History Of Mental Illness from the Stone Age to the 20th century

Engravings from 1525 showing trephination. It was believed that drilling holes in the skull could cure mental disorders.

Prehistoric and Ancient Beliefs

Prehistoric cultures often held a supernatural view of abnormal behavior and saw it as the work of evil spirits, demons, gods, or witches who took control of the person. This form of demonic possession often occurred when the person engaged in behavior contrary to the religious teachings of the time. Trephination is an example of the earliest supernatural explanation for mental illness. Treatment by cave dwellers used a technique called trephination, in which a stone instrument known as a trephine was used to remove part of the skull, creating an opening. Through it, the evil spirits could escape thereby ending the person’s mental affliction and returning them to normal behavior. Examination of prehistoric skulls and cave art from as early as 6500 BC has identified surgical drilling of holes in skulls to treat head injuries and epilepsy as well as to allow evil spirits trapped within the skull to be released (Restak, 2000). Abuse the body badly enough, and the spirit will want to leave it.

Early Greek,  Hebrew, Egyptian, and Chinese cultures used a treatment method called exorcism in which evil spirts were cast out through prayer, magic, flogging, starvation, having the person ingest horrible tasting drinks, or noise-making.

This is the Taijitu (太極圖), with black representing yin and white representing yang. It is a symbol that reflects the inescapably intertwined duality of all things in nature, a common theme in Taoism.

Around 2700 BC, Chinese medicine’s concept of complementary positive and negative bodily forces (“yin and yang”) attributed mental (and physical) illness to an imbalance between these forces. As such, a harmonious life that allowed for the proper balance of yin and yang and movement of vital air was essential (Tseng, 1973).

Mesopotamian and Egyptian papyri from 1900 BC describe women suffering from mental illness resulting from a wandering uterus (later named hysteriaby the Greeks): The uterus could become dislodged and attached to parts of the body like the liver or chest cavity, preventing their proper functioning or producing varied and sometimes painful symptoms. As a result, the Egyptians, and later the Greeks, also employed a somatogenic treatment of strong smelling substances to guide the uterus back to its proper location (pleasant odors to lure and unpleasant ones to dispel).

Throughout classical antiquity we see a return to supernatural theories of demonic possession or godly displeasure to account for abnormal behavior that was beyond the person’s control. Temple attendance with religious healing ceremonies and incantations to the gods were employed to assist in the healing process. Hebrews saw madness as punishment from God, so treatment consisted of confessing sins and repenting. Physicians were also believed to be able to comfort and cure madness, however.

Greco-Roman Thought

Greek physicians rejected supernatural explanations of mental disorders.Rejecting the idea of demonic possession, Greek physician, Hippocrates (460-377 B.C.), said that mental disorders were akin to physical disorders and had natural causes.

According to the theory of the four humors, the substances that make up the human body are: black bile, yellow bile, blood, and phlegm. Hippocrates linked each of these humors to an element in the universe and atmospheric conditions: Black bile: related to earth, with cold and dry properties.

He attempted to separate superstition and religion from medicine by systematizing the belief that a deficiency in or especially an excess of one of the four essential bodily fluids (i.e., humors)— blood which arose in the heart, black bile arising in the spleen, yellow bile or choler from the liver, and phlegm from the brain —was responsible for physical and mental illness. Mental disorders occurred when the humors were in a state of imbalance such as an excess of yellow bile causing frenzy and too much black bile causing melancholia or depression. Hippocrates believed mental illnesses could be treated as any other disorder and focused on the underlying pathology. For example, someone who was too temperamental suffered from too much blood and thus blood-letting would be the necessary treatment.

Hippocrates classified mental illness into one of four categories—epilepsy, mania, melancholia, and brain fever—and like other prominent physicians and philosophers of his time, he did not believe mental illness was shameful. Also important was Greek philosopher, Plato (429-347 B.C.), who said that the mentally ill were not responsible for their own actions and so should not be punished. It was the responsibility of the community and their families to care for them. Humorism remained a recurrent somatogenic theory up until the 19th century.

Many of Hippocrates’ medical theories are no longer practiced today. However, he pioneered medicine as an empirical practice and came up with the “Hippocratic oath,” which all doctors must swear to before joining the profession (i.e., the promise to never intentionally harm a patient). 

While Greek physician Galen (AD 130–201) rejected the notion of a uterus having an animistic soul, he agreed with the notion that an imbalance of the four bodily fluids could cause mental illness.  Galen  said mental disorders had either physical or mental causes and included fear, shock, alcoholism, head injuries, adolescence, and changes in menstruation.therefore, he opened the door for psychogenic explanations for mental illness by allowing for the experience of psychological stress as a potential cause of abnormality. Galen’s psychogenic theories were ignored for centuries, however, as physicians attributed mental illness to physical causes throughout most of the millennium.

