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Home , 20 Years Paranoid, Emil Kraepelin, History of psychiatry, Johann Christian Reil, Mogens Schou

History of

Psychobiology Research Group

Prof Nicol Ferrier BSc (Hons), MD, FRCP(Ed), FRCPsych

Emeritus Professor of Psychiatry Newcastle University :- Plan

1. Introduction 2. The concept of affective disorders: historical evolution 3. Current controversies:- a. Classification b. The bipolar/ dichotomy c. Mixed states 4. The history of UK asylums 5. The history of ECT and 6. Antipsychiatry developments 7. Conclusions The first page of Reil’s 1808 article, showing the first use of the word ‘psychiatry’.

Andreas Marneros BJP 2008;193:1-3

©2008 by The Royal College of , 1759-1813 Professor of at the University of , ,1787-1810

According to Reil, the causes of human cannot be distinguished into purely mental, chemical or physical ones, but rather there is an essential interaction among these three domains. ‘Therefore we will never find pure mental, pure chemical or mechanical diseases. In all of them one can see the whole: an affection of the one process of life, which sometimes accentuates this and sometimes that side.’ Reil’s key points about psychiatry

Marneros, A BJPsych 2008;193:1-3

Psychiatry (a) Psychiatry is a pure medical specialty. Philosophers and psychologists shall not be allowed to press for ‘incorporation’. (b) Only the best shall become psychiatrists. (c) A medical specific to the needs of the shall be fundamental to medical training. (d) Psychiatry, psychosomatics and medical psychology are closely allied. Reil’s key points about psychiatry

Marneros, A BJPsych 2008;193:1-3

Mental illness (a) Mental diseases are universal. Everybody can get them. (b) It should be examined whether the criminal responsibility of mentally ill people is diminished or even non-existent during the illness. (c) An anti-stigma campaign is required, and humanity should be primary in the treatment of the mentally ill. Treatment and care (a) Humane mental institutions are the basis of high-quality care. b) asylums should be changed into mental hospitals. (c) Prevention in free intervals: supportive measures and avoidance of ‘high-expressed emotions’ and of over- and under-stimulation. (d) (‘psychic therapy’) is an equivalent therapy method – in addition to surgery and pharmacotherapy – for mental as well as for somatic diseases. (e) Mental problems may cause somatic disorders (psychosomatic disorders).

Reil J, Hoffbauer J. Beytrage zur Beforderung einer Kurmethode auf psychischem Wege. Curtsche Buchhandlung, 1808. The concepts of affective disorders:- historical evolution

Prehistory to medieval periods

17th to 19th centuries

20th Century up to 1977 Affective Disorders

Henry Maudsley (1835-1918) proposed an overarching category of affective disorder. The term is similar to but different from . The latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others. Affective disorders-prehistory to medieval periods has always existed. King Saul is described as experiencing depression and committing suicide because of it in the Old Testament. Reports in early Greek literature of (Greek ania : anguish manos: relaxed) and perhaps in this cave painting (!) Depression-prehistory to medieval periods

• thought to be due to an imbalance in four body fluids or humours

Hippocrates (460-370BC) described melancholia (Greek melas :black, khole: bile) as a distinct disease characterized by “fears and despondencies, if they last a long time”

"Grief and fear, when lingering, provoke melancholia." Depression-prehistory to medieval periods

Aretaeus of Cappadocia (ca AD 30-90). Melancholics were “dull or stern: dejected or unreasonably torpid, without any manifest cause”

Aretaeus also worked on ideas about premorbid personalities and discovered that individuals who became manic were characteristically labile in nature, easily irritable, angry or happy. Those who developed melancholia tended to depression in their premorbid state. Emotional disorders were merely an extension or exaggeration of existing character traits, a very original idea for the time. Depression-prehistory to medieval periods

Galen (AD 30-90) Mental disease arose because either because the brain was directly afflicted (mania and melancholia) or because it was affected by disorder in another organ.

Souls Location Function Rational Brain Controls internal and external functions. Internal = imagination, judgement, memory, apperception, movement. External = the five senses.

