1900 to 1950

The first half of the twentieth century is marked by two somewhat opposing currents in the conception of mental illness: the entrance of the Freudian model of psychodynamics and a rash of somatically ori­ented theories and treatments.

Freud and the Unconscious

The realm of human activity and experience that lies outside normal consciousness was attracting con­siderable literary and scholarly attention in the late nineteenth and early twentieth centuries. Psycho­logical novels shared the theme that the rational intellect had only a limited ability to shape our lives. Neurological investigators, constructing ever more complex systems of reflex integration, described as unconscious those bodily activities that did not re­quire continuous volitional monitoring. Noncon- scious mentation was also investigated by academic psychologists, although the concept was often re­jected as oxymoronic. Some psychologically oriented neurologists, such as Charcot’s rival Hippolyte Bernheim, became interested in the powers of the mind over body - Ideodynamism - through the dra­matic effects of hypnosis and suggestion. The work of Morton Prince, Boris Sidis, and Pierre Janet fo­cused attention on the clinical significance of minds that have disintegrated, or even divided. Janet devel­oped an extensive theory of psychasthenia, parallel­ing neurasthenia, that referred to the inability of a weakened mind to maintain a unified integrity. Neu­rotic symptoms resulted from traumatic memories, such as unfortunate sexual episodes, that had been “split off” from the main consciousness.

Perhaps the strongest exponent of the unconscious before Freud was Frederic W. H. Myers, a nineteenth­century British psychologist known mostly for his advancement of psychicalist (paranormal) research. Myers popularized the theory of the subliminal self as a hidden domain that was vast and profound, provid­ing the basis for all psychic life. Incorporating such phenomena as genius, hypnosis, and even telepathy, Myers cast the unconscious world in a highly spiri­tual, positive light, establishing a rationale for the use of psychotherapy as a tool for unleashing the inner creative forces. In the United States, religious healing cults like Christian Science and the Emman­uel movement made psychotherapy synonymous with a practical means of tapping into the subcon­scious, the reservoir in human beings of God’s spirit and power.

Sigmund Freud was a Viennese neurologist trained in neuroanatomy, neurophysiology, and neuropsy­chiatry, who also boasted a deep knowledge of litera­ture and anthropology. Freud’s own journey into the hidden self, an exploration that commenced with TheInterpretation of Dreams (1900), has been gener­ally recognized as one of the monumental intellec­tual achievements of our time. Only a sketch of his work can be attempted here. Although the therapeu­tic merit of psychoanalysis remains a controversial issue, there can be little doubt that the Freudian model of human action has had a tremendous and pervasive influence in many areas of culture. In his early publications, Freud argued for the importance of the unconscious in directing most of our waking activities and all of our nocturnal ones. Conscious­ness represented only a fraction of our true selves. In contrast to the ideas of Myers and other supporters of psychotherapy, Freud’s conception of the uncon­scious referred to a realm of primitive, even carnal, desires that followed its own irrational inner logic of wish fulfillment. Indeed, our entire mental appara­tus, even our conscious selves, depended on the en­ergy, or libido, that derived from the unconscious.

In his later work, Freud developed a tripartite metapsychology of self, comprised of the id, the pool of unconscious desires and memories; the ego, the core adaptive mechanism, which was built on terri­tory reclaimed from the unconscious as the infantile pleasure principle was superseded by the mature reality principle; and the superego, the ego’s censor, a mostly unconscious system of rules and mores in­ternalized from parental and societal instruction. The ego, the component of self we most identify with, is a partly conscious and partly unconscious struc­ture that must continually mediate between the de­sires of the id and the restrictions of the superego. Toward the end of his career, in such publications as Civilization and Its Discontents (1929), Freud turned his attention to the interaction between individuals’ desires and society’s demands, highlighting the rela­tion between repression and culture.

From in-depth clinical studies, Freud assembled a model of the mind as a dynamic battleground where libidinous energies surge from the unconscious through a preconscious stage and then to conscious­ness, but only after intensive censorship that misdi­rects the energy to less threatening endpoints. Inter­nal harmony is maintained at the price of continual suppression of unwanted thoughts and memories; anxiety is the internal warning that the dynamic equilibrium is becoming unstable. Psychopathology results from the desperate attempts by the ego - weakened by childhood trauma and saddled by inse­curity and guilt - to maintain control in the face of intrapsychic conflict. At low levels of stress, the ego copes through simple defense mechanisms, such as displacement, projection, and denial.

