The origins of the medical approach to schizophrenia can be traced in the history of the language used to describe the symptoms. The key words and terms that are currently used to describe the symptoms—such as delusions, hallucinations, thought disorder and catatonia—all have long histories of usage, first to describe madness in general, and later as symptoms of earlier forms of mental disease that preceded the concept of schizophrenia.
Up to the middle of the nineteenth century the French word délire meant either madness or delusion, and when it was used for delusion the meaning was interchangeable with delirium.[1] This means that for several centuries in France the three concepts—madness, delusion and delirium—were often indistinguishable. Influenced by religious beliefs, all three forms of délire were thought to be organic in nature because ‘the soul is always in the same state and is not susceptible to change. So the error of judgement that is délire cannot be attributed to the soul but to bodily organs’.[2]
In pre-eighteenth century Italy a similar view was expressed about the cause of delusion and delirium.
"Delirium was caused by organic changes for the soul cannot become diseased: ‘How can delirium be called affection of the soul, in view of its [the soul’s] unchangeable nature?’ ‘Where is the seat of delirium?’ It is evident that true and basic errors of judgment and of reasoning, without any lesion in the organ of external senses, must be due to a physical disease of the brain."[3]
British thinkers appear to have had a more circumspect view of delusions and madness, sometimes being less willing to associate delusions with brain disease. Hobbes saw delusions as being the primary indicator of madness, but he was equivocal about the cause, unsure whether to adopt an ancient interpretation blaming ‘Daemons, or Spirits, either good, or bad, which . . . might enter into man, possess him, and move his organs in such strange, and uncouth manner,’[4] or whether to adopt the opinion current in his time that underlying ‘passions’ were the cause.
John Locke introduced the belief that delusions and madness were caused by associating inappropriate ideas: ‘some of our ideas have a natural correspondence and connection with one another: it is the office and excellency of our reason to trace these, and hold them together in that union and correspondence’. However, to Locke, madmen ‘do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles.’[5]
Locke’s view was amplified by eighteenth-century associationists such as David Hartley, and remained popular up to the middle of the nineteenth century. But Hartley believed, as did the French, that delusions and madness could also have organic causes:
"the causes of madness are of two kinds: bodily and mental. That which arises from bodily causes is nearly related to drunkenness, and to the deliriums attending distemper. That from mental causes is of the same kind with temporary alienation of the mind during violent passions, and with prejudices of opinionativeness, which much application to one set of ideas only occasions."[6]
In the late eighteenth century, French and German commentators agreed that hallucinations can be the cause of mental disorder, but they didn’t agree on the extent of this disorder. The Frenchman Dufor was of the opinion that ‘The false impression of the external senses, then, must necessarily create disorder and confusion in a person’s conduct.’[7] Crichton, a German, responded: ‘that the diseases of the external senses produce erroneous mental perceptions, must be allowed; but it depends on the concurrence of other causes, whether delusion follows’.[8]
Disagreements such as these led on to a nineteenth-century debate about whether hallucinations could be a cause for insanity. Hallucinations were defined early in the debate: ‘If a man has the intimate conviction of actually perceiving a sensation for which there is no external object, he is in a hallucinated state.’[9] The word hallucination was closely linked with the word vision, and its usage caused some difficulties in dealing with false perceptions that were not connected with the sense of sight. But early psychiatrists found these difficulties were outweighed by the advantages:
"Hallucinations of vision have been called visions but this is appropriate only for one perceptual mode. Who would talk about auditory visions, taste visions, olfactory visions? . . . However, the functional alterations, brain mechanisms and the clinical context involved in these three senses is the same as in visions. A generic term is needed. I propose the word hallucination."[10]
