History of Medical Psychology by LisaB1982

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									A HISTORY OF MEDICAL PSYCHOLOGY
Douglas Lehrer, M.D. Director of Medical Education Twin Valley Behavioral Healthcare

Why Study History?

“History is a set of lies agreed upon.”
Napolean Bonaparte

“Don’t forget your history, know your destiny, in the abundance of water the fool is thirsty.”
Bob Marley

Three basic trends

Magical Organic Psychological

Greece: Asklepios (Aesculapius)
• Asklepios: chieftain turned god • Mental illness resulted from mischief of the gods • Patients slept at the temple overnight • Treatment based on visions seen in sleep

Hippocrates
(c.460-377 BCE)

Humoral theories
Blood Phlegm Black Bile Yellow Bile Sanguine: confident, optimistic Phlegmatic: slow, stolid Melancholic: sad Choleric: irritable

Hippocratic Classification of Mental Disorders Epilepsy Mania Melancholia Paranoia Hysteria

Greek Philosophers
• Plato: Madness derives from disease OR gift of the gods – rational soul: seated in brain: immortal, divine – Irrational soul: pleasure, pain, audacity, fear, love, hope, anger • Aristotle: naturalistic; emotions; faculties

The Romans
• Embraced Greek culture, sciences, mathematics, etc. • Medicine amalgam of Greek & oriental, mixed with forms of charlatanism

Early post-Roman trends
• Rise of spiritualism • Decline of Greek tradition that every manifestation of human activity was worthy of scientific study • Center of attention: the soul and the beyond • Psychology moving from medicine to mystical philosophy & religion

Dark Ages: 2nd through 4th C’s
• Spiritual/ demonological basis of human ailments and suffering, esp. re. to the soul (= mind) • Centers of learning became religious institutions • 305: Practice of magic condemned in Spain • Late 4th cent: medicine to monasteries • Mental illness separated from medicine

Dark Ages: continued
• Early Christian DDx dilemma: Not all mental illness attributable to devil, given variable religious content saint vs. devil’s work • By 7th century: active rejection of sectarian or classicist (ie, pagan) learning, reading… • Study of psychiatry was study of devil, his cohorts, means, etc.

The Muslim Empire
• Muslim world followed Greco-Roman lineage; became the repository for that lineage during the dark ages in Europe • Tolerant of non-Muslims • Environment for learning and sharing of knowledge; Classics embraced • Strong pharmacological basis in ArabPersian medicine

Medical Psychology in Europe: A Loss of Reason

“A man or a woman who has a ghost or a familiar spirit shall be put to death; they shall be pelted with stones; their blood guilt shall be upon them.”
Leviticus 20:27

“If the work of G-d could be comprehended by reason, it would be no longer wonderful, and faith would have no merit if reason provided proof.”
Pope Gregory I (St. Gregory the Great, 540-604)

“Light thickens, and the crow Makes wing to th' rooky wood; Good things of day begin to droop and drowse, Whiles night's black agents to their preys do rouse.”
Macbeth, III.ii.50-3

Heresy: Diagnostic Criteria
• Error in reasoning • Error must be in matters concerning faith • Accused must be of Catholic faith (R/O Jew, pagan) • Accused still professes some Christian belief (R/O apostate) • Accused obstinately holds to the error

Treatment of Heretics By 12th century, the practice of persecuting heretics was rampant throughout Europe. Vigilante burnings were widespread.

Why Now? (or then rather…) Historical context: Plague and other pandemics/epidemics Steppe invasions Growth of the Muslim world Result? Fear, confusion

Treatment of Heretics
Early 13th Century: Frederick II

Emperor Frederick II outlawed heretics: • If they recanted: Imprisoned, property taken, home burned; children lost eligibility for positions unless they betrayed the heretic • If they did not recant: Burned

Treatment of Heretics
Early 13th Century: Frederick II Ironically, Frederick advanced general medical practices: • Established “modern” form of education, i.e., five years hospitalbased study followed by one year “internship,” followed by an examination • Allowed dissection of a human cadaver every five years

Inquisition
• The Church sought to bring order and “due process” to the investigation and treatment of heretics. • 1233: Pope Gregory IX inaugurated the inquisition, designating the Dominicans as the administrators of the formal investigation of heretics, a role formerly marginally held by the local Bishop.

Inquisition
• Cases of alleged heresy investigated by monastic authority • If the heretic was repentant, penance was determined by religious authority Imprisonment in monastery, pilgrimage, loss of property; +/- death • If condemned (ie, not repentant), heretic turned over to secular authority:

Burned

Medicine in the Inquisition
• By 14th-15th C, hard to consider any illness without considering soul, sin, etc • Non-psychiatric illness: visitation of sin on the body Natural and religious responses required

Non-Psychiatric Disease: DDx • Extrinsic cause ID’d: Due principally to natural causes

• Idiopathic, incurable, sudden: Witchcraft

• Psychiatric illness: purely in the realm of the spiritual • Former pity (at best) for the mentally ill gave way to fear (of the devil vs. church authority) • Afflicted cast into streets by their own kin

The Witches’ Hammer
• 1484: Pope Innocent VIII appointed Johann Sprenger and Heinrich Kraemer Inquisitors of Germany • 1486: They co-authored the Malleus Maleficarum • Inquisitors’ “DSM” & practice guidelines • 19 editions from 1486 - 1760

The Witches’ Hammer
• Part I: Argument proving existence of witches, witchcraft • Part II: Methods to ID (“diagnose”) a witch; clinical vignettes • Pat III: Legal forms of examining and sentencing a witch

Inquisitorial Due Process:
Questioning of accused and witnesses

“…common justice demands that a witch should not be condemned to death unless she is convicted by her own confession.”

