A HISTORY OF PSYCHIATRY
FROM ANCIENT TIMES UNTIL NOW
Psychiatry, the branch of medicine focused on the diagnosis, treatment, and prevention of mental illnesses, has evolved significantly over time. From ancient beliefs about supernatural causes of mental disorders to the development of modern science-based treatments, the history of psychiatry reflects humanity's changing understanding of the mind and its disorders.
ANCIENT TIMES: SUPERNATURAL BELIEFS
In ancient cultures, mental illness was often attributed to supernatural forces, such as demonic possession or punishment from the gods.
Ancient Egypt (circa 2000 BCE): Egyptians viewed mental disorders as a result of demonic influence or angered gods. Treatments included rituals, prayer, and in some cases, trepanation (drilling a hole in the skull to release evil spirits).
Ancient Greece and Rome (circa 400 BCE): Philosophers like Hippocrates were among the first to suggest that mental illnesses were caused by imbalances in bodily fluids, or "humours" (blood, phlegm, black bile, and yellow bile). He argued that mental disturbances were diseases of the brain, pioneering a more naturalistic explanation for mental illness. Treatments included dietary changes, rest, and herbal remedies.
Plato and Aristotle also contributed to early psychiatric thought, suggesting that life experiences, emotions, and desires influenced mental states.
MIDDLE AGES: THE AGE OF RELIGION AND SUPPRESSION
During the Middle Ages (5th–15th century), psychiatric care regressed as religious explanations for mental illness dominated. Mental disorders were seen as a sign of sin or possession by the devil, leading to cruel and superstitious treatments.
Europe: Mentally ill individuals were often subjected to exorcisms, prayer, or even torture in attempts to "cure" them. In some cases, people with mental illnesses were treated with kindness in monastic care, but most were feared and locked away in asylums or dungeons.
Islamic World (8th–12th century): The Islamic world, by contrast, made significant advancements. Scholars such as Avicenna (Ibn Sina) viewed mental illness as a medical condition and recommended treatments such as baths, massages, and medications. Hospitals like the Bimaristan in Baghdad provided care for the mentally ill with a more humane approach.
THE RENAISSANCE AND ENLIGHTENMENT: EMERGING SCIENTIFIC PERSPECTIVES
The Renaissance (14th–17th century) and Enlightenment (17th–18th century) saw a shift in thinking, with an increased focus on reason and scientific inquiry.
16th–17th Century Europe: Mental illness was still largely misunderstood, but reformers like Paracelsus argued that it had natural causes and could be treated with medicine rather than punishment. Johann Weyer (1515–1588), a Dutch physician, advocated for the humane treatment of the mentally ill and criticised the persecution of people thought to be possessed by demons.
The Enlightenment: Philosophers like John Locke argued that insanity was caused by irrational thinking, a precursor to cognitive approaches in psychiatry. Philippe Pinel (1745–1826), a French physician, famously removed chains from patients in Parisian asylums, advocating for moral treatment—a compassionate and dignified approach to care that emphasised better living conditions, exercise, and communication.
THE 19TH CENTURY: THE BIRTH OF MODERN PSYCHIATRY
The 19th century was a turning point in the history of psychiatry. The scientific method became central to understanding mental illness, and new treatments were developed.
Asylums and Hospitals: Asylums became the primary treatment centres for the mentally ill, but conditions were often poor. Reformers like Dorothea Dix campaigned for the improvement of these facilities, especially in the United States.
Emil Kraepelin (1856–1926) is often regarded as the father of modern psychiatry. He categorised mental illnesses, distinguishing between disorders like schizophrenia and bipolar disorder (then known as manic depression). His work laid the foundation for modern diagnostic systems.
Sigmund Freud (1856–1939): Freud's development of psychoanalysis revolutionised psychiatry. He proposed that unconscious conflicts, often rooted in childhood experiences, were the cause of many mental disorders. Although Freud's theories, such as the Oedipus complex, are controversial today, his focus on talk therapy profoundly influenced the field.
THE 20TH CENTURY: ADVANCES IN TREATMENT AND THEORY
The 20th century brought both great advancements and some ethical challenges in psychiatric care, especially regarding treatment methods.
Early Biological Treatments: The first half of the 20th century saw the rise of controversial biological treatments for mental illness, including insulin coma therapy, electroconvulsive therapy (ECT), and lobotomy (the surgical removal or destruction of brain tissue). While some treatments, like ECT, are still used effectively today, others, like lobotomy, are widely condemned due to the severe cognitive and personality changes they caused.
Antipsychotic Medications: The 1950s marked a major shift with the introduction of antipsychotic drugs such as chlorpromazine (Thorazine), which revolutionised the treatment of conditions like schizophrenia. This was followed by the development of antidepressants (e.g., imipramine) and anxiolytics (e.g., benzodiazepines).
Psychodynamic vs Behavioural: Freud’s psychoanalytic model dominated much of early 20th-century psychiatry, but by the mid-century, behaviourism—pioneered by John B. Watson and B.F. Skinner—gained influence, focusing on observable behaviour rather than unconscious conflicts. Cognitive-behavioural therapy (CBT) later merged these ideas by incorporating both thought patterns and behaviours into treatment.
LATE 20TH AND 21ST CENTURY: NEUROSCIENCE AND A BIOPSYCHOSOCIAL APPROACH
Biopsychosocial Model: Psychiatry today increasingly adopts a biopsychosocial approach, which integrates biological, psychological, and social factors in understanding and treating mental illness. This model acknowledges the role of brain chemistry and genetics while also considering the individual's environment and experiences.
