Homeopathic Medicine and Psychiatry
The Birth of Homeopathic Medicine
A German Physician, Samuel Hahnemann, developed the medical practice called homeopathy after becoming dissatisfied with the medical practice of his time, which consisted of bloodletting, purging, vomiting, prescriptions of twenty or more ingredients, and the corporal punishment to the insane.
While translating Cullen's Materia Medica's section on Cinchona (the Peruvian Park), which is used for the treatment of malaria, he noticed that Cinchona's secondary effects resembled the symptoms of malaria. After further experiments, with this and other substances, he developed the idea of treating diseases with substances capable of producing pathological conditions similar to the patient's complaints. Hippocrates and Paracelsus had postulated this therapeutic approach. (Hahnemann, 1842/1996).
Hahnemann tested his hypothesis by experimenting on himself, his family and a close group of physician friends. He carried out the "proving" of ninety-nine substances -mineral, vegetable, and animal- by the time of his death in 1843 at the age of 88. The substances were proven initially in substantial doses of one to four grains (a grain in Hahnemanns' time equaled approximately 62 mg.). Hahnemann changed the application of his theory during his career and, later, he prepared the medicines in serially diluted, and succussed solutions -shaken forcefully and struck against a hard surface-, up to 10 -60 in dilution. These preparations were ingested in a semi-controlled and strict fashion.
The symptoms that developed were recorded carefully and classified according to the organic systems these medicinal substances altered, from the mind and general systemic effects, to specific organ systems. In this way, Hahnemann thought, it was possible to determine the specificity and organotropism of the substances proven. Hahnemann postulated this as a way of discerning the actual therapeutic value of medicinal substances, which was lacking in his time.
Hahnemann also described his observation of two contrasting biological actions induced by the substances, a bi-phasic phenomenon, during the provings. A primary action, the biochemico-pharmacological, or toxic, effect of the substance; and a secondary effect, the organic reaction, which represents the drive of the organism to return to a state of equilibrium, directed by the homeostatic mechanisms. This is known today as the "rebound phenomenon," which appears after using certain drugs like vasoconstrictors, alcohol, coffee, benzodiazepines and narcotics.
The homeopathic system is described in detail, in the "Organon of the Medical Art." In it, Hahnemann describes the way of taking a very detailed clinical history, emphasizing the characteristic manner in which the individual and the organism respond to the environment. This clinical history is more detailed than any other traditional medical history. He also describes the process of preparation of the remedies, the selection of the therapeutic agent, and prescribing strategies. From 1810 to 1842 the Organon was reviewed and edited, up to a sixth edition. Hahnemann clarified, extended and corrected previous positions based on his continuous clinical experiences and observations.
Hahnemann and Mental Health
In the area of mental health Hahnemann was a pioneer. According to dates noted by Richard Haehl, Hahnemann started promulgating the humanistic treatment of the mentally ill in 1793, corresponding to the time when Pinel broke the chains at Bicetre. The fame of the latter is due to the larger number of patients that were affected by his action and the importance of the institution he directed.
In the asylum of Georgenthal near Gotha, Germany, Hahnemann treated Mr. Klockenbring, secretary of the chancery. The case description resembles an acute manic episode. Initially, the doctor dedicated his time to observation and direction of the treatment, some of which would be considered supportive and occupational therapy today. The medicines used are not reported but probably were according to the homeopathic principles, for it was around this time that Hahnemann started promulgating his theories. (Haehl.1922)
In 1796 Hahnemann wrote: "The physician in charge of such unhappy people (the insane) must, indeed have at his command an attitude which inspires respect but also creates confidence. He will never feel insulted because a being that cannot reason is incapable of insulting anyone". These are statements regarding the need to establish a therapeutic alliance and a recommendation about counter-transferential reactions.
In regard to mental disorders, in paragraph 215 of his Organon, he writes: "Almost all so-called mental and emotional diseases are nothing but physical diseases in which the symptom of mental and emotional disorder characteristic of each one increases more or less rapidly as the physical symptoms diminish, almost like a local disease transferred into the invisible subtle mental or emotional organs".