Irrational Heart Control all emotions and liver Depression-prehistory to medieval periods

• Physicians in the Persian and then the Muslim world developed ideas about melancholia and during the Islamic Golden Age. The 11th century Persian physician described melancholia as a depressive type of mood disorder in which the person may become suspicious and develop certain types of phobias • His work, The Canon of Medicine, became the standard of medical thinking in Europe alongside those of and . Moral and spiritual theories also prevailed. Aretaeus of Cappadocia (1st Century)1  ...such become euphoric, they laugh, they joke, they sing, ‘they show off in public with crowned heads as if they were returning victorious from the games; sometimes they laugh and dance all day and all night’

1. Roccatagliata, G.A (1986). History of ancient psychiatry. Greenwood Press, New York Aretaeus of Cappadocia (1st Century)1  The who previously was euphoric and hyperactive suddenly ‘has a tendency to melancholy; he becomes, at the end of the attack, languid, sad, taciturn, he complaints that he is worried about his future, he feels ashamed..’

1. Roccatagliata, G.A (1986). History of ancient psychiatry. Greenwood Press, New York Depression-prehistory to medieval periods Later medieval period Psychological problems were entwined with legal and religious issues. Era of the witch-hunt and notion of devil-possession. “..if doctors could find no cause for a disease and it did not respond to traditional treatment it was caused by the devil” Malleus Maleficarum,1486

Growth of palm-reading and astrology. The importance of celestial bodies on health lead to the term “lunatic”

Some dissenting voices… usually social philosophers Affective Disorders- 17th to 19th centuries • C17th “The Era of Reason and Observation” • Reformation 1517-1648 Depression- 17th to 19th centuries

The seminal scholarly work of the 17th century was English scholar Robert Burton's book, The Anatomy of Melancholy (1621) drawing on numerous theories and the author's own experiences. Burton suggested that melancholy could be combated with a healthy diet, sufficient sleep, music, and "meaningful work", along with talking about the problem with a friend. Depression- 17th to 19th centuries

Conflicting views continued in early C19 Heinroth’s views that sin was the causal factor in mental illnesses were influential But.. Hospital reformers ( eg Pinel in , Chiarugi in Italy and Tuke in UK) came along and applied humanitarian principles to the care of mentally ill But.. Pinel and Gail’s ideas that affective disorder arose in the abdomen or shape of the skull were strongly followed But… Esquirol emphasised the social and psychological origins of depression Pinel Depression- 17th to 19th centuries

An early usage referring to depression as a psychiatric symptom was by French Louis Delasiauve in 1856, and by the 1860s it was widely used to refer to a physiological lowering of emotional function. Melancholia had been associated with men of learning and intellectual brilliance. The newer concept became more associated with women through the 19th century. Although melancholia remained the dominant diagnostic term, depression gained increasing currency and was a synonym by the end of the century. German psychiatrist may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states. She experiences twin symptoms which are her constant companions, Mania and Melancholy, and they succeed each other in a double and alternate act; or take each other’s place like the smoke and flame of a fire. Falret, J. (1854). Memoire sur la folie circulaire. Bulletin de la Academie Imperiale de Medicin (), 19, 382–400

The case of Anne Greville, John Locke 1679. Manic-depressive illness- 17th to 19th centuries Jules Baillarger (1809-1890) Described “folie a double forme” in Jan 1854 Manic-depressive illness- 17th to 19th centuries Jean-Pierre Falret (1794-1870)

Falret described a circular disorder (la folie circulaire)1 in February1854

For the first time defining an illness in which ‘this succession of mania and melancholia manifests itself with continuity and in a manner almost regular’

This emphasised the concept that the manic and depressive episodes were not different attacks but rather different stages of the same attack, a single disease Falret, J. (185di(Paris), 19, 382–400 1.Falret, J. (1854). Memoire sur la folie circulaire. Bulletin de la Academie Imperiale de Medicin(Paris), 19, 382–400 The German School of C19

W Griesinger (1817-1886). Mental diseases were somatic and disorders of the brain. He also believed in the integration of the mentally ill into society

K L Kahlbaum (1843-1899) Wrote about cyclic insanity and depression in their milder forms which he termed “” and “”. Focussed on course and outcome

Both were strong influences on Emil Kraepelin…. Emil Kraepelin (1856 – 1926)

 Segregated psychotic illnesses from each other, clearly drawing a perimeter around manic– depressive illness1

 Emphasized those aspects of manic–depressive illness that separated it most clearly from praecox: ▪ The periodic or episodic course ▪ The more benign prognosis ▪ A family history of manic–depressive illness

Also first used term “involutional melancholia” to signify what we now call major depression and put forward a unitary concept of affective disorders.

