The term “schizophrenia” was coined by Eugen Bleuler.
The history of schizophrenia is complex and does not lend itself easily to a linear narrative. Accounts of a schizophrenia-like syndrome are rare in records before the 19th century. The earliest cases detailed were reported in 1797, and 1809.Dementia praecox, meaning premature dementia ( brain dementia odf the young) was used by German psychiatrist Heinrich Schüle in 1886, and then in 1891 by Arnold Pick in a case report of hebephrenia (Disorganized schizophrenia, or hebephrenia, is a subtype of schizophrenia) In 1893 Emil Kraepelin used the term in making a distinction, known as the Kraepelinian dichotomy, between the two psychoses – dementia praecox, and manic depression (now called bipolar disorder). Kraepelin believed that dementia praecox was probably caused by a systemic disease that affected many organs and nerves, affecting the brain after puberty in a final decisive cascade. It was thought to be an early form of dementia, a degenerative disease. When it became evident that the disorder was not degenerative it was renamed schizophrenia by Eugen Bleuler in 1908.
The word schizophrenia translates roughly as “splitting of the mind” and is Modern Latin from the Greek roots schizein (σχίζειν, “to split”) and phrēn, (φρεν, “mind”) Its use was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described four primary symptoms of schizophrenia. According to him, the ‘4A’s’ of schizophrenia were – Ambivalence, Autism, reduced Association (or disassociation) of ideas and flat Affect. In addition to this, Bleuler also observed that this disorder was different from dementia praecox, as some individuals recovered partially instead of progressively worsening.
The term schizophrenia used to be associated with split personality by the general population but that usage went into decline when split personality became known as a separate disorder, first as multiple identity disorder , and later as dissociative identity disorder. In 2002 in Japan the name was changed to integration disorder, and in 2012 in South Korea, the name was changed to attunement disorder to reduce the stigma, both with good results.
Scratch-drawings on the wall in St. Elizabeths Hospital made by a prisoner with “a disturbed case of dementia praecox”.
In the early 20th century, the psychiatrist Kurt Schneider listed the psychotic symptoms of schizophrenia into two groups of hallucinations, and delusions. The hallucinations were listed as specific to auditory, and the delusional included thought disorders. These were seen as the symptoms of first-rank importance and were termed first-ranksymptoms (FRS). Whilst these were also sometimes seen to be relevant to the psychosis in manic-depression, they were highly suggestive of schizophrenia and typically referred to as first-rank symptoms of schizophrenia. Schneider formulated this list of first-rank symptoms in order to classify and separate schizophrenia from other psychotic disorders. The major first-rank symptoms include – hallucinations (auditory and somatic), thought insertion, thought broadcasting and delusional perception. The most common first-rank symptom was found to belong to thought disorders.Schneider’s first-rank symptoms have been instrumental in designing the diagnostic criteria for schizophrenia, however, the exact nature of these symptoms is not very thorough and they have been questioned. In 2013 the first-rank symptoms were excluded from the DSM-5 criteria. First-rank symptoms are seen to be of limited use in detecting schizophrenia but may be of help in differential diagnosis.
A molecule of chlorpromazine, the first antipsychotic developed in the 1950s.
The earliest attempts to treat schizophrenia were psychosurgical, involving either the removal of brain tissue from different regions or the severing of pathways. These were notably frontal lobotomies and cingulotomies which were carried out from the 1930s. In the 1930s a number of shock therapies were introduced which induced seizures (convulsions) or comas. Insulin shock therapy involved the injecting of large doses of insulin in order to induce comas, which in turn produced hypoglycemia and convulsions. The use of electricity to induce seizures was developed, and in use as electroconvulsivetherapy(ECT)by 1938. Stereotactic surgeries were developed in the 1940s. Treatment was revolutionized in the mid-1950s with the development and introduction of the first typicalantipsychotic, chlorpromazine. In the 1970s the first atypical antipsychoticclozapine, was introduced followed by the introduction of others.
In the early 1970s in the US, the diagnostic model used for schizophrenia was broad and clinically-based using DSM II. It had been noted that schizophrenia was diagnosed far more in the US than in Europe which had been using the ICD-9 criteria. The US model was criticized for failing to demarcate clearly those people with a mental illness, and those without. In 1980 DSM III was published and showed a shift in focus from the clinically-based biopsychosocial model to a reason-based medical model. DSM IV showed an increased focus to an evidence-based medical model. DSM-5 was published in 2013 and introduced changes to DSM IV.
