If you are not a mental health professional, the weird names and stranger numbers we throw around may seem like a secret language. In many ways, diagnostic discussions are kind of like a language that can have very real and important implications in peoples’ lives. Today, we examine where our understanding of mental illness and mental health diagnoses come from.
Like many scientific inquiries, our understanding of mental health disorders evolved over time. The various classification systems used to diagnose and describe mental health disorders, during different periods of history, were bound by the knowledge, social attitudes, and the scientific paradigms available during the historical period in which they were conceived. An understanding of this historical context strengthens our ability to fully appreciate the research advancements that have informed our current understanding of these disorders. These scientific advancements subsequently guided the development of successful treatment approaches. Let’s start a REALLY long time ago…
3500 BC – 30 BC
Ancient Egyptian documents known as the Ebers papyrus appear to describe disordered states of concentration and attention, and emotional distress in the heart or mind. Some of these have been interpreted as indicating what would later be termed hysteria and melancholy. Somatic treatments typically included applying bodily fluids while reciting magical spells. Hallucinogens may have been used as part of healing rituals. Religious temples may have been used as therapeutic retreats, possibly for the induction of receptive states to facilitate sleep and the interpreting of dreams. In ancient China, mental disorders were treated mainly under Traditional Chinese Medicine by herbs, acupuncture or “emotional therapy”. The Inner Canon of the Yellow Emperor described symptoms, mechanisms and therapies for mental illness, emphasizing connections between bodily organs and emotions. Conditions were thought to comprise five stages or elements and imbalance between Yin and yang.
400 BC
During the 4th century BC, Hippocrates described all disease as an imbalance of the four bodily humors – phlegm, blood, yellow bile, and black bile. Variations in the levels of these fluids were believed to be connected to changes in people’s moods and behavior. Treatments were often terrible. The Greek physician Asclepiades (c. 124 – 40 BC), who practiced in Rome, discarded it and advocated humane treatments, and had insane persons freed from confinement and treated them with natural therapy, such as diet and massages. Arateus (ca AD 30–90) argued that it is hard to pinpoint where a mental illness comes from. However, Galen (AD 129 – ca. 200), practicing in Greece and Rome, revived humoral theory. Galen, however, adopted a single symptom approach rather than broad diagnostic categories, for example studying separate states of sadness, excitement, confusion and memory loss.
100 – 1300s
Well in advance of their European and African counterparts Persian and Arabic scholars were heavily involved in translating, analyzing and synthesizing Greek texts and concepts. As the Muslim world expanded, Greek concepts were integrated with religious thought and over time, new ideas and concepts were developed. Arab texts from this period contain discussions of melancholia, mania, hallucinations, delusions, and other mental disorders. Mental disorder was generally connected to loss of reason, and writings covered links between the brain and disorders, and spiritual/mystical meaning of disorders. Muslim scholars often wrote about fear and anxiety, anger and aggression, sadness and depression, and obsessions.
Authors who wrote on mental disorders and/or proposed treatments during this period include Al-Balkhi, Al-Razi, Al-Farabi, Ibn-Sina, Al-Majusi, Abu al-Qasim al-Zahrawi, Averroes, and Unhammad
Ready to have your mind blown? Under Islam, the mentally ill were considered incapable yet deserving of humane treatment and protection. For example, Sura 4:5 of the Qur’an states “Do not give your property which God assigned you to manage to the insane: but feed and cloth the insane with this property and tell splendid words to him.” Some thought mental disorder could be caused by possession by a djin (genie), which could be either good or demon-like. There were sometimes beatings to exorcise djin, or alternatively over-zealous attempts at cures. Islamic views often merged with local traditions. In Morocco the traditional Berber people were animists and the concept of sorcery was integral to the understanding of mental disorder; it was mixed with the Islamic concepts of djin and often treated by religious scholars combining the roles of holy man, sage, seer and sorcerer.
The first psychiatric hospital ward was founded in Baghdad in 705, and insane asylums were built in Fes in the early 8th century, Cairo in 800 and in Damascus and Aleppo in 1270. Insane patients were treated using baths, drugs, music and activities. In the centuries to come, The Muslim world would eventually serve as a critical way station of knowledge for Renaissance Europe, through the Latin translations of many scientific Islamic texts. Ibn-Sina’s (Avicenna’s) Canon of Medicine became the standard of medical science in Europe for centuries, together with works of Hippocrates and Galen.
