Janusz Rybakowski: 120 years of the Kraepelinian dichotomy of "endogenous psychoses" in historical perspective
Barry Blackwell’s comment
In a skillful and concise manner, Janusz Rybakowski examines the psychiatric literature from past to present to categorize the manner in which a variety of clinical, etiologic and developmental features support or negate Kraepelin’s dichotomy. This is an especially relevant essay coming at a time when the DSM system is under reproach and the NIMH has abandoned its use as a research instrument in favor of the RDoC criteria.
A majority of the variables studied support the dichotomy including dopamine function and a genetic feature (a polygenic risk score). Most medical therapeutic strategies also validate the distinction except the use of atypical antipsychotic drugs in the treatment of bipolar disorder. Prenatal maternal infections present a mixed picture; toxoplasma gondii and herpes simplex type 2 support the dichotomy while influenza produces a mixed outcome by concurrence in bipolar disorder with psychotic features but not in schizophrenia. Cognitive function (Wisconsin Card Sorting Test) was worse in schizophrenia than bipolar disorder, more so if the latter responded to lithium. Finally, premorbid neurodevelopmental disorders are significantly more common in schizophrenia, sometimes associated with hypoxia, urban living or migration during pregnancy. These developmental abnormalities may also be related to neuro-anatomical changes; lateral ventricular enlargement and grey matter abnormality in schizophrenia, not found in bipolar disorder.
Janusz summarizes these findings by concluding, “Kraepelin’s ‘great idea’ born in 1899, is “still partly valid” in 2009.
The data certainly support this assertion and they invite the historical question of how Kraepelin’s wisdom became so overlooked and neglected in the modern era, largely ignored by the DSM and ICD diagnostic systems. One obvious answer lies in the fact that not only Kraepelin, but an entire European concept of diagnosis was based on nosology and natural history evolved at a time when there were no effective treatments and neither genetic or epidemiological evidence of etiology.
It was this absence that fueled Freud’s turn from neurology to psychoanalysis creating the flawed hypothesis of an anxiety driven etiology for all psychiatric disorders. This took hold especially in America where its hegemony over academic psychiatry survived into the late 1960s until the advent of almost all the modern psychotropic in a relatively short time period (1949-1980). Serendipity, coupled with scientific curiosity and a basic belief in an organic etiology for the psychoses, turned the tables (Ayd and Blackwell 1970).
When, in the early 1970s, the American Psychiatric Association (APA) realized it was time to replace the psychoanalytic concepts underlying DSM-II they recruited Bob Spitzer to modernize the diagnostic system and Donald Klein became a leading member of the Task Force created to design the DSM-III, introduced in 1980. Klein’s pioneer work at Hillside Hospital laid the foundation based on his concept of “clinical dissection” described in a Eulogy for Don posted on inhn.org (Blackwell 2019).
Don had discovered specific pathophysiological etiologies among the “anxiety disorders,” a term that would replace the concept of “neurotic disorders” in DSM-II. This set the tone for the entire new system in which diagnostic entities would be categorized not by nosology or natural history but by symptom clusters agreed upon by consensus among the Task Force experts or, if lacking, by vote. While schizophrenia and bipolar disorder (Kraepelin’s dichotomy) survived, melancholia disappeared, replaced by major depression and depressive dysthymia.
Over time the homogeneity, validity and reliability of the new system would come under attack but, on the positive side, an ability to identify and take into account other features of the disorders was preserved by a multiaxial system to accommodate biological, social and psychological components contributing to the etiology of a disorder or that might influence its outcome with treatment.
Within two decades, however, use of the DSM system had shrunk practically to Axis 1 only, the main diagnosis. A number of factors may have contributed, some of which are referred to in Daniel Carlat’s 2010 autobiographical account of his psychiatric training (Blackwell 2018). Daniel began his residency training in 1992 at the prestigious Massachusetts General Hospital (MGH) at a time when, he says, “America was becoming a Prozac nation, and many of the key clinical trials of the new antidepressants were being conducted by MGH psychiatrists. These faculty members commanded millions of dollars in grants from the drug companies and government sources and walked around the hospital with a confident swagger.” Not surprisingly he found “the main thing that you learn in a psychiatric residency is how to write prescriptions.”
A few of the older, analytically trained psychiatrists still survived but, “learning how to do therapy was, by comparison, a complicated and mysterious endeavor. It was like sailing without a compass”; DSM was not a great deal of help. “The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days, psychiatrists are less interested in ‘why’ and more interested in ‘what.’”
By and large Daniel did not find DSM very helpful or easy to use: “It has drained the color out of the way we understand and treat our patients. It has deemphasized psychological mindedness and replaced it with the illusion that we understand our patients when all we are doing is assigning them labels.” Later on, he says of a particular patient: “I had fallen into the trap of what I call ‘DSM-think’ in which I spent too much time trying to fit her into categories and too little time trying to understand her as a person.”
