Abstract
Ackerknecht EH. A short history of psychiatry. New York: Hafner, 1968.
Healey D. The antidepressant era. Cambridge, MA: Harvard University Press, 1997.
Micale MS, Porter R. Discovering the history of psychiatry. Oxford: Oxford University Press, 1994.
Berrios GE. The history of mental symptoms: descriptive psychopathology since the nineteenth century. Cambridge: Cambridge University Press, 1996.
History is too serious to be left to historians (Iain Macleod, British politician, 1913–1970).
Over the past quarter of a century, the history of psychiatry has entered the modern age of historical scholarship. A post World War II wave of humanitarianism encouraged the development of the social sciences, and gave impetus to scholarly and often revisionist studies of the history of psychiatry. Ackerknecht's A short history of psychiatry is the best of the pre-modern ‘whig’ texts. Such was its popularity that it was translated from the German into English, Spanish and Japanese. Unlike most contemporary historians, the author feels that philosophical psychiatry has not been useful in practice. His volume stays closer to the history of the clinic than to the history of ideas.
Ackerknecht's history starts with traditional Greco-Roman psychiatry, and the dialectical interplay between naturalist and supernatural explanations of mental diseases. Dualist views of mind and body initially prevailed. However, the most comprehensive exponent of ancient psychiatry, Soranus of Ephesus (100 AD), was a somaticist, and advocated physicalist over psychological treatments. From his time to the late 18th century, mental illness was often regarded as incurable, and on this basis, physicians upheld their right to refuse treatment.
Of occidental psychiatry in the middle ages, Ackerknecht has ‘very little to say’! Islands of humanism (Zilboorg's first psychiatric revolution) existed amidst degenerate versions of Greek medicine. Weyer (1515–1588) and Paracelsus (1491–1541) vigorously spoke up against superstition, witch hunting and the injunctions of the Malleus Maleficarum. For both physicians, psychiatry was essentially empirical and naturalistic. Weyer regarded witches as melancholic, and Paracelsus, a chemical somaticist, wrote Diseases which lead to a loss of reason (1567).
Ackerknecht proceeds century by century. From the 17th century, absolutist governments dealt with social crises by incarcerating those with major mental illness alongside the poor (as late as 1828, the number of mentally ill individuals in British workhouses was 9000). The focus in ambulatory psychiatry appeared to devolve from the psychoses to the neuroses, particularly hypochondriasis and hysteria. Robert Burton's influential Anatomy of Melancholy appeared in 1624. One-third of the patients of Cheyne (1671–1743), and two-thirds of those of Trotter (1761–1832) were considered neurotic. Sydenham (1624–1689), puzzled by hysteria, regarded this disorder to be neither purely physical nor purely psychological. His treatment was either by phlebotomy or by purging; that of Denis, by blood transfusion (his was the first description of this procedure in medicine).
During the 18th century, psychiatry became an autonomous medicopsychological discipline. It was an age of enlightenment and optimism. Fatalistic beliefs in the incurability of psychiatric disorder were overcome. The names of those who opposed restraint of the mentally ill (Pinel, Tuke, Joly, Langermann and Chiarugi) loom large. However, the asylum movement with its excesses continued to grow. Modern protective legal codes pertaining to the mentally ill, and forensic psychiatry, did not arise until the first half of the 19th century.
Stahl (1660–1734) and his contemporaries combined psychological explorations of the mind with somaticism. Pinel (1745–1826) and his pupil Esquirol (1772–1840) were empiricists who supported their clinical studies with comprehensive statistics. Notions of nervous dysfunction and cerebral localisation arose for the first time. Treatments were not only physical; this century witnessed the birth of modern psychotherapy, and the first therapeutic community at Gheel in Belgium.
