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Since antiquity, persons with psychotic disorders and other forms of mental illness have been left to themselves, sent off in “ships of fools,” locked in cages, “flogged into reason,” chained or simply killed, in some instanced. Until the 1500s, the care of the insane in Europe -what little was offered- had been the responsibility of monks and nuns. For example, the oldest institution for the insane in England, the Bethlem Royal Hospital, was first established in 1247 as a priory, and by 1329 it functioned as a hospital. The patients were serviced by a 13th-century religious order known as the “Bethlehemites,” and on their habits they wore the special insignia of a red star with a dark blue center. The city of London took control of the place in 1346, and in 1547 it was made into a royal institution, headed by physicians, and the name was changed to St. Mary of Bethlehem. This was later changed to its present name, the Bethlehem Royal Hospital.
The “New Philosophy” and Madness-the 1600s
Many social and historical changes converged in the 17th century to change this dark state of affairs for people with mental disorders. First societies began to incarcerate mentally ill people in central institutions where many of them could be observed together for long periods of time. Second, physicians began to be put in charge of the care of the mentally ill in these institutions, in England and France. The institution of private madhouses for the care of the insane also began in this era and also involved physicians. And third, with the influence of Francis Bacon’s “new philosophy,” which sparked science as we know it, the concept of “disease” began to take on a new meaning. This was largely due to the influence of the English physician Thomas Sydenham (1624-1689) who emphasized the direct observation of illnesses and suggested their classification according to syndromes, or groups of symptoms.
The 1700s: Madness is classified
Throughout the 1700s, physicians who doctored to the mentally ill in madhouses began to be recognized for their medical specialty and were called “mad doctors” or “lunatic doctors” in England and its colonies. The more scientifically minded began to study the symptoms of mental illness for the first time in terms of syndromes. And many of the contributed treatises and classifications of their insane patients. In this endeavor the British led the way. Daringly, Haslam even reported on his autopsies of corpses of Bedlam patients, in an age where such practices were discouraged by British laws and “bodysnatchers” supplied medical students and professors which such commodities. Each author devised his own unique classification system for mental disorders, often burrowing concepts used for centuries, as well as coining new terms and phrases. It is certain that many cases of what we would now call schizophrenia were probably classified under one or more of these early attempts to devise a more scientific method of understanding mental illness.
The 1800s: Psychiatry (and Schizophrenia) Begins
Following the early lead of the British, after 1801 it was the French who dominated the medical study of the mentally ill until mid-century, when the Germans began their domination of this field. Indeed, the devotion of the early French alienistes to the study of classification of mental disorders directly led to the developments of a distinct medical specialty for mental illness, which is now universally known as “psychiatry.” The French were the first to include lectures of mental illness in their medical schools, and the British followed suit by the 1820’s.
In 1801 French physician Philippe Pinel Published his famous treatise on insanity (l’alienation mentale, or “mental alienation,” which led physicians who specialized in the care of the mentally ill to be called “alienists” in England). The first edition of Pinel’s Traite medico-philosphique sur l’alination mentale, ou la manie established him as the world’s leading authority on mental illness, and helped to persuade the world that mentally ill could be treated in a more humane manner through his philosophy of “moral treatment.” When Pinel was put in charge of the large institution of insane men in Paris following the French Revolution, he became famous for freeing 53 patients from their chains-without any disastrous consequences. Indeed, one of them, a former French soldier named Chivigne, became his bodyguard. The legend of Pinel unshackling the insane fit well with the revolutionary and democratic spirit of the times, and it helped to free psychological chains in the minds of caretakers of the mentally ill, that their charges were nothing more than beasts and should be treated as such. Variations of the “moral treatment” were already being developed in England by William Tuke at the York Retreat and by Vincenzo Chiarugi, ofthen referred to as “the Pinel of Italy.” This more humane treatment philosophy was not widely adopted in Europe until the mid-1800s, and even in England it took the reformist physician John Conolly’s “nonrestaint movement” in the 1840’s to finally bring lasting changes in the asylums in the country.
