Historical Roots of Schizophrenia  

Overview of Ancient Origins

Ethnographic studies have demonstrated that schizophrenia is present in all existing cultures, from the pre-literate to the most highly advanced. Psychotic symptomatology and schizophrenic-like syndromes were clearly present in ancient civilizations. Recorded descriptions of the disorder appeared before 2000 BC in the ancient Egyptian Book of Hearts, which is part of the Ebers papyrus. Psychological symptoms were thought to emanate from the heart and uterus, and were associated with blood vessels, purulent or fecal matter, poisons, or demons. Hindu descriptions date back to approximately 1400 BC and can be found in the Atharva Veda,^[1] one of the 4 Vedas, which are primary texts of Hinduism. The Vedas contain hymns and incantations from ancient India. It has been posited that health resulted from a balance between 5 elements (Buthas) and 3 humors (Dosas) and that an imbalance between these various elements might result in madness.^[2] A Chinese text entitled The Yellow Emperor's Classic of Internal Medicine, written around 1000 BC, described symptoms of insanity, dementia, and seizures.^[3] Demonic or supernatural possession was often implicated as the cause of psychotic behaviors. The universal prevalence of these symptoms attests to the robust longevity of this frequently devastating disorder.

Greek Rationalism

Although theories of demonic influences also held sway in Greek conceptions of madness, rationalist theories began to take hold. Plato, writing in the 5th and 4th centuries BC, advocated a very modern integrative conceptualization of the relationship between the mind and body. In the Dialogues^[4] he wrote that "...to think about curing the head alone, and not the rest of the body also, is the height of folly....And therefore if the head and body are to be well, you must begin by curing the soul." He advanced the idea of unconscious and illogical mental processes, suggesting that all people had a capacity for irrational thinking. He also speculated that "...when the rest of the soul -- which is rational, mild and its governing -- is asleep, and when that part which is savage and rude, being satisfied with food and drink, frisks about, drives away sleep, and seeks to go and accomplish its practice...that in every one resides a certain species of desires that are terrible, savage, and irregular, even in some that we deem ever so moderate...."

Sigmund Freud would later draw on Plato's speculations to support his own theories concerning unconscious processes as the foundation of mental disturbances, and Freud often cited Plato in support of his own theories.^[5] In Three Essays on the Theory of Sexuality^[6] Freud wrote "...anyone who looks down with contempt upon psychoanalysis from a superior vantage-point should remember how closely the enlarged sexuality of psycho-analysis coincides with the Eros of the divine Plato."

The Greek physician Hippocrates (Figure 1), widely considered the father of modern medicine, built upon the Greek tradition of rational and empirical explanations of nature and behavior. He dismissed the idea of demonic causation of psychosis and instead suggested that disorders such as epilepsy, confusion, and madness originated entirely from the brain. In The Holy Disease^[7] he contended that "...only from the brain spring our pleasures, our feelings of happiness, laughter and jokes, our pain, our sorrows and tears.... This same organ makes us mad or confused, inspires us with fear and anxiety...." In order to explain the presence of various mental and physical disturbances, he postulated the existence of body "humors" including blood, phledge, and yellow and black bile. Optimal mental and physical functioning could only be achieved if these humors were in balance and harmony. An uneven distribution of these fundamental elements might result in madness.

Figure 1. "Hippocrates was one of the first to believe that mental disorders came from the brain." Courtesy of the National Library of Medicine.

The origins of many enlightened treatments may be found in the Greek and Roman period. Asclepiades advocated the use of music and invented a swinging bed designed to relax the agitated patient.^[8] Soranus, in the 2nd century, suggested that patients should be housed in light and airy facilities.^[9] He believed that corporal punishment should not be used, and emphasized the importance of the physician's relationship with the patient and believed that it was important to understand the social environment to gain a full understanding of the patient. Therapeutic interventions by the Romans tended to be humane and emphasis was placed on warm baths, massage, and diet. Other treatments at this time were not as enlightened and benign, including shocks by electric eels. Cornelius Celsus suggested that starvation, fetters, and flogging would help to stir up the spirit.^[8] He justified these means on the belief that the anger of the gods caused these maladies.