After an evolving through six editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the exact definition of schizophrenia still remains elusive. Initially, diagnosing schizophrenia was focused on the Kraepelinian concepts of the disorders poor outcome, chronicity and patients avolition. A broader definition of the disorder was reflected in DSM – I and DSM – II. These two editions used Bleuler’s symptoms as a reference and focused mainly on the interpersonal pathology and negative symptoms. The DSM – III and subsequently the DSM – III R and DSM – IV, adopted Kurt Schneider’s first-rank symptoms and highlighted them in addition to the chronic nature and lack of functioning seen in the disorder. The primary construct of the DSM – IV was seen to be reliable, had a fair amount of validity, but more importantly, was clinically relevant. Therefore the primary definition of schizophrenia remains unchanged in the DSM – 5.
However, it is to be noted here that the heterogeneity of the disorder is inadequately described by the various subtypes of schizophrenia listed in the DSM – IV. In addition to this, the diagnostic effectiveness of Schneider’s first-rank symptoms have been scrutinized even more, as its focus on special hallucinations and bizarre delusions further obscure the diagnosis of schizophrenia. According to the DSM – 5, the five characteristic symptoms of schizophrenia of which, at least two are to be present for a period of one month, will remain unchanged. These include – hallucinations, delusions, disorganized speech, catatonic behavior and negative symptoms.
Prior to the elimination of its subtypes, schizophrenia had the following distinct clinical subtypes – paranoid, undifferentiated, disorganized and catatonic, with the paranoid subtype being the most commonly diagnosed among patients. However, studies have shown that these subtypes are not reliable, are not stable over a period of time and have little or no prognostic value. In addition, these subtypes do not tend to occur together in families and many a time, patients present with more than one subtype. Finally, the subtypes mentioned above do not respond to any particular pattern of treatment and they cannot be inherited from parent to offspring. As a result, these subtypes of schizophrenia have now been eliminated. The DSM – 5 focuses on the psychopathological aspects of the disorder in order to more effectively address its heterogeneity which can have a higher validity, better use clinically and encourage measurement-based treatment. Along with these new approaches and with the help of the DSM – 5 in combining the neurobiological and genetic aspects of schizophrenia, it might be possible to unravel the true nature behind this mysterious disorder.
It is important to note that 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.
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.
In 2017, the Global Burden of Disease Study estimated there were 1.1 million new cases, and in 2019 WHO reported a total of 20 million cases globally. Schizophrenia affects around 0.3–0.7% of people at some point in their life. About 1.1% of adults have schizophrenia in the United States. It occurs 1.4 times more frequently in males than females and typically appears earlier in men – Although schizophrenia can occur at any age, the average age of onset tends to be in the late teens to the early 20s for men, and the late 20s to early 30s for women. Onset in childhood, before the age of 12 can sometimes occur, however this is uncommon. A later onset can occur between the ages of 40 and 60, known as late onset, and also after 60 known as very late onset (also uncommon).
Schizophrenia has great human and economic costs. It results in a decreased life expectancy of 20 years. This is primarily because of its association with obesity, poor diet, a sedentary lifestyle, and smoking, with an increased rate of suicide playing a lesser role. Side effects of antipsychotics may also increase the risk. These differences in life expectancy increased between the 1970s and 1990s. An Australian study puts the rate of early death at 25 years, and views the main cause to be related to heart disease.
The symptoms of first-rank importance that are truly defining, or key, in the diagnosis of schizophrenia.
The Name “Schizophrenia” Is Heard Worldwide
However, the schizophrenia that Bleuler described was not free of problems. The secondary symptoms were difficult to define, open to misinterpretation, and fostered a purely psychological view of the condition.
Bleuler saw schizophrenia as an extension of normal personality that could, with perseverance, be understood and ultimately provide an insight into human nature. His classification was optimistic and gradualist, maintaining the option that it was ultimately a manifestation of the human condition.
Schizophrenia endures and will remain-in one form or another-as the Ã¼rword for psychiatry. To quote Tim Crow, “Schizophrenia is not just an illness of humans, it may be THE illness of humanity.”3 A century later, Bleuler would have good reason to be pleased with his creation.
