Direcções contemporâneas da psicopatologia. Fundamentos do dsm 5 e cid-11. Considerando falhas no dsm 5 devido a nossa ignorancia nas etiopatogenias e classificações psicopatologicas é relevante evidenciar que o trabalho
about the editorsTheodore Millon, PhD, DSc, is Dean and Scientific Director of the Institute for AdvancedStudies in Personology and Psychopathology. He was Founding Editor of the Journal of Per-sonality Disorders and inaugural president of the International Society for the Study of Per-sonality Disorders (ISSPD). Dr. Millon has held full professorial appointments at HarvardMedical School, the University of Illinois, and the University of Miami. A prolific author, hehas written or edited more than 30 books on theory, assessment, and therapy, as well as morethan 200 articles and book chapters. Dr. Millon is the recipient of the 2008 American Psycho-logical Foundation Gold Medal for Life Achievement in the Application of Psychology.Robert F. Krueger, PhD, is Professor of Psychology and Psychiatry at Washington Universityin St. Louis. His major research interests lie at the intersection of personality, psychopathol-ogy, psychometrics, and behavioral genetics. Dr. Krueger has received a number of awards,including the American Psychological Association’s Distinguished Scientific Award for EarlyCareer Contribution and the American Psychological Foundation’s Theodore Millon Awardfor midcareer contributions to personality psychology.Erik Simonsen, MD, is Director of Psychiatric Research in Region Zealand, Denmark; Di-rector of the Institute of Personality Theory and Psychopathology; and Associate ResearchProfessor at the University of Copenhagen. He has published widely on personality disorders,first-episode psychosis, personality assessment, outcome of psychotherapy, and psychiatricclassification. Dr. Simonsen is past president of the ISSPD and a recipient of the ISSPD Award.He has also served as president of the Section on Personality Disorders of the World Psychi-atric Association. v
ContributorsRenato D. Alarcón, MD, MPH, Mood Disorders Unit and Department of Psychiatry,Mayo Clinic College of Medicine, Rochester, MinnesotaSteven R. H. Beach, PhD, Institute for Behavioral Research, University of Georgia,Athens, GeorgiaEdward M. Bernat, PhD, Department of Psychology, Florida State University,Tallahassee, FloridaRoger K. Blashfield, PhD, Department of Psychology, Auburn University, Auburn, AlabamaSidney J. Blatt, PhD, Department of Psychiatry, Yale School of Medicine,New Haven, ConnecticutBekh Bradley, PhD, Trauma Recovery Program, Atlanta Veterans Affairs Medical Center,and Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GeorgiaJessica Combs, BA, Department of Psychology, University of Kentucky,Lexington, KentuckyRina Dutta, MRCPsych, Institute of Psychiatry, Kings College London,London, United KingdomNicholas R. Eaton, MA, Department of Psychology, Washington University in St. Louis,St. Louis, MissouriMichael B. First, MD, Department of Psychiatry, Columbia University, New York,New YorkElizabeth Flanagan, PhD, Department of Psychiatry, Yale School of Medicine,New Haven, Connecticut vii
viii ContributorsJoseph P. Gone, PhD, Department of Psychology, University of Michigan,Ann Arbor, MichiganSeth Grossman, PsyD, Counseling and Psychological Services Center, Florida InternationalUniversity, Miami, FloridaWilliam M. Grove, PhD, Department of Psychology, University of Minnesota,Minneapolis, MinnesotaRichard E. Heyman, PhD, Department of Psychology, Stony Brook University, StateUniversity of New York, Stony Brook, New YorkNadine J. Kaslow, PhD, Department of Psychiatry, Emory University School of Medicine,Atlanta, GeorgiaJared Keeley, MS, Department of Psychology, Auburn University, Auburn, AlabamaKenneth S. Kendler, MD, Virginia Institute for Psychiatric and Behavioral Genetics,Virginia Commonwealth University, Richmond, VirginiaLaurence J. Kirmayer, MD, Division of Social and Transcultural Psychiatry, McGillUniversity, and Institute of Community and Family Psychiatry, Jewish General Hospital,Montreal, Quebec, CanadaHelena Chmura Kraemer, PhD, Department of Psychiatry and Behavioral Sciences,Stanford University, Stanford, California; Department of Psychiatry, Universityof Pittsburgh, Pittsburgh, PennsylvaniaRobert F. Krueger, PhD, Departments of Psychology and Psychiatry, Washington Universityin St. Louis, St. Louis, MissouriMark F. Lenzenweger, PhD, Department of Psychology, State University of New Yorkat Binghamton, Binghamton, New YorkMark R. Lukowitsky, MA, Department of Psychology, Pennsylvania State University,University Park, PennsylvaniaPatrick Luyten, PhD, Department of Psychology, University of Leuven, Leuven, BelgiumMario Maj, MD, PhD, Department of Psychiatry, University of Naples, Naples, ItalyPaul E. Meehl, PhD (deceased), Department of Psychology, University of Minnesota,Minneapolis, MinnesotaTheodore Millon, PhD, DSc, Institute for Advanced Studies in Personologyand Psychopathology, Port Jervis, New YorkRobin M. Murray, MD, Institute of Psychiatry, Kings College London,London, United KingdomKile M. Ortigo, MA, Department of Psychology, Emory University, Atlanta, GeorgiaJoel Paris, MD, Department of Psychiatry, McGill University, and Institute of Communityand Family Psychiatry, Jewish General Hospital, Montreal, Quebec, CanadaChristopher J. Patrick, PhD, Department of Psychology, Florida State University,Tallahassee, FloridaAaron L. Pincus, PhD, Department of Psychology, Pennsylvania State University,University Park, Pennsylvania
Contributors ixKristin Raley, MS, Department of Psychology, Auburn University, Auburn, AlabamaDavid Reiss, MD, Yale Child Study Center, Yale University, New Haven, ConnecticutBryna Siegel, PhD, Department of Psychiatry, University of California, San Francisco,San Francisco, CaliforniaErik Simonsen, MD, Psychiatric Research Unit, Region Zealand, and Departmentof Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, DenmarkAndrew E. Skodol, MD, Sunbelt Collaborative and Department of Psychiatry, University ofArizona College of Medicine, Tucson, ArizonaGregory T. Smith, PhD, Department of Psychology, University of Kentucky,Lexington, KentuckySusan C. South, PhD, Department of Psychological Sciences, Purdue University,West Lafayette, IndianaMichael H. Stone, MD, Department of Psychiatry, Columbia University, and privatepractice, New York, New YorkRobert Tringone, PhD, Counseling Center, St. John’s University, Jamaica, New YorkScott I. Vrieze, BA, Department of Psychology, University of Minnesota,Minneapolis, MinnesotaJerome C. Wakefield, PhD, DSW, Silver School of Social Work and Departmentof Psychiatry, New York University, New York, New YorkMarianne Z. Wamboldt, MD, Department of Psychiatry, University of Colorado DenverSchool of Medicine, Aurora, ColoradoDrew Westen, PhD, Departments of Psychology and Psychiatry and Behavioral Sciences,Emory University, Atlanta, GeorgiaAidan G. C. Wright, MS, Department of Psychology, Pennsylvania State University,University Park, PennsylvaniaPeter Zachar, PhD, Department of Psychology, Auburn University at Montgomery,Montgomery, Alabama
prefacet he present book is similar in concept to a well-received volume that one of us (Theodore Millon) edited with Gerald L. Klerman of Harvard University in 1986; it is, however, analmost entirely new book, with only one chapter carried over from the earlier work. Gerryand I were colleagues at the Stanley Cobb Psychiatric Laboratories of Massachusetts GeneralHospital, as well as active participants in the development of DSM-III. Our aim in the earliervolume was to describe substantive and innovative advances since the publication of DSM-IIIin 1980, and to emphasize themes we believed should be considered in the forthcoming DSM-IV. We, the present editors, intend to do the same in this volume for DSM-IV(-TR) and for theforthcoming DSM-V and ICD-11. Numerous changes in the character of psychopathology have begun taking place in thepast several decades. Slow though progress has been, there are inexorable signs that the studyof mental disorders has advanced beyond its earlier history as an oracular craft. No longerdependent on the intuitive artistry of brilliant clinicians and theoreticians who formulateddazzling but often unfalsifiable insights, psychopathology has acquired a solid footing inthe empirical methodologies and quantitative techniques that characterize mature sciences.Although the term “psychopathology” was used in the past as synonymous with “descrip-tive symptomatology,” it can now be justly employed to represent “the science of abnormalbehavior and mental disorders.” Its methods of study comfortably encompass both clinicaland experimental procedures. Among the many indices of continuing progress is the construction of psychometricallysound diagnostic tools that wed the quantitative and statistical precision typifying rigorousempirical disciplines with the salient and dynamic qualities characterizing the concerns of aclinical profession. Contributing to this precision is the introduction of comprehensive andcomparable diagnostic criteria for each mental disorder—an advance that not only enhancesthe clarity of clinical communication, but strengthens the reliability of research, contributingthereby to the collection of reciprocal and cumulative data. Similarly, sophisticated multivari- xi
