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History of Psychiatric Hospitals

Philadelphia Hospital for the Insane, Philadelphia, PA c. 1900Philadelphia Hospital for the
Insane, Philadelphia, PA c. 1900The history of psychiatric hospitals was once tied tightly to that
of all American hospitals. Those who supported the creation of the first early-eighteenth-
century public and private hospitals recognized that one important mission would be the care
and treatment of those with severe symptoms of mental illnesses. Like most physically sick
men and women, such individuals remained with their families and received treatment in their
homes. Their communities showed significant tolerance for what they saw as strange thoughts
and behaviors. But some such individuals seemed too violent or disruptive to remain at home
or in their communities. In East Coast cities, both public almshouses and private hospitals set
aside separate wards for the mentally ill. Private hospitals, in fact, depended on the money
paid by wealthier families to care for their mentally ill husbands, wives, sons, and daughters to
support their main charitable mission of caring for the physically sick poor.

But the opening decades of the nineteenth-century brought to the United States new
European ideas about the care and treatment of the mentally ill. These ideas, soon to be called
“moral treatment,” promised a cure for mental illnesses to those who sought treatment in a
very new kind of institution—an “asylum.” The moral treatment of the insane was built on the
assumption that those suffering from mental illness could find their way to recovery and an
eventual cure if treated kindly and in ways that appealed to the parts of their minds that
remained rational. It repudiated the use of harsh restraints and long periods of isolation that
had been used to manage the most destructive behaviors of mentally ill individuals. It
depended instead on specially constructed hospitals that provided quiet, secluded, and
peaceful country settings; opportunities for meaningful work and recreation; a system of
privileges and rewards for rational behaviors; and gentler kinds of restraints used for shorter
periods.

Many of the more prestigious private hospitals tried to implement some parts of moral
treatment on the wards that held mentally ill patients. But the Friends Asylum, established by
Philadelphia’s Quaker community in 1814, was the first institution specially built to implement
the full program of moral treatment. The Friends Asylum remained unique in that it was run by
a lay staff rather than by medical men and women. The private institutions that quickly
followed, by contrast, chose physicians as administrators. But they all chose quiet and
secluded sites for these new hospitals to which they would transfer their insane patients.
Massachusetts General Hospital built the McLean Hospital outside of Boston in 1811; the New
York Hospital built the Bloomingdale Insane Asylum in Morningside Heights in upper
Manhattan in 1816; and the Pennsylvania Hospital established the Institute of the
Pennsylvania Hospital across the river from the city in 1841. Thomas Kirkbride, the influential
medical superintendent of the Institute of the Pennsylvania Hospital, developed what quickly
became known as the “Kirkbride Plan” for how hospitals devoted to moral treatment should
be built and organized. This plan, the prototype for many future private and public insane
asylums, called for no more than 250 patients living in a building with a central core and long,
rambling wings arranged to provide sunshine and fresh air as well as privacy and comfort.
Occupational Therapy Group, Philadelphia Hospital for Mental Diseases, Thirty-fourth and Pine
StreetsOccupational Therapy Group, Philadelphia Hospital for Mental Diseases, Thirty-fourth
and Pine StreetsWith both the ideas and the structures established, reformers throughout the
United States urged that the treatment available to those who could afford private care now
be provided to poorer insane men and women. Dorothea Dix, a New England school teacher,
became the most prominent voice and the most visible presence in this campaign. Dix
travelled throughout the country in the 1850s and 1860s testifying in state after state about
the plight of their mentally ill citizens and the cures that a newly created state asylum, built
along the Kirkbride plan and practicing moral treatment, promised. By the 1870s virtually all
states had one or more such asylums funded by state tax dollars.

By the 1890s, however, these institutions were all under siege. Economic considerations
played a substantial role in this assault. Local governments could avoid the costs of caring for
the elderly residents in almshouses or public hospitals by redefining what was then termed
“senility” as a psychiatric problem and sending these men and women to state-supported
asylums. Not surprisingly, the numbers of patients in the asylums grew exponentially, well
beyond both available capacity and the willingness of states to provide the financial resources
necessary to provide acceptable care. But therapeutic considerations also played a role. The
promise of moral treatment confronted the reality that many patients, particularly if they
experienced some form of dementia, either could not or did not respond when placed in an
asylum environment.

