Thomas A. Ban
Neuropsychopharmacology in Historical Perspective
Education in the Field in the Post-Neuropsychopharmacology Era
Background to An Oral History of the First Fifty Years
Update (Volume Nine): 2. Psychopathology and Nosology
Psychopathology studies the symptoms and signs of psychiatric disease. The term psychopathology first appeared in 1845 in Ernst Feuchtersleben’s textbook on “psychic diseases” (Feuchtersleben 1845). Subsequently, it was used only sporadically as a generic term for psychiatry in the remainder of the 19th century (Esquirol 1838; Griesinger 1845; Pichot 1983; Wernicke 1900).
During the 19th century the terminology of psychopathology steadily grew: Esquirol in the 1830s divided false perceptions into “illusions” and “hallucinations”; Griesinger in the 1840s distinguished “pale” or “pseudo-hallucinations” from “true” or “real” hallucinations”; and Wernicke in the 1880s separated “dysmnesia” from “dementia.”
Development of modern psychopathology began in the early 20th century with Karl Jaspers’ recognition that patients with different psychiatric diseases perceive the same experience differently. With the employment of the Aristotelian distinction between “form” and “content” in the analysis of mental symptoms, he defined and separated, in 1910, psychiatric disease, manifest in “pathological forms of experience,” from “abnormal personality development” (Jaspers 1910). By recognizing the distinctiveness of the information generated by “phenomenology,” the discipline that studies “subjective experiences,” from the information generated by “performance psychology,” the discipline that studies “objective performance changes,” Jaspers, in 1913, in his General Psychopathology, opened a new perspective for studying the pathology of a group of diseases referred to at the time as “functional” or “endogenous” psychoses” (Jaspers 1913).
In phenomenological psychopathology the distinction between “form” and “content” provides a means for the detection and differentiation of the pathological experiences encountered by patients. In a phenomenological analysis it is not the subject matter – the “content” (e.g., a “somatic hypochondriacal complaint”) – but the “form” in which this content is experienced by the patient, e.g., “bodily hallucinations,” “obsessive ideas,” “hypochondriacal delusions,” that is relevant to patient’s illness and psychiatric diagnosis (Fish 1967).
From 1918 to 1933 a group of psychiatrists in Kurt Wilmann’s department of psychiatry at Heidelberg University embarked on “phenomenological analysis” of the psychopathological symptom displayed in psychiatric patients (Shorter 2005). Their research yielded a set of symptoms that reflect the pathologies in the processing of signals in the brain from “symbolization” to “psychomotility” (Hamilton 1985). It also provided fine distinctions between manifestations, such as the difference between “dysphoria” and “dysthymia,” “psychomotor retardation” and “psychomotor inhibition,” etc. By linking the pathologies in the processing of signals to psychiatric diagnoses, e.g., “tangential thinking” to the schizophrenias, “circumstantial thinking” to the dementias, “rumination” to the depressions, the Heidelberg school set the foundation for a language of psychiatry that reflects the ongoing functional pathology in the brain (Mayer-Gross, Slater and Roth 1954).
The notion that different psychopathologic symptoms reflect different pathologies in the processing of experience in the brain was in keeping with Ramon y Cajal’s contributions in the late 19th and early 20th century. His findings that neural circuits in the brain consist of sensory, motor and inter-neurons, and his demonstration of the “connection specificity of neurons” provided the neural underpinning of “structural psychopathology,” spearheaded by Gyula Nyirö in the mid-20th century (Cajal 1894, 1895; Kandel 2006; Nyirö 1962).
In structural psychopathology psychopathological symptoms are organized, as in Carl Wernicke’s classification, into three psychic structures, based on the three phases of reflex mechanism: (1) afferent – cognitive, (2) central – affective and (3) efferent – adaptive. Each structure has several levels and each level is connected with each level within and across structures (Wernicke 1899). The five levels of the afferent – cognitive structure are: diffuse sensation, differentiated perception, image formation, concrete ideation and abstract ideation; the four levels of the central – affective structure are: undifferentiated primitive signal, sensorial and vital emotions, intellectual emotions and ethical, moral and social emotions; and the six levels of the efferent – adaptive structure are: autonomic (vegetative) movements, simple elementary reflexes, in-coordinated movements, emotional and instinctual stereotypes, and echo movements,
For the structural psychopathologist, psychopathological symptoms are abnormalities in these connections. Conceptualizing “structural sychopathology” in a Pavlovian frame of reference, Nyirö opened the path for the study of psychopathological symptoms with conditioned reflex methods (Nyirö 1958).
Psychiatric nosology deals with the methodology of synthesizing psychopathological symptoms into “diseases” and with classifying the diseases synthesized (Ban 2000). The term “nosology” first appeared in 1743 in Robert James’ Medical Dictionary (James 1743-45). Development of “nosology” as a discipline was triggered more than 100 years later, in the mid-18th century, by Francois Boissier de Sauvage’s postulation that a disease should be defined by “the enumeration of symptoms that suffice to recognize it and distinguish it from other diseases.” One of the essential nosologic premises is that a classification should “allow the attribution of each patient to one and only one class” (Sauvages de la Cross 1768).
The first nosologic organizing principle of “madness” was introduced by William Cullen (Cullen 1772). His division of the “vesanias,” which included all the different forms of madness, on the basis of “totality,” into “mania” or “universal madness,” and melancholia” or “partial madness,” dominated classifications in psychiatry during the 19th century (Pinel 1801; Kahlbaum 1863).