xii prefaceate statistical methods now provide quantitative grounds for analyzing symptom patterns andconstructing an orderly taxonomy. Theoretical formulations have also begun to take on a more logical and orderly struc-ture. Whereas earlier propositions were often presented in haphazard form, with circularderivations and ambiguous or conflicting empirical consequences, contemporary theoristsbegan to specify explicit criteria for their concepts, as well as to spell out objective proceduresand methods for testing their hypotheses. Moreover, theorists have become less doctrinairein their positions than formerly; that is, they no longer act and write as religious disciples of“theological purity.” A true “ecumenism” has emerged—an open-mindedness and sharing ofviews that are much more characteristic of disciplines with secure foundations. Thus erstwhileanalysts have shed their former dogmatisms and have begun to incorporate findings such asthose in the neurosciences and social psychology; similarly, once-diehard behaviorists havejettisoned their earlier biases and have integrated cognitive processes into their principles. Onmany levels and from several perspectives, the signs indicate consistently that psychopathol-ogy is becoming a full-fledged science. It is our intent in this book to draw attention to innovations that constitute continuationsof these directions. The volume is not intended to be a comprehensive textbook, but many ofits chapters provide thoughtful pedagogic reviews and heuristic recommendations that mayprove useful to the forthcoming DSM-V and ICD-11. In this latter regard, we very much favorcurrent efforts to construct further rapprochements between the American Psychiatric Asso-ciation’s DSM and the World Health Organization’s ICD. Work on the new editions of bothmanuals is well underway, and we believe that a successful accommodation will come fromthe combination of careful theoretical and conceptual analyses, and the parallel acquisitionof empirical data from well-designed research. This work not only reflects the current state ofpsychopathology as a science, but should help identify the issues and methods that can fosterthis important reconciliation. As noted, all but one of the 30 chapters in this volume is new. Only Paul E. Meehl’sclassic chapter on “diagnostic taxa” is a repeat from the earlier book; it is one that Mark F.Lenzenweger reflects on and thoroughly reviews. Notable in this edition are several chap-ters that bring to the forefront the role played by social context and culture in the roots ofnumerous mental disorders. The book begins with an extensive historical survey that leadsup to contemporary thinking. Here are traced the contributions of theorists and researchersfrom ancient times (e.g., Zang Zhongjing, Alcmaeon, Aretaeus), the many fruitful ideas of19th-century clinicians (e.g., Esquirol, Griesinger, Kahlbaum), and the work of more modernscholars (e.g., Kraepelin, Freud, Beck). Classification matters are explored deeply in chapters that deal with philosophical issuesunderlying construct validity, syndromal comorbidity, and the clinical utility of categoriesversus dimensions. Innovative proposals are presented on such topics as the neuroscientificfoundations of psychopathology and the use of evolutionary principles in articulating thedevelopment and composition of psychopathology. It is our hope that this volume will contribute further to the long and fruitful collabora-tion between the disciplines of psychology and psychiatry. Psychopathology needs “all thehelp it can get” if it is to fulfill its promise as a science. The best minds are not to be foundin one school of thought or in one mental health profession. Different perspectives not onlycontribute to “rounding out” important areas of content and technique, but help spark freshinsights and ideas. We three editors have found collaborative work to be both stimulatingand rewarding; we hope that this book will serve not only as a model of cooperation betweenour fields, but as an invitation to biochemists, epidemiologists, psychometricians, geneticists,sociologists, and professionals in other disciplines to join us in similar enterprises.
preface xiii In closing, we should like to express our appreciation to the book’s contributors. Amongthem are numerous distinguished scholars, as well as well-respected and promising younginvestigators from psychology, psychiatry, philosophy, and sociology. In addition to beingextremely pleased with the high quality and original thought that went into each chapter,we should note that both authorial and editorial royalties for this volume will be turned overto the World Health Organization, to provide it with additional resources to facilitate andexpedite the development of ICD-11. Theodore M illon roberT F. K rueger eriK SiMonSen
ContentsPart I. HIstorIcal and cultural PersPectIveschaPter 1. a précis of psychopathological history 3 Theodore Millon and Erik SimonsenchaPter 2. themes in the evolution of the 20th- Century Dsms 53 Roger K. Blashfield, Elizabeth Flanagan, and Kristin RaleychaPter 3. on the Wisdom of Considering Culture and Context 72 in psychopathology Joseph P. Gone and Laurence J. KirmayerchaPter 4. Cultural issues in the Coordination of Dsm-V and iCD-11 97 Renato D. AlarcónchaPter 5. a sociocultural Conception of the Borderline 111 personality Disorder epidemic Theodore MillonPart II. concePtual Issues In classIfIcatIonchaPter 6. philosophical issues in the Classification of psychopathology 127 Peter Zachar and Kenneth S. KendlerchaPter 7. Classification Considerations in psychopathology and personology 149 Theodore Millon xv
xvi ContentschaPter 8. Diagnostic taxa as open Concepts: metatheoretical 174 and statistical Questions about reliability and Construct Validity in the grand strategy of nosological revision Paul E. MeehlchaPter 9. Contemplations on meehl (1986): the territory, paul’s map, 187 and our progress in psychopathology Classification (or, the Challenge of Keeping Up with a Beacon 30 years ahead of the Field) Mark F. LenzenwegerchaPter 10. issues of Construct Validity in psychological Diagnoses 205 Gregory T. Smith and Jessica CombschaPter 11. the meaning of Comorbidity among Common mental Disorders 223 Nicholas R. Eaton, Susan C. South, and Robert F. KruegerchaPter 12. the Connections between personality and psychopathology 242 Susan C. South, Nicholas R. Eaton, and Robert F. KruegerchaPter 13. is it true that mental Disorders are so Common, 263 and so Commonly Co-occur? Mario MajchaPter 14. taking Disorder seriously: a Critique of psychiatric Criteria 275 for mental Disorders from the harmful- Dysfunction perspective Jerome C. WakefieldPart III. MetHodologIcal aPProacHes to categorIes, dIMensIons, and PrototyPeschaPter 15. on the substantive grounding and Clinical Utility of Categories 303 versus Dimensions William M. Grove and Scott I. VriezechaPter 16. a short history of a psychiatric Diagnostic Category 324 that turned out to Be a Disease Roger K. Blashfield and Jared KeeleychaPter 17. Concepts and methods for researching Categories 337 and Dimensions in psychiatric Diagnosis Helena Chmura KraemerchaPter 18. the integration of Categorical and Dimensional approaches 350 to psychopathology Erik SimonsenchaPter 19. Dimensionalizing existing personality Disorder Categories 362 Andrew E. Skodol
Contents xviichaPter 20. an empirically Based prototype Diagnostic system 374 for Dsm-V and iCD-11 Kile M. Ortigo, Bekh Bradley, and Drew WestenchaPter 21. the millon personality spectrometer: a tool for personality 391 spectrum analyses, Diagnoses, and treatments Theodore Millon, Seth Grossman, and Robert TringonePart Iv. InnovatIve tHeoretIcal and eMPIrIcal ProPosalschaPter 22. neuroscientific Foundations of psychopathology 419 Christopher J. Patrick and Edward M. BernatchaPter 23. Using evolutionary principles for Deducing normal 453 and abnormal personality patterns Theodore MillonchaPter 24. Biopsychosocial models and psychiatric Diagnosis 473 Joel ParischaPter 25. reactivating the psychodynamic approach to the Classification 483 of psychopathology Sidney J. Blatt and Patrick LuytenchaPter 26. a life Course approach to psychoses: 515 outcome and Cultural Variation Rina Dutta and Robin M. MurraychaPter 27. the interpersonal nexus of personality and psychopathology 523 Aaron L. Pincus, Mark R. Lukowitsky, and Aidan G. C. WrightchaPter 28. reconceptualizing autism spectrum Disorders as autism- specific 553 learning Disabilities and styles Bryna SiegelchaPter 29. Describing relationship patterns in Dsm-V: a preliminary proposal 565 Marianne Z. Wamboldt, Steven R. H. Beach, Nadine J. Kaslow, Richard E. Heyman, Michael B. First, and David ReisschaPter 30. on the Diversity of the Borderline syndromes 577 Michael H. Stone author index 595 subject index 607
chaPter 1a précis of psychopathological historytHeodore Millonerik siMonsenB efore we andanalysis text, it maytrends in a systematic our contributors undertakepsychopathology in this of current be use- The traditions of psychopathology today are not themselves tight systems of thought in the strict sense of scientific theories; they cer-ful to introduce the subjects with reference tainly are neither closed nor completed con-to its historical origins and evolution. Ef- structions of ideas that have been worked outforts to understand and resolve the problems in their final details. Rather, they are productsthat researchers studying mental disorders of obscure lines of historical development—continue to face can be traced through many movements often subject to the confusionscenturies in which solutions have taken un- and misunderstandings of our remote past,anticipated turns and have become enmeshed when a disaffection with complexities typi-in obscure beliefs and entangled alliances, fied life. Nevertheless, interest in ourselves,most of which have unfolded without the in our foibles as well as our achievements,care and watchful eye of modern scientific has always been central to our human curi-thoughts and methods. Psychopathology re- osity. The origins of interest in the workingsmains today a relatively young science. We of psychopathology were connected in theirfind that many techniques and theories of earliest form to studies of astronomy andour time have long histories that connect spiritual unknowns. Even before any recordcurrent thinking to preexisting beliefs and of human thought had been drafted in writ-systems of thought, many of which are in- ten form, we humans were asking fundamen-tertwined in chance associations, primitive tal questions, such as why we behave, think,customs, and quasi-tribal quests. The path act, and feel as we do. Although primitive into the present is anything but a simple and their ideas, ancient people were always openstraight line; it has come to its current state to the tragic sources in their lives. Earliestthrough an involvement in values and cus- answers, however, were invariably associ-toms of which we may be only partly aware. ated with metaphysical spirits and magicalMany are the product of historical accidents spells. Only slowly were more sophisticatedand erroneous beliefs that occurred centu- and scientific ideas formulated.ries ago, when mysticism and charlatanism It was not until the 6th century B.C. thatflourished. the actions, thoughts, and feelings of humans 3
