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The Psychology of Insanity is a book published in 1912 by the British physician and psychiatrist Bernard Hart (1879 – 1966). The book consists of 12 chapters that aim to provide an overview of the leading psychological theories on insanity during the early 20 th century. Rather than addressing the issue of insanity from an abstract scientific point of view, Hart describes psychological mechanisms and their disturbances in a simple manner that is understandable by the layman. The book outlines the views on the science of insanity at the time by providing several case studies and explaining the underlying psychological processes that are involved in the emergence of abnormal behaviour.

Historical development of insanity
Insanity can be traced back to the advent of mankind throughout all cultures. For most of human history, the insane were not treated with the same rights as the rest of the population. The first attempts to describe insanity from a medical point of view were provided by Hippocrates (460 – 377 BCE), who proposed that insanity was a disease of the brain resulting from an imbalance of four humours in the body. However, during the Middle Ages, as the influence of the Roman Catholic Church increased, the general view on insanity was that it was the consequence of demonic possessions and had to be treated with religious ceremonies, such as exorcisms. Moreover, it has been suspected that during the Witch-Hunts between the 15th and 18th centuries many of the persecuted suffered from mental disorders. Consequently, before the 19th century distinct manifestations of insanity had not been systematically differentiated, leading to a poor categorisation and treatment of the psychopathology. In order to segregate the insane from society, from the 16th century onwards asylums were established. However, since the insane were regarded to be incapable to reason for themselves and were thus compared to animals (i.e. animalism), most patients at such institutions were held without their consent and were treated inhumanely by today's standards. During the 18th and 19th century, however, a humanitarian movement contributed to better and more hygienic treatment of the patients at asylums.

Throughout the late 18th and the 19th centuries, two parallel conceptions of insanity dominated the field. Whereas the physiological conception treats insanity as the result from changes occurring in the brain, the psychological conception views insanity as a phenomenon of the mind. On the one hand, the physiological conception of insanity developed into the current field of psychiatry. On the other hand, during the early 20th century, the psychological conception of insanity was dominated by prevailing psychoanalytic theories proposed by Sigmund Freund, Carl Jung, and Pierre Janet between others. Through the publication of The Psychology of Insanity, Bernard Hart was one of the first authors to introduce such psychoanalytic theories on abnormal behaviour from German and French literature into the English literature.

Bernard Hart's life history
Bernard Hart's journey begun with his studies in medicine at the University College London Medical School. After completing his degree in 1903, he specialised in the field of psychiatry in Paris and Zurich, where he first encountered detailed accounts of psychoanalytic theories proposed by Freud, Jung, and Janet. Hart gathered his first practical experiences in the field of psychiatry as an assistant physician at the Hertfordshire County Asylum (Hill End Hospital), and at Long Grove Asylum, where he later got appointed as the first physician for psychological medicine in 1913. The practical and theoretical insights that Hart had during these years allowed him to be one of the first authors to introduce psychological conceptions of the mind into the English literature through his paper on The Conception of the Unconscious in 1910. Subsequently, Hart published The Psychology of Insanity with the aim of applying such psychoanalytic theories in clinical settings to explain abnormal behaviour.

Content
In The Psychology of Insanity Hart outlines contemporary psychoanalytic theories of the early 20th century, thereby aiming to explain the behaviour of the lunatic based on extreme manifestations of normal psychological phenomena. The author first provides an oversight of the most common symptoms associated with insanity before elaborating on the associated psychological mechanisms:

According to Hart, the mind is composed of more or less isolated mental processes, each pursuing its own development. Although such dissociation of consciousness is also present in the healthy adult, it is manifested in an exaggerated form that persists for longer in the insane. Therefore, when consciousness is dissociated from the preceding moment, episodes of somnambulism may develop. Similarly, obsessions, hallucinations, and delusions are characterised as ideas, senses, and beliefs that develop independently of a patients' personality, and are hence dissociated from it.
 * Quantitative mental defect: a diminution in the general mental capacity involving all the functions of the mind that can be manifested as imbecility or dementia.
 * Excitement, depression, and apathy: a qualitative change in the general attitude of the mind towards its experience that may be either transitory or permanent. Whereas excitement is characterised by exaggeratedly elevated arousal, affect, and energy levels that are out of harmony and without an adequate cause, depression is associated with slow responses, difficulty in thinking, and feelings of misery and unhappiness. Apathy, in contrast, is characterised by absolute indifference, without apparent interests, desires, or ambitions.
 * Somnambulism: rather than referring to the prevailing definition of somnambulism as sleepwalking, Hart defines this symptom as an abnormal mental condition that can start and end abruptly without the patients' awareness. Although patients do not forget the events prior to the somnambulism, they suffer from amnesia during the time the episode took place.
 * Hallucinations and delusions: whereas hallucinations are false sense-impressions (e.g. auditory or visual hallucinations), delusions are false beliefs (e.g. grandiose or persecutory delusions).
 * Obsessions: overweighting of a particular element in consciousness, absent of a definite false belief, that impels the patient to carry out repeatedly needless and useless actions.
 * Stereotyped action: when a patient carries out some action (often involving alterations in speech and phraseology) with monotonous repetition and regularity.

The author argues that the reason that consciousness is more dissociated in the insane is related to their underlying complexes. A complex represents a system of connected ideas, with strong emotional tone that tends to determine the behaviour of someone's conscious stream. Complexes might be inaccessible to conscious awareness as they may manifest themselves indirectly through behaviour. Moreover, when a complex is out of harmony with the individual's mind, an internal conflict between the person's complex and personality develop. The mutual inhibition between the complex and personality consequently divides the mind against itself, resulting in dissociation of consciousness and unpleasant emotional tension. Consequently, patients undergo a process of rationalisation, which serves as a bridge between the two systems of ideas. However, such rationalisation distorts the incompatibility of the two systems of ideas to such a degree that the conflict is efficiently avoided, thereby resulting in delusional beliefs that are typical for the insane.

