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The History of Psychiatry in 60 Minutes or Less Soumya Ranjan Parida Basic B.Sc. Nursing 4 th year Sum Nursing College

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  • The History of Psychiatry in 60 Minutes or LessSoumya Ranjan ParidaBasic B.Sc. Nursing 4th yearSum Nursing College

  • *Learning objectivesappreciate the historical context in which psychiatry is practicedrecognize similarities in the theory and practice of psychiatry across many cultures and erasdescribe how careful observation of patients has led to and supported models of mental illness

  • *TopicsBefore Hippocrates: divine possession, dream therapy, astrologyHippocrates and the humoral theory of illnessClassical descriptions of mental illnessMedieval mental illness: witch-hunting and heresy-hunting

  • *TopicsThe Enlightenment: madness versus reasonThe rise of the asylum; moral treatmentKraepelin: modern psychiatric diagnosisGreat and desperate curesCase presentation: Auguste D

  • *Before Hippocratestrephination & trepanning as early as 5000 BCEMesopotamia (7th c. BCE):At the time of his possession, his left eye moves to the side, a lip puckers, saliva flows from his mouth, and his hand, leg and trunk on the left side jerk If at the time of possession his mind is awake, the demon can be driven out; if at the time of his possession his mind is not so aware, the demon cannot be driven out.Nebuchadnezzar (6th c.)He was driven from men, and ate grass as oxen, and his body was wet with dew, till his hairs were grown like eagles feathers and his nails like birds claws. (Daniel 4)

  • *Before HippocratesAncient Greece (8th c. and on)keres: evil spirits associated with the ghosts of the deadentheos: one with godDionsysus: ecstatic excitement, Bacchic furyastrology

  • *Cult of Asclepiuscaduceus: snake = regenerationenkoimesis: sleeping in therapytestimonials:Agestratus was cured of headaches which were so severe he was never able to sleep.Euhippus had had a spear point fixed in his jaw for six year. As he was sleeping in the temple, Asclepius pulled out the spearhead and gave it into his hands.

  • *Hippocrates (460-377)careful observation; empiric approach to diagnosis & treatmentHippocratic corpusmedicine as a distinct disciplineagainst the Asclepians:[The sacred disease] appears to be to be no more divine nor more sacred than other diseases, but has a natural cause from which it originates. (On the Sacred Disease)

  • *The humoral model of illness* other black bile diseases: headache, vertigo, paralysis, spasm,epilepsy, quartian fever, hemorrhoids, dysentery & skin eruptions

    bloodphlegmyellow bileblack bileheartbrainliverspleenhot, wetcold, wethot, drycold, drydementiamaniamelan-cholia*

  • *Etiology of mental functionMen ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pains, griefs and tears. Through it, in particular, we think, see, hear, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant It is the same thing that makes us made or delirious, inspires us with dread and fear, whether by night or by days, brings sleeplessness, inopportune mistakes, aimless anxieties, absentmindedness, and acts that are contrary to habit. (On the Sacred Disease)

  • *Hippocrates on mental illnessphrenitis (paraphrosyne): fever, mental status change, acute onsetRigors and paraphrosyne after excessive drinking are bad signs. (Aphorisms)mania: chronic afebrile psychosis; a yellow bile diseasemelancholia: when fear and sadness last a long timeThe patient thinks he has something like a thorn, something pricking him in his viscera He flees from light and people He worries and sees frightening visions, fearful dream images and occasionally dead people. (On Diseases)

  • *Hippocratic therapiesremoval of excess humor, or replacement of deficient humor; or, treatment with opposites: hot regimen for cold illnessdietary modificationsexercise, mental and physicalmeds: emetics, laxativesbleedingbathssleep

  • *Classical descriptions of mental ilnessEmpedocles (490-430 BCE)And I am an immortal god to you I go about honored by all.Arataeus (circa 150-200 CE)Sufferers are dull or stern, dejected or unreasonably torpid, without any manifest cause They also become peevish, dispirited, sleepless Unreasonable fears also seize then They complain of life and the desire to die. (On the Causes and Signs of Diseases)

  • *Medieval Europe etiologies of mental illness:psychomachy: battle between Holy Ghost and the Devil for possession of the soulreligious despairdread of damnationseductions of Satanfear of bewitchmentgood madness: ecstatic revelationsheresyhumoral model of temperament

  • *Witch hunts (15th to 17th c.)Malleus Maleficarum (1487):If the patient can be relieved by no drugs, but rather, seems to be aggravated by them, then disease is caused by the devil. maleficium: malice directed by witches who had compacted with the devil, evidenced by uncontrolled speech & behavior

  • *The Stone of FollyMaster, cut the stone out quickly (1475)Robert Burton (1652):Tis not amiss to bore the skull with an instrument, to let out the fuliginous vapors Guinerius cured a nobleman in Savoy by boring along after two years of melancholy and madness, he was delivered.

  • *The return to the brainThomas Willis (1684): The distemper named from the womb [hysteria] is chiefly and primarily convulsive, and chiefly depends on the brain and nervous stock being affected.Nicholas Robinson (1729): insanity is a matter ofreal Affections of the Mind, arising from the real, mechanical Affections of Matter and Motion, whenever the Constitution of the Brain warps from its natural standard.Lady Mary Wortley Montagu (1763): Madness is as much a corporeal distemper as the gout or asthma.Descartes pineal gland

  • *The rise of the asylumhospital tradition has roots in Islamic medicinefirst hospitals for the indigent emerged in Europe in 12th c.Bedlam (St. Mary of Bethlehem)founded 1247; mentally ill moved there 1377only public institution for the mentally ill until the early 18th c.