In the young United States, Philadelphia physician Benjamin Rush of the Pennsylvania Hospital began to study the insane patients with his institution and published a book on the subject, his Medical Inquiries and Observations upon the Diseases of the Mind of 1812, the only major American text book of psychiatry to appear until the 1880s. Thus, American physicians played almost no role in the Scientific description of classification of mental disorders until the 20th century.
Schizophrenia now enters the picture. In 1809, the very first clinical descriptions of schizophrenia as we know it appeared in print in two separate works. Working independently in their respective countries, John Haslam of the Bethlem Royal Hospital in London and Philippe Pinel of the Salpetriere asylum in Paris both produced expanded second editions of books on mental illness that had been published previously; they contain the first complete reports of what we now know as schizophrenia in its “chronic” form. The expanded second edition of 1809 of Pinel’s original 1801 treatise has never been translated into English. Whereas the concept of degeneration probably referred to cases that we would label schizophrenia today, it also referred to cases of one of the most frequently encountered psychotic disorders of the 19th and early 20th century, the “general paralysis of the insane,” which was later found to be caused by tertiary syphilis.
After Morel’s contribution of the “mental degeneration” concept in the 1850’s, and Jules Baillarger’s very first description of the “double-formed insanity” (what we now call bipolar disorder) in 1854, the French alienists subsided in importance, and it was the Germans, led by Whilhelm Griesigner, who began to dominate psychiatry until well into the 20th century (except perhaps, for Charcot’s contributions in Paris in the 1880’s to the understanding of hysteria and the use of hypnosis). Griesinger’s 1854 textbook, Die Pathologie and Therapie der Psychische Krankheiten (The Pathology and Therapy of Mental Disorders), provided a detailed classification of mental disorders that was based on the notion that they were organically based, indeed that they were all largely diseases of the brain. Although not new notion, the work of Griesinger and later German psychiatrists and neurologists helped to establish to the biological approach in psychiatry. Because of the contributions of the Germans, the biological approach is the central research strategy in the study of schizophrenia and the psychotic disorders today.
The 1840’s was the pivotal decade in the history of the profession of psychiatry. By this time the actual word “psychiatry” was in use in both Germany and England, and the very first professional association of such physicians were formed in Germany, England, France and in the United States. In 1844, 13 superintendents of state asylums from across America met together in Philadelphia and formed the organization that is now known as the American Psychiatric Association. In the 1870s, following the study of wounded veterans of the American Civil War, the first professional society for the medical specialty of neurology was founded. Thus the study of mental disorders now ha two branches of medicine with two very different philosophies, which remained at odds with one another until well into the 20th century.
With the Germans taking the lead, Psychiatry began to resemble its present form. Indeed, by the end of the 19th century our present notion of psychosis as a disorder involving a gross impairment in reality testing (a “break with reality”) and creation of a new reality had taken shape. Even today psychosis encompasses phenomena that were labeled “insanity,” “alienation” and “dementia” or degeneration in the 19th century. German psychiatrists such as Karl Kahlbaum and Ewald Hecker described specific psychotic disorders that are still included in our present definitions o schizophrenia-catatonia (first named by Kahlbaum in 1874) and hebephrenia (described by Hecker in 1874). By the end of the 19th century, the stage was set for the decisive definition of the psychotic disorders.
Dementia Preacox (1896)
At the end of the 19th century psychiatry could not yet agree on a universally recognized classification system for mental disorders. Classification systems would differ from hospital to hospital (by 1900, no longer officially called “asylums”), and often one of the first questions to be asked by visiting colleagues upon arrival at the mental hospital they had never been to before was, “whose classification system do you use?” Some might use Griesinger’s or Kahlbaum’s or some other authority’s, but by the 20th century a universally recognized authority had emerged-German Psychiatrist Emil Kraepelin. It was the successive editions of his constantly revised textbook, Psychiatrie, that were eventually adopted as the standard in Europe and the United States.