An important early debate about the nature of hallucinations was concerned with whether the fault was to be found in the external sense organs or whether it was in the ‘central organ of sensitivity itself’.[11] Esquirol was of the opinion that ‘hallucination is a cerebral or psychological phenomenon that takes place independently from the senses. The pretended sensations of the hallucinated are images and ideas reproduced by memory, improved by the imagination, and personified by habit . . . visionaries are dreaming whilst awake’.[12]
Baillarger took up similar arguments after Esquirol died and in 1844 presented his views to the Royal Academy of Medicine in Paris: ‘The most frequent and complicated hallucinations affect hearing: invisible interlocutors address the patient in the third person, so that he is a passive listener in conversation . . . the insane deaf is more prone to hear voices.’[13] But Baillarger’s view was challenged by another of his countrymen named Michéa, who posed a complicated argument that ‘hallucination consisted of a metamorphosis of thinking, was neither a sensation nor a perception but intermediate between perception and pure conception. It occupies the middle ground between these two facts of consciousness and participates in both.’[14]
In the middle of the nineteenth century an important debate broke out amongst French psychiatrists about the nature of hallucinations. According to Berrios there were three main points to the debate: ‘could hallucinations ever be considered as "normal" experiences? Did sensation, image and hallucination form a continuum? Were hallucinations, dreams and ecstatic trance similar states? A fourth issue (as Henri Ey noticed) "haunted everyone but was not made the base of the debate", namely, whether hallucinations had a "psychological" origin.’[15]
All of these issues remain unresolved today. Indeed, they form much of the basis for the current controversy. It seems that although considerable progress has been made in the past century and a half in categorising, identifying and devising treatments for unusual mental phenomena, little progress has been made in understanding their underlying nature. This point is well illustrated by the example of thought disorder.
Thought disorder is indicated by disorganised or nonsensical speech. Although other schizophrenic symptoms such as delusions and hallucinations are often recognised by the people who experience them, this is less likely with thought disorder. Usually this symptom must be identified by an observer. For a long time, therefore, thought disorder was considered as secondary in importance to delusions and hallucinations. It wasn’t until the second half of the nineteenth century that psychiatrists began to form theories about the causes and nature of disordered thoughts.
Two broad theoretical frameworks emerged to explain disordered thoughts; and both are now deeply embedded in modern psychiatric thinking about schizophrenia. One is faculty theory, which holds that ‘the mind is a cluster of independent powers, capacities or faculties’.[16] After passing through dubious stages of development, such as the phrenology movement, based on the belief that personality could be revealed by measuring and mapping the pattern of bumps on the head, faculty theory is now largely at the base of current attempts to draw maps of the brain by identifying various mental functions with parts of the brain. This area of research, as will be discussed further on, is central to current scientific endeavours to link schizophrenia with defects in brain architecture.
The associationistic approach, on the other hand, ‘was the legacy of British empiricism and started with Locke’s description of simple and complex ideas’.[17] This theory had considerable influence on both Kraepelin and Bleuler, the two psychiatric researchers who are most commonly cited as being the first pioneers, the inventors/discovers/definers, of the disease entity called schizophrenia. Through Kraepelin and Bleuler the associationistic approach has had an important influence on the selection of the primary indicators for schizophrenia found in modern diagnostic manuals.
Next: 'Discoverers' of Schizophrenia
[1] German E. Berrios, The History of Mental Symptoms, p. 85.
[2] Arnulphe d’Aumont, 1754, quoted in Berrios, ibid.
[3] Vincenzo Chiarugi, quoted in Berrios, ibid., p. 86.
[4] Thomas Hobbes, quoted in Berrios, ibid., pp. 86–87.
[5] John Locke, quoted in Berrios, ibid., p. 88.
[6] David Hartley, quoted in Berrios, ibid., pp. 88–89.
[7] Jean Francois Dufor, quoted in Berrios, ibid., p. 35.
[8] Berrios, ibid., p. 35.
[9] E. Esquirol, quoted in Berrios, ibid., p. 37.
[10] Ibid.
[11] Ibid.
[12] Ibid., pp. 37–8.
[13] J. Baillarger, quoted in Berrios, ibid., p. 39.
[14] C. F. Michéa, quoted in Berrios, ibid.
[15] Berrios, ibid., p. 40.
[16] Berrios, ibid., p. 72.
[17] Ibid.