Kraepelin [1856-1926] Jaspers [1883-1969] Freud [1856-1939]
If you know of Karl Jaspers, you were probably one of those philosophy majors who read his commentaries on Kierkegaard and Nietzsche, knowing him as an important mid-20th century German philosopher. But he was, in fact, a psychiatrist who wrote a classic psychiatric text in 1913 at age thirty, before turning to philosophy some ten years later. I was pointed to this month’s World Psychiatry to look at another article altogether, but I was captured by this editorial marking the hundred year anniversary of Karl Jaspers’ Allgemeine Psychopathologie [General Psychopathology] which is as timely today as the day it was written:
Mental disorders as “brain diseases” and Jaspers’ legacy
by MARIO MAJ
World Psychiatry. 2013 12:1-3.
This year we celebrate the 100th anniversary of the publication of the first edition of Karl Jaspers’ General Psychopathology, and some authors have already noticed significant analogies between the historical moment in which that classical text appeared and the present one. The most striking analogy is that nowadays, exactly like one century ago, the enthusiasm brought about by a period of exceptional progress of research in neurosciences is being followed by some disillusionment, due to the limited relevance of that progress to the elucidation of the pathophysiology of mental disorders. To this disillusionment, the psychiatric field is now reacting in a way that resonates in several respects with Jaspers’ analysis, making a revisitation of his General Psychopathology extremely useful…
In line with Jaspers’ analysis is first of all the current acknowledgment of the limitations of the scientific paradigm of 19th century medicine [identifying signs and symptoms, constructing syndromes, taking course into account, and then looking for biological processes that explain the syndromes], when applied to psychiatry. That paradigm seemed to work in the case of general paresis of the insane. However, as Jaspers notices, that disease was not an appropriate “model for clinical psychiatric research”. In fact, the symptomatic psychoses occurring in general paresis were “in no way different from other psychoses associated with brain disease, neither in the psychological symptoms nor in the sequence of psychic phenomena throughout the illness”. Apart from general paresis, Jaspers argues, “there has been no fulfillment of the hope that clinical observation of psychic phenomena, of the life-history and of the outcome might yield characteristic groupings which would subsequently be confirmed in the cerebral findings”. “The idea of the disease-entity is in truth an idea in Kant’s sense of the world”. Even in the cases of schizophrenia and manic-depressive illness, “one is always confined to types”, that is, “fictitious constructs which in reality have fluid boundaries”….
When I began in psychiatry, that’s what I thought and still think. Without really realizing it was happening, I had become more interested in the sick people than the medical diseases that made them sick, and had been drawn to learn more. If I had thought that the mental illnesses were brain diseases, I would’ve happily stayed in Internal Medicine. When I got to psychiatry and encountered the major psychiatric illnesses like Schizophrenia and Melancholia, I will admit that even in those dire conditions [which I assume are biological], I remained more interested in the afflicted than their afflictions. It is refreshing to read Jaspers’ version of those same kind of thoughts after a third of a century of hearing endlessly from an overly-medicalized psychiatry.
In this context, the basic heterogeneity of mental disorders should not be overlooked. “Contemporary neo-Kraepelinian American psychiatry … practices as if there were biological commitments to over 300 DSM-defined entities, while the biological model may apply only to a few mental disorders, for instance, “schizophrenia, manic-depressive illness, melancholic depression and obsessive-compulsive disorder”. These recent statements resonate with Jaspers’ classification of mental disorders into three groups — cerebral illnesses [such as Alzheimer’s disease], major psychoses [such as schizophrenia and manic-depressive illness], and personality disorders [including neurotic syndromes and abnormal personalities] — which are “essentially different from each other” and not equally amenable to biological research [those of the third group may just represent “variations of human nature”].
… the biological model may apply only to a few mental disorders, for instance, “schizophrenia, manic-depressive illness, melancholic depression and obsessive-compulsive disorder.” Those are the very conditions that I think of as the psychiatric diseases – biological? yes. pathophysiology? unknown so far.
