Mental illness - One History

Mental illnesses are biologically-based disorders which interfere with an individual's ability to think, feel, act, and relate within the standard norms of society. The American Psychiatric Association identifies hundreds of mental disorders ranging from Attention Deficit Hyperactivity Disorder to Violent/Self-Destructive Behaviors. Mental illness can be physical as well as psychological and emotional, and some are classified as "major mental illnesses" because of their propensity to seriously impair an individual's ability to function. Severe mental illnesses are more common than cancer, diabetes, or heart disease. Mental illness can strike any person at any time (one in five Americans and Australians, and one in six Canadians, will be affected some time in their life), account for more hospital admissions than any other single disease, and cost U.S. society more than $150 billion annually.

Mental illness afflicts people of every age, race, creed, and socioeconomic background. It can be extremely frightening and confusing to the sufferer, their families and their friends. It was not until the 1950s that mental illness became part of mainstream medicine. For centuries, it was so misunderstood and feared that sufferers were confined to insane asylums where they were shackled and treated as wild animals. In 1953, metal from such shackles was melted down and formed into a 300-pound Mental Health Bell and placed at the headquarters of the National Mental Health Association in Alexandria, Virginia as a symbol of hope and liberty for people with mental illnesses. Yet even today, mental illness brings about feelings of shame, disapproval, discrimination, and rejection.

Human society has always been acquainted with mental illness, and has always devised ways of dealing with it. Before the middle of the nineteenth century, many villages of Europe had little tolerance for any individuals, such as the mentally ill, who did not conform to traditional social roles. Unless they were turned out into the streets, the insane were usually cared for by their families, but often under the most intolerable conditions of squalor and filth. Conditions in the New World at that time were scarcely better, where mentally ill persons were frequently kept in chains or cages.

Since the time of the Middle Ages, asylums have existed to house the insane, though few inmates were actually kept there. One of the oldest psychiatric hospitals in Europe was Bethlem, a name later corrupted to Bedlam, in London. Londoners would pay to watch the behavior of the insane there, jeering at the inmates from a distance in order to provoke them to even more crazed behavior. Accounts such as Hogarth's of eighteenth century patients at the asylum manacled to the floor with their heads shaved for lice have helped make the name Bedlam synonymous with chaotic madness today.

With the eighteenth-century Enlightenment came the notion that institutions could be made curative. In 1758, William Battie, the medical officer of St. Luke's Hospital in London, advanced the notion that madness is "as manageable as many other distempers, which are equally dreadful and obstinate, and yet are not looked upon as incurable; such unhappy objects ought by no means to be abandoned, much less shut up in loathsome prisons as criminals or nuisances to the society." Similar ideas were voiced on the Continent, and somewhat later in America.

The founders of the therapeutic asylum believed that the hospital setting with its orderly routines together with the doctor-patient relationship would lead to the cure of severe mental illness. The patient's body and his quarters were to be kept clean, and his diet light. The clinic was to be a sort of rest home. In France, the patient's day was structured with work. (The so-called minor mental illnesses such as anxiety, neurotic depression, and obsessive-compulsive disorder, meanwhile, were treated mainly by spa doctors. In theory, the waters of the spa were supposed to induce bowel movements, relieving chronic constipation and leading to improved health. This therapy later went into rapid decline with the outbreak of several syphilis epidemics.)

In 1800, only a few patients were confined to asylums, but by the end of the century, the number of mentally ill confined to these institutions had mushroomed. By 1904, there were 150,000 patients in U.S. mental hospitals. In 1891,France had 108 asylums; and a directory of asylums in German-speaking Europe published the same year listed over 400 public and private asylums for the mentally ill. A few years later, in the vicinity of London, there were at least 16 asylums for the insane. By the end of World War I, asylums had become little more than warehouses for the chronically insane and demented. And, of course, as these mental hospitals became overburdened with patients, their therapeutic effectiveness declined.

