Who suggested abnormal behavior is caused by an imbalance of 4 bodily fluids?

Lacking scientific information or ways to think about or approach situations, people in the past turned to other explanations for what caused mental disorders. It was common for them to believe that people with psychological disorders, or those exhibiting strange behavior, were possessed by demons or were being punished by God or gods for their sins. Following that logic, treatment involved forcing those afflicted to take part in exorcisms, suffer imprisonment, or even face execution.

Wilhelm Griesinger (1817–1868), is remembered for initiating reforms in the treatment of the mentally ill as well as introducing changes to the existing asylum system. Griesinger believed in the integration of the mentally ill into society and proposed that short-term hospitalization be combined with the close cooperation of natural support systems. He also provided valuable insights on the nature of psychopathic or antisocial behavior (characterized by persistent antisocial behavior, impaired empathy and remorse, and bold, disinhibited, and egotistical traits). Griesinger wrote, “Psychiatry has undergone a transformation in its relation to the rest of medicine. . . . This transformation rests principally on the realization that patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain.” Much later, asylums were built to house the mentally ill, but the patients received little to no treatment, and many of the methods used were cruel. During the 1800s, Philippe Pinel and Dorothea Dix argued for more humane treatment of people with psychological disorders.

Figure 1. This painting by Francisco Goya, called The Madhouse, depicts a mental asylum and its inhabitants in the early 1800s. It portrays those with psychological disorders as victims.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals, with an emphasis on short-term stays. However, most people suffering from mental illness are not hospitalized. A person suffering symptoms could speak with a primary care physician, who most likely would refer him to a psychiatrist or to someone who specializes in therapy. The person can receive outpatient mental health services from a variety of sources, including psychologists, psychiatrists, marriage and family therapists, school counselors, clinical social workers, and religious personnel. These therapy sessions would be covered through insurance, government funds, or private (self) pay.

Ancient Views on Mental Illness

Throughout history there have been three general theories of the etiology of mental illness: supernatural, somatogenic, and psychogenic. Supernatural theories attribute mental illness to possession by evil or demonic spirits, displeasure of gods, eclipses, planetary gravitation, curses, and sin. Somatogenic theories (from the Greek word soma meaning body, therefore biological causes) identify disturbances in physical functioning resulting from either illness, genetic inheritance, brain damage, or imbalance. Psychogenic theories focus on traumatic or stressful experiences, maladaptive learned associations, and cognitions, or distorted perceptions. Etiological theories of mental illness determine the care and treatment mentally ill individuals receive. As we will see below, an individual believed to be possessed by the devil will be viewed and treated differently from an individual believed to be suffering from an excess of yellow bile. Their treatments will also differ, from exorcism to blood-letting. The theories, however, remain the same. They coexist as well as recycle over time.

Trephination, as a treatment, is an example of possibly the earliest supernatural explanation for mental illness (Figure 2). Examination of prehistoric skulls and cave art from as early as 6500 BC has identified surgical drilling of holes in skulls to treat head injuries and epilepsy as well as to allow the evil spirits trapped within the skull, that were presumed to be causing the symptoms of mental disorder, to be released (Restak, 2000). Trephination ultimately fell out of favor as a treatment for psychological disorders.

Figure 2. Evidence of the ancient practice of trephination.

Around 2700 BC, Chinese medicine’s concept of complementary positive and negative bodily forces (yin and yang) attributed mental (and physical) illness to an imbalance between these forces. As such, a harmonious life that allowed for the proper balance of yin and yang and movement of vital air was essential (Tseng, 1973) to health and a good life.

Mesopotamian and Egyptian papyri from 1900 BC describe women suffering from mental illness resulting from a wandering uterus (later named hysteria by the Greeks): the uterus could become dislodged and attached to parts of the body like the liver or chest cavity, preventing their proper functioning or producing varied and sometimes painful symptoms. As a result, the Egyptians, and later the Greeks, also employed a somatogenic treatment of strong-smelling substances to guide the uterus back to its proper location (pleasant odors to lure and unpleasant ones to dispel).