“…direct or indirect evidence of the fact, or the legitimate production of witnesses…she is to be exposed to questions and torture to extort a confession of her crimes.”

The Judge should “not be too quick” to examination, for the Devil will render the accused “so insensible to the pains of torture that she will sooner be torn limb from limb than confess any of the truth.”

If a confession is obtained under torture, the accused is “conducted to another place, that he may confirm it and certify that it was not due alone to the force of the torture.”

“…written with firm conviction and a fervent zeal which made the authors totally anesthetic to the smell of burning flesh.”
Gregory Zilboorg

While not all accused of witchcraft were mentally ill, almost all mentally ill people were considered witches, sorcerers, or bewitched.

• Rationale needed to give free reign to fear and hatred of MI • Man chooses to succumb to the Evil One. Hence, punishment is moral and just (and necessary) • Soul must be delivered (body burned) = Act of supreme purification and devout communion with the will of G-d

The Power of Devils “clinical manifestations”
• induce an evil love in a man for a woman, or ...woman for a man • to plant hatred or jealously in anyone • bewitch them so that a man cannot perform the genital act with a woman, or conversely a woman with a man

The Power of Devils “clinical manifestations”
• to procure an abortion • to cause some disease in any human organs • to take away life • to deprive them of reason

• Demons and witches may do “injury to the use of reason, and...tormenting of the inner perceptions…” “…they can see absent things as if they were present; they can turn the minds of men to inordinate love or hatred…”

Role of the Physician
“As a physician, the medical man was considered of no consequence in these measures; he could only help as a citizen and as a Christian, since the problems involved were those of salvation, of suppressing sedition, of saving the faith, of the total destruction of the devil’s servants and their machinations.”
Gregory Zilboorg

Demographics of the Inquisition
• How many perished? • Estimates range from the tens of thousands to millions • Best estimate: 100,000-300,000 • Female to male ratio: Reports from 1:1 to 50:1 • 70% of those tried were executed • Last witch killed in 1792 in Switzerland by decapitation • Related to long departure of women from medical practice?

The Early Flicker of Reason
• 16th Century: Age of Michelangelo, Leonardo, Machievelli, Copernicus • Renewed increasing interest in human impulses, emotions, motivation of behavior

“I do not feel obliged to believe that the same God who endowed us with sense, reason, and intellect had intended for us to forgo their use.”
Galileo Galilei

Juan Luis Vives
(1492-1540) • Pious non-physician • Urged scholarly attention on common, poor people • Embraced intellectual potential of women • Community must act responsibly toward its unfortunate members, and show compassion for physically and mentally sick

Juan Luis Vives
(1492-1540)

De Anima et Vita (1538) • Physician should know nature & mind • Criticized cruelty toward mentally ill • Advocated for MI, medical treatment, gentle and friendly tx, minimal use of force/chains, and, above all, tranquility

Juan Luis Vives
(1492-1540)

De Anima et Vita (1538) • Described associations (fever/cherries) • Anticipated unconscious • Detailed attention to nature of emotions

Paracelsus
Theophrastus Bombastus von Hohenheim
(1493-1541)

• Physician; sought the open fight • Busy, energetic, iconoclastic clinician • Unequivocally denounced demonology and its dogmae re. MI

Paracelsus
Theophrastus Bombastus von Hohenheim
(1493-1541)

• Humoral ideas re. etiology of MI (heat/cold) • Writings more intuitive than rational, calculating

Johann Weyer (1515-1588)
• Personal physician to Duke William • Busy clinician, in the HippocraticGalenic tradition • Highly critical of inquisition

Johann Weyer (1515-1588)
• “It is highly unpleasant to see how people, in order to kill errors are busy killing human beings.” • Pled for right of medicine to care for poor (esp. women) called witches

Johann Weyer (1515-1588)
• Of contemporary medicine: “Ignorant physicians and surgeons cover their stupidity and errors by referring to sorcery and the virtue of saints.” • Brought methodical, systematic curiosity and common sense to his practice of clinical medicine

Johann Weyer (1515-1588)
• 1563: De Praestigiis Daemonium • Carefully, exhaustively, rationally attacked entire Malleus • Concluded “witches” are mentally sick • Monks who torture and torment the ill should be punished • Used scriptures to make argument

Johann Weyer (1515-1588)
• Attempted to divorce mental illness from theology • De Praestigiis Daemonum was banned by the Catholic church until early 20th century • 1st physician w/ major interest MI • “Founder of Modern Psychiatry”


								
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