In 1896 the fifth edition of Psychiatrie came out and introduced the world to the chronic, progressively degenerative psychotic disorder that Kraepelin called dementia praecox. The name referred to the disorder’s rapid mental deterioration. Kraepelin combined a degenerative form of the ancient psychotic disorder known as paranoia with Kahlabaum’s catatonia and Hecker’s hebephrenia. Kreapelin’s concept of dementia praecox was based on its poor prognosis: All cases eventually ended up with severe mental degeneration and without remission. This was in distinction to the “recoverable psychoses,” the primary one of which he later named manic-depressive psychosis. Thus Kraepelin classified the psychoses (manic-depressive psychosis) and poor prognosis psychoses (dementia praecox). In his very first published descriptions of dementia praecox, Kraepelin outlined the characteristics that are still largely true today for schizophrenia: it is a disease that begins in late adolescence or early adulthood; it afflicts more men that women; it is largely hereditary; and it is first and foremost a brain disease due to a “tangible morbid process in the brain.” Indeed, Kraepelin believed a toxin in the brain case it to “autointoxicate” itself, thus producing the progressively degenerative symptoms and course of dementia praecox. Kraepelin considered negative or deficit symptoms to be a greater clinical significance, but the characteristic symptoms of this disorder have increased or decreased with the broadening or narrowing of its definition by others over the last century.
Not everyone agreed with Kraepelin’s emphasis on classification by prognosis. Indeed on Swiss psychiatrist, Eugen Bleuler, began to question the notion, observing that there were many different courses to the disorder, and that some persons with dementia praecox would plateau at particular level of deficit and stay at that lever for the rest of their lives, without degenerating any further. In 1908 Bleuler published a paper challenging Kraepelin’s views, and suggested that the disorder be renamed shisophrenia (from two Greek words meaning “to split” and “mind”) to remove emphasis on prognosis suggested by the term dementia praecox. Bleuler had been using the term “schizophrenia” in lectures to his medical staff at the Burgholzli Hospital in Zurich, Switzerland, prior to this time. In 1911 Bleuler published his classic monograph, Dementia Preacox oder die Gruppe der Schizophrenien. His description of schizophrenia (to which he added a fourth subtype, Otto Diem’s “simple schizophrenia”) was hailed as a major contribution, and the ideas in Bleuler’s 1911 book are still largely reflected in the classification systems in use today. No one has ever matched Bleuler’s insightful description of this disease.
The 1970s: Schizophrenia Becomes a Physical Disease Once Again
Advances in the technology to study biochemistry, brain function and structure, genetics and the development of brain imagining techniques (e.g., the CT scan) all covered to stimulate a biological renaissance in the study of schizophrenia and the phychotic disorders in the 1970’s. Suddenly it was appropriate to speak of schizophrenia as a “brain disease,” and psychoanalytic and family interaction models largely began to be ignored as legitimate causes of this disease (although it was found that psychosocial factors can have an effect on relapse rates in persons with schizophrenia). Genetic transmission was now estimated to be responsible for about 80% of the cause of schizophrenia, with other unknown environmental factors comprising the other 20%. Viral theories of the cause of schizophrenia were also resurrected after first being mentioned by Kraepelin and Bleuler almost a century before. Perinatal factors in the development of schizophrenia again began to be studied in earnest. Cross-cultural studies of the prevalence rates of schizophrenia were initiated by the World Health Organization. Twins studies and adoption studies conducted in the 1960s helped to form new and complex theories of the genetic transmission of schizophrenia in the 1970s and the 1980s. After decades of disappointment and neglect, the search for the causes of schizophrenia once again was viewed as a promising endeavor.
