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Contemporary DireCtions in psyChopathology

Contemporary
DireCtions in
PsychoPathology
scientific Foundations of the Dsm-V and iCD-11

edited by
theodore millon
robert F. Krueger erik simonsen

the gUilForD press
new york london

© 2010 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the Publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Contemporary directions in psychopathology : scientific foundations of the DSM-V and ICD-11
/ edited by Theodore Millon, Robert F. Krueger, Erik Simonsen.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-60623-532-4 (hbk.)
1. Psychology, Pathological. 2. Mental illness—Etiology. 3. Mental illness—
Diagnosis. 4. Mental illness—Classification. I. Millon, Theodore. II. Krueger, Robert
F. III. Simonsen, Erik, 1949–
RC454.C647 2010
616.89—dc22
2009028186

about the editors

Theodore Millon, PhD, DSc, is Dean and Scientific Director of the Institute for Advanced
Studies in Personology and Psychopathology. He was Founding Editor of the Journal of Per-
sonality Disorders and inaugural president of the International Society for the Study of Per-
sonality Disorders (ISSPD). Dr. Millon has held full professorial appointments at Harvard
Medical School, the University of Illinois, and the University of Miami. A prolific author, he
has written or edited more than 30 books on theory, assessment, and therapy, as well as more
than 200 articles and book chapters. Dr. Millon is the recipient of the 2008 American Psycho-
logical Foundation Gold Medal for Life Achievement in the Application of Psychology.

Robert F. Krueger, PhD, is Professor of Psychology and Psychiatry at Washington University
in St. Louis. His major research interests lie at the intersection of personality, psychopathol-
ogy, psychometrics, and behavioral genetics. Dr. Krueger has received a number of awards,
including the American Psychological Association’s Distinguished Scientific Award for Early
Career Contribution and the American Psychological Foundation’s Theodore Millon Award
for midcareer contributions to personality psychology.

Erik Simonsen, MD, is Director of Psychiatric Research in Region Zealand, Denmark; Di-
rector of the Institute of Personality Theory and Psychopathology; and Associate Research
Professor at the University of Copenhagen. He has published widely on personality disorders,
first-episode psychosis, personality assessment, outcome of psychotherapy, and psychiatric
classification. Dr. Simonsen is past president of the ISSPD and a recipient of the ISSPD Award.
He has also served as president of the Section on Personality Disorders of the World Psychi-
atric Association.

v

Contributors

Renato D. Alarcón, MD, MPH, Mood Disorders Unit and Department of Psychiatry,
Mayo Clinic College of Medicine, Rochester, Minnesota
Steven R. H. Beach, PhD, Institute for Behavioral Research, University of Georgia,
Athens, Georgia
Edward M. Bernat, PhD, Department of Psychology, Florida State University,
Tallahassee, Florida
Roger K. Blashfield, PhD, Department of Psychology, Auburn University, Auburn, Alabama
Sidney J. Blatt, PhD, Department of Psychiatry, Yale School of Medicine,
New Haven, Connecticut
Bekh Bradley, PhD, Trauma Recovery Program, Atlanta Veterans Affairs Medical Center,
and Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia
Jessica Combs, BA, Department of Psychology, University of Kentucky,
Lexington, Kentucky
Rina Dutta, MRCPsych, Institute of Psychiatry, Kings College London,
London, United Kingdom
Nicholas R. Eaton, MA, Department of Psychology, Washington University in St. Louis,
St. Louis, Missouri
Michael B. First, MD, Department of Psychiatry, Columbia University, New York,
New York
Elizabeth Flanagan, PhD, Department of Psychiatry, Yale School of Medicine,
New Haven, Connecticut
vii

viii Contributors

Joseph P. Gone, PhD, Department of Psychology, University of Michigan,
Ann Arbor, Michigan
Seth Grossman, PsyD, Counseling and Psychological Services Center, Florida International
University, Miami, Florida
William M. Grove, PhD, Department of Psychology, University of Minnesota,
Minneapolis, Minnesota
Richard E. Heyman, PhD, Department of Psychology, Stony Brook University, State
University of New York, Stony Brook, New York
Nadine J. Kaslow, PhD, Department of Psychiatry, Emory University School of Medicine,
Atlanta, Georgia
Jared Keeley, MS, Department of Psychology, Auburn University, Auburn, Alabama
Kenneth S. Kendler, MD, Virginia Institute for Psychiatric and Behavioral Genetics,
Virginia Commonwealth University, Richmond, Virginia
Laurence J. Kirmayer, MD, Division of Social and Transcultural Psychiatry, McGill
University, and Institute of Community and Family Psychiatry, Jewish General Hospital,
Montreal, Quebec, Canada
Helena Chmura Kraemer, PhD, Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, California; Department of Psychiatry, University
of Pittsburgh, Pittsburgh, Pennsylvania
Robert F. Krueger, PhD, Departments of Psychology and Psychiatry, Washington University
in St. Louis, St. Louis, Missouri
Mark F. Lenzenweger, PhD, Department of Psychology, State University of New York
at Binghamton, Binghamton, New York
Mark R. Lukowitsky, MA, Department of Psychology, Pennsylvania State University,
University Park, Pennsylvania
Patrick Luyten, PhD, Department of Psychology, University of Leuven, Leuven, Belgium
Mario Maj, MD, PhD, Department of Psychiatry, University of Naples, Naples, Italy
Paul E. Meehl, PhD (deceased), Department of Psychology, University of Minnesota,
Theodore Millon, PhD, DSc, Institute for Advanced Studies in Personology
and Psychopathology, Port Jervis, New York
Robin M. Murray, MD, Institute of Psychiatry, Kings College London,
London, United Kingdom
Kile M. Ortigo, MA, Department of Psychology, Emory University, Atlanta, Georgia
Joel Paris, MD, Department of Psychiatry, McGill University, and Institute of Community
and Family Psychiatry, Jewish General Hospital, Montreal, Quebec, Canada
Christopher J. Patrick, PhD, Department of Psychology, Florida State University,
Tallahassee, Florida
Aaron L. Pincus, PhD, Department of Psychology, Pennsylvania State University,

Contributors ix

Kristin Raley, MS, Department of Psychology, Auburn University, Auburn, Alabama
David Reiss, MD, Yale Child Study Center, Yale University, New Haven, Connecticut
Bryna Siegel, PhD, Department of Psychiatry, University of California, San Francisco,
San Francisco, California
Erik Simonsen, MD, Psychiatric Research Unit, Region Zealand, and Department
of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
Andrew E. Skodol, MD, Sunbelt Collaborative and Department of Psychiatry, University of
Arizona College of Medicine, Tucson, Arizona
Gregory T. Smith, PhD, Department of Psychology, University of Kentucky,
Lexington, Kentucky
Susan C. South, PhD, Department of Psychological Sciences, Purdue University,
West Lafayette, Indiana
Michael H. Stone, MD, Department of Psychiatry, Columbia University, and private
practice, New York, New York
Robert Tringone, PhD, Counseling Center, St. John’s University, Jamaica, New York
Scott I. Vrieze, BA, Department of Psychology, University of Minnesota,
Jerome C. Wakefield, PhD, DSW, Silver School of Social Work and Department
of Psychiatry, New York University, New York, New York
Marianne Z. Wamboldt, MD, Department of Psychiatry, University of Colorado Denver
School of Medicine, Aurora, Colorado
Drew Westen, PhD, Departments of Psychology and Psychiatry and Behavioral Sciences,
Emory University, Atlanta, Georgia
Aidan G. C. Wright, MS, Department of Psychology, Pennsylvania State University,
Peter Zachar, PhD, Department of Psychology, Auburn University at Montgomery,
Montgomery, Alabama

preface

t he present book is similar in concept to a well-received volume that one of us (Theodore
Millon) edited with Gerald L. Klerman of Harvard University in 1986; it is, however, an
almost entirely new book, with only one chapter carried over from the earlier work. Gerry
and I were colleagues at the Stanley Cobb Psychiatric Laboratories of Massachusetts General
Hospital, as well as active participants in the development of DSM-III. Our aim in the earlier
volume was to describe substantive and innovative advances since the publication of DSM-III
in 1980, and to emphasize themes we believed should be considered in the forthcoming DSM-
IV. We, the present editors, intend to do the same in this volume for DSM-IV(-TR) and for the
forthcoming DSM-V and ICD-11.
Numerous changes in the character of psychopathology have begun taking place in the
past several decades. Slow though progress has been, there are inexorable signs that the study
of mental disorders has advanced beyond its earlier history as an oracular craft. No longer
dependent on the intuitive artistry of brilliant clinicians and theoreticians who formulated
dazzling but often unfalsifiable insights, psychopathology has acquired a solid footing in
the empirical methodologies and quantitative techniques that characterize mature sciences.
Although the term “psychopathology” was used in the past as synonymous with “descrip-
tive symptomatology,” it can now be justly employed to represent “the science of abnormal
behavior and mental disorders.” Its methods of study comfortably encompass both clinical
and experimental procedures.
Among the many indices of continuing progress is the construction of psychometrically
sound diagnostic tools that wed the quantitative and statistical precision typifying rigorous
empirical disciplines with the salient and dynamic qualities characterizing the concerns of a
clinical profession. Contributing to this precision is the introduction of comprehensive and
comparable diagnostic criteria for each mental disorder—an advance that not only enhances
the clarity of clinical communication, but strengthens the reliability of research, contributing
thereby to the collection of reciprocal and cumulative data. Similarly, sophisticated multivari-
xi