Dr Kaplanis Clinical Associate Professor at the Graduate School of Medicine, Wollongong University and Research Fellow, History Department, Stellenbosch University. He wrote about Eugen Bleuler in his bookThe Exceptional Brain and How it Changed the World (2011).
1. Kaplan RM. Being Bleuler: the second century of schizophrenia. Australas Psychiatry. 2008;16(5):305-311.
2. Bleuler E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press.
3. Crow TJ. ‘Is schizophrenia the price that Homo sapiens pay for language?’Schizophr Res. 1997; 28:127-141.
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The word "schizophrenia" is less than 100 years old. However the disease was first identified as a discrete mental illness by Dr. Emile Kraepelin in the 1887 and the illness itself is generally believed to have accompanied mankind through its history.
Written documents that identify Schizophrenia can be traced to the old Pharaonic Egypt, as far back as the second millennium before Christ. Depression, dementia, as well as thought disturbances that are typical in schizophrenia are described in detail in the Book of Hearts. The Heart and the mind seem to have been synonymous in ancient Egypt. The physical illnesses were regarded as symptoms of the heart and the uterus and originating from the blood vessels or from purulence, fecal matter, a poison or demons.
A recent study into the ancient Greek and Roman literature showed that although the general population probably had an awareness of psychotic disorders, there was no condition that would meet the modern diagnostic criteria for schizophrenia in these societies.
At one point, all people who were considered "abnormal," whether due to mental illness, mental retardation, or physical deformities, were largely treated the same. Early theories supposed that mental disorders were caused by evil possession of the body, and the appropriate treatment was then exorcising these demons, through various means, ranging from innocuous treatments, such as exposing the patient to certain types of music, to dangerous and sometimes deadly means, such as releasing the evil spirits by drilling holes in the patient's skull.
One of the first to classify the mental disorders into different categories was the German physician, Emile Kraepelin. Dr. Kraepelin used the term "dementia praecox" for individuals who had symptoms that we now associate with schizophrenia.
The nonspecific concept of madness has been around for many thousands of years and schizophrenia was only classified as a distinct mental disorder by Kraepelin in 1887. 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. Kraepelin 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. He used this term because his studies focused on young adults with dementia.
The Swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911. He was also the first to describe the symptoms as "positive" or "negative." Bleuler changed the name to schizophrenia as it was obvious that Krapelin's name 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.
The word "schizophrenia" comes from the Greek roots schizo (split) and phrene (mind) to describe the fragmented thinking of people with the disorder. His term was not meant to convey the idea of split or multiple personality, a common misunderstanding by the public at large. Since Bleuler's time, the definition of schizophrenia has continued to change, as scientists attempt to more accurately delineate the different types of mental diseases. Without knowing the exact causes of these diseases, scientists can only base their classifications on the observation that some symptoms tend to occur together.
Both Bleuler and Kraepelin subdivided schizophrenia into categories, based on prominent symptoms and prognoses. Over the years, those working in this field have continued to attempt to classify types of schizophrenia. Five types were delineated in the DSM-III: disorganized, catatonic, paranoid, residual, and undifferentiated. The first three categories were originally proposed by Kraepelin.
These classifications, while still employed in DSM-IV, have not shown to be helpful in predicting outcome of the disorder, and the types are not reliably diagnosed. Many researchers are using other systems to classify types of the disorder, based on the preponderance of "positive" vs "negative" symptoms, the progression of the disorder in terms of type and severity of symptoms over time, and the co-occurrence of other mental disorders and syndromes. It is hoped that differentiating types of schizophrenia based on clinical symptoms will help to determine different etiologies or causes of the disorder.
The evidence that schizophrenia is a biologically-based disease of the brain has accumulated rapidly during the past two decades. Recently this evidence has been also been supported with dynamic brain imaging systems that show very precisely the wave of tissue distruction that takes place in the brain that is suffering from schizophrenia.
With the rapid advances in the genetics of human desease now taking place, the future looks bright that greatly more effective therapies and eventually cures - will be identified.
More "History of Schizophrenia" information
More In-Depth History on Schizophrenia
(Source: Karolinska Institute, Department of Clinical Neuroscience)
Schizophrenia during the Middle Ages in the Muslim World
Psychiatry during the middle ages in the Western countries- an overview
Psychiatry during the early 20th century - A European Example
The Old Asylums
[Article revised on 4 May 2020.]
