History of psychiatry

Philippa Bolton

Begin at the beginning

• For the most part, through the ages, most people with mental health problems were simply cared for in the community.

• Much like modern day developing world, they probably did better than most clients do today.

Not all good

• However, people with active psychosis could well have lived in the wilderness, or become beggars.

• Could have been labelled witches, possessed, or imprisoned or executed for violence.

What was it like then?

• Different presentations of mental illness – less learning disability, no schizophrenia, more delirium and organic mental illness – esp syphillis

• No asylums until 8th century. None in Britain until 1300’s.

Hippocrates

• Pre medicine illness, including mental illness thought to be related to spiritual phenomena requiring prayer, sacrifice, exorcism.

• Hippocrates thought that mental illness based in the brain. Described mania, delirium, melancholia, anxieties, phobias and puerpural psychosis and paranoia.

Mania in Greece

• Some patients with mania are cheerful – they laugh, play, dance day and night, and stroll through the market, sometimes with a garland on their head, as if they had won a game: these patients do not worry their relatives. But others fly into a rage . . . The manifestations of mania are countless. Some manics, who are intelligent and well educated, deal with astronomy, although they never studied it, with philosophy, but autodidactically, they consider poetry a gift of muses (Kappadokien),

Humors

Mental illness thought due to disturbances of humors – black bile, yellow bile, blood and phlegm

• Black bile: earth, cold and dry, associated with melancholia.

• Yellow bile: fire, hot and dry, associated with mania.

• Needed to rebalance the humors to cure people – warm, cold, purging, bloodletting, diet, activity, rest and exercise etc. Persisted until 17th century. Many people died.

Weird and wonderful

• Socrates – hysteria – the womb wandered around the body causing problems. Therefore have babies to make it stay in the proper place – the womb as a cause of problems for women persisted as a belief right until the 20th Century.

Persian times

• Both physical and spiritual causes proposed.

• Many advances in medicine, including in mental illness.

• First psychiatric hospitals, which used baths, drugs, music and activities and counselling.

Middle ages in Britain

• Mental illness mixture of spiritual and medical causes – most understanding from ‘humors’.

• Also the first asylums started here – Bethleham hospital, later changed to Bedlam. The first place to use incarceration as a treatment for mad people.

One night with Venus is a lifetime with Mercury.• Treatments: Bloodletting,

purging, blistering, whipping – to restore humors and let out evil spirits. Inhalation of mercury.

• Also rest, music, diet, exercise.

Incarceration

• The idea of incarceration increased after Tudor times, as society shifted, and people were poorer and could not afford to care for non productive mad relatives. Private madhouses, for the wealthy, were dumping grounds for inconvenient relatives.

Masters of these places prided themselves on their ability to beat people. No inspections.

Bedlam

Bedlam

• Patients chained to the walls if violent.• Filthy living conditions• Used for the violently psychotic,

sometimes for morally ‘unusual’ people.• Patients beaten, poor sanitation.• By Victorian times people used to pay to

see the patients – a penny a viewing on the first Tuesday of the month.

• Bedlam beggars would go out on the streets to ask for money.

Moral therapy

• Pineal in Paris took the chains of patients.

• Nothing bad happened. • Pioneered asylums – peaceful

places, treating patients with care and compassion, with work to do – typically on farms. Replicated by William Tuke in UK

Aversion therapy

• Moral therapy encouraged good behaviour, but also punished ‘bad’ behaviour to act as an aversion to ‘mad rantings and violence’.

The Lunacy commission

• Asylums made mainstream in ‘lunatic asylums act’ by Lord Shaftesbury to stop incarceration in prison or workhouses. Local authorities forced to build them and forced to allow poor people right to good mental health care.

• No right for patients to appeal but had to have medical opinions and records of admission and could be discharged by the court.

The Lunacy Act 1890

• Right to appeal to court introduced.

• Over 20th century the concepts of informal and voluntary treatment came into being.

• Medicalisation of detention – enshrined in 1983 Mental health act.

Neuroses in Victorian times.• Neuroses were dealt with in a

medical manner by neurologists – rather fashionable for the upper class ladies to have ‘nerves’, smelling salts, rest therapy, and stimulation.

• Some objected – the Yellow Wallpaper

Psychoses

• Psychosis dealt with by psychiatrists – most common was secondary to syphilis. Asylums initially were about routine, work and high moral standards – psychiatrists initially did not treat mental illness directly.

Diagnostics

• Diagnostics started properly – the most famous being Kraepelin who defined, schizophrenia and manic depression, which is still used today.

• Diagnostic classifications and descriptions burgeoned. Differentiation between LD and mental illness

Top 10 weird treatments

• Dr Rushes spinning chair – to relieve brain congestion

• Warm baths for mania, cold baths for depression.

• Near drowning• Malaria for syphillis• Tooth extraction• Hysterectomies

• Lobotomies – mobile lobotomy van – Moniz: 20000 performed in USA.

• Insulin coma• Electric currents for mutism and

shell shock.• Insomnia for depression

Women with hysteria

• Charcot first put forward psychological explanation for hysteria.

Psychotherapy.

Freud (Charcot’s student) revolutionised this with talking therapy approaches and much work on ‘neuroses’ – Anna ‘O’

• Identified that many anxieties and phobias were based in internal conflicts, past experiences and traumas. Basis of modern day psychotherapy.

Chlopromazine

• 1954 saw Chlorpromazine invented and age of drug treatment began.

• Following this barbituates, benzodiazepines, antidepressants and mood stabilisers developed. Now second generation antipsychotics.

Anti-psychiatry movement• 1960’s• Goffman’s ‘Asylums’ – institutionalisation

rather than individualised therapy.• Criticism of social control – eugenics and

sterilisation in America and Nazi Germany.• Criticism of diagnostics – imprecise,

labelling normal reactions as abnormal diseases

• Criticism of biomedical model

Anti psychiatry continued• Thomas Szaz, RD Laing, Michal

Foucart.• Would say mental health reaction to

environment and society, not intrinsic to person.

• Advocated person centred therapeutic approaches, therapeutic communities, closure of institutions.

• Psycho-social approaches advocated.

Recent developments

• Outpatient work and community care developed

• Psychiatry split into subspecialities – adult, old age, LD, forensic and child.

• New treatments developed, others diminished (ECT, psychosurgery, sterilisation).

Today

• Community care developed.• Person centred approaches• Increased rights in law• Reduced hospital admissions• Debate on formulation vs diagnostics• Holistic care.• Nurse practitioners.

Conclusion

• Mental health is changing, presentations are evolving

• Treatments and thinking around mental illness are changing

• Challenge is always there.