A Brief History of Schizophrenia
Schizophrenia through the ages.
Posted Sep 08, 2012
[Article revised on 4 May 2020.]
What does ‘schizophrenia’ mean?
In 1910, the Swiss psychiatrist Paul Eugen Bleuler (d. 1939) coined the term 'schizophrenia’ from the Greek words schizo (‘split’) and phren (‘mind’). Bleuler had intended the term to denote a ‘loosening’ of thoughts and feelings, but, unfortunately, many people read it (and still read it) to mean a ‘split personality’.
What does ‘schizophrenia’ not mean?
Robert Louis Stevenson’s novel The Strange Case of Dr Jekyll and Mr Hyde (1886) did much to popularize the concept of a ‘split personality’, which is sometimes also referred to as ‘multiple personality disorder’ (MPD). However, MPD is a vanishingly rare condition that is entirely unrelated to schizophrenia. The vast majority of psychiatrists, myself included, have never seen a case of MPD, and many if not most suspect that such a condition does not exist. Yes, schizophrenia sufferers may hear various voices, or harbour strange beliefs, but this is not the same as having a ‘split personality’. Unlike Dr Jekyll, schizophrenia sufferers do not suddenly mutate into a different, unrecognizable person.
Ironically, Bleuler had intended to clarify matters by replacing the older, even more misleading term of dementia præcox [‘dementia of early life’]. This older term had been championed by the eminent German psychiatrist Emil Kraepelin (d. 1926), who believed, wrongly, that the illness only struck young people, and inevitably led to mental deterioration. Bleuler disagreed on both counts, and, therefore, renamed the illness ‘schizophrenia’. He held that, instead of mental deterioration, schizophrenia led to a sharpening of the senses and heightened consciousness of memories and experiences.
It is as common as it is unfortunate to hear the adjective ‘schizophrenic’ bandied about to mean something like ‘changeable’, ‘volatile’, or ‘unpredictable’, as in, ‘The weather today has been very schizophrenic.’ This sort of usage ought to be discouraged insofar as it perpetuates people’s misunderstanding of the illness, and, by extension, the stigmatization of schizophrenia sufferers. Even used correctly, the term ‘schizophrenic’ labels a person by an illness, implicitly reducing him or her to that illness. But people aren’t ‘schizophrenics’ any more than they are ‘diabetics’ or suffering with toothache.
Who ‘discovered’ schizophrenia?
Despite his shortcomings, Kraepelin was the first to distinguish schizophrenia from other forms of psychosis, and in particular from the ‘affective psychoses’ that can supervene in mood disorders such as depression and bipolar disorder. His classification of mental disorders, the Compendium der Psychiatrie, is the forerunner of today’s most influential classifications of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5) and the International Classification of Diseases 11th Revision (ICD-11). As well as listing mental disorders, these classifications provide operational definitions and diagnostic criteria that physicians and researchers use to establish and verify diagnoses.
Kraepelin first carved out schizophrenia from other forms of psychosis in 1887, but that is not to say that schizophrenia— or dementia præcox, as he called it—had not existed long before his 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 BCE. And archæological finds of Stone Age skulls with burr holes—drilled, presumably, to release evil spirits—have led to speculation that schizophrenia is as old as humankind.
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 disorder, 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.
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 (d. 377 BCE) that mental illness first became an object of scientific speculation.
Hippocrates taught that madness resulted from an imbalance of four bodily humours, and that it could be cured by rebalancing these humours 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 4th century BCE they represented a significant advance on the idea of mental disorder as a punishment from God.
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…
The Greek philosopher Aristotle (d. 322 BCE) and later the Roman physician Galen (d. 216 CE) expanded on Hippocrates’ humoural theories, and both men played an important role in establishing them as Europe’s dominant medical model.
In Ancient Rome, the physician Asclepiades (d. 40 BCE) and the statesman and philosopher Cicero (d. 43 BCE) rejected Hippocrates’ humoural 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 1st century CE the influence of these luminaries began to decline, and the influential Roman physician Celsus (d. 50 CE) reinstated the idea of madness as a punishment from the gods—an idea which gained currency with the rise of Christianity and the fall of the Roman Empire.
In the Middle Ages, religion became central to cure and, alongside the mediæval 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, 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 14th and 15th centuries. First published in 1563, De præstigiis dæmonum [The Deception of Demons] argued that the madness of ‘heretics’ resulted not from divine punishment or demonic possession, but from natural causes. The Church proscribed the book and accused its author, Johann Weyer, of being a sorcerer.
From the 15th century, scientific breakthroughs such as the anatomy of Vesalius (d. 1564) and the heliocentric system of Galileo (d. 1642) 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. Even so, the humoural theories of Hippocrates perdured into the 17th and 18th centuries, to be mocked by the playwright Molière (d. 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 (d. 1704) in England and Denis Diderot (d. 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 (d. 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’ 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?
Sigmund Freud (d. 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) had come to believe that mental disorders such as schizophrenia resulted from unconscious conflicts originating in early childhood.
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, schizophrenia is primarily seen as a biological disorder of the brain, although it is also acknowledged that psychological and social stressors can play an important part in triggering episodes of illness, and that different approaches to treatment should be seen not as competing but as complementary.
Even so, 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.
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 20th century, ‘fever therapy’ became a common form of treatment for schizophrenia. Psychiatrists attempted to induce fevers in their patients, sometimes by means of injections of sulphur or oil. Other popular treatments included sleep therapy, gas therapy, electroconvulsive (electroshock) therapy, and prefrontal leucotomy (lobotomy), which involved severing the part of the brain that processes emotions. Sadly, many such ‘treatments’ aimed more at controlling disturbed behaviour than at curing illness or alleviating suffering. In some countries, such as Germany during the Nazi era, the conviction that schizophrenia resulted from a ‘hereditary defect’ led to atrocious acts of forced sterilization and genocide. The first antipsychotic drug, chlorpromazine, first became available in the 1950s. Although far from perfect, it opened up an era of hope and promise for people with schizophrenia.
So, where to now?
In 1919, Kraepelin stated that ‘the causes of dementia præcox 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 ongoing medical research, a good outcome is increasingly likely.
Neel Burton is author of The Meaning of Madness and other books.