Chapter 59: History of Psychiatry

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Mental illness is as old as human history itself.

I mean, you think about Greek myth, right?

Hercules descending into what they call delirious mania.

That's right.

A classic if

mythological early account, but psychiatry, you know, as a specific field dedicated to treating the mind, that's surprisingly young, much younger than people often think.

Welcome to the deep dive.

Today we're taking a guided tour through the, well, sometimes troubling, but always revolutionary history of psychiatry.

We're using excerpts from the Kaplan and Sadok textbook as our guide, the definitive text for many.

And our mission really is to trace how this discipline moved from frankly chains and folklore to neuroscience and modern pharmaceuticals.

It's quite a story.

And we've tried to distill this complex history down into four major threads that kind of run alongside each other.

Okay.

If you follow these, you really get the roadmap.

So first there's the institutional shift moving from just locking people up to actual therapeutic care.

Right.

Second, that huge intellectual debate.

It's a biologic, you know, brain focus or psychological, mind focused.

The nature versus nurture in a way.

Sort of.

Yeah.

Third, the evolution of treatments themselves

from a pretty archaic methods to modern drugs.

And finally, finally the long, long quest to perfect nosology.

That's the classification of mental diseases, getting the definitions right.

Okay.

Let's start with the institutions.

Then if we go back before, say the late 18th century, before the enlightenment really took hold, care was, well, appalling.

Absolutely appalling.

Confinement meant these noisome hospices, as the book calls them, places where the mentally ill were just mixed in with the poor criminals, the elderly, no distinction.

And the doctors treating them were called alienists.

Exactly.

Because the mind was seen as fundamentally alien, something foreign to the person's true self.

Wow.

So the key conceptual leap was this idea, the therapeutic institution.

Meaning?

Meaning admitting a patient with the actual goal of recovery, of providing relief, not just, you know, protecting society by locking them away.

That sounds like the start of moral treatment.

Precisely.

That was the beginning of it.

Now, most of us probably learned about Philippe Pinel in France.

The story goes he struck the chains off the inmates at Salle Petrière.

Right.

Pinel is definitely the most famous figure associated with that.

But the idea of humane treatment was already bubbling up elsewhere.

Oh, really?

Where?

Well, Kaplan and Saddock point to Florence, Italy, back in 1788.

Vincenzo Chirurghi opened the Bonifacio Hospital exclusively for psychiatric patients.

Okay.

Earlier than Pinel's main work.

Yeah.

And he instituted things like gardens, music, exercise, dignified care.

He called it la cura moral.

The psychological treatment.

Exactly.

So Pinel's really huge contribution came a bit later, with his 1801 text, the Traite Medico Philosophique.

Ah, the first big textbook.

It became the first internationally recognized textbook.

And that really kicked off the serious long -term task of classifying these illnesses, of perfecting nosology.

And this reform idea spread.

Oh, absolutely.

Britain picked it up quickly.

John Connolly, for example, championed the non -restraint system around 1839.

Oh, bolshing chains entirely.

Yes.

He insisted these were afflicted persons whose brain and nerves are diseased, needing care, not chains.

But then the focus shifted again, didn't it?

From just humane care to something more scientific.

It did.

And this is where German -speaking Europe takes center stage, particularly between roughly 1850 and 1933.

Why Germany?

Unlike France and England, Germany established numerous university psychiatric departments, over 30 of them.

Ah, linking it directly to academic research.

Exactly.

It gave the field a scientific weight it hadn't really had before.

German effectively became the language of psychiatry during that period, a real golden age of scientific aspiration.

Which sets us up perfectly for our second thread, that big intellectual debate.

And you're saying with that German scientific dominance, the thinking was overwhelmingly biologic for a long time.

For most of the 19th century, yes.

It was all about the brain, the nerves.

Driven by figures like Griesinger.

Wilhelm Griesinger, yeah.

In 1845, he famously stated,

mental disease is brain disease.

Crystal clear.

That's quite a statement.

It led directly to the view that symptoms were, you know, caused by ailing nerves.

A very reductionist view, tied heavily to the idea of heredity.

Meaning you were just born predisposed to it.

Right.

Biological destiny, essentially.

So, if the field was so convinced it was all biology, all brain,

why the massive interruption?

How did psychoanalysis, Freud's depth psychiatry, take over so completely, especially in the U .S.

in the early to mid 20th century?

That is the great pivot, isn't it?

Sigmund Freud, working in Vienna, basically shifted the perceived cause.

