“Mental Disorders in the Classical World” (A Review)

Editor’s note: this review of
“Mental Disorders in the Classical World”
was posted yesterday in the journal
Electrone (ΗΛΕΚΤΡΥΩΝΗ).
It is re-posted on MIA at
the author’s request.

The motto of the Society for Classical Studies is Our Psychiatrist is Literature. If you find that translation of the Greek words psyches iatros ta grammata funny, it is probably because you assume a psychiatrist is a scientifically based doctor who cures brain diseases (lesions, cellular abnormalities, or chemical imbalances), rather than a metaphorical doctor who heals ailments of the spirit (dependency, frustration, or absence of autonomy).

Some of our ancestors apparently took the latter view, since the SCS took the motto from a fragment of a Greek New Comedy by Philemon (362 – 262 BC).¹ Today, by contrast, the average person believes that mental illnesses (or “disorders”) are brain diseases. His government and insurance company typically agree with him. Something has changed.

The current view of mental illness and its accessory idea, mental health, were born of the Enlightenment. Formerly, spiritual ailments had been considered sins or heresies. They were allegedly produced by the diabolical interventions of witches, Satan, and/or Jews, and confessors relied on prayer or holy water to remedy the soul. With the decline of Christianity in Europe, those ailments were reinterpreted in secular (mechanistic, atomistic, materialist) terms that reduced the self to its molecular substructure. The mind became equated with the brain, and remedies naturally became mechanical or chemical—insulin shock, lobotomy, electroshock, surgery, and drugs. Nevertheless, the fact that some mental health workers still prefer talk therapy to physical interventions is a startling admission that not everyone sees the mind as identical to the hardware it depends on.

If medieval and early modern Christianity conceived of mental distress as the product of sin or heresy—as sloth or acedia, say, instead of depression or schizophrenia—then what did the women and men of Europe think it was before the advent of Christianity? We know a great many of them were mechanists, or that they at least subscribed to atomistic philosophies that did not take their bearings primarily from theology. Did they too think it was a medical matter—that is, the product of a brain disease—or something else?

That is the central question addressed in this important new collection of 22 essays, the first two by practicing psychiatrists and the other twenty by classicists specializing in ancient medicine, philosophy, history, or literature. All are written in English, though authors come from France, Germany, and Italy as well as the Anglo- American world. Most papers are of the highest standard, written by seasoned scholars at the peak of their powers or impressive novices whose futures look bright. They have sifted and assembled a trove of information from ancient sources, chief among them Galen, Plato, and the Hippocratic writers, as well as epic, tragedy, and Roman legal writings. Most focus on Greece or Greek writers under the Empire; Rome’s Latin population receives far less attention. “The aim,” explains the editor on the first page, “is to speak intelligibly—and indeed persuasively—to mental health professionals concerned about the foundations and current state of modern psychiatry as well as to historians and classicists.” Since most but not all Greek and Latin is translated, mental health professionals may find some parts hard going, but they should read as much as they can.

W. V. Harris, the editor, is the William R. Shepherd Professor of History at Columbia University. He has published very impressive and important work on literacy, dreams, economics, and emotions in the ancient world. His familiarity with psychiatric controversies is less obvious. In the introduction he casually remarks (p. 13 n. 32), “In this essay I use the word ‘symptom’ to include also what technically speaking were formerly known as ‘signs’.”

This idiosyncratic decision is alarming and could have compromised the whole collection. The distinction between medical signs and symptoms is elementary and crucial and has not changed. In medicine, signs are objective—cellular abnormalities, tears in tissue, bleeding, lesions, broken bones, and so on. Symptoms are subjective—pain, fatigue, or anxiety that the patient complains of. Of all branches of medicine, psychiatry alone deals exclusively with symptoms, not signs, because— by definition—mental illnesses have no signs. They are diagnosed on the basis of symptoms. (If signs are ever found, mental illnesses are reclassified as neurological disorders, and treated by neurologists rather than psychiatrists.) Their inherently subjective nature is what makes mental illnesses, and psychiatric interventions, so controversial. The quest to find genetic causes of schizophrenia speeds on, for example, but until genetic markers are made the basis for a diagnosis of schizophrenia, that diagnosis will forever remain open to challenges.²

Happily, the volume’s other authors display a firm grasp of the distinction between signs and symptoms. Their essays, which are listed at the end of this review, are grouped in seven parts: (1) “Current Problems in the Classification of Mental Illnesses” (2) “Greek Classifications,” (3) “Particular Syndromes,” (4) “Symptoms, Cures, and Therapy,” (5) “From Homer to Attic Tragedy,” (6) “Mental Disorders and Responsibility,” and (7) “A Roman Coda.” The book ends with a comprehensive bibliography and index. In place of abstracts written by the individual authors, Harris summarizes the contents of each paper in his introduction. Unusually, in the course of doing so he often signals his personal disagreement with the thesis of an essay.

