Janusz Rybakowski: 120 years of the Kraepelinian dichotomy of "endogenous psychoses" in historical perspective

Nassir Ghaemi’s comment on Edward Shorter’s comment

       Dr. Shorter makes the two key distinctions of Kraepelin’s basic ideas needed for this discussion: first, the dichotomy between dementia praecox and manic-depressive insanity (MDI); and second, and more importantly in my view, Kraepelin’s refusal to divide MDI into bipolar illness and unipolar depression. 

       Most modern psychiatrists do not know the second point. They don’t realize that Kraepelin’s MDI is not bipolar illness, but rather bipolar illness plus unipolar depression. If this point is not understood, no one can discuss Kraepelin’s ideas accurately.

       DSM-III onward is NOT neo-Kraeplinian.  It is neo-Leonhardian because it rejects Kraepelin unitary MDI model in favor of the split into bipolar illness and unipolar depression.  It is neo-Leonhardian, as opposed to purely Leonhardian, becuase it also waters down the concept of unipolar depression to „major depressive disorder” (MDD), which is not the same thing since it combines the manic-depressive unipolar patients with „neurotic depression”, which had never been seen as being the same as MDI.  This is a major critique that Roth always made but that the psychiatric profession has not understood.

       So all in all, we cannot critique Kraepelin validly if we see him through the distorted lens of DSM-III onward concepts, like bipolar illness and MDD. 

       The claim, for instance, as Dr. Shorter makes, that dopamine blockers are „antidepressants” is not meaningful, because those studies are done in „MDD”, which is not a diagnostically meaningful concept, and certainly not the same thing as unipolar depression or MDI.  As I said, dopamine blockers improved mixed states. Most mood episodes, whether in bipolar illness or in unipolar depression, are mixed states. That’s a major reason why Kraepelin’s unitary MDI concept makes sense; there is no pure polarity for most patients. Hence improvement for depressive symptoms in mixed states is not an „antidepressant” effect, but an anti-mixed effect.  We think it’s antidepressant because the DSM definition of „MDD” is so broad that it includes most mixed states.

       Our vision is distorted by DSM, even when we criticize DSM.

       Another example to correct my friend Dr. Shorter: I don’t see Kraepelin as talking of a „firewall” but rather of two spectra of illnesses that didn’t overlap much.  The small overlap, in my view, is consistent with the schizoaffective picture.

       I think Kraepelin was enough of a biologist to have been suffused with Darwin’s anti-essentialism about species. Kraepelin’s entomologist older brother I’m sure would have taught him this fact also: there are no firewalls in nature.  There are variations on dimensions everywhere, with small amounts of overlap.  And, by the way, that overlap is where nature gets the flexibility to evolve via natural selection.

       So I am willing to believe that a number of different diseases and/or etiologies comprise the schizophrenia concept, and so too for MDI,  but I’m convinced by the evidence we have that the overall schizophrenia gropu is quite different than the overall MDI group, although by different I mean relatively, and not absolutely, consistent with the Darwinian nature of dimensional variability in all aspects of nature.

       So I suppose I think Kraepelin was right on both counts, much as it’s unpopular to think we haven’t figured things out better than the Old Man.

June 4, 2020