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The DSM-5, or the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is used to diagnose mental disorders in the United States today. Schizophrenia spectrum and other psychotic disorders are characterized by irregularities in at least one of the following areas: delusions, hallucinations, disorganized thinking and speech, overly disorganized or abnormal motor behavior, and negative symptoms. To be diagnosed with schizophrenia, one must exhibit at least two of the following symptoms for a significant portion of one month: delusions, hallucinations, disorganized speech, abnormally disorganized or catatonic behavior, or negative symptoms (such as decreased emotional expression).
The individual’s functionality in work, interpersonal relationships, or self-care must be lower than before the onset of the aforementioned symptoms, and evidence of disturbance must be exhibited for at least six months and not be attributable to substance use or another medical condition. Because the DSM-5’s current definition of schizophrenia is not the same criteria used to evaluate individuals throughout history, some argue that schizophrenia is a modern disease.
However, others argue that schizophrenia may have indeed been present in the past, but that its existence was merged with contemporary understandings of madness and is entangled in the language and culture of the time.
In this essay, I will demonstrate the complicated evolution of mental diseases, particularly schizophrenia. I will argue that schizophrenia spectrum and other psychotic disorders existed in some form in the past by detailing the development of the understandings and treatments of this mental illness, as well as the factors that influenced the ways of knowing and treating this disease.
Although the term “schizophrenia” is not even a century old,’ evidences of this mental illness are evident in ancient civilizations. Documents from old Pharaonic Egypt in the second millennium before Christ, such as the Book of Hearts, a part of the Eber papyrus, detail depression, dementia, and schizophrenic disturbances, although the term “schizophrenia” is not employed. “The Yellow Emperor’s Classic of Internal Medicine,” a Chinese document written around 1000 BC, details insanity, dementia, and seizures, and uses demonic or supernatural possession to explain these psychotic behaviors.’ In fact, many early societies explained these schizophrenic behaviors in supernatural terms, which informed their formulation of the treatment of the disease.
For example, skulls dated to the Stone Age display evidences of trepanning, a procedure in which holes are made in a person’s skull while he or she is alive to provide an escape for evil spirits in the mind. Another process to relieve symptoms attributed to supernatural possession was the exorcism of the demons, which could be accomplished by subjecting the patient to certain types of music or by trepanning and drilling holes into the skull. In general, madness, or any “irrational, unintelligible, or uncontrolled behavior,” can be found in Mesopotamian, classical Greek, and Latin literature, non-Western cultural writings, and the Bible. Although civilizations contemporaneous with the Greek and Roman people may have attributed mental illness and mad behavior to supernatural and demonic influences, the Greeks and Romans had begun to form a different understanding and approach to schizophrenia and psychotic illnesses. Fictional and historical accounts from these civilizations indicate that the general public was aware of psychotic disorders. Texts that describe the psychotic symptoms of ancient Greek and Roman inhabitants have also been discovered. 12 The Greeks in particular were especially intrigued by the human psyche and by madness.
Plato, for example, described two kinds of madness in the fifth and fourth centuries BC. One type of madness was of divine origin (harkening back to the belief that psychotic diseases were of supernatural origin), but took a positive route in that this divine madness resulted in the creation of prophets, who removed impurities from the people, inspired poets, or elicited a desire for beauty. The other form of madness had a physical origin.14 In a time when those with a mental illness were believed to be possessed by a devil, Hippocrates wanted to rationally and empirically understand disease and clearly differentiated between belief and knowledge. He believed that mental diseases were based in biology and criticized the use of magic to alleviate symptoms of disease.
In a time when astrology, magic, and occultism was widespread and priests attempted to cure the sick with medicinal herb, gymnastics, and exorcist therapies, the Hippocratic bile theory, also known as humoral pathology, emerged. Galen, a Greek physician of the second century AD who believed that mental diseases were symptoms of a brain or organ disease, adopted this humoral pathology theory as well.” Humoral pathology is a model that explains the source of diseases as an imbalance of the humours, or bodily fluids. The humours are divided into blood, phledge, yellow bile, and black bile.
Imbalance of bile and phlegm in particular were linked to diseases of the brain.19 Imbalances of the humours were attributable to the environment, inner physical factors,20 the change of the seasons, and even changes in temperature and humidity.21 To cure diseases caused by unbalanced humours, some physicians recommended changes in diet or lifestyle. For example, if the lack of blood was the cause of an illness, the person should be provided with wet and heat. Other physicians would attempt to rebalance the humours by removing excess fluid through bloodletting, purgatives, vomiting, and purulence.
Not all agreed with Hippocrates and Galen’s humoural pathological approach. Asclepiades believed mental illnesses arose from emotional disturbances, or “passions of sensation, “23 and prescribed music and a swing bed to relax agitated and unsettled patients. Cicero, the famous Roman philosopher, argued that philosophy could aid an individual to reach his own cure. In the second century AD, Soranus believed that corporal punishment should not be used on the mentally ill. Instead, he emphasized the physician-patient relationship and believed that an understanding of the patient’s social environment could lead to the understanding of the patient’s illness. Because of this way of understanding, Soranus advocated for the mentally ill to be housed in light and airy facilities. Roman therapy of the mentally ill was overall humane and encouraged the use of warm baths, massages, and diets. In contrast, inhumane treatments, such as the use of electric eels to deliver shocks, still persisted. Cornelius Celsus, for example, used his belief that mental illnesses were caused by the gods’ anger to justify the use of starvations, shackles, and flogging on patients to move their spirits.