xii preface

ate statistical methods now provide quantitative grounds for analyzing symptom patterns and
constructing an orderly taxonomy.
Theoretical formulations have also begun to take on a more logical and orderly struc-
ture. Whereas earlier propositions were often presented in haphazard form, with circular
derivations and ambiguous or conflicting empirical consequences, contemporary theorists
began to specify explicit criteria for their concepts, as well as to spell out objective procedures
and methods for testing their hypotheses. Moreover, theorists have become less doctrinaire
in their positions than formerly; that is, they no longer act and write as religious disciples of
“theological purity.” A true “ecumenism” has emerged—an open-mindedness and sharing of
views that are much more characteristic of disciplines with secure foundations. Thus erstwhile
analysts have shed their former dogmatisms and have begun to incorporate findings such as
those in the neurosciences and social psychology; similarly, once-diehard behaviorists have
jettisoned their earlier biases and have integrated cognitive processes into their principles. On
many levels and from several perspectives, the signs indicate consistently that psychopathol-
ogy is becoming a full-fledged science.
It is our intent in this book to draw attention to innovations that constitute continuations
of these directions. The volume is not intended to be a comprehensive textbook, but many of
its chapters provide thoughtful pedagogic reviews and heuristic recommendations that may
prove useful to the forthcoming DSM-V and ICD-11. In this latter regard, we very much favor
current efforts to construct further rapprochements between the American Psychiatric Asso-
ciation’s DSM and the World Health Organization’s ICD. Work on the new editions of both
manuals is well underway, and we believe that a successful accommodation will come from
the combination of careful theoretical and conceptual analyses, and the parallel acquisition
of empirical data from well-designed research. This work not only reflects the current state of
psychopathology as a science, but should help identify the issues and methods that can foster
this important reconciliation.
As noted, all but one of the 30 chapters in this volume is new. Only Paul E. Meehl’s
classic chapter on “diagnostic taxa” is a repeat from the earlier book; it is one that Mark F.
Lenzenweger reflects on and thoroughly reviews. Notable in this edition are several chap-
ters that bring to the forefront the role played by social context and culture in the roots of
numerous mental disorders. The book begins with an extensive historical survey that leads
up to contemporary thinking. Here are traced the contributions of theorists and researchers
from ancient times (e.g., Zang Zhongjing, Alcmaeon, Aretaeus), the many fruitful ideas of
19th-century clinicians (e.g., Esquirol, Griesinger, Kahlbaum), and the work of more modern
scholars (e.g., Kraepelin, Freud, Beck).
Classification matters are explored deeply in chapters that deal with philosophical issues
underlying construct validity, syndromal comorbidity, and the clinical utility of categories
versus dimensions. Innovative proposals are presented on such topics as the neuroscientific
foundations of psychopathology and the use of evolutionary principles in articulating the
development and composition of psychopathology.
It is our hope that this volume will contribute further to the long and fruitful collabora-
tion between the disciplines of psychology and psychiatry. Psychopathology needs “all the
help it can get” if it is to fulfill its promise as a science. The best minds are not to be found
in one school of thought or in one mental health profession. Different perspectives not only
contribute to “rounding out” important areas of content and technique, but help spark fresh
insights and ideas. We three editors have found collaborative work to be both stimulating
and rewarding; we hope that this book will serve not only as a model of cooperation between
our fields, but as an invitation to biochemists, epidemiologists, psychometricians, geneticists,
sociologists, and professionals in other disciplines to join us in similar enterprises.

preface xiii

In closing, we should like to express our appreciation to the book’s contributors. Among
them are numerous distinguished scholars, as well as well-respected and promising young
investigators from psychology, psychiatry, philosophy, and sociology. In addition to being
extremely pleased with the high quality and original thought that went into each chapter,
we should note that both authorial and editorial royalties for this volume will be turned over
to the World Health Organization, to provide it with additional resources to facilitate and
expedite the development of ICD-11.

Theodore M illon
roberT F. K rueger
eriK SiMonSen

Contents

Part I. HIstorIcal and cultural PersPectIves

chaPter 1. a précis of psychopathological history 3
Theodore Millon and Erik Simonsen

chaPter 2. themes in the evolution of the 20th- Century Dsms 53
Roger K. Blashfield, Elizabeth Flanagan, and Kristin Raley

chaPter 3. on the Wisdom of Considering Culture and Context 72
in psychopathology
Joseph P. Gone and Laurence J. Kirmayer

chaPter 4. Cultural issues in the Coordination of Dsm-V and iCD-11 97
Renato D. Alarcón

chaPter 5. a sociocultural Conception of the Borderline 111
personality Disorder epidemic
Theodore Millon

Part II. concePtual Issues In classIfIcatIon

chaPter 6. philosophical issues in the Classification of psychopathology 127
Peter Zachar and Kenneth S. Kendler

chaPter 7. Classification Considerations in psychopathology and personology 149
Theodore Millon

xv

xvi Contents

chaPter 8. Diagnostic taxa as open Concepts: metatheoretical 174
and statistical Questions about reliability and Construct Validity
in the grand strategy of nosological revision
Paul E. Meehl

chaPter 9. Contemplations on meehl (1986): the territory, paul’s map, 187
and our progress in psychopathology Classification
(or, the Challenge of Keeping Up with a Beacon 30 years
ahead of the Field)
Mark F. Lenzenweger

chaPter 10. issues of Construct Validity in psychological Diagnoses 205
Gregory T. Smith and Jessica Combs

chaPter 11. the meaning of Comorbidity among Common mental Disorders 223
Nicholas R. Eaton, Susan C. South, and Robert F. Krueger

chaPter 12. the Connections between personality and psychopathology 242
Susan C. South, Nicholas R. Eaton, and Robert F. Krueger

chaPter 13. is it true that mental Disorders are so Common, 263
and so Commonly Co-occur?
Mario Maj

chaPter 14. taking Disorder seriously: a Critique of psychiatric Criteria 275
for mental Disorders from the harmful- Dysfunction perspective
Jerome C. Wakefield

Part III. MetHodologIcal aPProacHes to categorIes, dIMensIons,
and PrototyPes

chaPter 15. on the substantive grounding and Clinical Utility of Categories 303
versus Dimensions
William M. Grove and Scott I. Vrieze

chaPter 16. a short history of a psychiatric Diagnostic Category 324
that turned out to Be a Disease
Roger K. Blashfield and Jared Keeley

chaPter 17. Concepts and methods for researching Categories 337
and Dimensions in psychiatric Diagnosis
Helena Chmura Kraemer

chaPter 18. the integration of Categorical and Dimensional approaches 350
to psychopathology
Erik Simonsen

chaPter 19. Dimensionalizing existing personality Disorder Categories 362
Andrew E. Skodol

Contents xvii

chaPter 20. an empirically Based prototype Diagnostic system 374
for Dsm-V and iCD-11
Kile M. Ortigo, Bekh Bradley, and Drew Westen

chaPter 21. the millon personality spectrometer: a tool for personality 391
spectrum analyses, Diagnoses, and treatments
Theodore Millon, Seth Grossman, and Robert Tringone

Part Iv. InnovatIve tHeoretIcal and eMPIrIcal ProPosals

chaPter 22. neuroscientific Foundations of psychopathology 419
Christopher J. Patrick and Edward M. Bernat

chaPter 23. Using evolutionary principles for Deducing normal 453
and abnormal personality patterns
Theodore Millon

chaPter 24. Biopsychosocial models and psychiatric Diagnosis 473
Joel Paris

chaPter 25. reactivating the psychodynamic approach to the Classification 483
of psychopathology
Sidney J. Blatt and Patrick Luyten

chaPter 26. a life Course approach to psychoses: 515
outcome and Cultural Variation
Rina Dutta and Robin M. Murray

chaPter 27. the interpersonal nexus of personality and psychopathology 523
Aaron L. Pincus, Mark R. Lukowitsky, and Aidan G. C. Wright

chaPter 28. reconceptualizing autism spectrum Disorders as autism- specific 553
learning Disabilities and styles
Bryna Siegel

chaPter 29. Describing relationship patterns in Dsm-V: a preliminary proposal 565
Marianne Z. Wamboldt, Steven R. H. Beach, Nadine J. Kaslow,
Richard E. Heyman, Michael B. First, and David Reiss

chaPter 30. on the Diversity of the Borderline syndromes 577
Michael H. Stone

author index 595

subject index 607

Part I

Historical and cultural PersPectives

chaPter 1

a précis of psychopathological history

tHeodore Millon
erik siMonsen

B efore we andanalysis text, it maytrends in
a systematic
our contributors undertake