The prototype of “partial insanity” was Lasègue’s diagnostic concept of “persecutory delusional psychosis,” the predecessor of Kahlbaum’s diagnostic concept of “paranoia.” In the prototype, “partial” means that the personality of patients remains preserved. A variation of “partial insanity” is ”abortive insanity,” used in reference to Westphal’s diagnostic concept of “obsessive states.” In this context, “abortive” indicates that the “insight” of the patients about the pathological nature of their persistent and uncontrollable intrusion of thoughts and urges to carry out actions, remains preserved.
Adoption of Thomas Sydenham’s conceptualization of disease as a “process” with a “natural history of its own” that “runs a regular and predictable course,” led to the identification and classification of psychiatric diseases on the basis of their “temporal characteristics,” including “onset” (sudden or insidious), “course” (episodic or continuous) and “outcome” (recovery or defect) (Sydenham 1862). It was Jean Pierre Falret first, in 1854, to identify a psychiatric disease, folie circulaire, on the basis of its “temporal” characteristics (Falret 1854). Karl Kahlbaum, in 1863, also proposed temporal course as a principle of classification without much resonance. So, it was only with Emil Kraepelin’s disease-oriented classification, in the 6th edition of his textbook, published in 1899, that “temporal characteristics” firmly entered psychiatry as a classifying principle of mental disease (Kraepelin 1899). Kraepelin’s division (“dichotomy”) of the “endogenous psychoses” into “manic depressive insanity,” a disease that follows an episodic course with full remission between episodes, and “dementia praecox,” a disease that follows a continuous deteriorating course, led to a re-evaluation of psychiatric diagnoses and classifications. In the course of this re-evaluation, diseases were divided into three groups. One of these groups that includes diseases characterized by episodic course with full remission between episodes, becomes manifest in the form of “attacks” that last from minutes to hours, e.g., Martin Roth’s “phobic-anxiety-depersonalization syndrome,” or in the form of “phases” that last from days to years, e.g., Edna Neele’s “phasic psychoses” (Neele 1949; Roth 1959). Another group that includes diseases characterized by recurring episodes without full remission between episodes, becomes manifest in the form of “thrusts” or “shifts,” e.g., Eugen Bleuler’s “schizophrenias” (Bleuler 1911). The third group that includes diseases characterized by continuous course, becomes manifest in the form of highly differentiated “end states,” e.g., Karl Leonhard’s “systematic schizophrenias” or in the form de-differentiated “dementia,” e.g., Alzheimer’s disease (Alzheimer 1906; Leonhard 1936).
Kraepelin’s classification was re-evaluated by Karl Kleist and Karl Leonhard between the 1920s and ‘50s (Kleist 1923, 1928; Leonhard 1957). Adding “polarity” to “totality” and “temporality” in classifying psychiatric disease, Leonhard separates within the “endogenous psychoses” “bipolar,” multiform diseases, such as “manic-depressive illness,” from “unipolar,” monomorph diseases, such as the “systematic schizophrenias,” and unipolar “pure mania” and “pure melancholia.” Recognizing that polarity is not restricted to mood but extends to thinking, emotions and motility, he also separates the “unsystematic schizophrenias” from the “systematic schizophrenias” and the “cycloid psychoses” from “manic depressive illness.” Then, with the employment of “totality,” Leonhard separates the “pure euphorias” from “pure mania” and the “pure depressions” from “pure melancholia; and with the adoption of Wernicke’s “psychic structure,” based on the three components of the reflex, he divides the “cycloid psychoses” into “confusion” psychoses, “anxiety-happiness psychosis” and “motility psychosis”; the “unsystematic schizophrenias” into “cataphasia,” “affect-laden paraphrenia” and “periodic catatonia”; and the “systematic schizophrenias” into “paraphrenias,” “hebephrenias” and “catatonias.” Furthermore, on the basis of the “dominant symptom” in the syndrome, he distinguishes five forms of “pure euphoria” (unproductive, hypochondriacal, enthusiastic, confabulatory and non-participatory); and five forms of “pure depression” (harried, hypochondriacal, self-torturing, suspicious and non-participatory). Similarly, on the basis of the dominant symptom in the syndrome, he distinguishes six sub-forms of paraphrenia (hypochondriacal, phonemic, incoherent, fantastic, confabulatory and expansive), four sub-forms of hebephrenia (silly, eccentric, insipid and autistic) and six sub-forms of catatonia (parakinetic, affected, proskinetic, negativistic, voluble and sluggish).
Leonhard’s classification was published in 1957 just about the time that neuropsychopharmacology was born. Two years later, in 1959, Christian Astrup was first to show that patients with unsystematic schizophrenia respond more favourably to neuroleptics than patients with systematic schizophrenia (Astrup 1959). It was also Astrup first, in the early 1960s, to delineate the conditioned reflex profile of Leonhard’s different forms and sub-forms of schizophrenia (Astrup 1969; Ban 1973; Saarma 1970).
During its first 50 years, inadequate classifications of psychiatric disease, disagreements about the means in which mental pathology is expressed and a lack of identification of treatment responsive forms of illness have impeded progress in the field in spite of the major advances in some research areas.
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May 16, 2019