The word schizophrenia was coined by Eugen Bleuler in 1911, and was intended to describe the separation of function between personality, thinking, memory, and perception. However, the history of ‘schizophrenia’ is not easy to write. According to some, the disease has always existed only to be ‘discovered’ during the early 20th century. The plausibility of this claim depends upon the success of retrospectively diagnosing earlier cases of madness as ‘schizophrenia’. According to others, ‘schizophrenia’ names a culturally-determined clustering of mental symptoms.[1] What is known for sure is that by the turn of the 20th century the old concept of insanity had become fragmented into ‘diseases’ (psychoses)[2] such as paranoia, dementia praecox, manic-depressive insanity and epilepsy (Emil Kraepelin’s classification).[3] Dementia praecox was reconstituted as schizophrenia, paranoia was renamed as ‘delusional disorder’ and manic-depressive insanity as ‘bipolar disorder’ (epilepsy was transferred from psychiatry to neurology). It is important to emphasize that the ‘mental symptoms’ included under the concept schizophrenia are real enough, make people suffer, and will always need understanding and treatment. However, whether the historical construct currently called ‘schizophrenia’ is required to achieve this therapeutic goal remains a moot point.
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A detailed case report in 1797 concerning James Tilly Matthews,[4] and accounts by Philippe Pinel published in 1809, are often regarded as the earliest cases of schizophrenia in the medical and psychiatric literature.[5] Schizophrenia was first described as a distinct syndrome affecting teenagers and young adults by Bénédict Morel in 1853, termed démence précoce (literally 'early dementia'). The term dementia praecox was used in 1891 by Arnold Pick to in a case report of a psychotic disorder. In 1893 Emil Kraepelin introduced a broad new distinction in the classification of mental disorders between dementia praecox and mood disorder (termed manic depression and including both unipolar and bipolar depression). Kraepelin believed that dementia praecox was primarily a disease of the brain,[6] and particularly a form of dementia, distinguished from other forms of dementia, such as Alzheimer's disease, which typically occur later in life.[7]
Kraepelin's classification slowly gained acceptance. There were objections to the use of the term "dementia" despite cases of recovery, and some defence of diagnoses it replaced such as adolescent insanity.[8] The concept of adolescent insanity or developmental insanity had been advanced by Scottish psychiatrist Thomas Clouston in 1873, describing a psychotic condition which generally afflicted those aged 18–24 years, particularly males, and in 30% of cases proceeded to ‘a secondary dementia’.[9]
The word schizophrenia—which translates roughly as "splitting of the mind" and comes from the Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind")[10]—was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence.[11] Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead. However, many at the time did not accept that splitting or dissociation was an appropriate description, and the term would later have more significance as a source of confusion and social stigma than scientific meaning.[12]
The term schizophrenia is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term schizophrenia (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet T. S. Eliot in 1933.[13]
In the first half of the 20th century schizophrenia was considered to be a hereditary defect, and sufferers were subject to eugenics in many countries. Hundreds of thousands were sterilized, with or without consent—the majority in Nazi Germany, the United States, and Scandinavian countries.[14][15] Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "Action T4" program.[16]
In 1970 psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category[17] and proposed that cases of schizophrenia where people recovered well were not really schizophrenia but a separate condition.[18]
In the early 1970s, the diagnostic criteria for schizophrenia was the subject of a number of controversies which eventually led to the operational criteria used today. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe.[19] This was partly due to looser diagnostic criteria in the US, which used the DSM-II manual, contrasting with Europe and its ICD-9. David Rosenhan's 1972 study, published in the journal Science under the title On being sane in insane places, concluded that the diagnosis of schizophrenia in the US was often subjective and unreliable.[20]
In the Soviet Union the diagnosis of schizophrenia has also been used for political purposes. The prominent Soviet psychiatrist Andrei Snezhnevsky created and promoted an additional sub-classification of sluggishly progressing schizophrenia. This diagnosis was used to discredit and expeditiously imprison political dissidents while dispensing with a potentially embarrassing trial.[21] The practice was exposed to Westerners by a number of Soviet dissidents, and in 1977 the World Psychiatric Association condemned the Soviet practice at the Sixth World Congress of Psychiatry.[22] Rather than defending his claim that a latent form of schizophrenia caused dissidents to oppose the regime, Snezhnevsky broke all contact with the West in 1980 by resigning his honorary positions abroad.[23]
The 1970s controversies lead to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the DSM-III in 1980.[24] The revision was based on Feighner Criteria and Research Diagnostic Criteria that had in turn developed from Robins' and Guze's criteria, and which were intended to make diagnosis more reliable (consistent). Since the 1970s more than 40 diagnostic criteria for schizophrenia have been proposed and evaluated.[25]
Accounts of a schizophrenia-like syndrome are thought to be rare in the historical record prior to the 19th century, although reports of irrational, unintelligible, or uncontrolled behavior were common.[5] There has been an interpretation that brief notes in the Ancient Egyptian Ebers papyrus may imply schizophrenia,[26] but other reviews have not suggested any connection.[27] A review of ancient Greek and Roman literature indicated that although psychosis was described, there was no account of a condition meeting the criteria for schizophrenia.[28]
Bizarre psychotic beliefs and behaviors similar to some of the symptoms of schizophrenia were reported in Arabic medical and psychological literature during the Middle Ages. In The Canon of Medicine, for example, Avicenna described a condition somewhat resembling the symptoms of schizophrenia which he called Junun Mufrit (severe madness), which he distinguished from other forms of madness (Junun) such as mania, rabies and manic depressive psychosis.[29] However, no condition resembling schizophrenia was reported in Şerafeddin Sabuncuoğlu's Imperial Surgery, a major Islamic medical textbook of the 15th century.[30] Given limited historical evidence, schizophrenia (as prevalent as it is today) may be a modern phenomenon, or alternatively it may have been obscured in historical writings by related concepts such as melancholia or mania.[5]