1. History of psychiatry
Philippa Bolton

2. Begin at the beginning
• For the most part, through the
ages, most people with mental
health problems were simply
cared for in the community.
• Much like modern day
developing world, they probably
did better than most clients do
today.

3. Not all good
• However, people with active
psychosis could well have lived
in the wilderness, or become
beggars.
• Could have been labelled
witches, possessed, or
imprisoned or executed for
violence.

4. What was it like then?
• Different presentations of
mental illness – less learning
disability, no schizophrenia,
more delirium and organic
mental illness – esp syphillis
• No asylums until 8th
century.
None in Britain until 1300’s.

6. Hippocrates
• Pre medicine illness, including
mental illness thought to be related
to spiritual phenomena requiring
prayer, sacrifice, exorcism.
• Hippocrates thought that mental
illness based in the brain. Described
mania, delirium, melancholia,
anxieties, phobias and puerpural
psychosis and paranoia.

7. Mania in Greece
• Some patients with mania are cheerful – they laugh,
play, dance day and night, and stroll through the
market, sometimes with a garland on their head, as
if they had won a game: these patients do not worry
their relatives. But others fly into a rage . . . The
manifestations of mania are countless. Some
manics, who are intelligent and well educated, deal
with astronomy, although they never studied it,
with philosophy, but autodidactically, they consider
poetry a gift of muses (Kappadokien),

8. Humors
Mental illness thought due to
disturbances of humors – black bile,
yellow bile, blood and phlegm
• Black bile: earth, cold and dry,
associated with melancholia.
• Yellow bile: fire, hot and dry,
associated with mania.
• Needed to rebalance the humors to
cure people – warm, cold, purging,
bloodletting, diet, activity, rest and
exercise etc. Persisted until 17th
century. Many people died.

9. Weird and wonderful
• Socrates – hysteria – the womb
wandered around the body
causing problems. Therefore
have babies to make it stay in
the proper place – the womb as
a cause of problems for women
persisted as a belief right until
the 20th
Century.

10. Persian times
• Both physical and spiritual
causes proposed.
• Many advances in medicine,
including in mental illness.
• First psychiatric hospitals,
which used baths, drugs, music
and activities and counselling.

11. Middle ages in Britain
• Mental illness mixture of
spiritual and medical causes –
most understanding from
‘humors’.
• Also the first asylums started
here – Bethleham hospital, later
changed to Bedlam. The first
place to use incarceration as a
treatment for mad people.

12. One night with Venus is
a lifetime with Mercury.
• Treatments: Bloodletting,
purging, blistering, whipping –
to restore humors and let out
evil spirits. Inhalation of
mercury.
• Also rest, music, diet, exercise.

15. Incarceration
• The idea of incarceration increased
after Tudor times, as society shifted,
and people were poorer and could
not afford to care for non productive
mad relatives. Private madhouses,
for the wealthy, were dumping
grounds for inconvenient relatives.
Masters of these places prided
themselves on their ability to beat
people. No inspections.

16. Bedlam

17. Bedlam
• Patients chained to the walls if violent.
• Filthy living conditions
• Used for the violently psychotic,
sometimes for morally ‘unusual’ people.
• Patients beaten, poor sanitation.
• By Victorian times people used to pay to
see the patients – a penny a viewing on the
first Tuesday of the month.
• Bedlam beggars would go out on the
streets to ask for money.

18. Moral therapy
• Pineal in Paris took the chains
of patients.
• Nothing bad happened.
• Pioneered asylums – peaceful
places, treating patients with
care and compassion, with work
to do – typically on farms.
Replicated by William Tuke in
UK

19. Aversion therapy
• Moral therapy encouraged good
behaviour, but also punished
‘bad’ behaviour to act as an
aversion to ‘mad rantings and
violence’.

22. The Lunacy commission
• Asylums made mainstream in
‘lunatic asylums act’ by Lord
Shaftesbury to stop incarceration in
prison or workhouses. Local
authorities forced to build them and
forced to allow poor people right to
good mental health care.
• No right for patients to appeal but
had to have medical opinions and
records of admission and could be
discharged by the court.

23. The Lunacy Act 1890
• Right to appeal to court
introduced.
• Over 20th
century the concepts
of informal and voluntary
treatment came into being.
• Medicalisation of detention –
enshrined in 1983 Mental health
act.

24. Neuroses in Victorian
times.
• Neuroses were dealt with in a
medical manner by neurologists
– rather fashionable for the
upper class ladies to have
‘nerves’, smelling salts, rest
therapy, and stimulation.
• Some objected – the Yellow
Wallpaper

26. Psychoses
• Psychosis dealt with by
psychiatrists – most common
was secondary to syphilis.
Asylums initially were about
routine, work and high moral
standards – psychiatrists
initially did not treat mental
illness directly.

27. Diagnostics
• Diagnostics started properly –
the most famous being
Kraepelin who defined,
schizophrenia and manic
depression, which is still used
today.
• Diagnostic classifications and
descriptions burgeoned.
Differentiation between LD and

28. Top 10 weird treatments
• Dr Rushes spinning chair – to
relieve brain congestion
• Warm baths for mania, cold
baths for depression.
• Near drowning
• Malaria for syphillis
• Tooth extraction
• Hysterectomies

29. • Lobotomies – mobile lobotomy
van – Moniz: 20000 performed in
USA.
• Insulin coma
• Electric currents for mutism and
shell shock.
• Insomnia for depression

32. Women with hysteria
• Charcot first put forward
psychological explanation for
hysteria.

33. Psychotherapy.
Freud (Charcot’s student)
revolutionised this with talking
therapy approaches and much
work on ‘neuroses’ – Anna ‘O’
• Identified that many anxieties
and phobias were based in
internal conflicts, past
experiences and traumas. Basis
of modern day psychotherapy.

35. Chlopromazine
• 1954 saw Chlorpromazine
invented and age of drug
treatment began.
• Following this barbituates,
benzodiazepines,
antidepressants and mood
stabilisers developed. Now
second generation
antipsychotics.

37. Anti-psychiatry
movement
• 1960’s
• Goffman’s ‘Asylums’ – institutionalisation
rather than individualised therapy.
• Criticism of social control – eugenics and
sterilisation in America and Nazi Germany.
• Criticism of diagnostics – imprecise,
labelling normal reactions as abnormal
diseases
• Criticism of biomedical model

38. Anti psychiatry
continued
• Thomas Szaz, RD Laing, Michal
Foucart.
• Would say mental health reaction to
environment and society, not
intrinsic to person.
• Advocated person centred
therapeutic approaches, therapeutic
communities, closure of institutions.
• Psycho-social approaches
advocated.

39. Recent developments
• Outpatient work and community
care developed
• Psychiatry split into
subspecialities – adult, old age,
LD, forensic and child.
• New treatments developed,
others diminished (ECT,
psychosurgery, sterilisation).

40. Today
• Community care developed.
• Person centred approaches
• Increased rights in law
• Reduced hospital admissions
• Debate on formulation vs diagnostics
• Holistic care.
• Nurse practitioners.

41. Conclusion
• Mental health is changing,
presentations are evolving
• Treatments and thinking around
mental illness are changing
• Challenge is always there.