psychopathology in this
of current
be use-
The traditions of psychopathology today
are not themselves tight systems of thought in
the strict sense of scientific theories; they cer-
ful to introduce the subjects with reference tainly are neither closed nor completed con-
to its historical origins and evolution. Ef- structions of ideas that have been worked out
forts to understand and resolve the problems in their final details. Rather, they are products
that researchers studying mental disorders of obscure lines of historical development—
continue to face can be traced through many movements often subject to the confusions
centuries in which solutions have taken un- and misunderstandings of our remote past,
anticipated turns and have become enmeshed when a disaffection with complexities typi-
in obscure beliefs and entangled alliances, fied life. Nevertheless, interest in ourselves,
most of which have unfolded without the in our foibles as well as our achievements,
care and watchful eye of modern scientific has always been central to our human curi-
thoughts and methods. Psychopathology re- osity. The origins of interest in the workings
mains today a relatively young science. We of psychopathology were connected in their
find that many techniques and theories of earliest form to studies of astronomy and
our time have long histories that connect spiritual unknowns. Even before any record
current thinking to preexisting beliefs and of human thought had been drafted in writ-
systems of thought, many of which are in- ten form, we humans were asking fundamen-
tertwined in chance associations, primitive tal questions, such as why we behave, think,
customs, and quasi-tribal quests. The path act, and feel as we do. Although primitive in
to the present is anything but a simple and their ideas, ancient people were always open
straight line; it has come to its current state to the tragic sources in their lives. Earliest
through an involvement in values and cus- answers, however, were invariably associ-
toms of which we may be only partly aware. ated with metaphysical spirits and magical
Many are the product of historical accidents spells. Only slowly were more sophisticated
and erroneous beliefs that occurred centu- and scientific ideas formulated.
ries ago, when mysticism and charlatanism It was not until the 6th century B.C. that
flourished. the actions, thoughts, and feelings of humans
3

4 historiCal anD CUltUral perspeCtiVes

were attributed to natural forces—that is, to learn how different modes of thought today
sources found within ourselves. Philosophers have their roots in chance events, cultural
and scientists began to speculate intelligent- ideologies, and accidental discoveries, as
ly about a wide range of psychological pro- well as in brilliant and creative innovations.
cesses; many of their ideas turned out to be From today’s perspective, it seems likely
remarkably farsighted. Unfortunately, much that future developments in the field will
of this early imaginative and empirical work reflect recent efforts to encompass and inte-
was forgotten through the centuries. Time grate biological, psychological, and sociocul-
and again, it was then slowly stumbled upon tural approaches. No longer will any single
and rediscovered by careful or serendipitous and restricted point of view be prominent;
efforts. For example, John Locke in the 17th each approach will enrich all others as one
century described a clinical procedure for component of a synergistic whole. Integrat-
overcoming unusual fears; the procedure he ing the disparate parts of a clinical science—
described is not very different from the sys- theory, nosology, diagnosis, and treatment—
tematic desensitization method developed is the latest phase in the great chain of
this past century by Joseph Wolpe. Similar- history that exhibits an evolution in mental
ly, Gustav Fechner, founder of psychophys- science professions from ancient times to the
ics in the mid-19th century, recognized that new millennium. Intervening developments
the human brain is divided into two parallel (both those that have been successful and
hemispheres that are linked by a thin band those that have not) were genuine efforts to
of connecting fibers (what we now term the understand more fully who we are and why
corpus callosum). According to Fechner’s we behave the way we do. The challenge
speculations, if the brain was subdivided, to know who we are is unending, owing to
it would create two independent realms of the complexity of human functioning. New
consciousness—a speculation confirmed concepts come to the fore each decade, and
and elaborated in the latter part of this past questions regarding established principles
century by Roger Sperry, in what has been are constantly raised. Perhaps in this new
referred to as “split-brain research.” century we will bridge the varied aspects of
Every historical period was dominated by our poignant yet scientific understanding of
certain beliefs that ultimately won out over psychopathology, as well as bring the diverse
previously existing conceptions while re- traditions of the past together to form a sin-
taining elements of the old. As the study of gle, overarching synthesis.
mental science progressed, different and fre-
quently insular traditions evolved to answer
questions posed by earlier philosophers, ancient history
physicians, and psychologists. Separate dis-
ciplines with specialized training procedures Primitive humans and ancient civilizations
developed. Today divergent professional alike viewed the unusual and strange within
groups are involved in the study of the mind a magical and mythological frame of refer-
(e.g., the neuroscientifically oriented psychi- ence. Behavior that could not be understood
atrists, with a clear-eyed focus on biological was thought to be controlled by animistic
and physiological processes; the psychoana- spirits. Although both good and evil spir-
lytic psychiatrists, with an austere yet sensi- its were conjectured, the bizarre and often
tive attention to unconscious or intrapsychic frightening behavior of persons with men-
processes; the personological psychologists, tal disorders led to a prevailing belief that
with the tools and techniques for appraising, demon spirits must inhabit them. The pos-
measuring, and integrating the mind; and the session of evil spirits was viewed as a punish-
academic psychologists, with a penchant for ment for failing to obey the teachings of the
empirically investigating the basic processes gods and priests. Fears that demons might
of behavior and cognition). Each group has spread to afflict others often led to cruel and
studied the complex questions generated by barbaric tortures. These primitive “thera-
mental disorders with a different focus and pies” of shock, starvation, and surgery have
emphasis. Yet the central issues remain the parallels in recent history, although the an-
same. By tracing the history of each of these cients based them on the more grossly naive
and other conceptual traditions, we will conception of demonology.

a précis of psychopathological history 5

What has been called the sacred approach tress. Within this worldview, eccentric or ir-
in primitive times may be differentiated into rational individuals were assuredly touched
three phases, according to Roccatagliata by spirits who possessed superhuman pow-
(1973): “animistic,” “mythological,” and ers to induce psychic pathology. Almost all
“demonological.” These divergent para- groups permitted healing to fall into the
digms shared one point of view: that psy- hands of priests and magicians—a situation
chopathology was the expression of tran- that still exists today in some societies. Liv-
scendent magical action brought about by ing in a world populated with imaginary be-
external forces. The animistic model was ings, these spiritual forces could often calm
based on pre-logical and emotional reason- the worst human anxieties and expunge the
ing derived from the deep connection be- ever-present terrors of life. Despite extensive
tween primitive beings and the mysterious archeological analyses, however, our knowl-
forces of nature. From this viewpoint, events edge of primitive times is no more than frag-
happened because the world was peopled by mentary. Nevertheless, we may assume that
animated entities driven by obscure and in- primitive humans saw a world populated
effable forces that acted upon human minds with spirits that were essentially illusions
and souls. The second phase, that character- created by their own state of anguish and
ized by mythological beliefs, transformed perplexity.
the animistic conception so that indistinct
and indefinable forces were materialized into
India, Babylonia, and china
myths. Every fact of life was imbued with the
powers of a particular entity; every symp- Many contributions of the early Hindus are
tom of disorder was thought to be caused by associated with the name of Susruta, who
a deity who could, if appropriately implored, lived 100 years before Hippocrates. His
benevolently cure it. In the third, or demon- works followed the traditional beliefs of his
ological phase, the transcendent mythologi- day regarding possible demonic possession.
cal deities were placed into a formal theo- However, Susruta suggested that the pas-
logical system such as the Judeo- Christian. sions and strong emotions of those mental
In line with this latter phase, two competing disorders might also bring about certain
forces struggled for superiority: one creative physical ailments calling for psychological
and positive, represented by a good father help (Bhugra, 1992). Anticipating the sig-
or God; the other destructive and negative, nificance of temperament or innate disposi-
represented by the willful negation of good tions, Hindu medicine proposed that three
in the form of demonic forces of evil. These such inclinations existed: wise and enlight-
three conceptions followed each other his- ened goodness, with its seat in the brain;
torically, but they did overlap, with elements impetuous passions, the sources of the plea-
of one appearing in the others at times. sure and pain qualities, with their seat in the
Many aspects of prehistoric life could chest; and the blind crudity of ignorance, the
not be understood; magic and supernatural basis of more animalistic instincts, its seat
concepts helped early humans make sense located in the abdomen.
out of the unfathomable and unpredictable. A concern with mental health has long
Weighted with life’s painful realities and been a part of Indian cultures, which
burdensome responsibilities, these beliefs evolved various ways of attempting to un-
gave an order and a pseudo-logic to fears derstand and negotiate mental disorder and
of the unknown—a repository of unfalsifi- psychological problems. Indians have long
able assumptions in which the supernatural been involved in constructing explanatory
filled in answers for that which could not techniques. In the first formal system of
be understood. Ultimately, supernaturalism medicine in India, Ayurveda (The Book of
became the dominant world view in which Life), physical and mental illnesses were not
the perplexing experiences of life could be clearly demarcated. Caraka Samhita dealt
objectified and comprehended. Priests and with medical diagnoses and management
wizards became powerful, capitalizing on possibly dating from 600 B.C. and was the
the fears and peculiarities of the populace to foremost text of the ancient Indian medical
undo spells, “heal” those with physical ill- system. Caraka defined ayu (life) as a state
nesses, and “purify” those with mental dis- consisting of shareera (body), indriya (sens-