The 1980s, 1990s and Beyond
The last two decades of the 20th century brought more scientific progress than the last 100 years combined in the understanding and treatment of schizophrenia and the other psychotic disorders. We now know for a fact that genetics plays a key role in the cause and development of schizophrenia, bipolar disorder, and schizoaffective psychosis. Several candidates for the locus of the genes that causes schizophrenia are the subject of intense scrutiny, but chromosome 6 and chromosome 8 continue to be the most promising sites. The National Institute of Mental Health Schizophrenia Genetics Initiative that began in 1989 in collecting and analyzing the DNA of persons with schizophrenia and their entire families in order to find a solution. Environmental factors still play an important role, too, in the development of the psychotic disorders, but no one knows what they are or how they interact with genes.
Bad news technique: perhaps one of the earliest “cognitive” psychotherapeutic techniques on record is the practice of inventing false “bad news” to tell patients in order to quell their manic mood states. There is evidence that this rather sadistic “counter-cognitions” technique was used in the Bethlem royal hospital in England as early as the 1500s to change the behavior of unmanageable patients.
Bath of surprise: A type of immersion therapy, used until the 19th century, in which the mentally ill person was plunged without warning into cold water. Consists of plunging the patient into water when he least expects it. This is done by precipitating the patient into a reservoir, a river, or the sea. It is the fright which renders this means efficacious in overcoming sensibility.
Camisole: a heavy-canvas coat, reaching from neck to waist,m with long, closed sleves that are designed to wrap the wearer’s arms across the chest and are tied with cords behind the wearer’s back. In the 19th century the term camisole was merely a euphemism for a type of straightjacket, a term that had taken on a negative connotation by the end of the 1800s.
Chemical restraint: the use of drugs, as opposed to mechanical restraints (such as straps, straightjackets, muffs) to subdue psychiatric patients. Although anti-psychotic drugs were only brought into use in the 1950s to treat psychotic disorders by reducing their symptoms, many different types of drugs have been used for centuries to restrain patients engaged in undesirable behaviors. Often such pharmacological agents were use as punishment. In the 18th and 19th centuries such drugs may have been administered as a daily “physic” said to improve the health of a patient. Camphor and opiates in particular are mentioned in these early accounts. By the end of the 19th century many sedatives had been created that were then widely used (often to the point of excess) in mental hospitals.
Coma Therapy: in the 20th century several biological treatments were developed for schizophrenia that were based on the deliberate induction of a comatose state in the patient, with the assumption that the patient would reawaken in a much improved state. The most famous variety of coma therapy was insulin coma therapy, developed by psychiatrist M. Sakel and his associates in Australia in 1936, in which a deep hypoglycemic coma was induced in schizophrenics as a sort of “shock” to their system. While coma therapy was widely used throughout the 1940s and 1950s, it disappeared after the introduction of anti-psychotic drugs for the treatment of schizophrenia. Other forms of coma therapy for schizophrenia involved inducing a comatose state through inhaling pure nitrogen or by injections of atropine, but neiter of these forms were widely utilized. No rational theory explaining why coma therapy worked for some patients was ever formulated.
Continuous sleep therapy: Swiss psychiatrist Jacob Klasi developed this form of therapy for schizophrenics in the early 1920s. it is perhaps the fist true physical treatment for schizophrenia. Klasi induced a prolonged sleep in his patients with the use of barbiturates. These periods of sleep lasted a week or more, and the patient was only allowed to ear or perform bodily functions upon wakings, after which more barbiturates would be administered and the patient would be put back to sleep. His only theory to rationalize this treatment was that schizophrenia was the result of a pathological excitement that resulted in inflammatory process in the brain that would be alleviated through rest, as other inflammatory conditions could be. However, the complications of the procedure (toxicity, the development of respiratory problems and pneumonia) outweighed the apparent therapeutic benefits, and thus the treatment was not widely used.
Conclusive therapies: Although no sound scientific theories have ever supported their use, the convulsive therapies have been among the most widely used somatic treatments for schizophrenia in this century. The basic idea is that deliberately inducing a convulsion or seizure-either by drugs or electricity- somehow has a therapeutic effect in schizophrenia.
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