1. Kraepelin, E. (1919). Manic–depressive insanity and paranoia (trans. R.M. Barclay). Livingstone, Köngliche Bayerische Nervenheilanstalt München, around 1900, nowadays the Department of Psychiatry LMU

Limitations of classifications of mental disorders

 They are poorly linked to pathophysiology

 They are not truly free of theory

 They are more reliable than valid

 They do not replace clinical knowledge and experience

 They have transcultural limitations

 They categorize dimensions

 They might have a negative impact on psychiatric and training Kraepelin‘s own criticism on his dichotomy

„Es erscheint indiskutabel, dass trotz ehrlicher Fortschritte wir heute nach wie vor unfähig sind eine große Anzahl von Fällen unter die bekannten Formen des Systems zu kategorisieren“

“It appears indisputably that, despite honest progress, we are still uncapable to summarize a large number of cases according to the established categories of the system.“

Emil Kraepelin (1856-1927)

Kraepelin 1920, „Die Erscheinungsformen des Irreseins“ WTCCC

Bipolar disorder Coronary heart disease Hypertension Rheumatoid arthritis Crohn’s disease Type 1 diabetes Type 2 diabetes Br J Psychiatry 2005; 186: 364-366 ?

19th Century 21st Century Br J Psychiatry, Feb 2010; 196, 92–95 Mixed States

▪ First Reported by Emil Kraepelin 1 ▪ As varying degrees of depression in mania ▪ Depressive or anxious mania ▪ Mania with poverty of thought ▪ Manic stupor ▪ As varying degrees of mania in depression ▪ Excited depression ▪ Depression with flight of ideas ▪ DSM-IV (2000): Requires coexistence of the full criteria of a manic and depressive episode2

1. Kraepelin 1921 2. DSM-IV-TR, American Psychiatric Association, 2000 3434 Mood state at presentation across the life cycle

Melancholia Mixed Mania 100%

80%

60%

40% Patients 20%

0% 15 20 25 30 35 40 45 50 55 60 65

Age (N=889)

Kraepelin E, Manic-Depressive Insanity and Paranoia, 1921; E & S Livingstone, Edinburgh 3535 Clinical characteristics of mixed bipolar episodes

• Mood disturbance is often severe1,2

•  Comorbid substance use disorders1,3 •  and attempts4,5

•  Psychosis1 • Less frequent remission/high risk of recurrence1,6 • Poorer response to some medications6

1. Akiskal HS et al, J Affect Disord, 2000; 59(suppl 1): S5-S30 2. DSM-IV-TR, American Psychiatric Association, 2000 3. Swann AC et al, Arch Gen Psychiatry, 1997; 54(1): 37-42 4. Shah NN et al, Psychiatr Q, 2004; 75(2): 183-196 5. Goldberg JF et al, J Affect Disord, 1999; 56(1): 75-81 6. Prien RF et al, J Affect Disord, 1988; 15(1): 9-15 Manic symptoms common in patients with bipolar depression

Number of DSM-IV Manic Symptoms During an Index Episode of Bipolar Bipolar I (n=401) Depression in STEP-BD (N=1380) Bipolar II (n=979)

No mania 40 Subsyndromal mania Full mixed episode (31%) (54%) (15%) 30

20

% of Patients% 10

0 0 1 2 3 4 5 6 7 Manic symptomsNumber may be easily of DSM overlooked-IV Manic if they Symptoms appear less prominent than depressive features

STEP-BD = Systematic Treatment Enhancement Programme of Bipolar Disorder Goldberg JF et al, Am J Psychiatry. 2009; 166(2): 173-181. 20th Century up to 1975

Selected Highlights Endogenous v Reactive Depression

Kurt Schneider put forward the terms endogenous and reactive depression in 1920 Disputed by Mapother in 1926 who found no clear distinction between groups. Controversy raged in 1960s and 1970s particularly between Roth (Newcastle) and Kendall (IoP and Edinburgh). DSM and ICD have largely gone with continuum view. Sir Martin Roth’s contribution to Affective Disorders Research

. Kay D, Roth M, Hopkins B. Affective disorders arising in the senium. I. Their association with organic cerebral degeneration. J Mental Science 1955 101:302-16.

Schapira K, Roth M, Kerr TA, Gurney C. The prognosis of affective disorders: the differentiation of anxiety states from depressive illnesses. Br J Psychiatry. 1972 Aug;121(561):175-81.

