Gerd Huber and Gisela Gross: The Development of the Psychopathology in Germany in the Last Decades (20th century) with an Introduction by Carlos R. Hojaij

Edward Shorter’s comments

         Gerd Huber, with his air-encephalographic discovery of enlarged ventricles in schizophrenia, is among the very founders of biological psychiatry.  It is a shame that his subsequent work on schizophrenic prodromes is not more widely known abroad because it was Prof. Huber, more than anyone else, who shifted the emphasis in schizophrenia from the first psychotic break to the previous amotivational and asocial experiences of many of these patients in the so-called “prodromal phase.”  Huber (he died in 2012), trained in Heidelberg and was professor of psychiatry in Bonn, among other places; he was known as the most learned and distinguished of the European schizophrenia experts.  This is part of the problem.

         In this article, which hitherto has languished in the obscurity of a Brazilian psychiatric journal, Huber offers a view of schizophrenia, or rather, of its investigation, that is highly Heidelberg-centered.  The Heidelberg tradition of psychopathology begins with Karl Jaspers’ famous book in 1910, then continues with a host of figures such as Hans Gruhle and Willy Mayer-Gross in the 1920s, then reaches its climax (after a Nazi interregnum) with Kurt Schneider in the 1950s.  These are figures of great international importance and seeing their contributions to psychopathology brought together in the compass of a single article, now available in English, is rather breathtaking.  So, full marks to Carlos Hojaij for making this happen. 

         There are different traditions in psychopathology, the systematic study of psychiatric signs and symptoms.  One tradition is that of Karl Kahlbaum, Emil Kraepelin and Karl Leonhard, who were actually not that interested in patients’ subjective experiences and who preferred, on the basis of signs, symptoms and course, to delineate nosological concepts.  This is the royal road in psychopathology and has vastly influenced such later documents as the DSM series after the third edition in 1980.  Huber disliked this tradition.

         Huber's concept of psychopathology, he tells us, is the Heidelberg concept. This concept privileges subjective patient experiences alongside somatic data, such as the information available from neuroradiologic studies, in order to gain some perspective on the entire illness experience.  Thus we are encouraged to understand “schizophrenia” better and indeed Huber individuated in 1957 a subtype of schizophrenia that he called “coenästhertic schizophrenia,” a kind of psychosis with powerful somatic sensations.

         So far, so good.   The problem is that a fixation upon the Heidelberg tradition did not permit him to go beyond the concept of “schizophrenia.”  At a time when international doubts about the very existence of schizophrenia as a disease of its own are mounting — and catatonia has just been extracted from the schizophrenia pool — these invocations of the “Heidelberg school of psychopathology” have the effect of casting this outmoded and questionable diagnosis of schizophrenia in concrete.  For the Germans, schizophrenia is as real as mumps.

         Agreed, the Heidelberg approach to patients’ sensations has the effect of opening up the prodrome.  From patients’ testimony it is clear that something has gone badly off track long before the first psychotic break.  This is a real plus and it would be foolhardy to urge that patients’ sensations be ignored.

         Yet Huber's focus on a single prodrome causes us to lose valuable information.  We learn, for example, that 40 percent of schizophrenia patients have “uncharacteristic” symptoms in the prodrome.  Maybe they have symptoms characteristic of something else?  Maybe there are several different diseases slumbering in the prodrome that have not yet been identified because of this single-minded fixation on “schizophrenia.”  Catatonia, as I said, has just been extracted as a disease of its own, the stupors, staring and muscular awkwardness not part of anything else.  The distinctive combination of autism and psychosis described elsewhere as the “iron triangle” is currently climbing out of the schizophrenia pot and seeking freedom.  Who knows what else will follow, as the schizophrenia concept is disaggregated and sectioned into its component parts.

         This article is a reminder of what powerful nosological instruments these German clinical scientists created.  It is also a reminder that it is time for the field to move on.

September 19, 2019