The Middle Ages – 500 AD to 1500 AD

The progress made during the time of the Greeks and Romans was quickly reversed during the Middle Ages with the increase in power of the Church and the fall of the Roman Empire. Mental illness was yet again explained as possession by the Devil and methods such as exorcism, flogging, prayer, the touching of relics, chanting, visiting holy sites, and holy water were used to rid the person of his influence. In extreme cases, the afflicted were exposed to confinement, beatings, and even execution. Scientific and medical explanations, such as those proposed by Hippocrates, were discarded.

By the late Middle Ages, economic and political turmoil threatened the power of the Roman Catholic church. Between the 11th and 15th centuries, supernatural theories of mental disorders again dominated Europe, fueled by natural disasters like plagues and famines that lay people interpreted as brought about by the devil. Superstition, astrology, and alchemy took hold, and common treatments included prayer rites, relic touching, confessions, and atonement. Beginning in the 13th century the mentally ill, especially women, began to be persecuted as witches who were possessed. At the height of the witch hunts during the 15th through 17th centuries, with the Protestant Reformation having plunged Europe into religious strife, two Dominican monks wrote the Malleus Maleficarum (1486) as the ultimate manual to guide witch hunts. Johann Weyer (1515-1588), a German physician, and Reginald Scot tried to convince people in the mid- to late-16th century that accused witches were actually women with mental illnesses and that mental illness was not due to demonic possession but to faulty metabolism and disease, but the Church’s Inquisition banned both of their writings. Witch-hunting did not decline until the 17th and 18th centuries, after more than 100,000 presumed witches had been burned at the stake (Schoeneman, 1977; Zilboorg & Henry, 1941).

Near the end of the Middle Ages, mystical explanations for mental illness began to lose favor and government officials regained some of their lost power over nonreligious activities. Science and medicine were called upon to explain psychopathology.

The Renaissance – 14th to 16th centuries

The most noteworthy development in the realm of philosophy during the Renaissance was the rise of humanism, or the worldview that emphasizes human welfare and the uniqueness of the individual. This helped continue the decline of supernatural views of mental illness.

Modern treatments of mental illness are most associated with the establishment of hospitals and asylums beginning in the 16th century. Such institutions’ mission was to house and confine the mentally ill, the poor, the homeless, the unemployed, and the criminal. War and economic depression produced vast numbers of undesirables and these were separated from society and sent to these institutions. Two of the most well-known institutions, St. Mary of Bethlehem in London, known as Bedlam, a term that today means “a state of uproar and confusion”, and the Hôpital Général of Paris—which included La Salpêtrière, La Pitié, and La Bicêtre—began housing mentally ill patients in the mid-16th and 17th centuries. As confinement laws focused on protecting the public from the mentally ill, governments became responsible for housing and feeding undesirables in exchange for their personal liberty. Hospitals and monasteries were converted into asylums. Though the intent was benign in the beginning, as they began to overflow patients came to be treated more like animals than people. Most inmates were institutionalized against their will, lived in filth and chained to walls, and were commonly exhibited to the public for a fee. Mental illness was nonetheless viewed somatogenically, so treatments were similar to those for physical illnesses: purges, bleedings, and emetics.

While inhumane by today’s standards, the view of insanity at the time likened the mentally ill to animals (i.e., animalism) who did not have the capacity to reason, could not control themselves, were capable of violence without provocation, did not have the same physical sensitivity to pain or temperature, and could live in miserable conditions without complaint. As such, instilling fear was believed to be the best way to restore a disordered mind to reason.

Reform Movement – 18th to 19th centuries

The rise of the moral treatment movement occurred in Europe in the late 18th century and then in the United States in the early 19th century. By the 18th century, protests rose over the conditions under which the mentally ill lived, and the 18th and 19th centuries saw the growth of a more humanitarian view of mental illness. In 1785 Italian physician Vincenzo Chiarughi (1759–1820) removed the chains of patients at his St. Boniface hospital in Florence, Italy, and encouraged good hygiene and recreational and occupational training. More well known, French physician Philippe Pinel (1745–1826) and former patient Jean-Baptise Pussin created a “traitement moral” ( Moral treatment) at La Bicêtre and the Salpêtrière in 1793 and 1795 that also included unshackling patients, moving them to well-aired, well-lit rooms, and encouraging purposeful activity and freedom to move about the grounds (Micale, 1985), stressing affording the mentally ill respect, moral guidance, and humane treatment, all while considering their individual, social, and occupational needs.