Evolution of Classification Systems

More accurate and systemized classifications of psychological disturbances began to evolve in the 1st and 2nd centuries AD. The physician Aretaeus of Cappadocia differentiated states of phrenitis or acute febrile confusion, hysterical suffocation including anxiety states, melancholy and mania.^[2] Melancholy included depression as well as schizophrenic-like withdrawal and deterioration. Mania encompassed periods of extreme excitement and agitation, including psychotic phenomena. He described paranoid symptoms and progressively deteriorating disorders characterized by individuals who "forget themselves, spending the remainder of their lives as brute beasts and lose all human dignity."

Beginning in the 1700s, increased emphasis was placed on detailed and accurate descriptions of abnormal mental processes and states. Philippe Pinel (Figure 2), a French physician considered to be one of the founders of modern psychiatry, argued for an objective medico-philosophical approach to psychological disorders. He advocated that "...only symptoms that are manifest to the senses through external signs, such as the speech, strange gestures, the expression of certain bizarre and uncontrolled emotions...are taken into account. Why not, therefore, bring into this part of medicine, as into its other parts, the method used in all the branches of natural history?"^[10] He distinguished a deteriorating psychological "dementia" from other states including idiocy, mania, and melancholia.

Figure 2. "Philippe Pinel considered to be one of the founders of modern psychiatry, argued for an objective medico-philosophical approach to psychological disorders." Courtesy of the National Library of Medicine.

Jean Etienne Esquirol, a student of Pinel, defined hallucinations in a way that is similar current terminology. They were described as an "intimate conviction of a sensation actually perceived, while no external object capable of exciting that sensation is accessible to the senses"^[11,12] He also identified "monomania", a clinical syndrome similar to modern descriptions of paranoid schizophrenia.

In addition to identification of specific symptoms, attempts were made to divide the clinical landscape into syndromes sharing both clinical features and course. Benedict Augustin Morel in his 1860 Traite des Maladies Mentales (Treatise on Mental Illness)^[13] was the first to use the term dementia praecox (demence precoce). He characterized a previously asymptomatic adolescent boy who became progressively more withdrawn and "degenerated into a state of dementia." The boy also expressed homicidal thoughts towards his father. He differentiated idiocy, a defect state apparent in early life from the deteriorating process associated with dementia praecox. This latter syndrome presented later in life and was potentially reversible. Morel postulated that some of these pathological states may be inherited, and reflected a familial form of degeneration. In support of this, he reported on a psychotic child whose mother had been insane and grandmother had been eccentric. Other symptom complexes identified included delusional states (France) and paranoid states, as described by the German physician Vogel in 1764.^[14] In 1868 Kahlbaum characterized a pattern of abnormal motor tension which he referred to as "katatonia" or catatonia.^[15]

Johann Christian August Heinroth^[16] outlined 48 distinct disease entities and thereby epitomized the general inability to develop straightforward, reliable criteria. He derided biologically oriented theorists as viewing the human mind "as a cadaver which one could cut to pieces with a knife, or as a chemical compound which could be broken down into elements, or as a mechanical contraption, the workings of which one could calculate with the help of mathematics." These theoretical controversies and confusion lead Heinrich Neumann^[17] to reject all systems of classification and suggest that it was necessary "to throw overboard the whole business of classifications" to bring order to the field. He suggested that "there is but one type of mental disturbance, and we call it insanity." Nevertheless, despite the intermittent sense of frustration and confusion, classificatory efforts continued unabated.

Kraepelin's Synthesis

It was not until the latter part of the 19th century that Emil Kraepelin (Figure 3) was able to integrate the diverse clinical phenomena into a coherent and far-reaching classificatory system. His synthetic formulation included the identification of "dementia praecox" to refer to the clinical entity we now call schizophrenia (Figure 4).^[18] "Dementia" referred to the progressive deteriorating course of both emotional and cognitive processes while "praecox" indicated the early age of onset in previously healthy individuals. Thus, fundamental to the diagnosis were both cross-sectional as well as longitudinal components. Importantly, Kraepelin differentiated the generally deteriorating course of dementia praecox from the more episodic and customarily better outcome seen in manic depressive disorder.

