Schizophrenia – From devilry to disease

Symptoms of psychotic diseases historically instilled fear and distrust in onlookers, who associated them with witchcraft, demonic spirits, and the devil. From Egyptian medicine to medieval witch hunts, psychotic diseases have been associated with the supernatural throughout history. Yet even with advancements in neuroscience and improvements in our understanding of mental illness, stigma surrounding mental health remains prevalent today. Schizophrenia is a psychiatric illness which has evaded a clinical definition until relatively recently; even now, the precise features that constitute a schizophrenic patient are open to dispute. This article explores the ancient history of mental health with a particular emphasis on psychosis, and also considers the changing attitudes and understanding of schizophrenia throughout the last century, leading to its clinical definition as a treatable condition. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISBN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, 2014, 22(1): 126-132. doi:10.2218/resmedica.v22.i1.746. Res Medica 2014, Volume 22, Issue 1 Owen, R. Schizophrenia – From devilry to disease, Res Medica 2014, 22(1): pp.126-132. doi:10.2218/resmedica.v22i1.746 126 Schizophrenia – From devilry to disease


Schizophrenia -From devilry to disease Introduction
Schizophrenia is a neurological disorder manifested by a variety of symptoms including hallucinations, delusions, and often disorder of speech.However, it is a condition which has evaded a clinical definition until relatively recently. 1In the past, symptoms of psychosis have been attributed to the heart and paranormal entities, and it has been only in the last 150 years that the various forms of schizophrenia have been characterised as a single mental condition, by Dr Emil Kraepelin. 2The symptoms of schizophrenia, particularly paranoid schizophrenia, have been described for thousands of years, including in Ancient Egyptian medicine, Hindu culture, Ancient Greece and China, and have been the source of much persecution and adversity for those with the disease. 3By highlighting possible references to schizophrenia in history, a clearer view of not only the changes in medical definitions of psychosis, but also the changes in public opinion of those considered psychotic, may be formulated.

Ancient medicine
Some of the oldest medical texts originate from Ancient Egypt, and a closer analysis provides an insight into the attitudes towards mental diseases of that time.The Papyrus Ebers, a scroll written around 1500 BC, contains references to mental conditions with associated diagnoses.
However, it appears that the academics of that time assumed the heart and mind to be of the same entity: "When the Heart is miserable and is beside itself, behold it is the Breath of the heb-xer Priest". 4 The Ancient Egyptians therefore diagnosed most conditions as diseases of the heart, occasionally attributing particular conditions on the invasion of demons, a theme that was common throughout many ancient medical texts. 3Apart from containing references to some mental disorders, such as depression, the Papyrus Ebers do not to contain any direct descriptions of schizophrenia, contrary to what Theocharis Kyziridis argues in his Notes on the History of Schizophrenia. 3 Nevertheless, it is worth citing these ancient papyri as some of the first recorded references to disorders of the mind.
Mental illness and schizophrenia-like conditions appear in ancient Hindu culture, with symptoms being mentioned in many texts of that time, including the Atharva Veda. 5 It was believed that good health was maintained through the interactions of "Buthas" and "Dosas", and that if these two entities were unbalanced, insanity may result. 3The Atharva Veda contains a multitude of hymns to cure ill health, some of which were used to cure "possession by demons of disease".One particular extract makes reference to someone who "has been maddened by the sin of the gods, or been robbed of sense by the Rakshas" -the stereotypes of madness are often synonymous with the symptoms of schizophrenia.Therefore, it could be argued that the disease was present in this ancient population.This text also highlights the recurring attitude that such a condition must be caused by devilry or a sinister entity. 5ch like the Ancient Egyptian medicine 500 years before, Chinese medicine revolved around the concept that the heart was the centre of the mind and spirit, as depicted in The Yellow Emperor's Classic of Internal Medicine: "The heart controls the spirit, the spleen controls ideas".Symptoms of insanity and madness were therefore associated with diseases infecting the heart, with the cause being "evil influences" or an imbalance between "Yin" and "Yang". 6 400 BC, Hippocrates described mental conditions as problems of the brain and was one of the first to record these diseases as tangible, medical conditions: "… from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pains, griefs and tears.[…] Madness comes from its moistness." 7Although ground breaking in his time, the work of Hippocrates was often met with scepticism and misunderstanding from the public. 7cient diagnoses of diseases were summarized in a medical handbook, written by Aretaeus in the second century AD.
Symptoms of schizophrenia were depicted as conditions of "mania" and "melancholy", with treatment methods revolving around a theory of humoral pathology and a rectification of imbalances of the body. 3moral pathology was also practised by Galen, who attributed mental disorders to a disease of the brain and welcomed the possible involvement of other organs, marking an improvement in the approach to mental disorders and setting the foundation for further advancements in the field that would later become psychiatry. 8