It wasn't just bad genes or faulty nerves anymore.

It was conflict.

Conflict, yes.

But specifically conflict within the unconscious mind.

This was revolutionary.

It offered a psychological story, a narrative where before there was mostly just biological determinism.

And he gave us the tools to understand that narrative.

He introduced these key structural concepts.

The id, our sort of primal unconscious drives, sex, aggression.

The superego, our internalized sense of morality, guilt, societal rules, often rooted in childhood fears.

And the ego, the conscious self, basically trying to negotiate between the id's demands, the superego's restrictions, and, you know, reality.

I see.

So it offered a model based on talking, on understanding your internal world, your nurture, not just your biological fate.

Precisely.

And psychoanalysis just took off, especially in major American cities.

It shifted the clinical focus too, away from the classic psychoses, towards things like depressive neurosis.

But that dominance didn't last forever.

No.

It was relatively short lived in the grand scheme of things.

There was a minor counter movement between the 40s and 80s, social and community psychiatry.

Right.

Arguing society was the patient.

Yeah.

Focusing on social causes.

Yeah.

But that got eclipsed too.

By the 1970s, psychoanalysis itself was really being marginalized.

Why?

What pushed it aside?

Did the therapy just stop being effective?

It wasn't necessarily that it stopped working for individuals, but it was pushed aside by the powerful reemergence of the biologic approach.

Ah, the pendulum swings back.

Violently back, you could say.

And this time, it was powered by two massive forces,

new technology, specifically neuroimaging.

Seeing the brain in action.

Right.

And maybe even more importantly,

incredibly effective new treatments, actual medications that worked.

Leading to that famous quote from Ralph Gerrard in 1955.

There can be no twisted thought without a twisted molecule.

That really captured the spirit of the second biologic revolution.

Okay.

That leads us neatly into our third thread,

the treatment arsenal.

Before those twisted molecules were targeted,

what did treatments look like?

You mentioned some were ancient.

Yeah, some borrowed from old humoral theories.

Practices like depletion, bleeding patients, or using harsh purgatives.

Which sound actively harmful.

They often were.

But some older agents were surprisingly effective, even if people didn't fully know why.

Opium, for instance.

Used for melancholia.

For centuries, yes.

Thomas Sydenham's Laudanum was famous.

It clearly had antidepressant effects.

But its use dropped off significantly after the hypodermic syringe was invented in the 1850s.

Because of addiction risk.

Exactly.

Made it much easier to abuse.

There were other experiments, too.

Like Moreau trying hashish in 1845.

Didn't work for dementia, but he thought it might help melancholia.

Interesting.

And then came the first wave of purely chemical interventions.

From the synthetic chemical industry, yes.

Agents like bromides, chloral hydride, and then the big one, the barbiturates.

Starting around 1903 with veronal.

The first major sedatives.

Right.

They calmed people down, but they didn't really treat the underlying major illnesses like schizophrenia or severe depression.

For those, for decades, the main treatments remained physical and often quite drastic.

Like?

Well, you had insulin coma therapy, introduced by Sokol in the 30s for schizophrenia, and chemically induced seizures pioneered by Meduna around 1935 for catatonia.

And then ECT.

And then ECT, electroconvulsive therapy developed by Serrati in 1938.

It quickly became, and honestly still is, one of the most powerful and rapid treatments for severe melancholic depression, mania, and catatonia.

Despite the controversy surrounding it.

Despite the controversy, yes.

Its effectiveness for specific severe conditions is hard to dispute based on evidence.

Okay.

Then we hit the 1950s.

The golden decade of psychopharmacology.

This really cemented that second biologic psychiatry.

Absolutely.

It kicked off in 1952 with chlorpromazine, known as the thorazine in the US.

The first true anti -psychotic or neuroleptic.

And that spurred research.

Massively.

If this drug works, how does it work?

What molecule is it hitting?

Then came the antidepressants.

Imipramine, the first of the tricyclics, TCA's, was found almost by accident by Roland Kuhn in Switzerland in 1959.

He saw it helped depression.

Exactly.

And around the same time, the MAOIs, monoamine oxidase inhibitors, were also discovered, effective for serious depression too.

And the 60s brought anxiety relief.

The 60s brought the benzodiazepines.

Librium in 1960, Valium in 1963.

They became phenomenally successful.

The most prescribed psychoactive drugs for decades.

Mainly for anxiety.

What about mood stabilization?

We hear that term a lot now.

Well, lithium had been identified as effective back in 1949 by John Cade in Australia.

