Carlos Mora and Mateo Kreiker: General Psychopathology 17
Thomas A. Ban: Development of the Language of Psychiatry
Introduction of Psychopathology
It was Galen (131-201) who was first to recognize that “symptoms” follow disease as shadow its substance (Garrison 1929). Yet, development of “psychopathology,” the “language of psychiatry,” began only in the mid-19th century in the course of early attempts to differentiate sub-populations within “insanity.”
The term psychopathology first appeared in the psychiatric literature in 1845 in Feuchtersleben’s textbook (the same book in which the term ”psychosis” was adopted) and throughout the second half of the 19th century the term was used as a synonym for psychiatry.
During the 19th century the vocabulary of psychopathology steadily grew. Esquirol (1838) divided false perceptions into “illusions” (distortion or misinterpretation of real perception) and “hallucinations” (perceptual experiences without corresponding stimuli in the environment); Griesinger (1845) distinguished between “pale (pseudo) hallucinations” (that appear in the inner subjective space and can be controlled voluntarily) and “true (real) hallucinations” (usually referred to “hallucinations”), and Wernicke (1881) separated “dysmnesia” (memory impairment) from “dementia” (personality deterioration).
Psychopathology became a discipline to provide a foundation for psychiatry in the early years of the 20th century. Instrumental to this development was Karl Jaspers (1910, 1913) who observed that in different psychiatric diseases patients’ process (in their brain) and consequently perceive the same “content” (information) in different “forms.” His recognition of the relationship between the “forms” in which information (“content”) is perceived by patients and their illness, led to the birth of “phenomenological psychopathology” (phenomenology), the branch of psychopathology that deals with “abnormal subjective experiences of individual psychic life.” It also led to his separation of “psychiatric disease process,” displayed by “abnormal forms of experiences,” from “abnormal personality development,” displayed by behavior that deviates from the statistical norm.
For the “phenomenologist,” it is not the subject matter, the information (“content”) the patient talks about, but how (“form”) the patient talks; and it is not the “somatic (hypochondriacal) complaints” (“contents”), but the form of how these complaints are experienced, i.e., as “bodily hallucinations” (somatic experiences without corresponding stimuli in the environment); “obsessive ideas” (ideas that persist against one’s will); and “hypochondriacal delusions” (false beliefs based on a priori evidence) that are relevant to diagnosis (Fish 1967; Taylor 1981). Even in case of “delusions” -- a “content disorder of thinking” that signals the presence of an ongoing psychiatric disease (“psychosis”) -- it is not the “content“ of the “delusions,” such as “delusions of reference,” “delusions of love,” “delusions of persecution,” etc., but the “form” in which the “delusion” appears, i.e., a “sudden delusional idea” (a delusional idea that appears to be fully formed), a “delusional perception” (a delusional meaning attributed to a normally perceived object), that is relevant to the characteristic abnormality of the processing of signals by the brain that differentiates one psychiatric disease (process) from another (Guy and Ban 1982; Hamilton 1985).
It was on the basis of “phenomenological analyses” that Kurt Schneider (1920, 1950) distinguished between “vital depression” (a disease) from the “other depressions” and separated “personality disorders,” displayed in “abnormal variations of psychic life” and the subject matter of “abnormal psychology,” from “psychoses” (mental disorders), displayed in “abnormal forms of experiences,” the subject matter of “psychiatry.”
During the years from 1918 to 1933 a group of psychiatrists that included Hans Gruhle and Wilhelm Mayer-Gross, in Kurt Wilmanns’ department of psychiatry at Heidelberg University in Germany, spearheaded “phenomenological analyses” in psychiatric patients (Shorter 2005). Their efforts yielded a vocabulary that includes distinct words (symptoms) from pathologies of “symbolization,” such as “condensation” (combining diverse ideas into one concept) and “onematopoesis” (building new phrases in which the usual language conventions are not observed), to pathologies of “psychomotility,” such as “ambitendency” (the presence of opposite tendencies to action) and “parakinesis” (qualitatively abnormal movements). In “phenomenology,” “dysphoria,” the negative pole of “vital emotions,” is distinguished from “dysthymia,” the negative pole of mood; “psychomotor retardation,” the experience of a spontaneous slowing down of motor activity, is distinguished from “psychomotor inhibition,” the experience of slowed down motor activity, etc.