Throughout classical antiquity, we see a return to supernatural theories of demonic possession or godly displeasure to account for abnormal behavior that was beyond the person’s control. Temple attendance with religious healing ceremonies and incantations to the gods were employed to assist in the healing process. Hebrews saw madness as punishment from God so treatment consisted of confessing sins and repenting. Physicians were also believed to be able to comfort and cure madness, however.

Greek physicians rejected supernatural explanations of mental disorders. It was around 400 BC that Hippocrates (460–370 BC) attempted to separate superstition and religion from medicine by systematizing the belief that a deficiency in or especially an excess of one of the four essential bodily fluids (i.e., humors)—blood, yellow bile, black bile, and phlegm—was responsible for physical and mental illness. For example, someone who was too temperamental suffered from too much blood and thus blood-letting would be the necessary treatment. Hippocrates classified mental illness into one of four categories—epilepsy, mania, melancholia, and brain fever—and like other prominent physicians and philosophers of his time, he did not believe mental illness was shameful or that mentally ill individuals should be held accountable for their behavior. Mentally ill individuals were cared for at home by family members and the state shared no responsibility for their care. Humorism remained a recurrent somatogenic theory up until the 19th century.

While Greek physician Galen (AD 130–201) rejected the notion of a uterus having an animistic soul, he agreed with the notion that an imbalance of the four bodily fluids could cause mental illness. He also opened the door for psychogenic explanations for mental illness by allowing for the experience of psychological stress as a potential cause of abnormality. Galen’s psychogenic theories were ignored for centuries, however, as physicians attributed mental illness to physical causes throughout most of the millennium.

Mental Health during the Middle Ages

By the late Middle Ages, economic and political turmoil threatened the power of the Roman Catholic Church. Between the 11th and 15th centuries, supernatural theories of mental disorders again dominated Europe, fueled by natural disasters like plagues and famines that laypeople interpreted as brought about by the devil. Superstition, astrology, and alchemy took hold, and common treatments included prayer rites, relic touching, confessions, and atonement. Beginning in the 13th century, the mentally ill, especially women, began to be persecuted as witches who were possessed. At the height of the witch hunts during the 15th through 17th centuries, with the Protestant Reformation having plunged Europe into religious strife, two Dominican monks wrote the Malleus Maleficarum (1486) as the ultimate manual to guide witch hunts. Johann Weyer and Reginald Scot tried to convince people in the mid-to late-16th century that accused witches were actually women with mental illnesses and that mental illness was not due to demonic possession but to faulty metabolism and disease, but the Church’s Inquisition banned both of their writings. Witch-hunting did not decline until the 17th and 18th centuries, after more than 100,000 presumed witches had been burned at the stake (Schoeneman, 1977; Zilboorg & Henry, 1941).

Also during medieval times, a person with mental illness might be considered to be possessed by demons. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: incantations and prayers were said over the person’s body, and they may have been given some medicinal drinks. Trephining was also practiced during this time—a small hole was made in the afflicted individual’s skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly. The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil.

Supernatural Perspectives of Psychological Disorders

Convents throughout Europe in the 16th and 17th centuries reported hundreds of nuns falling into a state of frenzy in which the afflicted foamed at the mouth, screamed and convulsed, sexually propositioned priests, and confessed to having carnal relations with devils or Christ. Although today these cases would suggest serious mental illness, at the time, these events were routinely explained as possession by devilish forces (Waller, 2009a). Similarly, grievous fits by young girls are believed to have precipitated the witch panic in New England late in the 17th century (Demos, 1983). Such beliefs in supernatural causes of mental illness are still held in some societies today; for example, beliefs that supernatural forces cause mental illness are common in some cultures in modern-day Nigeria (Aghukwa, 2012).

Dig Deeper: Dancing Mania

Figure 3. In The Extraction of the Stone of Madness, a 15th century painting by Hieronymus Bosch, a practitioner is using a tool to extract an object (the supposed “stone of madness”) from the head of an afflicted person.

