Monday, 25.09.2017

Comment by Hector Warnes

Hector Warnes’ comment on Thomas A Ban’s Neuropsychopharmacology and the Forgotten Language of Psychiatry: From Psychiatry to Neuronology

It is a pleasure to read this monumental study on the evolution of the pivotal ‘forgotten language’ of psychopathology and the conflicting nosologies based on semiology that have arisen in our attempts to understand mental illnesses since the 19th century.  Prof. Ban has written a panoramic and systematic view of the latest integrative discoveries of our young discipline, which cannot be independent of the neurosciences nor of multifactorial triggers, internal and external, with different degrees of importance as in most of medicine. Let   us not forget Antoine Laurent Bayle, who in 1822 discovered a medical pathology for a mental disease, which in fact, was neurosyphillis and called it chronic arachnoiditis, the cause of a ‘symptomatic mental alienation’. Bayle thus introduced the medical model in psychiatry. Constantin von Economo studied the sequelae of the encephalitis lethargica following the flu pandemic in 1917-1918 and described not only the neurological, but also various psychopathological sequelae (Pierre Pichot: A Century of Psychiatry. Hoffmann- La Roche: Basle Switzerland; 1983), later emphasized by Oliver Sacks in his book ‘Awakenings’. He attributed this eruption into life of severe Parkinsonian patients that had many depressive features and that were able to respond to L-dopa given by George Cotzias.  Oliver Sacks at first was skeptical about L-dopa because he was anti-reductionist and believed that there were other factors in what he called ‘a post-encephalitic disorder of far greater complexity, severity and strangeness’   (Oliver Sacks: Awakenings. Harper Perennial; 1990). Electroencephalography was introduced by a German psychiatrist Hans Berger in 1929, which later on allowed further understanding of different psychopathological symptoms manifested by EEG changes and the newer neuropharmacological therapies in the nineteen-fifties also reflected in EEG disturbances.  Ictal manifestations were known to improve psychotic states and were used by Cerletti and Bini as treatment for depression or acute functional psychosis with Electroconvulsive therapy.  What was less known was the interictal psychosis, the forced normalization of Landolt, the postictal psychosis, the paranoid and affective states, cognitive disorders, confusional states, bizarre conducts, language disturbances and dreamy states, the latter described by W. Penfield during neuro-surgical  stimulation of  the temporal lobe with micro- electrodes  (Gerhard-Schorsch: Epilepsie: Klinik und Forschung. In Psychiatrie der Gegenwart-Band II. Springer-Verlag; 1960). There are many medical diseases preceded by depression for months such as cancer of the colon, pancreas and lung and finally the dementias that have a very complex psychopathology, which may affect any area of the brain with its distinct psychopathological symptom before we can reach a clear diagnosis. We psychiatrist still have a wider field in the research of the psychiatric aftermaths of craneo-encephalic traumata that are so prevalent. For further reading on this issue, I recommend Psychiatric Aspects of Neurologic Disease, edited by D.F. Benson and D. Blumer (Grune and Stratton: New York; 1975)..

Tom Ban citing Pierre Pichot writes: ‘Every mental disorder implies a disease of the nervous system, but not every defect of the nervous system is accompanied by mental disorder’. This statement sums up the above arguments.

The introduction of experimental psychopathology thanks to the work of Pavlov, Horsley Gantt, Masserman and H.S. Lidell among others were reviewed by Ban in his book Conditioning and Psychiatry (Aldine Publishing Company: Chicago;1964). Quoting Prof. Ban in his ‘Forgotten language’ page 8: ‘Hence, abnormal Conditional Reflex functions could be linked to psychopathology and its underlying abnormality; C.R. parameters would provide a bridge between the ‘language’ of mental pathology and the ‘language of pathological brain functioning’.

Charles Shagass wrote a chapter on Experimental Psychopathology in ‘The Comprehensive Textbook of Psychiatry”, edited by A.M. Freedman and H.I. Kaplan (The William and Wilkins Company; 1967). In the same book there are excellent chapters on Hallucinogens (psychotomimetics) by Arnold Mandell and Louis Jolyon West (Ban cited Moreau de Tours who first described the psychodysleptic effects of Hashish in 1845) and on the pathogenic effects of Sensory Deprivation first explored by Bexton, W.H, Heron, W. and Scott, T.H. (Effects of decreased variation in the sensory environment. Canad. J. Psychology 1954;  8: 7) and further expanded by H. Azima, R. Vispo and F.J. Azima at the Allan Memorial Institute in Montreal.

Prof. Ban   in citing Carl Wernicke who classified psychiatric disease on the basis of hyperfunctioning, hypofunctioning or parafunctioning in the psychosensory, intrapsychic (transcortical) and psychomotor components of the psychic reflect (first noted by Griesinger)   takes us from physiology to molecular biology. Professor Ban has clarified many issues regarding Leonhard’s nosology particularly thanks to the English school (Frank Fish) and American-Hungarian school at Vanderbilt University in Nashville to end at the Hungarian school of the University of Semmelweis in Budapest where a new psychopathological classification was launched.

Ban reminds us that the Heidelberg school first introduced the distinction between pathologies of symbolization (condensation and onomatopoesis) later taken up by Freud and pathologies of psychomotility (ambitendency and parakinesis). Ambitendency or ambivalence was taken up by E. Bleuler as one of the primary symptoms of schizophrenia. He further reminds us of Jaspers monumental work on psychopathology largely phenomenological in the sense of describing abnormal subjective experiences: ‘while nosology deals with the synthesis of disease entities from symptoms and signs and a classification of the diseases synthesized’ (p. 12). As Prof. Ban stated, we have made a great leap forward since Abraham Wikler’s book, published in 1957,  which emphasized the biological underpinning of mental disorders up to the latest advances in Positron Emission Tomography, Single Photon Emission Tomography and other neuroimaging techniques which support Ban’s analysis, including  molecular biology and molecular genetics.

I would like to put forward the nosological schema proposed by Henry Ey, who was inspired by the British neurologists, C.S. Sherrington regarding the integration of the CNS and Hughlings Jackson regarding the dissolution or disintegration of higher mental functions, releasing lower levels of brain activity:

 

1.      Pathology of consciousness: acute psychosis, manic and depressive episodes, cloudiness of sensorium, confusional psychosis, acute delirium and acute delusional states. I would add Meduna’s oneirophrenia.

2.      The ´pathology of personality refers to psychopathies and neurosis, chronic schizophrenias, delusional psychosis and dementias (Henri Ey: Ëtudes psychiatriques- structure des psychoses aigues et déstructuration de la conscience. Volume III. Desclée de Brouwer: Paris; 1954). The “pathologie du champ de la conscience” seems to coincide in part with the “acute exogenous reaction types” of Bonhoeffer and with the “bouffées delirantes”.  A very impressive review on this issue was published by Klaus Conrad (Die symptomatischen

Psychosen in Psychiatrie der Gegenwart. Band II. Springer Verlag; 1960).

Henry Ey appears to be influenced as well by Jaspers,  who distinguished between phasic or periodic and process or development of the personality. Further reading of the most significant contributions of European psychiatry can be found in Themes and Variations of European Psychiatry edited by S.R. Hirsch and M. Shepherd (University Press of Virginia: Charlottesville; 1974). In this book, there is a chapter on Patterns (Die Erscheinungsformen) of mental disorders written by E. Kraepelin, who in supporting Birnbaum’s view, states: ‘we may say that the pathognomonic disturbances -those which unfailingly appear in the same illness- are produced directly by the basic underlying cause, while the less constant phenomena, which appear in varying guise or which may be altogether absent, are attributable to factors personal to the patient’ (p.16). As you recall, Birnbaum differentiated between pathogenic and pathoplastic factors.

Karl Leonard classification was validated by Frank Fish (1964). Between 79% of 123 unsystematic schizophrenics and 84.4% of 51 cases of affect-laden paraphrenics responded to phenothiazines while only 23 % of 311 systematic schizophrenics and 23 % of 100 systematic hebephrenics responded to the same drug (page 20).

In another study by Guy, Ban and Wilson (1985), 4.3 % of unsystematic schizophrenics developed tardive dyskinesia while 13.3 % of systematic schizophrenics had this complication.

                      Regarding the Composite Diagnostic Evaluation (CODE) which showed a high inter-rater reliability was compared with the DSM-III and Ban noted that the latter ‘reified pharmacologically heterogenous diagnostic concepts’ implying that was far from a-theoretical.

The CODE-DD was adopted to fit neuropsychopharmacological research. Ban found that of 322 patients with major depression, only 37% were validated using the CODE-DD.

An original ‘structural pspychopathology’ was proposed by Gyula Nyirö (1958, 1962) from Budapest. The structures were three: afferent cognitive, central affective and efferent adaptive ones. Ban proposes a ‘nosological homotyping’ which would ‘provide a potential diagnostic concept for a mental disorder in which psychopathological symptoms represent distinct abnormalities in the processing of signals between levels within and across these  three mental structures’ p. 28,  taking into account the onset, the course and the dynamic totality of the pathological process. For Ban, the nosological homotyping would allow pharmacological validation.

In this complex E-book, Ban includes in the validation studies the latest development of molecular biology such as G protein coupled receptors, nuclear hormonal receptors, ion channels, enzymes, and so on (p, 26), which using a treatment responsive population to a psychotropic drug could serve as a reference point for testable genetic hypotheses’ p.26. Since the discovery of the role of neurotransmitters alterations in schizophrenia and major depression, we have come a long way because it would appear that the substratum of mental illnesses is far more complex. Unfortunately, even reading Ban’s paper, which is far from being reductionist, we cannot yet follow an Occam’s razor argument: ‘entia non sunt multiplicanda praetor necessitate’ (entities are not to multiplied beyond necessity) (Simon Blackburn: Oxford Dictionary of Philosophy. Oxford University Press; 1996).

Ban’s E-Book is an overview of the developments of psychopathology and nosology, matching each syndrome or cluster of sign and symptoms with the latest advances in neuropsychopharmacology and the neurosciences.  He has gone with great originality into sorting out disease entities by ‘nosological homotyping’, which would take into account the genome and the environment. The existence of signals of facilitation and suppression in the cortex are well established as the role of different brain circuits in most mental disorders.

I am inclined to suggest that the glia has as much importance as the neurone per se and that the validation of the DSM-5 or that of the Leonhard nosology is far from completed because of limitations in our understanding of the basic substratum of many mental disorders.

 

Hector Warnes

March 26, 2015