4 historiCal anD CUltUral perspeCtiVeswere attributed to natural forces—that is, to learn how different modes of thought todaysources found within ourselves. Philosophers have their roots in chance events, culturaland scientists began to speculate intelligent- ideologies, and accidental discoveries, asly about a wide range of psychological pro- well as in brilliant and creative innovations.cesses; many of their ideas turned out to be From today’s perspective, it seems likelyremarkably farsighted. Unfortunately, much that future developments in the field willof this early imaginative and empirical work reflect recent efforts to encompass and inte-was forgotten through the centuries. Time grate biological, psychological, and sociocul-and again, it was then slowly stumbled upon tural approaches. No longer will any singleand rediscovered by careful or serendipitous and restricted point of view be prominent;efforts. For example, John Locke in the 17th each approach will enrich all others as onecentury described a clinical procedure for component of a synergistic whole. Integrat-overcoming unusual fears; the procedure he ing the disparate parts of a clinical science—described is not very different from the sys- theory, nosology, diagnosis, and treatment—tematic desensitization method developed is the latest phase in the great chain ofthis past century by Joseph Wolpe. Similar- history that exhibits an evolution in mentally, Gustav Fechner, founder of psychophys- science professions from ancient times to theics in the mid-19th century, recognized that new millennium. Intervening developmentsthe human brain is divided into two parallel (both those that have been successful andhemispheres that are linked by a thin band those that have not) were genuine efforts toof connecting fibers (what we now term the understand more fully who we are and whycorpus callosum). According to Fechner’s we behave the way we do. The challengespeculations, if the brain was subdivided, to know who we are is unending, owing toit would create two independent realms of the complexity of human functioning. Newconsciousness—a speculation confirmed concepts come to the fore each decade, andand elaborated in the latter part of this past questions regarding established principlescentury by Roger Sperry, in what has been are constantly raised. Perhaps in this newreferred to as “split-brain research.” century we will bridge the varied aspects of Every historical period was dominated by our poignant yet scientific understanding ofcertain beliefs that ultimately won out over psychopathology, as well as bring the diversepreviously existing conceptions while re- traditions of the past together to form a sin-taining elements of the old. As the study of gle, overarching synthesis.mental science progressed, different and fre-quently insular traditions evolved to answerquestions posed by earlier philosophers, ancient historyphysicians, and psychologists. Separate dis-ciplines with specialized training procedures Primitive humans and ancient civilizationsdeveloped. Today divergent professional alike viewed the unusual and strange withingroups are involved in the study of the mind a magical and mythological frame of refer-(e.g., the neuroscientifically oriented psychi- ence. Behavior that could not be understoodatrists, with a clear-eyed focus on biological was thought to be controlled by animisticand physiological processes; the psychoana- spirits. Although both good and evil spir-lytic psychiatrists, with an austere yet sensi- its were conjectured, the bizarre and oftentive attention to unconscious or intrapsychic frightening behavior of persons with men-processes; the personological psychologists, tal disorders led to a prevailing belief thatwith the tools and techniques for appraising, demon spirits must inhabit them. The pos-measuring, and integrating the mind; and the session of evil spirits was viewed as a punish-academic psychologists, with a penchant for ment for failing to obey the teachings of theempirically investigating the basic processes gods and priests. Fears that demons mightof behavior and cognition). Each group has spread to afflict others often led to cruel andstudied the complex questions generated by barbaric tortures. These primitive “thera-mental disorders with a different focus and pies” of shock, starvation, and surgery haveemphasis. Yet the central issues remain the parallels in recent history, although the an-same. By tracing the history of each of these cients based them on the more grossly naiveand other conceptual traditions, we will conception of demonology.
a précis of psychopathological history 5 What has been called the sacred approach tress. Within this worldview, eccentric or ir-in primitive times may be differentiated into rational individuals were assuredly touchedthree phases, according to Roccatagliata by spirits who possessed superhuman pow-(1973): “animistic,” “mythological,” and ers to induce psychic pathology. Almost all“demonological.” These divergent para- groups permitted healing to fall into thedigms shared one point of view: that psy- hands of priests and magicians—a situationchopathology was the expression of tran- that still exists today in some societies. Liv-scendent magical action brought about by ing in a world populated with imaginary be-external forces. The animistic model was ings, these spiritual forces could often calmbased on pre-logical and emotional reason- the worst human anxieties and expunge theing derived from the deep connection be- ever-present terrors of life. Despite extensivetween primitive beings and the mysterious archeological analyses, however, our knowl-forces of nature. From this viewpoint, events edge of primitive times is no more than frag-happened because the world was peopled by mentary. Nevertheless, we may assume thatanimated entities driven by obscure and in- primitive humans saw a world populatedeffable forces that acted upon human minds with spirits that were essentially illusionsand souls. The second phase, that character- created by their own state of anguish andized by mythological beliefs, transformed perplexity.the animistic conception so that indistinctand indefinable forces were materialized into India, Babylonia, and chinamyths. Every fact of life was imbued with thepowers of a particular entity; every symp- Many contributions of the early Hindus aretom of disorder was thought to be caused by associated with the name of Susruta, whoa deity who could, if appropriately implored, lived 100 years before Hippocrates. Hisbenevolently cure it. In the third, or demon- works followed the traditional beliefs of hisological phase, the transcendent mythologi- day regarding possible demonic possession.cal deities were placed into a formal theo- However, Susruta suggested that the pas-logical system such as the Judeo- Christian. sions and strong emotions of those mentalIn line with this latter phase, two competing disorders might also bring about certainforces struggled for superiority: one creative physical ailments calling for psychologicaland positive, represented by a good father help (Bhugra, 1992). Anticipating the sig-or God; the other destructive and negative, nificance of temperament or innate disposi-represented by the willful negation of good tions, Hindu medicine proposed that threein the form of demonic forces of evil. These such inclinations existed: wise and enlight-three conceptions followed each other his- ened goodness, with its seat in the brain;torically, but they did overlap, with elements impetuous passions, the sources of the plea-of one appearing in the others at times. sure and pain qualities, with their seat in the Many aspects of prehistoric life could chest; and the blind crudity of ignorance, thenot be understood; magic and supernatural basis of more animalistic instincts, its seatconcepts helped early humans make sense located in the abdomen.out of the unfathomable and unpredictable. A concern with mental health has longWeighted with life’s painful realities and been a part of Indian cultures, whichburdensome responsibilities, these beliefs evolved various ways of attempting to un-gave an order and a pseudo-logic to fears derstand and negotiate mental disorder andof the unknown—a repository of unfalsifi- psychological problems. Indians have longable assumptions in which the supernatural been involved in constructing explanatoryfilled in answers for that which could not techniques. In the first formal system ofbe understood. Ultimately, supernaturalism medicine in India, Ayurveda (The Book ofbecame the dominant world view in which Life), physical and mental illnesses were notthe perplexing experiences of life could be clearly demarcated. Caraka Samhita dealtobjectified and comprehended. Priests and with medical diagnoses and managementwizards became powerful, capitalizing on possibly dating from 600 B.C. and was thethe fears and peculiarities of the populace to foremost text of the ancient Indian medicalundo spells, “heal” those with physical ill- system. Caraka defined ayu (life) as a statenesses, and “purify” those with mental dis- consisting of shareera (body), indriya (sens-