Meanwhile, in fin de siècle Vienna, a young neurologist by the name of Sigmund Freud was experimenting with a "talk-therapy" that he called psychoanalysis to treat primarily the neuroses of middle-class women whose parents or grandparents had left the shetls of Eastern Europe to seek assimilation in anti-Semitic Vienna. Freud's doctrine embraced three central ideas: study of the patient's resistance to thoughts that attempted to enter the conscious mind from the unconscious; focus on the casual significance of sexual matters; and emphasis on the importance of early childhood experiences. Freud's core doctrine was that neurotic symptoms represented a trade-off between sexual and aggressive drives and the demands of reality. Although Freud never intended his therapy for the treatment of major mental illnesses, he did speculate on their origins, arguing, for example, that schizophrenia had its origins in the fear of homosexuality.

Thus, in the first half of the twentieth century, there were two schools of thought among psychiatrists about treating the severely mentally ill: psychiatrists could either institutionalize their patients in the hope that the patients would spontaneously recover when left to themselves, or they could treat them with psychoanalysis, which had the disadvantage that it was expensive and not really intended for the treatment of severe mental illness.

In the years between the end of World War II and the mid 1960s, the psychoanalytic ideas that Freud had postulated in turn-of-the century Vienna were at the peak of their influence in the United States. Even though psychoanalysts never accounted for more than 10 percent of all American psychiatrists, they dominated the profession in this country. The one advantage that psychoanalysis had over other modes of treatment for the severely mentally ill was that it offered hope to the patients and their families, something that the alternative treatments could not do. It made no difference that these hopes were mostly wishful thinking; psychoanalysis was able to offer explanations, even though few of these explanations could be verified.

But other psychiatrists held an alternate view of mental illness, one that sought the origins of mental illness in the psychic distress of the cerebral cortex, through studies of brain chemistry, brain anatomy, and the effects of medication. The modern era of biological psychiatry began in the 1920s with the isolation of the first neurotransmitter, i.e., a chemical that transmits nerve impulses from one neuron to another across the synapse (the gap between neurons). In 1952, French psychiatrists began the experimental treatment of hyperactive mental patients with an anti-anxiety drug they called chlorpromazine. By May of 1953, the disturbed wards of Paris mental hospitals had been revolutionized: the physical restraints that had bound the mentally ill no longer proved necessary when the patients were given chlorpromazine. While chlorpromazine did not cure diseases causing psychosis, it did alleviate the symptoms of persons suffering schizophrenia sufficiently that those patients could lead relatively normal lives and not be confined to an institution.

The discovery of chlorpromazine led to the discovery of many other antipsychotic, antimanic, and antidepressant drugs. Suddenly psychiatry was transformed from a branch of social work into a quantitative science, as investigators attempted to understand the effect of these drugs on the body.

As it turned out, the United States proved to be the most difficult market into which to introduce chlorpromazine, largely because of resistance by the psychoanalytically oriented psychiatrists who claimed they could cure even schizophrenia by talking to their patients. While it is true that many psychoanalysts did achieve impressive results in transforming the lives of the mentally ill for the better with so-called "talking cures," there is little evidence that anyone ever cured schizophrenia or any other psychosis with that approach. In 1973, psychoanalyst Bruno Bettelheim made the claim that he had succeeded in curing 85 percent of all autistic children (whose symptoms included almost complete withdrawal from reality) who came under his care before age seven or eight with his psychoanalytic milieu therapy. But all of the available evidence now indicates that Bettelheim was fabricating those numbers. The fact that Dr. Bettelheim was a very public man, and one constantly quoted by the news media, did little to advance, and probably a lot more to harm, the causes of both biological and psychotherapeutic psychiatry.

In the United States, in the fifteen-year period from 1955 (when the state hospital population reached its peak and antipsychotic drugs were widely introduced) to 1970, the inmate populations of state hospitals fell from 559,000 to 339,000. In the ten years between 1970 and 1980, however, seemingly well-intentioned lawsuits aimed at deinstitutionalizing mental patients caused the inmate population to fall even further to 130,000. These lawsuits had the effect of making it impossible for the states to keep patients with severe mental illnesses in their hospitals. And federal legislation, meanwhile, kept the states from passing the burden of caring for the mentally ill to the federal government. The result was, and continues to be, a swelling of the ranks of the homeless population by the non-medicated mentally ill.