Philadelphia Hospital for the Insane, Philadelphia, PA c. 1900Philadelphia Hospital for the
Insane, Philadelphia, PA c. 1900The medical superintendents of asylums took such critiques
seriously. Their most significant effort to improve the quality of the care of their patients was
the establishment of nurses’ training schools within their institutions. Nurses’ training schools,
first established in American general hospitals in the 1860s and 1870s, had already proved
critical to the success of these particular hospitals, and asylum superintendents hoped they
would do the same for their institutions. These administrators took an unusual step. Rather
than following an accepted European model in which those who trained as nurses in
psychiatric institutions sat for a separate credentialing exam and carried a different title, they
insisted that all nurses who trained in their psychiatric institutions sit for the same exam as
those who trained in general hospitals and carry the same title of “registered nurse.” Leaders
of the nascent American Nurses Association fought hard to prevent this, arguing that those
who trained in asylums lacked the necessary medical, surgical, and obstetric experiences
common to general-hospital-trained nurses. But they could not prevail politically. It would be
decades before American nursing leaders had the necessary social and political weight to
ensure that all training school graduates—irrespective of the site of their training—had
comparable clinical and classroom experiences.
Byberry State Hospital, Philadelphia, PA c. 1920Byberry State Hospital, Philadelphia, PA c.
1920It is, at present, hard to assess the impact of nurses’ training schools on the actual care of
patients in psychiatric institutions. In some larger public institutions, the students worked only
on particular wards. It does seem that they had a more substantive impact on the care of
patients in much smaller and private psychiatric hospitals where they had more contact with
more patients. Still, it may be that their most enduring contribution was opening the practice
of professional nursing to men. Training schools in asylums, unlike those in general hospitals,
actively welcomed men. Male students found places either in schools that also accepted
women or in separate schools formed just for them.

Training schools for nurses, however, could not stop the assault on psychiatric asylums. The
economic crisis of the 1930s drastically cut state appropriations, and World War II created
acute shortages of personnel. Psychiatrists, themselves, began looking for other practice
opportunities by more closely identifying with general, more reductionistic, medicine. Some
established separate programs—often called “psychopathic hospitals”—within general
hospitals to treat patients suffering from acute mental illnesses. Others turned to the early-
twentieth-century’s new Mental Hygiene Movement and created outpatient clinics and new
forms of private practice focused on actively preventing the disorders that might result in a
psychiatric hospitalization. And still others experimented with new forms of therapies that
posited brain pathology as a cause of mental illness in the same way that medical doctors
posited pathology in other body organs as the cause of physical symptoms: they tried insulin
and electric shock therapies, psychosurgery, and different kinds of medications.

By the 1950s, the death knell for psychiatric asylums had sounded. A new system of nursing
homes would meet the needs of vulnerable elders. A new medication, chlorpromazine, offered
hopes of curing the most persistent and severe psychiatric symptoms. And a new system of
mental health care, the community mental health system, would return those suffering from
mental illnesses to their families and their communities.

Today, only a small number of the historic public and private psychiatric hospitals exist.
Psychiatric care and treatment are now delivered through a web of services including crisis
services, short-term and general-hospital-based acute psychiatric care units, and outpatient
services ranging from twenty-four-hour assisted living environments to clinics and clinicians’
offices offering a range of psychopharmacological and psychotherapeutic treatments. The
quality and availability of these outpatient services vary widely, leading some historians and
policy experts to wonder if “asylums,” in the true sense of the word, might be still needed for
the most vulnerable individuals who need supportive living environments.

(www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-psychiatric-hospitals/)

18/08/2017)
Pré 1400

Ancient civilizations like the Romans and Egyptians considered mental health problems
to be of a religious nature. Some thought a person with a mental disorder may be
possessed by demons, thus prescribing exorcism as a form of treatment. During the
5th century BC, Greek physician Hippocrates, however, believed that mental illness
was physiologically affiliated. As a result, his methods involved a change in
environment, living conditions, or occupations.