But the actual term mood stabilizer became more popular later.

When?

It really got traction linked to the kindling hypothesis around 1986.

Explain kindling quickly.

The idea was that repeated mood episodes, particularly manic ones, might make the brain more sensitive, like kindling a fire, making future episodes easier to trigger.

And that led to the idea that anticonvulsant drugs like carbamazepine or Valprote, which stop seizures, might also stabilize mood by preventing this kindling effect.

Makes sense.

And then the late 80s brought the blockbusters.

The SSRIs, selective serotonin reuptake inhibitors.

Prozac launched in 1986 and became, well, iconic.

The most commercially successful drug class ever.

By far.

They really brought discussions about mental health into the mainstream.

But here's the crucial point Kaplan and Sadok made.

While these drugs clearly worked for many people, the initial civil theories behind them, like depression is just low serotonin, turned out to be way too simplistic.

So the drug discoveries outpaced the understanding.

Exactly.

We knew that they worked often, before we really knew why they worked on a deep biological level.

The brain is complicated.

Which brings us back to that complexity and our fourth thread,

nosology, the classification.

You said Pinell started with just four diseases.

How did we get to the, what, 300 or so in DSM -5?

That whole journey is really dominated by one towering figure,

Emil Kraepelin.

Kraepelin again?

Yes.

Active in the late 19th and early 20th century,

he had very little time for psychological theories of cause.

For him, diagnosis had to be based purely on the observable clinical course and outcome of an illness.

How did it progress over time?

That was key for him.

Precisely.

And he's responsible for establishing what's often called the Kraepelinian Firewall.

The Firewall.

A strict conceptual separation between two major groups of disorders.

On one side, dementia praecox, characterized by thought disorder, hallucinations, delusions, and typically a deteriorating course.

Which later became known as schizophrenia.

Correct.

Blüter renamed it schizophrenia later, emphasizing the splitting of psychic functions.

And on the other side of the firewall was manic -depressive insanity.

Defined by mood swings.

Primarily a mood disorder, with a phasic or cyclical course periods of illness, followed by periods of relative wellness.

This fundamental distinction, based on course and outcome, is arguably Kraepelin's most enduring legacy in modern diagnosis.

But the U .S.

developed its own system, the DSM, the Diagnostic and Statistical Manual.

How did that interact with Kraepelin's ideas?

It seems like it shifted.

It shifted dramatically.

The very first DSM, DSMI in 1952, was heavily influenced by psychoanalysis, which was dominant in the U .S.

then.

To focus on anxiety and neurosis.

Very much so.

Spearheaded by figures like William Menninger, it saw anxiety as the motor driving most symptoms.

Kraepelin wasn't the main focus there.

But then came DSM3.

Then came DSM3 in 1980.

And that was a revolution.

Led by Robert Spitzer, it was an explicit rejection of psychoanalytic theory as the basis for diagnosis.

A return to description.

A return to Kraepelin's focus on observable criteria, symptoms, course,

objective checklists, you might say.

This is where diagnoses like bipolar disorder and major depression,

rooted in that Kraepelinian tradition, really got cemented in the American system.

And that's why the number of diagnoses exploded.

That's a big part of it.

Trying to define every possible presentation based on descriptive criteria led to a proliferation of categories from finals four to hundreds in DSM5.

Let's maybe look at one or two specific diagnoses mentioned in the text.

What about catatonia?

Its understanding seems to have changed significantly.

Yes, catatonia is a fascinating example.

Karl Kahlbaum first described it as a distinct syndrome way back in 1874, characterized by motor abnormalities, stupor, excitement, posturing, waxy flexibility.

But Kraepelin put it under schizophrenia.

Kraepelin subsumed it under dementia precox, yes, which made sense then as many patients with those symptoms did have a deteriorating course.

But modern psychiatry recognizes it differently.

We now know catatonia isn't exclusive to schizophrenia.

It frequently occurs with severe mood disorders, both depression and mania, and also with various medical conditions.

And the treatment insight is key.

Crucially, catatonia is often highly and rapidly responsive to benzodiazepines like lorazepam.

There's even a diagnostic test called the lorazepam challenge.

Give the drug and see if the cataconic symptoms resolve.

Exactly.

If they do, it strongly suggests catatonia and points away from needing antipsychotics immediately, which can sometimes worsen it.

It shows how refining diagnosis directly impacts treatment.

So alongside these diagnostic shifts, the field was also getting better tools moving into universities.

Absolutely.