I had never read about Jaspers’ psychiatrist days. I don’t think I even knew he was a psychiatrist. My main recollection of him was as an existentialist that was somewhat intelligible to the likes of me [one of the few]. But reading this, I think his change of career was psychiatry’s loss. This is an eminently sensible way to conceptualize mental disorders. This larger circle [personality disorders – “variations of human nature”] with its heterogeneity and indistinct borders has been concretely partitioned these days into target symptoms for a hungry pharmaceutical industry, and has recently escaped an attempt at inclusion under the biological umbrella without solid evidence that it belongs there [DSM-5]. Our modern classifications are so complicated by disciplines, economics, industries, ideologies, institutions, and the like, it’s refreshing to read the thoughts of someone who was outside the monotonous contemporary dialogs and primarily thinking about the mentally ill people.
Finally, Jaspers’ emphasis on patients’ “working through the illness”, of which the “laborious development of a delusional system out of delusional experiences” is the best example, resonates with the contemporary notion that “the role of the person in mental disorder is not peripheral, merely as a passive victim of a disease to be fixed by medicine”, and that person–disorder interactions are crucial in the shaping of psychopathological symptoms. So, not only patients’ primary subjective experiences should be a major focus of psychopathological and neuroscientific enquiry, but patients’ “attitude to their illness” can represent an important target for both research and intervention. These are just a few examples of basic philosophical issues in psychiatry that are as relevant today as they were one century ago. They suggest that, although our diagnostic systems may be devised as “atheoretical”, contemporary psychiatry does need a guiding philosophy. “If anyone thinks he can exclude philosophy and leave it aside as useless, he will eventually be defeated by it in some obscure form or other”. This is one of the reasons why a revisitation of Jaspers’ General Psychopathology, on the occasion of the 100th anniversary of the publication of its first edition, may represent a useful exercise for everyone involved in psychiatric research and practice.
As a philosopher, Jaspers, like many of his contemporaries, worried about the human encounter with technology, science, and collective institutions – seeing them as barriers to personal freedom. He urged a Transcendence of the limits of rational objectivism to achieve what he called Existenz – an authentic subjectivity. Like so many, his career was suspended during the Nazi era when he and his Jewish wife spent the war in fear of the very kinds of technology and ideology he had written about. After the war, he resumed teaching, writing about the German responsibility for the atrocities of the Third Reich [Die Shuldfrage]. Where Jaspers’ Allgemeine Psychopathologie criticized Kraepelin for an over-reliance on a medical model, he would later criticize Freud for over-generalizing about human experience from a limited field of observation.
Stepping back from the loftier interface between science and philosophy that are such a pleasure for an old man to think about, Jaspers the psychiatrist, the philosopher, and the person presaged and lived through many of the issues that plague the psychiatry of 2013. Author Mario Maj points to the obvious:
"The most striking analogy is that nowadays, exactly like one century ago, the enthusiasm brought about by a period of exceptional progress of research in neurosciences is being followed by some disillusionment, due to the limited relevance of that progress to the elucidation of the pathophysiology of mental disorders."
I agree with Maj, but see that more as an expected phase in the exhaustion of a scientific paradigm – the swinging of a pendulum. But what I do ponder is how this particular scientific revolution in psychiatry in 1980 gave rise to such a widespread level of corruption in both individuals and institutions. Jaspers turned to philosophy after World War I, warning about existential despair and the threats to individuals in the face of ideology, scientific technology, and political institutions. He then had to live through the worst perversion of those very things the world has ever known, Hitler’s Germany, kept in place by a powerful German industrial complex. One must always be careful about analogizing anything to the Nazis, such an easy place for exaggeration, but the massive intrusion of industry into the field of psychiatry does touch a similar point. Much of the psychiatric literature that followed our scientific revolution and open commitment to evidence-based medicine will stand in history as a testament to a perversion of those very principles in the service of commercial goals. Jaspers felt that all of German Society was culpable for the Nazi atrocities. I think he would similarly hold the whole of psychiatry responsible for the many misadventures of the last thirty years. And back to Jaspers the psychiatrist. He saw three different versions of the psychiatric disorders:
… Jaspers’ classification of mental disorders into three groups — cerebral illnesses [such as Alzheimer’s disease], major psychoses [such as schizophrenia and manic-depressive illness], and personality disorders [including neurotic syndromes and abnormal personalities] — which are “essentially different from each other” and not equally amenable to biological research [those of the third group may just represent “variations of human nature”].
