Tuesday, 21.09.2021

Thomas A. Ban
Neuropsychopharmacology in Historical Perspective.

Education in the field in the post- psychopharmacology era. The Wernicke - Kleist - Leonhard

Tradition with Special Reference to Mania, Melancholiaand Manic- Depressive Psychosis

Collated 7

 

Hector Warnes’ comment on Nassir Ghaemi's comment

 

        I am impressed with Nassir Ghaemi's comment that the initial locus of investigation of a suspected disease entity (neuropathological, genetical, chemical, molecular biological, psychological, sociological or historical) would influence the taxonomy, why not the treatment and the outcome? The data that correlated with the neuropathological findings of Bayle led to clusters of symptoms that were changing over time. Ghaemi pointed out that Wernicke started off from neuropathology (looking for the lesion or lesions in the brain that would explain the particular cluster of symptoms) while Kraepelin systematized the clinical syndromes and attempted to find a common basic or primary cause. So far, we have not found a one-to-one relationship between mental states and brain states. Thomas A. Ban shed considerable light on the Wernicke-Kleist -Leonhard tradition

        Edward Shorter (2015) in his excellent overview, “The History of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders,” sharply reminds us that boundaries of many psychiatric disorders were blurred (three of the susceptibility loci associated with bipolar disorder in chromosome 13, 18 and 22 seem also to contribute to the risk of schizophrenia) over time until a causal agent was discovered (e.g., Pellagra, Neurosyphilis, Encephalitis, Multiple Sclerosis, Myxedema, Addictions or intoxications, Temporal Lobe Epilepsy, Auto-immune disorders, etc.). Many of these illnesses with clusters of psychiatric symptoms were abducted from psychiatry and taken over by other medical specialities. It is strange that psychiatry has been changing its nosology or taxonomy in different countries with few exceptions for over centuries and still we are debating on the right nosology.

        Shorter rightly observed that the classifications tend to be either symptom-based or causation-based or a combination of both. The categorical classification with a plethora of discreet entities does not necessarily imply that each entity would be independent of others. Nor do we know what are the precise boundaries that differentiate them. Nor we can ascertain that every patient that has the same diagnosis would have the same response to treatment or the same intensity of symptoms or the same outcome.

        Once we have ruled out a particular cause for the illness, we have to decide which doctor is most likely to help the patient (endocrinologist, immunologist, neurologist, infectologist and so on). On the other hand, the patient may have co-morbidity which would be increasing with age and may have drug-interactions with multiple adverse effects due to polypharmacy which in turn may be triggering new symptoms not related to the original psychiatric illness and bringing the organism to a cascade of physical-biochemical decline.

        It is always advisable to identify neural correlates (e.g., functional brain imaging techniques or neurochemical dysfunction or even genetic factors) with the clinical syndrome. Over the past 50 years the frequency of certain psychiatric illnesses has changed. One hardly sees classical catatonic schizophrenia, conversion hysteria, multiple personality disorders, hysterical psychosis except in more isolated or third world countries. On the contrary, depression in all its forms (even somatic), has been one of the three or four most common disorders in the world. Unfortunately, in spite of the advances with anti-depressants, psychotherapy and social therapies at best we have a 70% cure rate.

 

Reference:

Shorter E. The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues Clin Neurosci. 2015; 17(1):59–67.

 

May 14, 2020