1400 – early 1900

 1407: The first facility specifically for mental health is established in


Spain.
 1700s: Advocacy for mentally ill persons occurred in France. Phillipe
Pinel, displeased with living conditions in hospitals for those with mental
disorders, orders a change of environment. Patients are given outside
time as well as more pleasant surroundings like sunny rooms. He forbids
the use of shackles or chains as restraints.
 1840s: Dorothea Dix fights for better living conditions for the mentally ill.
For over 30 years she lobbies for better care and finally gets the
government to fund the building of 32 state psychiatric facilities.
 1883: German psychiatrist Emil Kraepelin studies mental illness and
begins to draw distinctions between different disorders. His notes on the
differences between manic-depressive disorder and schizophrenia are
still used today.
 Early 1900s: Using psychoanalytical theories, Sigmund Freud and Carl
Jung treat their patients for mental illness. Many of the theories they
employed are still discussed today and used as a basis for the study of
psychology.

1930 to actually

After the 1920s, the United States saw yet again another shift in society’s view
on mental health. A Mind That Found Itself, a book by Clifford Beers, prompts
discussion on how mentally ill people are treated in institutions. His ideas begin
the roots of the National Mental Health Association. Countless other books like
Ken Kesey’s One Flew Over the Cuckoo’s Nest in 1962 also offered an
interesting perspective on how people are treated in psychiatric hospitals. This
early period of the 20th century marked a big movement in advocacy and care
standards for mental health care.
After the 1920s, the United States saw yet again another shift in society’s view
on mental health. A Mind That Found Itself, a book by Clifford Beers, prompts
discussion on how mentally ill people are treated in institutions. His ideas begin
the roots of the National Mental Health Association. Countless other books like
Ken Kesey’s One Flew Over the Cuckoo’s Nest in 1962 also offered an
interesting perspective on how people are treated in psychiatric hospitals. This
early period of the 20th century marked a big movement in advocacy and care
standards for mental health care.

 1946: President Harry Truman signs a law that aims to reduce mental
illness in the United States, the National Mental Health Act. This law
paved the way for the foundation of the National Institute on Mental
Health (NIMH) in 1949.
 1950s to 1960s: A wave of deinstitutionalization begins, moving patients
from psychiatric hospitals to outpatient or less restrictive residential
settings. Institutionalization was often thought of as the best method of
treatment but overstaffing and poor living conditions prompted a push to
outpatient care. This movement also sparks the development of
antipsychotic drugs, so as to make a person’s life outside an institution
more manageable. In fact, over a 30-year period the number of
institutionalized patients dropped from 560,000 in the 1950s to 130,000
in 1980.
 1990s: A new generation of prescription antipsychotic drugs emerge, as
well as new technology in the medical field.
 2008 to 2010: The Wellstone and Domenici Mental Health Parity and
Addiction Equity Act passes into law. This made it so insurers who did
provide mental health coverage could not put limitations on benefits that
are not equal to limits on other medical care coverage.

Wider Outrage in the 1880s


Placing the mentally ill in facilities allowed members of the general public to ignore the
problem. They didn’t see anyone who had a mental illness roaming the streets, and if they
placed a person in an institution like this, they may not have come back to visit or shared
stories of any visits they did make. The people just seemed to disappear.

Much of that changed in the late 1880s, due to the work of a writer named Nelly Bly. She
agreed to pose as a mentally ill woman on an assignment for a local newspaper, and she
documented everything that happened to her in a series of articles, which were later turned
into a book. Bly was a wonderful writer, and her descriptions were hard to ignore.
By McD (Penn University library) [Public domain], via Wikimedia Commons

By McD (Penn University library) [Public domain], via Wikimedia Commons

By McD (Penn University library) [Public domain], via Wikimedia Commons

“… I could not sleep, so I lay in bed picturing to myself the horrors in case a fire should break
out in the asylum. Every door is locked separately and the windows are heavily barred, so that
escape is impossible. In the one building alone there are, I think Dr. Ingram told me, some
three hundred women. They are locked, one to ten in a room. It is impossible to get out unless
these doors are unlocked.”[4]