Hahnemann was a precursor in the field of psychosomatics. He saw the human being having an integrated mind and body, in contrast to the prevailing dualism of his time. In paragraph 210 he says: "In all diseases being treated, the psychic condition of the patient should be written down among the totality of symptoms as one of the most important, if one desires to have a faithful picture of the disease from which to make a successful homeopathic cure."
For him,"..emotional and mental disorders...do not constitute a class of diseases completely separated from all others, because in so-called physical diseases the emotional and mental state is always affected. For example, how often does not one find, in the most painful diseases of many years standing, a mild gentle disposition commanding the physician's tender consideration and compassion? But when he overcomes the disease and restores the patient...he is often surprised and shocked at the dreadful change in the patient's nature, ingratitude, hardheartedness, unusual maliciousness, and a disposition most disgraceful and degrading to mankind often make their appearance. These are exactly the qualities that this patient had before he became ill. One often finds that people that were patient when they were healthy become obstinate, violent, hasty or unbearable and self-willed, impatient or despairing-when they are ill, those who were discrete and modest become obscene and shameless, those who were clearheaded become dull-witted, those who were inclined to be feebleminded seem to become rather clever and more sensible, those who were slow to decide acquire great presence of mind and decisiveness, etc.". In that paragraph we can see how keen Hahnemann was in observing emotional and behavioral reactions and personality characteristics.
In paragraph 220 he mentions the occurrence of cases with a periodicity of violent insanity with melancholic depression, and the return of certain conditions during specific months of the year. According to W.M Butler (1880), it was Baillarger and Falvert, in 1854, who discribed and named the "Folie Circulair" and "Folie a Double Form" respectively. The differentiation of this syndrome, called "manic-depression", from schizophrenia is attributed to Kraepelin in 1896. (APA, 1944). Yet, Hahnemann made important observations in the field of psychopathological phenomenology, without ever being credited for it.
Hahnemann made a distinction between organic and psychological diseases. In fact, he prescribed psychotherapeutic techniques. In paragraph 224 he recommends: "If the disease is not yet fully developed and if there is some doubt whether it really has come from a physical disease or from bad upbringing, bad habits, perverted morals, lack of mental discipline, superstition or ignorance, the following will help one to decide."
"In the latter case it will diminish and improve from understanding, well intentioned exhortations, consoling arguments, earnest and sensible explanations. On the other hand, a real emotional or mental disease due to a physical disease, is quickly aggravated by such an approach: melancholia becomes more profound, plaintive, inconsolate, and withdrawn; Malicious insanity becomes more spiteful; foolish chatter becomes noticeably more silly."
"Conversely, there are of course a few psychic diseases that have not merely degenerated from physical ones; Instead, with only slight physical illness, they arise and proceed from the psyche, from persistent grief, resentment, anger, humiliation, and repeated exposure to fear and fright. In time such psychic diseases often greatly harm the physical health". In these forms of disease he also exhorts the use of psychological treatment.
From this we can see the clarity with which he conceived the body-mind relationship. Therefore, he can be considered a pioneer in the study of psychosomatic diseases. It was not until the beginning of the 20th century, 100 years after Hahnemann's writings, that the concept of psychosomatic medicine comprised a cohesive body of knowledge. Dunbar, in a review of the literature on this topic, reports: "Whereas in the past it has been occasional leaders who have called attention to the problem of psyche-soma as fundamental for the physician, within the last decades this realization has begun to permeate medical literature, changing it intrinsically." It seems that Hahnemann was one of those leaders, ahead of his time by more than 100 years. (Dunbar, 1935)
His insights into the role of the mind in disease were such that he noted: "It is possible to create a very grave disease by acting on the vital principle through the power of imagination and to cure it in the same way". He also mentions the use of suggestion and countersuggestion in the treatment of patients. He even endorsed the use of "mesmerism", which is regarded today as the antecedent of hypnosis. (Organon, Paragraphs 17, 288ss.)