es), satva (psyche), and atma (soul). Soul stars produced many gods, a result largely
could not be destroyed, and it underwent of their intellectual leaders’ fertile imagina-
reincarnation. The mind was responsible for tions. Help from the gods was often sought
cognition, and it directed the senses, con- through magical rites, incantations, prayers,
trolled the self, reasoned, and deliberated. and the special powers of those who were
The equilibrium between the self and mind physicians or priests. The Babylonians as-
was viewed as paramount to good health. signed a demon to each disease; insanity,
Caraka used the general term doshas for for example was caused by the demon Idta.
the body fluids or humors, vata, pitta, and Each was to be exorcised through special
kapha. The theory of doshas may have de- medicines (primarily herbs and plants), con-
veloped independently of the Greek humoral fessions, and other methods to help restore
theory, or possibly the Hindu system may a balance between conflicting supernatural
have traveled to Greece. Types of food were forces. As the Babylonians saw it, invariable
thought to influence the mind, personality tensions existed among the different gods—
characteristics, and the interactions among but, more importantly, between a more or
the three doshas. Different personality types less rational, as opposed to a superstitious,
were described in detail as leading to men- explanation of psychic ailments.
tal illness, through either unwholesome diet The first medical book in China, Neijing
or moral transgressions. In the Hindu sys- (The Canon of Internal Medicine), was com-
tem, mental disorders were seen as largely piled between 300 B.C. and 100 B.C. Organic
metaphysical, but different appearances of syndromes, like epileptic seizures (dian) and
mental disorders (like unmada, insanity) delirium-like states, were also described, but
were described as resulting from heredity, with no clear distinction from the concepts
imbalanced doshas, temperament, inappro- of insanity and psychosis (kuang). The pri-
priate diet, and metapsychological factors. mary causes of psychiatric illness were sug-
Caraka also contained many descriptions of gested to be vicious air, abnormal weather,
possession states regarded as arising from and emotional stress. The famous doctor
supernatural agents—a belief that is still Zang Zhongjing, the Hippocrates of China,
apparent in many parts of highly religious introduced other concepts and syndromes,
Indian society. Religious connotations and such as febrile delirium, globus hystericus,
references to spiritual enlightenments were and puerperal psychosis, in his Jinkuiyaolue
only challenged in the early 19th century by (A Sketchbook in a Golden Box). Chinese
the emerging Western-science-based medi- medicine has tended to explain pathology
cine introduced by British rulers. In India, change by means of philosophical concepts,
colonial medical institutions became brick- and this framework has undergone little
and-mortar symbols of Western intellectual change. It includes the notions of the comple-
and moral power, with European doctors mentary yin and yang; the five elements, gold,
even being taken as the sole excuse for em- wood, water, fire, and earth; and the prin-
pire. Indian magical practices and religious ciple of Tao (i.e., the way), which has been
customs have been marginalized to some ex- considered as the ultimate regulator of the
tent, but a variety of shamans—whose ther- universe and the most desirable state of well-
apeutic efforts combine classical Indian al- being and longevity achieved by integrating
chemy, medicine, magic, and astrology with the individual self into the realm of nature.
beliefs and practices from folk and popular These ontological principles were described
traditions—are still present. in The Yellow Emperor’s Classic of Inter-
In the Middle East was the ancient civi- nal Medicine some 20 centuries ago (Liu,
lization of Babylonia; it was not only a 1981). Different personality types were por-
vast geographical expanse, but the founda- trayed as resulting from combinations of the
tion of philosophical thought for most na- five elements (e.g., the fiery type, the earthy
tions in the Mediterranean region. In fact, type, the golden type, and the watery type).
many of the traditions discussed among the Phenomena occurring inside human beings
Greeks and Romans can be traced to ideas were understood in terms of phenomena oc-
generated initially in the Babylonian empire. curring outside in nature. Chinese medicine
Babylonians were oriented toward astro- later became organ-oriented; that is, every
nomical events; superstitions regarding the visceral organ was believed to have charge of


a specific function. The heart was thought to “uterus”) was caused, as the Egyptians saw
house the mind, the liver to control the spiri- it, by a wandering uterus that had drifted
tual soul, the lung the animal soul, the spleen from its normal resting location; the task of
ideas and intelligence, and the kidney vitality the physician was to bring the uterus back to
and will. No attention was paid to the brain! its normal setting. This explanation for hys-
For a long time psychiatric symptoms were teria continued until the late Middle Ages.
interspersed with those of physical disease. In the earliest periods of Greek civilization,
The mind–body dichotomy was not a central insanity was considered a divine punishment,
theme. Mood disturbances and psychiatric a sign of guilt for minor or major transgres-
symptoms attributed to menstrual irregu- sions. Therapy sought to combat madness by
larities tended to be expressed in somatic various expiatory rites that removed impuri-
terms. In Chin-Yue’s Medical Book, the Chi- ties, the causes of psychic disorders. Priests
nese word for “depression” literally meant mediated an ill person’s prayers to the gods
“stagnation,” implying obstruction of vital so as to assure his or her cure. Thus, with
air circulation in the body. Case vignettes of divine help, the person’s heart could be puri-
patients with “deceiving sickness” (i.e., hys- fied of its evil. Albeit slowly, Greek schol-
terical neurosis) were presented in the same ars realized that little of a rational nature
book explaining symptom formation in peo- characterized their way of thinking about
ple trapped in very difficult situations. In a mental pathology. To them, external but
similar way, sexual impotence was explained unseen agents could no longer serve as a
by excessive worry. In summary, psychiatric logical basis for a genuine understanding of
concepts of mental illness in China have un- mentally troublesome phenomena. A funda-
dergone basically the same sequence as in mental shift began to take place, not merely
the West: supernatural, natural, somatic, in the manner in which different types of
and psychological stages. However, Chinese mental disorders might be described, but in
medicine has been relatively less influenced the basis for thinking about ways to alter
by religious thoughts compared than early these aberrant behaviors. In order to “treat”
European medicine was; patients in Eu- mental disorders, the Greeks began to recog-
rope in the Middle Ages were declared by nize the necessity of understanding how and
priests to be bewitched and were punished. why mental disorders were expressed in the
Acupuncture, traditional Chinese medicine, natural world; only then could they success-
folk herbs, and psychotherapy have been the fully deal therapeutically with the tangible
most commonly used treatment approaches symptoms of everyday mental life. Instead of
in China. leaving the treatment of mental disorders to
the supernatural and mystical, they began to
develop a more concretely oriented perspec-
egypt, greece, and rome
tive. This transition was led by a number of
In Egypt, as in other early civilizations, there imaginative thinkers in the 5th and 6th cen-
is evidence that the heart was thought to be turies B.C.
the center of mental activity. Egyptians also A central intellectual effort of Greek phi-
had difficulty in separating prevailing super- losophers was the desire to reduce the vast-
natural beliefs from beliefs about things that ness of the universe to its fundamental el-
could be observed and modified in nature. ements. Most proposed that complexities
Astronomical phenomena were the primary could be degraded to one element—be it
objects of worship. “Natural” qualities were water, air, or fire. Their task was to iden-
usually turned aside in favor of the mysti- tify the unit of which all aspects of the
cal powers of the gods. Over the course of a universe were composed. Among the first
century or two, Egyptian philosophers and philosopher-scientists to tackle this task was
physicians began studying the brain, ulti- Thales (652–588 B.C.). What little we know
mately recognizing it as the primary source of Thales comes largely from the writings of
of mental activity. Egyptians recognized later Greek philosophers, notably Aristotle,
that emotional disorders could be described Plato, and the historian Herodotus. This
in line with ideas proposed by the Greeks. nimble-witted Greek proposed that the fun-
Thus the set of disturbances the Greeks damental unit of the universe was a tangible
termed “hysteria” (using their word for and identifiable substance, water.


