Carlos Morra and Mateo Kreiker: Psychopathology
Thomas A. Ban: The AMDP System
Central to psychopharmacological research is the identification of pharmacologically homogeneous populations within the pharmacologically heterogeneous psychiatric diagnoses. The need for a pharmacological re-evaluation of psychiatric nosology (Freyhan 1959) led to the development of the AMP documentation system in German speaking countries. To overcome the difficulty of demonstrating therapeutic efficacy in pharmacologically heterogeneous diagnostic population, the BLIPS was developed in the United States. Both systems were introduced in the 1960s and are defined below.
The AMP System
Activities which led to the introduction of the AMP System began in the late 1950s by two independent teams of university based psychiatrists, one in the Federal Republic of Germany (FRG) and the other in Switzerland, collaborating in clinical studies with psychotropic drugs. The psychiatrists in the FRG included: D. Bente (Erlangen,) M.P. Engelmeier (Essen,) K. Heinrich (Dűsseldorf,) H. Helmchen and H. Hippius (Berlin,) and N. Schmitt (Saarbrűcken.) The psychiatrists in Switzerland included: J. Angst (Zurich,) F. Cornu (Bern,) P. Dick (Geneva,) H. Heimann (Lausanne,) and O. Pöldinger (Basel.)
In the early 1960s, members of the two groups, together with Peter Berner from the Department of Psychiatry, University of Vienna (Austria,) and Paul Schmidlin from Geigy, a Swiss pharmaceutical company, embarked on the development of a common documentation system for studying and characterizing the clinical effects of the new drugs. The working relationship was formalized in 1965 by the founding of the Arbeitsgemeinschaft fűr Methodik und Documentation in der Psychiatry (Working Group for the Methodology and Documentation in Psychiatry) with a secretariat at the Psychiatric Clinic of the Free University in West Berlin. The documentation system of the Working Group (Angst, Battegay, Bente et al. 1967). In the 1970s, the acronym was, completed in 1967, was referred to as the AMP System, using the acronym changed to AMDP (Angst, Battegay, Bente et al. 1969a).
The AMDP System consists of five integrated forms for recording: (1) Demographic Data, (2) Life Events, (3) Psychiatric History, (4) Psychopathological Symptoms (PSF) and (5) Somatic Signs (SSF). Two of the five forms, the PSF and the SSF, are suitable for the assessment of change in the clinical state of patients. The PSF includes 100 items, organized into 13 categories; the SSF consists of a catalogue of 41 physical symptoms (signs), listed under seven headings (Angst, Battegay, Bente et al. 1969b)
The thirteen categories of the PFS: (1) intellectual deficit, (2) disorders of consciousness, (3) disturbance of orientation, (4) disturbance of attention and memory, (5) formal disorders of thought, (6) phobias and compulsions, (7) delusions, (8) disorders of perception, (9) disorders of ego, (10) disturbances of affect, (11) disorders of drive and psycho-motility, (12) circadian disturbances and (13) other disturbances, including social withdrawal, excessive social contact, aggressiveness, suicidal tendencies, self-mutilation, lack of feeling ill, lack of insight, uncooperativeness and lack of self-care. The seven headings of the SSF catalogue: (1) disturbance of sleep and vigilance, (2) appetite disturbances, (3) gastrointestinal disturbance, (4) cardiac-respiratory disturbances, (5) other autonomic disturbances, e.g., blurred vision, (6) other somatic disturbances, e.g., headache, and (7) neurological disturbance.
Programs for computer processing of the AMP (AMDP) data were developed in the 1960s and 1970s at several centers, including Berlin, Erlangen, Munich and Zurich (Bente, Feder and Stegordner 1970).
Since its first edition in 1971 (Sharfetterb 1971), the AMP (AMDP) Manual has been revised several times. It’s most recent, eighth edition, was published in 2007 (AMDP 2007).
The Manual was translated into several languages, e.g., Croatian, Dutch, English, Estonian, French, Greek, Italian, Japanese, Portuguese, Russian, and Spanish, because it seemed a more suitable instrument for the delineation of the therapeutic profile of psychotropic drugs than the conventional rating scales used in clinical trials (Ban, Lehmann, Galvan et al 1974).