Other forces contributed to Axis 1 becoming the sole focus of interest. It was the only Axis required for reimbursement by insurance companies. Biological extremists who had replaced the analysts as lucrative grant raising experts extolled the virtue of a system they felt was scientifically based, strengthening the bonds between “scientific” psychiatry and the medical profession. Lastly, the DSM system allowed for an Axis 1 diagnosis of a major disorder as “Not Otherwise Specified” or NOS – if a problem failed to fit the categorical requirements for a specific category. Driven by “productivity” requirements imposed on physician employees by major health care corporations (allegedly “not for profit”) this became a refuge for the over-worked, overwhelmed or poorly trained.
In 1992, the same year that Daniel Carlat began his residency training, I became a collaborator on a project designed to address the kind of concerns he would later express in his book. An idea initiated by a cognitive-behavioral psychologist was to author a book designed to capitalize on the DSM multiaxial system to teach psychiatrists, particularly those in training, how to make diagnostic formulations, a concise, coherent, reasonably brief synopsis of the case. It includes a summary of several components: the phenomenal aspects; an etiologic understanding of the social, psychological and biological component contributing to the disorder and an explicit statement of the treatment choice how it would be delivered; and lastly the prognosis – a prediction of the likely outcome while cognizant of the natural history of the condition.
Aware that a formulation is colored by the theoretical framework of the person making it we were a group of four mental health professionals from differing academic backgrounds representing Psychodynamic, Biological, Behavioral and Biopsychosocial perspectives. All were faculty members at three different medical schools: The Medical College of Wisconsin, The University of Wisconsin Medical School, Milwaukee Campus, and The University of South Carolina Medical School. Practically, our disciplines were those of a psychopharmacologist, a cognitive-behavioral psychologist, a psychoanalytic and a community psychiatrist.
Each of us was involved in teaching and mentoring psychiatric residents, aware of the conflicts and controversies surrounding the DSM system and of former study in the U.K. showing that 87% of oral board examiners found their chief reason for failing a candidate was the inability to present a coherent formulation of the case (Reveley 1983).
Our book, Psychiatric Case Formulations (Sperry, Gudeman, Blackwell and Faulkner 1992) was published by the American Psychiatric Press, an arm of the APA. It was successful, appeared to meet a need but was never republished. Over the next four decades the APA was making large profits from a DSM system it was satisfied with and had no wish to call into question. Residency training programs spent scant time teaching how to use the multi-axial system especially when insurance companies began restricting psychiatrists to “med checks” backed up by only an Axis 1 diagnosis. Therapy, however justified, was to be provided by non-medical mental health professionals often with no or tenuous contact with a prescribing psychiatrist, taking time to collaborate that went un-remunerated.
Readers interested in how the biological approach was represented can find that in either Chapter 18 of my book, Treating the Brain: An Odyssey, when published or now posted on inhn.org (Blackwell 2018).
As decades have come and gone matters relating to diagnosis and treatment have become worse and more confused. In the mid 1970s the Federal Government closed the ECDEU system and in the 1980s a Republican Congress legislated “information transfer” of academically derived knowledge to industry.
The quality of research declined rapidly due to a combination of industry corruption, FDA lassitude and academic complicity unchecked by professional organizations’ inattention to conflicts of interest and journal editorial indifference. NIMH funding for drug research dwindled, diverted to genetics and basic neuroscience. NIMH declared the DSM system unacceptable as a research instrument (Reveley 1983).
Academic psychopharmacology shriveled and the ACNP began considering a name change to the “Academy of Neuroscience and Psychiatry,” cleverly preserving its ACNP acronym. Perhaps this discouraging perspective can be a rationale for welcoming Janus Rybakowski’s compelling demonstration that Kraepelin’s historical hypothesis and underlying methodology finds relevance and some support in contemporary neuropsychopharmacology and neuroscience dictated by the RDoC system. In his exciting essay Janusz takes a certainty of the past and turns it into a hopeful glimpse of an uncertain future.
Ayd FJ, Blackwell B. Discoveries in Biological Psychiatry. Philadelphia, JB Lippincott. 1970
Blackwell B. Eulogy for Donald F. Klein (1928-2019). inhn.org.biographies. December 5, 2019.
Blackwell B. Daniel J. Carlat. Unhinged. inhn.org.books. June 27, 2019.
Blackwell B. Pioneers and Controversies in Psychopharmacology. Chapter 18: The Biological Basis of Psychiatric Diagnosis and Treatment. inhn.org.ebooks. April 12, 2018.
Carlat DJ. Unhinged. New York, London, Toronto, Sydney. Free Press. 2010.
Reveley A. Why Do Candidates Fail the MRC Psych Part II? BJPsych Bull 1983: 7(3);51.
Sperry L, Gudeman JE, Blackwell B, Faulkner LR. Psychiatric Case Formulations. Arlington, VA, US: American Psychiatric Association. 1992.
January 2, 2020