Meanwhile, conceptions of madness in Europe were a mixture of the divine, diabolical, magical and transcendental. Theories of the four humors (black bile, yellow bile, phlegm, and blood) were applied, sometimes separately (a matter of “physic”) and sometimes combined with theories of evil spirits (a matter of “faith”). Arnaldus de Villanova (1235–1313) combined “evil spirit” and Galen-oriented “four humours” theories and promoted trephining as a cure to let demons and excess humours escape. Other bodily remedies in general use included purges, bloodlettingand whipping. Madness was often seen as a moral issue, either a punishment for sin or a test of faith and character. Christian theology endorsed various therapies, including fasting and prayer for those estranged from God and exorcism of those possessed by the devil. Thus, although mental disorder was often thought to be due to sin, other more mundane causes were also explored, including intemperate diet and alcohol, overwork, and grief.[20] The Franciscan monk Bartholomeus Anglicus (ca. 1203 – 1272) described a condition which resembles depression in his encyclopedia, De Proprietatibis Rerum, and he suggested that music would help. A semi-official tract called the Praerogativa regis distinguished between the “natural born idiot” and the “lunatic”. The latter term was applied to those with periods of mental disorder; deriving from either Roman mythology describing people “moonstruck” by the goddess Luna or theories of an influence of the moon.
Episodes of mass dancing mania are reported from the Middle Ages, “which gave to the individuals affected all the appearance of insanity”. This was one kind of mass delusion or mass hysteria/panic that has occurred around the world through the millennia.
The care of lunatics was primarily the responsibility of the family. In England, if the family were unable or unwilling, an assessment was made bycrown representatives in consultation with a local jury and all interested parties, including the subject himself or herself. The process was confined to those with real estate or personal estate, but it encompassed poor as well as rich and took into account psychological and social issues. Most of those considered lunatics at the time probably had more support and involvement from the community than people diagnosed with mental disorders today. As in other eras, visions were generally interpreted as meaningful spiritual and visionary insights; some may have been causally related to mental disorders, but since hallucinations were culturally supported they may not have had the same connections as today.
1500s – 1700s
It was not uncommon for mentally disturbed people to become victims of the witch-hunts that spread in waves in early modern Europe. However, those judged insane were increasingly admitted to local workhouses, poorhouses and jails (particularly the “pauper insane”) or sometimes to the new private madhouses. Restraints and forcible confinement were used for those thought dangerously disturbed or potentially violent to themselves, others or property. The latter likely grew out of lodging arrangements for single individuals (who, in workhouses, were considered disruptive or ungovernable) then there were a few catering each for only a handful of people, then they gradually expanded (e.g. 16 in London in 1774, and 40 by 1819). By the mid-19th century there would be 100 to 500 inmates in each. The development of this network of madhouses has been linked to new capitalist social relations and a service economy, that meant families were no longer able or willing to look after disturbed relatives.
By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon, no longer involving the soul or moral responsibility. The mentally ill were typically viewed as insensitive wild animals. Harsh treatment and restraint in chains was seen as therapeutic, helping suppress the animal passions. There was sometimes a focus on the management of the environment of madhouses, from diet to exercise regimes to number of visitors. Severe somatic treatments were used, similar to those in medieval times. Madhouse owners sometimes boasted of their ability with the whip. Treatment in the few public asylums was also barbaric, often secondary to prisons. The most notorious was Bedlam where at one time spectators could pay a penny to watch the inmates as a form of entertainment.
Concepts based in humoral theory gradually gave way to metaphors and terminology from mechanics and other developing physical sciences. Complex new schemes were developed for the classification of mental disorders, influenced by emerging systems for the biological classification of organisms and medical classification of diseases.
Towards the end of the 18th century, a moral treatment movement developed, that implemented more humane, psychosocial and personalized approaches. Notable figures included the medic Vincenzo Chiarugi in Italy under Enlightenment leadership; the ex-patient superintendent Pussinand, the Quakers in England, led by businessman William Tuke; and later, in the United States, campaigner Dorothea Dix. Philippe Pinel observed there were a group of patients who behaved in irrational ways even though they seemed to be in touch with reality and were aware of the irrationality of their actions. Pinel’s documented observations during this period appear to be one of the first explicit attempts at describing what we would nowadays call a personality disorder.
1800s – 1950s
By the early 1900s, European diagnostic systems were beginning to describe different temperaments and personality types. At this point in history, mental conditions and disorders were not very well defined because the scientific professions of psychology and psychiatry were still in their infancy. Most psychiatrists were purely focused on describing the phenomena of mental illness and disturbances they observed. From these early descriptions we can determine that much of what was observed and described would today be considered a personality disorder. However, at that time, the symptoms that were observed were thought to be something else, namely the early stages of some other, more severe mental illnesses such as manic depression (now called Bipolar Disorder).
During the 1920’s and 30’s Sigmund Freud and his colleagues were one of the first to move beyond mere descriptive categorization of mental disorders. Instead, Freud and his camp theorized the etiology (causes) of behavioral and emotional problems. Although our modern understanding of personality disorders has advanced significantly beyond these earlier theories of Sigmund Freud, he is still often credited as the “father of psychology.”