Kerr TA, Roth M, Schapira K, Gurney C. The assessment and prediction of outcome in affective disorders. Br J Psychiatry. 1972 Aug;121(561):167-74.

Roth M, Gurney C, Garside RF, Kerr TA. Studies in the classification of affective disorders. The relationship between anxiety states and depressive illnesses. I. Br J Psychiatry. 1972 Aug;121(561):147-61. Depression – further developments in the concept

Freud had likened the state of melancholia to mourning in his 1917 paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious “narcissistic” process.

Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively, but the ego itself is compromised. The patient's decline of self-perception is revealed in his belief of his own blame, inferiority, and unworthiness. He also emphasized early life experiences as a predisposing factor.

Source Wikipedia. Depression – further developments in the concept

Adolf Meyer (1866-1950) put forward a mixed social and biological framework emphasizing reactions in the context of an individual's life. He reframed mental disease as biopsychosocial "reaction types" rather than as biologically-specifiable natural disease entities. He argued that the term depression should be used instead of melancholia.

His work and influence lead to the development of DSM-I and its publication in 1952. DSM-I contained depressive reaction and the DSM-II (1968) depressive neurosis, defined as an excessive reaction to internal conflict or an identifiable event. Bipolar disorder – further developments in the concept

The term "manic-depressive reaction" appeared in the first American Psychiatric Association Diagnostic Manual in 1952, influenced by the legacy of Adolf Meyer who had argued that the illness was a reaction of biogenetic factors to psychological and social influences.

In 1968, both the newly revised classification systems ICD- 8 and DSM-II termed the condition "manic-depressive illness“.

Source Wikipedia Bipolar disorder – further developments in the concept (1904 – 1988) In 1957, he noted that patients with mania had a higher incidence of mania in their families compared with those with depressions only.

He coined the terms Bipolar and Unipolar. Bipolar disorder – further developments in the concept : Bipolar II

The first diagnostic distinction to be made between manic-depression involving mania, and that involving , came from Jung in 1903. Jung illustrated the hypomanic variation with five case histories, each involving hypomanic behaviour, occasional bouts of depression, and mixed mood states, which involved personal and interpersonal upheaval for each patient. In 1975, Jung's original distinction between mania and hypomania gained support. Fieve and Dunner published an article recognizing that only individuals in a manic state require hospitalization. Empirical evidence, combined with treatment considerations, led the DSM-IV Mood Disorders Work Group to add bipolar II disorder as its own entity in the 1994 publication. Classification: an enduring crisis • Essentially descriptive: constructed in the age of steam • equated with Diseases • Very few categories meet validity standards • Heterogeneity conspires against this • Reliability reasonable in research settings, poor in clinical ones • Poor utility of diagnostic categories for specific treatment selection and neurobiological or psychological research • NONETHELESS Operational criteria rescued psychiatry in the 1970s (NB US-UK Diagnostic Study,1971) • A DSM revision has taken place with limited focus and within silos – a better steam engine….. Conclusions re classification

1. A great deal is now known about affective disorders, but our understanding of classification has not really moved forward in two millennia! 2. Much of the change in how we view affective disorders follows social, cultural and non-specific scientific developments. 3. Our current classifications are pragmatically useful but have major drawbacks and limitations and must be viewed with caution. History of Psychiatry:- Plan

1. Introduction 2. The concept of affective disorders: historical evolution 3. Current controversies:- a. Classification b. The bipolar/schizophrenia dichotomy c. Mixed states 4. The history of UK asylums 5. The history of ECT and psychopharmacology 6. Antipsychiatry developments 7. Conclusions The growth of the asylums in England and Wales 1842-1910 (Myers,2005)

140000

120000

100000

80000

NUMBER 60000

40000

20000

0 1842 1860 1870 1880 1890 1900 1910 YEAR

Asylum Workhouse Licenced houses With relatives Total 4 main reasons speculated:-

1. greater number of individuals transferred from workhouses 2. a greater willingness of families to seek institutional solutions for their mentally unwell family members, 3. a widening of the definition of insanity 4. a ‘real’ increase in prevalence of certain mental disorders Mortality associated with severe mental illness

People with die on average 15-20 years sooner than the general population (McGrath et al, 2008 ; Crump et al,2013)

Evidence that the mortality gap is widening across the world. In the UK, the gap has gradually increased from 2005 and rapidly from 2010 (Smith et al, 2013 ; Hayes et al, 2017)

