Thomas A. Ban:  Wernicke – Kleist – Leonhard tradition with special reference to mania, melancholia and manic–depressive psychosis

Edward Shorter’s comment on Nassir Ghaemi’s comment

       Juxtaposing “neo-Leonhardian” to “neo-Kraepelinian” as the two great intellectual streams in modern psychiatry is a conceptual masterstroke — as is  identifying the Kraepelinian tradition as the true path and the Leonhardian as the pathway of error that leads us to the DSM castle of artifacts and to the extinction of meaningful psychopathology in US psychiatry.   This is concept-making of breathtaking artistry, as though these two giant Germanic figures stood in stark juxtaposition to each other.

       But they do not, exactly.

       In the introduction to his classic The Classification of the Endogenous Psychoses (Die Aufteilung der endogenen Psychosen (1957), Leonhard actually speaks quite highly of Kraepelin’s subtle differentiations.  It was subsequent generations, he said, who erected a gross dichotomy of  untreatable schizophrenia versus  treatable manic-depressive insanity.  Leonhard said,  “The plenitude of fine observations that Kraepelin made as the core of the symptomatology and the classification of the endogenous psychoses were soon forgotten.”

       Leonhard set out, not to overturn Kraepelin, but to insert some other diagnoses between these two huge bookends: schizophrenia and manic depression.  And he inserted so many diagnoses  that the Leonhardian system took on a grotesque, incomprehensible aspect that put off everyone outside of German-speaking Europe.  (It was also unhelpful that Leonhard wrote almost entirely in German, a language that in the 1950s had the same international allure as ancient Aramaic.)

       My own view is that DSM is, pace Ghaemi, not an essentially Leonhardian document.  Classifying depression on the basis of polarity is Leonhardian, for sure.  And that came from Leonhard’s influential disciples.  At the time of DSM-III there was a huge international scream of dismay that the two classical depressions — melancholia and non-melancholia — had been merged into one!  That this error has been continued in subsequent editions seems incredible and is the single greatest mistake in the entire DSM enterprise.  But aside from that, I cannot detect much of Leonhard in DSM.   The Angst-Glück psychosis and the other bipolar diagnoses, so important to Leonhard’s thinking, did not make it in.  The distinction of  “systematic” versus “non-systematic” definitely did not make it in.   In fact, aside from Paula Clayton, I’m not sure that any members of the DSM Task Force actually knew who Leonhard was.

       But they knew who Kraepelin was.  And they erected in DSM Kraepelin’s fatal firewall between mood disorders and madness, a firewall that does not exist in Leonhard.  This has been a baleful development because it has given us two supposedly separate drug classes, "antidepressants” and “antipsychotics,” that have been worth billions of dollars to the pharmaceutical industry.

       That’s with a “B.”

       There has been some impatience expressed about paying too much attention to these German heavyweights, as part of a tradition that has wreaked much evil upon the world.  (Leonhard’s teacher, Karl Kleist, actively argued in 1936 for expanding the indications for eugenic sterilization.)  The point is valid.  Scandinavia has produced a number of important thinkers whose work has been largely ignored.  Electroconvulsive treatment for malignant catatonia was first introduced in Spain.  The Delay-Deniker-Pichot school in Paris has essentially given us modern psychopharmacology.  Paul Janssen was Belgian! The streams that have fed psychiatric science are truly international, not just Germanic.

October 15, 2020