Furthermore, by linking the terms that identify the different abnormalities to psychiatric diagnoses in use at the time, e.g., “tangential thinking,” characterized by talking past and around the point, with the “schizophrenias,” “circumstantial thinking,” characterized by overbearing elaboration on insignificant details without losing track, with the “dementias” and “rumination,” characterized by endless repetition of unpleasant thoughts, with “depressions,” the Heidelberg group set the foundation of a language for psychiatry.
Heidelberg School of Psychiatry
(1918-1933)
Phenomenological Analysis
VOCABULARY
for
language of psychiatry
WORDS
from pathologies of “symbolization” (“condensation,” “onematopoesis”)
to
pathologies of “psychomotility” (“ambitendency,” parakinesis”)
DISTINCTIONS
between
“dysphoria” vs “dysthymia”
“psychomotor retardation” vs “psychomotor inhibition”
SYMPTOMS & DIAGNOSES
tangential thinking - schizophrenias
circumstantial thinking – dementias
rumination - depressions
Introduction of Nosology
The vocabulary of “psychopathology” that deals with cross-sectional features of disease was extended to include the vocabulary of “psychiatric nosology” for describing psychiatric disease in its “dynamic totality” from “onset” through “course” to “outcome” (Ban 1987).
The two disciplines, “psychopathology” and “psychiatric nosology,” are intrinsically connected: psychopathology deals with symptoms, i.e., abnormal subjective experiences (“phenomenology”) and signs, i.e., “objective performance changes” (“performance psychology”), whereas ”nosology” deals with the synthesis of “disease entities” from symptoms and signs and classification of the diseases synthesized (Jaspers 1963). While classifications provide names (denominations) and descriptions of disease (qualifications), nosology provides the methodology for “how” diseases and classification of diseases are derived (Ban 2000).
The term “nosology” first appeared in 1743 in Robert James’ Medical Dictionary. Twenty-five years later in 1768, it reappeared in the title of Francois Boissier de Sauvages‘ Nosologia Methodica.
In his treatise, Sauvages stipulates that a disease should be defined by the enumeration of symptoms that suffice to recognize it and distinguish it from others (diseases), and a classification should be devised in a manner that it should allow the attribution of each patient to one and only one class. Thus, the emphasis in disease is that each patient with the same disease displays the same symptoms and thereby is different in terms of symptoms from patients with any other disease, whereas the emphasis in a class is on shared characteristics of diseases in terms of “course” and “outcome” regardless of differences in symptomatic expressions.
One year after the publication of Sauvages’ treatise, the term “nosology” was adopted also by William Cullen (1869, 1872) in the title of his Synopsis Nosologiae Methodicae.
Cullen divided “madness” into four classes of disease: “amentia“ (“imbecility of judgment, by which people do not perceive, or do not remember the relation of things”), “melancholia” (“partial madness without dyspepsia, varying according to the different subjects concerning which the person raves”), “mania” (“universal madness”), and “oneroidynia” (violent and troublesome imagination in time of sleep”) (Mennninger, Mayman and Pruyser 1968). His separation of “universal” (total) from “partial” madness, on the basis of “totality” of mental pathology, was to dominate classifications of insanity in the 19th century from those of Philippe Pinel’s (1798) and Jean-Étienne Dominique Esquirol’s (1838) in France, who distinguished between “mania” (universal insanity) and the “monomanias” (partial insanities), and Karl Kahlbaum’s (1863) in Germany, who distinguished between the vesanias (total-universal insanities) and the vecordias (partial insanities).