In his early writings in 1887 Kraepelin^[19] equated hebephrenia with dementia praecox and differentiated this state from catatonia and dementia paranoides. In 1898, however, Kraepelin presented a landmark paper^[20] in Heidelburg entitled "The Diagnosis and Prognosis of Dementia Praecox" and indicated that these various psychotic conditions were actually part of 1 overall disease entity. He recognized that, although the course of dementia praecox was variable, repeated relapses and progressive deterioration was the rule. "The prognosis, however, is really by no means simple. Whether dementia praecox is susceptible of a complete and permanent recovery...is still very doubtful, if not impossible. But improvements are not at all unusual....It is a more serious matter that in most of these cases the improvement is only temporary, and that such patients are in great danger of relapsing sooner or later, without any particular cause, and then generally suffer more serious injury from their illness."^[21] He noted however that approximately 13% of patients did not exhibit a dementing course. Kraepelin thought that there was an organic basis underlying dementia praecox. In his 1899 textbook Psychiatrie^[22] he wrote that "...in dementia praecox, partial damage to, or destruction of, cells of the cerebral cortex must probably occur, which may be compensated for in some cases, but which mostly brings in its wake a singular, permanent impairment of the inner life."

Figure 3. "Emil Kraepelin devised a classification system for mental illnesses." Courtesy of the National Library of Medicine.

Figure 4. Dementia Praecox. Courtesy of the National Library of Medicine.

Kraepelin divided dementia praecox into 4 subtypes: paranoid, hebephrenic, catatonic, and simple. The paranoid patient primarily exhibited persecutory delusions. The hebephrenic individual presented with silly and facetious behaviors. The hallmarks of the catatonic patient were motor symptoms such as increased muscle tone and sustained postures. The simple subtype exhibited apathy as well as social withdrawal and decline rather than florid psychotic symptoms.^[23]

20th Century Schemas

Eugen Bleuler was the first to use term the word "schizophrenia", derived from the Greek words for "split" and "mind". In contrast to the popular interpretation of split personality, Bleuler referred to a splitting of the psychic functions. He wrote, "If the disease is marked, the personality loses its unity....Often ideas are only partially worked out, and fragments of ideas are connected in an illogical way to constitute a new idea. Concepts lose their completeness, seem to dispense with 1 or more of their essential components; indeed, in many cases they are only represented by a few truncated notions....Thus, the process of association often works with mere fragments of ideas and concepts. This results in associations which normal individuals will regard as incorrect, bizarre, and utterly unpredictable....Instead of continuing the thought, new ideas crop up which neither the patient nor the observer can bring into any connection with the previous stream of thought....In the severest cases emotional and affective expressions seem to be completely lacking...."^[24]

Bleuler took exception to the Kraepelinian notion that schizophrenia almost invariantly involved both a deteriorating course and early onset. He viewed "the schizophrenias" as being composed of several different entities rather than a single disease state as Kraepelin conceptualized. He argued that the schizophrenias had varying underlying causes as well as prognosis. Despite the clinical diversity posited by Bleuler, he asserted that there were 4 cardinal features almost invariably present in schizophrenic patients. These have been termed the "four As":

• Blunted Affect
• Loosening of Associations
• Ambivalence
• Autism

In a lecture in 1926, Bleuler delineated these central clinical characteristics of the disorders.^[25] "In all forms of schizophrenia, however mild, we find a specific disorder of thought characterized by a loosening of the normal associations....Many other problems, relating to logic and concepts, can be deduced from this loosening, such as deficiency of judgment, imprecision, the condensation of several concepts into 1, etc. In the affective sphere, the emotional responses are uneven; normal in relation to certain events, they may be entirely absent with others...it is out of step with the changes occurring either in the outside world or in the individual himself." With regards to ambivalence, Bleuler suggested that "two opposing feelings may simultaneously color the same mental representation." In autism "we encounter inadequate contact with the world outside, an inner life turned in on itself."

Other symptoms of schizophrenia include delusions, hallucinations, catatonia, negativism, and stupor. These were thought to be "secondary" symptoms and present in reaction to the individual's intentions, drives, psychotic state, and environmental conditions. Bleuler noted that these secondary symptoms were present in schizophrenia as well as in other disorders. He also asserted that despite the secondary nature of these symptoms, they formed the basis of the Kraepelinian classificatory system.

Other clinicians also advocated a hierarchical system of symptom classification like Bleuler's. In 1959, Kurt Schneider termed the core features "first-rank" symptoms.^[26] These symptoms included:

• Hearing one's thoughts spoken aloud
• Auditory hallucinations commenting on one's own behavior
• Thought withdrawal, insertion and broadcasting
• Somatic hallucinations, or the experience of one's thoughts as being controlled or influenced from the outside

Manifestation of 1 first-rank symptom in the absence of organic disease, persistent affective disorder, or drug intoxication, was sufficient for a diagnosis of schizophrenia. Second-rank symptoms included other forms of hallucinations, depressive or euphoric mood changes, emotional blunting, perplexity, and sudden delusional ideas. When first-rank symptoms were absent, schizophrenia might still be diagnosed if a sufficient number of second-rank symptoms were present. Although the schneiderian criteria have been criticized as being nonspecific, they have been incorporated into clinical diagnostic tools such as the Research Diagnostic Criteria (RDC) and Diagnostic and Statistical Manual of Mental Disorders (DSM) classificatory systems.

