History of psychiatry

Ancient

Specialty in

During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin,^[4] a view which existed throughout ancient Greece and Rome.^[4] The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century,^[5] although one may trace its germination to the late eighteenth century.

Some of the early manuals about mental disorders were created by the Greeks.^[5] In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders.^[4] In 4th- to 5th-century BCE Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy.^[6]

Religious leaders often turned to versions of exorcism to treat mental disorders, often utilizing methods that many consider to be cruel and/or barbaric.^[4]

Middle Ages

A number of hospitals known as bimaristans were built throughout Arab countries beginning around the early 9th century, with the first in Baghdad.^[7] They sometimes contained wards for mentally ill patients, typically those who exhibited violence or had debilitating chronic illness.^[8]

Physicians who wrote on mental disorders and their treatment in the Medieval Islamic period included

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment.^[12]

Early modern period

During the early modern period, mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society.^[13]

From the 13th century onwards, sick and poor people were kept in newly founded ecclesiastical hospitals, such as the "Spittal sente Jorgen" erected in 1212 in Leipzig, in Saxony, Germany. Here, those with serious mental problems were isolated from the rest of the community in accordance with contemporary European practice.^[13] Also founded in the 13th century, Bethlem Royal Hospital in London was one of the oldest lunatic asylums.^[12]

In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem Royal Hospital, London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".^[14] Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building for its inhabitants to roam around its confines and possibly throughout the general neighborhood in which the hospital was situated.^[15] In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates.^{[16]: 155 [17]: 27}

In 1621,

In 1713, the Bethel Hospital Norwich was opened, the first purpose-built asylum in England, founded by Mary Chapman.[20]

Humanitarian reform

In Saxony, a new social policy was implemented at the beginning of the 18th century in which criminals, prostitutes, vagrants, orphans, and the mentally ill were incarcerated and re-educated in the concepts of the Enlightenment. As a result, a variety of jails, approved schools, and insane asylums were constructed, including the hospital "Chur-Sachisches Zucht-Waysen und Armen-Haus" in Waldheim in 1716, which was the first governmental institution dedicated to the care of the mentally ill on the German territory.^[13]

Attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In 1758, English physician

In 1792, Pinel became the chief physician at the Bicêtre Hospital. In 1797, Jean-Baptiste Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead.^[23][24]

Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pussin and Pinel's approach was seen as remarkably successful and they later brought similar reforms to a mental hospital in Paris for female patients,

William Tuke's grandson, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel's Treatise On Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders.^[29] The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now The Institute of Living).

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with — a situation he finally achieved in 1838. In 1839, Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient.^[30][31]

Phrenology

Scotland's Edinburgh medical school of the eighteenth century developed an interest in mental illness, with influential teachers including William Cullen (1710–1790) and Robert Whytt (1714–1766) emphasising the clinical importance of psychiatric disorders. In 1816, the phrenologist Johann Spurzheim (1776–1832) visited Edinburgh and lectured on his craniological and phrenological concepts; the central concepts of the system were that the brain is the organ of the mind and that human behaviour can be usefully understood in neurological rather than philosophical or religious terms. Phrenologists also laid stress on the modularity of mind.

Some of the medical students, including William A. F. Browne (1805–1885), responded very positively to this materialist conception of the nervous system and, by implication, of mental disorder. George Combe (1788–1858), an Edinburgh solicitor, became an unrivaled exponent of phrenological thinking, and his brother, Andrew Combe (1797–1847), who was later appointed a physician to Queen Victoria, wrote a phrenological treatise entitled Observations on Mental Derangement (1831). They also founded the Edinburgh Phrenological Society in 1820.

Institutionalization

The modern era of providing care for the mentally ill began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. Édouard Séguin developed a systematic approach for training individuals with mental deficiencies,^[36] and, in 1839, he opened the first school for the severely "retarded". His method of treatment was based on the assumption that the mentally deficient did not experience disease.^[37]

In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The

At the turn of the century, England and France combined had only a few hundred individuals in asylums.[39] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization was soon disappointed.^[40] Psychiatrists were pressured by an ever-increasing patient population.^[40] The average number of patients in asylums kept on growing.^[40] Asylums were quickly becoming almost indistinguishable from custodial institutions,^[41] and the reputation of psychiatry in the medical world had hit an extreme low.^[42]

Scientific advances

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include

In 1870, Louis Mayer, a gynecologist in Germany, cured a woman's "melancholia" using a pessary: "It relieved her physical problems and many severe disorders of mood ... application of a Mayer Ring improved her quite considerably."^[47] According to The American Journal of Obstetrics and Diseases of Women and Children Mayer reportedly decried the "neglect of the investigation of the relations between mental and sexual diseases of women in German insane hospitals".^[48]

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry.^[49] Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry.^[49] Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry.^[50] Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum.^[51] The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry.^[52] However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities.^[53]: 221 While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation.^[54]

Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry.^[55] The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums.^[55] Freud resisted subjecting his theories to scientific testing and verification, as did his followers.^[56] As evidence-based investigations in cognitive psychology led to treatments like cognitive behavioral therapy, many of Freud's ideas appeared to be unsupported or contradicted by evidence.^[56] By the 1970s, the psychoanalytic school of thought had become marginalized within the field.^[55]

Biological psychiatry reemerged during this time.

Now, genetics are once again thought by some prominent researchers to play a large role in mental illness.[57]^[63] The genetic and heritable proportion of the cause of five major psychiatric disorders found in family and twin studies is 81% for schizophrenia, 80% for autism spectrum disorder, 75% for bipolar disorder, 75% for attention deficit hyperactivity disorder, and 37% for major depressive disorder.^[64] Geneticist Müller-Hill is quoted as saying "Genes are not destiny, they may give an individual a pre-disposition toward a disorder, for example, but that only means they are more likely than others to have it. It (mental illness) is not a certainty.”^{[65][unreliable medical source?]} Molecular biology opened the door for specific genes contributing to mental disorders to be identified.^[57]

Deinstitutionalization