History of Psychiatry

History of Psychiatry Psychobiology Research Group Prof Nicol Ferrier BSc (Hons), MD, FRCP(Ed), FRCPsych Emeritus Professor of Psychiatry Newcastle University 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 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 Psychiatrists Johann Christian Reil, 1759-1813 Professor of medicine at the University of Halle, Germany,1787-1810 According to Reil, the causes of human diseases 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 physicians shall become psychiatrists. (c) A medical psychology specific to the needs of the physician 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) Lunatic 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) Psychotherapy (‘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 mood disorder. 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 Depression 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 mania (Greek ania : anguish manos: relaxed) and perhaps in this cave painting (!) Depression-prehistory to medieval periods • Ancient Greece Disease 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 bipolar disorder during the Islamic Golden Age. The 11th century Persian physician Avicenna 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 Hippocrates and Galen. Moral and spiritual theories also prevailed. Aretaeus of Cappadocia (1st Century)1 ...such patients 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 patient 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 France, 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 psychiatrist 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 Emil Kraepelin 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 (Paris), 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

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