Freudian psychoanalytic formulations viewed psychotic symptoms as manifestations of unresolved conflict resolution resulting in defective object-relations. Freud's conceptualizations influenced Bleuler's thinking and were incorporated into his fundamental clinical constructs of autism, ambivalence, and disturbances of the sense of self^[27] Carl Jung, a resident under the tutelage of Bleuler at the Burghoelzli in Zurich, Switzerland, was the first to apply psychoanalytic techniques directly to schizophrenia. Employing experimental techniques, such as word-association tests, he developed the concept of "autochthonous complex."^[28] These disturbing, emotionally charged complexes were viewed as isolated from consciousness and maintained in an independent psychic existence. Jung helped to foster the concept that psychotic symptoms were meaningful in the context of the individual's psychodynamic issues and not simply impenetrable manifestations of a disorganized mind. His later formulations included the concepts of "archetypes" of the "collective unconscious" which could be expressed in psychotic symptoms.

Adolph Meyer (Figure 5), an American theorist was founder of the psychobiological school of psychiatry. He contended that psychological symptoms emanated directly from the patient's past social, physical and psychological issues.^[29] He believed that each individual's psychiatric disorder was unique and therefore was unable to accept the classificatory schemas of either Kraepelin or Bleuler. He also rejected Freudian assertions of the presence of hidden psychodynamic factors causing the mental maladies.

Figure 5. "Adolph Meyer contended that psychological symptoms emanated directly from the individual's past social, physical and psychological issues." Courtesy of the National Library of Medicine.

In the United States, the prevalence of mental illness began to be recorded starting with the 1840 census. Cases were divided into idiocy and insanity. Many of the findings of these early surveys supported the prevailing socio-political beliefs. For example, it was reported in the 1840 census that freed northern Negroes had higher rates of insanity than did white inhabitants or southern Negro slaves. In an 1855 survey in Massachusetts it was asserted that there was an association between poverty and mental illness. In addition, the Irish were thought to have higher rates of mental infirmities due to their inability to adapt to the new environment in the United States. In the 1880 census the categories were expanded to 7 and included mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.

In 1949, the American Psychiatric Association in collaboration with the New York Academy of Medicine began an initiative to standardize the diagnostic system throughout the United States. The result was the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), which was published in 1952. The classification was influenced by the theories of Adolf Meyer, and psychiatric disorders were viewed as reactions of the personality to psychological, social, and biological factors. The manual has gone through several major revisions. The DSM-II was published in 1968, but did not differ significantly from its predecessor. The DSM-III was published in 1980, the DSM-IV in 1994,^[30] and DSM-IV-TR in 2000.^[31] The third edition marked a major change in the classification system.^[32] Attempts were made to make the manual theoretically neutral and based on a descriptive lists or clusters of symptoms. Previous editions of the manual contained categories that were vague and often based on unobservable processes that could not be agreed upon by different practitioners. The DSM-IV outlines 17 different categories of mental disorders. Schizophrenia and other related disorders include schizophrenia, delusional disorder, and schizoaffective disorder. Schizophrenia is divided into 5 subtypes including paranoid, disorganized, catatonic, undifferentiated, residual.^[31]

Modern theoretical conceptualizations of the schizophrenic syndrome reflect our rapidly expanding knowledge of the neurobiological underpinnings of the disorder. Neuroimaging techniques such as positron emission tomography (PET) scans and functional magnetic resonance imaging (fMRI) allow for real-time analysis of thinking and emotional processes. Furthermore, contributions from disciplines such as genetics, neurochemistry, and cognitive science have resulted in increasingly more complex and comprehensive conceptualizations of the schizophrenic process. It is hoped that these new techniques will help in the development of more accurate and clinically meaningful diagnostic divisions.