6 historiCal anD CUltUral perspeCtiVeses), satva (psyche), and atma (soul). Soul stars produced many gods, a result largelycould not be destroyed, and it underwent of their intellectual leaders’ fertile imagina-reincarnation. The mind was responsible for tions. Help from the gods was often soughtcognition, and it directed the senses, con- through magical rites, incantations, prayers,trolled the self, reasoned, and deliberated. and the special powers of those who wereThe equilibrium between the self and mind physicians or priests. The Babylonians as-was viewed as paramount to good health. signed a demon to each disease; insanity,Caraka used the general term doshas for for example was caused by the demon Idta.the body fluids or humors, vata, pitta, and Each was to be exorcised through specialkapha. The theory of doshas may have de- medicines (primarily herbs and plants), con-veloped independently of the Greek humoral fessions, and other methods to help restoretheory, or possibly the Hindu system may a balance between conflicting supernaturalhave traveled to Greece. Types of food were forces. As the Babylonians saw it, invariablethought to influence the mind, personality tensions existed among the different gods—characteristics, and the interactions among but, more importantly, between a more orthe three doshas. Different personality types less rational, as opposed to a superstitious,were described in detail as leading to men- explanation of psychic ailments.tal illness, through either unwholesome diet The first medical book in China, Neijingor moral transgressions. In the Hindu sys- (The Canon of Internal Medicine), was com-tem, mental disorders were seen as largely piled between 300 B.C. and 100 B.C. Organicmetaphysical, but different appearances of syndromes, like epileptic seizures (dian) andmental disorders (like unmada, insanity) delirium-like states, were also described, butwere described as resulting from heredity, with no clear distinction from the conceptsimbalanced doshas, temperament, inappro- of insanity and psychosis (kuang). The pri-priate diet, and metapsychological factors. mary causes of psychiatric illness were sug-Caraka also contained many descriptions of gested to be vicious air, abnormal weather,possession states regarded as arising from and emotional stress. The famous doctorsupernatural agents—a belief that is still Zang Zhongjing, the Hippocrates of China,apparent in many parts of highly religious introduced other concepts and syndromes,Indian society. Religious connotations and such as febrile delirium, globus hystericus,references to spiritual enlightenments were and puerperal psychosis, in his Jinkuiyaolueonly challenged in the early 19th century by (A Sketchbook in a Golden Box). Chinesethe emerging Western-science-based medi- medicine has tended to explain pathologycine introduced by British rulers. In India, change by means of philosophical concepts,colonial medical institutions became brick- and this framework has undergone littleand-mortar symbols of Western intellectual change. It includes the notions of the comple-and moral power, with European doctors mentary yin and yang; the five elements, gold,even being taken as the sole excuse for em- wood, water, fire, and earth; and the prin-pire. Indian magical practices and religious ciple of Tao (i.e., the way), which has beencustoms have been marginalized to some ex- considered as the ultimate regulator of thetent, but a variety of shamans—whose ther- universe and the most desirable state of well-apeutic efforts combine classical Indian al- being and longevity achieved by integratingchemy, medicine, magic, and astrology with the individual self into the realm of nature.beliefs and practices from folk and popular These ontological principles were describedtraditions—are still present. in The Yellow Emperor’s Classic of Inter- In the Middle East was the ancient civi- nal Medicine some 20 centuries ago (Liu,lization of Babylonia; it was not only a 1981). Different personality types were por-vast geographical expanse, but the founda- trayed as resulting from combinations of thetion of philosophical thought for most na- five elements (e.g., the fiery type, the earthytions in the Mediterranean region. In fact, type, the golden type, and the watery type).many of the traditions discussed among the Phenomena occurring inside human beingsGreeks and Romans can be traced to ideas were understood in terms of phenomena oc-generated initially in the Babylonian empire. curring outside in nature. Chinese medicineBabylonians were oriented toward astro- later became organ-oriented; that is, everynomical events; superstitions regarding the visceral organ was believed to have charge of
a précis of psychopathological history 7a specific function. The heart was thought to “uterus”) was caused, as the Egyptians sawhouse the mind, the liver to control the spiri- it, by a wandering uterus that had driftedtual soul, the lung the animal soul, the spleen from its normal resting location; the task ofideas and intelligence, and the kidney vitality the physician was to bring the uterus back toand will. No attention was paid to the brain! its normal setting. This explanation for hys-For a long time psychiatric symptoms were teria continued until the late Middle Ages.interspersed with those of physical disease. In the earliest periods of Greek civilization,The mind–body dichotomy was not a central insanity was considered a divine punishment,theme. Mood disturbances and psychiatric a sign of guilt for minor or major transgres-symptoms attributed to menstrual irregu- sions. Therapy sought to combat madness bylarities tended to be expressed in somatic various expiatory rites that removed impuri-terms. In Chin-Yue’s Medical Book, the Chi- ties, the causes of psychic disorders. Priestsnese word for “depression” literally meant mediated an ill person’s prayers to the gods“stagnation,” implying obstruction of vital so as to assure his or her cure. Thus, withair circulation in the body. Case vignettes of divine help, the person’s heart could be puri-patients with “deceiving sickness” (i.e., hys- fied of its evil. Albeit slowly, Greek schol-terical neurosis) were presented in the same ars realized that little of a rational naturebook explaining symptom formation in peo- characterized their way of thinking aboutple trapped in very difficult situations. In a mental pathology. To them, external butsimilar way, sexual impotence was explained unseen agents could no longer serve as aby excessive worry. In summary, psychiatric logical basis for a genuine understanding ofconcepts of mental illness in China have un- mentally troublesome phenomena. A funda-dergone basically the same sequence as in mental shift began to take place, not merelythe West: supernatural, natural, somatic, in the manner in which different types ofand psychological stages. However, Chinese mental disorders might be described, but inmedicine has been relatively less influenced the basis for thinking about ways to alterby religious thoughts compared than early these aberrant behaviors. In order to “treat”European medicine was; patients in Eu- mental disorders, the Greeks began to recog-rope in the Middle Ages were declared by nize the necessity of understanding how andpriests to be bewitched and were punished. why mental disorders were expressed in theAcupuncture, traditional Chinese medicine, natural world; only then could they success-folk herbs, and psychotherapy have been the fully deal therapeutically with the tangiblemost commonly used treatment approaches symptoms of everyday mental life. Instead ofin China. leaving the treatment of mental disorders to the supernatural and mystical, they began to develop a more concretely oriented perspec-egypt, greece, and rome tive. This transition was led by a number ofIn Egypt, as in other early civilizations, there imaginative thinkers in the 5th and 6th cen-is evidence that the heart was thought to be turies B.C.the center of mental activity. Egyptians also A central intellectual effort of Greek phi-had difficulty in separating prevailing super- losophers was the desire to reduce the vast-natural beliefs from beliefs about things that ness of the universe to its fundamental el-could be observed and modified in nature. ements. Most proposed that complexitiesAstronomical phenomena were the primary could be degraded to one element—be itobjects of worship. “Natural” qualities were water, air, or fire. Their task was to iden-usually turned aside in favor of the mysti- tify the unit of which all aspects of thecal powers of the gods. Over the course of a universe were composed. Among the firstcentury or two, Egyptian philosophers and philosopher-scientists to tackle this task wasphysicians began studying the brain, ulti- Thales (652–588 B.C.). What little we knowmately recognizing it as the primary source of Thales comes largely from the writings ofof mental activity. Egyptians recognized later Greek philosophers, notably Aristotle,that emotional disorders could be described Plato, and the historian Herodotus. Thisin line with ideas proposed by the Greeks. nimble-witted Greek proposed that the fun-Thus the set of disturbances the Greeks damental unit of the universe was a tangibletermed “hysteria” (using their word for and identifiable substance, water.