Freud and his followers began to theorize how character types and emotional issues developed. Freud’s theory proposed the existence of unconscious mental processes that influence our character development and subsequent behavior. He explained these unconscious mental processes as consisting of three competing component parts. He named these three parts the Id, the Ego, and the Superego. The Id referred to a collection of instinctual impulses and drives, seeking immediate gratification. The Superego referred to a set of moral values and self-critical attitudes. The term “Ego” was used to describe a set of regulatory functions intended to keep the Id under control by preventing the Id from indulging its every whim. The Ego’s purpose was to mediate a balance between the impulsive Id and the harsh, moralistic Superego. In Freudian theory, the goals of these three mental components were in conflict with each other, causing anxiety. The Ego relied on “defense mechanisms” to keep such conflicts from entering our conscious awareness so as to reduce this anxiety.
Freud and his colleagues were also interested in exploring infantile sexual development. It was theorized that we are born with the Id, so that every infant has the inborn raw impulses that seek immediate gratification. Over time, the Ego develops and keeps the Id in check, trying to keep the person anchored in reality. The Superego consisted of moral values and harbored a concept of an ideal self. It was thought to develop last. The psychoanalysts (as followers of Freud’s theory and his methods came to be known) believed that during childhood, we undergo different stages of psychosexual maturation. Frustrations, or conversely overindulgences, experienced during particular stages of development, could cause a person to become stuck, or “fixated” at that particular developmental stage. This fixation interfered with the proper and timely development of the Ego or Superego. As a result, the normal and appropriate Ego balance of Id and Superego energies could not be achieved. Some psychoanalysts viewed personality disorders (or “character disorders” as they were once called) as fixations that emerged during early developmental stages. At this point in history, character disorders were considered to be difficult to treat and quite resistant to change.
In Nazi Germany, the institutionalized mentally ill were among the earliest targets of sterilization campaigns and covert “euthanasia” programs. It has been estimated that over 200,000 individuals with mental disorders of all kinds were put to death, although their mass murder has received relatively little historical attention. Despite not being formally ordered to take part, psychiatrists and psychiatric institutions were at the center of justifying, planning and carrying out the atrocities at every stage, and “constituted the connection” to the later annihilation of Jews and other “undesirables” such as homosexuals in the Holocaust.
1950s – Present
By the 1950s, the concept of “character disorders” had become widely accepted within the psychoanalytic community, and psychoanalytic clinicians were distinguishing character disorders from the more severe forms of mental illnesses that cause people to lose touch with reality (i.e., to become psychotic). But, character disorders were not viewed as legitimate mental illnesses in their own right. Instead, they were typically understood as weaknesses of character or willfully deviant behavior caused by problems in a person’s upbringing. Some of these patients were treated in psychoanalysis (psychotherapy based on Freud’s theories) where they typically regressed and got worse. The term “Borderline” dates back to this historical time period, as these character disordered patients were thought to be functioning at the borderline between the psychoses (disorders characterized mainly by suspended reality testing such as Schizophrenia), and the neuroses (disorders characterized mainly by anxiety arising from the conflict among the Id, Ego, and Superego).
Theories and models of the mental components and fixations of psychosexual development laid the foundation for conceptually understanding “character disorders” and their causes. However, these theories were not themselves formal diagnoses. It was not until the 1950s, with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM), that the character disorders became formally recognized. The original DSM, devised to reduce confusion surrounding psychiatric diagnosis and diagnostic systems prevalent at the time, defined the personality disorders as patterns of behavior that were quite resistant to change, but not connected to a lot of anxiety or personal distress on part of the patient. This first DSM relied heavily on the psychoanalytic tradition and Freud’s ideas which were the prevailing view of that time period.
DSM II, published in 1968, reflected an attempt to make the American psychiatric classification system compatible with the International Classification of Diseases devised by the World Health Organization. It also reflected an attempt to adopt neutral language that did not endorse specific and controversial theoretical viewpoints (such as Freudian, psychoanalytic theories). In DSM II, personality disorders were described as follows, “This group of disorders is characterized by deeply ingrained, maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms.” Then each disorder was briefly described by a few short sentences. The names of these disorders, and their brief descriptions, bear only a slight resemblance to what we know today as personality disorders.
The third incarnation, DSM III, was published in 1980. At this time, the fields of psychology and psychiatry were struggling to establish themselves as scientific fields of study. This new version of the DSM reflected the fact that newer, more contemporary models of mental illness and treatment were emerging. More importantly, these newer models rested upon evidence-based practices: i.e., these models were not based on unproven or un-testable theories, but instead rested upon scientific evidence.