The 18th and 19th centuries saw the polarisation between physicalist and psychological approaches which have continued to characterise psychiatry to this day. Anatomical advances in explaining medical disorder were not paralleled by somatic findings in the psychiatric domain, and the somaticists underwent a period of ‘disillusionment’. This was reflected in Darwinian theories of hereditary degeneration, particularly those of Morel (1809–1873) and Magnan (1835–1916), and of Lombroso (1836–1909) in the forensic field. Such theories were not fully exploded until well past the end of the 19th century. The field ultimately spawned psychiatric genetics.
German somaticism in the 19th century was tempered by prevailing romanticism. In the landmark work of Griesinger (1817–1869), a reflex theorist and cerebral localisationist, can also be found notions of the unconscious and ego [sic] psychology. He regarded mental illnesses as progressive and psychoses as unitary (Einheitspsychosen). Illnesses are only curable in the first ‘emotional’ stage and become progressively less amenable as they move towards organic end states characterised by disorders of cognition and volition. Ackerknecht regards him as the ‘father of neuropsychiatry’ and writes ‘All current trends in psychiatry can be traced to parts of his work’.
Griesinger's gifted successors, Westphal (1833–1890), Meynert (1833–1893) and Wernicke (1848–1905) were more restricted purveyors of brain psychiatry, and it was left to Kraepelin (1856–1926) to transform psychiatric nosology and facilitate its entry into the 20th century. At the German Research Institute of Psychiatry, he combined clinical empiricism with an experimental approach. His textbook was first published in 1883, reaching its classic form in 1899. Its strength was in the description of disease pictures and prognosis rather than in theory. Adolph Meyer (1866–1950) and his contemporaries broadened Kraepelin's approach to classification, and Eugen Bleuler (1857–1939) integrated Kraepelin and Freud's schemata.
Neuropsychiatry was complemented by developments in dynamic psychiatry. As Ackerknecht mentions, it is one of the great paradoxes of the history of psychiatry that neurology, which hitherto had strengthened somaticist trends, produced the pioneers of psychogenic research. Charcot's (1825–1893) studies with hypnosis in hysteria were extended by Janet (1859–1847) in Paris, and Prince (1854–1929) in Boston. The work of Janet was ultimately eclipsed by Freud (1859–1939). Regrettably, Ackerknecht was not able to record the current renaissance of interest in Janet's oeuvre. Ackerknecht completes his masterly review with a consideration of the newer somatic treatment methods. The age of pharmacotherapy was foreshadowed. The recent work by Healey, The antidepressant era, is reviewed below, and will bring us up to date.
Patrick Vandermeersch writes in Micale and Porter's Discovering the history of psychiatry: ‘Not every science finds its own history very exciting… Psychiatry is an unusual contradiction to this rule’. The dust wrapper describes this work as ‘the first attempt to study comprehensively the multiple mythologies that have grown up around the history of madness’. It achieves this admirably. The authors gathered luminaries in the field to set the record straight. First, what do they have to say about Ackerknecht's volume? Otto Marx described it as a ‘brief but useful’ whig history, and Mora noted its clear exposition of the dialectic between somatic and psychological models of the mind, linking it in stature with Zilboorg's ‘immensely important work’ A history of medical psychology. He regretted that Ackerknecht's much-revised third edition had not been translated into English.
Micale and Porter's book is divided into five sections. ‘Early developments’ contrasts the origins of European and American psychiatry; ‘Five major voices’ examines the work of five eminent psychiatric historians; ‘The psychoanalytic strain’ follows; and ‘Critics of psychiatry’ examines feminism, and Foucault.