It is impossible to summarize the book’s riches in short compass. Most essays demonstrate their arguments conclusively and draw their documentation from a vast range of sources. Here let me simply extract a few of the most important or provocative points and findings. I should add that in the interest of brevity and intelligibility, in the following remarks I use some modern terms, such as depression or mind, instead of the ancient names, such as melancholia or soul, that these concepts sometimes resembled.

• Galen (129 – c. 200/c. 216 AD) did not believe that mental illnesses were bodily illnesses (Boudon-Millot and Holmes, contra Nutton in this volume).
• Plato (428/427 or 424/423 – 348/347 BC) did believe that epilepsy—a neurological disorder—was a mental illness (Lo Presti).
• In Timaeus 87-89 Plato recommends exercise, talk therapy (“philosophy”), and only lastly drugs, as therapy for mental illness (Sassi).
• In fiction, the rudimentary logic and rhetoric of the insanity defense is found already in the Iliad (Konstan), while it was Socrates, according to Xenophon, though not Plato, who pioneered its use in real life (Sassi, p. 419). These ideas seem worthy of further discussion.³

• Aristotle ascribed depression to humoral imbalances (Lo Presti, p. 209). Going further, the author known as Pseudo-Aristotle retroactively diagnosed all geniuses as melancholic (Kazantzidis).
•   The Hippocratic treatise On the Sacred Disease is responsible for associating the brain and the soul (Jouanna).
•   In contrast to many contemporary vague ideas about the soul, ancient thinkers had a definite material notion of the soul, susceptible to physical influences (van der Eijk).
•   Ancient “philosophical essays were intended to function as a psychological analogue for ancient medical regimen, or what we call ‘life-style management’ or ‘preventive medicine’” (Gill, 339—a superb and accessible essay).
•   Roman legal authorities were perfectly aware that individuals sometimes pretend to be crazy in order to escape the consequences of their criminal behavior (Toohey, citing the Digest of Roman Law). In Greek myth, of course, Odysseus represents the archetype of malingered psychosis.
•   When the family could not or would not care for a criminally insane individual, only then did the Roman government confine him in (a) prison (Toohey, citing the Digest; regrettably he cites it only in translation, since the key word for the place of confinement, carcer, does not refer to any obvious permanent place in ancient Rome, and the lack of a definite article in Latin compounds the confusion.)
• It was, of all people, the tragedian Aeschylus (c. 525/524 – c. 456/455 BC) who apparently invented the metaphor of “mental illness” (Saïd).

This last point is new and important. In Persians (472 BC), Darius denounces the “mental illness” of his son, Xerxes, and attributes it to Xerxes’ youthful ambition or demonic activity (daimon). Saïd cites Persians 750-1:

πῶς τάδ’ οὐ νόσος φρενῶν εἶχε παῖδ’ ἐμόν;

Surely this was a mental illness (nosos phrenon) that had my son in its grip.

Actually, Saïd could have pointed out that Aeschylus, if in fact he wrote Prometheus Bound, also invented the metaphor of conversation as medicine (“talk therapy”). In v. 308 of that play Ocean contends that orges nosouses eisin iatroi logoi, “words are the doctors of a mind [or “anger”] diseased.” In both passages the playwright either invented or took for granted the idea that one’s mind could become medically “diseased” and “healed,” but in both cases it is transparent that the expressions are metaphors. As Sassi emphasizes, it apparently fell to Plato a century later to take those metaphors literally and thereby devise the notion of “mental health.”⁴ (Sigmund Freud trod a similar path when he invented the idea of “psychopathology.”)

It is easy to disagree about many incidental claims made in the book, such as Glenn Most’s contention that madness is prominent in tragedy because it is easier to stage visual hallucinations than auditory ones.⁵ The point is debatable but the consequences are negligible. A few essays, however, actually disturbed me. One is Helen King’s, which retroactively diagnoses a man named Nicanor with “performance anxiety” (p. 282) and deems him sexually incompetent. It is a lucid demonstration, albeit unintentionally, of how readily psychoanalysis and diagnostic labels can become weapons for stigmatizing individuals (“patients”), especially when the resistance of the individuals themselves to such explanations, figured as “lack of insight,” can then be taken as further proof of their madness.