In cases where such avoidance strategies are not available, patients may repress one of these systems of ideas by banishing it from consciousness entirely, thereby allowing the opposing part to take full possession of their behaviour. However, given the internal conflict, the repressed complex may still affect consciousness through a devious and indirect path that distorts the original complex. A patient may for example develop episodes of somnambulism or double personality during the periods where the complex expresses itself indirectly and takes full possession of the person's conscious stream. Similarly, obsessions may result from censure of morally questionable childhood memories that lead the patient to overweight certain elements in consciousness, which he attempts to compensate by repeatedly engaging certain symbolic actions (e.g. washing mania).

A repressed complex may also be censured and expressed indirectly simultaneously through the process of projection, where it is no longer regarded to belong to the individual, but rather as the production of other real or imaginary individuals. Such projections may result in delusions of persecution or reference, as well as hallucinations. Moreover, when patients find themselves in situations where the complex is not compatible with reality, they may no longer attempt to combine the two opposing forces, allowing the dissociation to become more pronounced and permanent. Consequently, they may build pleasant mental pictures where the complexes attain an imaginary fulfilment through the process of phantasy.

According to Hart, the insane adhere to the same reasoning powers that govern the sane mind, since in both cases complexes have a non-rational origin and immediate subjective sense of obviousness. However, the logic of the insane may seem irrational to the healthy adult, as it is out of harmony with the collective herd instinct. Therefore, the insane possess the same psychological mechanisms as the healthy adult, but in the lunatic the degree of dissociation is so large that it is no longer compatible with normal thought or behaviour, even when presented by contradictory facts of experience.

Hart's stance on the nature vs. nurture debate
Although Hart admits that based on the knowledge at the time one could not conclude whether nature or nurture was responsible for the development of psychiatric illnesses, he is one of the first authors to suggest that insanity may be less dependent upon intrinsic defects than on the environment surrounding a patient. Consequently, Hart proposes that selective breeding may not be the solution in getting rid of insane behaviour, but rather that the environment in which patients find themselves in should be adjusted appropriately. However, during the end of the 19th century and beginning of the 20th century, Francis Galton contributed to the eugenics movement, inspired by Darwinism, to become more popular across the Western world. The rising acceptance of the eugenics movement consequently contributed to implementations of selective breeding policies across the West. For example, in Germany, Nazi eugenics contributed to the extermination of countless of minority groups to promote the biological improvement of the Aryan race. In this sense, Robert Lowie positions Hart as an early proponent of the nurture side of the debate, given his opposition to selective breeding as proposed by the eugenics movement.

Reception
In The Psychology of Insanity Bernard Hart managed to clearly communicate his reasoning by substantiating his theoretical claims with ample case studies that link psychological concepts with different psychopathologies. Thereby, he argued that the psychological laws governing the sane are the same involved in the development of abnormal behaviour. The reception of the book as a pedagogical masterpiece can be attributed to its brevity and simplicity, as well as its breakaway from traditional schools of psychology, which gave rise to new dynamic concepts in the field. Moreover, the book is characterised for its clear exposition and conciseness, allowing those within and without the medical profession to gain a comprehensive understanding of psychological theories at the time. As a result, The Psychology of Insanity accomplished to compete with popular works on psychiatry until the 1960s in both the United Kingdom as well as the United States of America, with five published editions that essentially remained unchanged since the book first appeared in 1912. Moreover, Hart was able to combat the public stigma that psychoanalysis is solely involved in a discussion of sex, as he barely mentions the topic in his book. This attributed to the book becoming a classic in the English psychoanalytic literature and being recommended to students of psychiatry well into the second half of the 20th century. Following the publication of the book, the theoretical field of psychoanalysis expanded into the United States of America, where proponents such as Heinz Hartmann contributed to the emergence of ego psychology. In the practical domain, psychoanalysis keeps being an integral part to clinical interventions for patients with psychopathologies nowadays. This can be easily recognised when taking into consideration that during the second decade of the 21st century there are over 30 active psychoanalytic training institutions accredited by the American Psychoanalytic Association and abundant autonomous training societies appointed by the International Psychoanalytical Association throughout all of the Western hemisphere.

After the original publication of the book in 1912, Hart continued to practice in the field of psychiatry by treating veterans with shell-shock during World War I (WWI), and holding lectures on mental illness at Moss Side Military Hospital in Maghull. Moreover, as a member of the Royal Army Medical Corps, Hart served as a psychiatric consultant for military officers at distinct military hospitals in London. Following WWI, Hart practiced as a physician at the National Hospital for Neurology and Neurosurgery, as well as at the Maudsley Hospital. Additionally to his practical engagement, Hart contributed to the academic side of psychiatry by forming part of the editorial committee for the Journal of Neurology and Psychopathology in 1920. Furthermore, Hart gave multiple lectures related to mental disorders, such as his lecture on The modern treatment of mental & nervous disorders at the University of Manchester in 1918 or the Goulstonian lecture on The Development of Psychopathology and its Place in Medicine in, which he gave in 1926. Additionally to The Psychology of Insanity, Hart further contributed to English literature on the psychological conception of abnormal behaviour with his subsequent works The Psychology of Rumor in 1916, as well as Psychopathology, its development and its place in medicine in 1927.

Literature

 * Hart, Barnard (1916). The Psychology of Insanity. Cambridge University Press.