Psychopathology - unedited notes from the 1990s

 1. PSYCHOPATHOLOGY: DEFINITION: SCOPE AND BOUNDARIES

 The term "psychopathology" was first used in psychiatry in 1878 as a synonym for "psychiatry" by H. Emminghaus, the predecessor of Emil Kraepelin, in the Department of Psychiatry at the University of Dorpat (Tartu-Estonia). It reappeared about a quarter of a century later in the title of Sigmund Freud's Psychopathology of Everyday Life, before being adopted by Karl Jaspers in his seminal work on General Psychopathology, published in 1913.

Within Jaspers' frame of reference, "psychiatry is a clinical practice", whereas "psychopathology" is a "science" with the explicit purpose to generate new knowledge and  "to  recognize, describe and analyze general principles rather than individuals". The information obtained by psychiatrists ("clinicians") on the mental life of their patients is complex. The "individual momentary experience" is "woven from a number of phenomena" and the "conscious psychic life" is in a "constant flux" of entangled clinical pictures in a "total relational context". It is the task of the "psychopathologist", the "scientist", to disentangle, if necessary even by narrowing or restricting this complex material; to break it into distinct, clearly definable concepts, i.e., symptoms and signs, which can be communicated and used in the formulation of "laws and principles", relevant to "pathologic psychic realities", and in the demonstration of "relationships" between "mental illness" and "psychopathologic symptoms".

In his original formulation, Jaspers defined "psychopathology" as the scientific discipline concerned with the entire field of "pathologic psychic reality", i.e., with every "conscious psychic event", which can be rendered "intelligible by a concept of constant significance". In keeping with this broad definition, the scope of "psychopathology" in his General Psychopathology extends from the "subjective   phenomena   of   morbid   psychic life" ("phenomenology") through the "objective performance changes" ("performance psychology") and "somatic accompaniments of psychic morbidity" ("somatopsychology") to the "synthesis of disease entities" ("nosology”) and the "social and historical aspects of the psychoses and personality disorders".

Between the years of 1913 and 1959, General Psychopathology was published in seven subsequent editions (including the first) and translated into several languages, including English, by Jan Hoenig and Marion W. Hamilton, from the last edition; and "psychopathology", the subject matter of General Psychopathology became the foundation of a "self-contained psychiatry", which qualifies for a distinct clinical discipline. By providing a terminology in which pathologic mental events and mental illness can be expressed within the frame of reference of their own --without the need to use the  terminology  of  another  discipline,  e.g., social behavior-- and can be shared across cultures and  languages  , "psychopathology"  has provided the  necessary   means  to  practice psychiatry as any of the other medical disciplines.

On the basis of theoretical and practical considerations, the all-embracing discipline of "psychopathology” was split into several distinct areas of research. First, "nosology", the field of research concerned with the "synthesis of disease entities" and the "classification of mental illness", was separated from "psychopathology" by the distinctiveness of its methodology, i.e., "synthesis" versus "analysis".  Later on, "abnormal psychology", the discipline in which  "abnormal mental phenomena" are perceived and understood in terms of deviations from the statistical mean (norm), accepted as normal with the subject's social background, was separated by the distinctiveness of its frame of reference, i.e., social-statistical versus biological-medical. Gone with "abnormal psychology" was to a great extent "performance psychology" and "somatopsychology", with the scope of "psychopathology" becoming increasingly restricted to "phenomenology", or more precisely "phenomenological psychopathology", the clinical elaboration of Jaspers "phenomenology" by the Heidelberg school of psychiatry (Gruhle, Homburger, Mayer-Gross, Willmans and others). Jaspers left the university clinic in 1915 to exchange his short (5-7 years) career in psychiatry for a lifetime career in philosophy.

The term "phenomenology" was adopted by Jaspers from Husserl, but aside from the term "phenomenological psychopathology", has nothing in common with Husserl's "phenomenology", a philosophy, which is based on the assumption that "phenomenology", i.e., the "study of subjective experience of psychological events" is the science of sciences, i.e., the science which preceded and governs all other sciences. Phenomenological psychopathology is also distinct from Binswanger's "existentialist interpretative psychology," in which "existential --phenomenological-- analysis" is used to reformulate "morbid psychic experiences" in terms of Heidegger's "existentialist  philosophy", on  the  basis  of  the presumption  that  the  formulation  of  "morbid psychic experiences"  within the frame of reference of Heidegger's philosophy would  render  the "pathologic realities" understandable.