8 historiCal anD CUltUral perspeCtiVes Though Thales was not the prime fore- Pythagoras considered mental life asrunner of a modern understanding of mental reflecting a harmony between antitheti-processes, he was a radical thinker who re- cal forces: good–bad, love–hate, singular–directed attention away from mysticism, rec- plural, limited–unlimited, and so on. Lifeognizing that psychic disorders were natural was regulated according to his conception ofevents that should be approached from a sci- opposing rhythmic movements (e.g., sleep–entific perspective. As a pivotal figure in his wakefulness, inspiring– expiring). Mentaltime, he ushered in an alternative to earlier disorders reflected a disequilibrium of thesesupernatural beliefs. Equally significant was basic harmonies, producing symptoms ofThales’s view that efforts should be made to psychic impairment. To him, the soul coulduncover underlying principles on which overt rise or descend from and to the body. Thephenomena were based. Oriented toward more the soul was healthy, in balance, andfinding these principles in physical studies without psychic symptoms, the more it re-and “geometric proportions,” he turned to sembled solar energy. Pythagoras spoke of“magnetic” phenomena, convinced that the the soul as composed of three parts: reason,essential element of all life was its animat- which reflected truth; intelligence, whiching properties. To Thales, action and move- synthesized sensory perceptions; and im-ment, based on balanced or disarrayed mag- pulse, which derived from bodily energies.netic forces, was what distinguished human The rational part of the soul was centeredfrailty. In this belief, he further derogated in the brain; the irrational one, in the heart.the view that external supernatural forces Incidentally, Pythagoras coined the termintruded on the psyche; rather, the source “philosophy” by putting together the wordsof pathology was inherent within persons philo, meaning “love,” and sophia, meaningthemselves. “wisdom.” Paralleling the views of Thales, Pythago- Ostensibly through his father, Apollo,ras (582–510 B.C.) reasserted the importance Aesculapius (ca. 550 B.C.) gained his under-of identifying the underlying scientific prin- standing of the nature of mental disordersciples that might account for all forms of be- through the divination of dreams, which hehavior. He differed from Thales in that he then transmitted to his sons, Machaon andretrogressively preferred to use ethics and Podaleirius. A series of followers, called Aes-religion as the basis for deriving his scientific culapians, established long- enduring “medi-principles. More progressively, however, he cal temples” and a distinguished cult. It iswas the first philosopher to claim that the unclear historically whether Aesculapiusbrain was the organ of the human intellect, actually existed or whether his ideas shouldas well as the source of mental disturbanc- properly have been attributed to Pythagoras.es. He adopted an early notion of biologi- As the Aesculapian cult spread throughoutcal humors (i.e., naturally occurring bodily the Greek empire, numerous temples wereliquids), as well as positing the concept of erected in the main cities of the Mediterra-emotional temperament to aid in decoding nean basin, including Rome in 300 B.C.the origins of aberrant passions and behav- What may be best known about Aescula-ior. The mathematical principles of balance piad temples today is the symbol of medi-and ratio served to account for variations cal knowledge they employed: a serpentin human characterological styles (e.g., de- wrapped around a rod. Medicine graduallygrees of moisture or dryness, the proportion evolved into a branch of philosophy in theof cold or hot, etc.). Balances and imbal- 6th and 7th centuries B.C. No one of thatances among humoral fundamentals would early period achieved the mythic statureaccount for whether health or disease was of Aesculapius, however—the presumedpresent. Possessing a deep regard for his founder of temple-based hospitals designed“universal principles,” Pythagoras applied to execute the healing traditions in whichhis ideas to numerous human, ethical, and he believed, notably a rest from life’s stres-religious phenomena. Though he believed in sors and opportunities for positive mentalimmortality and the transmigration of souls, growth. Located in peaceful and attractivethis did not deter him from making a serious settings, these temples were established toeffort to articulate the inner “equilibrium” encourage patients to believe that there wereof human anatomy and health. good reasons to want to recover. Included
a précis of psychopathological history 9among the temples’ treatment techniques cesses such as attraction and repulsion. All ofwere a balanced diet, a daily massage, quiet the elements/humors could be combined, butsleep, priestly suggestions, and warm baths, Empedocles wondered what the consequenc-all of which were thought to comfort and es would be if they were organized in dif-soothe patients. ferent ways. He set out to weave the several Also of value during this early period was threads of his theory and concluded that thethe work of Alcmaeon (557–491 B.C.), pos- force of attraction (love) would be likely tosibly a son or favorite student of Pythagoras, bring forth a harmonic unity, whereas repul-carried out in the 5th century B.C. Alcmaeon sion (strife) would set the stage for a personalbecame a philosopher-physiologist who as- breakdown or social disintegration.serted that the central nervous system was To Empedocles, blood was a perfect rep-the physical source of mental activity, and resentation of an equal mix of water, earth,that cerebral metabolism was based on the air, and fire. He therefore suggested thatstability of “the humoral fluxes”; if these persons with problematic temperaments andfluxes were imbalanced or unstable, they mental disorders would exhibit imbalanceswould create shifts in cerebral tissue func- within their blood. Among his other contri-tioning, leading then to various mental dis- butions, Empedocles posited a rudimentaryorders. Metabolic fluxes were caused by a model of an evolutionary theory, anticipat-disequilibrium between the nervous system’s ing Darwin’s by 2,000 years. As he phrasedqualities of dry–moist and hot–cold. it, “creatures that survive are those whose Most notable were Alcmaeon’s efforts to blood elements are accidentally compound-track the sensory nerves as they ascended ed in a suitable way,” whereas a problematicto the brain. He articulated, as perhaps no compounding will produce “creatures thatone else before him had done, the structural will perish and die.” To him, nature cre-anatomy of the body through methods of ated a wide variety of healthful and perish-careful dissection. No less significant was ing blood configurations—that is, differenthis conviction that the brain, rather than the ways in which the four elements combined.heart, was the organ of thought. As Aescu- Some philosophers disagreed with the no-lapius reportedly did, he also anticipated the tion that the universe was composed of awork of Empedocles and Hippocrates, in that simple and permanent element. Heraclitushe believed that health called for a balance (530–470 B.C.), for example, proposed thatamong the essential components of life— all nature was made up of fire. He asserted,coolness versus warmth, wetness versus dry- however, that the universe was composed ofness, and so on. The notion of fundamental no lasting substance— nothing stable, solid,elements in balance became a central theme or enduring. All real and tangible thingsin the work of Aesculapius and Alcmaeon; would inevitably vanish, change their form,it also served to guide the views of their dis- even become their very opposites.ciples. Alcmaeon’s “biological model” based In a similar manner, Anaxagoras (500–on the concept of metabolic harmony, called 428 B.C.) asserted that a reduction to the basic“isonomy,” took the place of Greek’s early elements could not explain the universe. Hemythological theology and was an extension differed from Heraclitus in that he did notof the growing secular and democratic spirit believe the universe lacked an enduring sub-of Greek’s 6th- century B.C. culture. stance. He asserted that an endless number Empedocles (495–435 B.C.) adopted the ho- of qualitatively different elements existed,meostatic model generated in the work of Py- and that the organization or arrangementthagoras, Aesculapius, and Alcmaeon. Most of these diverse elements was central to thesignificant was his proposal that the basic structure of the universe. Anaxagoras’s be-elements of life (fire, earth, air, and water) lief that the character of these constituentsinteracted with two other “principles” (love could not be explained except through thevs. strife). Empedocles stressed that a bal- action of human thought was novel—a viewance among the four elements could be com- similar to one asserted many centuries laterplicated by the fact that they might combine by the phenomenologists and the gestaltists,in either a complementary or a counteractive who claimed that the structure of objectiveway. Love and strife represented human ex- matter was largely in the interpretive eye ofpressions of more elementary magnetic pro- the perceiver.
10 historiCal anD CUltUral perspeCtiVes Later the philosopher Democritus (460– stitions of temple medicine. The astuteness362 B.C.), following Leucippus (ca. 445 B.C.), and prodigious work of Hippocrates high-proposed that the universe was made of lighted the naturalistic view that the sourcevariously shaped atoms—small particles of of all disorders, mental and physical alike,matter in constant motion, differing in size should be sought within the patient and notand form, but always moving and combin- within spiritual phenomena. For example,ing into the many complex components that the introductory notes to the Hippocraticcomprise the universe as we know it. This book on epilepsy state:innovative speculation endures to the pres-ent time. Extending the theme proposed a It seems to me to be no more divine and nocentury earlier by Anaxagoras, Democritus more sacred than other diseases, but like otherstressed the view that all truths were relative affections, it springs from natural causes. . . . Those who first connected this illness with de-and subjective. As noted, he asserted that mons and described it as sacred seem to mematter was composed of numerous invisible no different from the conjurers, purificators,particles called atoms. Each atom was com- mountebanks and charlatans of our day. Suchposed of different shapes that combined and persons are merely concealing, under the cloakwere linked in numerous ways; again, al- of godliness, their perplexity and their inabil-though this idea was based on pure specula- ity to afford any assistance. . . . It is not a godtion, it was highly innovative and is regarded which injures the body, but disease.as essentially correct to this day. The physi-cal thesis of contemporary times known as As a number of his progenitors had done,the Heisenberg principle also has its origins Hippocrates emphasized that the brain wasin Democritus’s speculation. the primary center of thought, intelligence, A contemporary of Democritus, born the and emotions. It is only from within thesame year, became the great philosopher- brain, he asserted, that pleasures and joysphysician who set the groundwork for so- and laughter arise, as well as sorrows, griefs,phisticated clinical medicine for the ensu- and tears. It is, he went on to say, this verying centuries. The fertility of this wondrous same source that makes us mad or delirious,period of Grecian thought cannot be over- inspires us with dread and fear, and bringsestimated, ranging from the brilliant ideas sleeplessness, inopportune mistakes, aimlessof Democritus and Aristotle to the creative anxieties, absentmindedness, and other actsfoundations of scientific medicine by Hip- contrary to the person’s habitual ways. Allpocrates. of these stem from the brain when it is not Hippocrates (460–367 B.C.; see Figure1.1) was born on the island of Cos, the cen-ter of an ancient medical school. He was theson of an Aesculapian priest, from whom heacquired his first medical lessons and whosephilosophy he would follow in his own futuretherapeutic efforts. In the work of Hippo-crates—the inheritor of his father’s traditionand the humoral concepts of Pythagoras andEmpedocles— mental disorders progressedfrom the magical and mythical realm, andthe demonological and superstitious thera-peutic approaches of an earlier era, to oneof careful clinical observation and inductivetheorizing. He synthesized the practical andsympathetic elements of the Aesculapiancult with the more “biological” proposalsof Pythagoras, blending these elements to el-evate mental processes and disequilibria intoa clinical science. Thus in the 5th century B.C., truly radicaladvances were made to supplant the super- FIgure 1.1. Hippocrates.
