[Article updated on 17 September 2017]
Our understanding of mental illness has changed dramatically in recent times and is continuing to evolve. A look at the past can cast equal measures of doubt and enlightenment.
In antiquity, people did not think of ‘madness’ (a term that they used indiscriminately for all forms of psychosis) in terms of mental disorder but of divine punishment or demonic possession. Evidence for this comes from the Old Testament, and more particularly the First Book of Samuel, which relates how King Saul became ‘mad’ after neglecting his religious duties and angering God. Nothing is more revealing of Saul’s madness than the story of his senseless slaughter of the eighty-five priests at Nob. That David played on his harp to make Saul feel better suggests that, even in antiquity, people believed that psychotic disorders, or psychosis, 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, 23 (KJV)
In Greek mythology and the Homerian epics, madness is similarly thought of as a punishment from God—or the gods. Thus, Hera punished Herakles by ‘sending madness upon him’, and Agamemnon confided to Achilles that ‘Zeus robbed me of my wits’. It is in fact not until the time of Hippocrates (460-377 BC) that madness first became an object of scientific speculation. Hippocrates thought that madness resulted from an imbalance of four bodily fluids or humours. Melancholy, for instance, resulted from an excess of black bile (melaina chole), and could be cured by restoring the balance of the bodily humours by 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 4th century BC they represented a significant advance on the idea of madness as divine punishment or demonic possession. Aristotle (384-322 BC) and, later, the Roman physician Galen (129-200) elaborated on Hippocrates’ humoural 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 interesting to note that not all minds in Ancient Greece invariably thought of ‘madness’ as a curse or disease. In the Phaedrus, Plato quotes Socrates as saying that madness, ‘provided it comes as the gift of heaven, is the channel by which we receive the greatest blessings… madness comes from God, whereas sober sense is merely human.’
The Roman Empire
In Ancient Rome, physician Asclepiades (124-40 BC) and philosopher Cicero (106-43 BC) rejected Hippocrates’ humoural theories, asserting, for example, that melancholy results not from an excess of black bile but from emotions such as grief, fear, and rage. Cicero’s questionnaire for the assessment of mental disorders bore remarkable similarities to today’s psychiatric history and mental state examination (see Chapter 2). Used throughout the empire, it included, among others, sections on habitus (‘appearance’), orationes (‘speech’), and casus (‘life events’). Unfortunately, the influence of these luminaries began to decline in the 1st century AD, and physician Celsus (25 BC-50) reinstated the idea of madness as divine punishment or demonic possession, an idea which gained currency with the rise of Christianity and the decline of the Roman Empire.
The Middle Ages
In the Middle Ages, religion became central to cure, and, alongside the mediaeval asylums such as the Bethlehem (an infamous asylum in London that is at the origin of the expression, ‘like a bad day at Bedlam’), some monasteries transformed themselves into centres for the treatment of mental disorder. This is not to say that the humoural theories of Hippocrates had been supplanted, but merely that they had been incorporated into the prevailing Christian dogma, with older treatments such as purgatives and blood-lettings continuing alongside the prayers and confession.
During the Middle Ages, classical ideas had been kept alive in Islamic centres such as Baghdad and Damascus, and their re-introduction by St Thomas Aquinas (1225-1274) and others in the 13th century once again led to an increased separation of mind and soul, and to a shift from the Platonic metaphysics of Christianity to the Aristotelian empiricism of science. This movement laid the foundations for the Renaissance, and, later, for the Enlightenment.
The burning of the so-called heretics, often people with psychosis, began in the early Renaissance and reached its peak in the 14th and 15th centuries. First published in 1563, De praestigiis daemonum (The Deception of Demons) argued that the madness of heretics resulted not from supernatural forces but from natural causes. The Church promptly proscribed the book and accused its author, Johann Weyer, of being a sorcerer.
From the 15th century, scientific breakthroughs such as the heliocentric system of astronomer Galileo (1564-1642) began challenging the authority of the Church. Man, not God, became the focus of attention and study, and it is also around this time that anatomist Vesalius (1514-1564) published his landmark De humani corporis fabrica libri septem (The Seven Books on the Structure of the Human Body). The Fabrica represented the first serious challenge to Galenic anatomy and brought its author considerable fame and fortune. By the age of 28, Vesalius had become physician to the Holy Roman Emperor (neither Holy nor Roman, but in fact the Emperor of Germany), Charles the Quint.