The section, ‘Historical themes and topics’ covers, among other issues, the history of the asylum and of psychiatry in Nazi Germany. Brown examines the construction, and distortion, of history in Russian-Soviet psychiatry. Heroic figures occupy centre stage, reinforcing the notion of the psychiatrist as revolutionary hero. Shifting to revolutionary France, Wiener ‘re-shackles’ the inmates of Bicetre. Pinel it seems made no such liberating gesture, although he certainly upheld patients’ rights. He advocated a humanitarian patient-centred, psychosomatic approach to psychiatry, which went against contemporaneous organicist and authoritarian trends. His son and fellow psychiatrist, Scipion, and his student, Esquirol, apparently reduced their mentor to a cipher, subverting the truth to advance their own ambitions. Pinel, however, did little to explode the myths which quickly arose around him. Challenges to Pinel's pre-eminence followed thick and fast in the political and religious as much as the professional and scientific arenas. Ackerknecht noted that Bayle's neuropathological findings at autopsy of mental patients further reinforced organicist trends. Paradoxically, sociologists and those supporting the antipsychiatry movement have recently come to regard Pinel as a figurehead of the bourgeois establishment, exploiting the mentally ill for his own scientific ends.
Grob revisits the history of the asylum in the USA, and his classic three volume study of US psychiatry Mental illness and society. Its whig, historicist antecedent, Albert Deutsch's The mentally ill in America (1937) held sway for more than a generation. From the 1960s, war, racism, sexism and poverty stimulated innovative approaches to the history of US psychiatry. The best known work emerging from this new tradition was Rothman's The discovery of the asylum (1971). It proposes that asylums were ostensibly established to reform deviant individuals and reinforce social cohesion but rather worked to subjugate and marginalise them. In a Marxian analysis, Scull's chapter further sees the asylum as the product of capitalism. The author, a committed social democrat, challenges these views, advocating multi-over uni-dimensional and reductionist views. He notes that ‘asylums were hardly monolithic’ and he argues against received views of custodialism, institutionalisation and community psychiatry, regarding them as simplistic and often far from the whole truth.
Cocks reflects on psychiatry in Nazi Germany in terms of ‘missed resistance’. He writes: ‘A systematic confrontation with the psychiatry's past did not occur until the 1980s’ and ‘Only recently have members of the psychiatric community begun to question their collective past’. Cocks is the leader. He notes historical continuities leading to psychiatric participation during the Nazi era. Two moral positions emerged: the first suggests that moral choice is ‘obviated by membership in historically determined collectivities’. The other emphasises individual choice between good and evil.
In the section, ‘Five major voices’, Porter examines the prolific collaboration between the only mother and son team of historians, Ida Macalpine and Richard Hunter. Their quality and the extent of their output was all the more extraordinary in view of the lack of scholarly interest shown by the British psychiatric community. Three hundred years of psychiatry is described as a ‘stunning anthology’, and Colney Hatch Asylum ‘set new standards in exploring the history of a single asylum’. Their vast private library is now housed in Cambridge University Library and has been curated by German Berrios. Porter lists their achievements as follows: they reinforced the fact that investigation and treatment in psychiatry have a very long pedigree; they broke with heroic approaches to the history of psychiatry; their research extended beyond the narrow medical domain; and finally, they were ‘sticklers for scholarship’! Macalpine and Hunter were subsequently regarded as tainted by whiggery. Porter writes, however, that they were avowedly so. Over a period of 20 years, their work evolved from a Freudian to a ‘medico-scientific’ outlook. Porter speculates that this reflected a concomitant devolution of intellectual power from mother to son.
Micale's mentor Henri Ellenberger, a brilliant independent, is the subject of a stimulating chapter. His The discovery of the unconscious, a classic in the history of dynamic psychiatry, remains ‘indispensable’ to historical research. In this, and some three dozen articles, Ellenberger identified untapped primary sources and brilliantly re-interpreted existing ones. However, he was ultimately marginalised by the Freudian revisionists, and the rising tide of biological psychiatry. Micale has been instrumental in Ellenberger's rightful professional rehabilitation. He identifies five ways in which Ellenberger expanded inherited historical traditions: he obliterated the positivist distinction between whig and scientific interpretations, establishing its pre-scientific and multidisciplinary basis; he brought to attention undervalued historical figures, of which Pierre Janet has become one of the most notable; he provided a history of psychoanalysis, persistently questioning the official rendition; he elaborated the concept of the paradigmatic patient (e.g. Janet's cases of Marie, Achilles, Madame D, and Irene); and finally, he broadened the focus to the history of ideas and cultural history. Reflecting on Ellenberger's shortcomings, Micale notes his relatively uncritical acceptance of the concept of the unconscious, and his reluctance to evaluate psychoanalysis per se.
