ABSTRACT | PDF
SEMINAR
History of psychiatry
Arnab Bhattacharya
Postgraduate Trainee, Department of Psychiatry, Silchar Medical College and Hospital
Ancient ages Early Egypt - Mental illness was believed to be due to magical forces of deities and the priests were the therapists who used magicoreligious treatment.
Ancient Greece - Psychiatry was seen from religious, philosophical and medical points of view, conceptualizing mental illness as mainly psychological, mainly somatic or a mixture of both.
Hippocrates - Body had four humours i.e. phlegm, yellow bile, black bile and blood; and brain functioning depended on equilibrium between these. Excess black bile led to melancholia, yellow bile led to manic rage and phlegm caused dementia. He classified personalities into phlegmatic, choleric, sanguine types (first attempt to classify personality).
Plato - Divided soul into rational, appetitive (lust and greed) and spirit affective. He said madness occurred when appetitive soul lost influence of rational soul.
Aristotle - Plato’s pupil, he considered mental illness occurred when soul was subject to changes in temperature, black bile and emotions.
Phrenitis - Term used to refer to an inflammation that produced disturbances in both mind and body but whose precise location was not well defined. Later replaced by delirium, clouding and confusion.
Roman psychiatry - Followed from Greek school, thought mental illness resulted from passions and unsatisfied desires which acted upon the soul.
Galen - Great physician who said humours exist in hot, cold, dry and moist forms and were needed to form temperaments. He thought disease was due to bad air/bad diet acting on an existing predisposition (abnormal humour).
Neither Greece nor Rome took responsibility to treat the mentally ill. Most insane patients were kept restrained at home and insanity was evaluated by judges not physicians.
India - Psychiatry was labelled “bhut vidya” i.e. demonology and heredity was believed to have a causative role in mental disorders. Three main personality types were named: satvik, rajasik and tamasik. The sage Agasthya wrote a treatise on mental disorders called “Agastiyar kirigai nool.” King Ashoka in his rule established many hospitals in which mentally ill were humanely cared for along with physically ill people.
Middle ages Arab Islamic influence came to light. Some forms of mental illness were devil possession, dance mania, acedia (a type of depression). Treatment was by physicians or people claiming to have special powers.
Avicenna of Persia thought of various temperaments in humans, coined the term “vermis,” considered depression to be a mix of humours and gave music therapy for emotional disorders.
Arabs built asylums in Baghdad, Cairo, Damascus and other cities. In Europe first asylum to be built was in Hamburg in 1375. Around 1400 AD, the Bethlem hospital in London began and became a pioneer institute for care of the mentally ill.
Renaissance period In this time witchcraft came to prominence and Malleus described witches as women who had psychotic or hysterical symptoms. Torture was prescribed to force confessions of guilt from those who were accused. Witch hunting continued for about 150 years in which thousands of suspected witches were executed. Other methods were also practised like cauterization for “mal-i-hulya” (a variety of neurotic disorders) which was done in Turkey.
Seventeenth to nineteenth century Thomas Willis did autopsies and found out differences between mental symptoms of gross brain disease and those in which brain seemed normal (which he attributed to animal spirits). Rene Descartes said that man had a thinking substance, the soul which did not interact with the body thus creating a mind-body dichotomy. In Europe a practice of incarceration of mentally ill people began in which they were locked up for indefinite periods of time. With 18th century enlightenment demonic beliefs were gradually being replaced by rational thoughts and new theories of mental illness. Sauvages in France (1763) divided diseases into ten classes with class eight representing mental illness.
In 1765 William Cullen in England developed his own nosology and coined the term “neurosis” which he thought were due to the various parts of the brain being in stages of collapse and excitement. Franz Gall in Germany introduced “Phrenology” and said the brain had separate organs that occupied separate areas and shaped the personality and that the organs could be mapped on the surface. Philippe Pinel in France classified mental illness into four types - mania, melancholia, dementia and idiocy. He advocated the removal of chains of mentally ill patients at Bicetre and Salpetriere asylums in 1793 and 1800 respectively. He called this “Moral treatment of the insane”. Jean Esquirol developed theory of moral therapy and saw asylum as a weapon against mental illness. He differentiated illusion and hallucination. He separated mental illness into monomania and a general delirium like mania.