The Middle Ages
The writings of Aretaeus and Galen developed the notion of mind-body unity.
However, the concept of Galenism that predominated medical thinking throughout the Middle Ages, brought to Europe through Arabic writings, was often at odds with cultural beliefs and myths of the time, and instead religious superstition dominated the field of mental health. 9,10spite the founding of Europe's first "asylum" in the 15 th century, the general public viewed hallucinations and delusions as justification of demonic possession and witchcraft. 11Upon confession, "witches" were made to recount their seduction by the devil, which often occurred at times when they were psychologically vulnerable.As a result, in 1919, Dr Elmer Ernest Southard proposed the term "dementia praecox" to be dropped in favour of Bleuler's term "schizophrenia", which he had coined 8 years earlier. 3,16The word "schizophrenia" is derived from the Greek words schizo and phren, to mean "split mind".
Bleuler originally intended this to depict the disjointed and often confused thoughts of sufferers of the disease, however, this has also been the source of many misconceptions surrounding schizophrenia, such as its incorrect association with multiple personality disorder. 17   In the 1950s, the first antipsychotic drug, chlorpromazine, was released onto the market and rapidly became the primary treatment for schizophrenia, making in the region of US$75 million in its first year. 21lorpromazine is defined as a firstgeneration neuroleptic, as it acts by blocking the dopamine D 2 receptors in the brain and reduces the effects of dopamine secretions, theoretically normalizing particular neurochemical imbalances. 22In the 1990s, a new series of antipsychotics came onto the market: second-generation neuroleptics, namely risperidone, olanzapine, sertindole, and quentiapine. 21These new antipsychotic drugs claimed to offer better symptom control for patients in the treatment of schizophrenia.However, after a series of studies, it was revealed that the difference between effectiveness of second-generation antipsychotics and placebos was marginal, with 2 out of the 4 (sertindole and quentiapine) shown to be no more effective than conventional neuroleptics.One may speculate that this disparity could be due to competing interests involved in clinical trials or perhaps simply real-life factors that are difficult to truly replicate in controlled environments. 21econd-generation antipsychotics act on a variety of dopamine receptors, ranging from D 1 to D 5 , and some also affect histamine, muscarinic, and serotonin receptors.These neuroleptics therefore have much more distinct and specific side effects that vary from that of conventional drugs. 22

Learning Points
What is already known • The term "schizophrenia" describes a number of different diseases, presenting with a variety of cognitive, perceptual, and behavioural changes.• No single cause of the disease has been identified, however, it is thought that both genetic and environmental factors are involved.• Modern definitions of schizophrenia were significantly influenced by the work of Emil Kraepelin and Eugen Bleuler.

What this article adds
• A speculation into whether historical references of 'madness' could be attributed to cases of psychosis.
Both Kraepelin and Bleuler defined the multitude of different forms of schizophrenia, with 3 of Kraepelin's original definitions still in use today: hebephrenic (disorganized), catatonic, and paranoid schizophrenia.Little has changed in the definition of the disease in the last century.

, 18 Modern
treatment and attitudes towards schizophrenia Early treatments of schizophrenia were restricted by a lack of knowledge of the brain and an immature understanding of the physical and neurochemical aspects of the disorder.Therefore, early 20 th century treatment techniques were often crude and under-researched, based primarily on theory and lacking solid scientific evidence.Treatments for psychosis often involved sleep therapy, gas therapy, prefrontal leucotomy, and even injecting substances such as sulphur or oils into patients to induce fever. 14,19In the 1940s, electroconvulsive therapy (ECT) was developed as a treatment for certain forms of schizophrenia and became widespread by the 1950s and 1960s.It comprises an electric current that is transmitted through the brain to induce a seizure, temporarily alleviating some of the symptoms of psychotic disorders. 14However, a variety of side effects and complications from ECT have become apparent, ranging from headaches, distress and temporary memory loss to more severe consequences, such as long-term memory loss or changes in personality. 14It is the unfavourable side effects of these early psychotic treatments, combined with the development of antipsychotic drugs and an advancement in brain imaging (with the invention of computed tomography in 1973 by Godfrey Hounsfield), 20 that has made their usage less common over the last 40 years.

24 Conclusion
Some of the most common antipsychotics in use are firstgeneration neuroleptics and, like chlorpromazine, are mainly derivatives of phenothiazine.These are primarily used to reduce anxiety and suffering in the patient and to lessen the positive symptoms such as hallucinations, delusions, and thought disjunction characteristic of schizophrenia. 22The advancement of medical imaging techniques has had significant implications for the field of psychiatry, by initiating a shift in disease models.Schizophrenia became viewed as a medically treatable disease as the abnormal neuroanatomy of schizophrenic patients was highlighted. 23This was most significant in disbanding psychodynamic speculations of the cause of schizophrenic symptoms and gave a more clinically focused edge to research into treatment.Modern theories about the causes of schizophrenia mainly revolve around a neurochemical imbalance, but psychosis has also been attributed to brain oxygen deficiency or other biological or anatomical causes, similar to that of epilepsy.The history of schizophrenia is a history of changing attitudes towards mental illness: it is the progression from demonic possession to identifiable disease, and from exorcisms to neuroleptics.The documentation of insanity and mental afflictions throughout historical texts depicts the development of medical knowledge about the brain and its constituents, and also shows how the illogical and often disconcerting thoughts of schizophrenics can have an impact on prejudices of mental disease.As this article has progressed chronologically through periods of history, specifically concerned with mental disorder, there has been a notable change in public opinion of mental conditions, the most significant being in recent decades.However, there still remains a certain stigma surrounding schizophrenia, one that has migrated from associations of devilry to implications of violent crime.Although treatment methods are now available to dampen the positive symptoms of schizophrenia, science has yet to develop a cure.It is widely believed that schizophrenia is a complex disease which originates from the interaction between the patients' genes and environment, and future research into schizophrenia will continue to explore this interaction.