in the UK) believed that schizophrenia resulted from unconscious conflicts originating in childhood.
Since then, the advent of antipsychotic medication, advanced brain imaging, and molecular genetic studies has confirmed beyond any reasonable doubt that schizophrenia is a biological disease of the brain.
Yet it is also recognized that psychological and social stresses can play an important role in triggering episodes of illness, and that different approaches to treatment should be seen not as competing but as complementary. Thanks to this fundamental realization, the advent of antipsychotic medication, and the shift to care in the community, schizophrenia sufferers today stand a better chance than ever before of leading a healthy, productive, and fulfilling life.
What treatments were used before the advent of antipsychotic medication?
Febrile illnesses such as malaria had been observed to temper psychotic symptoms, and in the early twentieth century ‘fever therapy’ became a common form of treatment for schizophrenia. Psychiatrists tried to induce fevers in their patients, sometimes by means of injections of sulphur or oil. Other popular but unsatisfactory treatments included sleep therapy, gas therapy, electroconvulsive or electroshock treatment, and prefrontal leucotomy—the removal of the part of the brain that processes emotions. Sadly, many such ‘treatments’ were aimed more at controlling disturbed behaviour than at curing illness or alleviating suffering. In some countries, such as Germany during the Nazi era, the belief that schizophrenia resulted from a ‘hereditary defect’ even led to atrocious acts of forced sterilization and genocide. The first antipsychotic drug, chlorpromazine, first became available in the 1950s, and opened up an era of hope and promise for schizophrenia sufferers and their carers. Since the advent of antipsychotic drugs, the use of electroconvulsive therapy in schizophrenia has become increasingly rare. Nevertheless, it should be underlined that modern electroconvulsive therapy is a safe and humane intervention, and that it can be highly effective in the treatment of severe mood symptoms that have not responded to medication.
So, where to now?
In 1919, Kraepelin stated that ‘the causes of dementia praecox are at the present time still mapped in impenetrable darkness’. Since then, greater understanding of the causes of schizophrenia has opened up multiple avenues for the prevention and treatment of the illness, and a broad range of pharmacological, psychological, and social interventions have been scientifically proven to work.
Today, schizophrenia sufferers stand a better chance than at any other time in history of leading a normal life. And thanks to the fast pace of on-going medical research, a good outcome is increasingly likely.
Neel Burton is author of Living with Schizophrenia.
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