Hector Warnes’ comment
Leonardo Tondo: Interviews with Pioneers – Sir Martin Roth
I very much enjoyed the clinical narrative of the interview with Professor Roth whom I have met several times and whose extraordinary psychopathological skills, personal charisma and outstanding contributions to psychiatry I have very much appreciated. From the outset he painstakingly sorted out Kraepelin’s nosology at the Crichton Royal Psychiatric Hospital in Dumfries, Scotland, under Wilhelm Meyer-Gross (the book he wrote with Meyer-Gross, Roth and Eliot Slater is a classic in Psychiatry). He set himself apart from Sir Aubrey Julian Lewis, who was heavily influenced by Adolf Meyer, and held the view of a continuum between endogenous and reactive or neurotic depressions. Kraepelin, on the contrary, held the view that neurosis and psychopathies were not illnesses but were related to living styles, personality and upbringing.
The only certainty is that unipolar and bipolar disorders are distinct entities and that neurosis and neuroticism have lost momentum and are now called dysthymic disorders. Roth, in his research on the effect of imipramine on the affective disorders, clearly differentiated the beneficial effect of imipramine in endogenous depression and the negative effect on the neurotic disorders. Likewise, while ECT has no effect on neurotic depression, it has a very beneficial effect on endogenous depression, particularly if it is manifested with neurovegetative symptoms, anhedonia and psychomotor retardation and retardation of thought. Donald F. Klein described the hysteroid dysphoria responsive to MAOI. The diagnosis based on the response to treatment is not limited to psychiatry; it has been observed in medicine as a whole.
Akiskal has been studying this heterogenous group of dysthymic disorders and, on follow up, found a sub-group which are really endoreactive (double-depression) and respond to anti-depressants. This interview illustrates the evolution of psychiatric nosology which not only tried to distinguish the endogenous versus the exogenous components, traits versus states (the former related to personality and the later to conspicuous psychopathological symptoms), but the categorical versus the dimensional (or multi-dimensional) approaches to the disorder. I am surprised that attempts are made by clinicians to diagnose a personality disorder in the midst of a florid psychotic or panic disorder. There is no doubt that many periodic mood disorders on the one hand and other reactive affective disorders may converge in a bipolar disorder in the long run.
The frequency of co-morbidity has complicated the matter: what is primary and what is secondary? The relationship between psychic traumatic events, the onset of physical illness, the atypical depressions and the issue of masked depression and so on has long been accepted. This has led to investigations which confirm the affective states as a risk factor in some physical illnesses, but also the fact that a depressive disorder can be the prodrome of a physical illness. The blurring of boundaries or overlapping of symptoms of our traditional taxonomy and the uniqueness of each individual patient has complicated our clinical praxis. It must be clearly stated that reliability or inter-rater reliability has not resolved our problems because long-term validity of psychiatric diagnosis continues to be questioned with few exceptions.
I agree with Professor Roth that Agoraphobia is a distinct entity and so it is with the Obsessive Compulsive Disorder in its purest form. Why I say “in its purest form” is because it may appear as well in the bipolar disorder and in the severe reactive anxiety states. As Roth reminds us, the first clinical observations of Agoraphobia were published by Karl Friedrich Otto Wesphal in 1871. I mentioned his complete name because he was also a prominent neurologist, as were his father and brother, and because he described in 1877 narcolepsy and cataplexy.
The Obsessive Compulsive Disorder is so patent and easy to diagnose because of the thoughts, ideas, images and/or impulses that assail the person against his will. The patient tries to suppress, discard or annul an unwelcome intruder into his consciousness that filled him with fear. A female patient recently refused to marry the man she loved because she had the alien idea that she might harm babies or even kill them. Paroxetine had a curative effect.
Roth also published on the Phobic-Anxiety-Depersonalization syndrome which I have seen in my praxis many times.
I shall cite Professor Roth: “depersonalization occurring in schizophrenia, affective disorder, obsessional states, temporal lobe epilepsy, head injury, encephalitis, carbon monoxide poisoning, hashish intoxication and botulism… it is a persistent and intractable change in the experience of the self or the outer world.” In this list of etiological factors not only hashish, but any psychedelic drug may be the culprit. Roth found the association with “calamitous” circumstances striking. Among 135 cases studied the authors found that 40% had features of temporal lobe dysfunction such as déjá vu phenomena, metamorphopsia and panoramic memory. Most of the cases were exacerbation of a chronic neurosis with obsessional, hysterical, depressive and vasomotor disturbances. The personality profile was that of a dependent, immature, scrupulous, fastidious and inflexible type.
Regarding the issue of a unitary psychosis (Einheit Psychosen) or neurosis, for that matter (the vulnerable phenotype), opens the doors to a statement of Professor Roth in his interview: “the same genes are associated with different syndromes.” I would add that current research points to a “genetic polymorphism” in most psychiatric disorders. Since Tondo’s interview was conducted in 1990 Professor Roth himself admitted that he was not aware of the latest research. Nevertheless, in my dialogue with him I had the distinct impression that he was indeed an erudite and great clinician. The question about not exploring childhood events (e.g., maternal care) and other epigenetic issues, as mentioned in the interview, has in my opinion, a drawback as research in mammals has shown.
References:
Roth, M. The Phobic Anxiety-Depersonalization Syndrome (abridged). Proc. B. Soc. Med. 1959 Aug; 52 (8): 587-595.
Wesphal, K.F.O. Die Agoraphobie, eine neuropathische Erscheinung. Archiv für Psychiatrie un Nervenkrankheiten. 1871-1872. 3:138-160.
March 15, 2018