Though Thales was not the prime fore- Pythagoras considered mental life as
runner of a modern understanding of mental reflecting a harmony between antitheti-
processes, he was a radical thinker who re- cal forces: good–bad, love–hate, singular–
directed attention away from mysticism, rec- plural, limited–unlimited, and so on. Life
ognizing that psychic disorders were natural was regulated according to his conception of
events that should be approached from a sci- opposing rhythmic movements (e.g., sleep–
entific perspective. As a pivotal figure in his wakefulness, inspiring– expiring). Mental
time, he ushered in an alternative to earlier disorders reflected a disequilibrium of these
supernatural beliefs. Equally significant was basic harmonies, producing symptoms of
Thales’s view that efforts should be made to psychic impairment. To him, the soul could
uncover underlying principles on which overt rise or descend from and to the body. The
phenomena were based. Oriented toward more the soul was healthy, in balance, and
finding these principles in physical studies without psychic symptoms, the more it re-
and “geometric proportions,” he turned to sembled solar energy. Pythagoras spoke of
“magnetic” phenomena, convinced that the the soul as composed of three parts: reason,
essential element of all life was its animat- which reflected truth; intelligence, which
ing properties. To Thales, action and move- synthesized sensory perceptions; and im-
ment, based on balanced or disarrayed mag- pulse, which derived from bodily energies.
netic forces, was what distinguished human The rational part of the soul was centered
frailty. In this belief, he further derogated in the brain; the irrational one, in the heart.
the view that external supernatural forces Incidentally, Pythagoras coined the term
intruded on the psyche; rather, the source “philosophy” by putting together the words
of pathology was inherent within persons philo, meaning “love,” and sophia, meaning
themselves. “wisdom.”
Paralleling the views of Thales, Pythago- Ostensibly through his father, Apollo,
ras (582–510 B.C.) reasserted the importance Aesculapius (ca. 550 B.C.) gained his under-
of identifying the underlying scientific prin- standing of the nature of mental disorders
ciples that might account for all forms of be- through the divination of dreams, which he
havior. He differed from Thales in that he then transmitted to his sons, Machaon and
retrogressively preferred to use ethics and Podaleirius. A series of followers, called Aes-
religion as the basis for deriving his scientific culapians, established long- enduring “medi-
principles. More progressively, however, he cal temples” and a distinguished cult. It is
was the first philosopher to claim that the unclear historically whether Aesculapius
brain was the organ of the human intellect, actually existed or whether his ideas should
as well as the source of mental disturbanc- properly have been attributed to Pythagoras.
es. He adopted an early notion of biologi- As the Aesculapian cult spread throughout
cal humors (i.e., naturally occurring bodily the Greek empire, numerous temples were
liquids), as well as positing the concept of erected in the main cities of the Mediterra-
emotional temperament to aid in decoding nean basin, including Rome in 300 B.C.
the origins of aberrant passions and behav- What may be best known about Aescula-
ior. The mathematical principles of balance piad temples today is the symbol of medi-
and ratio served to account for variations cal knowledge they employed: a serpent
in human characterological styles (e.g., de- wrapped around a rod. Medicine gradually
grees of moisture or dryness, the proportion evolved into a branch of philosophy in the
of cold or hot, etc.). Balances and imbal- 6th and 7th centuries B.C. No one of that
ances among humoral fundamentals would early period achieved the mythic stature
account for whether health or disease was of Aesculapius, however—the presumed
present. Possessing a deep regard for his founder of temple-based hospitals designed
“universal principles,” Pythagoras applied to execute the healing traditions in which
his ideas to numerous human, ethical, and he believed, notably a rest from life’s stres-
religious phenomena. Though he believed in sors and opportunities for positive mental
immortality and the transmigration of souls, growth. Located in peaceful and attractive
this did not deter him from making a serious settings, these temples were established to
effort to articulate the inner “equilibrium” encourage patients to believe that there were
of human anatomy and health. good reasons to want to recover. Included


among the temples’ treatment techniques cesses such as attraction and repulsion. All of
were a balanced diet, a daily massage, quiet the elements/humors could be combined, but
sleep, priestly suggestions, and warm baths, Empedocles wondered what the consequenc-
all of which were thought to comfort and es would be if they were organized in dif-
soothe patients. ferent ways. He set out to weave the several
Also of value during this early period was threads of his theory and concluded that the
the work of Alcmaeon (557–491 B.C.), pos- force of attraction (love) would be likely to
sibly a son or favorite student of Pythagoras, bring forth a harmonic unity, whereas repul-
carried out in the 5th century B.C. Alcmaeon sion (strife) would set the stage for a personal
became a philosopher-physiologist who as- breakdown or social disintegration.
serted that the central nervous system was To Empedocles, blood was a perfect rep-
the physical source of mental activity, and resentation of an equal mix of water, earth,
that cerebral metabolism was based on the air, and fire. He therefore suggested that
stability of “the humoral fluxes”; if these persons with problematic temperaments and
fluxes were imbalanced or unstable, they mental disorders would exhibit imbalances
would create shifts in cerebral tissue func- within their blood. Among his other contri-
tioning, leading then to various mental dis- butions, Empedocles posited a rudimentary
orders. Metabolic fluxes were caused by a model of an evolutionary theory, anticipat-
disequilibrium between the nervous system’s ing Darwin’s by 2,000 years. As he phrased
qualities of dry–moist and hot–cold. it, “creatures that survive are those whose
Most notable were Alcmaeon’s efforts to blood elements are accidentally compound-
track the sensory nerves as they ascended ed in a suitable way,” whereas a problematic
to the brain. He articulated, as perhaps no compounding will produce “creatures that
one else before him had done, the structural will perish and die.” To him, nature cre-
anatomy of the body through methods of ated a wide variety of healthful and perish-
careful dissection. No less significant was ing blood configurations—that is, different
his conviction that the brain, rather than the ways in which the four elements combined.
heart, was the organ of thought. As Aescu- Some philosophers disagreed with the no-
lapius reportedly did, he also anticipated the tion that the universe was composed of a
work of Empedocles and Hippocrates, in that simple and permanent element. Heraclitus
he believed that health called for a balance (530–470 B.C.), for example, proposed that
among the essential components of life— all nature was made up of fire. He asserted,
coolness versus warmth, wetness versus dry- however, that the universe was composed of
ness, and so on. The notion of fundamental no lasting substance— nothing stable, solid,
elements in balance became a central theme or enduring. All real and tangible things
in the work of Aesculapius and Alcmaeon; would inevitably vanish, change their form,
it also served to guide the views of their dis- even become their very opposites.
ciples. Alcmaeon’s “biological model” based In a similar manner, Anaxagoras (500–
on the concept of metabolic harmony, called 428 B.C.) asserted that a reduction to the basic
“isonomy,” took the place of Greek’s early elements could not explain the universe. He
mythological theology and was an extension differed from Heraclitus in that he did not
of the growing secular and democratic spirit believe the universe lacked an enduring sub-
of Greek’s 6th- century B.C. culture. stance. He asserted that an endless number
Empedocles (495–435 B.C.) adopted the ho- of qualitatively different elements existed,
meostatic model generated in the work of Py- and that the organization or arrangement
thagoras, Aesculapius, and Alcmaeon. Most of these diverse elements was central to the
significant was his proposal that the basic structure of the universe. Anaxagoras’s be-
elements of life (fire, earth, air, and water) lief that the character of these constituents
interacted with two other “principles” (love could not be explained except through the
vs. strife). Empedocles stressed that a bal- action of human thought was novel—a view
ance among the four elements could be com- similar to one asserted many centuries later
plicated by the fact that they might combine by the phenomenologists and the gestaltists,
in either a complementary or a counteractive who claimed that the structure of objective
way. Love and strife represented human ex- matter was largely in the interpretive eye of
pressions of more elementary magnetic pro- the perceiver.


Later the philosopher Democritus (460– stitions of temple medicine. The astuteness
362 B.C.), following Leucippus (ca. 445 B.C.), and prodigious work of Hippocrates high-
proposed that the universe was made of lighted the naturalistic view that the source
variously shaped atoms—small particles of of all disorders, mental and physical alike,
matter in constant motion, differing in size should be sought within the patient and not
and form, but always moving and combin- within spiritual phenomena. For example,
ing into the many complex components that the introductory notes to the Hippocratic
comprise the universe as we know it. This book on epilepsy state:
innovative speculation endures to the pres-
ent time. Extending the theme proposed a It seems to me to be no more divine and no
century earlier by Anaxagoras, Democritus more sacred than other diseases, but like other
stressed the view that all truths were relative affections, it springs from natural causes. . . .
Those who first connected this illness with de-
and subjective. As noted, he asserted that mons and described it as sacred seem to me
matter was composed of numerous invisible no different from the conjurers, purificators,
particles called atoms. Each atom was com- mountebanks and charlatans of our day. Such
posed of different shapes that combined and persons are merely concealing, under the cloak
were linked in numerous ways; again, al- of godliness, their perplexity and their inabil-
though this idea was based on pure specula- ity to afford any assistance. . . . It is not a god
tion, it was highly innovative and is regarded which injures the body, but disease.
as essentially correct to this day. The physi-
cal thesis of contemporary times known as As a number of his progenitors had done,
the Heisenberg principle also has its origins Hippocrates emphasized that the brain was
in Democritus’s speculation. the primary center of thought, intelligence,
A contemporary of Democritus, born the and emotions. It is only from within the
same year, became the great philosopher- brain, he asserted, that pleasures and joys
physician who set the groundwork for so- and laughter arise, as well as sorrows, griefs,
phisticated clinical medicine for the ensu- and tears. It is, he went on to say, this very
ing centuries. The fertility of this wondrous same source that makes us mad or delirious,
period of Grecian thought cannot be over- inspires us with dread and fear, and brings
estimated, ranging from the brilliant ideas sleeplessness, inopportune mistakes, aimless
of Democritus and Aristotle to the creative anxieties, absentmindedness, and other acts
foundations of scientific medicine by Hip- contrary to the person’s habitual ways. All
pocrates. of these stem from the brain when it is not
Hippocrates (460–367 B.C.; see Figure
1.1) was born on the island of Cos, the cen-
ter of an ancient medical school. He was the
son of an Aesculapian priest, from whom he
acquired his first medical lessons and whose
philosophy he would follow in his own future
therapeutic efforts. In the work of Hippo-
crates—the inheritor of his father’s tradition
and the humoral concepts of Pythagoras and
Empedocles— mental disorders progressed
from the magical and mythical realm, and
the demonological and superstitious thera-
peutic approaches of an earlier era, to one
of careful clinical observation and inductive
theorizing. He synthesized the practical and
sympathetic elements of the Aesculapian
cult with the more “biological” proposals
of Pythagoras, blending these elements to el-
evate mental processes and disequilibria into
a clinical science.
Thus in the 5th century B.C., truly radical
advances were made to supplant the super- FIgure 1.1. Hippocrates.


