The label schizophrenia is a recent term, first used in 1908 by Eugen Bleuler, a Swiss psychiatrist, and was meant to describe the disunity of functioning between personality, perception, thinking and memory. Whilst the label is new, accounts of schizophrenia-like symptoms can be found in ancient texts dating back to 2000 BC, and across a number of cultural contexts. The oldest of these texts is the ancient Egyptian Ebers papyrus, around two millennia old.
There are descriptions of illnesses marked by bizarre behaviour and lack of self-control in the Hindu Arthava Veda, dating approximately 1400 BC, and a Chinese text from approximately 1000 BC called The Yellow Emperor’s Classic of Internal Medicine, which attributes insanity and seizures to supernatural and demonic forces.
The Greeks and Romans are also found to have a general awareness of psychotic illnesses. Plato, who lived in the fourth and fifth centuries BC, spoke of a madness of divine origin, which could inspire poets and create prophets. Demonic possession and supernatural forces as the cause of mental illness are a common theme in the ancient literature.
Whilst we can infer these ancient scribes were reporting on the symptoms and causes of the illness we currently describe as schizophrenia, we cannot be certain of it. Some suggest that the lack of clear diagnostic examples in the older literature points to schizophrenia being an entirely modern affliction. Perhaps cultural differences in the understanding of a sufferer’s behaviour can account for the discrepancy in reporting of the illness in ancient times.
The Middle Ages – A Demonic Affliction
The Medieval era saw the beginnings of formal detention and institutionalisation of those deemed mentally ill. In Europe, sufferers were occasionally cared for in monasteries. Some towns had “fools towers”, which housed madmen. In The 1400’s, a number of hospitals to treat the insane sprang up throughout Spain.
In England in 1247, The Priory of Saint Mary of Bethlehem was founded – later known as the notorious Bedlam, the word becoming synonymous with madness itself.
Whilst scholars and Universities at this time had developed a scientific approach towards mental disturbances, there was still a great deal of belief in the lay population in supernatural forces.
In 15th century Europe, delusions and hallucinations were seen as proof of demonic possession. Treatments to overcome these disturbances included confession and exorcism.
Schizophrenia and Early Psychiatry
It is not until the middle of the 19th century that European psychiatrists begin to describe a disease, of unknown origin, typically with an adolescent onset and with a propensity towards chronic deterioration. Emil Kraeplin, a German psychiatrist, utilised the term “dementia praecox” to describe a variety of previously separately recognised illnesses, such as adolescent insanity and catatonia syndrome.
Kraeplin’s long term studies of a large number of cases led him to believe that despite the diversity of clinical presentations, the commonalities in the progression of the illness meant they could be categorised under the singular heading of dementia praecox. Later, he suggested nine categories of the disorder.
This leads us to Eugen Bleuler, who coined the term schizophrenia, meaning “split mind”, replacing the previous terminology dementia praecox. Bleuler’s “schizophrenia” incorporated an understanding that the disorder was a group of illnesses, and did not always deteriorate into a permanent state of “dementia” – as was previously considered by Kraeplin to be a hallmark of the disease.
Further, Bleuler suggested schizophrenia had four main symptoms, known as the 4 A’s: blunted Affect – a reduction in emotional response to stimuli, loosening of Associations and disordered pattern of thought, Ambivalence, or difficulty making decisions, and Autism, by which he meant a loss of awareness of external events and preoccupation with one’s own thoughts.
Schizophrenia and Eugenics
Increased scientific understanding of schizophrenia and other mental illness was overshadowed by persistent stigma and misunderstanding of mental illness. Schizophrenia was thought to be an inheritable disorder, and as such sufferers were subject to Eugenics and sterilisation.
In 1910, Winston Churchill, wrote to the Prime Minister Herbert Asquith, insisting on the implementation of mass forced sterilisations of those deemed feeble minded and insane.
Churchill was not successful in implementing this policy. Forced sterilisation was, however, practised in parts of the USA throughout the twentieth century, and Nazi Germany utilised Eugenics as justification for extreme measures against those it saw as undesirable, including the mentally ill.
Examples of treatments for what would be recognised today as a mental illness go back thousands of years, and include trepanning, the drilling of holes into the skull to allow evil spirits to exit, and various forms of exorcism. The ancient Greeks and Romans tended to employ somewhat enlightened and humane treatment methods.
The Greeks applied their theory of humoural pathology, or the belief that an imbalance in the body’s various fluids could induce madness, amongst other illnesses.
Treatment involved correcting the imbalance in fluids, and encompassed dietary and lifestyle changes, to blood-letting and purging. The Roman treatments consisted of warm baths, massage and diets, although more punitive treatments were also suggested by Cornelius Celsus, stemming from the belief that the symptoms were caused through having angered the gods, and included flogging and starvation.
We may view some of the older techniques for treating mental illness as deplorable, yet many modern pre-pharmacotherapy treatments were unfortunately not much better in some respects.
From the wretched conditions of many asylums, the raising of the body temperature by injection of sulphur and oils to insulin shock therapy, which kept the patient in a coma, deep sleep therapy and electroconvulsive therapy, which were all widely used treatments for schizophrenia and a variety of other mental illnesses prior to the advent of anti-psychotics, patients could expect widely variable results and the risk of further harm.
Lobotomy, developed in the 1930’s, also became a popular treatment for schizophrenia. Initially, the procedure required an operating theatre as holes were drilled into the skull, and either alcohol injected into the frontal lobes or an instrument called a leucotome used to create lesions in the brain.
The technique was soon refined and simplified. American psychiatrist Walter Freeman, seeking to make the procedure accessible to patients in asylums where there was no access to an operating theatre, developed the trans orbital lobotomy. Freeman accessed the prefrontal area through the eye socket, and using an instrument similar to an ice pick made a series of cuts.
The process was quick, and for many had devastating effects, patients were left with impairments of intellectual, social and cognitive function, and often there was no great improvement in the symptoms for which the procedure was performed.
Current Treatments and Research
Antipsychotic drugs to treat schizophrenia were first introduced in the 1950’s. Their success led, in part, to the deinstitutionalisation and integration of sufferers into the community. Antipsychotics, whilst allowing many sufferers of schizophrenia to lead functional lives, have their drawbacks.
Common adverse side effects can include weight gain, involuntary movements, lowered libido, low blood pressure and tiredness. Antipsychotics do not represent a cure for schizophrenia, but used in combination with community based and psychological therapies, sufferers have every chance of recovery.
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Scientific investigations in to the causes and treatment of schizophrenia are ongoing, with a focus on genetic research, which will hopefully lead to more effective treatments and possibly prevention. Information on current research is available here.