Peter Pormann’s essay furnishes a striking illustration of these risks. Discussing the notion of “scholarly melancholy”—that is, the idea that thinking too much can make you depressed or crazy—he states (223, with my emphasis):

“When people hallucinate, thinking that they are earthen jars, or seeing things that do not actually exist, their judgments are obviously impaired. Therefore, their opinions about the outside world cannot be relied upon, nor do they correspond to reality. But more fundamentally, madness poses an even greater problem, as the madman often does not realise that he is mad: he constructs his own, alternative reality that possesses internal cohesion and therefore remains unchallenged.

He cites the novel Shutter Island and its Hollywood film adaptation, rather than a case study, to make his point.

Yet herein lies the risk of great harm. Who is to say what obviously exists and what does not? Does God exist? Do witches? Your soul or mind? The benefits of capitalism, socialism, democracy, science, of diet and exercise? What about race, IQ, or manmade climate change? If not (or if so), what actions should we take—if any at all—against our fellow women and men in the name of helping them? Besides, if the things “do not actually exist,” how do we know these people “see” them?

Again, as Harris points out in his own essay on hallucinations, Socrates and Jesus said they heard voices. Were they crazy? In Mark 3:21 we learn that Jesus’ friends thought that yes, He was, but that is not the common view today. Was the apostle Thomas sane or insane to doubt Jesus’ resurrection?

My point—and it is hardly mine alone—is that this is tricky, sensitive stuff and we had better be careful. Pormann does not raise the possibility that the man who says crazy things could be speaking in metaphors for his sense of greatness, worthlessness, helplessness, or the sense that others have done him wrong. We recognize it is not always literally (physically) true when someone says his parents “abused” him as a child, but what about a young woman who says she has been raped? In the absence of objective proof, the consequences of taking action or withholding it can be equally dire.

From this perspective, the man who thinks he is an earthen jar—if anyone has in fact ever made this claim⁶—could be trying to communicate that he feels fragile. Poets speak this way and we praise them for it. So do comedians and we laugh with them for it; Plautus, the great comedian of ancient Rome, makes a joke along these very lines in Bacchides 199/200-203.

What follows from Pormann’s thinking? He cites an anecdote from Galen in which a slave commits violence against his master: he throws the master out a window. Pormann sides with Galen in concluding that the slave was a madman. Was he? Was Spartacus also a madman, or Malcolm X? Yet this is the very assumption that once gave us the psychiatric diagnosis of “drapetomania”—that is, the mental illness that caused black slaves in the American South to flee captivity.

I make these points to show that most of the papers in this volume could have been more candid or reflective about the role that presuppositions, power, and coercion play in understanding mental illnesses. Indeed, the most remarkable thing the book does show, and shows it clearly, is that many ancients did not conceive of human distress in medical terms nor seek to change it by physicochemical means. Perhaps that conclusion only became clear at the conference it arose from; that would explain why the volume leans so heavily on the ancient medical writers, with correspondingly less attention given to philosophers, playwrights, novelists, and other perennial observers of human behavior.

One major omission in the book calls for comment. Over a long and prolific career, the American psychiatrist Thomas Szasz (1920-2012) of SUNY Upstate Medical Center in Syracuse, New York, made clear his belief that the central issues sowing confusion in psychiatric controversies were (1) whether a psychiatric intervention was voluntary or involuntary (coerced, forced), and (2) the inherent uncertainty of what is meant by the term “mental illness.” For him, mental illnesses were metaphorical illnesses that, in our time, have ceased to be recognized as metaphors and instead are seen as bodily illnesses “like any other.” Cui bono?, he asked. In his view, mental illnesses were stigmatizing labels couched in pseudomedical Greek and Latin jargon and devised to blame or excuse deviant behaviors.⁷ Analogously, he saw psychiatrists as metaphorical doctors wrongly accredited as medical doctors, doctors whose true aim of helping patients overcome their problems in living was impeded by mankind’s ongoing belief that those problems were the expression of diseases in the brain (cellular abnormalities, lesions, and chemical imbalances). For him, the whole gamut of mental illnesses—from depression to psychosis—could be understood only in moral and political terms.