In addition to describing the physical building, Bly describes the harsh treatments she
obtained, including solitary confinement, hair pulling and more. Bly’s book was a sensation,
and according to news reports,[5] the institution in which she lived was reformed as a result of
her work. But she also managed to outline what living in a facility like this was actually like and
how it didn’t seem to help anyone to get better, and that may have deepened the discussion
people in this country had about mental illness, and it may have spurred experts to come up
with radical treatments that could actually effectively treat mental illnesses. If housing them
and isolating them didn’t work, they needed to find something else that would.
Innovative Therapies in the 1930s

Innovative Therapies in the 1930s


In the early part of the 1900s, experts began to try to understand what might
make a person behave in an erratic way, and what kinds of thoughts and
opinions might be attached to what outsiders would deem “madness.” Sigmund
Freud was a major influence here, obviously, as he developed a number of
theories that attempted to explain unusual behavior, and he devised therapies
that aimed to help people who might once have been placed in a prison with no
help at all.[6]But work advocated by Freud could take months or even years to
complete, and some people didn’t seem to get better when they were under the
guidance of the so-called “talking cure.” As a result, practitioners began
dabbling in radical cures in the 1930s,[7] hoping to eliminate mental illnesses
altogether with one big gesture.

By Cesar Blanco from Mexico (Sigmund Freud Uploaded by Viejo sabio) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via
Wikimedia Commons

By Photography Harris A Ewing (Saturday Evening Post, 24 May 1941, pages 18-19) [Public domain], via Wikimedia Commons

Techniques that were used on the mentally ill included:

 Insulin-induced comas
 Lobotomies
 Malarial infections
 Electroshock therapy
By Otis Historical Archives National Museum of Health and Medicine (originally posted to Flickr as Reeve041476) [CC-BY-2.0
(http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

https://youtu.be/Z38GFD3IyXI

https://youtu.be/bUE8PAjqZgY

Chemical Interventions

In the 1940s and 1950s, chemists began to


experiment with different powders and pills that could calm imbalances inside the brain
and deliver real relief to people who had mental illnesses. Rather than strapping people
down to their beds, or asking people to simply talk about their problems, these chemists
hoped to use a form of chemical restraint. People would feel better, and they might
behave better, and no institutionalization would be needed at all.To a large extent, this
was a successful project. Medications like lithium seemed capable of soothing people
with very severe cases of bipolar disorder, while antipsychotic medications seemed
capable of helping people with schizophrenia.

At the same time, the number of people hospitalized due to mental illness had reached
staggering proportions. [8]
It was a global problem, and experts began to wonder if they could take people
out of the institutions and provide them with medications they could use at
home.
Deinstitutionalization Movement

Beginning in the 1950s, experts began moving people out of institutions and into
communities, and the number of people enrolled in formal institutions dropped
dramatically in just a few short years.[9]Unfortunately, communities were slow to adapt
to this onslaught of people who needed very intense care.
Few were able to provide the support needed, such as:

 Housing assistance
 Job training
 Psychiatric counseling
 Life skills training
 Social support
As a result, many people who moved out of terrible facilities moved into situations that
were merely different, not noticeably better. For example, in a grueling piece from The
New York Times, [10] a story emerges of a number of very young men who were
removed from state institutions and forced to work in a turkey-processing plant for
years, for less than $100 per month. These men had no contact with their families, no
opportunities to learn life skills and no way to get out.
“A lucky few returned South for a week’s vacation every year. Others tried to
stay in touch with family by schoolhouse telephone, some of them calling
disconnected numbers, over and over, year after year. Or they lingered at the
post office, where there was rarely anything for them, other than the candy on
the counter … But every once in a great while, a lucky man received a birthday
card or Christmas letter, sent from another world.”
They were left there until 2009, when inspectors from the federal Department of
Labor, as well as officials from nearby communities, reported conditions that
they felt were abusive.