Homeopathy and Mental Health
Psychiatry continued to be undefined as a specialty into the 20th century, and physicians from other specialties carried on the instruction in this field. Some asylums were founded in early 19th century, and by 1843 there were around 24 hospitals for the care of the mentally ill. (APA, 1944)
The first homeopathic hospital for the mentally ill was founded in Middletown, New York, in May 1874. According to the attending physicians "...did not require the use of the opiates, bromides or chloral hydrate in order to control the patients"(Stiles, 1875).
A report published in the Transactions of the American Institute of Homeopathy's meeting, 1891, reports a difference of 50% of patients discharged from the homeopathic mental hospitals in the State of New York, between 1883 and 1890, compared to 30% from conventional hospitals. There was also a difference of a 33% higher death rate at the conventional mental health hospitals as compared to the homeopathic. (Talcott, 1891)
By the end of the 19th century, homeopathic treatment was provided in public mental health hospitals in seven states; two of these states had more than one hospital. (Keith, 1899). Allentown State hospital, in Pennsylvania, opened in the early 20th century and was associated with Hahnemann Hospital in Philadelphia. Unfortunately, the clinical records from that period of time no longer exist.
From the theoretical point of view, philosophers and theologians were the ones that tackled the concepts of mental illness, while the rest of medicine was centered in the cellular pathology and disinterested in psychiatry. Nevertheless, there was already a more humanitarian approach to the treatment of the mentally ill and the doctrines of Pinel, Esquirol, Tuke and Bucknill were primordial. They were taught in most medical schools regardless of its orientation. (APA, 1944)
At Hahnemann Hospital, in Philadelphia, Professor H.N Guernsey was one of the teachers of psychiatry, even though he was an Obstetrician. In 1866, in a paper on Hysteria, he presents a process of hysterical affections as a result of sexual or emotional conflicts, an hypothesis presented many years later by Freud. (Guernsey, 1866)
Another prominent physician who used homeopathy to treat the mentally ill was Charles Frederick Menninger, founder of the Menninger Clinic in Kansas, which is still in operation but no longer uses homeopathy. He was an active member of the American Institute of Homeopathy and is quoted as saying, "Homeopathy is wholly capable of satisfying the therapeutic demands of this age better than any other system or school of medicine." "It is imperative that we exhaust the homeopathic healing art before resorting to any other mode of treatment, if we wish to accomplish the greatest success possible." (Menninger, 1897)
Davidson has noted that there are similarities between modern psychiatry and homeopathy. Recent neurobiological research tends to validate old homeopathic concepts. Psychotherapeutic techniques tend to elicit the patient's symptoms, in a controlled manner, in order to heal the patient. Such is the case in cognitive, behavioral as well as psychoanalytic treatments. In his article Davidson discusses other points such as the self-healing principle, the microdose effect, disappearance of the symptoms in reverse order of their appearance, and diagnosis by pattern recognition of the symptoms. (Davidson, 1994)
Other biological treatments involve the concept of similarity in their treatment. Such is the case in the treatment of depression with sleep deprivation (Wu, et.al., 1990), or the use of Reserpine in the treatment of refractory depression (Ananth and Ruskin, 1974). Tricyclic antidepressants are used in small dosages in the treatment of panic disorder since these antidepressants tend to cause an exacerbation of those symptoms at larger dosages in these patients. (Kaplan and Sadock, 1995, Pg.1201)
Homeopaths assert that symptoms are the expression of the organism's effort to restore health. Post and Weiss (1992) and Nesse (2000) present a similar view in contemporary psychiatry. They contend that symptoms of major affective disorders can be adaptive and may reflect the body's self-treating activity. Post and Weiss suggest the need to develop therapeutic strategies that stimulate the organism's self-correcting processes. This is a supposed mechanism of action of the homeopathic remedies. (Kent, 1979)
Most conventional practitioners do not take homeopathy seriously because it is difficult to accept that very diluted substances could have any therapeutic value. Usually, homeopathy is rejected without adequate scientific evaluation. Many scientists postulate that accepting homeopathy would require the abandon of accepted theories of physics and chemistry. This is not necessarily so, just as Newtonian theories are not superseded by quantum physics. It is necessary, and possible, to evaluate homeopathy according to conventional scientific standards.