What does ‘schizophrenia’ mean?
In 1910, the Swiss psychiatrist Paul Eugen Bleuler (d. 1939) coined the term 'schizophrenia’ from the Greek words schizo (‘split’) and phren (‘mind’). Bleuler had intended the term to denote a ‘loosening’ of thoughts and feelings, but, unfortunately, many people read it (and still read it) to mean a ‘split personality’.
What does ‘schizophrenia’ not mean?
Robert Louis Stevenson’s novel The Strange Case of Dr Jekyll and Mr Hyde (1886) did much to popularize the concept of a ‘split personality’, which is sometimes also referred to as ‘multiple personality disorder’ (MPD). However, MPD is a vanishingly rare condition that is entirely unrelated to schizophrenia. The vast majority of psychiatrists, myself included, have never seen a case of MPD, and many if not most suspect that such a condition does not exist. Yes, schizophrenia sufferers may hear various voices, or harbour strange beliefs, but this is not the same as having a ‘split personality’. Unlike Dr Jekyll, schizophrenia sufferers do not suddenly mutate into a different, unrecognizable person.
Ironically, Bleuler had intended to clarify matters by replacing the older, even more misleading term of dementia præcox [‘dementia of early life’]. This older term had been championed by the eminent German psychiatrist Emil Kraepelin (d. 1926), who believed, wrongly, that the illness only struck young people, and inevitably led to mental deterioration. Bleuler disagreed on both counts, and, therefore, renamed the illness ‘schizophrenia’. He held that, instead of mental deterioration, schizophrenia led to a sharpening of the senses and heightened consciousness of memories and experiences.
It is as common as it is unfortunate to hear the adjective ‘schizophrenic’ bandied about to mean something like ‘changeable’, ‘volatile’, or ‘unpredictable’, as in, ‘The weather today has been very schizophrenic.’ This sort of usage ought to be discouraged insofar as it perpetuates people’s misunderstanding of the illness, and, by extension, the stigmatization of schizophrenia sufferers. Even used correctly, the term ‘schizophrenic’ labels a person by an illness, implicitly reducing him or her to that illness. But people aren’t ‘schizophrenics’ any more than they are ‘diabetics’ or suffering with toothache.
Who ‘discovered’ schizophrenia?
Despite his shortcomings, Kraepelin was the first to distinguish schizophrenia from other forms of psychosis, and in particular from the ‘affective psychoses’ that can supervene in mood disorders such as depression and bipolar disorder. His classification of mental disorders, the Compendium der Psychiatrie, is the forerunner of today’s most influential classifications of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5) and the International Classification of Diseases 11th Revision (ICD-11). As well as listing mental disorders, these classifications provide operational definitions and diagnostic criteria that physicians and researchers use to establish and verify diagnoses.
Kraepelin first carved out schizophrenia from other forms of psychosis in 1887, but that is not to say that schizophrenia— or dementia præcox, as he called it—had not existed long before his day. The oldest available description of an illness closely resembling schizophrenia can be found in the Ebers papyrus, which dates back to the Egypt of 1550 BCE. And archæological finds of Stone Age skulls with burr holes—drilled, presumably, to release evil spirits—have led to speculation that schizophrenia is as old as humankind.
How was schizophrenia thought of in antiquity?
In antiquity, people did not think of ‘madness’ (a term that they used indiscriminately for all forms of psychosis) in terms of mental disorder, but in terms of divine punishment or demonic possession. Evidence for this comes from the Old Testament, and most notably from the First Book of Samuel, according to which King Saul became ‘mad’ after neglecting his religious duties and angering God. The fact that David used to play on his harp to make Saul better suggests that, even in antiquity, people believed that psychotic illnesses could be successfully treated.
But the spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him … And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him.
When did people first start thinking of schizophrenia as an illness?
In Greek mythology and the Homerian epics, madness is similarly thought of as a punishment from God—or the gods—and it is in actual fact not until the time of the Greek physician Hippocrates (d. 377 BCE) that mental illness first became an object of scientific speculation.