Between the 11th and 17th centuries, a curious epidemic swept across Western Europe. Groups of people would suddenly begin to dance with wild abandon. This compulsion to dance—referred to as dancing mania—sometimes gripped thousands of people at a time (Figure 2). Historical accounts indicate that those afflicted would sometimes dance with bruised and bloody feet for days or weeks, screaming of terrible visions and begging priests and monks to save their souls (Waller, 2009b). What caused dancing mania is not known, but several explanations have been proposed, including spider venom and ergot poisoning (“Dancing Mania,” 2011).

Figure 4. Although the cause of dancing mania, depicted in this painting, was unclear, the behavior was attributed to supernatural forces.

Historian John Waller (2009a, 2009b) has provided a comprehensive and convincing explanation of dancing mania that suggests the phenomenon was attributable to a combination of three factors: psychological distress, social contagion, and belief in supernatural forces. Waller argued that various disasters of the time (such as famine, plagues, and floods) produced high levels of psychological distress that could increase the likelihood of succumbing to an involuntary trance state. Waller indicated that anthropological studies and accounts of possession rituals show that people are more likely to enter a trance state if they expect it to happen, and that entranced individuals behave in a ritualistic manner, their thoughts and behavior shaped by the spiritual beliefs of their culture. Thus, during periods of extreme physical and mental distress, all it took were a few people—believing themselves to have been afflicted with a dancing curse—to slip into a spontaneous trance and then act out the part of one who is cursed by dancing for days on end.

From the Middle Ages to the Twentieth Century

By the 18th century, people who were considered odd and unusual were placed in asylums. Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

In the late 1700s, a French physician, Philippe Pinel, argued for the more humane treatment of the mentally ill. Pinel suggested that they be unchained and talked to, and that’s just what he did for patients at La Salpêtrière in Paris in 1795. Patients benefited from this more humane treatment, and many were able to leave the hospital.

Figure 5. This painting by Tony Robert-Fleury depicts Dr. Philippe Pinel ordering the removal of chains from patients at the Salpêtrière asylum in Paris.

In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States. She investigated how those who are mentally ill and poor were cared for, and she discovered an underfunded and unregulated system that perpetuated abuse of this population (Tiffany, 1891). Horrified by her findings, Dix began lobbying various state legislatures and the U.S. Congress for change (Tiffany, 1891). Her efforts led to the creation of the first mental asylums in the United States.

Figure 6. Dorothea Dix was a social reformer who became an advocate for the indigent insane and was instrumental in creating the first American mental asylum. She did this by relentlessly lobbying state legislatures and Congress to set up and fund such institutions.

Despite reformers’ efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades. At Willard Psychiatric Center in upstate New York, for example, one treatment was to submerge patients in cold baths for long periods of time. Electroshock treatment was also used, and the way the treatment was administered often broke patients’ backs; in 1943, doctors at Willard administered 1,443 shock treatments (Willard Psychiatric Center, 2009). (Electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many of the wards and rooms were so cold that a glass of water would be frozen by morning (Willard Psychiatric Center, 2009). Willard’s doors were not closed until 1995. Conditions like these remained commonplace until well into the 20th century.

European psychiatry in the late 18th century and throughout the 19th century struggled between somatogenic and psychogenic explanations of mental illness, particularly hysteria, which caused physical symptoms such as blindness or paralysis with no apparent physiological explanation. Franz Anton Mesmer (1734–1815), influenced by contemporary discoveries in electricity, attributed hysterical symptoms to imbalances in a universal magnetic fluid found in individuals, rather than to a wandering uterus (Forrest, 1999). James Braid (1795–1860) shifted this belief in mesmerism to one in hypnosis, thereby proposing a psychogenic treatment for the removal of symptoms. At the time, famed Salpetriere Hospital neurologist Jean-Martin Charcot (1825–1893), and Ambroise Auguste Liébault (1823–1904) and Hyppolyte Bernheim (1840–1919) of the Nancy School in France, were engaged in a bitter battle over the best explanation for hysteria, with Charcot maintaining that the hypnotic suggestibility underlying hysteria was a neurological condition while Liébault and Bernheim believed it to be a general trait that varied in the population. Josef Breuer (1842–1925) and Sigmund Freud (1856–1939) would resolve this dispute in favor of a psychogenic explanation for mental illness by treating hysteria through hypnosis, which eventually led to the cathartic method that became the precursor for psychoanalysis during the first half of the 20th century.

