History of schizophrenia

The word schizophrenia was coined by the Swiss psychiatrist and eugenicist Eugen Bleuler in 1908, and was intended to describe the separation of function between personality, thinking, memory, and perception. He formally introduced the term on 24 April 1908 in a lecture given at a psychiatric conference in Berlin and in a publication that same year.^[1][2] Bleuler later expanded his new disease concept into a monograph in 1911, which was finally translated into English in 1950.^[3][4]

The history of ‘schizophrenia’ is complex and not easy to characterize in a linear historical narrative, although attempts continue to be made.^[5] According to some, the disease has always existed only to be ‘discovered’ during the early 20th century. The plausibility of this claim depends upon the success of retrospectively diagnosing earlier cases of madness as ‘schizophrenia’. According to others, ‘schizophrenia’ names a culturally determined clustering of mental symptoms.^[6] What is known for sure is that by the turn of the 20th century the old concept of insanity had become fragmented into ‘diseases’ (psychoses)^[7] such as paranoia, dementia praecox, manic-depressive insanity and epilepsy (Emil Kraepelin’s classification).^[8] Dementia praecox was reconstituted as schizophrenia, paranoia was renamed as ‘delusional disorder’ and manic-depressive insanity as ‘bipolar disorder’ (epilepsy was transferred from psychiatry to neurology). It is important to emphasize that the ‘mental symptoms’ included under the concept schizophrenia are real enough, make people suffer, and will always need understanding and treatment. However, whether the historical construct currently called ‘schizophrenia’ is required to achieve this therapeutic goal remains contentious.

Diagnoses in ancient times

Accounts of a schizophrenia-like syndrome are thought to be rare in the historical record prior to the 19th century, although reports of irrational, unintelligible, or uncontrolled behavior were common.^[9] There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia,^[10] but other reviews have not suggested any connection.^[11] A review of ancient Greek and Roman literature indicated that although psychosis was described, there was no account of a condition meeting the criteria for schizophrenia.^[12]

Bizarre psychotic beliefs and behaviors similar to some of the symptoms of schizophrenia were reported in Arabic medical and psychological literature during the Middle Ages. In The Canon of Medicine, for example, Avicenna described a condition somewhat resembling the symptoms of schizophrenia which he called Junun Mufrit (severe madness), which he distinguished from other forms of madness (Junun) such as mania, rabies and manic depressive psychosis.^[13] However, no condition resembling schizophrenia was reported in Şerafeddin Sabuncuoğlu's Imperial Surgery, a major Ottoman medical textbook of the 15th century.^[14] Given limited historical evidence, schizophrenia (as prevalent as it is today) may be a modern phenomenon, or alternatively it may have been obscured in historical writings by related concepts such as melancholia or mania.^[9]

Influential earlier concepts

A detailed case 1809 report by John Haslam concerning James Tilly Matthews,^[15] and a separate account by Philippe Pinel also published in 1809, are often regarded as the earliest cases of schizophrenia in the medical and psychiatric literature.^[9] The Latinized term dementia praecox entered psychiatry in 1886 in a textbook by asylum physician Heinrich Schüle (1840-1916) of the Illenau asylum in Baden. He used the term to refer to hereditarily predisposed individuals who were "wrecked on the cliffs of puberty" and developed acute dementia, while others developed the chronic condition of hebephrenia. Emil Kraepelin had cited Schüle's 1886 textbook in the 1887 second edition of his own textbook, Psychiatrie, and hence was familiar with this term at least six years before he himself adopted it.^[16][17] It later appeared in 1891 in a case report by Arnold Pick which argued that hebephrenia should be regarded as a form of dementia praecox. Kraepelin first used the term in 1893. In 1899 Emil Kraepelin introduced a broad new distinction in the classification of mental disorders between dementia praecox and mood disorder (termed manic depression and including both unipolar and bipolar depression). Kraepelin believed that dementia praecox was caused by a lifelong, smoldering systemic or "whole body" process of a metabolic nature that would eventually affect the functioning of the brain in a final decisive cascade. Hence, he believed the entire body—all the organs, glands and peripheral nervous system—was implicated in the natural disease process.^[18] Although he used the term "dementia," Kraepelin seemed to use the term synonymously with "mental weakness," mental defect," and "mental deterioration," but distinguished it from other uses of the term dementia, such as in Alzheimer's disease, which typically occur later in life.^[19] In 1853 Bénédict Morel used the term démence précoce (precocious or early dementia) to describe a group of young patients who were suffering from "stupor".^[20] It is sometimes argued that this first use of the term signals the medical discovery of schizophrenia. However, Morel employed the phrase in a purely descriptive sense and he did not intend to delineate a new diagnostic category. Moreover, his traditional conception of dementia differed significantly from that employed in the latter half of the nineteenth-century. Finally, there is no evidence that Morel's démence précoce had any influence on the later development of the dementia praecox concept by either Arnold Pick or Emil Kraepelin.^[6]

Kraepelin's classification slowly gained acceptance. There were objections to the use of the term "dementia" despite cases of recovery, and some defence of diagnoses it replaced such as adolescent insanity.^[21] The concept of adolescent insanity or developmental insanity had been advanced by Scottish psychiatrist Sir Thomas Clouston in 1873, describing a psychotic condition which generally afflicted those aged 18–24 years, particularly males, and in 30% of cases proceeded to ‘a secondary dementia’.^[22]

Coinage in 1908

Scratch-drawings on the wall in St. Elizabeths Hospital made by a prisoner with "a disturbed case of dementia praecox".

