Schizophrenia and the History of Madness

History of madness. Introduction

The psychiatric diagnosis “schizophrenia” describes a disorder distorting reality proof, creating delusions and hallucinations was and still is associated with such negative terms as “madness”, “lunacy” or “insanity”. This enigmatic human condition has accompanied mankind through its history.

Historical and ethnographic studies have demonstrated that schizophrenia was and still is present in all existing cultures, from the pre-literate to the most highly advanced.

In this article we reflect on the perception of mental illnesses, especially schizophrenia, the epitome of madness, from the earliest records to the modern time.

History of madness in the antiquity

Psychotic symptoms and schizophrenic-like syndromes were clearly present in ancient civilizations. Recorded descriptions of the disorder appeared before 1500 BC in the ancient Egyptian Book of Hearts, which is part of the Ebers papyrus.

Throughout millenia psychotic behaviours were thought to be caused by demonic or supernatural forces.

Although theories of demonic influences also held sway in Greek conceptions of madness and rationalist theories began to take hold. Plato, writing in the 5th and 4th centuries BC, advocated a very modern integrative conceptualization of the relationship between the mind and body. In his book “The Dialogues” he wrote that “…to think about curing the head alone, and not the rest of the body also, is the height of folly….and therefore if the head and body are to be well, you must begin by curing the soul.”

The Greek physician Hippocrates, widely considered the father of modern medicine, built upon the Greek tradition of rational and empirical explanations of nature and behaviour. He dismissed the idea of demonic causation of psychosis and instead suggested that madness originated entirely from the brain. In his book “Holy Disease” he contended that “…only from the brain spring our pleasures, our feelings of happiness, laughter and jokes, our pain, our sorrows and tears…. This same organ makes us mad or confused, inspires us with fear and anxiety….” In order to explain the presence of various mental and physical disturbances, he postulated the existence of body “humors”. Optimal mental and physical functioning could only be achieved if these humors were in balance and harmony. He believed that an uneven distribution of these fundamental elements was the cause of madness.

Madness and insanity in the Middle Ages

The treatment and understanding of madness in medieval Europe varied. However, madness in Europe was mostly associated with demonic possession. Consequently, such individuals were subjected to barbaric treatments even burned at the stake. Mostly mentally ill were confined in cages or in towers known as “fools’ towers.” In some, rare case institutions, mostly monasteries attempted to offer care.

In the Islamic world, so the treatment of mentally ill was in general much better. They were taken care in so called Bimaristans, however their reach was limited.

Madness. Change of paradigm in Renaissance and Enlightenment

First the Renaissance brought about a transformation in the perception of mental illnesses. It witnessed a shift toward a more humane understanding of madness, with the emergence of the first mental asylums. Despite primitive condition these institutions provided care and treatment to the mentally ill.

First the Enlightenment era with its admiration for reason and rationality ignited a revolution in the approach to mental illnesses. This led to the birth of psychiatry as a medical discipline, spearheaded by figures like Philippe Pinel liberating the mentally ill from lunatic asylums.  

Philippe Pinel. Pioneer of clinical psychiatry

Philippe Pinel (1745-1826) initially studied mathematics and medicine in Toulouse and Montpellier, obtaining degrees in both fields. At the age of 41, he worked at the private institution Maison Belhomme in Paris, before assuming the directorship of the Bicêtre Asylum, the Hospital for the Poor, Sick, and Criminal, in 1792, followed by the Hôpital de la Salpêtrière two years later. He held these positions until his death, while also serving as a professor at the Ecole de Santé and as Napoleon’s medical advisor from 1805.

Pinel’s reforms and “traitement morale”

Based on enlightened humanism, Pinel advocated for the reduction of coercive measures. In his major work, A Philosophical-Medical Treatise on Mental Disorders from 1801, he declared:

“Undoubtedly, one can maintain a semblance of order in asylums, just as in despotic states, through involuntary and unlimited confinement, through chains, and through barbaric treatment; but is this not the tranquility of graves and death? Calculated freedom, in accordance with the strict principles of humanity, distinguishes the maintenance of such an order, which spreads some gentleness over the unfortunate existence of the insane, often dispelling the symptoms of madness entirely and, in any case, reducing their severity.”

According to Pinel the mad person, as a citizen, has a natural right to assistance. This perspective forms an ethical core of early psychiatry as a civil reform institution. Pinel developed an educational “moral” treatment (“traitement morale”), which was developed in parallel in Scotland by Sir John Batty Tuke, in Germany by Johann Christian Reil, who coined the term “psychiatry”, and in Italy by Vincenzo Chiarugi. 

