A Brief History of Schizophrenia (2024)

In 1910, the psychiatrist and eugenicist Paul Eugen Bleuler coined the term ‘schizophrenia’ from the Greek words schizo (‘split’) and phren (‘mind’). Bleuler had intended the term to denote or connote a ‘loosening’ of thoughts and feelings, but many people understood it—and, unfortunately, still do—to mean a ‘split personality’.

What 'schizophrenia' does not mean

Robert Louis Stevenson’s novel The Strange Case of Dr Jekyll and Mr Hyde (1886) did much to popularize the concept of a ‘split personality’, sometimes also referred to as ‘multiple personality disorder’ (MPD). However, MPD is a vanishingly rare condition that has nothing to do with schizophrenia. The vast majority of psychiatrists, myself included, have never come across a case of MPD, and many suspect that the condition does not even exist. Yes, schizophrenia sufferers may hear voices, or have bizarre beliefs, but this does not amount to having a ‘split personality’. Unlike Dr Jekyll, schizophrenia sufferers do not suddenly morph into another, unrecognizable person.

Ironically, Bleuler had been trying to clarify matters by displacing the older, even more misleading term dementia præcox [‘dementia of early life’], which had been championed by the psychiatrist Emil Kraepelin. Kraepelin believed that the illness only struck young people, and invariably led to cognitive decline—hence dementia præcox. But Bleuler disagreed on both counts, and, accordingly, renamed the illness ‘schizophrenia’.

It is just as common as it is unfortunate to hear the adjective ‘schizophrenic’ being bandied about to mean something like ‘changeable’, ‘erratic’, or ‘contradictory’, as in, ‘The weather today is completely schizophrenic’ or, ‘The reaction from the White House has been typically schizophrenic’. This sort of colloquialism ought to be discouraged insofar as it perpetuates people’s misunderstanding of the illness and contributes to the stigmatization of schizophrenia sufferers. Even used correctly, the term ‘schizophrenic’ does nothing more than label a person by an illness, implicitly reducing him or her to that illness. But people aren’t ‘schizophrenics’ any more than they are ‘diabetics’ or sufferers of toothache.

Who ‘discovered’ schizophrenia?

For all his shortcomings, Kraepelin was the first to distinguish schizophrenia from other forms of psychosis, in particular the ‘affective psychoses’ that can supervene in mood disorders such as depression and bipolar disorder. Kraepelin’s classification of mental disorders, the Compendium of Psychiatry [Compendium der Psychiatrie], is the forerunner of today’s most influential classifications of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, 5th Revision (DSM-5), published by the American Psychiatric Association (APA), and the International Classification of Diseases, 11th Revision (ICD-11), published by the World Health Organization (WHO) in Geneva. As well as listing mental disorders, DSM-5 and ICD-11 provide operational definitions and diagnostic criteria that physicians and researchers can use to make or verify diagnoses.

Although the concept of schizophrenia is of Kraepelin and the nineteenth century, the illness itself, or something like it, has been with us for centuries and millennia. The oldest extant description of an illness closely resembling schizophrenia is contained in the Ebers papyrus, an Egyptian medical compendium compiled in around 1500 BCE, possibly from earlier texts. And archaeological finds of Stone Age skulls with burr holes—drilled, in all likelihood, to release evil spirits—have led some to speculate that schizophrenia may be as old as mankind itself.

How was schizophrenia thought of in antiquity?

In antiquity, people did not think of ‘madness’—a term that they used indiscriminately for all forms of psychosis—in terms of mental disorder, but more in terms of divine punishment or demonic possession. Evidence for this comes, among others, from the Old Testament, and most notably from the First Book of Samuel, according to which King Saul became ‘mad’ after neglecting his religious duties and angering God.

That David played on his harp to appease Saul suggests that, even in biblical times, people understood that psychotic illnesses could be successfully treated:

But the spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him … And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him.

In Greek mythology and the Homerian epics (circa eighth century BCE), madness is similarly thought of as a punishment from God—or the gods. Thus, Hera punishes Hercules by ‘sending madness upon him’, and Agamemnon confides to Achilles that ‘Zeus robbed me of my wits’.