Theory of degeneration - Benedict Morel and Valentin Magnan opined that mental illness may be congenitally transmitted, could be activated by influence of alcohol, syphilis etc.
Functional psychosis descriptions Emil Kraepelin classified functional psychoses into manic depressive illness with good prognosis and dementia praecox which deteriorated into dementia. Eugene Bleuler coined schizophrenia for dementia praecox and said it does not always deteriorate. He introduced four A’s of schizophrenia (association, affect, autism and ambivalence). In France Baillarger (1854) described a dual form insanity called folie a double forme which was one of the earliest descriptions of bipolar disorder. Around the same time another Frenchman Jean Pierre Falret described an entity called folie circularie or circular insanity which was also a close description of bipolarity.
Some descriptions of psychoses - Karl Wernicke and Sergei Korsakoff described a syndrome in chronic alcoholics with multiple neuritis, memory failure and disorientation. Alois Alzheimer reported case of progressive psychosis and dementia in a woman with neurofibrillary degeneration and plaques in the brain, disorder named Alzheimer’s Disease. Antoine Bayle suggested General Paresis a common psychosis of that time was a separate entity, his view was initially ignored but later the infectious aetiology was proved.
Medical treatment of mental disorders Julius von Wagner Jauregg caused remissions in general paresis of insane (GPI) patients by inducing malarial fever in them. Was the first psychiatrist to be awarded Nobel prize in 1927 for this. Dementia due to pellagra was treated with foods having pellagra preventing factor (now known to be niacin or vit. B4). George Beard described “neurasthenia”, a syndrome of physical and mental exhaustion mostly seen among rich upper class and was treated by rest, massage, exercise etc.
Biological and psychological model Works of Morel and Bayle paved way for the supposition that mental illness may be explained by somatic causes. But in places like Germany the group of “mentalists” thought differently that the soul was the seat of these ailments. The other group “somatists” like Jakobi and Freidreich held the first type of view. Wilhelm Griesinger founded the speciality of neuropsychiatry and believed that all mental diseases are brain diseases. He also propounded the concept of “unitary psychosis” or einheitpsychose. With Griesinger, medical psychiatry was established in Germany as a branch of natural sciences. In England Henry Maudsley also believed in organic etiology of mental illness.
Neuroses and birth of psychotherapies The term coined by Cullen included two very ancient entities - hysteria and hypochondriasis. Charcot, a neurologist became interested in these subjects and developed a neurological theory for the disease and studied them using hypnosis. He was criticised by Bernheim, a Professor of Medicine saying suggestion played a key role in Charcot’s methods and many of his patients were instructed to perform to Charcot’s commands. Janet also studied these patients, coined the term “dissociation” and held that trauma was an important antecedent to it. Even Kraepelin was influenced by neurosis and included a chapter in his Textbook about purely psychological causes of some ailments. Johann Reil described “psychic therapy” which could help patients on the basis of psychological mechanisms of action.
From beginning of 20th century to World War II - Newer therapies emerged to treat mental illness: Malarial therapy for GPI (Jauregg), Insulin coma for schizophrenia (Sakel), Camphor induced seizure (Von Meduna), Electroconvulsive therapy (Bini, Cerletti), Barbiturate coma (Kalesi), Nazi euthanasia for mentally ill (“life unworthy of life”) at Hadamar, Germany - 200000 mentally ill people killed.
Freud - Austrian neurologist. Founder of psychoanalysis. Moved emphasis from organic to psychological approach. Some contributions of him: psychodynamics, infantile sexuality, libido theory, concepts of repression, transference, countertransference, topographical theory (concsious, preconscious, subconscious); structural theory (id, ego, superego), slips of tongue. His work influenced psychiatric thought for many decades.
