Edward Shorter`s comment on Jack R. Foucher et al. Wernicke-Kleist-Leonhard phenotypes of endogenous psychoses : a review of their validity

Hector Warnes’  comment

        I  am fascinated by the neuropathological orientation of Wernicke who divided consciousness into three distinct zones: auto-psyche, allo-psyche and body-psyche, all connected by psycho-sensorial, intra-psychic and psycho-motor pathways.

        Edward Shorter underlines the fact that phenotypes are grouped into five families according to their course, mono or bipolarities and the domains of affect, thought and psychomotricity. He clearly follows the original observations of Wernicke who identified areas of the brain where pathology is consistently observable, recurrent and manifested which would be the phenotype or rather the trait expression of the genotype with its genetic code.

        I am also intrigued about why in our human genome most of our genes are not expressed or remain "mute."

        I do agree with Shorter that the existing classifications have not contributed greatly to surpassing our Tower of Babel (maelstrom, confusion, muddle) based on Genesis II:1-9. Shorter writes, "There will be no progress in drug discovery until we can isolate homogenous clinical populations who may share the same underlying pathophysiology and respond to the same remedies." The time shall come when we can no longer understand one another.

        We are constantly at odds with the scientific method based on reliability, measurement, replicability, predictability, validity, specificity, sensitivity, correction for chance events, false negatives and false positives and other limitations to the correspondence of the clinical, the anatomo-pathological, the neurophysiological, the environmental, the imagenological and the experimental.

        Long term follow-up studies have shown that the percentage of confirmation and validation of psychiatric diagnoses decades after onset hardly held. One wonders whether the changes are due to the drug treatment, to the non-therapeutic environment, to chance events, to the uniqueness of each person, to the natural course of the illness, to aging or to co-morbidity decades after onset. However, late onset morbidities may or may not be related to the evolution of the original pathology which was diagnosed decades ago. 

        I was very impressed by E. Stengel’s 1959 paper on “Classification of Mental Disorders” in which he reviews 39 existing psychiatric nosologies the world over, bringing to our awareness  that they all have some clinical basis and operational definitions. I am not sure why most diagnostic categories by top psychiatrists listed by Stengel in the 39 psychiatric nosologies were removed or dismissed (e.g., neurovegetative dystonia, neurasthenia and so on). The USA adopted an engulfing neo-Kraepelinian approach. On the other hand, we have the WKL approach and countless others to be reckoned with: Essen-Moller; Rumke; Bosch and Ciampi; Henri Ey; K. Schneider; Krapf; Rado; the Dutch; the Danish; two classifications of Russia; Van de Horst's, Henderson and Gillespie; Kloos; Langfeld; Pacheco e Silva, Selbach, Mira Lopez, Sjögren, Lecomte et al; Lopez Ibor; Adolf Meyer and so on. The WHO International Classification of Diseases (ICD-10), released in 2018, was revised by 300 specialists, divided into 30 working groups covering 55 countries. Judging by Jack Foucher el al.’s review, regardless of the extensive work on the WKL nosology, the ICD-10 and the DSM 5, we seem to be competing with different models. 

        Not unlike other findings in Medicine or Neurology and other illnesses the outcome of many  psychiatric diseases is not always the same. I have seen many cases of Rheumatoid Arthritis, Hashimoto Auto-immune thyroiditis, Demyelinating disorders (e.g., Multiple sclerosis) and even cancer who may in the long run have a spontaneous remission, do fairly well with treatment or follow a severe deteriorating or lethal course. Many cases of severe refractory endogenous depression over many years have been observed to deteriorate into co-morbidities and even dementia. I would not support the view that  the phenotype and clinical or phenomenological presentation of the various types of  endogenous or non-endogenous illnesses are likely to remain unchangeable over many decades.

Reference:

Stengel E. Classification of Mental Disorders. Bull World Health Organ. 1959; 21:601-63.

September 3, 2020