History of Institutionalization/Treatment

The Age of Asylums

Institutions for the mentally ill were established beginning in the 14th century. These facilities, or asylums, were opened in Florence, Spain, Belgium, and England. One of the most renowned was St. Mary of Bethlehem, located outside London -- better known as Bedlam (Figure 6). Mental patients were first accepted in 1403, and by 1547 it was totally devoted to the care of the insane. This asylum was well known for the brutal treatment of the insane. Bedlam was later used as a term to refer to all asylums.

Figure 6. "Bethlehem Asylum 'Bedlam' one of the first asylums (1403)." Courtesy of the National Library of Medicine.

William Battie, whose name gave origin to the word "batty", also advocated the use of "therapeutic" asylums in his Treatise on Madness in 1758.^[33] Many of the mentally ill were being treated in prisons or other inappropriate institutions. Asylums, however, continued to be known for their dehumanizing conditions. In the 18th century, an asylum in Newcastle, England, housed both sexes together tethered in chains in a dungeon-like atmosphere. In 1845, Esquirol reported on the inhumane aspects of the asylum environment: "If the patient's violence is extreme, he is fastened onto his bed and his movements are brought under control with a straitjacket....How many manic patients have become paralyzed through being fastened too long on their bed or in an armchair." Treatments included agents such as opium or camphor mixed with vinegar. In more extreme cases moxa, a flaming pitch applied to the head, was used.^[34] Esquirol also suggested that: "You can, if you wish, substitute for an iron heated in the fire, an iron heated in boiling water." In England as well as in the United States, patients would be placed on display on Sunday for the curious to view.

Generally, however, throughout the 18th and 19th centuries, a humane and compassionate approach to the mentally ill was advocated. Pinel, after assuming his role as a superintendent of a French asylum in 1793, removed the insane from their chains. He developed a "moral treatment" for the mentally ill, which included a kindly but firm disposition toward the patients. Groups, such as the Quakers, also advocated an attitude of kindness toward the mentally ill.

Benjamin Rush (Figure 7), often called the father of American Psychiatry -- one of the signers of the Declaration of Independence -- championed a variety of progressive causes including the abolition of slavery, alleviation of excessive hardship for prisoners, and the need to overcome discriminatory practices against the Indians. It was his advocacy for humane treatment of the mentally ill, however, that was to gain him international acclaim. He oversaw the care of the mentally ill at the Pennsylvania Hospital in Philadelphia and stressed the physical as well as environmental basis of psychiatric disorders. He also promoted sympathetic listening as a way of enhancing the treatment process -- "...catch the patient's eye and look him out of countenance. Be always dignified. Never laugh at or with them. Be truthful. Meet them with respect. Act kindly towards them in their presence. If these measures fail, coercion is necessary. Tranquillizing chair...." (Figure 8).^[35]

Figure 7. "Benjamin Rush, often called the father of American Psychiatry. His advocacy for humane treatment of the mentally ill gained him international acclaim." Courtesy of the National Library of Medicine.

In 1812, a year before his death, he published Medical Inquiries and Observations upon the Diseases of the Mind.^[35] For the ensuing 70 years, this treatise was to be the only psychiatric text in America^[36] Thus, moral treatment emphasized respect for the afflicted individual and reeducation in a conducive rather than punitive setting.

Figure 8. "Wooden chair called the tranquilizing chair designed by Benjamin Rush the founder of American psychiatry and a signer of the US Constitution, equipped with restraints, he called it 'the tranquilizer'." Courtesy of the National Library of Medicine.

Dorothea Dix was a major figure in the United States mental hygiene movement in the 19th century. She forcefully advocated for the establishment of more psychiatric hospitals. Since there were few large existing buildings comparable to those in Europe, she lobbied for the setting aside of over 12 million acres of wilderness for the mentally ill (Figure 9). She was unsuccessful in this endeavor, however. She helped to found many asylums, which reached 48 in number by 1861. Approximately 8500 patients were hospitalized at that time in which there were 27 million residents in the United States.

Figure 9. "State hospitals called 'lunatic asylums' were advocated by Dorothea Dix in the early 1800's for compassionate treatment of the mentally ill." Courtesy of the National Library of Medicine.

In Philadelphia in 1844, thirteen asylum directors formed the Association of Medical Superintendents of the American Institutions for the Insane. This was later called the American Medico-Psychological Association, which later became the American Psychiatric Association. The American Journal of Insanity was first published in the 19th century at the New York State Lunatic Asylum in Utica. This would later be called the American Journal of Psychiatry.^[36]

Stigma and Early Treatments

Witchcraft and demonic possession. Throughout history, the seriously mentally ill have often been viewed with suspicion, disgust, and fear. During the Middle Ages and Renaissance Period witchcraft and demonic possession were considered to be the root of emotional disturbances. Confession and exorcism were therefore advocated as the means for overcoming and expelling these malevolent influences. The range of individuals to which these treatments were applied included those with organic psychosis and dementia in addition to schizophrenics and other severely mentally ill.