In variance with Husserl, for Jaspers, "phenomenology" was simply a "science," dedicated to the study of the "subjective phenomena of morbid psychic life", and not the "primordial science”; a methodology to render the "pathologic realities" accessible, and to break the complex "pathologic realities" accessed, into communicable concepts. And, in variance with Binswanger, for the Heidelberg school of psychiatry, "phenomenological psychopathology" was a clinical research method used to study and to relate the concepts of "pathologic realities", and not to understand "pathologic realities", to mental illness. By the employment of "phenomenological psychopathology" in painstaking, detailed and laborious analyses of individual patients, the Heidelberg group, within a period of less than two decades, turned psychiatry into a discipline with the capability to detect mental disease, and to separate reliably one mental illness from another.

The "golden years" in the development of "phenomenological psychopathology" ended in 1933 with the removal of Willmans from his position by the Nazi regime, partly because of his reference to Adolf Schicklgruber's, alias Adolf Hitler's, "hysterical blindness" towards the end of the first World War, in his lectures, and the appointment of Carl Schneider, the psychiatrist, who authorized the murder and sterilization of many mental patients, as the head of the university psychiatric clinic. Gruhle, who was the intellectual leader of the group, left the university to take a position  at  a  provincial psychiatric hospital, Mayer-Gross  moved  to England and before long Karl Jaspers himself  was  found  to  be  teaching  at  a  Swiss University.

The "golden years" ended, but the tradition of Heidelberg continued with Carl Schneider, himself a formidable clinician, who, in spite of his lack of emotional resonance and betrayal of his patients, has made significant contributions to the field, and especially to the phenomenological psychopathology of acute schizophrenia. By the time Kurt Schneider took the torch, in 1946, at the  Heidelberg clinic --himself deeply embedded in Karl Jaspers teachings-- "psychopathology" provided the necessary knowledge base to allow the teaching of psychiatry as a medical discipline. It also provided the necessary terminology for psychiatrists to meaningfully communicate with other medical specialists and generalists about mental illness. A pragmatist by heart, he was ready to recognize that contrary to the commonly held belief, psychiatric diagnosis is based "on the pathological picture and not on the course and outcome" --ending an era in psychiatry which began with Emil Krepelin in 1896, who died in 1926, just around the time when "phenomenological psychopathology" began to flourish in Heidelberg in the hands of Hans Gruhle and his peers.

2. PSYCHOPATHOLOGY AND PSYCHOPHARMACOLOGY

By the end of the 1960s, i.e., in about ten years from  the introduction   of  the   first  set  of  therapeutically effective psychotropic drugs, i.e., lithium,  chlorpromazine,  meprobamate, imipramine and iproniazid, some  of those with background in “psychopathology” believed  that phenomenological  psychopathology could provide the  necessary orientation  points  for   the clinician for the discriminate use of psychotropic drugs and for the researcher for the study of the action mechanism responsible for the therapeutic effect of psychotropic drugs. They were hopes for a psychopharmacological re-evaluation of diagnostic concepts in psychiatry. By the mid-1980s, it was recognized that research in psychiatry was moving in a different direction. 

3. ROOTS OF PSYCHOPATHOLOGY

The roots of "psychopathology" can be traced to Galen's (131-201 AC) recognition that "animal faculties" comprised of "sensation," "cerebration via imagination" ("forebrain"), "cogitation" ("mid-brain"), "memory"  ("hindbrain") and  "voluntary motions", i.e., "faculties,". These faculties provide an elementary conceptual framework of mental activities which are selectively affected in "mental illness." Similarly, the roots of "clinical psychopathology", the particular area of research dedicated to the study of the relationship between "psychopathologic symptoms" and "mental illness", can be traced to Galen's postulation that "symptoms follow the disease as shadow follows its substance", and the "signs  of the disease show  what the disease is and how it will end". By suggesting a relationship between "symptoms" and "disease," with the  "disease" defining its "symptoms"  to  the extent that it becomes possible to determine ("diagnose") from  the  "symptoms"  "what  the  disease is", and to provide from the "symptoms"  a  prediction  ("prognosis"), in  terms  of  "course"  and "outcome,"  "how it will end", Galen  formulated the first concept of "disease", which was to become the basis of clinical medicine, in case of "somatic illness". By the generation of a set of concepts in which "mental illness" is expressed, Jaspers rendered the relationship between "psychopathologic symptoms" and "mental illness" a testable hypothesis.