In the last section, ‘Critics of Psychiatry’, Gutting critically examines the difficulties professional historians have with Foucault's History of Madness. Views are subject to the same splits and schisms which characterise the substantive subject matter. For some, Foucault is a prophet; for others, a charlatan. For some, Foucault's unified vision is good history, for others bad history, and for yet others, it is not history at all. While acknowledging the weaknesses in his historical research, the field has, however, fully endorsed Foucault's premises that madness is partly a social construct, and that the history of madness is constitutive to the history of ideas. Madness’ ‘innocent animality’ and consequent alienation is located in the domain of unreason. Foucault contends that the mad [sic] have always been excluded and confined, and could be regarded as social lepers. An attempt was made at their psychosocial rehabilitation by 19th century reformers by redefining madness as mental illness (i.e. as medicalising an essentially social problem). Gutting believes that Foucault's historical data were illustrative rather than supportive, and that his analysis is not refuted by the empirical ‘deviations’ noted by his detractors. As such, it contributes to idealist rather than empiricist approaches to history. Gutting reserves his judgment and writes: ‘This idealist cast makes professional historians very uneasy with Foucault's work’. Not only historians!
Do Micale and Porter, drawing on the work of so many able scholars, do any better than Ackerknecht? In their introduction, they compare whig with revisionist approaches, and find them both lacking in self-reflexivity, and ultimately wanting. Porter comes in for some criticism from Gutting for his own critique of Foucault. Clearly, the last word has yet to be said on historical approaches to psychiatry!
The works by Berrios and Healey are professional rather than social histories. Both achieve their goals admirably. Berrios’ The history of mental symptoms, a ‘calibration of the language of psychiatry’, systematically explores the empirical and conceptual evolution of descriptive psychopathology. It is a worthy successor to Jaspers. The author's familiarity with the principal romance languages ensures comprehensive coverage of the western literature. He is adept with words and has a penchant for novel terms (e.g. loss of ‘semantic pregnancy’ refers to the loss of belief that aberrant mental contents mean something). Berrios'sources range from clinical to experimental (‘numerical’) and philosophical works. There are nice chapter summaries, and some 78 pages (nearly 15% of the text) contain the references.
Berrios' principal concerns are with the origins of the language of description and explanation, and with the history of taxonomic systems. Methodological issues are not neglected. Thus, Berrios' dedication to Chaslin regarding the importance of precision in terminology reflects his roots in the Cambridge philosophical school of logical positivism. However, he does not neglect symbolic and hermeneutic approaches to the description and understanding of psychopathology. His erudition thus extends to continental schools of semiology, which regard psychiatric symptoms as linguistic signs and which see psychiatry as meshing with linguistic philosophy. For Berrios, however, a sign principally reflects a neurobiological lesion. Symptoms result from the interaction between such somatic signals and prevailing personal and psychosocial codes. His explanatory model is that of the Chinese boxes, which progress from inner philosophicopsychological to outer sociopolitical compartments.
Berrios’ phenomenological categories are: cognition and consciousness, mood and emotions, and volition and action. His surveys of these categories are exhaustive but by no means exhausting. Rather, they are fascinating and absorbing descriptions. Disorders of consciousness interestingly includes an historical appraisal of mental retardation, which although currently regarded as a (quantitative) intellectual failure is felt by the author to be no less linked to (qualitative) psychotic and neurological disorder.