Emil Kraepelin (1856–1926) was a German psychiatrist. H.J. Eysenck’s Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology, and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated psychiatry at the start of the 20th century and, despite the later psychodynamic influence of Sigmund Freud and his disciples, enjoyed a revival at century’s end. Kraepelin announced that he had found a new way of looking at mental illness, referring to the traditional view as “symptomatic” and to his view as “clinical.” This turned out to be his paradigm-setting synthesis of the hundreds of mental disorders classified by the 19th century, grouping diseases together based on classification of syndrome—common patterns of symptoms over time—rather than by simple similarity of major symptoms in the manner of his predecessors. Drawing on his long-term research, and using the criteria of course, outcome, and prognosis, he developed the concept of dementia praecox, which he defined as the “sub-acute development of a peculiar simple condition of mental weakness occurring at a youthful age.” This led Kraepelin to name what we now know as schizophrenia, dementia praecox (the dementia part signifying the irreversible mental decline). As a colleague of Alois Alzheimer, he was a co-discoverer of Alzheimer’s disease (thought to be a brain disease leading to dementia), and his laboratory discovered its pathological basis. This may have led to the medical model of illness. 

As we will discuss later in this course, in psychology, the term medical model refers to the assumption that psychopathology is the result of one’s biology, that is to say, a physical/organic problem in brain structures, neurotransmitters, genetics, the endocrine system, etc., as with traumatic brain injury, Alzheimer’s disease, or Down’s syndrome. One aspect of such a model is that an ill patient should not be held responsible for the condition. The patient should not be blamed or stigmatized for the illness. The medical model is useful in many situations as a guide for diagnosis, prognosis, and research. However, for most mental disorders, exclusive reliance on the medical model leads to an incomplete understanding, and, frequently, to incomplete or ineffective treatment interventions.

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Glossary

asylum: institution created for the specific purpose of housing people with mental disorders

deinstitutionalization: process of closing large asylums and integrating people back into the community where they can be treated locally

dementia praecox: a “premature dementia” or “precocious madness”

etiology: the causal description of all of the factors that contribute to the development of a disorder or illness

humorism (or humoralism): a belief held by ancient Greek and Roman physicians (and until the 19th century) that an excess or deficiency in any of the four bodily fluids, or humors—blood, black bile, yellow bile, and phlegm—directly affected their health and temperament

hysteria: term used by the ancient Greeks and Egyptians to describe a disorder believed to be caused by a woman’s uterus wandering throughout the body and interfering with other organs (today referred to as functional neurological symptom disorder, or conversion disorder, in which psychological problems are expressed in physical form)

mesmerism: derived from Franz Anton Mesmer in the late 18th century, an early version of hypnotism in which Mesmer claimed that hysterical symptoms could be treated through animal magnetism emanating from Mesmer’s body and permeating the universe (and later through magnets); later explained in terms of high suggestibility in individuals

psychogenesis: developing from psychological origins

psychopathic: a personality disorder characterized by persistent antisocial behavior; impaired empathy and remorse; and bold, disinhibited, and egotistical traits

somatogenesis: developing from physical/bodily origins

supernatural: developing from origins beyond the visible observable universe

stigma: social attitudes and prejudice against persons who are different that devalue the person or make them feel disgraced or ashamed and that can lead to exclusion or discrimination against others

syndrome: common patterns of symptoms over time

trephination: the drilling of a hole in the skull, presumably as a way of treating psychological disorders

Who discovered abnormal behavior?

What did Hippocrates believe was the cause of abnormal behavior?

Which Greek physician developed the theory that psychological disorders are caused by imbalances in bodily fluids?

What are the 4 D's in abnormal psychology?