Linde, et.al, performed a meta-analysis of 189 trials using homeopathy, 89 of which fit pre-defined criteria. Their results show that the patients taking homeopathic medicines were 2.45 times more likely to experience a positive therapeutic effect than the ones taking placebo. (Linde, 1997). Kleijnen et al, reviewed 107 studies, 81 (77%) of which showed a positive effect in favor of homeopathy. Of the best 22 studies, 15 showed homeopathy as efficacious. The researchers concluded that, "the evidence presented in this review would probably be sufficient for establishing homeopathy as a regular treatment for certain indications". They note that: "the amount of positive evidence even amongst the best studies came as a surprise to us". (Kleijnen, 1991)
There have been very few published studies on the use of homeopathy in the mental health field and even fewer follow good scientific methodology. Included in the studies reviewed by Kleijnen, et.al, there were ten studies on the treatment of mental or psychological problems including depression, insomnia, nervous tension, agitation, aphasia, behavior problems in children and other conditions. Of these ten studies, eight showed positive effects in favor of the homeopathic treatment. None of those studies have been replicated.
Davidson and his colleagues conclude that homeopathy may be useful in the treatment of anxiety or depression, either as an adjunctive treatment or as a sole treatment of patients who specifically request it. Obviously, the clinician must weigh the risks and benefits of a homeopathic intervention especially in situations when there are demonstrably effective conventional treatments and when the patient is either acutely psychotic or suicidal. There are several limitations in that study, as presented by the author, and only larger, double-blind, controlled, trials can provide answers to the questions that arise when using homeopathy in the treatment of disease, in general, and in psychiatry in particular. (Davidson, 1997)
Chapman, et.al, performed a randomized, double-blind, placebo controlled study on 60 patients with persistent mild traumatic brain injury. Their results suggest that homeopathy, alone or used concurrently with conventional pharmacological and rehabilitation therapies, may be effective in treating patients with persistent mild traumatic brain injury, a condition for which current treatment has limited effectiveness. (Chapman, 1999)
Lamont, J, performed a double-blind placebo controlled study on the treatment of 43 children with diagnosis of Attention Deficit Hyperactivity Disorder. He showed statistically significant differences supporting the notion that homeopathic treatment is superior to placebo. This type of study needs to be repeated. (Lamont, 1997)
Hundreds of case reports have been published, in homeopathic journals from the 19nd 20th centuries, of patients suffering from mental disorders who have been treated successfully with homeopathy. Even though some of the cases are inadequately presented for proper evaluation, many of these patients would meet criteria for a mental disorder according to the DSM-IV and would have been candidates for conventional pharmacotherapy.
A case series of 120 patients with diagnosis of anxiety neurosis, phobias, psychosomatic disorders, or neurotic depression was published by Gibson et.al.(1953). Priestman (1951) described 20 cases of anxiety, phobias and hypochondriasis. Reichenberg-Ullman and Ullman (1996, 1999) have published books with series of patients with attention deficit hyperactivity disorders, depression, and behavior disorders.
Detinis (1994) presents six cases of patients suffering from depression with suicidal ideation, chronic pain, sleep disorder, premenstrual syndrome and anxiety disorder. Bodman (1990) presents a series of cases of depression, anxiety, sleep disorder, phobias, neurosis, cerebral sequelae from a stroke, Menniere's disease, migraines, and other conditions treated successfully with homeopathy.
Boltz (1968) and Phalnikar (1962) presented small series of patients with acute psychosis who recovered after homeopathic treatment without relapses after long term follow ups even after failure of conventional treatment. Saine (1997) presents a series of cases of patients with psychosis, manic-depressive disorder, obsessions, and neurosis. Shevin (1989) presents several cases of patients with dissociative disorders, character pathology, and post-traumatic stress disorder.
Gallavardin (1960) published a series of patients with alcoholism who recovered with homeopathic treatment. Many of those patients were treated without their knowledge. Grazyna M, et.al, (1993) presented a series of 30 men treated for alcohol withdrawal and delirium tremens. They report that about 30% of the patients continued treatment for 12-18 months with most of them maintaining abstinence during a long follow up of up to seven years.