a précis of psychopathological history 11healthy (i.e., as when an imbalance exists be- They adhered closely, however, to the firsttween hot and cold or moist and dry). nonsupernatural schema that specified tem- Hippocrates’s approach was essentially perament dimensions in accord with theempirical, despite the growing eminence of doctrine of bodily humors. Interestingly,philosophical thought that characterized history has come full circle, in that much ofhis time. He was a practical biologist stress- contemporary psychiatry continues to seeking the role of bodily humors and focusing answers with reference to inner biochemicalon the use of physical treatments (notably and endocrinological processes.diet, massage, music, and remedies promot- Hippocrates identified four basic tempera-ing sleep and rest) rather than philosophical ments: the “choleric,” the “melancholic,” theones. Central to the medical practices of Hip- “sanguine,” and the “phlegmatic.” Thesepocrates and his followers was the crucial corresponded, respectively, to excesses inrole given keen observation and fact gath- yellow bile, black bile, blood, and phlegm.ering. Contrary to the work of Plato, who As elaborated by a Roman, Galen, centuriesrelied on abstract hypotheses and so- called later, the choleric temperament was associ-self-evident truths, Hippocrates focused his ated with a tendency toward irascibility; theattention on observable symptoms, their sanguine temperament prompted an individ-treatments, and their eventual outcomes. In ual toward optimism; the melancholic tem-this regard, Hippocrates modeled Aristotle’s perament was characterized by an inclinationempirical orientation, emphasizing facts toward sadness; and the phlegmatic temper-rather than abstractions. ament was conceived as an apathetic dispo- As were a number of his forebears, Hip- sition. Although the doctrine of humors haspocrates was convinced that dreams could long been abandoned, giving way to studiesserve as indicators of health or illness. Men- on topics such as neurohormone chemistry,tal pathology stemmed from a disparity be- its archaic terminology still persists in con-tween the content of dreams and that which temporary expressions such as persons beingexisted in reality. Dream symbolism, as re- “sanguine” or “good-humored.”garded by Hippocrates, led him to anticipate Hippocrates and his Cos associates werelater hypotheses concerning the operation of among the first to stress the need for a re-“unconscious forces.” lationship between diagnosis and treatment. Hippocrates also established the tradition The mere description of a clinical distur-of carefully recording personal case history, bance was not sufficient for them, unless itdetailing the course and outcome of the dis- provided a clear indication of the course thatorders he observed. These histories provide therapy should follow. Indeed, Hippocratessurprisingly accurate descriptions of such anticipated that much effort may be wastedvaried disorders as depression, phobias, in specifying diagnosis, unless followed byconvulsions, and migraine. With his associ- a consideration of its utility for therapeuticates at the Cos College of Medicine in Ath- decisions. Although naive in conception andens, he provided a logic for differentiating execution, Hippocrates’s approach to thera-among various mental ailments—not only py followed logically from his view that dis-those we now label the DSM-IV-TR Axis I orders were of natural origin. To supplantsyndromes, but also the Axis II personality the prevalent practices of exorcism andtypes, the latter of which were construed as punishment, he recommended such variedabnormalities of temperament. Temperament prescriptions as exercise, tranquility, diet,was associated with the four-humors model, venesection or bloodletting where neces-which transformed earth, fire, water, and air sary, and even marriage. Systematically (ininto their parallel bodily elements. Individu- a contemporaneous sense), Hippocrates andals were characterized in terms of which one his colleagues devised a series of therapeuticof the four elements predominated. Among regimens that they believed would reestab-other clinical syndromes differentiated were lish the humoral balance thought to underliedelirium, phobia, hysteria, and mania. Lack- most diseases; they also employed surgicaling precise observations of bodily structure, techniques such as trephining to relieve pur-and prevented by taboo from performing ported pressure on the brain.dissections, Hippocratic physicians pro- Several themes relevant to the mind andposed hypothetical explanations of disease. its difficulties characterize Plato’s (429–347
12 historiCal anD CUltUral perspeCtiVesB.C.) work: (1) Powerful emotional forces pirical observables in order to minimize thecould come to the foreground and overwhelm risk of subjective misinterpretations. Despitethe everyday behavior typifying a person’s these reservations, Aristotle believed thatlife; (2) conflicts could exist between differ- thought transcended the sensory realm. Asent components of the psyche (e.g., the per- he saw it, imagination could create thoughtssonal discord that often arises between an of a higher order of abstraction than couldindividual’s rational side—that which is de- sensations themselves.sired—and the surge of emotional feelings); Yet not all matters were successfullyand (3) mental disorders did not result from brought within Aristotle’s purview. De-simple ignorance, but from irrational super- spite growing evidence that the brain wasstitions and erroneous beliefs. To Plato, all the center of thought and emotion, Aris-humans were partly animal-like; hence all totle retained the erroneous belief that thehumans acted irrationally at times—some heart served as the seat of these psychologi-more, some less. He found evidence for these cal experiences. He made keen and signifi-conclusions in dreams, where bizarre events cant observations, however, in recognizinginvariably occur and unnatural connections the psychological significance of cognitiveamong thoughts and images are dominant. processes, dreams, and emotional cathar- Not to be overlooked was his contention ses. For example, it was Aristotle who saidthat therapeutic efforts could modify any that events, objects, and people were linkedand all forms of mental illness. For Plato, the by their relative similarity or their relativeuse of educational procedures could dispel difference from one another. To Aristotle,ignorance and uncover “truth” through the things became “associated” if they occurredapplication of fundamental principles. No together; in this, he was clearly a forerunnerless important with regard to therapy was of the associationist school of the 18th andPlato’s use of a dialectical model to change 19th centuries. Aristotle viewed dreams asa patient’s cognitions and belief systems. In afterimages of the activities of the precedingthis regard, Plato’s philosophy provided a day. Although he recognized that dreamsmethodology for engaging in therapy, essen- might fulfill a biological function, he judgedtially the application of rational discussions the content of dreams to be ideal gauges ofto modify faulty cognitions (shades of con- potential pathology. He had a specific inter-temporary cognitive therapies!). est in how physical diagnoses could be de- Plato had many distinguished students, duced from dream content.the most eminent of whom was Aristo- Aristotle’s scope was exceptionally broadtle (384–322 B.C.). Though he was Plato’s and inventive. It was he who wrote most per-student for over 20 years, Aristotle turned ceptively of the intellectual and motivationalsharply away from Plato and toward matters features of the mind from the viewpoint ofmore realistic and tangible than abstract a natural scientist. Thus, in what might beand idealistic. Some would say that Aristotle termed a psychobiological theory, he out-provided history’s first integrated and sys- lined the basics of human perception and ra-tematic accounts not only of psychological tional thought, stressing the importance andmatters, but of astronomy, physics, zoology, validity of sense impressions as the sourceand politics. The last of the great philoso- for an objective form of experimental study.phers of the 4th century B.C., Aristotle was Along the same lines, Aristotle articulated amore scientist than philosopher. He gave series of proposals concerning the nature ofspecial attention to the need for experimen- learning—a model based on the principles oftal verification and the use of sensory-based association and reinforced by what we haveobservable data; in fact, he was the first of come to term the “pleasure principle.” Simi-the major philosophers to take an inductive larly, he emphasized the importance of earlyand empirical approach in his writings. He experience and education in the acquisitionwas interested in the concrete observables of of skills, and the role of habit and practice inexperience as registered through the senses. the formation of psychological attitudes. ToAlthough he admired the abstract rational- him, the processes of development were keyism of Plato, he was much more disposed to themes in understanding human behavior.deal with the tangible world than with high- When Aristotle left Athens in the yearorder abstractions or broad principles. He 322 B.C., following the death of Alexanderbelieved that data should be grounded in em- the Great, he arranged to have his associate
