The neuroses and the birth of the psychotherapies

The study of the neuroses, in which the relations between psychiatry and neurology were also involved, resulted in completely different, but equally important, changes to psychiatry as a medical specialty. The term neurosis had been coined in 1769 by Cullen to describe a class of diseases he attributed to a dysfunction of the nervous system. In this very heterogenous group, two entities of very ancient origin, hysteria and hypochondriasis, had predominantly psychological manifestations. Since the affected patients were not usually commited to asylums, they were not normally studied by alienists, but by specialists in internal medicine such as Briquet who, in 1859, wrote the classical Treatise on Hysteria. Because of the assumed nature of the neuroses, the new discipline of neurology rapidly took an interest in them.

Charcot, the founder of the French neurological school, was responsible for the internal medicine wards at the Salpêtrière—they were not associated with the 'divisions of the insane' at the same hospital, the domain of the alienists. In about 1880 he became interested in hysterical patients which, because of their seizures, were admitted to the same ward as the epileptics. He developed a purely neurological theory of the disease which he described and studied using hypnosis. This was the former 'animal magnetism', long fallen into disrepute, but to which he gave a new scientific status. Charcot's descriptions of the grande hystérie, which he demonstrated on selected patients in his famous public lectures, were justly criticized later, but his international fame attracted students from all over the world. One of them was a young lecturer in neuropathology at the University of Vienna, Sigmund Freud, who, impressed by Charcot's lectures, decided to devote all his energies to the study and the treatment of the neuroses. Another was a French professor of philosophy (psychology was then a branch of philosophy), Pierre Janet, who had become interested in the psychological aspects of the neuroses. He was later to develop in parallel with Freud a psychopathological theory which, despite the traces it has left (the concepts of psychasthenia and the dissociative processes in hysteria) were not to be as internationally successful as Freud's psychoanalysis. Charcot's ideas were opposed by Bernheim, the professor of internal medicine at the Nancy Medical School and also an adept of hypnosis. He attacked the neurological interpretations of the Salpêtrière and claimed that suggestion played a central role in the phenomena described by Charcot.

The general interest in the neuroses, which extended beyond medicine to fin de siècle literature, was an international phenomenon. In 1880 Beard, an American neurologist, described a new neurosis, neurasthenia, which soon aroused even more interest than Charcot's hysteria. Psychiatry had played almost no part in this evolution, but this was to change under the influence of three related developments: the changes which took place within the concept of neurosis, the birth of the psychotherapies, and the incorporation in the field of psychiatry of psychopathological manifestations, even if they were of minor intensity.

The transformation of the concept of neurosis is apparent in the position taken by Kraepelin in the 1904 edition of his Textbook. He introduced a chapter, 'The psychogenic neuroses', on the grounds that 'among the neuroses, to which belong epilepsy and chorea, one must isolate a sub-group characterized by the purely psychological cause of the apparition of the symptoms'. The disintegration of the old concept left to neurology, which from now on abandoned the generic term, diseases (such as epilepsy and chorea) whose somatic manifestations could be shown to express a dysfunction of a precise part of the nervous system. Psychiatry took charge of hysteria, hypochondriasis, neurasthenia, and the related phobic, obsessional, and anxious disorders, which constituted the new neuroses. This concept was justified by the psychological nature of the symptoms and the causes recognized even by a biologically oriented psychiatrist such as Kraepelin. This redrawing of the frontier between the neurological and psychiatric specialties also testified to the extension of the limits of psychiatry. Pinel's insanity, until then defined by the necessity of commitment to special institutions, was replaced by a broader concept. A new class corresponding to our present personality disorders had already appeared in the 1894 edition of Kraepelin's Textbook. It had been isolated for the first time in 1872-1874 by the psychiatrist Koch. Like the neuroses, the cases were rarely observed in asylums but nevertheless they were now considered as belonging to the psychiatric field of study.

This field was further modified by the birth of the psychotherapies. In fact, they had a long history. In 1803 one of the first German mentalists, Reil, had described under the name of 'psychic therapy' (psychische Curmethode) a number of procedures, including very violent somatic ones, which could influence the 'perturbed passions of the soul', and Pinel's moral therapy contained psychotherapeutic elements. However, psychotherapies as techniques whose formal rules were based on an explicit theory about their psychological mechanisms of action derived mainly from Mesmer's animal magnetism as rehabilitated by Charcot. The emergence of the psychotherapies, characteristic of the last decades of the nineteenth century, was intimately related to the renewed study of the neuroses. After he had abandoned hypnosis, Freud developed psychoanalysis, but many other techniques evolved during the same period, which were as well or even better known at the time although they were to have a less lasting success. One of these was the method of Janet, who still occasionally used hypnosis. In 1904 Dubois, a Swiss neuropathologist from Bern, introduced a technique influenced by Bernheim's theory of suggestion in The Psychoneuroses and their Moral Treatment, and claimed to produce a 'psychological re-education' by a combination of rational and persuasive elements. His international reputation brought him patients from all over the world. The 'rest cure', proposed in 1877 by the American neurologist S. weir Mitchell for the treatment of hysteria and later of neurasthenia, was combined with Dubois' method by Dejerine, Charcot's successor as professor of neurology in Paris.

This very incomplete summary illustrates the striking fact that, because of their intimate connections with the neuroses, the psychotherapies originated inside neurology. When the study and treatment of the neuroses were incorporated into psychiatry, the psychiatrists considered that they were an integral part of their activity and tried to retain the monopoly of their practice. They never completely succeeded. Already Freud had, according to his biographer Jones, 'warmly welcomed the incursion in the therapeutic field of suitable people from another walk of life than medicine'. The problem of the 'lay analysts', a source of conflict within the psychoanalytic movement, is only an aspect of a broader question which was later to involve the relations of the medical specialty of psychiatry with the new professional group of clinical psychologists.

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