The separation of “universal” from “partial” madness during the second half of the 19th century was based on the pervasiveness of pathology manifested by “deterioration of personality” and/or “absence of insight.” Thus, Ernest-Charles Lasègue’s (1852) diagnostic concept of “persecutory delusional psychosis,” the predecessor of Kahlbaum’s (1874) diagnostic concept of ”paranoia,” was referred to as “partial insanity” because of a lack of “personality deterioration,” and Carl Friedrich Otto Westphal’s (1878) diagnostic concept of “obsessive states” (Zwangsvorstellungen), the predecessor of the diagnostic concept of “obsessive-compulsive neurosis,” was referred to as “abortive insanity,” a form of “partial insanity,” because patients had “insight” about the pathological nature of their condition.
The distinction between “universal” and “partial” madness lingered on during the first six decades of the 20th century. In 1913, in the 8th edition of his textbook, Emil Kraepelin used the distinction between “universal” and “partial madness” for the separation of “paranoia” and the “paraphrenias” (partial insanities) from “dementia praecox” (total insanity); and in 1957 in his Classification of Endogenous Psychoses, Karl Leonhard used the distinction for the separation of “pure mania” and “pure melancholia (total insanities) from the “pure euphorias” and “pure depressions.”
Prior to Boissier de Sauvages and Cullen in the late 17th century, Thomas Sydenham conceptualized disease as a “process” with a “natural history of its own” that “runs a regular and predictable course” (Ban 2000). Yet, in psychiatry, it was only about 200 years later that Jean-Pierre Falret (1854) identified a disease, fôlie circulaire, the predecessor of “manic-depressive insanity,” on the basis of its “temporal characteristics.” It was also Falret, first in the mid-1860s, to stipulate that “a natural form of psychiatric illness implies a well-defined predictable course,” and vice versa, “a well-defined predictable course presupposes the existence of a natural species of disease with a specified pattern of development” (Pichot 1983). A similar notion to Falret’s was expressed in 1874 by Karl Ludwig Kahlbaum in his “nosological postulate.” It was also Sydenham’s concept of disease that led Emil Kraepelin to replace his syndromic classification in the 4th edition of his textbook, published in 1894, with a disease oriented classification in the 5th edition (1896).
Kraepelin’s (1899) division (“dichotomy”) of the “endogenous psychoses” on the basis of “temporal characteristics,” i.e., “course” and “outcome,” in the 6th edition of his textbook into “manic depressive insanity,” a disease that follows an episodic course with full remission between episodes, and “dementia praecox,” a disease that follows a continuous deteriorating course, led to a re-evaluation of psychiatric diagnoses and classifications, especially (but not only) the classification of diseases that Paul Julius Möbius (1893, 1900) referred to as “endogenous psychoses.” In the course of this re-evaluation both diseases with and episodic course and diseases with a continuous course were divided into several forms. Within the diseases with an episodic course with full remission between episodes, diseases which manifest in “attacks” (that last from minutes to hours), as Lasegue’s (1877) “mental vertigo,” or in “phases” (that last from days to years), as Edna Neele’s (1949) “phasic psychoses,” were distinguished from diseases characterized by an episodic course without full remission between episodes which manifest in “thrusts” (“shifts”), such as Bleuler’s schizophrenias (1911). And within the diseases with “continuous course,” diseases which lead to highly differentiated “end-states,” such as Leonhard’s (1936) “defect (referred to later as ‘systematic’) schizophrenias” in the “endogenous psychoses,” were distinguished from diseases which lead to a dedifferentiated “terminal state,” such as Alzheimers’ (1907) disease (Ban 2000).
Kraepelin’s classification of the “endogenous psychoses” was first re-evaluated in the 1920s by Karl Kleist (1921, 1923, 1928) then by Karl Leonhard (1957) with the incorporation of some of Kleist’s contributions, e.g., the diagnostic concept of “cycloid psychoses.”