A distinguishing characteristic of Freud’s system was the insistence that mental disorders had mean­ings. Being neither random nonsense nor mere neu­rological defects, such symptoms were in fact cre­ative responses to specific problems that confronted a troubled individual. (Freud thus departed from Janet’s model of neurosis as a product of a weakened mind, seeing it instead as resulting from a mind that was all too vigorous.) A psychopathological symptom was like a key to an unidentified lock; the clinical challenge was to make the shape of the lock visible. Psychoanalysis was to provide the clinician with the knowledge and tools necessary for recognizing what the immediate conflict was and then tracing back­ward to the distant trauma that had engendered this particular symptom formation. Until the underlying conflict was disinterred, neurotics were condemned to react inappropriately to current challenges, unwit­tingly seeing in them replays of a past battle that could no longer be won. Therapy consisted of analyz­ing unconscious material, as revealed in dreams, slips of the tongue, and free associations, and a care­ful manipulation of the patient-physician relation­ship, in which patients made visible their neurotic structures by transferring onto the therapist their unresolved emotions.

After Freud, the analysis of human behavior would never again be simple. Henceforth, the sur­face or manifest meaning of any action might belie multiple hidden or latent desires that would have to be decoded. The nineteenth-century hierarchical model of reason mastering desire was humbled by the realization that there existed no pure rational part of self that acted without the distorting influ­ence of the unconscious; and every noble accomplish­ment of civilization was now sullied as a by-product of excess libido. The lines between sanity and insan­ity, and between normality and abnormality, were forever blurred, for each individual existed in a dy­namic equilibrium in which unconscious forces held sway every night and at times during the day. Fur­thermore, in making a distinction between our in­stinctual aims and their objects (the aim of the sex drive was reproduction; the object was one’s lover), Freud severed the connection whereby mental dis­ease was equated with behavior contrary to instinct. Normal desires could lead to perverse acts, and vice versa. Judgments of mental illness were no longer simply statements of what was “unnatural.”

Freud’s immediate effect within psychiatry was to achieve for the neuroses what Kraepelin had accomplished for the psychoses. In Kraepelin’s sys­tem, neuroses were an unsettled mixture of somatic and functional disorders. Freud directed psycho­analysis at the latter group, heightening the distinc­tion by the use of the term psychoneurosis. Thus, certain disparate conditions, such as hysteria, obses­sions, compulsions, and phobias, were united in a single category, yet each retained its own integrity as a clinical syndrome, recognizable in case histo­ries.

Psychoanalysis provided a fresh solution to the vexing problems facing neurologists who had built their practices on theories of neurasthenia, already in decline. Where psychological interactions of pa­tient and physician were devilish problems for prac­titioners following organically justified systems, Freud’s psychogenically based models turned a liabil­ity into a virtue. As a high technique of the mind, created by a distinguished Viennese physician, psy­choanalysis co-opted religiously suspect psychother­apy, transforming it into a medically legitimate tool that office practitioners could adopt. Even better, for those physicians who relied on uncertain methods of suggestion, hypnosis, or enforced discipline, psycho­analysis provided a direct means of handling those nervous patients who undermined the doctors’ com­petence by refusing to get better. The fault was thrown back into the patient as “resistance.”

In the United States, which would become the largest supporter of Freud’s theories (rejected as “Jewish psychology” in his homeland), not only psy­chologically oriented neurologists but many psychia­trists as well welcomed the new model. Even though psychoanalysis was irrelevant in the institutional context, which represented the majority of psychiat­ric care, the advent of a system that brought with it the trappings of learned study and European pres­tige was welcomed by many as a means of raising the status of what was widely regarded as the most backward of medical specialties. This interest was particularly strong in research institutes, which many states had created in this period to serve as catalysts for scientific advance.

The precise manner in which the Freudian doc­trine rose to prominence in general culture is still not well understood. As one example, recent histori­cal work suggests that World War I played a precipi­tating role in Britain when a large number of sol­diers broke down in battle. That anyone might act insane, given sufficient stress, was forceful testi­mony of sanity’s fragility. Neurologists diagnosed these soldiers as suffering from “shell shock,” origi­nally interpreted in terms of a somatic injury. Nei­ther reflex hammer nor rest cure proved useful, how­ever. The best success was obtained by physicians who applied a form of Freudian psychotherapy to relieve the trauma. Overnight, psychoneuroses gained national currency. Those neurologists in­volved in the war effort were precisely the ones who would later gain for Freudianism a solid profes­sional footing in Britain.