Despite the scientific developments of the Renaissance, Hippocrates’ humoural theories perdured into the 17th and 18th centuries, to be mocked by playwright Molière (1622-1673) in such works as Le Malade imaginaire (The Imaginary Invalid) and Le Médecin malgré lui (The Doctor in Spite of Himself). Empirical thinkers such as John Locke (1632-1704) in England and Denis Diderot (1713-1784) in France challenged this status quo by arguing, in the same vein as Cicero, that the psyche arises from sensations to produce reason and emotions.
Also in France, physician Philippe Pinel (1745-1826) began regarding mental disorder as the result of exposure to psychological and social stressors, and, to a lesser extent, of heredity and physiological damage. A landmark in the history of psychiatry, Pinel’s Traité Médico-philosophique sur l’aliénation mentale ou la manie (A Treatise on Insanity) called for a more humane approach to the treatment of mental disorder. This ‘moral treatment’, as it had already been dubbed, included respect for the patient, a trusting and confiding doctor-patient relationship, decreased stimuli, routine activity and occupation, 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.
The Modern Era
In the 19th century, hopes of successful cures lead to the burgeoning of mental hospitals in North America, Britain, and many of the countries of continental Europe. Unlike the mediaeval asylums, these hospitals treated the ‘insane poor’ according to the principles of moral treatment. Like Pinel before him, Jean-Etienne-Dominique Esquirol, Pinel’s student and successor at the Salpêtrière Hospital, attempted a classification of mental disorders, and his resulting Des Maladies mentales… (Concerning Mental Illnesses) is regarded as the first modern treatise on clinical psychiatry. Half a century later, psychiatrist Emil Kraepelin (1856-1926) carried out his landmark classification of mental disorders, the Compendium der Psychiatrie, in which he distinguished schizophrenia (or dementia praecox, as he called it) from other forms of psychosis. Kraepelin further distinguished three clinical presentations of schizophrenia: (1) paranoia, dominated by delusions and hallucinations; (2) hebephrenia, dominated by inappropriate reactions and behaviours; and (3) catatonia, dominated by extreme agitation or immobility and odd mannerisms and posturing. Kraepelin’s Compendium is the forerunner of modern classifications of mental disorders such as the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5) and the International Classification of Diseases 10th Revision (ICD-10, see Chapter 2).
In the early 20th century, psychiatrist and philosopher Karl Jaspers (1883-1969) brought the methods of phenomenology—the direct investigation and description of phenomena as consciously experienced—into the field of clinical psychiatry. This so-called descriptive psychopathology created a scientific basis for the practice of psychiatry, and emphasized that symptoms of mental disorder should be diagnosed according to their form rather than to their content. This means, for example, that a belief is a delusion not because it is deemed implausible by a person in a position of authority, but because it conforms to the definition of a delusion, that is, ‘a strongly held belief that is not amenable to logic or persuasion and that is out of keeping with its holder’s background or culture.’
Sigmund Freud (1856-1939) and his disciples influenced much of 20th century psychiatry, and by the second half of the century a majority of psychiatrists in the US (although not in the UK) believed that mental disorders such as schizophrenia resulted from unconscious conflicts originating in early childhood. As a director of the US National Institute of Mental Health put it, ‘From 1945 to 1955, it was nearly impossible for a non-psychoanalyst to become a chairman of a department or professor of psychiatry.’
In the latter part of the 20th century, neuroimaging techniques, genetic studies, and pharmacological breakthroughs such as the first antipsychotic drug chlorpromazine completely reversed this psychoanalytical model of mental disorder, and prompted a return to a more biological, ‘neo-Kraepelinian’ model.
At present, mental disorders are primarily seen as a biological disorder of the brain, although it is also recognized that psychological and social stressors can play important roles in triggering episodes of illness, and that different approaches to treatment should be seen not as competing but as complementary.
However, critics tend to deride this ‘bio-psycho-social’ model as little more than a ‘bio-bio-bio’ model, with psychiatrists reduced to mere diagnosticians and pill pushers. Many critics question the scientific evidence underpinning such a robust biological approach, and call for a radical rethink of mental disorders, not as detached disease processes that can be cut up into diagnostic labels, but as subjective and meaningful experiences grounded in both personal and larger sociocultural narratives.