Reductions in mortality from cardiovascular and respiratory diseases have occurred in general populations but not in SMI (Lawrence et al, 2010) Metabolic Disturbances Common in Severe Mental Illness

Higher BMI, waist Disorders of glucose circumference, and homeostasis waist to hip ratio

Increased coronary Dyslipidaemia heart disease risk Morbidity and mortality in C19 asylums • Many early reports that patients in asylums died in excess and prematurely e.g. Burrows (1828) “insanity tends to the shortening of human life”. • Farr (1841) started data collection and confirmed the high mortality of lunatic asylums in comparison with the general population. Death rates (deaths/inmate) were 5-7 times higher that of aged matched populations (gap ~ 15 years). Some of this relates to deaths from conditions like, for example, GPI, epilepsy, imbecility but also found in “insanity”. Continued to the end of C19. • More marked in men, early in admission, in migrants and the malnourished. Lower is some asylums e.g. in York • Pritchard (1835) drew attention to the dangers of unchecked mania contending that “fatal termination” could follow from “exhaustion arising from continual excitement”. Deaths during restraint were also reported. MPhil topic: Mortality in Severe Mental Illness IN Victorian asylums

General Adult Population.

Dying to Get Out of the Asylum: Mortality and Madness in Four Mental Hospitals in Victorian Canada, c. 1841–1891 Wright D, Jacklin L, Themeles T (2013) Bulletin of the , 87, 590- 621 History of Psychiatry:- Plan

1. Introduction 2. The concept of affective disorders: historical evolution 3. Current controversies:- a. Classification b. The bipolar/schizophrenia dichotomy c. Mixed states 4. The history of UK asylums 5. The history of ECT and psychopharmacology 6. Antipsychiatry developments 7. Conclusions Historical Treatment of the Patient with Severe Acute Mania Milestones in the development of

1930’s 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s 2000

FIRST GENERATION CONVENTIONAL SECOND GENERATION (ATYPICAL)

Clozapine ECT Zotepine Reserpine Amisulpride Risperidone Olanzapine Haloperidol Quetiapine Fluphenzazine Thioridazine Ziprasidone Asenapine Aripiprazole

Asylums close…..

But problems remain…..

1983…

Lithium and relapse prevention in manic- depressive illness , M.D. Professor of at and director of the psychopharmacology research unit at the , Risskov, Psychosomatics 24, 533–541 Antidepressants

Monoaminergic Neurotransmission: The History of the Discovery of Antidepressants from 1950s Until Today Francisco López-Muñoz* and Cecilio Alamo Current Pharmaceutical Design, 2009, 15, 1563-1586 1563 Nathan Kline: Key pioneer of clinical research into Antidepressants

Rates of prescribing ECT

F:M 2.3:1 47% > 65 yrs 73% voluntary patients 81% affective disorders 6% schizophrenia etc 6% unspecified ECTAS dataset report Sep 2015

 2,148 acute courses of ECT were given to 1,969 people  cf 2012 when 2,022 courses of ECT were given to 1,856 people; 18,057 individual treatments  179 people had more than one course during the year  65% patients were female  mean age of patients was 61  major depression 84% patients  mean number of treatments per course was 9.5  51% patients were informal and had capacity to consent  52% were rated ‘severely ill’ at the start of treatment  92% showed clinical improvement by the end of treatment  155 people undergoing maintenance ECT during March 2015 History of Psychiatry:- Plan

1. Introduction 2. The concept of affective disorders: historical evolution 3. Current controversies:- a. Classification b. The bipolar/schizophrenia dichotomy c. Mixed states 4. The history of UK asylums 5. The history of ECT and psychopharmacology 6. Antipsychiatry developments 7. Conclusions “Anti-Psychiatry” in C19th

“”

Mental illness a social construct -Michel Foucault (Madness and Civilisation) - Andrew Scull (Museums of Madness)

Mental illness as a product of industrialization and capitalism. “Anti-Psychiatry” in C20th

1. The birth of patient movements 2. Nazi and Soviet psychiatry 3. 1960s Prominent anti-psychiatrists - Cooper, Szasz, Laing, Foucault 4. Challenges from 5. The 6. Critical Psychiatry etc Conclusions

• Many of the controversies in Psychiatry have been around for centuries • Humanitarian motives underpin most of the developments in Psychiatry • Mental illness is frequent and real but how it is perceived, understood and treated have strong social and cultural influences.