Biology

In the 1920s and 1930s, virtually every branch of biomedical science sought to apply the tools of experi­mental medicine to the problem of psychiatry. In­deed, given the isolation of the asylum from centers of medical advance, it was an even bet whether the next scientific breakthrough would emerge from within psychiatry or from an outside field. The para­digm was syphilis, whose tertiary state, general pe­resis, had been responsible for up to 20 percent of mental hospital admissions. In 1897 Richard von Krafft-Ebing demonstrated the long-suspected con­nection between syphilis and paresis, a link soon confirmed by the Wasserman test. The culpable spiro­chete was identified in paretic brains by Hideyo Noguchi in 1913. Finally, in 1917 the Austrian physi­cian Julius von Wagner-Juaregg developed a method of fever therapy to halt further paretic deterioration; in 1927 he was awarded the Nobel Prize. The success of a purely organic solution to a major psychiatric disorder suggested that other such achievements were sure to follow.

Leading researchers thus pursued metabolic, endo­crine, neurophysiological, and even toxicological models for psychopathology. Constitutional theories were advanced by the German Ernst Kretschmer, who correlated body types to predispositions for spe­cific mental illnesses. Franz Kallman investigated the genetics of mental illness by studying schizo­phrenic twins. I. V. Pavlov launched a model of ex­perimental neurosis in which animals Ihistrated in conditioned learning tests developed forms of mental breakdowns. The introduction of a wave of somatic treatments for mental illness in the middle 1930s transformed psychiatric practice. Insulin shock, me- trazole shock, electric shock, and psychosurgery had dramatic effects on patient behavior, raising hopes that the fatalism associated with severe mental ill­ness might prove untrue. Psychosurgery in particu­lar was believed to restore chronic schizophrenics to productive citizenship. Its inventor, Portuguese neu­rologist Antonio Caetano de Egas Moniz, was awarded the 1949 Nobel Prize in medicine.

Classification at Midcentury

After World War II, professional organizations such as the American Psychiatric Association became ac­tive in the creation of standardized systems of no­menclature. Military experience and the growth of centralized reporting bureaus highlighted the ιfeed for diagnostic uniformity. The first Diagnostic and Statistical Manual, Mental Disorders (DSM), created in 1950, reflected the extension of the Kraepelin and Freudian systems, augmented by new theories of personality. Earlier, dementia praecox had been re­conceptualized by Swiss psychiatrist Eugen Bleuler into the schizophrenias (hebephrenia, catatonia, paranoia), a term that referred to the splitting of thoughts from affects. Incorporating some aspects of psychoanalysis. Bleuler emphasized the develop­ment of the psychotic mental process.

In contrast to Kraepelin, Bleuler argued that favor­able outcomes were possible in many cases. The DSM followed Bleuler in its description of the category of major psychoses, referring to personality disintegra­tion and a failure to relate effectively to people or work. Included within this group were the schizophre­nias, as well as paranoia, manic-depression, and invo­lutional psychosis (depression of old age). The second major category consisted of psychoneuroses, de­scribed in Freudian terms as disorders caused by the unconscious control of anxiety through the use of defense mechanisms. These included anxiety reac­tions, dissociation, conversion reaction, obsessive­compulsion, and depression. The third category, com­prising personality disorders, was differentiated by its stress on behavioral as opposed to emotional dis­turbances. Described in this category were such popu­lar terms as sociopath, antisocial behavior, and sexual deviate.

As a shift from earlier attempts at standard psychi­atric nosology, which were directed toward inpatient populations, the DSM reflected the new reality of psychiatry’s burgeoning private-practice base, as well as the experiences of military psychiatrists, whose observations on broad populations revealed that the vast majority of psychopathologies did not fit the earlier classifications. Published statements of nosology do not necessarily reflect full clinical reality, however. The DSM was by no means univer­sally adopted. It reflected more the penetration of Freudian psychiatrists into the power structure of the profession than it did any dramatic shift in the state hospitals, where niceties of diagnosis were con­sidered superfluous to the daily choice of treatment plan.