Those who weren’t shipped to programs like this sometimes slipped between
the cracks altogether, and they made a life on the streets, sleeping in cardboard
boxes, begging for food and railing at the sky when the days were bad. In one
study of the issue,[11] conducted in 1988, researchers found that 28 percent of
the homeless people they studied had a diagnosable mental illness. That’s a
remarkably high number.
In the 1990s, experts discovered that many people with mental illness entered
the criminal justice system, due to a combination of drug use and mandatory
sentencing rules.[12] Administrators of these facilities scrambled to keep up
with the demand for services from people who were profoundly ill and unable to
get the help they needed on the outside.
Modern Therapies
Community agencies have worked for years to provide people with the help
they need to manage their conditions without entering a facility for life. Social
workers, mental health counselors and more have all been involved in this
movement, and while it’s safe to say that some communities provide help that’s
superior to the level of assistance seen in other communities, it’s clear that
people have options for treatment today through community resources that just
didn’t exist a decade or so ago.

Laws have also changed, and they now allow concerned family members and
community members to place people with mental illnesses inside therapeutic
facilities for a short period of time, until they gain control. Some state laws even
force people with mental illnesses to take medications, even if they don’t wish to
do so.[13]

It’s easy to view these legislative changes as a method that can allow people in
the community to live with people who have mental illnesses, without worrying
about their health and harm. But people who have mental illnesses have rights,
and some don’t wish to accept this kind of treatment. Some patients want to
manage their own conditions, using online resources as well as their doctors,
and they’d like to have much more autonomy.[14]
It’s unclear what role this might play in the future. But it is clear that practitioners
now respect people with mental illnesses to an unprecedented degree,
compared with previous years. Rather than silencing them with restraints and
drugs, experts now want to partner with patients and help them. This could
bring about a form of mental health treatment everyone could support.

If you’d like to know more about how mental health issues are treated in
Foundations Recovery Network facilities, we urge you to give us a call. Our
admissions coordinators are here 24/7 to answer your questions.
[1] “Women and Psychiatry.” (n.d.). Science Museum. Accessed March 14, 2014.
[2] Parry, M. (April 2006). “Dorothea Dix (1802-1887).” American Journal of Public
Health. Accessed March 14, 2014.
[3] “Dorothea Dix Pleads for a State Mental Hospital.” (n.d.). Learn NC. Accessed
March 14, 2014.
[4] “Nellie’s Madhouse Memoir.” (n.d.). American Experience. Accessed March 14,
2014.
[5] DeMain, B. “Ten Days in a Madhouse: The Woman Who Got Herself Committed.”
(2011). Mental Floss. Accessed March 14, 2014.
[6] “Sigmund Freud.” (n.d.). NNDB. Accessed March 14, 2014.
[7] “Timeline: Treatments for Mental Illness.” (n.d.). American Experience. Accessed
March 14, 2014.
[8] Ibid.
[9] Koyanagi, C. (August 2007). “Learning from History: Deinstitutionalization of
People with Mental Illness as a Precursor to Long-Term Care Reform.” Kaiser
Commission on Medicaid and the Uninsured. Accessed March 14, 2014.
[10] Barry, D. (March 9, 2014). “The ‘Boys’ in the Bunkhouse: Toil, Abuse and
Endurance in the Heartland.” The New York Times. Accessed March 14, 2014.
[11] Koegel, P.; Burnam, M.A. & Farr, R. (December 1988). “The Prevalence of
Specific Psychiatric Disorders Among Homeless Individuals in the Inner City of Los
Angeles.” JAMA Psychiatry, Accessed March 14, 2014.
[12] Diamond, P.; Wang, E.; Holzer, C.; Thomas, C. & Cruser, A. (September 2001).
“The Prevalence of Mental Illness in Prison.” Administration and Policy in Mental
Health and Mental Health Services Research. Accessed March 14, 2014.
Mental Health Diagnoses: A (Nearly) Complete History
of Mental Illness