It is not until the time of Hippocrates (d. 377 BCE) that madness first became an object of scientific speculation. Hippocrates taught that madness resulted from an imbalance in four bodily fluids or ‘humours’. Melancholy, for instance, resulted from an excess of black bile [Greek, melaina chole], and could be cured by such ‘restorative’ treatments as special diets, purgatives, and bloodlettings.

To modern readers, Hippocrates’ ideas may seem far-fetched, perhaps even on the dangerous side of eccentric, but in the fourth century BCE they represented a significant advance on the idea of madness as divine punishment or demonic possession:

Only from the brain springs 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…

Aristotle and, later, the Roman physician Galen (d. c. 210 CE) elaborated upon Hippocrates’ humoral theories, and helped to establish them as Europe’s dominant medical model.

In Rome, the physician Asclepiades (d. 40 BCE) and the statesman and philosopher Cicero (d. 43 BCE) rejected Hippocrates’ humoral theories, advancing, for example, that melancholy results not from an excess of black bile but from emotions such as rage, fear, and grief.

Unfortunately, the influence of these luminaries began to decline in the first century CE, and the physician Celsus (d. 50 CE) sought to re-establish the idea of madness as a punishment from the gods—an idea which returned to currency with the fall of Rome and rise of Christianity.

In the Dark or Middle Ages, religion became central to cure, and, alongside the mediaeval asylums such as the Bethlehem (a famous or infamous asylum in London that is at the origin of the expression, ‘like a bad day at Bedlam’), some monasteries transformed themselves into centres for the treatment of mental disorder. This is not to say that the humoral theories of Hippocrates had been supplanted, but merely that they had been incorporated into the prevailing Christian dogma, with older treatments such as bleeding, cupping, and leeching continuing alongside the prayers and confession.

How did beliefs change?

The burning of the so-called heretics—often people suffering from psychotic illnesses such as schizophrenia—began in the early Renaissance and peaked in the fourteenth and fifteenth centuries.

First published in 1563, The Deception of Demons [De præstigiis dæmonum] argued that the madness of ‘heretics’ resulted from natural rather than supernatural causes. Not content with proscribing the book, the Church accused its author, Johann Weyer, of being a sorcerer.

From the fifteenth century, scientific advances such as the anatomy of Vesalius (d. 1564) and the heliocentric system of Galileo (d. 1642) began challenging the authority of the Church, and the centre of attention and study gradually shifted from God to man and from the heavens to the Earth.

Even so, the humoral theories of Hippocrates perdured well into the nineteenth century, to be lampooned by the playwright Molière (d. 1673) in such works as The Imaginary Invalid [Le Malade imaginaire] and The Doctor in Spite of Himself [Le Médecin malgré lui]. In the 1830s, France alone imported around forty million leeches a year for medicinal purposes.

Empirical thinkers such as John Locke (d. 1704) in England and Denis Diderot (d. 1784) in France challenged this status quo by arguing, in the same vein as Cicero, that reason and emotion are a product of the senses. Also in France, the physician Philippe Pinel (d. 1826) began to regard mental disorder as the result of exposure to psychological and social stressors, and, to a lesser extent, of heredity and physiological damage.

A landmark in the history of psychiatry, Pinel’s Treatise on Insanity [Traité Médico-philosophique sur l'aliénation mentale…] called for a more humane approach to the treatment of mental disorder. This so-called moral treatment included decreased stimuli, routine activity and occupation, and a trusting and confiding doctor-patient relationship. At about the same time as Pinel in France, the Tukes (father and son) in England founded the York Retreat, the first institution ‘for the humane care of the insane’ in the British Isles.

In the nineteenth century, hopes of successful cures lead to a burgeoning of mental hospitals in North America, Britain, and many other parts of Europe. Unlike the foreboding mediaeval asylums, these hospitals treated the ‘insane poor’ according to the principles of moral treatment.

Like Pinel before him, Jean-Etienne-Dominique Esquirol, Pinel’s student and successor at the Salpêtrière in Paris, attempted a classification of mental disorders, and his resulting Concerning Mental Illnesses [Des Maladies mentales...] is regarded as the first modern treatise on clinical psychiatry.