Szasz split medicine. In 1973 the American Humanist Association named him Humanist of the Year, putting him in company with Linus Pauling (1961) and Jonas Salk (1976). Within his own profession he became a pariah. Since the potential implications of his simple proposition are so terrifying, I was stunned to find his name mentioned only a single time, and then in passing, in the 500 pages of this book.⁸ In a collection that sought to learn what our forebears thought about mental illnesses before the rise and decline of Christianity in Europe, his views should have been made the central point of discussion.

Readers unfamiliar with these controversies probably assume they were ignored because Szasz’s ideas have been disproven by brain scans or other tests. That is incorrect. Actually, it is the popularly accepted chemical imbalance theory of mental illness that remains unproven and that is, at this very moment, in the process of being discarded.⁹ Indeed, when I presented a paper comparing the work of Szasz and Epicurus at the 2014 meeting of the American Psychiatric Association meeting in New York, several practicing psychiatrists confided in me that they believed Szasz was and is right.¹⁰

The failure to engage with Szasz’s ideas in this book is, therefore, egregious. Every one of its essays would have benefitted from putting them in dialogue with ancient thought. For example, in his 1996 monograph The Meaning of Mind, Szasz stated a remarkable contention:

“Like a minute grain of sand stimulating an oyster to form a pearl, this seemingly minor reluctance to confront the moral problem of self-murder [i.e. suicide] stimulated Western society to form the concept of mental illness. If this hypothesis is correct, then the entire scholarly and scientific apparatus that traces the origin of the mind to the soul and equates mind with brain is fundamentally erroneous.

“I maintain that the modern idea of the mind derives not from the ancient idea of the soul, but from the Renaissance idea of a “malady” with a special predilection for attacking the minds of self-murderers.”¹¹

I would have been enormously interested to know what the 22 scholars in this volume think of that idea.

Despite their silence, however, many contributors reach conclusions perfectly in harmony with Szasz’s ideas. It is clear that some of them (e.g. Boudon-Millot, Lo Presti, and van der Eijk) understand what Szasz was arguing about mental illness, though I do not of course mean to suggest they would agree with him.

Equally clear, however, is that some of the volume’s authors are not familiar with that point of view, or consider it so incredible they ignore it. In an interesting passage Peter Toohey attacks the practice of retrospective diagnosis—the kind that King carries out in her essay—but draws a false parallel that muddies the issues. He states that retrospective diagnosis can work (442-3):

where there are actual remains, such as mummified or frozen bodies. So, retrospective diagnosis may be helpful in ascertaining the cause of death for example of a King Tutankamen—a badly broken femur. His body survives and it can be subjected to scanning with an MRI, the DNA can be examined, and pathogens can be pored over. But retrospective diagnosis does not seem to help much where there is no body. So it is that the problems relating to retrospective diagnosis become especially prominent when it comes to the understanding of ancient madness…. What makes retrospective diagnosis of mental illness so perilous an enterprise is that a clear-cut expression for madness is usually lacking in passages such as the one that has just been quoted. The phrase which Suetonius uses, valetudo mentis [health or strength or fitness of mind], could apply to any one of a number of neurological conditions.

Toohey is mistaken about both his premises. Even if we had the body of a dead madman we could not diagnose the mental illness, because mental illness—by definition—produces no lesions. It is not just that we cannot figure out what is wrong with his brain. The problem is that all the evidence tells us that there is nothing wrong with his brain. (If there were, you would call a neurologist.) Finding Ovid’s brain and scanning it could not tell us whether he wrote the Tristia because he was depressed or melancholic, though it might tell us whether he had a neurological disease.

Toohey is also wrong to maintain that retroactive diagnosis of madness fails because language is too slippery. He implies that if we could only define an illness— in English or in Latin—more precisely, as the ongoing revisions to the DSM perennially seek to do, we could identify and fix it. Yet if Szasz was right, we will never be able to define it because “it” may not be a real thing in the body—as opposed to a term we give to certain groupings of behaviors, beliefs, or attitudes in others that we disapprove of.

That is why it was no surprise to read the first 100 pages of the book, which gathers the essays by Simon, Hughes, and Thumiger, and to discover that the ancients had no clearer definition of or distinctions among mental illness than contemporary psychiatrists do. As Thumiger demonstrates, Greek medical writers had a litany of mutually contradictory and confused names for being crazy.¹²

But enough criticism. I salute Harris in the warmest terms for inaugurating the conversation between Classics and the mental health professions. I agree with him that our fields can learn a great deal from each other. This book marks an important first step. It deserves to be read by Classicists of all backgrounds and interests and, to the extent they can, by everyone interested in the diagnosis and treatment of mental disorders today.

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Footnotes: