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Tuesday, 28.09.2021

Carlos Mora and Mateo Kreiker: General Psychopathology 17

 

Thomas A. Ban: Development of the Language of Psychiatry

                                                                           

Introduction of Psychopathology 

        It was Galen (131-201) who was first to recognize that “symptoms” follow disease as shadow its substance (Garrison 1929). Yet, development of “psychopathology,” the “language of psychiatry,” began only in the mid-19th century in the course of early attempts to differentiate sub-populations within “insanity.”

        The term psychopathology first appeared in the psychiatric literature in 1845 in Feuchtersleben’s textbook (the same book in which the term ”psychosis” was adopted)  and throughout the second half of the 19th century the term was used as a synonym for psychiatry.

        During the 19th century the vocabulary of psychopathology steadily grew. Esquirol (1838) divided false perceptions into “illusions” (distortion or misinterpretation of real perception) and “hallucinations” (perceptual experiences without corresponding stimuli in the environment); Griesinger (1845) distinguished between “pale (pseudo) hallucinations” (that appear in the inner subjective space and can be controlled voluntarily) and  “true (real) hallucinations” (usually referred to “hallucinations”), and Wernicke (1881) separated  “dysmnesia” (memory impairment) from “dementia”  (personality deterioration).

        Psychopathology became a discipline to provide a foundation for psychiatry in the early years of the 20th century. Instrumental to this development was Karl Jaspers (1910, 1913) who observed that in different psychiatric diseases patients’ process (in their brain) and consequently perceive the same “content” (information) in different “forms.” His recognition of the relationship between the “forms” in which information (“content”) is perceived by patients  and their  illness, led to the birth of “phenomenological psychopathology” (phenomenology), the branch of psychopathology that deals with “abnormal subjective experiences of individual psychic life.” It also led to his separation of “psychiatric disease process,” displayed by “abnormal forms of experiences,” from “abnormal personality development,” displayed by behavior that deviates from the statistical norm.   

        For the “phenomenologist,” it is not the subject matter, the information (“content”) the patient talks about, but how (“form”) the patient talks; and it is not the “somatic (hypochondriacal) complaints” (“contents”), but the form of how these complaints are experienced, i.e., as “bodily hallucinations” (somatic experiences without corresponding stimuli in the environment); “obsessive ideas” (ideas that persist against one’s will); and “hypochondriacal delusions” (false beliefs based on a priori evidence) that are relevant to diagnosis (Fish 1967; Taylor 1981). Even in case of “delusions” -- a “content disorder of thinking” that signals the presence of an ongoing psychiatric disease (“psychosis”) -- it is not the “content“ of the “delusions,”  such as “delusions of reference,” “delusions of love,” “delusions of persecution,” etc.,   but the “form” in which the “delusion” appears,  i.e., a “sudden delusional idea” (a delusional idea that appears to be fully formed),  a “delusional perception” (a delusional meaning  attributed to a normally perceived object),  that is relevant to the characteristic abnormality of the processing of signals by the  brain that differentiates one psychiatric disease (process) from another (Guy and Ban 1982;  Hamilton 1985).

        It was on the basis of  “phenomenological analyses” that Kurt Schneider (1920, 1950) distinguished between “vital depression”  (a disease) from the “other depressions” and separated “personality disorders,” displayed in “abnormal variations of psychic life” and the subject matter of “abnormal psychology,” from “psychoses” (mental disorders), displayed in “abnormal forms of experiences,” the subject matter of “psychiatry.”

        During the years from 1918 to 1933 a group of psychiatrists that included Hans Gruhle and Wilhelm Mayer-Gross, in Kurt Wilmanns’ department of psychiatry at Heidelberg University in Germany, spearheaded “phenomenological analyses” in psychiatric patients (Shorter 2005). Their efforts yielded a vocabulary that includes distinct words (symptoms) from pathologies of “symbolization,” such as “condensation” (combining diverse ideas into one concept) and “onematopoesis” (building new phrases in which the usual language conventions are not observed), to pathologies of “psychomotility,” such as “ambitendency” (the presence of opposite tendencies to action) and “parakinesis” (qualitatively abnormal movements). In  “phenomenology,” “dysphoria,” the negative pole of “vital emotions,” is distinguished from “dysthymia,” the negative pole of mood;  “psychomotor retardation,” the experience of a spontaneous slowing down of motor activity, is distinguished from “psychomotor inhibition,” the experience of slowed down motor activity, etc.

        Furthermore, by linking the terms that identify the different abnormalities to psychiatric diagnoses in use at the time, e.g., “tangential thinking,” characterized by talking past and around the point, with the “schizophrenias,” “circumstantial thinking,” characterized by overbearing elaboration on insignificant details without losing track, with the “dementias” and “rumination,” characterized by endless repetition of unpleasant thoughts, with “depressions,” the Heidelberg group set the foundation of a language for psychiatry.

  

Heidelberg School of Psychiatry

(1918-1933)

 

Phenomenological Analysis

 

VOCABULARY

for

language of psychiatry

 

WORDS

from pathologies of “symbolization” (“condensation,”  “onematopoesis”)

to

pathologies of “psychomotility” (“ambitendency,” parakinesis”)

 

DISTINCTIONS

between

“dysphoria”  vs  “dysthymia”

“psychomotor retardation” vs “psychomotor inhibition”

  

SYMPTOMS  & DIAGNOSES

tangential thinking  - schizophrenias

circumstantial thinking – dementias

rumination - depressions

  

Introduction of Nosology

 

        The vocabulary of “psychopathology” that deals with cross-sectional features of disease was extended to include the vocabulary of “psychiatric nosology” for describing psychiatric disease in its “dynamic totality” from “onset” through “course” to “outcome” (Ban 1987).

        The two disciplines, “psychopathology” and “psychiatric nosology,” are intrinsically connected: psychopathology deals with symptoms, i.e., abnormal subjective experiences (“phenomenology”) and signs, i.e., “objective performance changes” (“performance psychology”), whereas ”nosology” deals with the synthesis of “disease entities” from symptoms and signs and classification of the  diseases  synthesized (Jaspers 1963). While classifications provide names (denominations) and descriptions of disease (qualifications), nosology provides the methodology for “how” diseases and classification of diseases are derived (Ban 2000).  

        The term “nosology” first appeared in 1743 in Robert James’ Medical Dictionary. Twenty-five years later in 1768, it reappeared in the title of Francois Boissier de Sauvages‘ Nosologia Methodica.

        In his treatise, Sauvages stipulates that a disease should be defined by the enumeration of symptoms that suffice to recognize it and distinguish it from others (diseases), and a classification should be devised in a manner that it should allow the attribution of each patient to one and only one class. Thus, the emphasis in disease is that each patient with the same disease displays the same symptoms and thereby is different in terms of symptoms from patients with any other disease, whereas the emphasis in a class is on shared characteristics of diseases in terms of “course” and “outcome” regardless of differences in symptomatic expressions.

        One year after the publication of Sauvages’ treatise, the term “nosology” was adopted also by William Cullen (1869, 1872) in the title of his Synopsis Nosologiae Methodicae.      

        Cullen divided “madness” into four  classes of disease:  “amentia“ (“imbecility of judgment, by which people do not perceive, or do not remember the relation of things”),  “melancholia” (“partial madness without dyspepsia, varying according to the different subjects concerning which the person raves”), “mania” (“universal madness”),  and “oneroidynia” (violent and troublesome imagination in time of sleep”) (Mennninger, Mayman and Pruyser 1968).  His separation of “universal” (total) from “partial” madness, on the basis  of “totality” of mental pathology,  was to dominate  classifications of insanity in the 19th century from those of Philippe Pinel’s (1798) and Jean-Étienne Dominique Esquirol’s (1838) in France, who distinguished between “mania” (universal insanity) and the “monomanias” (partial insanities), and Karl Kahlbaum’s (1863) in Germany, who distinguished between the  vesanias (total-universal insanities) and the  vecordias (partial insanities).

        The separation of “universal” from “partial” madness during the second half of the 19th century was based on the pervasiveness of pathology manifested by “deterioration of personality” and/or “absence of insight.” Thus, Ernest-Charles Lasègue’s (1852) diagnostic concept of “persecutory delusional psychosis,” the predecessor of Kahlbaum’s (1874) diagnostic concept of ”paranoia,” was referred to as “partial insanity”  because of a lack of “personality deterioration,” and Carl Friedrich Otto Westphal’s (1878) diagnostic concept of “obsessive states” (Zwangsvorstellungen), the predecessor of the diagnostic concept of “obsessive-compulsive neurosis,” was referred to as “abortive insanity,” a form of “partial insanity,” because patients had “insight” about the pathological nature of their condition. 

        The distinction between “universal” and “partial” madness lingered on during the first six decades of the 20th century. In 1913, in the 8th edition of his textbook, Emil Kraepelin used the distinction between “universal” and “partial madness” for the separation of “paranoia” and the “paraphrenias” (partial insanities) from “dementia praecox” (total insanity); and in 1957 in his Classification of Endogenous Psychoses, Karl Leonhard used the distinction for the separation of “pure mania” and “pure melancholia (total insanities) from the “pure euphorias” and “pure depressions.” 

        Prior to Boissier de Sauvages and Cullen in the late 17th century, Thomas Sydenham conceptualized disease as a “process” with a “natural history of its own” that “runs a regular and predictable course” (Ban 2000). Yet, in psychiatry, it was only about 200 years later that Jean-Pierre Falret (1854) identified a disease, fôlie circulaire, the predecessor of “manic-depressive insanity,” on the basis of its “temporal characteristics.”  It was also Falret, first in the mid-1860s, to stipulate that “a natural form of psychiatric illness implies a well-defined predictable course,” and vice versa, “a well-defined predictable course presupposes the existence of a natural species of disease with a specified pattern of development” (Pichot 1983). A similar notion to Falret’s was expressed in 1874 by Karl Ludwig Kahlbaum in his “nosological postulate.”  It was also  Sydenham’s concept of disease that led Emil Kraepelin to replace his syndromic classification in the 4th edition of his textbook, published in 1894, with a disease oriented classification in the 5th edition (1896).

        Kraepelin’s (1899) division (“dichotomy”) of the “endogenous psychoses” on the basis of “temporal characteristics,” i.e., “course” and “outcome,” in the 6th edition of his textbook into “manic depressive insanity,” a disease that follows an episodic course with full remission between episodes, and “dementia praecox,” a disease that follows a continuous deteriorating course, led to a re-evaluation of psychiatric diagnoses and classifications, especially (but not only) the classification of diseases that Paul Julius Möbius (1893, 1900) referred to as “endogenous psychoses.” In the course of this re-evaluation both diseases with and episodic course and diseases with a continuous course were divided into several forms. Within the diseases with an episodic course with full remission between episodes, diseases which manifest in “attacks” (that last from minutes to hours), as Lasegue’s (1877) “mental vertigo,” or  in “phases” (that last from days to years), as Edna Neele’s (1949) “phasic psychoses,” were distinguished from diseases characterized by an episodic course without full remission between episodes which manifest in “thrusts” (“shifts”), such as Bleuler’s schizophrenias (1911). And within the diseases with “continuous course,” diseases which  lead to highly  differentiated “end-states,” such as Leonhard’s (1936) “defect (referred to later as ‘systematic’) schizophrenias” in the “endogenous psychoses,” were distinguished from diseases which lead to a dedifferentiated “terminal state,” such as Alzheimers’ (1907)  disease (Ban 2000). 