The scientific toolkit expanded massively.

Epidemiology, for instance, large scale population studies.

What did they show?

Studies like the NIMH -ECA in the 1980s showed conclusively that psychiatric disorders often begin surprisingly young adolescents, young adulthood.

And remember the heredity debate.

Famous studies like the Danish -American Adoption Cohort Studies Looking at Schizophrenia provided really convincing evidence that genetics, heredity played a significant role.

Another blow to purely nurture -based theories for severe illnesses.

And we got better with numbers,

statistics.

Huge strides.

We moved from just simple tabular bookkeeping in asylums to rigorous controlled trials.

The first proper randomized controlled trial or RCT in psychiatry was reported in 1955.

That's quite late, actually.

Relatively late compared to other fields of medicine, yes.

And we developed useful metrics like the number needed to treat or NTT.

A way to measure drug effectiveness, simply.

Yeah, that's you.

How many patients do you need to treat with this drug for one patient to actually experience a specific benefit compared to a placebo?

Very practical measure.

And then the ultimate tool for the biologic view, neuroimaging.

Euroimaging, starting really in the 1970s and exploding afterwards, was the game changer for visualizing the brain.

Technologies like SPECT, PET, MRI.

Exactly.

SPECT and PET could measure blood flow and metabolism, showing which brain areas were active or inactive during certain tasks or in certain conditions.

MRI and fMRI gave incredibly detailed pictures of brain structure and function.

Leading to findings like hycofrontality.

Right, the observation of reduced activity in the frontal lobes, the brain's executive control center in many patients with schizophrenia.

Discoveries like that were findings of hippocampal volume loss in chronic depression.

They provided visible physical evidence.

They provided objective biological correlates for these illnesses, strongly reinforcing the mental diseases, brain disease premise.

You can see the difference.

Okay, so we've traced this incredible scientific journey from asylums to university labs, from chains to molecules, from four diagnoses to hundreds.

But that shift away from the asylum led to a major crisis, didn't it?

Deinstitutionalization.

It absolutely did.

Starting mainly in the 1960s, the movement to close large state mental hospitals,

deinstitutionalization had complex roots.

Some anti -psychiatry ideology,

belief in community care, the promise of new medications.

But the reality was different.

The reality, as Kaplan and Sadok describe it, often became transinstitutionalization.

Patients were discharged, often without adequate support.

But the money saved didn't follow them effectively into community services.

It got dumped on the cities, as the text puts it.

And the consequences.

Devastating for many.

The numbers are just stark.

Public psychiatric beds plummeted.

In the US, from about 255 beds per 100 ,000 people in 1964,

down to just 11 per 100 ,000 by 2014.

A massive drop.

Where did those seriously ill people go?

Many ended up homeless.

Many ended up in the criminal justice system.

So the US basically reversed centuries of reform.

In a tragic way, yes.

The book highlights that the US now has roughly 10 times as many people with serious mental illness in prisons and jails as it does in state hospital beds.

Prisons as the new asylums.

That's the grim reality.

It's at the complete opposite of the humanitarian impulse that started figures like Kirgui and Pinel on their path centuries ago.

So wrapping this up, what does this whole deep dive mean for you, the listener?

We've seen this incredible journey.

From treating this vague idea of madness with chains and opium, through Freud's psychological revolution focusing on the inner world.

And swinging back again to a highly sophisticated science -driven biologic model focusing intensely on the brain, on molecules, on circuits.

And throughout it all, that quest for better diagnosis, for nosology, has been absolutely central.

How we define the illness shapes everything.

The research, the treatment, the institutions.

It's a continuous process of refinement.

Definitely.

The field is always refining its definitions, its tools, trying to move towards greater scientific rigor, even though the brain still holds so many secrets.

So here's a final thought.

Something provocative maybe for you to take away from this history.

What this journey really shows us is that periods of stunning scientific progress, like that golden age of psychopharmacology in the 50s.

Yeah.

They didn't actually solve the fundamental problem of care.

Despite all the incredible advances in understanding molecules and refining diagnoses, perhaps the most significant challenge remaining is the social one.

Ensuring people get the support they need.

Exactly.

Ensuring that the most seriously ill don't fall through the cracks, ending up homeless or incarcerated.

Because, as this history painfully demonstrates, that's the ultimate failure of the system.

The ultimate reversal of the very reforms that gave birth to psychiatry as a humane discipline in the first place.

A powerful point to reflect on.

The science matters immensely.

But how society cares for its most vulnerable matters just as much, if not more.