The word schizophrenia—which translates roughly as "splitting of the mind" and comes from the Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind")^[23]—was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence.^[24] Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead. However, many at the time did not accept that splitting or dissociation was an appropriate description, and the term would later have more significance as a source of confusion and social stigma than scientific meaning.^[25]

In popular culture, the term schizophrenia is often thought to mean that affected persons have a "split personality". But for contemporary psychiatry, schizophrenia does not involve a person changing among distinct multiple personalities. The stigmatising confusion arises in part due to Bleuler's own use of the term schizophrenia, which for many signalled a split mind, and his documenting of a number of cases with split personalities within his classic 1911 description of schizophrenia. The earliest known use of the term to mean "split personality" was by Psychologist G. Stanley Hall in 1916. And many early 20th century psychiatrists and psychologists can also be found using the term in this sense (indeed some reference Jekyll and Hyde) before a later rejection of this usage took place.^[26]

In the early 20th century, the psychiatrist Kurt Schneider listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called first-rank symptoms or Schneider's first-rank symptoms. They include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices.^[27] Although they have significantly contributed to the current diagnostic criteria, the specificity of first-rank symptoms has been questioned. A review of the diagnostic studies conducted between 1970 and 2005 found that they allow neither a reconfirmation nor a rejection of Schneider's claims, and suggested that first-rank symptoms should be de-emphasized in future revisions of diagnostic systems.^[28]

In the first half of the 20th century schizophrenia was considered to be a hereditary defect, and sufferers were subject to eugenics in many countries. Hundreds of thousands were sterilized, with or without consent—the majority in Nazi Germany, the United States, and Scandinavian countries.^[29][30] Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "Action T4" program.^[31]

Anti-psychiatry

Anti-psychiatry refers to a diverse collection of thoughts and thinkers that challenge the medical concept of schizophrenia. Anti-psychiatry emphasizes the social context of mental illness and re-frames the diagnosis of schizophrenia as a labeling of deviance. Anti-psychiatry represented dissension of psychiatrists themselves about the understanding of schizophrenia in their own field.^[32] Prominent psychiatrists in this movement include R. D. Laing, David Cooper. Related criticisms of psychiatry were launched by philosophers such as Michel Foucault, Jacques Lacan, Gilles Deleuze, Thomas Szasz, and Félix Guattari.^[33]

Anti-psychiatrists agree that 'schizophrenia' represents a problem, and that many human beings have problems living in modern society. But they protest the notion that schizophrenia is a disease, and that people who suffer from it are sick. Instead, they often suggest that schizophrenics appear crazy because they are intelligent and sensitive beings confronted with a mad world. The sane patient can choose to go Against medical advice, but the insane usually can not. Anti-psychiatry often describes the institutional world as itself pathological and insane because of the way it subordinates human beings to bureaucracy, protocol, and labels.^[32]

Controversies over validity in the 1970s

In 1970 psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category^[34] and proposed that cases of schizophrenia where people recovered well were not really schizophrenia but a separate condition.^[35]

In the early 1970s, the diagnostic criteria for schizophrenia was the subject of a number of controversies which eventually led to the operational criteria used today. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.^[36] This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9. David Rosenhan's 1972 study, published in the journal Science under the title On being sane in insane places, concluded that the diagnosis of schizophrenia in the US was often subjective and unreliable.^[37]

Politicization in the Soviet Union

In the Soviet Union the diagnosis of schizophrenia has also been used for political purposes. The prominent Soviet psychiatrist Andrei Snezhnevsky created and promoted an additional sub-classification of sluggishly progressing schizophrenia. This diagnosis was used to discredit and expeditiously imprison political dissidents while dispensing with a potentially embarrassing trial.^[38] The practice was exposed to Westerners by a number of Soviet dissidents, and in 1977 the World Psychiatric Association condemned the Soviet practice at the Sixth World Congress of Psychiatry.^[39] Rather than defending his claim that a latent form of schizophrenia caused dissidents to oppose the regime, Snezhnevsky broke all contact with the West in 1980 by resigning his honorary positions abroad.^[40]

DSM III (1980)

The 1970s controversies lead to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III in 1980.^[41] The revision was based on Feighner Criteria and Research Diagnostic Criteria that had in turn developed from Robins' and Guze's criteria, and which were intended to make diagnosis more reliable (consistent). Since the 1970s more than 40 diagnostic criteria for schizophrenia have been proposed and evaluated.^[42]

See also

• dementia praecox
• Physical health in schizophrenia
• The Protest Psychosis: How Schizophrenia Became a Black Disease

References