Conceptual development of "psychopathology" began with Jaspers' recognition of the distinctiveness of the "case history", i.e., the "history determined by illness", which may be referred to as "nosography", from the "life history", i.e., the history determined by life experiences, which may be referred to as "biography", of individual patients. It was the examination of the nature of this "distinctiveness", by the employment of "understanding psychology" first, i.e., "empathy" and "introspection" that lead him to separate "process", or "disease" responsible for the "case history" that is inaccessible to understanding by "meaningful connections", from "development", or "personality" responsible for the "biography" of individual subjects. The "life history" is based on the experiences of the individual and is accessible to "understanding" by "meaningful connections".  Personality development, he found, has its primary source in a specific "Anlage or disposition," which "grows, evolves and absorbs in a continuous sequence of the changes brought about by respective age epochs", whereas the "disease process", intervenes and interrupts "personality development" by becoming superimposed on and intervening with personality development. The findings were published in 1910, by Jaspers in his seminal paper on Morbid (Delusional) Jealousy (Eifersuchtswahn: Entwicklung einer Personlicchkeit oder Prozess). It opened the path for the separation of "mental illness" from "abnormal personality" by separating "process" from "development”.

The signal difference between “development” and “process” is that "personality development"  is understandable  by "empathy" and/ or "introspection" because it  is based  on   "meaningful  psychic  connections" (referred to also as "genetic understanding"  of one "psychic event" arising from another), whereas the (disease) "process" is not. As a "stranger, who has intruded into the understandable development of  the  personality",  the  "disease process breaks  the  continuity  of the meaningful connections of psychic life and interferes  with comprehension. In variance with personality development, which belongs to the realm of "understanding psychology", the field of "psychodynamics," disease process belongs to the realm of "explanatory psychology", that deals with the  "causal connections of psychic life", i.e., connections, or patterns formed, from different elements, repeatedly and with regularity, which are not amenable to "genetic understanding", but can be explained by the disease process caused by heredity and/or  environmental factors.

It was the validation of the distinctiveness between "process" and "development" which lead Jaspers (1913) to examine the "symptoms" and "signs" in which "mental pathology" is expressed; and it was the information collected in the course of this examination which lead him to hypothesize  a relationship between specific illness and particular "symptom" displays.

Thomas A. Ban

July 14, 2016

Dr. Morey's analysis uncovered an error in our last response, i.e., the figure of 39% of patients responding, was incorrect. The request for calculating "positive" and "negative percentage predictions" (NPP) is also, understandable. We have, however, as he agrees, already well established that the negative predictive value (NPP) is about 90%. That means that the finding that an absence of early improvement in the patient almost certainly leads to non-clinical response at outcome of treatment, is essentially validated. I and my co-authors have acknowledged in a previous paper that this is a small study and requires a larger study for confirmation of all the results. The Stassen et al (1996) and Szegedi et al (2009) studies that involved thousands of patients essentially confirmed the large part of those results. We do not believe that the statistics recommended by Morey will add significantly to what has already been learned, and to avoid "overanalyzing" data from what was essentially a small study, are not inclined to conduct any further analyses.   

References

Stassen HH, Angst J, Delini-Stula A. Delayed onset of action of antidepressant drugs? Survey of recent results. Eur Psychiatry 1996; 12: 166-76.

Szegedi A, Jansen WT, van Wugenburg AP. Early improvement in the first two weeks as predictors of treatment outcome in patients with major depressive disorder: a met-anlysis including 6,562 patients. J clin Psychiatry 2009; 70:344-53

Martin M.  Katz
January 14, 2016