Today, some of the most modern institutions for the mentally ill can be found in the open air, e.g., parks, alleys, vacant lots, and the steam gates on city sidewalks. In California, one adolescent gang wears t-shirts emblazoned with the logo "Trollbusters," an allusion to the gang's practice of preying on defenseless people living on the streets. It is clear that the act of discharging defenseless human beings into a hostile community is little more than are turn to attitudes prevailing during the Middle Ages, when the mentally ill roamed the streets and children threw rocks at them. Contrary to popular belief, the mentally ill have always had much more to fear from the so-called "normal" people of society, than the latter have ever had to fear from them. And while it may sometimes happen that an individual in the throes of psychosis, i.e., someone who has completely lost contact with any sense of reality, becomes violent or commits an act of murder, most violent acts and murders are carried out by people who are clearly not mentally ill in any medical sense of the word.

There is no clearly identifiable single-root cause of all mental illnesses. Biochemical imbalances may be triggered by environmental and emotional stresses, and genetic predisposition may sometimes be a factor. Symptoms are usually behavioral, such as confused thinking, prolonged depression, high anxiety/panic attacks, delusions of grandeur and hallucinations, suicidal thoughts, social withdrawal, dramatic swings between highs (mania) and lows (depression).Depression in the elderly is common and commonly unrecognized. Mental illness is often unrecognized in children; warning signs include poor grades despite strong efforts, excessive worry or anxiety, hyperactivity, persistent nightmares, frequent temper tantrums, substance abuse, excessive complaints of physical ailments, inability to cope with daily activities, and frequent outbursts of anger.

Mental illnesses recognized by the American Psychiatric Association (APA) include

• schizophrenia
• mood or affective disorders (depression/manic-depression)
• anxiety disorders, including panic disorder, posttraumatic stress syndrome, and > obsessive-compulsive disorder
• eating disorders (anorexia nervosa and bulimia nervosa)
• personality disorders

In addition, psychiatrists regularly treat many cases of mental illness in the elderly (e.g., depressive disorders) and in children (e.g., attention-deficit disorder).

Schizophrenia is one of the most common of the severe mental illnesses, affecting approximately 2.5 million people in the United States. The illness typically begins between the ages of 15 and 25; although the disease strikes men and women in equal numbers, symptoms may appear later in women than in men. Early symptoms, which may include difficulty concentrating and/or sleeping, isolation and social withdrawal, are followed by symptoms of psychosis, often including hallucinations, disordered thinking, and delusions, as the disease progresses. Individuals who suffer from schizophrenia often experience depression, and about 2 out of every 10 individuals afflicted attempt suicide, with a success rate of about 50 percent. The causes of schizophrenia are poorly understood, but heredity and environmental factors are highly suspected contributing factors. Investigators have found that the brains of persons with schizophrenia are often overly sensitive to, or produce too much of, the neurotransmitter dopamine. The disease is usually treated with antipsychotic medication, although no single medication has been found to be effective for all sufferers. Counseling and rehabilitation, including individual psychotherapy (i.e., meeting with a therapist to discuss feelings, problems, and life experiences; not to be confused with psychoanalysis, which is infrequently practiced today), are often valuable adjuncts in the treatment of the disorder.

Of the mood or affective disorders, bipolar disorder (also known as manic depression) is one of the most familiar. The individual suffering from this illness typically experiences mood swings that range from the depths of depression and the peaks of mania. Bipolar disorder affects approximately 1 in every 100 persons. The disease has been found to run in families, with 89 to 90 percent of all sufferers being related to someone with depression or bipolar disorder. Although the disease can become very disabling, bipolar disorder is highly treatable. Lithium carbonate is commonly prescribed to stabilize the manic phase of the illness and to prevent further mood swings, though other medications are available if lithium proves ineffective.