a précis of psychopathological history 13Theophrastus (371–286 B.C.) succeed him as or conflicts, but by the periodic enlargementhead of the Lyceum. Shortly thereafter, Ar- or excessive tightening of the pores in theistotle, alone and despondent over the turn brain. In this corpuscular hypothesis, a de-of political events in Athens, died in exile. rivative of the atomistic notions of Democri-Theophrastus was only a decade younger tus of Greece, the task of the mental healerthan Aristotle and had come to Athens to was to confirm and normalize the diameterstudy with Plato. He and Aristotle had been of the pores. Persons with certain mental ill-friends, joined together in their travels and nesses were seen as apathetic, fearful, andshared in their study of nature. Theophras- in a depressed mood, by what was called atus remained head of the Lyceum for some laxum state. Those with other disorders pre-30 years. Perhaps most significant was the sented an excited, delirious, and aggressiveattention Theophrastus paid to the study of appearance; they were in a strictum state.botany, establishing him as the true founder If both sets of these symptoms co-occurred,of that science, just as Aristotle’s works es- there was a mixtum state.tablished the field of zoology. A follower of the vitalist school of thought A prolific and sophisticated thinker, Theo- that adopted the concept of pneuma, thephrastus wrote no less than 220 treatises on natural or animal spirit, as the physical em-a variety of different topics. Although this bodiment of the soul, Aretaeus (30–90 A.D.)diversity of work was substantial, he became was little known in his time and was rarelybest known for a secondary aspect of his ca- quoted by fellow Roman scholars. This wasreer, the writing of personality sketches he probably owing to the fact that his workscalled “characters.” Each of these portray- were written in the Ionic dialect rather thanals emphasized one or another psychologi- in Latin or Greek. Furthermore, his vital-cal trait, providing a vignette of various per- istic philosophy, based on the fluidity ofsonality “types” (e.g., individuals who were the soul’s nature, and adopted by Galen aflatterers, garrulous, penurious, tactless, century later, rivaled the more atomistic orboorish, surly, etc.). solidistic corpuscular theory of his contem- Whether these portrayals were penetrat- porary Roman thinkers. Scarcely familiaring or poignant, Theophrastus (as well as with the Greek language and its medicallater novelists) was free to write about his philosophies, Aretaeus was a born cliniciansubjects without the constraints of psy- who was retained as a physician for the rul-chological or scientific caution. Such lively ing Roman classes.and spirited characterizations most assur- According to Aretaeus, the vicissitudes ofedly captured the interest of many, but they the soul served as the basis of psychic dis-could also often mislead their readers about turbances. Specifically, the interconnectingthe true complexities of natural personality linkages among “solid organs, the humours,patterns. and the pneuma” generated all forms of Although the beginning and ending of the mental aberration. For example, anger andRoman period cannot be sharply demarcat- rage stirred the yellow bile, thereby warminged, it basically spanned a 12-century period the pneuma, increasing brain temperature,from the 7th century B.C. to the 5th century and resulting in irritability and excitabil-A.D., when the last of the major Roman em- ity. Conversely, fear and oppression stirredperors was deposed. As a formal organiza- black bile, augmenting its concentration intion, the Roman Republic dated from the the blood, and thus leading to a cold pneu-5th century B.C. to the 3rd century A.D. ma and consequent melancholy. The more cultured classes of Rome were Disturbances of consciousness usually re-determined to eliminate magic and supersti- sulted from the sudden diminishing of thetion as elements in considering psychic pro- strength of the pneuma around the heart.cesses. A mechanistic conception of mental Aretaeus’s descriptions of epilepsy were no-disorders came to the foreground; it was tably impressive. He spoke of its premoni-fundamentally materialistic and opposed to tory symptoms, such as vertigo and nausea,all transcendental mythologies, which were the perception of sparks and colors, and theregarded as superstitious beliefs that origi- perception of harsh noises or nauseatingnated from fear and ignorance. Mental dis- smells. Aretaeus also described the originsorders were caused not by the action of mys- and characteristics of fanaticism; he for-terious forces, nor by biohumoral movements mulated a primitive psychosomatic hypoth-
14 historiCal anD CUltUral perspeCtiVesesis in stating that emotions could produce acteristics of his patients, contending that aproblematic effects on humoral metabolism, clear demarcation could be made betweennoting that “the black bile may be stirred by the basic personality disposition of a patientdismay and immoderate anger.” Similarly, and the form in which a symptomatic andhe formulated what we speak of as cyclothy- transient disorder manifested itself periodi-mia in describing the alternation of depres- cally.sion with phases of mania. He stated, “Some No less important was Aretaeus’s speci-patients after being melancholic have fits of fication of the premorbid conditions of pa-mania . . . so that mania is like a variety of tients; he viewed these conditions as forms ofmelancholy.” In discussing the intermittent vulnerability or susceptibility to several clin-character of mania, he recognized its several ical syndromes. As Aretaeus phrased this,variants, speaking of one type as arising in he found that persons disposed to mania aresubjects “whose personality is characterized characteristically “irritable, violent, easilyby gayness, activity, superficiality, and child- given to joy, and have a spirit for pleasantryishness.” Other types of mania were more or childish things.” By contrast, those proneexpansive in which the patient “feels great to depression and melancholia were seen asand inspired. Still others become insensitive characteristically “gloomy and sad often. . . and spend their lives like brutes.” realistic yet prone to unhappiness.” In this Perceptive observations by Aretaeus manner, Aretaeus elaborated those essen-strengthened the notion of mental disorders tially normal traits that make an individualas exaggerated normal processes. He assert- susceptible to a clinical state. As Zilboorged that a direct connection existed between and Henry (1941) have noted, the melancho-an individual’s normal characteristics of per- lia of Aretaeus is still observed in our time,sonality and the expression of the symptoms although under different psychiatric labels.the individual displayed when afflicted. His Owing to his observations of patients overinsightful differentiation of disorders ac- extended periods of time, Aretaeus proposedcording to symptom constellations (i.e., syn- a series of predictions about the general out-dromes) was a striking achievement for his comes of different mental conditions. Moreday. than other physicians of his day, Aretaeus Although Hippocrates may have been the not only described psychological conditionsfirst to provide a medical description of de- with keen sensitivity and humane under-pression, it was Aretaeus who presented a standing, but (in a spirit more akin to recentcomplete and modern portrayal of the dis- scientific work) sought to compare variousorder. Moreover, Aretaeus proposed that clinical syndromes and illuminate ways inmelancholia was best attributed to psycho- which they could be differentiated.logical causes (i.e., that it had nothing to do Claudius Galenus (Galen) (131–201; seewith bile or other bodily humors). As noted, Figure 1.2) was the last major contributor tohe may have been the first to recognize the adopt a psychological perspective in Rome.covariation between manic behaviors and He preserved much of the earlier medicaldepressive moods, antedating the views of knowledge, yet generated significant newmany clinical observers in the 16th and 17th themes of his own. Galen lived more thancenturies. 600 years after the birth of Hippocrates. A Aretaeus was also a major contribu- Greek subject of the Roman Empire, he wastor to the humanistic school of thought in born in Asia Minor about 131 A.D. Duringearly Rome. Most notably, he introduced his mature years, numerous radical politicallong-term follow-up studies of patients. He and cultural changes took place in Rome.tracked their lifetime course, their periodic Galen and his medical associates set out todisease manifestations, and their return to synthesize primitive conceptions of diseasea more normal pattern of behavior; in this with then-modern methods of curing theregard, he anticipated the authoritative writ- sick. Following the ideas of Hippocrates, heings of Emil Kraepelin, who recognized the stressed the importance of observation andcourse of an illness as a key factor in dis- the systematic evaluation of medical pro-criminating a specific disorder from others cedures, arguing against untested primitiveof comparable appearance. He seriously and philosophical hypotheses in favor ofstudied the sequence and descriptive char- those based on empirical test. As a follower
a précis of psychopathological history 15 whose damaging effects would cause neuro- logical symptoms; and those that had more directive functions, such as coordinating and organizing imagination, reason, and memo- ry. To him, most psychiatric symptomatol- ogy stemmed from alterations of the second group of functions. In describing catatonic psychosis, Galen suggested a paralysis of the animal spirits in which the imaginative faculty was “blocked or incomplete.” As far as the syndrome of hysteria was concerned, he disagreed strong- ly with Hippocrates’s uterocentric view. Galen asserted that hysteria, on the basis of his own clinical examinations, could not be a disease that reflected the uterus “wander- ing agitated in the body.” As he saw it, hys- terical symptoms were provoked by the toxic action of vapors that formed in the normal FIgure 1.2. Galen. uterus and vagina; it arose from the stagna- tion of semen, owing to a lack of sufficient sexual intercourse. The disease therefore sig-of Aristotle as well as Hippocrates, Galen nified a lack of sexual hygiene.emphasized the data of experience, rather Galen’s stature grew over the next mil-than logical hypotheses that were devoid of lennium—so much so that his views werefactual evidence. Unfortunately, he doubted thought to be sacrosanct. His writings werethat environmental and psychological fac- summarized and commented on by manytors could affect the course of human dis- lesser physicians, most of whom were recog-ease. Although Galen avoided philosophical nized as being wrong-headed; indeed, theirthemes concerning the nature of illness, he books were often referred to as “wretchednevertheless proposed a principle termed treatises.” Some of these post-Galen compi-spiritus anima, in which he asserted that hu- lations were not based on his work at all, butmans possessed an extraphysical life-giving dishonestly carried his name for its ability toforce; this thesis was based on his efforts to promote the sale of untenable or alien ideas.distinguish organic from inorganic matter. Although many of his notions were diluted Galen’s conception of psychic pathology by the passage of time