History of schizophrenia
"All the world's mad except thee and me, and even thee's a little cracked."
Cited Porter, 1991.
The earliest descriptions
Although there are still mysteries surrounding schizophrenia, it is not a new illness. Symptoms relating to schizophrenia have been noted since the age of antiquity. A popular belief was that strange behaviour was a result of possession by the devil or assaults from the gods for immoral behaviour.
Stone Age skulls have been found with holes made in them, evidence of re growth shows that these holes were made when the person was alive.
It is believed that the holes were made to provide a portal for evil spirits to escape from (Tallis 1998) Supernatural explanations remained the dominant theory behind mental illness for many years and in some countries still do.
Greek physicians blamed delusions and paranoia on an imbalance of bodily humours. Hippocrates believed that insanity was caused by a morbid state of the liver, this notion was based on work by an earlier physician who examined the liver of a dumb animal in search of the cause for madness.
Over the years the gut, boiling blood and broken hearts have all been blamed by eminent medical men for causing madness.
In the 18th century the nervous system came under suspicion and as understanding increased about the relationship between nerves and organs, it was finally decided that the answer to insanity was in the head
From pillar to post
The theories surrounding mental illness have been reflected in the way those afflicted have been treated through the ages. Mental illness has been the concern of priests, theologians, humanitarians, scientists and doctors.
It is possible that early Christian saints who heard voices and saw visions were in fact having hallucinations. However their experiences were treated as divine rather than demonic.
In 15th century Europe hallucinations and delusions were seen as evidence that an individual was possessed. Many women suffering from these symptoms were thought to be witches and burnt at the stake.
As medical notions again gained momentum, institutions became popular. Although confinement was not a new idea, it grew in popularity in the 16th century. Chains and stocks employed to quell the spirit of demons were slowly abandoned as medical thinking began to quash the notion of possession.
The 17th century saw the beginnings of psychiatric hospitals in Europe, with these hospitals came attendants and medical supervisors and the birth of psychiatry.
But the ideas of early psychiatrists made no more sense than those who had tried to cure the mentally ill before them. It was widely believed in the asylums that the way to cure someone was to shock them. Early shock methods included pinning patients down a pouring cold water on their faces until they were nearly drowned, or strapping patients to chairs so that they lost sensation and became calm.
The 19th century saw an explosion of information about the body and mind. Evidence was mounting that mental illness was caused by disease in the brain after a link had been found between general paresis of the insane and syphilis. Psychiatry had found its place in the medical world.
Organic aetiologies of mental illness were adopted and separate illnesses identified. There were several fragmented descriptions of schizophrenia. Psychiatrists noted that many of their young patients had grandiose delusions or developed unusual postures, while others developed mental deficiency and mania. But no connection was made between the symptoms. (Lewis & Buchanan 1998)
A name at last
The big breakthrough came in 1899 when German psychiatrist Emil Kraepelin combined all the symptoms under a single diagnosis - dementia praecox (dementia of early life)
Kraepelin noted that patients with this condition showed emotional dullness, loss of inner unity and that they would at times laugh or cry without apparent reason, and that the symptoms worsened with time.
Ten years later a Swiss psychiatrist, Eugen Bleuler disagreed with Kraeplin. He concluded that dementia praecox was not an illness that necessarily deteriorated. So Bleuler coined the term schizophrenia, which means split mind, a label which although has stuck, has brought about much misunderstanding about the illness.
People often assume the schizophrenia means 'split personality,' but the name actually refers to the splitting or fragmentation of an individual's thinking and feeling processes (WPA)
Bleuler noted that the primary symptoms of the illness were: abnormal associations, abnormal affect, autistic behaviour and ambivalence.
The descriptions by Kraepelin and Bleuler remain largely unchanged today.
The wonder years
Once schizophrenia had been defined, the next challenge for the medical profession was to find an effective treatment. The cause of schizophrenia was still unknown, so the first half of the 20th century saw trial and error treatments, many of which were painful and unsuccessful.
The emphasis was not on making patients better, or improving their lives, but on making them manageable. Sedation was the key.
Fever therapy was one such treatment. It was noted that people with schizophrenia recovered slightly when their temperature was high, so psychiatrists experimented by inducing fevers in their patients, often by injecting sulphur and oil, or causing abscesses.