Depression is a serious medical illness that affects nearly 17 million (about one in 10) Americans each year. Although depression has a variety of symptoms, one of the most common is a deep feeling of sadness. Factors that play a role in the onset of depression include biochemical deficiencies, genetic predisposition, personality, and environment. Antidepressant medications, often in conjunction with psychotherapy, is the preferred treatment for depression. Most people (80 to 90 percent) who receive treatment experience significant improvement.

Anxiety disorders are the most common emotional disorders, annually affecting more than 20 million Americans (about one in nine). Symptoms may include overwhelming feelings of panic and fear; uncontrollable obsessive thoughts; painful, intrusive memories and recurring nightmares; and uncomfortable physical reactions such as nausea, sweating, and muscle tension. Types of anxiety disorder include panic disorder (characterized by an overwhelming fear of being in danger); phobias (uncontrollable, irrational, and persistent fear of an object, situation, or activity); obsessive-compulsive disorder (characterized by frequently occurring irrational thoughts that cause great anxiety but which cannot be controlled through reasoning; post-traumatic stress disorder (occurring in individuals who have survived a severe or terrifying physical or emotional event); and generalized anxiety disorder (characterized by an ongoing, exaggerated tension that interferes with daily functioning). Although each anxiety disorder has its own unique set of symptoms, most respond well to medication and psychotherapy.

Eating disorders are illnesses in which the sufferer becomes obsessed with food and body weight. These disorders affect some half-million individuals at any given time, most often young women between the ages of 12 and 25. Anorexia nervosa is diagnosed when patients weigh at least 15 percent less than their normal weight for their height and frame. Sufferers of this disorder refuse to eat enough, frequently exercise obsessively, and sometimes use laxatives or emetics inappropriately. Over time, individuals with anorexia nervosa develop all of the symptoms of starvation; as their bodies struggle to survive, the victims experience lethargy, and feelings of worthlessness and hopelessness. Individuals with bulimia nervosa are of normal weight or somewhat obese. Sufferers also experience severe eating binges at least twice a week for at least 3 months in a row. During the binges, the victims may consume thousands and thousands of calories from foods high in sugars, carbohydrates, and fat. Following the binge, the victims purge themselves by vomiting or by using a laxative. Psychotherapy helps individuals with eating disorders understand the emotions that trigger these disorders, to correct distorted self-images, to overcome morbid fears of weight gain, to change obsessive-compulsive behaviors related to food and eating, and to learn appropriate eating behaviors. Antidepressants are commonly prescribed for individuals with both eating disorders and depression.

Personality disorders are characterized by persistent patterns of inner experience and behavior that deviate markedly from cultural expectations, that are pervasive and inflexible, that begin in adolescence or early adulthood, that are stable over time, and that lead to distress or impairment. This category of mental illness includes the following disorders:

• paranoid personality disorder (characterized by distrust and suspiciousness of others' motives)
• schizoid personality disorder (characterized by social detachment)
• schizotypal personality disorder (characterized by acute distress in close relationships, distortions of perception or understanding)
• antisocial personality disorder (characterized by disregard or violation of other's rights)
• borderline personality disorder (characterized by instability in personal relationships and self-image, and marked impulsivity)
• histrionic personality disorder (characterized by excessive emotionality and attention seeking)
• narcissitic  personality disorder (characterized by grandiosity, and the need for admiration
• avoidant personality disorder (characterized by social inhibition, and feelings of inadequacy)
• dependent personality disorder (characterized by submissive and clinging behavior)

Individual therapies aim at reducing symptoms, improving social and personal functioning, and strengthening coping skills. Many types of therapies and medications are available and can be grouped in categories of psychosocial rehabilitation, biomedical therapy, psychotherapy, and behavioral therapy. These can be used alone or in combination.

Mental illnesses are not the same as mental retardation. While they cannot be cured (and none are contagious), most can be treated effectively. The first step in the road to recovery is awareness that something is wrong followed by accurate diagnosis and treatment from well-informed specialists. Appropriately licensed psychiatrists, psychologists, psychiatric nurses and social workers, mental health counselors, case managers, and outreach workers are all available to treat and rehabilitate people suffering from mental illness.

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