Some authors have presented cases of children with mental retardation that have improved with homeopathic treatment. Haidvogl, et.al.,(1993) presented a series of 40 cases of handicapped children. They report that close to 75% of the children responded to treatment, with close to 50% showing improvement of all the target symptoms. The authors pointed out that the children with organic brain injury, autism and definite syndromes responded well, generally, in comparison to the children whose handicap was due to social deprivation. Griggs (1968) presents a series of four of those cases, including one with a seizure disorder. Wright-Hubbard (1965) presents four cases of mental retardation, with seizures, autism, and muscle twitching, who responded well to homeopathic remedies when there was nothing else conventional to offer them.
Cortina (1994) presented a series of 20 cases of children with enuresis and behavioral problems, treated with Ilex, a plant derived remedy. They reported a 50% improvement in the enuresis and behavioral symptoms. Unfortunately, the study was not controlled and difficult to evaluate.
There are a number of single case reports of patients suffering from Anorexia Nervosa (Gray,1981), Anxiety Neurosis (Crothers, 1980) and Manic Depressive Illness (Whitmont, 1980) treated successfully with homeopathy. Boericke (1965) presented an interesting case of a patient suffering for dementia with psychosis whom he treated with a homeopathic preparation of Chlorpromazine after the patient had worsened at usual dosages of this drug.
These cases have a clear enough description of their disorders to stand up for a close scrutiny. However, many cases reported do not have adequate data to be evaluated by modern diagnostic standards. Most single case reports in the homeopathic literature give only anecdotal information primarily to show the homeopathic practitioner how the remedy was chosen. These cases are used as educational tools rather than scientific case presentations.
Slonim and White (1983) have reviewed the particular issues inherent in the preparation and evaluation of case reports, particularly in the areas outside mainstream medicine and homeopathy in particular. They point out that there exists as much clinical evidence for homeopathic treatment as there is for many conventional interventions that have not been subject to stringent testing.
Homeopathic Remedies in the Treatment of Mental Disorder
Homeopaths use various remedies with apparently different biological actions. Some have acute symptomatology in its picture like Belladona, Hyosciamus, Stramonium and Veratrum album. In these, the symptoms appear soon after the remedy is ingested.
Other, so called slow acting remedies, like Natrum Muriaticum (Sodium Chloride), Silica, Phosphorus or Sepia (Cuttlefish Tincture), take longer time and repeated dosages in order to manifest their particular symptomatology and sphere of action. (Hahnemann's Organon, Par.221).
The selection of the remedies is always based on the totality of symptoms of the patient, and in the consideration of the peculiar, or characteristic, qualities of the organism, such as: congestion of the face, red skin, glaring eyes, throbbing carotids, excited mental state, hyperaesthesia of all senses, delirious and restless sleep, dryness of the mouth etc. That particular picture is found in the Belladona (Atropa Belladona) picture. These are the symptoms of an anticholinergic intoxication.
A manic state, of a quarrelsome and obscene character, inclined to immodest acts, gestures and expressions, disposed to uncovering and exposing, are characteristic of Hyosciamus. These symptoms were evidenced in the provings, and would be the symptoms to be matched with the symptoms of the patient. The therapeutic doses used to treat the problem are to be minuscule.
There are other thirty-nine remedies cited by Guernsey with their characteristic symptoms for the treatment of mental illness. (Guernsey,1866; Boericke, 1927) Besides the mental symptoms, the characteristics of local pathology, in different organs are matched with the clinical pictures observed during the provings in healthy subjects in order to select the correct remedy.
Hahnemann noted that frequently one can observe an initial aggravation of the patient's symptoms after which there follows an improvement of the condition. This is similar to the phenomenon observed in the treatment of anxiety disorders with tricyclics.(Kaplan & Sadock, 1995).