In disorders of perception, pseudohallucinations are analysed as a limiting case of hallucinations, and ‘need(s) to be abandoned’. However, they are not considered in regard to dissociation, which may well prove to be their nosological home. Delusion is synonymous with insanity, and thought disorder is ‘secondary and parasitical’ on theories of thinking, be they 19th century associationist or 20th century holist. Obsessions and compulsions are dealt with, via Freud and emotion, under the rubric of cognition and consciousness, the current Zeitgeist, rather than under volition and action as in the previous two centuries. Dementia, is the ‘flavor of the month’. Berrios historically contextualises the current putative epidemic of Alzheimer's disease. As with amentia, ‘the cognitive paradigm has been an obstacle to research, and fortunately a reexpansion of the symptomatology…is taking place’. Berrios’ chapter on memory disorders reflects the current neuropsychological and neurobiological attempt to employ memory and its disorders as an overarching paradigm for the neurosciences. In keeping with the overall level of scholarship, the book provides an excellent historical survey of the term ‘memory’ and related symptoms and syndromes.
At the half-way point, Berrios explores ‘the diaphanous nature of consciousness’. Here, he remains a traditionalist focusing on disorders of insight and orientation. As with disorders of memory, there is no mention of trauma or dissociation. Multiple personality and its clinical congeners are neither mentioned nor indexed. Depersonalisation is classified in the next major section with mood and emotions.
This section commences with anxiety and its cognate disorders. Berrios perceptively notes that with the advent of Freud and post-Freudianism, those who had previously contributed to their conceptualisation have been neglected by the historians. Janet, in examining psychasthenia (present day anxiety and obsessional disorders) for example, drew on three ‘conceptual traditions: positivism of Ribot and Taine, introspectionism of Main de Birain and the hierarchical approach of Hughlings Jackson’. Berrios plays down the subsequent Freudian integrative view of the anxiety concept, and we are untypically left by the author in an anxious nosological vacuum. Historically, affects have been neglected over intellectual functions. Berrios notes that our current notions of depression and mania, and their combination in bipolar affective disorders, only date from the second half of the 19th century. Anhedonia is regarded as a complex symptom underpinned by disorder at a number of hierarchical levels in the central nervous system, and extending across the nosological spectrum. The author feels that it deserves further psychobiological elucidation, and so it is given its own chapter.
At the millennium, psychiatry is not only beginning to rediscover consciousness, affect and ‘emotional intelligence’. It is also rediscovering volition. Chapter 14 deals with will and its disorders. Berrios notes the 20th century demise of will, and its deficiency aboulia, leaving psychiatry without a ‘pathology of action’. Terms such as motivation and frontal lobe executive are not regarded as having any greater conceptual value. A pathography of will would contribute to the understanding, for example, of multidimensional feelings of fatigue, and of neurasthenia and its possible contemporary congener, chronic fatigue syndrome. Berrios continues with an historical evaluation of disorders of action: catalepsy, catatonia, stupor, Parkinsonian symptoms and stereotypy. As with the gamut of psychopathology, Berrios is particularly keen to encourage neurophysiological and neurochemical studies of these disorders. The tome charmingly terminates with a miscellany: a consideration of personality disorders and self-harm.
Healey's The antidepressant era is a compendium of mini histories within the overarching history of the antidepressant drugs. It provides fascinating sidetrack glimpses into medical empiricism versus inductivism, organic chemistry and drug synthesis, and placebos, probability, and the randomised controlled trial (RCT). It is the story of the latter-day medicalisation of the neuroses in which depression is portrayed as the front runner.
Overall, Healey's reportage gives a sense of providing the inside story. The narrative style ranges from startlingly erudite to rambling and occasionally obscure. Discussions of primogeniture in the discovery of drugs is fascinating but at times tedious. Thus, in Chapter two, the Swiss psychiatrist Kuhn's pharmacodiagnostic work with Geigy's thymoleptic, imipramine is presented as antedating the work of Kline with Roche's psychic energiser, isoniazid. Ultimately, both parties were eclipsed: Kuhn excluded by the psychopharmacology establishment, and Kline by his drug company. Imipramine ushered in the antidepressant era.