In England, humanitarian reforms rose from religious concerns. William Tuke (1732–1822) , a Quaker tea merchant, urged the Yorkshire Society of (Quaker) Friends to establish the York Retreat in 1796, where patients were guests, not prisoners, and where the standard of care depended on dignity and courtesy as well as the therapeutic and moral value of physical work (Bell, 1980). The Quakers believed that all people should be accepted for who they were and treated kindly. At the retreat, patients could work, rest, talk out their problems, and pray (Raad & Makari, 2010).

While America had asylums for the mentally ill—such as the Pennsylvania Hospital in Philadelphia and the Williamsburg Hospital, established in 1756 and 1773—the somatogenic theory of mental illness of the time—promoted especially by the father of America psychiatry, Benjamin Rush (1745–1813)—had led to treatments such as blood-letting, gyrators, and tranquilizer chairs. When Tuke’s York Retreat became the model for half of the new private asylums established in the United States, however, psychogenic treatments such as compassionate care and physical labor became the hallmarks of the new American asylums, such as the Friends Asylum in Frankford, Pennsylvania, and the Bloomingdale Asylum in New York City, established in 1817 and 1821 (Grob, 1994).

The choice of Rush (1746-1813) for the seal reflects his place in history.

Rush advocated for the humane treatment of the mentally ill, showing them respect, and even giving them small gifts from time to time.  Despite this, his practice included treatments such as bloodletting and purgatives, the invention of the “tranquilizing chair,” and a reliance on astrology, showing that even he could not escape from the beliefs of the time.By 1844 these practices were considered erroneous and abandoned.

Rush, however, was the first American to study mental disorder in a systematic manner, and he is considered the father of American Psychiatry.

Dorothea Dix worked to change the negative perceptions of people with mental illness and helped create institutions where they could receive compassionate care.

Moral treatment had to be abandoned in America in the second half of the 19th century, however, when these asylums became overcrowded and custodial in nature and could no longer provide the space nor attention necessary. When retired school teacher Dorothea Dix discovered the negligence that resulted from such conditions, she advocated for the establishment of state hospitals. Dix was a New Englander who observed the deplorable conditions suffered by the mentally ill while teaching Sunday school to female prisoners. Over the next 40 years, from 1841 to 1881, she motivated people and state legislators to do something about this injustice and raised millions of dollars to build over 30 more appropriate mental hospitals and improve others. Her efforts even extended beyond the U.S. to Canada and Scotland.

By the late 19th century, moral treatment had given way to the mental hygiene movement, Its main proponent in the United States was Dorothea Dix but the movement was founded by former patient Clifford Beers with the publication of his 1908 memoir A Mind That Found Itself, in which he described his personal struggle with bipolar disorder and the cruel and inhumane treatment people with mental illnesses received. He witnessed and experienced horrific abuse at the hands of his caretakers. At one point during his institutionalization, he was placed in a straight-jacket for 21 consecutive nights. His story aroused sympathy in the public and led him to found the National Committee for Mental Hygiene, known today as Mental Health America, which provides education about mental illness and the need to treat these people with dignity. Today, MHA has over 200 affiliates in 41 states and employs 6,500 affiliate staff and over 10,000 volunteers.

Riding on Louis Pasteur’s breakthrough germ theory of the 1860s and 1870s and especially on the early 20th century discoveries of vaccines for cholera, syphilis, and typhus, the mental hygiene movement reverted to a somatogenic theory of mental illness. European psychiatry in the late 18th century and throughout the 19th century, however, struggled between somatogenic and psychogenic explanations of mental illness, particularly hysteria, which caused physical symptoms such as blindness or paralysis with no apparent physiological explanation. Franz Anton Mesmer (1734–1815), influenced by contemporary discoveries in electricity, attributed hysterical symptoms to imbalances in a universal magnetic fluid found in individuals, rather than to a wandering uterus (Forrest, 1999). James Braid (1795–1860) shifted this belief in mesmerism to one in hypnosis, thereby proposing a psychogenic treatment for the removal of symptoms. At the time, famed Salpetriere Hospital neurologist Jean-Martin Charcot (1825–1893), and Ambroise Auguste Liébault (1823–1904) and Hyppolyte Bernheim (1840–1919) of the Nancy School in France, were engaged in a bitter etiological battle over hysteria, with Charcot maintaining that the hypnotic suggestibility underlying hysteria was a neurological condition while Liébault and Bernheim believed it to be a general trait that varied in the population. Josef Breuer (1842–1925) and Sigmund Freud (1856–1939) would resolve this dispute in favor of a psychogenic explanation for mental illness by treating hysteria through hypnosis, which eventually led to the cathartic method that became the precursor for psychoanalysis during the first half of the 20th century.