Shift from “madness” to “schizophrenia”. Beginning of modern psychiatry

One of the first to classify the mental disorders into different categories was the German psychiatrist, Emil Kraeplin. He used the term “dementia praecox” for individuals who had symptoms that we now associate with schizophrenia. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox and manic depression.

Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia. He named the disorder “dementia praecox” (early dementia) to distinguish it from other forms of dementia (such as Alzheimer`s disease) which typically occur late in life. Kraepelin also emphasized the genetic (inheritance) factor but added physical illnesses like brain inflammation in the childhood.

The term “schizophrenia” has been introduced for the first time 1911 by the Swiss psychiatrist, Eugen Bleuler (1857-1939). He was also the first who described the “positive” or “negative” symptoms of schizophrenia. Bleuler changed the name to schizophrenia as it was obvious that Kraepelin`s term “dementia praecox” was misleading as the illness was not a dementia (it did not always lead to mental deterioration) and could sometimes occur late as well as early in life.

Both, Kraepelin and Bleuler, were both in favour of the hereditary cause of schizophrenia. Bleuler wrote on the root cause of schizophrenia: “Schizophrenia appears to be independent of external conditions and circumstances.” However, today’s view on the origin of schizophrenia also includes the external triggering factors.

Social Darwinism, eugenics, and euthanasia

The story about schizophrenia and development of modern psychiatry wouldn’t be complet without mentioning the darkest chapter of psychiatry.

Early sociologists embraced Darwin’s ideas too eagerly, misapplying concepts such as the struggle for existence and survival of the fittest to political phenomena. This gave rise to Social Darwinism, a disreputable movement. Precursors of this movement can be found as early as Charles Darwin (1809-1882, “Struggle for life”) and Herbert Spencer (1820-1930), who coined the term “survival of the fittest.”

Unfortunately, Social Darwinism was employed by imperialists to justify the extermination of primitive populations, by Marxists to incite class struggle massacres, by Hitler to support his genocidal fantasies, by militarists as a justification for war and finally by eugenicists to justify selective euthanasia.

In the course of emerging heredity studies, the eugenics movement as a “branch” of social Darwinism gained increasing popularity in many countries since the late 19th century. Eugenics is a term that encompasses strategies to “improve” human heredity. According to this idea, there are hereditary traits that are worth promoting and desirable. Conversely, it was intended to prevent the reproduction of individuals whose genetic traits were deemed negative. The early eugenic approaches were already discussed and implemented in antiquity for example in Sparta, where the new-born children considered to be unfit as warrior were dropped into caves.

However, eugenics unfolded the most horrific effect in the 20-century ending in extermination of mentally ill in Nazi Germany.

Racial hygiene and the “Aktion T4”

Although the eugenics movement led to inhumane measures in other countries as well (such as forced sterilizations), this social Darwinist approach formed a particularly ominous alliance with Nazi “racial hygiene” in the Third Reich.

Systematically, several hundred thousand people with disabilities or mental illnesses, became victims of measures aimed at the “extermination of life unworthy of living.” Notorious among these were “Action T4” and child euthanasia. The Aktion T4 took place from September 1939 until the end of the war in 1945. By using gas, lethal injections, or starvation the Nazis killed an estimated number of 300,000 mentally ill in psychiatric hospitals across Germany, Austria, occupied Poland, the Protectorate of Bohemia and Moravia (now the Czech Republic) and the occupied parts of the Soviet Union.

The effective treatment for schizophrenia

With the discovery of chlorpromazine in 1952, the foundation for psychiatric pharmacotherapy was laid. It was the first antipsychotic used in treatment for schizophrenia. Chlorpromazine became prototype for numerous subsequent products and were considered a major breakthrough in modern psychiatry.

In the early 1960s, the group of benzodiazepines also entered the market as sedatives. However, the first so called “typical neuroleptics” caused major side effects and many patients rejected medication. They were referred to as “chemical straitjackets” since these early medications primarily induced sedation and motor restriction.

The 1990s were marked in psychiatry by a series of new, so-called atypical antipsychotics, intended to be less prone to side effects and more effective than the old medications. Drugs such as risperidone, amisulpride, and quetiapine were introduced to the market.

Today, a wide range of different psychopharmaceuticals is available. Current pharmaceutical research approaches schizophrenia as the result of chemical imbalance of neurotransmitters in the brain, which on the neurobiological level is true. However, the oset of schizophrenia depends not only on the genetic, inherited predisposition but also on external triggers such as environmental and traumatizing life events.

The new psychopharmaceuticals can undoubtedly reduce the suffering of many patients, and in the early stage of schizophrenia can lead to a full cure.