healthy (i.e., as when an imbalance exists be- They adhered closely, however, to the first
tween hot and cold or moist and dry). nonsupernatural schema that specified tem-
Hippocrates’s approach was essentially perament dimensions in accord with the
empirical, despite the growing eminence of doctrine of bodily humors. Interestingly,
philosophical thought that characterized history has come full circle, in that much of
his time. He was a practical biologist stress- contemporary psychiatry continues to seek
ing the role of bodily humors and focusing answers with reference to inner biochemical
on the use of physical treatments (notably and endocrinological processes.
diet, massage, music, and remedies promot- Hippocrates identified four basic tempera-
ing sleep and rest) rather than philosophical ments: the “choleric,” the “melancholic,” the
ones. Central to the medical practices of Hip- “sanguine,” and the “phlegmatic.” These
pocrates and his followers was the crucial corresponded, respectively, to excesses in
role given keen observation and fact gath- yellow bile, black bile, blood, and phlegm.
ering. Contrary to the work of Plato, who As elaborated by a Roman, Galen, centuries
relied on abstract hypotheses and so- called later, the choleric temperament was associ-
self-evident truths, Hippocrates focused his ated with a tendency toward irascibility; the
attention on observable symptoms, their sanguine temperament prompted an individ-
treatments, and their eventual outcomes. In ual toward optimism; the melancholic tem-
this regard, Hippocrates modeled Aristotle’s perament was characterized by an inclination
empirical orientation, emphasizing facts toward sadness; and the phlegmatic temper-
rather than abstractions. ament was conceived as an apathetic dispo-
As were a number of his forebears, Hip- sition. Although the doctrine of humors has
pocrates was convinced that dreams could long been abandoned, giving way to studies
serve as indicators of health or illness. Men- on topics such as neurohormone chemistry,
tal pathology stemmed from a disparity be- its archaic terminology still persists in con-
tween the content of dreams and that which temporary expressions such as persons being
existed in reality. Dream symbolism, as re- “sanguine” or “good-humored.”
garded by Hippocrates, led him to anticipate Hippocrates and his Cos associates were
later hypotheses concerning the operation of among the first to stress the need for a re-
“unconscious forces.” lationship between diagnosis and treatment.
Hippocrates also established the tradition The mere description of a clinical distur-
of carefully recording personal case history, bance was not sufficient for them, unless it
detailing the course and outcome of the dis- provided a clear indication of the course that
orders he observed. These histories provide therapy should follow. Indeed, Hippocrates
surprisingly accurate descriptions of such anticipated that much effort may be wasted
varied disorders as depression, phobias, in specifying diagnosis, unless followed by
convulsions, and migraine. With his associ- a consideration of its utility for therapeutic
ates at the Cos College of Medicine in Ath- decisions. Although naive in conception and
ens, he provided a logic for differentiating execution, Hippocrates’s approach to thera-
among various mental ailments—not only py followed logically from his view that dis-
those we now label the DSM-IV-TR Axis I orders were of natural origin. To supplant
syndromes, but also the Axis II personality the prevalent practices of exorcism and
types, the latter of which were construed as punishment, he recommended such varied
abnormalities of temperament. Temperament prescriptions as exercise, tranquility, diet,
was associated with the four-humors model, venesection or bloodletting where neces-
which transformed earth, fire, water, and air sary, and even marriage. Systematically (in
into their parallel bodily elements. Individu- a contemporaneous sense), Hippocrates and
als were characterized in terms of which one his colleagues devised a series of therapeutic
of the four elements predominated. Among regimens that they believed would reestab-
other clinical syndromes differentiated were lish the humoral balance thought to underlie
delirium, phobia, hysteria, and mania. Lack- most diseases; they also employed surgical
ing precise observations of bodily structure, techniques such as trephining to relieve pur-
and prevented by taboo from performing ported pressure on the brain.
dissections, Hippocratic physicians pro- Several themes relevant to the mind and
posed hypothetical explanations of disease. its difficulties characterize Plato’s (429–347


B.C.) work: (1) Powerful emotional forces pirical observables in order to minimize the
could come to the foreground and overwhelm risk of subjective misinterpretations. Despite
the everyday behavior typifying a person’s these reservations, Aristotle believed that
life; (2) conflicts could exist between differ- thought transcended the sensory realm. As
ent components of the psyche (e.g., the per- he saw it, imagination could create thoughts
sonal discord that often arises between an of a higher order of abstraction than could
individual’s rational side—that which is de- sensations themselves.
sired—and the surge of emotional feelings); Yet not all matters were successfully
and (3) mental disorders did not result from brought within Aristotle’s purview. De-
simple ignorance, but from irrational super- spite growing evidence that the brain was
stitions and erroneous beliefs. To Plato, all the center of thought and emotion, Aris-
humans were partly animal-like; hence all totle retained the erroneous belief that the
humans acted irrationally at times—some heart served as the seat of these psychologi-
more, some less. He found evidence for these cal experiences. He made keen and signifi-
conclusions in dreams, where bizarre events cant observations, however, in recognizing
invariably occur and unnatural connections the psychological significance of cognitive
among thoughts and images are dominant. processes, dreams, and emotional cathar-
Not to be overlooked was his contention ses. For example, it was Aristotle who said
that therapeutic efforts could modify any that events, objects, and people were linked
and all forms of mental illness. For Plato, the by their relative similarity or their relative
use of educational procedures could dispel difference from one another. To Aristotle,
ignorance and uncover “truth” through the things became “associated” if they occurred
application of fundamental principles. No together; in this, he was clearly a forerunner
less important with regard to therapy was of the associationist school of the 18th and
Plato’s use of a dialectical model to change 19th centuries. Aristotle viewed dreams as
a patient’s cognitions and belief systems. In afterimages of the activities of the preceding
this regard, Plato’s philosophy provided a day. Although he recognized that dreams
methodology for engaging in therapy, essen- might fulfill a biological function, he judged
tially the application of rational discussions the content of dreams to be ideal gauges of
to modify faulty cognitions (shades of con- potential pathology. He had a specific inter-
temporary cognitive therapies!). est in how physical diagnoses could be de-
Plato had many distinguished students, duced from dream content.
the most eminent of whom was Aristo- Aristotle’s scope was exceptionally broad
tle (384–322 B.C.). Though he was Plato’s and inventive. It was he who wrote most per-
student for over 20 years, Aristotle turned ceptively of the intellectual and motivational
sharply away from Plato and toward matters features of the mind from the viewpoint of
more realistic and tangible than abstract a natural scientist. Thus, in what might be
and idealistic. Some would say that Aristotle termed a psychobiological theory, he out-
provided history’s first integrated and sys- lined the basics of human perception and ra-
tematic accounts not only of psychological tional thought, stressing the importance and
matters, but of astronomy, physics, zoology, validity of sense impressions as the source
and politics. The last of the great philoso- for an objective form of experimental study.
phers of the 4th century B.C., Aristotle was Along the same lines, Aristotle articulated a
more scientist than philosopher. He gave series of proposals concerning the nature of
special attention to the need for experimen- learning—a model based on the principles of
tal verification and the use of sensory-based association and reinforced by what we have
observable data; in fact, he was the first of come to term the “pleasure principle.” Simi-
the major philosophers to take an inductive larly, he emphasized the importance of early
and empirical approach in his writings. He experience and education in the acquisition
was interested in the concrete observables of of skills, and the role of habit and practice in
experience as registered through the senses. the formation of psychological attitudes. To
Although he admired the abstract rational- him, the processes of development were key
ism of Plato, he was much more disposed to themes in understanding human behavior.
deal with the tangible world than with high- When Aristotle left Athens in the year
order abstractions or broad principles. He 322 B.C., following the death of Alexander
believed that data should be grounded in em- the Great, he arranged to have his associate