20th – 21st Centuries

The decline of the moral treatment approach in the late 19th century led to the rise of two competing perspectives – the biological or somatogenic perspective and the psychological or psychogenic perspective.Psychoanalysis was the dominant psychogenic treatment for mental illness during the first half of the 20th century, providing the launching pad for the more than 400 different schools of psychotherapy found today (Magnavita, 2006). Most of these schools cluster around broader behavioral, cognitive, cognitive-behavioral, psychodynamic, and client-centered approaches to psychotherapy applied in individual, marital, family, or group formats. Negligible differences have been found among all these approaches, however; their efficacy in treating mental illness is due to factors shared among all of the approaches (not particular elements specific to each approach): the therapist-patient alliance, the therapist’s allegiance to the therapy, therapist competence, and placebo effects (Luborsky et al., 2002; Messer & Wampold, 2002).

In contrast, the leading somatogenic treatment for mental illness can be found in the establishment of the first psychotropic medications in the mid-20th century. Restraints, electro-convulsive shock therapy, and lobotomies continued to be employed in American state institutions until the 1970s, but they quickly made way for a burgeoning pharmaceutical industry that has viewed and treated mental illness as a chemical imbalance in the brain.

Both etiological theories coexist today in what the psychological discipline holds as the biopsychosocial model of explaining human behavior. However much we want to believe that we are above the treatments described above, or that the present is always the most enlightened time, let us not forget that our thinking today continues to reflect the same underlying somatogenic and psychogenic theories of mental illness discussed throughout this cursory 9,000-year history.

Emil Kraepelin studied and promoted ideas of disease classification for mental disorders

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of German psychiatrist Emil Kräpelin (1856–1926) reflects the convergence of different disciplines in psychiatry. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry. Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry. However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities. While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favored the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation. While diagnoses were recognized as far back as the Greeks, it was not until 1883 that Kräpelin published a comprehensive system of psychological disorders that centered around a pattern of symptoms (i.e., syndrome) suggestive of an underlying physiological cause. Other clinicians also suggested popular classification systems but the need for a single, shared system paved the way for the American Psychiatric Association’s 1952 publication of the first Diagnostic and Statistical Manual (DSM).

Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory was popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. Freud resisted subjecting his theories to scientific testing and verification, as did his followers. As evidence-based investigations in cognitive psychology led to treatments like cognitive behavioral therapy, many of Freud's ideas appeared to be unsupported or contradicted by evidence. By the 1970s, the psychoanalytic school of thought had become marginalized within the field.

Otto Loewi's work led to the identification of the first neurotransmitter, acetylcholine.

Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. In the 1920s and 1930s, most asylum and academic psychiatrists in Europe believed that manic depressive disorder and schizophrenia were inherited, but in the decades after World War II, the conflation of genetics with Nazi racist ideology thoroughly discredited genetics.

Now genetics are once again thought by some prominent researchers to play a large role in mental illness. The genetic and heritable proportion of the cause of five major psychiatric disorders found in family and twin studies is 81% for schizophrenia, 80% for autism spectrum disorder, 75% for bipolar disorder, 75% for attention deficit hyperactivity disorder, and 37% for major depressive disorder.

Psychiatry, like most medical specialties, has a continuing, significant need for research into its diseases, classifications and treatments. Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically.

Martin Seligman, who is credited with starting the positive psychology movement, attributes the inspiration to his prior work on learned helplessness. New research prompted him to instead focus on the good in people’s lives.

Most recently, the field of abnormal psychology is benefiting from the positive psychology movement, which emphasizes the science of human flourishing and the potential for growth and change throughout life. Positive Psychology is an applied science with and the movement views psychological disorders as difficulties that inhibit the individual’s ability to achieve highly subjective well-being and feelings of fulfillment. Positive psychology began as a new domain of psychology in 1998 when Martin Seligman chose it as the theme for his term as president of the American Psychological Association. It is a reaction against psychoanalysis and behaviorism, which have focused on "mental illness", meanwhile emphasizing maladaptive behavior and negative thinking. It builds further on the humanistic movement, which encouraged an emphasis on happiness, well-being, and positivity, thus creating the foundation for what is now known as positive psychology.In addition, the positive psychology movement emphasizes prevention rather than intervention. The discipline of positive psychology stresses both individual and societal well-being. Instead of fixing problems after they occur, this viewpoint proposes that it would be more beneficial to emphasize prevention. Although its goals are similar to those of the humanitarian approach, the positive psychology movement has a strong base in empirical research and as a result is gaining wide support in the field. We will discuss the Positive psychology movement in the next module.

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