The initial English translation was completed from the second edition of the Manual (Scharfetter 1972) by Jűri Saarma, in collaboration with Thomas Ban and Heinz Lehmann in 1974. Saarma, chairman of the Department of Psychiatry at the University of Tartu (Dorpat), where Emil Kraepelin began his career, was at the time Visiting Professor with the WHO Training Program in Biological Psychiatry in Montreal, Canada
In 1977, the third German edition of the system, now called AMDP-III, was published (AMDP 1977). The changes in AMDP-III were significant enough to warrant a new English translation. This was prepared by Guy and Ban collaboration with D. Bobon, J. Hoenig, R. Jamieson, Y. Lapierre, A. Leeds, H. Lehmann, J. Libiger and J. Saarma, and consultation with J. Angst, P. Berner, P. Grof, M. Hamilton, H. Helmchen, M. Hollender, E. Koranyi and N. Sartorius, and published in 1982 (Guy and Ban 1982). The advent of AMDP-III has created a similar situation for other translations(Bobon 1978; Bobon and Saarma 1978) coordinate activities among the groups involved with AMDP outside of German speaking countries, an International AMDP Secretariat was established at The University of Liege, Belgium, under the leadership of Daniel Bobon (Bobon, Bauman, Angst et al.1983).
AMDP. Das AMDP System Manual zur Dokumentation psychiatrischer Befunde. 3, Auflage. Berlin: Springer; 1977.
AMDP. Das AMDP System Manual zur Dokumentation psychiatrischer Befunde. 8, űberarbeitete Auflage. Gottingen: Hogrefe; 2007.
Angst J, Battegay R, Bente D, Cornu F, Dick P, Engelmeier MP, Hermann H, Henrich K, Hippius H, Pöldinger W, Schmdlin P, Schmitt W, Weis P. On the Proceedings of German and Swiss Association for the study of psychiatric documentation. Schweiz Arch Neurol Nerochir Psychiat 1967; 100:207-11 (In German).
Angst J, Battegay R, Bente D, Berner P, Broeren W, Cornu F, Dick P, Engelmeier MP, Heimann H, Heinrich K, Helmchen H, Hippius H, Lukács G, Pöldinger W, Schmidlin P, Schmitt W, Weis P. Clinical documentation of psychopharmacology. (Association for Methodology and Documentation in Psychiatry.) In: Cerletti A, Bové FJ, editors. The Present Status of Psychotropic Drugs . Amsterdam: Excerpta Medica; 1969a. p. 361-5 (In French).
Angst J, Battegay R, Bente D, Berner P, Broeren W, Cornu F, Dick P, Engelmeier MP, Heimann H, Helmchen H, Hippius H, Pöldinger W, Schmidlin P, Schmitt W, Weis P. The documentation system of the Association for Methodology and Documentation in Psychiatry (AMP.) Arzneim Forsch 1969b; 19:399-405 (In German).
Ban TA, Lehmann HE, Galvan L, Pecknold JC, Climan M. A transcultural study with Comparison of two assessment methods. Current Therapeutic Research. 1974; 16:971-89.
Bente D, Feder J, Siegordner K. A computer program for interregional storage and statistical evaluation of AMP data. Arzneim Forsch. 1970; 20:913-5 (In German).
Bobon D. Conceptual and semantic problems raised by the French translation of the AMP Psychopathology Scale. In: Deniker P, Radouco-Thomas C, Villeneuve A, editors. Proceedings of the Xth Cogress CINP. London: Pergamon Press; 1978. p. 1583-8.
Bobon D, Saarma J. Summary of the First Workshop on Translation of the`AMP System. In: Deniker P, Radouco-Thomas C, Villeneuve A, editors. Proceedings of the Xth Congress CINP. London: Pergamon Press; 1978. p. 1555-6.
Bobon D, Baumann U, Angst J, Helmchen H, Hippius H, editors. AMDP-System in Pharmacopsychiatry. Basel: Karger; 1983.
Freyhan F. Selection of patients from the clinical point of view. In: Cle JO, Gerard RW, editors. Evaluation of Pharmacotherapy in Mental Illness. Washington: National Academy of Sciences; 1959. p. 372-89.
Guy W, Ban TA. The AMDP System. Hedelberg: Springer; 1982.
Scharfetter C. The AMP System. Berlin: Springer; 1971 (In German).
Scharfetter C. The AMP System. 2nd edition. Berlin: Springer; 1972 (In German).
