Psychiatric history reflects the thoughts and views of philosophers, clerics, and clinicians, predominantly male. The dominant paradigm is male. In order to understand current concepts regarding women and psychosis, it is important to learn about the history of psychiatry from a female perspective. The search for historical contributions from early female thinkers yields little. Interestingly, the famous female patron saint of the mad, St. Dympna, gained her status by mishap. St. Dympna was a seventh-century martyr who fled from Ireland to Belgium to escape the incestuous desire of her father. He caught her and struck off her head in his fury at her rejection. This was observed by several “lunatics,” who were immediately shocked into sanity. She then earned the title of “protectress of the mad,” and favorable changes in psychosis were attributed to her intercession. This myth contains several messages about the associations between women and madness. Unlike many male saints, St. Dympna was a victim and not a powerful
person in her own right. The accidental but beneficial outcome for the mad patients conferred martyr status on St. Dympna but enshrined her role as passive. To this day, many inpatient units around the world are called St. Dympna’s Ward.

The twelfth century and other middle ages saw the devastating persecution of women, in particular women with mental illness, through the notorious witch hunts. For women, the consequence of psychotic symptoms was in many instances a painful death. A famous religious visionary in the twelfth century was Hildegard of Bingen. She wrote extensively about gender differences, sexuality, and medicine with a particular regard for women suffering from psychotic disorders. Hildegard claimed her revolutionary treatments for psychosis were transmitted to her in “dreams” and were in fact the ideas of the current pope. In this way she cleverly avoided persecution for witchery, which would have been her fate had she not adopted a passive role. Hildegard of Bingen’s theories about mental illness in women actually fit our current thinking in that she advocated a biopsychosocial approach to the etiology and treatment of psychosis.

During the midseventeenth century, rising unemployment and economic crises throughout Europe led to the building of institutions for the poor, the criminal, the alcoholic, and the mad. During this “classical age,” madness was seen as a type of moral corruption. Toward the end of the eighteenth century, particularly in France, industry was growing and workers were needed. This led to the release of psychiatric inmates who were capable of working, in particular large numbers of women deemed less severely mad than their male counterparts. Foucault claims that, at this time, when disease spread through French towns, the mad were blamed for the various epidemics and hence doctors became involved with the insane. Initially, doctors acted as moral guardians for the mad, rather than as physicians, but a medical interest in psychosis developed over time. The nineteenth century saw the proliferation of scientific theories about psychosis, coincident with the weakening power of the church and the rising importance of science. In the Victorian era, English psychiatrists theorized that female insanity was largely due to the woman overstepping the boundaries of femininity as determined by Victorian society. By the 1850s, the population of public asylums increased dramatically, with proportionally larger numbers of women than men. The Victorians associated female sexuality, deviancy, and madness. Women who were promiscuous, or who bore an illegitimate child, or those who were sexually assaulted and traumatized as a result, were seen as “mad” because they posed a threat to the view of women as passive and sexually innocent. On frequent occasions, such women were hidden away in asylums. The number of women assumed to be suffering from mental illness in the Victorian era was only partly reflected in the number restrained in asylums, since many were confined to attics or other hiding places. Literary works of the Victorian era, such as Florence Nightingale’s Cassandra, were to some extent semi-autobiographical accounts, and some portrayed the female perspective about the plight of the mad woman. The madness of Bertha, one of the main characters in “Jane Eyre,” was linked to her sexuality, and her worst episodes were related to her menstrual cycle. In the novel, Bertha was managed by confinement to a windowless attic and was treated as a brutish animal. This novel had a profound effect on Victorian readers, including psychiatrists, who subsequently advocated asylum treatment for women in preference to isolation at home.

Darwin’s theories of biologic sex differences gave scientific confirmation to the Victorian ideals of femininity. In The Descent of Man, Darwin described differences
in mental powers of the two sexes. He claimed that, through natural selection, man had become superior to woman in intellect, courage, and inventive genius. Henry Maudsley, a notable Victorian era psychiatrist and the editor of the journal Mental Science, was profoundly influenced by Darwin’s theories. Maudsley’s view was that higher education of women directly contributed to their mental illness.

