Psychiatry is the medical discipline concerned with the diagnosis and treatment of mental disorders – that is to say, serious abnormalities reflected in behaviour, cognition, mood or perception. Whereas psychologists look at the human mind and its workings in general, psychiatrists seek to address specific dysfunctions. As the American humourist Shannon Fife put it: ‘Psychiatry is the art of teaching people how to stand on their own feet while reclining on couches.’
In ancient times, mental disorders were commonly seen either as evidence of supernatural displeasure or as manifestations of moral degeneration or physiological problems (the latter being a view shared by Hippocrates and Democritus among the ancient Greeks). In the 11th century, Avicenna, that leading light of the Islamic golden age, identified broad categories of emotional disorder (among them anger, anxiety, depression and obsession) and even suggested the possibility of reordering a patient’s disordered thinking patterns.
Nonetheless, for the next eight hundred years or so, those with serious psychiatric illnesses were contained rather than treated – often in asylums where terrible conditions typically prevailed. Only in the 18th century was there a concerted move towards more compassionate care of the mentally ill, and even then it remained a case of managing, not curing, sufferers.
The term psychiatry – the word derives from the Greek for ‘physician of the mind’ – was used for the first time in 1808 in a paper by a German, Johann Christian Reil. As the discipline gained greater academic prestige, the trend was to seek physiological causes of serious mental conditions such as mania, psychosis and depression. The associated field of neurology, meanwhile, sought to explain more minor cases of neuroses by reference to physical dysfunctions within the nervous system. Then, around the turn of the 20th century, an Austrian, Sigmund Freud, arrived on the scene. In a series of landmark works, most famously The Interpretation of Dreams (1900), Freud established the unconscious – that part of the mind inaccessible to the conscious (i.e. aware) part but which nonetheless is taken to affect behaviour and emotions – as a subject of serious scientific study. In doing so, he virtually single-handedly created psychoanalysis as a method of treating mental disorder. As Freud himself once wrote: ‘The poets and philosophers before me discovered the unconscious; what I discovered was the scientific method by which the unconscious can be studied.’
The ego and the id
In his 1923 paper, ‘The Ego and the Id’, Freud significantly revised his 1900 model as he introduced the idea of:
• the ego – the seat of our conscious perception and intellectual functioning;
• the id – that which strives for the immediate satisfaction of pleasure and, correspondingly, avoidance of pain;
• the super-ego – the self-critical, moralizing part of ourselves (our conscience, if you like), which reflects the standards of wider society.
In The Interpretation of Dreams, Freud described the mind as split into three distinct hypothetical areas – the conscious (the part of the mind comprising those things of which we are aware); the preconscious (consisting of those ideas and memories that are latent most of the time but which may easily become conscious); and the unconscious (those desires, impulses and wishes normally inaccessible to the conscious mind). He suggested that much like an iceberg, only a small proportion of the mind – the conscious – is visible above the water line, while the rest is hidden beneath. Moreover, the conscious and unconscious constantly battle each other, while the preconscious attempts to mediate between the two.
Psychoanalysis became the dominant mode of treatment in psychiatry for much of the first half of the 20th century, but in the second half it lost ground to the rival school of biological psychiatry. The development of an array of apparently highly effective antipsychotic drugs and antidepressants saw a move towards pharmacological treatments at the expense of psychotherapy (which by its nature struggles to provide empirical proof of its success). The widespread use since the 1970s of neuroimaging – scans that provide detailed images of the neurological system – has further bolstered the cause of biological psychiatry, so that today psychiatry remains firmly split between the two approaches. Others, meanwhile, remain sceptical of psychiatry in its totality, arguing that we remain far from a true, broad-ranging understanding of how the human mind works. In the words of G. K. Chesterton, writing for the Observer in 1934: ‘It seems a pity that psychology has destroyed all our knowledge of human nature.’
The unconscious desire
Freud argued that the unconscious is primarily driven by the libido (i.e. sexual desires and instincts). As we grow older, his theory went, we repress our unconscious thoughts because they run contrary to the interests of the conscious mind and are incompatible with social norms. However, the unconscious continues to manifest itself in a number of ways – for example, in our dreams, in slips of the tongue (Freudian slips), jokes and also in nervous conditions.
It is the interrelationship between these aspects of the mind, Freud said, that induces in us feelings such as anxiety, guilt and inadequacy, which we strive to deal with by employing strategies including denial, displacement and repression. It is by mining the unconscious, he believed, that we may discover and address the causes of our anxieties and neuroses – a process that we know today as psychoanalysis.