In his re-evaluation, Leonhard employed Neele’s (1948) “polarity” and Wernicke’s (1881, 1899) “mental structure” in classifying patients. With the employment of “polarity” he divided the population already separated by “course” and “outcome” into “bipolar” and “unipolar diseases” and separated within both several subpopulations on the basis of the site of the dominant psychopathology, i.e., the afferent-cognitive (“psychosensory”), central-affective (“intrapsychic”) or efferent-motor (“psychomotor”) component, in Wernicke’s “mental structure.”
In Leonhard’s (1957) classification “bipolar diseases” are characterized by a continuously changing “polymorph” (multiform) disease picture with a potential to display both extremes in mood, thinking, emotions and/or motility, whereas “unipolar (monopolar) diseases” are characterized by a consistent, unchanging, “monomorph” (simple, also referred to as pure) disease picture with no variation of mood, thinking, emotions and/or motility.
On the basis of “polarity” Leonhard splits Kraepelin’s “dementia praecox” (Bleuler’s [1911] “schizophrenias”) into two classes of disease: “(bipolar) unsystematic (non-systematic) schizophrenias” and “(unipolar) systematic schizophrenias;” on the basis of Wernicke’s “mental structure” he divides “unsystematic schizophrenias” into three diseases, i.e., “cataphasia,” “affect-laden paraphrenia” and “periodic catatonia.” Similarly, he divides the “systematic schizophrenias” into three groups of diseases, i.e., “paraphrenias” (with six psychopathology-based sub-forms), “hebephrenias” (with four psychopathology-based sub-forms) and “catatonias” (with six psychopathology-based sub-forms).
He also splits, on the basis of “polarity,” “manic depressive insanity” into “(bipolar) manic depressive disease” and “(unipolar) phasic psychoses,” and with consideration of Wernicke’s “mental structure,” he separates “manic depressive disease” from the “cycloid psychoses” and divides the “cycloid psychoses” into “excited-inhibited confusion psychosis,” “anxiety-happiness psychosis” and “hyperkinetic-akinetic motility psychosis.”
Furthermore, on the basis “totality,” the organizing principle introduced by Cullen (1769), he separates “pure mania” and “pure melancholia” from the “pure euphorias” and “pure depressions,” each displayed in five distinct psychopathology-based forms.
Within the “bipolar-polymorph” diseases the signal difference between “manic depressive disease” and the “cycloid psychoses” is that in “manic depressive disease” the “polarity” is prevailingly in mood, whereas in the “cycloid psychoses” the “polarity” is prevailingly in thinking (“excited-inhibited confusion psychosis”), emotions (“anxiety-happiness psychosis”) or psychomotility (“hyperkinetic-akinetic motility psychosis”). Within the “unipolar-monomorph” diseases the signal difference between “pure mania/melancholia” and the “pure euphorias/depressions” is that in “pure mania” and in “pure melancholia” the entire “mental structure” is affected, whereas in the “pure euphorias” and “pure depressions” only parts of the mental structure is involved.
Leonhard’s classification of “endogenous psychoses” was published in 1957 just about the time when neuropsychopharmacology was born.
Karl Leonhard
1957
Classification of Endogenous Psychoses
UNIPOLAR
Pure Mania
Pure Melancholia
Pure Euphorias
unproductive, hypochondriacal, enthusiastic, confabulatory, non-participatory
Pure Depressions
harried, hypochondriacal, self-torturing, suspicious, non-participatory
SystematicSchizophrenias
paraphrenias (hypochondriacal, phonemic, incoherent, fantastic, confabulatory, expansive), hebephrenias (silly, eccentric, insipid, autistic) catatonias (parakinetic, affected, proskinetic, negativistic, voluble, sluggish)
BIPOLAR
Manic Depressive Psychosis
Cycloid Psychoses
excited/inhibited confusion psychosis; anxiety/happiness psychosis
hyperkinetic/akinetic motility psychosis
Unsystematic Schizophrenias
cataphasia, affect-laden paraphrenia, periodic catatonia
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November 5, 2020