Hippocrates taught that madness resulted from an imbalance of four bodily humours, and that it could be cured by rebalancing these humours with such treatments as special diets, purgatives, and blood-lettings. To modern readers, Hippocrates’ ideas may seem far-fetched, perhaps even on the dangerous side of eccentric, but in the 4th century BCE they represented a significant advance on the idea of mental disorder as a punishment from God.
Only from the brain springs 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…
The Greek philosopher Aristotle (d. 322 BCE) and later the Roman physician Galen (d. 216 CE) expanded on Hippocrates’ humoural theories, and both men played an important role in establishing them as Europe’s dominant medical model.
In Ancient Rome, the physician Asclepiades (d. 40 BCE) and the statesman and philosopher Cicero (d. 43 BCE) rejected Hippocrates’ humoural theories, asserting, for example, that melancholia (depression) resulted not from an excess of ‘black bile’ but from emotions such as rage, fear, and grief. Unfortunately, in the 1st century CE the influence of these luminaries began to decline, and the influential Roman physician Celsus (d. 50 CE) reinstated the idea of madness as a punishment from the gods—an idea which gained currency with the rise of Christianity and the fall of the Roman Empire.
In the Middle Ages, religion became central to cure and, alongside the mediæval asylums such as the Bethlehem (an infamous asylum in London that is at the origin of the expression, ‘like a bad day at Bedlam’), some monasteries transformed themselves into centres for the treatment of mental disorder. This is not to say that the humoural theories of Hippocrates had been supplanted, but merely that they had been incorporated into the prevailing Christian dogma, and the purgatives and blood-lettings continued alongside the prayers and confession.
How did beliefs change?
The burning of the so-called heretics—often people suffering from psychotic illnesses such as schizophrenia—began in the early Renaissance and reached its peak in the 14th and 15th centuries. First published in 1563, De præstigiis dæmonum [The Deception of Demons] argued that the madness of ‘heretics’ resulted not from divine punishment or demonic possession, but from natural causes. The Church proscribed the book and accused its author, Johann Weyer, of being a sorcerer.
From the 15th century, scientific breakthroughs such as the anatomy of Vesalius (d. 1564) and the heliocentric system of Galileo (d. 1642) began challenging the authority of the Church, and the centre of attention and study gradually shifted from God to man and from the heavens to the Earth. Even so, the humoural theories of Hippocrates perdured into the 17th and 18th centuries, to be mocked by the playwright Molière (d. 1673) in such works as Le Malade imaginaire [The Imaginary Invalid] and Le Médecin malgré lui [The Doctor in Spite of Himself].
Empirical thinkers such as John Locke (d. 1704) in England and Denis Diderot (d. 1784) in France challenged this status quo by arguing, very much as Cicero had done, that reason and emotions are caused by nothing more or less than sensations. Also in France, the physician Philippe Pinel (d. 1826) began regarding mental disorder as the result of exposure to psychological and social stressors, and, to a lesser extent, of heredity and physiological damage. A landmark in the history of psychiatry, Pinel’s Traité Médico -philosophique sur l’aliénation mentale ou la manie [A Treatise on Insanity] called for a more humane approach to the treatment of mental disorder. This ‘moral treatment’ included respect for the person, a trusting and confiding doctor-patient relationship, decreased stimuli, routine activity, and the abandonment of old-fashioned Hippocratic treatments. At about the same time as Pinel in France, the Tukes (father and son) in England founded the York Retreat, the first institution ‘for the humane care of the insane’ in the British Isles.
How did beliefs evolve in the 20th century?
Sigmund Freud (d. 1939) and his disciples influenced much of 20th century psychiatry, and by the second half of the century a majority of psychiatrists in the US (although not in the UK) had come to believe that mental disorders such as schizophrenia resulted from unconscious conflicts originating in early childhood.
In the latter part of the 20th century, neuroimaging techniques, genetic studies, and pharmacological breakthroughs such as the first antipsychotic drug chlorpromazine completely reversed this psychoanalytical model of mental disorder, and prompted a return to a more biological, ‘neo-Kraepelinian’ model. At present, schizophrenia is primarily seen as a biological disorder of the brain, although it is also acknowledged that psychological and social stressors can play an important part in triggering episodes of illness, and that different approaches to treatment should be seen not as competing but as complementary.