March 11, 2014/by contributor

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.
Passeio Pela Loucura

A conceituação de loucura varia de acordo com o momento sócio-histórico


onde se atrelam os conceitos de “normalidade” e “anormalidade”, sejam esses
conceitos estatística, teleológica ou ideologicamente determinados. Quando se
fala em anormalidade há que se levar em conta que critérios se está utilizando.
As concepções de saúde e enfermidade variam de acordo com o contexto social
de onde são retirados.
Fazendo menção ao tema, Baumgart (2006) traz que
“Lo psiquicamente anormal depende de la concepción imperante en cada sociedad y es
relativo a un ordem etnográfico e histórico. Así como lãs personas adquierem los estilos de
expressión, las creencias, sus superticiones, sus modos de vínculo social, también se
adquieren los modos culturales en los que se manifestan las anormalidades de la vida
psiquica”

Até o início do estudo das “aberrações humanas” ser incluído no campo da


medicina há cerca de 2.500 anos na Grécia, existiam apenas alusões à loucura
como comportamentos estranhos, personalidades incomuns ou desagradáveis
e mesmo “possessões demoníacas” (STONE, 1999). As possessões foram uma
das formas mais significativas usadas para explicar comportamentos tidos como
desviantes. Coleman (1973), aponta que é compreensível que a chamada
loucura tenha sido explicada de tal forma já que os espíritos eram também
utilizados para explicar o raio e o trovão, por exemplo.
A loucura era considerada, de um modo geral, uma manifestação dos
deuses. O ataque epiléptico era inclusive chamado de “doença divina”. A
extensão desse modo de ver o mundo abarcaria tudo o mais que não fosse por
eles passível de entendimento ou explicações.
Na antiguidade, filósofos como Platão e Aristóteles elaboravam teorias sobre
a natureza da alma e de seus transtornos. Hipócrates, considerado pai da
medicina e contemporâneo de Platão, acabou por sistematizar a nosologia já
existente, adicionando apenas poucos conceitos. Nela constavam basicamente
mania, histeria, paranóia e melancolia. Hipócrates tinha uma explicação natural
para os fenômenos da personalidade que seriam influenciados por humores
oriundos da terra, fogo, água e ar. Durante a Idade Média, Stone (1999, p. 32)
defende que
“O que era entendido como estados mentais anormais baseado em estados humorais ou
lesões anatômicas foi reformulado na linguagem dos padres e astrólogos. Fenômenos
mentais aberrantes eram agora explicados em termos quase morais envolvendo referências
a espíritos maus, fantasmas, íncubos e súcubos e assim por diante”

Na Idade Média e período da contra-reforma pessoas consideradas loucas


eram ditas possuídas pelo demônio e queimadas na fogueira. Na Renascença,
há a volta aos valores humanistas greco-romanos e com eles indagações sobre
as origens e causalidades naturais dos fenômenos mentais. São dessa época
os primeiros asilos psiquiátricos, o primeiro deles oficialmente fundado em
Valência na Espanha, 1410.
BAUMGART (2006), mostra que há a retirada do doente mental da
convivência com os outros homens, ele passa a ser um “desprovido”, já que a
enfermidade mental resultaria com o decorrer do tempo num desaparecimento
de suas funções superiores. O culto à razão disseminado nesse período
renascentista e bem representado pela dúvida Cartesiana parece sentir-se
ameaçado pela “não-razão” da loucura, toda ela de uma forma bem genérica
passa a ser rotulada sempre como uma não verdade, o sistema cartesiano não
a abarcava.
O surgimento dos asilos por volta do século XV e XVI, no entanto, não se
restringiu a internação apenas dos considerandos doentes mentais, pelo menos
a princípio, era um espaço de isolamento social que engloba todas as “espécies”
que fossem incomodas aos olhos da sociedade como pobres, vagabundos,
presidiários, prostitutas, etc.
Esses asilos tomam lugar, muitas vezes situando-se inclusive nas mesmas
instalações físicas, dos antigos leprosários da Idade Média, abandonados por
um certo tempo pela regressão da lepra. Os leprosários constituem espaços
“malditos” caracterizados pelo isolamento físico e social que em particular se
direcionava aos leprosos. FOUCAULT (1961, p. 6) afirma que
“A Lepra se retira, deixando sem utilidade esses lugares obscuros e esses ritos que não
estavam destinados a suprimi-la, mas sim a mantê-la a uma distancia sacramentada, a fixá-
la numa exaltação inversa. Aquilo que sem dúvida vai permanecer por muito mais tempo
que a Lepra, e que se manterá ainda numa época em que, há anos, os leprosários estavam
vazios, são os valores e as imagens que tinham aderido à personagem do leproso”.