or refuted by empiri-was based on the physiology of the central cal knowledge, his vast contributions mustnervous system. He viewed clinical symp- be considered significant, in that no othertoms as signs of dysfunctional neurological figure in history exercised so extended anstructures and characterized mental dis- influence on the course of medicine.eases as “a concourse of symptoms,” among Later in Roman history, there emerged anwhich a specifically pathognomonic one organized theology known as Christianity,could be isolated. According to his organic- including faith healing, magic, and super-functional approach, mental symptoms orig- stition. The doctrine of the early Christianinated from the pathogenic action of a toxic, church became the dominant approach tohumoral, vaporous, febrile, or emotional thought, medicine, and mental healing infactor that affected the brain physically the Western world until the 17th century.and then altered certain of its psychic func- Most of the populace remained illiteratetions. Consonant with the beliefs of his time, during this period. Education was religious,Galen believed that the activities of the mind otherwise inchoate, and of dubious value.were prompted by animal spirits that carried The idea of a scientific basis for understand-out both voluntary and involuntary actions. ing mental disorders barely appeared on theThese animalistic spirits (pneuma) were di- scene. Faith was the all-powerful guide.vided by Galen into two groups: those that During the first two to three centuriescontrolled sensory perceptions and motility, A.D., a distinction was made between psy-
16 historiCal anD CUltUral perspeCtiVeschologically normal individuals who doubt- end of the first millennium A.D. are worthyed the dogma of the church’s ideology, and of note: Rhazes, Unhammad, and Avicen-those whose “peculiar” beliefs arose not na. Each proposed helpful ideas that cameout of opposition, but out of a mental af- to represent a fresh and innovative point offliction. Nevertheless, both groups were view concerning mental illness.considered guilty of heresy and subjected to Rhazes (860–930) lived during the latepunishment. In a similarly irrational twist, 9th and early 10th centuries and wroteothers’ implausible or nonsensical behavior textbooks dealing with a wide variety ofostensibly demonstrated their fervent adher- medical, psychological, philosophical, andence to church authorities and their dogma. religious subjects. In contrast to the pre-Such persons were venerated. It was not long dominant religious orientation of Baghdad,thereafter that the works of Aristotle and Rhazes strongly argued against the notionother Greek philosophers were condemned. of a demonological concept of disease and Christianity in the 3rd century led physi- the use of arbitrary authority to determinecians to assume a moralistic and judgmental what is scientific and what is not. He at-approach to psychic pathology. Unable to tacked the superstitious religious beliefs ofescape the growing spirit of superstitious- his contemporaries and was strongly in favorness, they proposed that mental cases were of developing a rational schema for under-definitely the products of mystical events standing all disorders. Empirically oriented,that could not be understood in the natu- he nonetheless subscribed to the theory ofral world. More seriously, they adopted the the four elements originally developed byancient belief that demons often appeared Empedocles and Hippocrates.under the guise of confused humans, and Unhammad (870–925) was a contem-that it was the job of physicians to identify porary of Rhazes who provided intelligentand to “eliminate” them. In this and other descriptions of various mental diseases. Thesimilar matters, they laid the groundwork observations he compiled of his patients re-for a return to the age of supernaturalism sulted in a nosology that was the most com-and superstitions; they were nevertheless plete classification of mental disorders in itsthought well of until the close of the 17th day. Unhammad described nine major cat-century. egories of mental disorders, which, as he saw Aurelius Augustine (354–430) was a key it, included 30 different diseases. Amongfigure in the transition from early Roman the categories was an excellent descriptionthought to the Middle Ages. Better known of anxious and ruminative states of doubt,as St. Augustine of Hippo, we can see in his which correspond in our thinking todaywritings an effort to synthesize the Greek with compulsions and obsessions. Other cat-and the new Christian perspectives on men- egories of mental disease were judged by Un-tal maladies. Perhaps the most influential hammad to be degenerative in their nature;philosopher of his time, Augustine set the a few were associated with the involutionalfoundation and tone of Christian intellec- period of a man’s life. The term used by thetual life for centuries to come. To him, all Greeks for mania was borrowed to describeknowledge was based on the belief that only states of abnormal excitement. Another cat-God could provide the ultimate truth, and egory, most closely associated with grandi-that to know God was the ultimate goal. ose and paranoid delusions, manifested it-To think otherwise, as Augustine averred, self, according to Unhammad, in the mind’swould not only be vain, but would assuredly tendency to magnify all matters of personallead to error and corruption. Individuals, as significance, often leading to actions thatchildren of God, would in their faith begin proved outrageous to society.to understand the very nature of life, and A most significant and influential philoso-thereby would be able to lead a life of grace pher and physician of the Muslim world wasand honor. Avicenna (980–1037), often referred to as the “Galen of Islam,” largely as a consequence of his vast and encyclopedic work called thethe early Muslim World Canon of Medicine. The Canon became theThree major medical figures from the Mus- medical textbook chosen throughout Eu-lim world of the Middle East around the ropean universities from the 10th through
a précis of psychopathological history 17the 15th centuries. However, Avicenna was demic manias spread throughout other partsnot regarded as a highly original writer, but of Europe, where they were known as St.rather as a systematizer who encompassed Vitus’s Dance.all knowledge from the past that related to During the early Middle Ages, before latermedical events. Similar to Galen, Avicenna catastrophes of pestilence and famine, fewnoted the important connection between people with mental illnesses were totallyintense emotions and various medical and destitute. Monasteries served as the chiefphysiological states, although he fully ac- refuge for such individuals, providing prayer,cepted Hippocrates’s humoral explanations incantation, holy water, relic touching, andof temperament and mental disorder. To mild exorcism as prescriptions for cure. Ashis credit as a sophisticated scholar of the the turmoil of natural calamity grew morebrain, Avicenna speculated that intellectual severe, mental disorders were equated in-dysfunctions were in large part the results of creasingly with sin and Satanic influence.deficits in the brain’s middle ventricle, and Significant advances were made in agricul-asserted that common sense and reasoning ture, technology, and architecture duringwere mediated by the frontal areas of the the Middle Ages, but the interplay betweenbrain. changing theological beliefs and naturalistic catastrophe speeded acceptance of the belief that “madness” and “depravity” were thethe Middle ages devil’s work. At first, it was believed that the devil had seized mentally ill individualsThe enlightened ideas of Hippocrates were against their will, and such individuals weresubmerged for centuries after the death of treated with established exorcistic practices.Galen and the fall of the Roman Empire. Soon, however, the afflicted were consid-During the thousand years of the so- called ered willing followers of Satan; classed nowDark Ages, superstition, demonology, and as witches, they were flogged, starved, andexorcism returned in full force and were fur- burned.ther intensified by sorcery and witch burn- Among the major tenets of this medievaling. With few dissenting voices during this mythology was a belief that an internationalperiod, the naturalism of the Greco-Roman conspiracy, based on Satanic forces, was bentperiod was all but condemned or distorted on destroying all forms of Christianity. Theby notions of magic. Only in the Middle agents of this widespread conspiracy wereEast did the humane and naturalistic aspects witches, who not only worshipped Satan atof Hippocratic thought remain free of the secret meetings, but attempted to desecrateprimitivism and demonology that overcame Christian symbols and beliefs, as well as toEurope. engage in murder, cannibalism, and sexual Signs for detecting demonic possession orgies. The ideas of a demonic and Satanicbecame increasingly indiscriminate in the conspiracy existed first and foremost in theChristian world. During epidemics of fam- imagination of the religious leaders of theine and pestilence, thousands wandered day. It was Pope Gregory IX who establishedaimlessly until their haggard appearance the Inquisition in 1233 to root out witches,and confusion justified the fear that they heretics, and all other agents of Satan, whowere cursed. The prevalent turmoil, the fear he asserted were setting out rapidly to de-of one’s own contamination, and the frenet- stroy the clerical and political orders of theic desire to prove one’s spiritual purity led Church. Those with an administrative statuswidespread segments of the populace to use possessed the legal right to judge which as-these destitute and ill roamers as convenient pects of Satanic witchcraft would be deemedscapegoats. demonic. It was not only higher-order reli- As the terrifying uncertainties of medieval gious leaders who conveyed this dogma; thelife persisted, fear led to wild mysticism and common people took these belief systems tomass pathology. Entire societies were swept heart, as well. From the 15th through theup simultaneously. Epidemic manias of rav- 17th century, demonic possession and exor-ing, jumping, drinking, and wild dancing cism became common phenomena amongwere first noted in the 10th century. Re- the masses. In the postmedieval period,ferred to as “tarantism” in Italy, these epi- both Catholics and Protestants believed that