During the latter part of the nineteenth century, the feminist movement gathered momentum, with women campaigning for access to universities, the professions, and the vote. Many of these women were labeled mentally disturbed, and the diagnosis of hysteria rose in prominence. A strong association was made between rebelliousness and nervous disorders, and there are documented cases of radical women being committed to asylums with symptoms of “overeducation and rebelliousness.” One such case was that of Edith Lancaster, described as an honors student at London University working for the Social Democratic Federation in 1895, who was committed to a private London asylum by her father after she began to live with a young railway clerk. The doctor involved explained that her opposition to conventional matrimony and her overeducation were the causes of her insanity. The diagnosis of hysteria, known as the “daughter’s disease” was also understood as a mode of expression for women deprived of social and intellectual outlets.

Freud attributed hysterical symptoms to sexual conflicts. Through Freud’s work, the female patient’s voice became audible. Following World War I, psychiatric attention turned again toward the psychotic disorders—grouped under the heading of “dementia praecox” by Kraepelin in 1896. Kraepelin believed that psychological dysfunction, “a loss of inner unity of intellect, emotion and volition,” was secondary to organic brain changes. Kraepelin’s theory was modified by Eugene Bleuler, who suggested the term “schizophrenia” in 1908. Bleuler believed the primary problem was an organic loosening of associations, which was the substrate for subsequent psychological mechanisms resulting in delusions and hallucinations. During the 1920s and 1930s, the concept of schizophrenia became much looser and acquired a strong social component that included adolescent turmoil, cultural maladjustment, and political deviation. In this era, the woman with schizophrenia became a central cultural figure, a symbol of linguistic, religious, and sexual breakdown. Yeats’s poem “Crazy Jane” in the 1930s and other literature such as “The Mad Woman of Chaillot” in 1945 depicted psychotic women as symbols of repression by society. Women were overrepresented in the number of asylum inpatients in the 1940s and received the majority of organic treatments (insulin and shock therapies). Since 1941, most of the 15,000 leucotomies and lobotomies performed have been on women.

By the 1960s, the feminist movement had grown and found favor with antipsychiatry groups (e.g., R. D. Laing). By the early 1970s, feminists became disenchanted with the antipsychiatry movement, and the early 80s saw the beginning of deinstitutionalization, a worldwide phenomenon of downsizing mental hospitals. The deinstitutionalization process has meant that many psychiatric patients in previous long-stay hospitals are now treated in general hospital units with an emphasis on community-based treatment. This has no doubt improved the quality of life of a significant proportion of patients with mental illness but has raised another issue for women in general—the burden of care. Sedgwick described women as being tied to “traditional servicing roles for their disabled kinfolk … the reinforcing of an archaic sexual division of labour”(1). The 1990s and
onward have seen the further growth of neuroscience technologies. This has, in turn, impacted on psychiatric research and, in particular, on schizophrenia research. Newer treatments have been developed, and there is greater understanding of brain impairment in psychosis. The consideration of differences between the sexes in schizophrenia has also received new attention. Sex differences in brain development, organization, and, eventually, degeneration are relevant to understanding sex differences in schizophrenia. Understanding sex differences in the experience of schizophrenia becomes increasingly important as the efficacy of newer treatments is being assessed.

It is almost universally accepted that schizophrenia first manifests at a later mean age in females than males. Most of the epidemiologic findings come from the Danish Case Register and the Central Institute of Mental Health, Mannheim, Germany (2,3,4). The mean age of onset of schizophrenia in women is now established as being between 5 and 10 years later than in men. Another well-documented sex difference is in the course and outcome of schizophrenia. Many studies report that women have a more benign course of illness than men (5). Overall, women show fewer negative symptoms, better social adaptation, and treatment response at relatively lower dosages of antipsychotic drug (6). However, social stressors such as homelessness, poverty, and victimization can create a very poor quality of life for women with psychotic illness (7).