  • *Hogarths view of Bedlam (1763)

  • *Epidemiology at Bedlam (1810)

  • *Other homes for the mentally illhomes for the mad (England)1810 census: approximately 2590became big business for mad-doctors running the trade in lunacyWorkhouses (Bridewells, Poor Houses)houses of correctioncharitable institutionsin the community

  • *Phillipe Pinel (1745-1826)

  • *Pinels methodThe science of psychiatry: Nothing has contributed more to the rapid improvement of modern natural history than the spirit of minute and accurate observation that has distinguished its votaries. (Treatise on Insanity, 1801.)Rudimentary nosology: melancholia, mania (including periodical insanity), dementia and idiocy.Generally did not ascribe lunacy to organic causes, citing the success of moral treatment in curing lunatics.Key proponent of moral treatmentno violence by keepers and minimal use of restraintsflexible treatment that matches the presenting symptoms

  • *The York RetreatEstablished in 1796 by the tea merchant William Tuke and fellow QuakersMoral treatment: humanity, reason & kindnessDecidedly non-medical model: No physicians, minimal use of medications and restraints.High staff:resident ratio (10:30) Tuke on resocialization: All who attend dress in their best clothes, and vie with each other in politeness and propriety.Tuke on behavior modification: Their treatment depends in great measure upon their conduct.Metaphor of family

  • *Psychiatry in America: asylums ascendantPsychiatry was essentially synonymous with asylums. Practitioners referred to themselves as asylum superintendents.First public hospital in U.S. was Pennsylvania Hospital (1751.) First one exclusively for the insane was established in Williamsburg, VA (1773.)The APA was founded in 1844 as the Association of Medical Superintendents of American Institutions for the Insane.Benjamin Rush (1745-1813) was an important early figure who wrote the first textbook in U.S.

  • *Emil Kraepelin (1856-1926)Founded new Psychiatric University Clinic in Munich, which became the home of Nissl, Alzheimer, and Brodmann (briefly); frequent visitors included Creutzfeld, Jakob and Lewy.Lehrbuch die Psychiatre - premier textbook of psychiatry that went through 8 editions in Kraepelins lifetimeZhlkarten: Kraepelin kept detailed information on all his patients - presumably this aided in his program to systematize psychiatric diagnosis

  • *Kraepelins catatonicsEmil Kraepelin, Psychiatre, 5e (1896)

  • *Kraepelins philosophyThe principle requisite in the knowledge of mental diseases is an accurate definition of the separate disease processes. In the solution of this problem, one must have, on the one hand, knowledge of the physical changes in the cerebral cortex, and on the other of the mental symptoms associated with them. (Memoirs)If we possessed a comprehensive knowledge of any one of these three fields - pathological anatomy, symptomatology or etiology - we would at once have a uniform and standard classification of mental illness. (Memoirs)

  • *Kraepelin: precursor to DSMclassification system based on careful delineation of symptoms and clinical courseKraepelin may have been the first to recognize that several disparate presentations of chronic psychosis may represent a single entity, namely, dementia praecoxdistinction between a chronic & potentially progressive illness (dementia praecox) and a relapsing-remitting illness (circular insanity)

  • *The trouble with asylumsProportion of populationin asylums (per 1000)Average daily censusof UK asylums

  • *Great & desperate curesFever cure of neurosyphilisProlonged narcosisInsulin comaMetrazol-induced seizuresElectroconvulsive therapypsychosurgeryprefrontal leucotomytransorbital lobotomy

  • *The birth of psychopharmopiates (morphine, 1806)chloral hydrate (1832)alkaloid sedatives (henbane, 1833)bromides (1857)barbiturates (1903)chlorpromazine (1953)lithium (1950s)MAO inhibitors (1950s)

  • *Case presentation

  • *Case presentation51-yo married woman whose first symptoms were jealousy of her husband, followed by rapid loss of memory.On admission (1901): completely disoriented to time and space; confabulatory; screaming; paranoid; amnestic; agraphia; alexia; naming errors; neurological exam normal

  • *Case presentationSometimes she greets the attending physician like company and asks to be excused for not having completed the household chores; sometimes she protests loudly that he intends to cut her. Often she screamed for many hours.

  • *Case presentationWhat is your name? Auguste. Last name? Auguste. What is your husbands name? Auguste, I think. Your husband? Ah, my husband. Are you married? To Auguste

  • *Case presentationCourse: At the end, the patient was lying in bed in a fetal position, completely pathetic, incontinent.Died 5 years after admission.

  • *Case presentationGross anatomy: evenly atrophic brain arteriosclerotic changeHistopathology:distributed all over the cortex minute miliary foci1/4 to 1/3 of neurons had very striking changes of the neurofibrilsAmyloid plaque (125x)Neurofibrillary tangles (125x)

  • *Case presentationThe physician: Alois AlzheimerThe patient: first reported patient with Alzheimers disease (An unusual illness of the cerebral cortex.)

  • *ConclusionModern psychiatric practice occurs in a rich historical context.Ideas about mental illness and approaches to addressing mental illness have cycled through history.Generally, careful observation of people with mental illness has led to coherent models of etiology and treatment.