It is important to understand that scientific study cannot proceed without a means for measuring what is being studied. Thus, in order for the scientific study of mental disorders to proceed, these disorders had to be defined in such a way as to make them observable, and therefore measurable. Freud’s concepts did not lend themselves to measurement. For instance, one cannot observe, nor measure the Id. Therefore, the DSM III removed these abstract Freudian concepts that could not be measured. They were replaced with observed behaviors and/or reported thoughts as these concepts were more easily measurable.
These newer and more contemporary models of mental illness reflected a significant paradigm shift within psychology and psychiatry during the 1970s and 80s. This shift represented the declining influence of psychoanalysis and Freudian theory, and the ascendance of the cognitive-behavioral model within psychology (emphasizing the observable, behavioral manifestations of disorders), and the medical model within psychiatry (cataloging pathological symptoms and their biological causes).
As the name suggests, cognitive-behavioral theory was principally concerned with people’s thoughts and behaviors. Thoughts were easily reported, and people’s behaviors were easily observed. As such, the cognitive-behavioral theory was perfectly suited to measurement and research, and met the scientific requirements of the day. Treatments for mental conditions took the form of interventions designed to help people learn better and more effective, healthy ways to think and behave in order to relieve their distress.
Psychoanalytic theory’s fell from grace. This was because it could not be tested or proven using the scientific methods and technologies available at that time. Unfortunately, it merely theorized the causes of mental distress. These theorized causes were completely invisible; and therefore, not measurable. This included the invisible Id, Ego, and Super-Ego; the invisible conflicts between these invisible mental structures; and the invisible psycho-sexual stages of developments. In contrast, the cognitive-behavioral theory restricted itself to addressing only the observable and measurable causes of distress. Caught in the crossfire between these two influential, psychological theories, one waxing and the other waning, and the rising role of pharmacological treatments within psychiatry, the authors of DSM III attempted to stay out of the conflict by making their document atheoretical. They achieved this by ensuring that their disorder definitions were primarily descriptive. They refrained from endorsing one particular theory accounting for the origin and cause of mental disorders over another.
The goal of DSM III was to outline the diagnostic criteria for as many conditions as possible, and to rely on, and to foster research on mental disorders. The biggest change in DSM III was the introduction of a multi-axial (multi-dimensional) format for making diagnoses. This multi-axial system placed personality disorders onto a separate axis called Axis II. This Axis II was separated personality disorders from the rest of the major mental disorders and clinical syndromes (such as Major Depression, Schizophrenia, and Bipolar Disorder, to name but a few). These disorders were described using the first axis (Axis I), while the personality disorders, and developmental conditions such intellectual disabilities were described on the Axis II.
The goal of this separation of diagnostic dimensions was to enable clinicians to record a person’s current state and prevailing difficulties on Axis I while simultaneously describing a person’s lifelong and pervasive personality characteristics on Axis II. In other words, Axis I disorders were thought to be transient conditions, while personality disorders and other developmental conditions, described on Axis II, were thought to be permanent conditions. The rationale was that it was necessary to describe these “permanent” conditions on a separate diagnostic dimension in order to highlight them so that they would not otherwise be overshadowed by the more acute Axis I clinical syndromes. This multi-axial system remained in place from 1980 until 2013 when it was abandoned with the introduction of DSM-5 due to numerous problems and controversies.
Prior to DSM III, personality disorders were only vaguely described categories that did not lend themselves to research. However, the publication DSM III (APA, 1980) changed all that. Personality disorders were now recognized as a distinct and separate category of disorders in their own right. As such, research on personality disorders flourished. Researchers developed assessment methods facilitating the systematic study of the personality disorders. This new research resulted in the refinement of the criteria sets for personality disorder diagnoses present in DSM-III-R, DSM-IV, DSM-IV-TR, and DSM-5. The most recent version of the diagnostic manual, DSM-5, proposes an entirely different model of personality disorders for future research. Depending on the outcome of that research, we may someday assess personality disorders using a dimensional system of various personality traits. The current, prevailing diagnostic method and this proposed dimensional system will be compared and discussed in another section.
As a result of ongoing research, people with personality disorders are no longer seen as people with untreatable moral weakness, or willfully bad behavior. Personality disorders are now recognized as deeply troubling, and legitimate conditions, that have a large negative impact on people’s lives, and in most cases, can be successfully treated.
Mental health and illness have had a fascinating history. Without understanding the context of mental illness and it’s subsequent treatments, we are at risk of oversimplifying the complex. Mental health and how cultures responded over history tells a story of compassion, resiliency as well as some pretty ugly choices. But the story continues to unfold as research, treatment and even religion turn the page on the next chapter.