November 26, 2020
Carlos Morra and Mateo Kreiker: Psychopathology
Thomas A. Ban: Psychotropic Drug Development and the Language of Psychiatry*
Psychopharmacology is the scientific discipline that is dedicated to the detection of psychopathologic symptoms and syndromes, and the identification of nosologic entities that are affected by psychotropic drugs.
The term, “psychopharmacology” was coined in 1920 by David Macht, an American pharmacologist, to describe the effects of drugs on psychometric performance tests. The roots of the discipline, however, were in the discovery of Moreau de Tours, a French psychiatrist, in 1845, that the effects of “dawamsec,” an electuary of hashish, were different in the depressed (melancholic), than in the regressed (“aliéné stupide”) and in the demented. In the 1940s, with the availability of lysergic acid diethylamide, research in psychopharmacology was extended to include the “model psychoses,” psychopathologies induced by psychotropic drugs, with the hope that they would provide the key for the understanding of naturally occurring psychoses. In the 1950s, with the rapidly growing number of psychotropic drugs in the pipelines of the pharmaceutical industry, research in psychopharmacology was further extended to efficacy studies with the new compounds.
Introduction of psychotropic drugs in the 1950s focused attention on the differential responsiveness to the same drug within the same diagnostic category. The pharmacological heterogeneity within the diagnoses created difficulties for the pharmaceutical industry in demonstrating the therapeutic effectiveness of drugs, and for psychiatrists in prescribing the new drugs in a predictable manner. Academic psychiatry was confronted with the need to resolve the heterogeneity within the diagnostic categories by re-evaluating psychiatric nosology and to develop a pharmacologically relevant classification of mental illness. But this did not happen. Instead, a statistical methodology, the randomized clinical trial, was adopted for the demonstration of therapeutic effectiveness in pharmacologically heterogeneous diagnostic populations. Consequently, semi-finished psychotropic drugs have been released for clinical use without the delineation of their therapeutic profile, detection of their differential effects or the benefit of orientation points given by clinical psychopharmacological research to predict in which patients they might have therapeutic effects.
There are two essential prerequisites for the adoption of a statistical methodology for the demonstration of therapeutic effectiveness: rating scales, which can detect and document changes and diagnostic end-points, which can be reliably identified. It was in response to the need of documenting changes that in the early 1970s a German-speaking academic group developed a “Manual for the Assessment and Documentation of Psychopathology” (Angst, Battegay, Bente et al. 1969; Guy and Ban 1982; Scharfetter 1971); a Swedish academic team constructed a “Comprehensive Psychiatric Rating Scale” (Asberg, Perris, Schalling and Sedvall 1978); and William Guy (1976) in the United States assembled rating scales for the assessment of change and published them in the Early Clinical Drug Evaluation Units manual which was to become the most important source book of scales for efficacy studies with psychotropic drugs.
The need for diagnostic end points that can reliably be identified was met by the Third Edition of the Diagnostic and Statistical Manual (DSM-III) of the American Psychiatric Association, published in 1980. DSM-III, the first consensus-based classification of mental illness with operationalized diagnostic criteria, was so successful that by the mid-1980s it replaced all other diagnostic classifications in the clinical development of psychotropic drugs
The adoption of a statistical methodology in psychiatry for the study of therapeutic efficacy had a major impact on academic psychiatry by providing a means to evaluate the effectiveness of various treatment modalities. It was on the basis of findings in these evaluations that pharmacotherapy has become the primary form of treatment in schizophrenia and mania in the 1960s; in depression and bipolar disorder in the 1970s; in the anxiety disorders in the 1980s; and in Alzheimer’s type of dementia in the 1990s. As decisions regarding the choice of treatment were to become based increasingly on findings in the clinical development of psychotropic drugs, psychiatric nosology was replaced by consensus-based classifications and psychopathology by rating scale variables used in the clinical studies conducted for the demonstration of therapeutic effects.