Some other psychological therapies - Cognitive therapy (Beck), Interpersonal psychotherapy (Weissman, Klerman), Family therapy, Psychodrama (Jacob Moreno), Token economy (Allyon, Azrin), Dialectical behavioural therapy (Linehan), Hypnosis (Mesmer, Braid), Systematic desensitization (Wolpe), Social skills training.
Advent of psychopharmacology Opium has been used since long ago to treat psychiatric patients. Barbiturates, bromides, hypnotics, sedatives were used for marginal benefits.
1949 - Cade observed beneficial effect of lithium in mania, later Mogens Schou extended the research and applied it.
1952 - Delay and Deniker used chlorpromazine to calm psychotic patients.
1957 - Imipramine antidepressant (Kuhn).
1958 - Haloperidol (Paul Janssen).
1959 - Clozapine.
More antipsychotics, antidepressants, mood stabilizers evolved over time to strengthen the psychiatrist’s armamentarium.
Psychosurgery In early times digging a hole in skull was supposed to help mental patients. Egaz Moniz and Almeida Lima pioneered the art of psychosurgery to treat mental illness by prefrontal leukotomy. Now neurosurgical procedures using sophisticated gamma knife systems are available in various centers.
Antipsychiatry Hungarian born psychiatrist Thomas Szasz associated with antipsychiatry movement of 1960s and 70s. He opines that psychiatry should be a contractual service between consenting adults. He favours abolition of involuntary hospitalization for mental illness and has authored a book called "The myth of mental illness." Michel Foucault, the French philosopher in his book "Madness and civilization" says the very practice of the field was repressing and controlling. R D Laing, a psychoanalyst proposed that delusions of a schizophrenia patient was simply a different opinion and argues that these varying opinions threaten our security and are thus they are denied by imposing a diagnosis and “pathologizing” them.
Some Indian perspectives 1745 - Bombay asylum first to be built in India.
1787 - Calcutta asylum for insane europeans.
1793 - Madras private lunatic asylum (Dalton’s madhouse).
1795 - Lunatic asylum for Indian sepoys in Monghyr.
Girindra Shekhar Bose used psychoanalytic means to treat patients. He published the first psychoanalytic journal “Samikhsha” in India. He opened the first psychiatry unit in R G Kar Medical College, Calcutta. S Siddiqui and R Siddiqui isolated five alkaloids from snakeroot Rauwolffia serpentina plant. Ganesh Sen and Kartik Bose used it in cases of high blood pressure and psychosis (1931).
In Ranchi Indian Mental Asylum and Hospital for mental diseases were opened and became important centers for care in eastern India, now renamed RINPAS and CIP respectively. Indian Psychiatric Society formed in 1947 and Indian Journal of Neurology and Psychiatry formed and renamed Indian Journal of Psychiatry in 1958. Mental Health Act drafted in 1949 and passed in 1987.
Nobel prizes in psychiatry and related fields Ivan Pavlov (1904) – classical conditioning.
Hideyo Noguchi (1913) - T Pallidum causes GPI.
J Von Wagner Jauregg (1927) - Malaria therapy for GPI.
Egaz Moniz (1949) - prefrontal leukotomy.
Konrad Lorenz (1973) - Ethology (imprinting in animal behaviour).
Eric Kandel (2000) - physiological basis of memory storage in neurons.
References
Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th Ed
New Oxford Textbook of Psychiatry, Oxford University Press, 2003
Morgan and King Introduction to Psychology, 7th ed
Vyas and Ahuja Textbook of Postgraduate Psychiatry, Jaypee Publishers
A century of psychiatry by Hugh Freeman, Mosby
History of psychiatry, psychology and allied sciences by MS Bhatia and T Jagawat, CBS Publishers
Internet references
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