Even so, critics tend to deride this ‘bio-psycho-social’ model as little more than a ‘bio-bio-bio’ model, with psychiatrists reduced to mere diagnosticians and pill pushers. Many critics question the scientific evidence underpinning such a robust biological approach, and call for a radical rethink of mental disorders, not as detached disease processes that can be cut up into diagnostic labels, but as subjective and meaningful experiences grounded in both personal and larger sociocultural narratives.
What treatments were used before the advent of antipsychotic medication?
Febrile illnesses such as malaria had been observed to temper psychotic symptoms, and in the early 20th century, ‘fever therapy’ became a common form of treatment for schizophrenia. Psychiatrists attempted to induce fevers in their patients, sometimes by means of injections of sulphur or oil. Other popular treatments included sleep therapy, gas therapy, electroconvulsive (electroshock) therapy, and prefrontal leucotomy (lobotomy), which involved severing the part of the brain that processes emotions. Sadly, many such ‘treatments’ aimed more at controlling disturbed behaviour than at curing illness or alleviating suffering. In some countries, such as Germany during the Nazi era, the conviction that schizophrenia resulted from a ‘hereditary defect’ led to atrocious acts of forced sterilization and genocide. The first antipsychotic drug, chlorpromazine, first became available in the 1950s. Although far from perfect, it opened up an era of hope and promise for people with schizophrenia.
So, where to now?
In 1919, Kraepelin stated that ‘the causes of dementia præcox are at the present time still mapped in impenetrable darkness’. Since then, greater understanding of the causes of schizophrenia has opened up multiple avenues for the prevention and treatment of the illness, and a broad range of pharmacological, psychological, and social interventions have been scientifically proven to work.
Today, schizophrenia sufferers stand a better chance than at any other time in history of leading a normal life. And thanks to the fast pace of ongoing medical research, a good outcome is increasingly likely.
Neel Burton is author of The Meaning of Madnessand other books.
Was schizophrenia called what originally
The diagnostic concept of schizophrenia: its history, evolution, and future prospects
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History of schizophrenia
The word schizophrenia was coined by the Swiss psychiatrist and eugenicistEugen Bleuler in 1908, and was intended to describe the separation of function between personality, thinking, memory, and perception. He introduced the term on 24 April 1908 in a lecture given at a psychiatric conference in Berlin and in a publication that same year. Bleuler later expanded his new disease concept into a monograph in 1911, which was finally translated into English in 1950.
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. 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) such as paranoia, dementia praecox, manic-depressive insanity and epilepsy (Emil Kraepelin’s classification). 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). 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. There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia, but other reviews have not suggested any connection. 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.
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. However, no condition resembling schizophrenia was reported in Şerafeddin Sabuncuoğlu's Imperial Surgery, a major Ottoman medical textbook of the 15th century. 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.
Influential earlier concepts
Main article: Dementia praecox
A detailed case report in 1809 by John Haslam concerning James Tilly Matthews, 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. 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. 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. 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. 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". 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.
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. 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’.
Coinage in 1908
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")—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 four A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence. 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.
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 (some reference Jekyll and Hyde) before a later rejection of this usage took place.
In the early 20th century, the psychiatrist Kurt Schneider listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. He termed these as 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. 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.
State abuses in the 20th century
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. Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "Action T4" program.
Schizophrenia under Nazi rule
In 1933 Dr. Ernest Rüdin, who was in-charge of the Genealogical-Demographic Department of the German Institute for Psychiatric Research in Munich, expressed his interest in schizophrenia and with the help of Feanz Kallmann, supported the idea that schizophrenia was a Mendelian inherited disease. Kallmann believed that the disorder was transmitted by a regressive gene.
Both Rüdin's and Kallmann’s theories coincided with the growing interest in the idea of Rassenhygiene or “race hygiene”. The eugenics movement had gained great strength in the United States and Britain. Following suit, in 1933 Rüdin became a guiding force in the passage of Germany’s first compulsory sterilization laws known as “the law for the prevention of progeny with hereditary defects” which would target individuals with mental retardation, schizophrenia, manic-depressive disorder, epilepsy, Huntington chorea, hereditary blindness and deafness, hereditary alcoholism and “grave bodily malformation.” It is suggested by the limited data available that of the 400,000 (1% of the entire population) that were sterilized, 132 000 were sterilized for schizophrenia.