        Kraepelin’s classification of the “endogenous psychoses” was first re-evaluated in the 1920s by Karl Kleist (1921, 1923, 1928) then by Karl Leonhard (1957) with the incorporation of some of Kleist’s contributions, e.g., the diagnostic concept of “cycloid psychoses.”

        In his re-evaluation, Leonhard employed Neele’s (1948) “polarity” and Wernicke’s (1881, 1899) “mental structure” in classifying patients.   With the employment of “polarity” he divided the population  already separated by “course” and “outcome” into “bipolar” and “unipolar diseases” and separated within both several subpopulations on the basis of the site of the dominant psychopathology, i.e.,  the afferent-cognitive (“psychosensory”), central-affective (“intrapsychic”) or efferent-motor (“psychomotor”) component, in  Wernicke’s “mental structure.” 

        In Leonhard’s (1957) classification “bipolar diseases” are characterized by a continuously changing “polymorph” (multiform) disease picture with a potential to display both extremes in mood, thinking, emotions and/or motility, whereas “unipolar (monopolar) diseases” are characterized by a consistent, unchanging, “monomorph” (simple, also referred to as pure) disease picture with no variation of mood, thinking, emotions and/or motility.

        On the basis of “polarity” Leonhard splits Kraepelin’s “dementia praecox” (Bleuler’s [1911] “schizophrenias”) into two classes of disease: “(bipolar) unsystematic (non-systematic)  schizophrenias” and “(unipolar) systematic schizophrenias;” on the basis of Wernicke’s “mental structure” he divides “unsystematic schizophrenias” into three diseases, i.e., “cataphasia,” “affect-laden paraphrenia” and “periodic catatonia.” Similarly, he divides the “systematic schizophrenias” into three groups of diseases, i.e., “paraphrenias” (with six psychopathology-based sub-forms), “hebephrenias” (with four psychopathology-based sub-forms) and “catatonias” (with six psychopathology-based sub-forms).

        He also splits, on the basis of “polarity,” “manic depressive insanity” into “(bipolar) manic depressive disease” and “(unipolar) phasic psychoses,” and with consideration of Wernicke’s “mental structure,” he separates “manic depressive disease” from the “cycloid psychoses” and divides the “cycloid psychoses” into “excited-inhibited confusion psychosis,” “anxiety-happiness psychosis” and “hyperkinetic-akinetic motility psychosis.”

        Furthermore, on the basis “totality,” the organizing principle introduced by Cullen (1769), he separates “pure mania” and “pure melancholia” from the “pure euphorias” and “pure depressions,” each displayed in five distinct psychopathology-based forms.

        Within the “bipolar-polymorph” diseases the signal difference between “manic depressive disease” and the “cycloid psychoses” is that in “manic depressive disease” the “polarity” is prevailingly in mood, whereas in the “cycloid psychoses” the “polarity” is prevailingly in thinking (“excited-inhibited confusion psychosis”), emotions (“anxiety-happiness psychosis”) or  psychomotility (“hyperkinetic-akinetic motility psychosis”). Within the “unipolar-monomorph” diseases the signal difference between “pure mania/melancholia” and the “pure euphorias/depressions” is that in “pure mania” and in “pure melancholia” the entire “mental structure” is affected, whereas in the “pure euphorias” and “pure depressions” only parts of the mental structure is involved.

        Leonhard’s classification of “endogenous psychoses” was published in 1957 just about the time when neuropsychopharmacology was born.

 

Karl Leonhard

1957

 

Classification of Endogenous Psychoses

 

UNIPOLAR

Pure Mania

Pure Melancholia

Pure Euphorias

unproductive, hypochondriacal, enthusiastic, confabulatory, non-participatory

Pure Depressions

harried, hypochondriacal, self-torturing, suspicious, non-participatory

 

Systematic Schizophrenias

paraphrenias (hypochondriacal, phonemic, incoherent, fantastic, confabulatory, expansive), hebephrenias (silly, eccentric, insipid, autistic) catatonias (parakinetic, affected, proskinetic, negativistic, voluble, sluggish)

 

BIPOLAR

Manic Depressive Psychosis

 

Cycloid Psychoses

excited/inhibited confusion psychosis; anxiety/happiness psychosis

hyperkinetic/akinetic motility psychosis 

 

Unsystematic Schizophrenias

cataphasia, affect-laden paraphrenia, periodic catatonia

 

References: 

Alzheimer A. Über eine Eigenartige Erkrankung der Hirnrinde. Allg Z Psychiat 1907; 64:146-8. 