Reginald Scot's^[37] depiction of witches clearly includes symptoms and characteristics of the mentally ill. These individuals are described as "Old, lame, bleare-eyed, pale, fowle and full of wrinkles...in whose drowsie minds the divell hath gotten a fine seat...leane and deformed, showing melancholie in their faces...doting, scolds, mad, divellish." Instruments of torture and other barbarous means of confession were employed to rid the individual of devilish influences. These methods often resulted in death.

Malleus Maleficarum (the Witches Hammer)^[38] written by the Dominican friars Jakob Sprenger and Heinrich Kramer in 1486 was a guidebook for the recognition, judgment, and punishment of those who practiced witchcraft. Although many of the suggested techniques were brutal and inhumane, it was considered to be the "bible" for dealing with demonic influences by both church and state throughout the 17th century

Physical intervention. Physical interventions included bloodletting with leeches, and induction of emesis to eliminate poisons from the body. Trepanation, or the boring of holes in the skull to release the evil elements was practiced as early as 10,000 BC,^[39] and was utilized widely in many cultures. Some treatments were designed to induce fear or intense psychical and physical discomfort. Spinning the patient until loss of consciousness occurred was thought to be helpful in rearranging the contents of the brain (Figure 10). At times, an unsuspecting victim was immersed into ice water in order to shock the system. Other techniques included therapy, insulin shock, frontal lobotomy as well as other crude neurosurgical procedures.

Figure 10. "A whirling chair and bed was one of the early treatments for mental disorders." Courtesy of the National Library of Medicine.

Treatments in the 20th Century

ECT. Convulsive therapy was introduced in 1934 by von Meduna^[40] He contended that patients rarely suffered from epilepsy and schizophrenia, although this observation was later called into question. He also noted that some patients improved after a spontaneous convulsion. He initially utilized intramuscular injections of camphor, but the technique did not reliably induce seizures. In 1938, the Italians Cerletti and Bini^[41] introduced electrically induced seizures. Early use of this procedure sometimes resulted in complications such as fractures due to inadequate anesthesia. Some patients also complained of memory difficulties; however; the exact extent and permanence of these deficits continues to be controversial. Unilateral ECT is considered to have less amnestic side effects compared with bilateral treatments. Despite the current safety and effectiveness of this treatment, especially in refractory patients, it is an often feared and maligned treatment. This is a result of the crude means of administration used by early practitioners, forced treatment prior to the institution of adequate patient rights, as well as ignorance concerning the safety and efficacy of the technique. Legislative initiatives and patient protests have therefore limited the application of this modality. In addition, there is insufficient evidence showing a significant positive clinical impact on the treatment of schizophrenia.

The advent of psychopharmacology. The discovery of the antipsychotic chlorpromazine by the French team of scientists Pierre Deniker, Henri Leborit, and Jean Delay in the early 1950s ushered in the psychopharmacologic era. Not only were these medications efficacious in alleviating some of the most disturbing positive symptoms of the psychotic patient, they helped to initiate the understanding of the neurobiological processes underlying these disorders. Other, so-called "typical" agents such as thioridazine, trifuloperazine, and haloperidol had different side-effect profiles but similar mechanisms of action. They also had problems with potentially serious side effects of tardive dyskinesia. Treatment was significantly advanced through the introduction of the "atypical" neuroleptic clozapine. This agent helped to alleviate negative symptoms such as social withdrawal and apathy as well as cognitive deficits. The side effects, including potentially life threatening agranulocytosis, limited the utility of the drug. Newer atypical agents include risperidal, olanzapine, quetiapine, and ziprasidone. Not only do these medications have an improved side-effect profile, but new clinical uses are being discovered that extend their utility. For example, olanzapine was approved as a mood stabilizing medication.

Modern psychological explanations of schizophrenia have at times ascribed blame for the onset or perpetuation of the disorder to either victim or caregiver. Some psychodynamic theories, for example, posited that the individual's early upbringing was a major force in the development of psychotic disorders. A school of family therapy fostered the idea of a "schizophrenogenic" mother as the primary disorganizing force leading to a psychotic break. Our more recent understanding of the biological basis of behavior has helped to place the schizophrenic disorder in a less stigmatized and more comprehensive and realistic light.