The clinical picture elicited in the proving of several remedies seems so specific that they resemble clinical syndromes found in today's nosology. The narrative of the proving of Aurum metallicum (gold) reports: "hopeless, despondent and great desire to commit suicide, disgust of life, feeling of self-condemnation and utter worthlessness". This can be contrasted to the picture found when proving Staphisagria: "Nervous affections with marked irritability; ill effects of anger and insults; very sensitive to what is said of her; prefers solitude". (Guernsey, 1866).
The first picture could correspond to a melancholic depression and the latter is akin to the rejection sensitivity of a patient with Donald Klein's Hysteroid Dysphoria or atypical depression.(Kaplan & Sadock,1995). These clinical pictures, elicited by the remedies, are brought upon individuals who are already susceptible to develop these syndromes. To participate in a proving an individual has to free from any evident pathology so the symptoms can get included in the materia medica accurately.
The remedy is selected not only on the mental picture but the concomitant symptoms found in the review of systems. For example, Aurum seems to have an affinity towards cardiovascular system, while Staphisagria has it towards the genitourinary system.
Another interesting picture is that of Arsenicum Album. It is characterized by great anguish, restlessness, and changes place continually. It has fear of death and of being left alone. These are symptoms commonly found in anxiety disorders, especially with panic attacks.
The picture of Natrum Muriaticum (sodium chloride) presents with ill effects from grief, fright, anger etc.; Is depressed and irritable, gets into a passion about trifles; Wants to be left alone to cry. These symptoms may be found in Dysthymic or Adjustment disorders.
Nux Vomica will manifest with a zealous fiery temperament, very irritable, cannot bear noises, odors, light, or touch. Sullen and fault-finding, seeks stimulants, sometimes in excess and suffers from constipation. These symptoms are found in patients suffering from neurovegetative dystonia as well as other for of dysthymia, usually of organic nature.
These are some of the mental symptoms that the homeopathic materia medicas report as observed in people taking these remedies during a "proving." Provings are the clinical pictures elicited in "healthy" subjects while taking remedies (prepared with the technique of dilution and potentizing). They are the basis for the homeopathic therapeutics. The question at the center of the controversy is: Are these diluted solutions, in which no molecules of the original solute remain, biologically active?
Homeopathy, A Placebo Response?
Because of the self-righteousness and enlightened mystification homeopaths display at times, scientific scrutiny of its tenets has been limited. The need to individualize the homeopathic remedy to suit the patient's symptoms presents a difficulty in the design and execution of well designed trials. This makes double-blind studies complicated.
In a review of the homeopathic literature by Scofield (1984) it says: "..in spite a great deal of experimental and clinical work there is only a little scientific evidence to suggest that homeopathy is effective. This is because of bad design, execution, reporting or failure to repeat experimental work and not necessarily because of the inefficacy of the system. Which has yet to be properly tested on a large enough scale. It is suggested that there is sufficient evidence to warrant the execution of well-designed, carefully controlled experiments. Some of the experimental work already done suggests that homeopathy may be of value in the treatment and prevention of diseases in crops, as well as animals and humans."
In a double-blind clinical trial Reilly et al.(1986) concluded that: "The homeopathically treated patients showed a significant reduction in patient and doctor assessed symptom scores. No evidence emerged to support the idea that placebo action fully explains the clinical responses to homeopathic drugs."
From the discussion above we may conclude that: Hahnemann was one of the early innovators of the humane treatment of the insane and mentally ill, the conceptualization of psychosomatic illness, and the explorations in pharmacology and toxicology. He attached importance to the observation of the natural reactivity of living organisms to medicinal substances and disease, fine tuned the clinical history and placed importance on the patient rather than on nosology.
Homeopathic practitioners had a considerable influence in the way that medicine is practiced today. Recent research has concluded that some of the homeopathic postulates could well be true, and this could bring a new perspective into medicine. Modern homeopathic provings of drugs are done under double-blind placebo control conditions and the results show statistical significance.(Int.Hom.Med.League, 1987)
Proving that homeopathic medicine is effective would revolutionize the medical arts and offer people a cost effective, less toxic and more integral treatment. This would have immense implications economically, socially, and politically.
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