Essa herança de degredo foi repassada aos personagens antes citados que
mais tarde iriam habitar tais espaços, não para serem “tratados” e sim isolados
e disciplinarizados funcionando o asilo como um terceiro poder junto ao Estado
e à Polícia.
A igreja, até então responsável por acolher, alimentar e cuidar moralmente
daqueles que lá se apresentassem voluntariamente ou que para lá fossem
encaminhados foi aos poucos tendo seu poder substituído pelo poder do Estado.
Os asilos ficam divididos por um certo período entre esse assistencialismo
eclesiástico que cuida, controla moralmente, exalta a loucura e a pobreza como
divinas e o controle, disciplinarização exercidos pela burguesia nascente que vê
a população dos asilos como uma mão-de-obra não-funcional, não-produtiva e
nos asilos uma maneira de arregimenta-la de forma a fazer com que produza
sob certos sistemas com poucos gastos além de, através desse método de
“emprego” e ocupação desses ociosos, conseguir proteção social contra
agitações e revoltas.
O hospital geral não se caracteriza apenas como um “depósito” para os
“inválidos socialmente” ele é antes de tudo uma instituição responsável por
corrigir as “falhas morais” da sociedade, motivadas pela ameaça da desrazão ou
pelo improdutividade inaceitável ao sistema de produção no qual estamos
inseridos.
Em meados de 1700, uma credibilidade ainda maior foi dada à racionalidade,
com a influência da Igreja em declínio, as explorações anatômicas puderam
prosseguir e desenvolver-se consideravelmente resultando em teorias
neurofuncionais e anatômicas mais profundas (STONE, 1999). Nesse contexto
tem-se o nascimento da Psiquiatria, que adentra os hospitais gerais instalando
a hegemonia da medicina nesses espaços
O poder exercido no interior dessas casas pertencente majoritariamente à
Igreja e ao Estado esse vai passando paulatinamente à Psiquiatria que sente
necessidade de validar sua presença nessa instituição. A princípio a Psiquiatria
não surge como uma especialização do saber ou área da ciência médica, mas
como um ramo especializado da higiene pública. Foucault (1975, p.148) traz que:
“Antes de ser uma especialidade da medicina, a psiquiatria se institucionalizou como
domínio particular da proteção social, contra todos os perigos que o fato da doença, ou de
tudo o que se pode assimilar direta ou indiretamente à doença pode acarretar à sociedade.
Foi como precaução social, foi como higiene do corpo social inteiro que a psiquiatria se
institucionalizou.”

Sendo assim, ainda segundo Foucault, para existir como instituição de saber
necessária à sociedade a psiquiatria deveria alcançar duas condições. A
primeira delas era alcançar o patamar de ciência. Para poder incluir-se no ramo
da medicina codificou-se a loucura como doença, dando-lhe nosologias,
patologia, prognósticos, observações, diretrizes diagnósticas, etc. Foram
tornadas patológicas as condutas e traços referentes ao louco.
Simultaneamente, foi necessário provar sua importância à sociedade o que
foi feito relacionando a loucura, seu objeto de estudo, com a noção de perigo. A
psiquiatria, portanto, como a maior detentora de conhecimentos sobre esse mal
se torna imprescindível ao bem-estar da sociedade. Assim nasce mais um ramo
da ciência.

Fonte: https://psicologado.com/psicopatologia/psiquiatria/passeio-pela-loucura ©
Psicologado.com

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