Advances in Neuroscience: With the rise of modern brain imaging techniques, such as MRI and fMRI, neuroscientists have gained a deeper understanding of how mental illnesses are linked to brain structure and function. Research into neurotransmitters such as serotonin, dopamine, and glutamate has led to better-targeted medications.
Deinstitutionalisation: From the 1960s onwards, many countries moved away from large psychiatric institutions to community-based care, partly in response to the overuse of asylums and the availability of more effective medications. While this shift improved care for some, others were left without adequate support.
CONTEMPORARY PSYCHIATRY
Personalised Medicine: Psychiatry is increasingly focused on personalised medicine, using genetic, neurobiological, and psychological data to tailor treatment to the individual.
Stigma Reduction: Modern psychiatry also focuses on reducing the stigma surrounding mental health. Campaigns like Time to Change in the UK and increased public awareness of mental health issues have encouraged more open discussions about mental illness.
Controversies: Psychiatry still faces challenges, including debates about the over-prescription of psychiatric medications and the ethics of treatments like deep brain stimulation (DBS) or transcranial magnetic stimulation (TMS), which use electrical currents to alter brain function.
CONCLUSION
From its roots in supernatural beliefs to its evolution as a scientific discipline, psychiatry has undergone profound changes throughout history. While significant progress has been made in understanding and treating mental illness, psychiatry continues to evolve, driven by new discoveries in neuroscience, genetics, and psychology. As society’s understanding of mental health deepens, psychiatry will likely continue to expand its approaches to care, aiming for more effective, humane treatments for mental illness.
EXAMPLES OF PSYCHOSURGERY, INCLUDING THE CASE OF HM
Psychosurgery refers to surgical operations that alter brain tissue in an attempt to treat severe mental or neurological disorders. Historically, it has been a controversial area of treatment, especially before the development of more effective and less invasive techniques, such as medication and psychotherapy. Below are some key examples of psychosurgery, including the famous case of HM:
LOBOTOMY
Lobotomy was one of the most notorious forms of psychosurgery. It involved severing connections in the prefrontal cortex, the part of the brain thought to be associated with mood, behaviour, and personality. Initially, it was used to treat severe cases of depression, schizophrenia, and anxiety.
Procedure: The surgery either involved cutting into the brain through the skull or using an "ice-pick" method through the eye sockets to sever neural connections.
Outcome: While some patients showed temporary improvements in behaviour, lobotomies often resulted in severe side effects, including personality changes, emotional flatness, and cognitive impairments. In many cases, patients lost the ability to live independently.
CINGULOTOMY
Cingulotomy is a more targeted form of psychosurgery still occasionally used today to treat patients with severe obsessive-compulsive disorder (OCD), depression, or chronic pain who have not responded to other treatments. The procedure involves the destruction of a small part of the brain called the anterior cingulate cortex, which is involved in emotional regulation and compulsive behaviours.
Procedure: A neurosurgeon uses imaging technology to guide electrodes that destroy specific parts of the anterior cingulate cortex.
Outcome: In certain cases, patients report improvements in symptoms, although there are risks of side effects, such as seizures or cognitive deficits.
SUBCAUDATE TRACTOTOMY
This type of psychosurgery was developed in the mid-20th century as an alternative to lobotomy. It involves targeting and severing specific brain fibres in the subcaudate region of the brain, thought to be associated with emotional regulation and mood.
Procedure: The surgery is performed using stereotactic techniques, which allow precise targeting of brain structures.
Outcome: Subcaudate tractotomy was used to treat depression and anxiety disorders, with mixed results and the potential for serious side effects, such as apathy or emotional blunting.
HEMISPHERECTOMY
This procedure involves the removal or disabling of one hemisphere (half) of the brain and is used to treat severe epilepsy, especially in cases where seizures are localised to one side of the brain and do not respond to medication.
Procedure: The surgeon removes or disables parts of one hemisphere of the brain.
Outcome: While patients, especially children, may retain cognitive functions, there can be significant side effects such as motor deficits on the opposite side of the body.
THE CASE OF HM (HENRY MOLAISON
Henry Molaison, known as HM, is one of the most famous cases in the history of psychosurgery. He underwent an experimental surgery to alleviate severe epileptic seizures that could not be controlled by medication. The surgery involved the removal of parts of his medial temporal lobes, including the hippocampus, which is crucial for memory formation.
Procedure: In 1953, surgeons removed HM’s hippocampus and nearby structures in both hemispheres of his brain to stop the seizures.
Outcome: While the surgery successfully reduced HM's seizures, it resulted in profound memory loss. HM suffered from anterograde amnesia, meaning he was unable to form new memories after the surgery. His case became foundational in the study of memory, illustrating the role of the hippocampus in transferring short-term memories into long-term storage, even though his intelligence and procedural memory remained intact.
AMYGDALOTOMY
This surgery involves lesioning or removing parts of the amygdala, a brain structure involved in emotional responses, especially fear and aggression. Amygdalotomy has been used in rare cases to treat individuals with extreme aggressive or violent behaviours that are resistant to other treatments.
Procedure: The surgeon uses electrodes to destroy parts of the amygdala.
Outcome: While it can reduce aggression in certain cases, the long-term side effects include emotional flatness or difficulty recognising emotions in others.
SUMMARY
Psychosurgery has evolved from crude and often destructive methods like lobotomy to more precise, targeted procedures like cingulotomy and amygdalotomy. The case of HM remains a landmark example of how brain surgery, while effective in treating one condition (in this case, epilepsy), can also provide insights into brain functions—in HM's case, revealing the importance of the hippocampus in memory. While psychosurgery is less common today, it remains a last resort for treatment-resistant conditions