Half a century later, Emil Kraepelin published his landmark classification of mental disorders, the Compendium of Psychiatry, in which he isolated schizophrenia (or dementia præcox, as he called it) from other forms of psychosis.

Kraepelin further distinguished three clinical presentations, or variants, of schizophrenia:

• Paranoia, dominated by delusions and hallucinations;
• Hebephrenia, dominated by inappropriate reactions and behaviours; and
• Catatonia, dominated by agitation or immobility, together with odd mannerisms and posturing.

In the early twentieth century, the psychiatrist and philosopher Karl Jaspers (d. 1969) brought the methods of phenomenology—the direct investigation and description of phenomena as consciously experienced—into the field of psychiatry. This so-called descriptive psychopathology created a more objective foundation for the practice of psychiatry by emphasizing that symptoms of mental disorder ought to be diagnosed on the basis, not of their content, but of their form. This means, for example, that a belief is a delusion not because it is deemed implausible by a person in a position of authority, but because it conforms to the formal definition of a delusion, namely, ‘a strongly held belief that is not amenable to reason and that is out of keeping with its holder’s background or culture.’

How did beliefs evolve in the 20^th century?

Sigmund Freud (d. 1939) and his school influenced much of twentieth century psychiatry, and by the second half of the century a majority of psychiatrists in the US had come to believe that mental disorders such as schizophrenia resulted from unconscious conflicts originating in childhood. As a director of the US National Institute of Mental Health (NIMH) put it, ‘From 1945 to 1955, it was nearly impossible for a non-psychoanalyst to become a chairman of a department or professor of psychiatry.’

In the latter half of the twentieth century, genetic studies, neuroimaging techniques, and pharmacological developments such as the first antipsychotic drugs completely overturned this psychoanalytical model of mental disorder, prompting a return to a more empirical ‘neo-Kraepelinian’ model.

At present, schizophrenia is regarded as a biological disorder of the brain, although it is acknowledged that psychological and social stressors can play an important role in precipitating episodes of illness, and that different approaches to treatment are more complementary than competing.

Even so, critics deride this ‘bio-psycho-social’ model as little more than a ‘bio-bio-bio’ model, with doctors and psychiatrists reduced to mere diagnosticians and pill pushers. Many critics question the scientific evidence underpinning such a robust biological approach, and call for a radical rethink of mental disorders, not as detached disease processes that can be carved up into diagnostic labels, but as subjective and meaningful experiences grounded in personal and larger sociocultural narratives.

What treatments were used before the advent of antipsychotic medication?

Febrile illnesses such as malaria had long been known to temper psychotic symptoms, and in the early twentieth century ‘fever therapy’ became a common treatment for schizophrenia. Psychiatrists attempted to induce fevers in their patients, including, in some cases, with injections of sulphur or oil.

Other treatments included sleep therapy, electroconvulsive therapy, and prefrontal leucotomy (lobotomy), which involved severing the connection between the frontal lobe and other parts of the brain.

Unfortunately, many such ‘treatments’ or interventions aimed more at controlling disturbed behaviour than at curing illness or alleviating suffering. In some countries, such as Germany during the Nazi era, the conviction that mental disorders such as schizophrenia amounted to a ‘hereditary defect’ led to barbarous acts of genocide and forced sterilization.

The first antipsychotic drug, chlorpromazine, came out in the 1950s, and, although far from perfect, inaugurated an era of hope and optimism for schizophrenia sufferers and their carers.

So, where to now?

In 1919, Kraepelin stated that ‘the causes of dementia præcox are at the present time still mapped in impenetrable darkness’. Since then, greater understanding of the causes of schizophrenia has opened up multiple avenues for the prevention and treatment of the illness, and a broad range of pharmacological, psychological, and social interventions have been scientifically proven to work.

Today, schizophrenia sufferers stand a better chance than at any other time in history of leading a normal life. And thanks to the fast pace of ongoing medical research, a good outcome is increasingly likely.

Read more in The Meaning of Madness.