Introduction of consensus-based classifications, based primarily on Kraepelin’s (1899) nosology, has created an impasse in resolving the heterogeneity within the diagnostic groups. Since these classifications were developed to reconcile widely different diagnostic formulations with the use of broad diagnostic categories they covered up component diagnoses. One such component diagnosis is “vital depression” -- a form of depression in Kurt Schneider’s (1920, 1950) clinical psychopathology that is characterized by “corporization,” “disturbance of vital balance” and the “feeling of loss of vitality”-- which allowed Roland Kuhn (1957) to discover imipramine’s antidepressant effect. This diagnosis is covered up to the extent that even in a severely ill patient who displays all the possible symptoms and signs considered for the DSM-IV-TM (American Psychiatric Association 1994) diagnosis of “major depression,” one still would not know whether the patient qualifies for “vital depression.” Another covered up diagnosis is “affect-laden paraphrenia” -- a form of “unsystematic schizophrenia” in Karl Leonhard’s (1957) classification of endogenous psychoses that is characterized by “paranoid delusions with affective loading and mood swings -- in which Frank Fish (1964) found that more than 4 in 5 patients responded favorably to antipsychotic phenothiazines.
The sensitive scales introduced for the demonstration of therapeutic effects compounded the problems with consensus-based classifications. Rating scales can be sensitized by the omission of psychopathological symptoms, relevant to psychiatric nosology which are not influenced by treatment, or by retaining only those items (variables) of a scale which show the largest changes. While the use of sensitive scales helps to demonstrate therapeutic effectiveness in the shortest possible time in the smallest number of patients, the omission of relevant psychopathological symptoms to psychiatric nosology precludes the possibility of finding by meta-analyses any relevant information for the identification of treatment-responsive forms of illness in the data collected in efficacy studies with psychotropic drugs. Since one of the essential prerequisites for the development of neuropsychopharmacology is the identification of a treatment responsive form of illness, consensus-based classifications and sensitized rating scales blocked the development of the combined discipline. By interfering with the development of neuropsychopharmacology, they also precluded the possibility of using psychotropic drugs meaningfully in biological research in psychiatry.
American Psychiatric Association. Diagnostic and Statistical Manual-Third Edition, Washington: American Psychiatric Association; 1980.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Washington: American Psychiatric Association; 1994.
Angst J, Battegay R, Bente D, Berner P, Broeren W, Cornu F, Dick P, Engelmeier MP, Heimann H, Heinrich K, Helmchen H, Hippius H, Lukacs G, Pöldinger W, Schmidlin P, Schmitt W, Weis P. The Documentation System of the Association for Methodology and Documentation in Psychiatry (AMP). Arzneim. Forsch. 1969; 19:399-405.
Asberg M, Perri C, Schalling D, Sedvall G. The CPRS-development and application of a psychiatric rating scale, Acta Psychiatr. Scand. 1978; Suppl. 271:69.
Ban TA. They used to call it psychiatry. In: Healy D. The Psychopharmacologists. London: Altman, an Imprint of Chapman and Hall; 1996, pp. 587-620.
Fish F. The influence of the tranquilizer on the Leonhard schizophrenic syndromes. Encephale 1964; 53:245-9.
Guy W. ECDEU Assessment Manual for Psychopharmacology – Publ. No. (ADM). (DHEW No. 76-338), Rockville: National Institute of Mental Health), United States Government Printing Office; 1976.
Guy W, Ban TA, editors and translators The AMDP-System. Manual for the Assessment and Documentation in Psychopathology. Berlin: Springer; 1982.
Kraepelin E. Psychiatrie. Ein Lehrbuch für Studierende und Ärzte. 6 Auflage, Leipzig: Barth; 1899.
Kuhn R. Über die Behandlung depressives Zustande mit einem iminodibenzyl-derivat (G22355), Schweiz. Med. Wochenschr. 1957; 87:1135-40.
Leonhard K. Aufteilung der endogenen Psychosen, Berlin: Akademie-Verlag; 1957.
Macht DI. Contributions to psychopharmacology (The John Hopkins Hospital Bulletin Vol. XXXI, No. 351), 1920, pp.167-73.
Moreau de Tours J. Du Hachich et de L’Aliénation Mentale. Etudes Psychologiques Paris: Fortin & Mason; 1845.
Scharfetter C. The AMP System. New York: Springer; 1971.
Schneider K. Die Schichtung des emotionalen Lebens und der Aufbau der Depressionszustände, Z Ges. Neurol Psychiatr. 1920; 59:281-5.
Schneider K. Klinische Psychopathologie. 3. Auflage, Stuttgart: Thieme; 1950.
*Extracted from Ban TA. Academic Psychiatry and the Pharmaceutical Industry. Progress in Neuropsychopharmacology Biological Psychiatry, 2006; 30(3):429-41.
November 19, 2020