Ban TA. Chronic schizophrenias: a guide to Leonhard’s classification. Comprehensive Psychiatry 1982; 23:155-70. 

Ban TA. Prolegomenon to the clinical prerequisite: psychopharmacology and the classification of mental disorders. Progress in Neuro-Psychopharmacology and Biological Psychiatry 1987; 1:527- 80.  

Ban TA. Nosology in the teaching of psychiatry. Jornal Brasileiro de Psquiatria 2000; 49:39-49. 

Ban TA. Neuropsychopharmacology the interface between genes and neuropsychopharmacology. In: Lerer B, editor. Pharmacogenetics of Psychotropic Drugs. Cambridge: Cambridge University Press; 2002, pp. 36-56.  

Bleuler E. Dementia Praecox oder Gruppe der Schizophrenien. Leipzig: Deuticke; 1911.   

Cullen W. Synopsis Nosologiae Methodicae. Edinburgh: Kincaid & Creech; 1769, 1772. 

Cullen W. First Lines of the Practice of Physics. Edinburgh: Kincaid & Creech; 1777. 

Esquirol JED. Des maladies mentales Considerees sous les raports medical, hygienique  et medico-legal. Paris: JP Bailliere; 1838. 

Falret JP. Leçonc clinique de le mêdecine mentale faites a l’hospice de Salpêtriêre. Paris: Bailliere; 1954. 

Feuchtersleben E. Lehrbuch der Ärztlichen Selenkunde. Vienna: Carl Gerold; 1845.  

Fish F. Guide to Leonhard’s classification of chronic schizophrenias. Psychiatric Quarterly 1964; 38:438-50. 

Fish F. The influence of the tranquilizers on the Leonhard schizophrenic syndromes. Encéphale 1964; 53:245-9.   

Fish F. Clinical Psychopathology. Bristol: John Wright & Sons; 1967. 

Griesinger W. Über psychische Reflexactionen. Archiv für Physiologische Heilkunde  1843;  2:76-112.

Griesinger W. Die Pathologie und Therapie der PsychischenKrankheiten. Braunschweig: Wreden; 1845.

Guy W, Ban TA, Wilson WH. An international survey of tardive dyskinesia. Prog Neuro-psychopharmacol & Biol Psychiatry 1985; 9:401-5.  

Hamilton M, editor. Fish’s Clinical Psychopathology.Bristol: John Wright & Sons; 1985. 

Heinroth JC. Lehrbuch der Störungen des Seelenlebens. Leipzig: Vogel; 1818.

James R. Medical Dictionary. London: T. Osborne; 1743.  

Jaspers K. Eifersuchtswahn: Entwicklung einer Persoenlichkeit oder Prozess. Zeitschrift für die gesamte Neurologie und Psychiatrie 1910; 1:567-637. 

Jaspers K. Allgemeine Psychopathologie. Berlin/Heidelberg: Springer; 1913. 

Jaspers K. General Psychopathology. (Translated from the 7th edition of the German original into English by Hoenig J and Hamilton MW).  Manchester: Manchester University Press; 1962.    

Kahlbaum KL. Die Grouppierung der psychische Krankheiten und die Enteilung der Seelenstoerungen. Danzig: AW Kaufman; 1863. 

Kahlbaum KL. Die Katatonie oder des Spannungsirresein  Berlin: Hirschfeld; 1874.   

Kleist K. Autochtonous Degenerationpsychosen. Z gen Neurol Psychiat 1921; 69:1-11.  

