Janusz Rybakowski: The Kraepelinian dichotomy in historical perspective
Edward Shorter’s response to Janusz Rybakowski’s reply
I have enormous respect for the work of Professor Rybakowski and I don’t intend to enter into a debate with him about these huge questions such as whether mood disorders may be meaningfully classified by polarity (the German for unipolar is einpolig, bipolar zweipolig). The literature on this is so vast, that either side would have little difficulty in demonstrating its point. But I do want to correct an error that seems to be entering the literature, and it is the error of attributing the one-polar two-polar terminology to Karl Kleist, the longstanding professor of psychiatry in Frankfurt beginning in 1920. Rybakowski cites the 2001 article by Jules Angst and Andreas Marneros as the source of Kleist’s supposed coinage.
In support of their attribution to Kleist of the einpolig-zweipolig concept, the authors cite four articles by Kleist. These articles do not introduce this einpolig-zweipolig terminology, although there is no doubt that Kleist believed mood disorders could alternate between depression and mania. This concept, however, is not original with him. (What is original with Kleist is making a whole panoply of psychiatric psychopathology the object of cyclic and cycloid behavior.)
It is Kleist’s two students, Karl Leonhard and Edda Neele who introduce, after the Second World War, the einpolig-zweipolig terminology (Shorter 2015). They must have been exposed to this kind of thinking in Kleist’s lectures and seminars and it may well have been Kleist who implanted the concept in their heads. Yet, as far as I can determine, Kleist himself did not introduce it.
Why belabor this rather obscure nosological footnote? For two reasons:
1. Polarity as a means of classifying depressive disorders has taken on a life of its own and DSM-5 owes its two huge and very separate chapters on “major depression (unipolar) and bipolar disorder to Leonhard’s distinction, as transmitted through the work of Jules Angst, among others. It is worth properly assigning credit (or discredit) to the originators of a concept of this importance. Otherwise, it would be like expressing indifference to the originators of “schizophrenia” or “catatonia” or some other huge psychiatric notion.
2. Karl Kleist is now being cited as a pioneering figure. But even though he did refine some features of the catatonia diagnosis — and make other non-epochal contributions — he advocated a very neurological style of psychiatry that really reduced everything to brain disease. This meant swinging the pendulum so far in the direction of organicity that it almost flew off the hook. I also think we should bear in mind that Kleist bought heavily into the Nazi agenda. Nobody who maintained a professorship of psychiatry during the Nazi years could have come away entirely unblemished. Yet his supporters sought, in “de-Nazification” procedures after the War, to hustle him through. And they succeeded in this farcical process. Yet we find Kleist recommending in 1936 an expansion of the indications for eugenic sterilization.
Today, we are very quick to drum people out of the tent for shortcomings in regard to gender and so forth. We’re dealing here with the Holocaust. Kleist should have been drummed out of the tent long ago.
Angst J, Marneros A. Bipolarity From Ancient to Modern Times: Conception, Birth and Rebirth. J Affect Disord, 2001; 67(1-3):3-19.
Kleist K, et al. Katatonie und Degenerationspsychosen. Allgemeine Zeitschrift für Psychiatrie, 1936; 104:124-127, 124.
Shorter E. What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today
New York: Routledge, Taylor & Francis Group, 2015, pp. 78-80.
October 29, 2020