Other failed but fashionable treatments included gas therapy, sleep therapy, insulin therapy, electroconvulsive treatment and lobotomies. (Lehmann and Ban 1997)
The first antipsychotics
The first antipsychotic medication came on the market in the 1950s. Chlorpromazine was discovered by a surgeon looking to find an anaesthetic which could control cardiorespiratory shock. He noted that the cocktail of sedating, hypnotic and narcotic drugs caused his patients to become indifferent, he described the effect of the drug as a 'chemical lobotomy' and recommended it to his psychiatric colleagues.
Within ten years of chlorpromazine hitting the market, over twenty other antipsychotic drugs were in the pipeline. It was soon noted that these drugs caused numerous side effects; tremors, restlessness, loss of muscle tone and postural disorders (EPS) and so the group of drugs earned their name - neuroleptics, which means nerve seizing.
Link to Side Effects
But the neuroleptics had the desired effect, although they turned many patients into zombies they took away the positive symptoms and made the patients manageable, so there was no rush to find a drug that did not have such disabling side effects. And so it stayed until 30 years later.
The pharmacological breakthrough came when new 'atypical' antipsychotics appeared on the scene, clozapine was one of the first. Clozapine was not a new drug; it had been around since the 1960s, but due to fears that it caused a severe blood disorder - agranulocytosis, it did not hit the UK or US markets until 1990.
The new atypical drugs were deemed 'cleaner' than the old neuroleptics, and although not side effect free, they were an improvement on the old medications. Other advantages were that the new drugs helped to alleviate some negative symptoms of schizophrenia, not just the positive ones. They also worked in patients who had shown little response to the old neuroleptics.
Link to Medication
More than just medication
While the pharmacological revolution of the 50s and 60s was happening, a new wave of ideas from America was reaching Europe. The ideas that Freud introduced at the turn of the century were starting to have an impact. The psychoanalytical approach was proving popular in the treatment of mental illness. It was felt that exploring people's childhood experiences and unconscious desires would help to alleviate mental suffering.
The anti psychiatry movement was also gaining strength. Laing, an influential psychiatrist challenged the psychiatric establishment claiming that diagnosis was merely a way of labelling socially undesirable behaviour and was scientifically meaningless (Kotowicz 1997)
Counselling and behavioural therapy became increasingly popular, and as a result of de-institutionalisation and care in the community, such therapies became an essential part of the treatment strategy for people with schizophrenia. Controlling symptoms with medications was only one half of the equation, enabling individuals with schizophrenia to function in society was paramount.
Cognitive behavioural therapy was used to teach people basic skills such as personal hygiene and money management. Psychotherapy was used to help people distinguish between what was real and unreal.
Here and now
Today the search continues to find the exact causes and best methods of treatment for schizophrenia. While the symptoms and diagnosis of the illness have changed little in the past hundred years, the aims and objectives of those involved are barely recognisable. Gone is the notion of punishment and confinement.
The challenge is to address the chronic negative symptoms; the apathy, social withdrawal and lack of emotions, so that people with schizophrenia can live balanced and fulfilled lives.
Over the last 10 years visualising the structure and function of the brain has become a major area of investigation. Advances in technology have meant that detailed scans of the brain can be made, so it is possible to map the illness and find the most effective treatments.
There are a growing body of organisations and service users who are working together to improve the lives of people with schizophrenia. Local groups and world wide initiatives are battling to reduce the stigma surrounding schizophrenia and better the lives of those who live with it.
Useful sources of information
Andreasen,N.C. (1997) The evolving concept of schizophrenia from Kraepelin to present and future Schizophrenia Research 28:
Healy, D. (1997) Psychiatric Drugs Explained. Second Edition. loc.unknown: Mosby
Lehmann, H.E. and Ban, T.A. (1997) The history of psychopharmacology of schizophrenia Canadian Journal of Psychiatry vol.42
Lewis, S.W. and Buchanan, R.W. (1998) Schizophrenia - Fast Facts Oxford: Health Press
Porter, R. (1991) The Faber Book of Madness London: Faber and Faber
Tallis, F. (1998) Changing Minds - The History of Psychotherapy as an answer to human suffering London: Cassell
Open The Doors - an international site from the World Psychiatric Association
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