Kleist K. Die Auffassung der Schizophrenien als Systemkrankheiten. Klinische Wochenschrift 1923; 2:962-3. 

Kleist K. Über zykloide, paranoid und epileptoide psychosen und über die Frage  der Degenerationspsychosen. Schweiz Arch Neurol Psychiat 1928; 13:1-35.  

Kraepelin E. Lehrbuch der Psychiatrie. 4 Aufl. Barth: Leipzig; 1893. 

Kraepelin E. Lehrbuch der Psychiatrie. 5 Aufl. Barth: Leipzig; 1896. 

Kraepelin E. Lehrbuch der Psychiatrie. 6 Aufl. Barth: Leipzig; 1899. 

Kraepelin E. Lehrbuch der Psychiatrie. 8 Aufl. Barth: Leipzig; 1913. 

Kretschmer E.  Der sensitive Beziehungswahn. Berlin: Springer; 1927. 

Lasègue EC. Du delire de persecution. Arch gen Med 1852; 28:129-50. 

Lasègue EC. Mental vertigo. Gazette des hôpitoux (Paris). 1877. In: Shorter E. A Historical Dictionary of Psychiatry. Oxford: Oxford Univerity Press; 2005, p. 29.  

Leonhard K. Die Defektschizophrenen Krankheitsbilder. Leipzig: Thieme; 1936.

Leonhard K. Aufteilung der endogenen Psychosen. Berlin:  Akademie Verlag; 1957. 

Leonhard K. Classification of Endogenous Psychoses (translated from the 5th edition of the German original by Berman R.) New York: Irwington Press; 1979.  

Littre E. Dictionnaire de la Langua Francoise. Paris; Hachette Cie; 1877. 

Menninger K. Mayman M, Pruyser P. The Vital Balance. The Life Process in Mental Health and Illness. New York: The Viking Press; 1968. 

Moebius JP. Abriss der Lehre von den Nervenkrankheiten. Leipzig: Barth; 1893. 

Moebius JP. Ueber die Physiologischen Schwachsinn des Weibes. Halle: Marhold; 1900.  

Moreau de Tours J. Du Hachich et de L’Aliénation Mentale. Etudes Psychologiques, Paris:  Fortin & Mason; 1845. 

Neele E. Die phasische Psychosen nach Ihren Enscheinungs  und Erbbild . Leipzig: Barth; 1949. 

Pichot P. A Century of Psychiatry. Paris: Roger Dacosta; 1983.  

Pinel P. Nosographie Philosophique ou la Methode de l’Analyse Appliquée a la Medicine. Paris: Brosson; 1798.  

Reil JC (1808). In Reil JC, Hoffbauer JC, eds. Beitrage zur Besorderung eine Kurmethode auf psychischen Wege. Halle: In der Kurtschen Buchhandlung; 1808.  

Sauvages de la Croix Boissier F. Nosologia Methodica. Amsterdam: Frat de Tournes; 1768. 

Schneider K. Die Schichtung des emitionalen Lebens und der Aufbau der Depressions zustände. Z Ges Neurol Psychiat 1920; 59:81-5.  

Schneider K. Klinische Psychopathologie. Stuttgart: Thieme; 1950.  

Shorter E. A Historical Dictionary in Psyhiatry. Oxford/New York: Oxford University Press; 2005. 

Taylor MA. The Psychiatric Mental Status Examination. New York: Pergamon Press; 1981.

Wernicke C. Lehrbuch der Geisteskrankheiten für Aerzte und Studierende. Vol. 2. Berlin: Theodor Fischer Kassel; 1881-1883, pp.  229-42.  

Wernicke C. Über die Klassifikation der Psychosen. Breslau: Schletter; 1899. 

Wernicke C. Grundrisse der Psyhiatrie. Leipzig: Thieme; 1900, 1906.   

Westphal C. Ueber Zwangsvorstellungen Archive fuer Psychiatrie und Nervenkrankheiten 1878; 8:734-50.

  

November 5, 2020