Healey's main message is that clinical empiricism tempered by economic rationalism has ultimately failed to advance therapeutics. Psychiatry early adopted the bacteriological model of mental disease and its treatment. In seeking to pharmacologically dissect depression and match drugs (‘magic bullets') with diagnostic entities, depressive categories, it allowed the pharmaceutical industry to shape, not only the development of drug treatment, but also related diagnostic concepts. Ever in search of windows of opportunity, these companies soon surmised that depression held as much if not more promise of lucrative markets than the major and minor tranquilisers. They also correctly anticipated that more compounds, rather than diminishing the usage of existing drugs, would expand the market. Amitriptyline followed imipramine, making the tricyclic antidepressants successful. The selective serotonin re-uptake inhibitors (SSRIs) brought the ‘antidepressant era'to fruition. Healey found no evidence for a conspiratorial pharmaceutical juggernaut, and limited evidence for collusion between drug companies and the psychiatric profession. However, pharmaceutical development has apparently been at the expense of scientific pharmacological research.
Healey notes the key role played by government in drug regulation, particularly through the US Food and Drug Administration. Drug registration has tended to focus on cost-benefit as much as on risk-benefit, and on economically as much as scientifically driven pharmacological imperatives. Further restriction of the scientific development of psychopharmacology occurred as a result of politicoeconomically driven cost containment through fostering purchasing consortia: managed care in the USA, and family health service authorities in the UK.
According to Healey, the depression concept, while at least dating back to Kraepelin, only became widespread following the relatively recent and widespread introduction of antidepressant drugs in outpatient psychiatry. Healey shows how the current diagnostic concept is continuously influenced by a number of non-scientific factors. Rating scales, in particular the ‘Hamilton’ and the ‘Beck, shape the concept as they seek to identify it; grant-giving bodies support diagnostic and treatment concepts originating in the mercantile as much as the psychiatric arena; books sponsored by drug companies draw attention to the untapped diagnostic reservoir of depression (e.g. Frank Ayd's Recognizing the depressed patient), and the media markets potent popular images of drugs as magic bullets.
What of the development of these antidepressive magic bullets? Most of the initial treatment outcome research on antidepressants was in open clinical studies. Randomised controlled trial methodology had been used by Linford Rees in Cardiff and Michael Shepherd at the Maudsley with antipsychotic drugs. However, Kuhn's and Kline's work was uncontrolled. With the influx of government and drug company funds, US hegemony in ‘R and D’ was quickly established. Large-scale, multi-centre clinical trials of drug treatments for depression became the norm.
In the laboratory, the molecular biology of neuro-transmission and medical engineering (‘binding and grinding') has held sway from the 1980s. Pharmacological dissection of depression (e.g. by van Praag) led to the development of antidepressant drug typologies. These seemed to augur a shift from Kraepelinian categories to dimensional approaches to nosology. Prozac was discovered by Wong at Eli Lily in 1972. Cloning of SSRIs for specific receptor proteins ensued. These drugs, however, were found to be necessary but not sufficient for an antidepressive effect. Different SSRI drugs manifest different clinical profiles, suggesting covert ‘downstream’ differences and biological heterogeneity. As the clinical limits of the SSRIs became apparent, the drug companies pursued other markets: social phobia and obsessive-compulsive disorder for patients, designer drugs for the walking unwell. Healey catalogues the rise and fall of the beta receptor model of depression: first the demise of the chemist's vision, then that of the psychopharmacologist leading ultimately to the estrangement of the clinic and the research laboratory. Research is increasingly seen as marginal to practice, and practitioners are once again prescribing tricyclic antidepressants. It is back to ‘dirty’ drugs! As Rifkin once wrote: we have needles (e.g. amine findings in depression) but no haystacks. While there have been astonishing advances in neuroscience, progress in psychiatry has been more limited. Clearly, a paradigm shift is required, rather than market-driven panacea therapy.