Hanfried Helmchen: The role of psychopharmacotherapy in the early development of social psychiatry in Germany
Hanfried Helmchen‘s reply to Edward Shorter’s comments
I thank Edward Shorter for his questions about the apparent disappearance of classical psychopathology and lack of interest in traditional psychiatric nosology. I am grateful for the questions because they motivate me to review (very briefly and roughly) my present impression of three aspects of psychiatry in Germany: 1. The social dimension of psychiatry; 2. Psychopathology; and 3. Nosology.
1. The postwar development of social psychiatry in Germany had at least two powerful sources: first, the rediscovery of the individuality of the mentally ill in contrast to the predominance of the collectivistic (and eugenic) mainstream of National Socialism and, by this orientation towards the subjectivity of the patient, a revival of phenomenological psychopathology, however without major therapeutic consequences; and second, the engagement of mainly young psychiatrists to overcome the catastrophic situation of mentally ill patients in the large lunatic asylums that were in a disintegrating condition – almost the lowest level of a destroyed and ailing country. This engagement was embedded in the broader 1960s’ rebellion of the youth in many parts of the world. Although there were some ideological exaggerations – such as Basaglia’s perspective in Italy or the socialistic patient collective (Sozialistisches Patientenkollektiv - SPK) in Heidelberg – this turmoil led in Germany to a fundamental improvement of the care of the mentally ill, initiated by the Parliament. Furthermore, gradually the medical view of the patient broadened and increasingly includes the seriously taken view of the patient; and finally, under the influence of the UN Convention on the Rights of Persons with Disabilities (CRPD), care is oriented toward empowering patients for self-determination and shared decision-making. Not the least due to the disappointing stagnation of psychopharmacology (after its stimulating rise in the 1950s and 1960s) and its lack of new breakthroughs, the interest of therapeutically engaged psychiatrists moved to social psychiatry. However, although side-effects of psychotropic drugs are a major obstacle of their application and a source of non-adherence of patients, most psychiatrists still see psychopharmacotherapy as a basic component of a comprehensive therapy. (And, in addition, after a period of ideological damnation and avoidance, ECT regained clinical acceptance as an effective and safe treatment for defined indications as a component of a comprehensive treatment plan (Scientific Council of the Federal Board of Physicians 2003; Vocke, Bergmann, Chikere et al. 2015). Thus, the disappointment about postwar narrowed psychopathology without new therapeutic perspectives and the need for therapeutic action for the chronically mentally ill led to the revival of “reform psychiatry,” respectively “social psychiatry” (Ilberg 1904) of the 1920’s (Sharma 2018; Helmchen 2018). With regard to Shorter’s notion of “a story without a beginning,” I refer to the sections "3.2.1 Psychopathologie" and "3.3 Die soziale Perspektive" in my 2017 book, The Janus Face of Psychiatry. Benefits and Risks of Psychiatric Action.
2. The observation, description, and understanding of psychopathological phenomena as the core of clinical psychopathology (Schneider 1959) has been further developed by the standardization of their assessment with lists of defined symptoms, guidelines for interviews and by training courses of its application; the best known of such systems is the AMDP-System developed in the 1960s by psychiatrists from university departments in Germany, Switzerland and Austria (Bobon, Baumann, Angst et al. 1983; Stieglitz, Haug, Fähndrich et al. 2017). This development was driven by the need to compare the efficacy of new psychotropic drugs with each other as well as in the course of treatment, e.g., for the elaboration of algorithms, “a stepwise treatment regimen with critical decision points at the end of each treatment step based on standardized and systematic measurements of response,” which resulted in evidence that an “algorithm-guided decision-making process increases the chances of achieving remission and optimizes prescription behaviors for antidepressants” (Bauer, Rush, Ricken et al. 2019). Furthermore, the mass of electronically comparable psychopathological phenomena available at that time assessed in a standardized way at different sites and collected systematically over years were used for large data analyses such as analyses of the interrelationships of symptoms in order to establish psychopathological syndromes (Freyberger and Möller 2003). However, the process of standardization and objectification of psychopathology revealed the risk of reducing the richness of assessing individual psychopathology as well as the influence of social construction on psychopathology and not the least epistemological consequences of the application of experimental measures of observation on subjective experiences (Balz 2010). Such aspects are also elucidated during training courses with the AMDP system, which continues to be widely used as a didactic tool in psychopathological training of young psychiatrists (Fähndrich and Stieglitz 2016). They learn to value the precise understanding of psychopathological phenomena as well as the fact that faulty psychopathological data are diagnostically misleading (Linden and Muschalla 2012).
3. The major reasons for a loss of nosological interest in general may be the standardization of assessment of psychopathology and the reduction of the clinical view to the descriptive aspect of psychopathology, the continuing troubles with diagnostic schemes DSM and ICD (with categorical versus dimensional approaches; the misleading conception of comorbidity; construed by conventions rather than by evidence; only fairly small impact for a differentiated therapy [Helmchen 1994]) as well as findings of overlapping genetic influences on both schizophrenic and affective disorders. In this context the seemingly over differentiation and clinically unconvincing assessment of the Kleist-Leonhard nosological differentiations may have contributed to their neglect although some of them are clinically useful. Another source of a reduced interest in nosology (and etiology) may be that the overwhelming multitude and complexity of (and sometimes unvalidated) neuroscientific findings of brain alterations in mental disorders produce some frustrations for clinicians because up to now they cannot decisively influence clinical action.
The future will show whether new interdisciplinary concepts such as social neuroscience will lift the old bio-psycho-social paradigm to a new level, e.g., by clarifying causal relationships between social factors and genes or the modulation of gene expression (epigenetics). The bio-psycho-social model was accepted by clinicians because it illustrates the reality that psychiatrists experience that biological, social and psychological variables mutually interact in relation to psychopathology. As Karl Jaspers wrote 100 years ago: “Expressing absolutely any one of these components will be misleading” (Helmchen 2013).
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October 10, 2019