Theophrastus (371–286 B.C.) succeed him as or conflicts, but by the periodic enlargement
head of the Lyceum. Shortly thereafter, Ar- or excessive tightening of the pores in the
istotle, alone and despondent over the turn brain. In this corpuscular hypothesis, a de-
of political events in Athens, died in exile. rivative of the atomistic notions of Democri-
Theophrastus was only a decade younger tus of Greece, the task of the mental healer
than Aristotle and had come to Athens to was to confirm and normalize the diameter
study with Plato. He and Aristotle had been of the pores. Persons with certain mental ill-
friends, joined together in their travels and nesses were seen as apathetic, fearful, and
shared in their study of nature. Theophras- in a depressed mood, by what was called a
tus remained head of the Lyceum for some laxum state. Those with other disorders pre-
30 years. Perhaps most significant was the sented an excited, delirious, and aggressive
attention Theophrastus paid to the study of appearance; they were in a strictum state.
botany, establishing him as the true founder If both sets of these symptoms co-occurred,
of that science, just as Aristotle’s works es- there was a mixtum state.
tablished the field of zoology. A follower of the vitalist school of thought
A prolific and sophisticated thinker, Theo- that adopted the concept of pneuma, the
phrastus wrote no less than 220 treatises on natural or animal spirit, as the physical em-
a variety of different topics. Although this bodiment of the soul, Aretaeus (30–90 A.D.)
diversity of work was substantial, he became was little known in his time and was rarely
best known for a secondary aspect of his ca- quoted by fellow Roman scholars. This was
reer, the writing of personality sketches he probably owing to the fact that his works
called “characters.” Each of these portray- were written in the Ionic dialect rather than
als emphasized one or another psychologi- in Latin or Greek. Furthermore, his vital-
cal trait, providing a vignette of various per- istic philosophy, based on the fluidity of
sonality “types” (e.g., individuals who were the soul’s nature, and adopted by Galen a
flatterers, garrulous, penurious, tactless, century later, rivaled the more atomistic or
boorish, surly, etc.). solidistic corpuscular theory of his contem-
Whether these portrayals were penetrat- porary Roman thinkers. Scarcely familiar
ing or poignant, Theophrastus (as well as with the Greek language and its medical
later novelists) was free to write about his philosophies, Aretaeus was a born clinician
subjects without the constraints of psy- who was retained as a physician for the rul-
chological or scientific caution. Such lively ing Roman classes.
and spirited characterizations most assur- According to Aretaeus, the vicissitudes of
edly captured the interest of many, but they the soul served as the basis of psychic dis-
could also often mislead their readers about turbances. Specifically, the interconnecting
the true complexities of natural personality linkages among “solid organs, the humours,
patterns. and the pneuma” generated all forms of
Although the beginning and ending of the mental aberration. For example, anger and
Roman period cannot be sharply demarcat- rage stirred the yellow bile, thereby warming
ed, it basically spanned a 12-century period the pneuma, increasing brain temperature,
from the 7th century B.C. to the 5th century and resulting in irritability and excitabil-
A.D., when the last of the major Roman em- ity. Conversely, fear and oppression stirred
perors was deposed. As a formal organiza- black bile, augmenting its concentration in
tion, the Roman Republic dated from the the blood, and thus leading to a cold pneu-
5th century B.C. to the 3rd century A.D. ma and consequent melancholy.
The more cultured classes of Rome were Disturbances of consciousness usually re-
determined to eliminate magic and supersti- sulted from the sudden diminishing of the
tion as elements in considering psychic pro- strength of the pneuma around the heart.
cesses. A mechanistic conception of mental Aretaeus’s descriptions of epilepsy were no-
disorders came to the foreground; it was tably impressive. He spoke of its premoni-
fundamentally materialistic and opposed to tory symptoms, such as vertigo and nausea,
all transcendental mythologies, which were the perception of sparks and colors, and the
regarded as superstitious beliefs that origi- perception of harsh noises or nauseating
nated from fear and ignorance. Mental dis- smells. Aretaeus also described the origins
orders were caused not by the action of mys- and characteristics of fanaticism; he for-
terious forces, nor by biohumoral movements mulated a primitive psychosomatic hypoth-


esis in stating that emotions could produce acteristics of his patients, contending that a
problematic effects on humoral metabolism, clear demarcation could be made between
noting that “the black bile may be stirred by the basic personality disposition of a patient
dismay and immoderate anger.” Similarly, and the form in which a symptomatic and
he formulated what we speak of as cyclothy- transient disorder manifested itself periodi-
mia in describing the alternation of depres- cally.
sion with phases of mania. He stated, “Some No less important was Aretaeus’s speci-
patients after being melancholic have fits of fication of the premorbid conditions of pa-
mania . . . so that mania is like a variety of tients; he viewed these conditions as forms of
melancholy.” In discussing the intermittent vulnerability or susceptibility to several clin-
character of mania, he recognized its several ical syndromes. As Aretaeus phrased this,
variants, speaking of one type as arising in he found that persons disposed to mania are
subjects “whose personality is characterized characteristically “irritable, violent, easily
by gayness, activity, superficiality, and child- given to joy, and have a spirit for pleasantry
ishness.” Other types of mania were more or childish things.” By contrast, those prone
expansive in which the patient “feels great to depression and melancholia were seen as
and inspired. Still others become insensitive characteristically “gloomy and sad often
. . . and spend their lives like brutes.” realistic yet prone to unhappiness.” In this
Perceptive observations by Aretaeus manner, Aretaeus elaborated those essen-
strengthened the notion of mental disorders tially normal traits that make an individual
as exaggerated normal processes. He assert- susceptible to a clinical state. As Zilboorg
ed that a direct connection existed between and Henry (1941) have noted, the melancho-
an individual’s normal characteristics of per- lia of Aretaeus is still observed in our time,
sonality and the expression of the symptoms although under different psychiatric labels.
the individual displayed when afflicted. His Owing to his observations of patients over
insightful differentiation of disorders ac- extended periods of time, Aretaeus proposed
cording to symptom constellations (i.e., syn- a series of predictions about the general out-
dromes) was a striking achievement for his comes of different mental conditions. More
day. than other physicians of his day, Aretaeus
Although Hippocrates may have been the not only described psychological conditions
first to provide a medical description of de- with keen sensitivity and humane under-
pression, it was Aretaeus who presented a standing, but (in a spirit more akin to recent
complete and modern portrayal of the dis- scientific work) sought to compare various
order. Moreover, Aretaeus proposed that clinical syndromes and illuminate ways in
melancholia was best attributed to psycho- which they could be differentiated.
logical causes (i.e., that it had nothing to do Claudius Galenus (Galen) (131–201; see
with bile or other bodily humors). As noted, Figure 1.2) was the last major contributor to
he may have been the first to recognize the adopt a psychological perspective in Rome.
covariation between manic behaviors and He preserved much of the earlier medical
depressive moods, antedating the views of knowledge, yet generated significant new
many clinical observers in the 16th and 17th themes of his own. Galen lived more than
centuries. 600 years after the birth of Hippocrates. A
Aretaeus was also a major contribu- Greek subject of the Roman Empire, he was
tor to the humanistic school of thought in born in Asia Minor about 131 A.D. During
early Rome. Most notably, he introduced his mature years, numerous radical political
long-term follow-up studies of patients. He and cultural changes took place in Rome.
tracked their lifetime course, their periodic Galen and his medical associates set out to
disease manifestations, and their return to synthesize primitive conceptions of disease
a more normal pattern of behavior; in this with then-modern methods of curing the
regard, he anticipated the authoritative writ- sick. Following the ideas of Hippocrates, he
ings of Emil Kraepelin, who recognized the stressed the importance of observation and
course of an illness as a key factor in dis- the systematic evaluation of medical pro-
criminating a specific disorder from others cedures, arguing against untested primitive
of comparable appearance. He seriously and philosophical hypotheses in favor of
studied the sequence and descriptive char- those based on empirical test. As a follower