The era of deinstitutionalization. Beginning in the 1950s, a large exodus from US state hospitals began. Often termed "deinstitutionalization," this policy resulted in the transfer of patients and care from chronic inpatient services to community-based services. The movement was driven by several factors.^[42] First, modern scientific developments have allowed for an ever-widening group of previously refractory patients to live outside of the confines of the hospital walls. Second, financial pressures have resulted in decreased funding by state governments and greater reliance on federal support for community programs. Third, advocacy groups have successfully argued for the introduction of more humane and less restrictive environments. In 1950 there were 322 state hospitals in the United States serving 512,501 residents. By 1996, the census had dropped to 61,722 residents in 254 institutions.^[43,44]

In order to address some of the needs of the chronically and persistently mentally ill patient, a variety of services have been developed, including short-term general psychiatric units, day treatment programs, halfway houses, social and vocational rehabilitation services, and case management programs. Despite the array of services offered, critics of the current system have contended that there is a lack of a sufficient number, integration, or effectiveness of programs available. Thus the care of patients in the community has at times resulted in a lack of adequate care for a proportion of these individuals. Social problems such as homelessness and violence have at times been attributed to the deinstitutionalization process.^[45]

In response to these criticisms and problems, more active community interventions have been developed. For example, Assertive Community Treatment programs, or ACT programs, have been implemented.^[46] The model for the ACT program was developed in the 1970s by Arnold Marx, MD, Leonard Stein, MD, and Mary Ann Test, PhD, and based on an inpatient unit of Mendota State Hospital, Madison, Wisconsin.^[47] The programs are designed specifically to aggressively reach and intervene with difficult-to-treat individuals, such as recidivists and the homeless. Although the cost of the program can be high, it is often less than the costs incurred by the fragmented care of these difficult-to-treat patients.^[48] Not only are repeated hospitalizations more expensive in the long run, many schizophrenic individuals are inappropriately incarcerated for aggressive behavior manifested during a psychotic state. Court mandated outpatient treatment has also become an increasingly available option in many states as a means of enforcing treatment in potentially violent or self-injurious patients.

The rise of patient advocacy groups, such as the National Alliance for the Mentally Ill (NAMI) (http://www.nami.org/), has provided a forceful clinical and legislative forum advocating for the rights of the patients and their families. In contrast to the passive role the patient has accepted in the past, the client is now newly empowered to participate actively in the clinical decision process. For example, patient advocacy groups have placed stabilized patients who have suffered from serious mental illnesses on inpatient psychiatric units. The role of these advocates is to help the patient deal with the illness as well as cope with the system of care providers. In this way they provide a bridge to wellness for the acutely ill individual. In addition, they help the care providers to understand the patient's perspective of the mental health system and suggest means of improving the delivery of care.

The Internet has also become a powerful force in helping patients and families to understand and cope with this disorder. Web sites offer chat rooms, personal histories, information about new treatments, as well as suggestions about how to cope with the disorder (eg, http://www.schizophrenia.com/). For example, NAMI is actively supporting the ACT programs and offers information and advice on its Web site about ways of organizing these programs. Coordinated political, media, and community activity is suggested. In addition the process of mobilization of mental health officials and resources is delineated.

Summary and Conclusions

Civilizations have been struggling with understanding and treating psychotic disorders such as schizophrenia since ancient times. It was not until the advent of the Greek philosophical tradition, however, that the basis of our modern day theoretical structures began to form. Plato, Hippocrates, and other philosophers theorized about the physical basis of mental disorders, mind-body integration, and unconscious mental processes. Later thinkers such as Kraepelin and Bleuler refined our classificatory schemas, helping us to reliably identify and classify the various psychotic disorders. We are now encountering an explosion of scientific knowledge about the neurobiological underpinnings of schizophrenia that is helping us to unravel the mysteries of this disorder.

Our intellectual understanding of the schizophrenic syndrome has not only resulted in better means of treatment but is also beginning to lessen the stigma that has accompanied this disorder. Deinstitutionalization, community care, and patient advocacy are just some of the movements that are helping both caregivers and patients to cope effectively with the many facets of this complex syndrome.

References for:
Historical Roots of Schizophrenia

[Psychiatry Clinical Management Volume 05 - © 2001 Medscape, Inc.]

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