According to E. Fuller Toddy and Robert H. Yolken, it was in 1939 that Hitler asked his private physician and his officials to draft a law that would allow the systematic killing of individuals with mental disorders, sticking to a claim that he had made shortly after assuming office in 1933: “it is right that the worthless lives of such creatures should be ended, and that this would result in certain savings in terms of hospitals, doctors and nursing staff.” In 1932 Berthold Kihn had estimated that mentally ill patients were costing Germany 150 million Reichsmarks per year.
In October 1939, German psychiatric hospitals were asked to carry out a survey which established that 70,000 patients would qualify for the goal of the program which was known as Aktion (action) T–4. The patients were killed with the use of carbon monoxide which they were given in a closed “shower” room. According to Friedlander, the “overriding criterion” for selection for death in the T–4 program “was the ability to do productive work” useful by doing work such as dentistry or by pretending to be “asylum director”. Psychiatric asylums implemented two diets: minimum calories for those who could work and a starvation diet of vegetables only for those who could not.
Bruce Levine quotes the reaction of the superintendent of the Virginia Hospital from 1934 in regards to the sterilization of these populations by the Nazis, an indication to the reaction that was formed abroad: “The Germans are beating us at our own game".[better source needed]
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. 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. 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.
Development of treatments in the 20th century
Harry Stack Sullivan applied the approaches of Interpersonal psychotherapy to treating schizophrenia in the 1920s viewing early schizophrenia as a problem-solving attempt to integrate life experiences, arguing that recovered patients were made more competent after a psychotic experience than before.: 76
In the early 1930s insulin coma therapy was trialed to treat schizophrenia but faded out of use in the 1960s following the advent of antipsychotics.
Antipsychotics were introduced to US hospitals in 1950s, following the discovery of chlorpromazine in 1952 and its trialing in French hospitals. Adoption was encouraged by advertising by the Smith, Kline & French company after it received permission to advertise use of the drug in 1954. Advertised under the brand name Thorazine, more than 2 million people had received the drug within 8 months. In the first report on chloropromazine's use in the US, John Vernon Kinross-Wright suggested that the drug could be used as an adjunct to psychotherapy to improve its effectiveness. : 33–35
By the 1960s adverts started to imply that antipsychotics explicitly addressed the causes of psychosis using terms like "psychocorrective." The 1973 text book, "The Companion to Psychiatric Studies" asserted that antipsychotics 'a specific therapeutic effect in schizophrenia, and that the term “tranquiliser” is a misnomer’ using the term anti-schizophrenic, discussing the dopamine hypothesis and by 1975 adverts asserted that drugs had an antipsychotic action through acting on dopamine receptors. : 54–55
Criticism of mainstream 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. 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.
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 cannot. 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.
R. D. Laing
In his book, The Divided Self, published in 1960, R. D. Laing proposed a psychodynamic model of schizophrenia using the concept of ontological security. He presented a model where schizophrenia is the attempt of the "self", the attention of the mind, to escape the experiences of the world, the "body". The understanding and connection of others, he argued, is felt as either an attack or "smothering understanding" while simultaneously being longed for. Laing posited that in this state the "self" could become angry, hateful, and split and that the strange language of metaphor present in schizophrenia was simultaneously at attempt to avoid being understood, and to be partially understood, or to test a conversation partner. This position was supported by quotations from those diagnosed with schizophrenia. Laing stated that true understanding of the self can resolve schizophrenia.: 137
Evolution of diagnostic approaches
Controversies over validity in the 1970s
In 1970 psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category and proposed that cases of schizophrenia where people recovered well were not really schizophrenia but a separate condition.
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. 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.
DSM-III (1980) and DSM-IV (1994)
The 1970s controversies led 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. The revision was based on Feighner Criteria and Research Diagnostic Criteria that had in turn developed from Robins's 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.
The DSM-IV of 1994 showed an increased focus on an evidence-based medical model, with the diagnostic criteria for schizophrenia slightly adjusted to require one month of positive symptoms instead of one week.
Subtypes of schizophrenia are no longer recognized as separate conditions from schizophrenia by DSM-5 or ICD-11. Before 2013, the subtypes of schizophrenia were classified as paranoid, disorganized, catatonic, undifferentiated, and residual type. The subtypes of schizophrenia were eliminated because of a lack of clear distinction among the subtypes and low validity of classification.
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