In twelfth century Europe, 26 although scholars at universities appear to have a more scientific and rational understanding of psychotic disorders, the advent of Christianity supported the beliefs that madness and schizophrenic symptoms were caused by demons or where punishments from God. Seventeenth century Europe was characterized by the Enlightenment and the use of reason in the discovery of truth. Francis Bacon championed the experimental method and called for the use of unbiased observations to understand natural laws. This method directly inspired the publication of detailed case studies and psychiatric histories.
With the Protestant Reformation and the decline of the belief in original sin, mental illnesses were no longer viewed as supernatural in origin, but potentially treatable.28 However, Bacon’s rational method had not yet influenced treatments, which were not scientific or evidence based, especially because the origin of the disease in the brain had not been identified yet.29 During this time, psychiatric hospitals, attendants, and medical supervisors emerged. The mentally ill in these asylums were often treated by shock methods, such as holding the patients down while pouring cold water on their faces until they almost drowned and strapping patients to chairs until they lost sensation.
Other neglectful and inhumane treatments employed included chaining, bloodletting, purgatives, and exhibiting patients for a fee. In the eighteenth century, the process of describing diseases accurately and in detail had arisen. This process was also used in the understanding of mental diseases. Accounts by Haslam and Pinel in 1809 are sometimes viewed as the earliest reports of schizophrenia in medical and psychiatric literature33 that conform to the definition of schizophrenia today. Philippe Pinel was a French physician who is regarded as one of the founders of modern psychiatry, and he advocated for an objective medical and philosophical approach in the study of psychological diseases. One of Pinel’s students, Jean Etienne Esquirol, defines hallucinations as “an intimate conviction of a sensation actually perceived, while no external object capable of exciting that sensation is accessible to the senses.’ ”
This definition and his definition of monomania mirror the modern characterizations of hallucinations and paranoid schizophrenia, respectively. The nineteenth century was characterized by a growth in the knowledge and understanding of the body and the mind. After a connection between paresis and insanity and syphilis was discovered, evidence that psychological disorders were caused by brain diseases emerged. Psychiatry and medicine became more and more professional, wherein the treatment for mental illnesses became more responsible, and these psychological disorders began to be increasingly well documented.
In 1878, Emil Kraepelin categorized catatonia, dementia paranoides, dementia simplex, and hebephrenia under the group “dementia praecox. .” The name “dementia praecox” or “early dementia” was used to separate this category from other types of dementia, such as Alzheimer’s, that occur later in life, and because his studies concentrated on young adults. Symptoms of dementia praecox that he noted included emotional dullness, “loss of inner unity,” and crying or laughing for no evident reason. The twentieth century was characterized by a sharp increase in psychopathological literature. Between 190843 and 1911,44 the term “schizophrenia” was coined by Eugen Bleuler to rename Emil Kraepelin’s dementia praecox. Bleuler characterized schizophrenia into the four “A’s”: affect (lessened emotional response to stimuli), loosened associations (disorganized thoughts), ambivalence (an inability make decisions), and autism (unawareness of external events and engrossments with one’s own thoughts). He also was the first to name and detail positive and negative symptoms. Today’s diagnostic criteria of schizophrenia spectrum and psychotic disorders are a direct result of both Kraepelin and Bleuler’s definitions.
However, because the biological cause of schizophrenia had not been discovered by the twentieth century, there were many unsuccessful trial and error treatments. One such treatment was fever therapy, which arose due to the observation that patients seemed to improve somewhat when their temperature was increased. Psychiatrists employing fever therapy would induce fevers by injecting sulfur and oil and causing abscesses. Other treatments such as gas therapy, sleep therapy, insulin therapy, electroconvulsive treatment, and lobotomies, were also practiced. The latter half of the twentieth century was characterized by a pharmacological breakthrough.
In the 1950’s, the first antipsychotic medication, chlorpromazine, became available after a surgeon looking for an anesthetic for cardiorespiratory shock discovered it. Soon after chlorpromazine was on the market, twenty other antipsychotic medicines became available. These drugs became known as neuroleptics because of their many side effects, such as tremors, restlessness, loss of muscle tone, and posture disorders.49 A new round of new atypical antipsychotics appeared with the approval of clozapine, which appeared in American and British markets in 1990. These drugs helped to relieve some of schizophrenia’s negative symptoms and symptoms of patients who did not respond to neuroleptics. During the 1950’s and 1960’s, Freudian ideas from America were introduced in Europe.
Freud’s theories, or “psychotherapy,” encouraged the exploration of childhood experiences and unconscious desires to cure mental illnesses. Coupled with de-institutionalization, counseling and behavior therapy became the prevalent treatment methods for schizophrenia. Cognitive behavioral therapy was also employed to teach patients basic skills, such as personal hygiene and money management. 50 Although much debate about the existence of schizophrenia before modern times still exists,51 in this essay, I have clearly provided evidence for the presence of schizophrenia spectrum and psychotic disorders by detailing the understanding and treatment of psychological diseases in the past, particularly of psychotic illnesses. The challenge of attempting to evaluate the existence of this disease in the past lies in the various shapes and definitions of abnormal behaviors, psychotic behaviors, madness, lunacy, and insanity, which differ based on cultural and linguistic interpretations. However, although many advances have been made in medicines and treatments, schizophrenia remains a scientific challenge as its definition continues to change.
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