whose damaging effects would cause neuro-
logical symptoms; and those that had more
directive functions, such as coordinating and
organizing imagination, reason, and memo-
ry. To him, most psychiatric symptomatol-
ogy stemmed from alterations of the second
group of functions.
In describing catatonic psychosis, Galen
suggested a paralysis of the animal spirits in
which the imaginative faculty was “blocked
or incomplete.” As far as the syndrome of
hysteria was concerned, he disagreed strong-
ly with Hippocrates’s uterocentric view.
Galen asserted that hysteria, on the basis of
his own clinical examinations, could not be
a disease that reflected the uterus “wander-
ing agitated in the body.” As he saw it, hys-
terical symptoms were provoked by the toxic
action of vapors that formed in the normal
FIgure 1.2. Galen. uterus and vagina; it arose from the stagna-
tion of semen, owing to a lack of sufficient
sexual intercourse. The disease therefore sig-
of Aristotle as well as Hippocrates, Galen nified a lack of sexual hygiene.
emphasized the data of experience, rather Galen’s stature grew over the next mil-
than logical hypotheses that were devoid of lennium—so much so that his views were
factual evidence. Unfortunately, he doubted thought to be sacrosanct. His writings were
that environmental and psychological fac- summarized and commented on by many
tors could affect the course of human dis- lesser physicians, most of whom were recog-
ease. Although Galen avoided philosophical nized as being wrong-headed; indeed, their
themes concerning the nature of illness, he books were often referred to as “wretched
nevertheless proposed a principle termed treatises.” Some of these post-Galen compi-
spiritus anima, in which he asserted that hu- lations were not based on his work at all, but
mans possessed an extraphysical life-giving dishonestly carried his name for its ability to
force; this thesis was based on his efforts to promote the sale of untenable or alien ideas.
distinguish organic from inorganic matter. Although many of his notions were diluted
Galen’s conception of psychic pathology by the passage of time or refuted by empiri-
was based on the physiology of the central cal knowledge, his vast contributions must
nervous system. He viewed clinical symp- be considered significant, in that no other
toms as signs of dysfunctional neurological figure in history exercised so extended an
structures and characterized mental dis- influence on the course of medicine.
eases as “a concourse of symptoms,” among Later in Roman history, there emerged an
which a specifically pathognomonic one organized theology known as Christianity,
could be isolated. According to his organic- including faith healing, magic, and super-
functional approach, mental symptoms orig- stition. The doctrine of the early Christian
inated from the pathogenic action of a toxic, church became the dominant approach to
humoral, vaporous, febrile, or emotional thought, medicine, and mental healing in
factor that affected the brain physically the Western world until the 17th century.
and then altered certain of its psychic func- Most of the populace remained illiterate
tions. Consonant with the beliefs of his time, during this period. Education was religious,
Galen believed that the activities of the mind otherwise inchoate, and of dubious value.
were prompted by animal spirits that carried The idea of a scientific basis for understand-
out both voluntary and involuntary actions. ing mental disorders barely appeared on the
These animalistic spirits (pneuma) were di- scene. Faith was the all-powerful guide.
vided by Galen into two groups: those that During the first two to three centuries
controlled sensory perceptions and motility, A.D., a distinction was made between psy-


chologically normal individuals who doubt- end of the first millennium A.D. are worthy
ed the dogma of the church’s ideology, and of note: Rhazes, Unhammad, and Avicen-
those whose “peculiar” beliefs arose not na. Each proposed helpful ideas that came
out of opposition, but out of a mental af- to represent a fresh and innovative point of
fliction. Nevertheless, both groups were view concerning mental illness.
considered guilty of heresy and subjected to Rhazes (860–930) lived during the late
punishment. In a similarly irrational twist, 9th and early 10th centuries and wrote
others’ implausible or nonsensical behavior textbooks dealing with a wide variety of
ostensibly demonstrated their fervent adher- medical, psychological, philosophical, and
ence to church authorities and their dogma. religious subjects. In contrast to the pre-
Such persons were venerated. It was not long dominant religious orientation of Baghdad,
thereafter that the works of Aristotle and Rhazes strongly argued against the notion
other Greek philosophers were condemned. of a demonological concept of disease and
Christianity in the 3rd century led physi- the use of arbitrary authority to determine
cians to assume a moralistic and judgmental what is scientific and what is not. He at-
approach to psychic pathology. Unable to tacked the superstitious religious beliefs of
escape the growing spirit of superstitious- his contemporaries and was strongly in favor
ness, they proposed that mental cases were of developing a rational schema for under-
definitely the products of mystical events standing all disorders. Empirically oriented,
that could not be understood in the natu- he nonetheless subscribed to the theory of
ral world. More seriously, they adopted the the four elements originally developed by
ancient belief that demons often appeared Empedocles and Hippocrates.
under the guise of confused humans, and Unhammad (870–925) was a contem-
that it was the job of physicians to identify porary of Rhazes who provided intelligent
and to “eliminate” them. In this and other descriptions of various mental diseases. The
similar matters, they laid the groundwork observations he compiled of his patients re-
for a return to the age of supernaturalism sulted in a nosology that was the most com-
and superstitions; they were nevertheless plete classification of mental disorders in its
thought well of until the close of the 17th day. Unhammad described nine major cat-
century. egories of mental disorders, which, as he saw
Aurelius Augustine (354–430) was a key it, included 30 different diseases. Among
figure in the transition from early Roman the categories was an excellent description
thought to the Middle Ages. Better known of anxious and ruminative states of doubt,
as St. Augustine of Hippo, we can see in his which correspond in our thinking today
writings an effort to synthesize the Greek with compulsions and obsessions. Other cat-
and the new Christian perspectives on men- egories of mental disease were judged by Un-
tal maladies. Perhaps the most influential hammad to be degenerative in their nature;
philosopher of his time, Augustine set the a few were associated with the involutional
foundation and tone of Christian intellec- period of a man’s life. The term used by the
tual life for centuries to come. To him, all Greeks for mania was borrowed to describe
knowledge was based on the belief that only states of abnormal excitement. Another cat-
God could provide the ultimate truth, and egory, most closely associated with grandi-
that to know God was the ultimate goal. ose and paranoid delusions, manifested it-
To think otherwise, as Augustine averred, self, according to Unhammad, in the mind’s
would not only be vain, but would assuredly tendency to magnify all matters of personal
lead to error and corruption. Individuals, as significance, often leading to actions that
children of God, would in their faith begin proved outrageous to society.
to understand the very nature of life, and A most significant and influential philoso-
thereby would be able to lead a life of grace pher and physician of the Muslim world was
and honor. Avicenna (980–1037), often referred to as the
“Galen of Islam,” largely as a consequence
of his vast and encyclopedic work called the
the early Muslim World
Canon of Medicine. The Canon became the
Three major medical figures from the Mus- medical textbook chosen throughout Eu-
lim world of the Middle East around the ropean universities from the 10th through


the 15th centuries. However, Avicenna was demic manias spread throughout other parts
not regarded as a highly original writer, but of Europe, where they were known as St.
rather as a systematizer who encompassed Vitus’s Dance.
all knowledge from the past that related to During the early Middle Ages, before later
medical events. Similar to Galen, Avicenna catastrophes of pestilence and famine, few
noted the important connection between people with mental illnesses were totally
intense emotions and various medical and destitute. Monasteries served as the chief
physiological states, although he fully ac- refuge for such individuals, providing prayer,
cepted Hippocrates’s humoral explanations incantation, holy water, relic touching, and
of temperament and mental disorder. To mild exorcism as prescriptions for cure. As
his credit as a sophisticated scholar of the the turmoil of natural calamity grew more
brain, Avicenna speculated that intellectual severe, mental disorders were equated in-
dysfunctions were in large part the results of creasingly with sin and Satanic influence.
deficits in the brain’s middle ventricle, and Significant advances were made in agricul-
asserted that common sense and reasoning ture, technology, and architecture during
were mediated by the frontal areas of the the Middle Ages, but the interplay between
brain. changing theological beliefs and naturalistic
catastrophe speeded acceptance of the belief
that “madness” and “depravity” were the
the Middle ages devil’s work. At first, it was believed that
the devil had seized mentally ill individuals
The enlightened ideas of Hippocrates were against their will, and such individuals were
submerged for centuries after the death of treated with established exorcistic practices.
Galen and the fall of the Roman Empire. Soon, however, the afflicted were consid-
During the thousand years of the so- called ered willing followers of Satan; classed now
Dark Ages, superstition, demonology, and as witches, they were flogged, starved, and
exorcism returned in full force and were fur- burned.
ther intensified by sorcery and witch burn- Among the major tenets of this medieval
ing. With few dissenting voices during this mythology was a belief that an international
period, the naturalism of the Greco-Roman conspiracy, based on Satanic forces, was bent
period was all but condemned or distorted on destroying all forms of Christianity. The
by notions of magic. Only in the Middle agents of this widespread conspiracy were
East did the humane and naturalistic aspects witches, who not only worshipped Satan at
of Hippocratic thought remain free of the secret meetings, but attempted to desecrate
primitivism and demonology that overcame Christian symbols and beliefs, as well as to
Europe. engage in murder, cannibalism, and sexual
Signs for detecting demonic possession orgies. The ideas of a demonic and Satanic
became increasingly indiscriminate in the conspiracy existed first and foremost in the
Christian world. During epidemics of fam- imagination of the religious leaders of the
ine and pestilence, thousands wandered day. It was Pope Gregory IX who established
aimlessly until their haggard appearance the Inquisition in 1233 to root out witches,
and confusion justified the fear that they heretics, and all other agents of Satan, who
were cursed. The prevalent turmoil, the fear he asserted were setting out rapidly to de-
of one’s own contamination, and the frenet- stroy the clerical and political orders of the
ic desire to prove one’s spiritual purity led Church. Those with an administrative status
widespread segments of the populace to use possessed the legal right to judge which as-
these destitute and ill roamers as convenient pects of Satanic witchcraft would be deemed
scapegoats. demonic. It was not only higher-order reli-
As the terrifying uncertainties of medieval gious leaders who conveyed this dogma; the
life persisted, fear led to wild mysticism and common people took these belief systems to
mass pathology. Entire societies were swept heart, as well. From the 15th through the
up simultaneously. Epidemic manias of rav- 17th century, demonic possession and exor-
ing, jumping, drinking, and wild dancing cism became common phenomena among
were first noted in the 10th century. Re- the masses. In the postmedieval period,
ferred to as “tarantism” in Italy, these epi- both Catholics and Protestants believed that

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