I don’t doubt that a few of the inhabitants of Jaspers’ greater circle [personality disorders – “variations of human nature”] may turn out to have some biologic aspect to their illnesses, and that some may be genuinely helped by mood altering drugs. But the recurrent rhetoric of organized and academic psychiatry that the great hope for these people is in biological research and pharmacologic treatment strikes me as delusional [a delusion = a fixed, false belief]. What Jaspers said a century ago remains true:
… “there has been no fulfillment of the hope that clinical observation of psychic phenomena, of the life-history and of the outcome might yield characteristic groupings which would subsequently be confirmed in the cerebral findings”. “The idea of the disease-entity is in truth an idea in Kant’s sense of the world”.
The only difference is that we’ve amassed a lot more cerebral findings these days. And for that matter, we’ve made up a whole lot more disease entities…
I interpret this post to just reiterate the timeless adage of:
The more things change, the more they stay the same.
Oh and also, power corrupts, and absolute power corrupts absolutely.
See the movie “Contact” near the end, when the alien disguised as Ellie’s father tells her “your species is capable of such beautiful dreams, and such terrible nightmares”, something close to that. We as a species have made the line between greatness and tragedy so thin, it is too easy to now blur the differences.
And over tolerate entrenched flaws not capable of repair.
Nowadays we might modify Jaspers’ Venn diagram. The large outer circle he terms Personality Disorders could be reframed as Problems of Living plus Adjustment Reactions in addition to Personality Disorders per se. That reformulation allows due acknowledgment that individuals are dealt different cards in life – genetically, developmentally, socially, medically. In their personal trajectories they try to cope with issues in life by responding with understanding and self narrative. It is a case of social, psychological, and biological capital interacting with unequal fate and circumstance. Whatever strengths they possess or don’t possess shape the outcome. The results are experienced as resilience or breakdown. This is what I take to be Jaspers’ notion of patients “working through the illness,” and it has been forgotten. Thank you for this reminder.
This issue bears on the current debate about the bereavement exclusion. Most of the time we will do well to respect the patient’s existential and cultural narrative of bereavement rather than to apply a false positive diagnosis of major depression. Besides, the evidence base for successful treatment of major depression in bereavement is nugatory – certainly not enough to force a change in DSM-5 (see PubMed IDs 11379835 and 18597854).
Dr. Carroll,
Thanks for that. Your clarification of the contents of the “acquired” mental illness is the kind of thing we need to rediscover. Psychiatrists [not just analysts, social workers, psychologists, and philosophers] had added a lot to our understanding of the inhabitants of Jaspers’ greater circle – and abandoned much that was of value in the this age of neuroscience. What’s worse, including those patients in the clinical trial and epidemiologic cohorts has made productive biological research much more difficult.
“What’s worse, including those patients in the clinical trial and epidemiologic cohorts has made productive biological research much more difficult.”
Had the architects of the DSM-5 wished to do something useful they could have come up with some MDD subtypes (or simply restored some of the previous ones). Some refinement (heck, any sensible refinement) of this category, would have been a boon to research. They would not have had to sacrifice any potential billable or medicatable potential patients. It would not have fit their agenda because the subtypes would not have been defined according to improperly functioning neural curcuits, but it would have had immediate practical benefit.
What is so frustrating is that that could have done some good along with the ridiculousness. And, they did so little good.
If they had spent half the energy on effectively making a better manual with the available research, as they did telling everyone why this vanity product is such a great manual, we would have received a much better DSM-5.
If we had followed Dr. Carroll’s and Mickey’s sage advice, the DSM-5 volume would have been about a fifth of what it is to be. In other words, back to future so to speak, as it was in DSM-II.There was nothing fundamentally wrong with the categories of neurotic depression or anxiety– this is what the expanded Venn circle encompassed.
“Jasper’s argues, ‘there has been no fulfillment of the hope that clinical observation of psychic phenomena, of the life-history and of the outcome might yield characteristic groupings which would subsequently be confirmed in the cerebral findings’.”
In approximately 1883 Prof. Albert Mairet published “Melancholic Dementia”. He made the observation that melancholic patients were found postmortem to have changes in the temporal lobe. He suggested that this area might be related to sadness, and suggested that nihilistic delusions were secondary developments derivative of the spread of the lesion in the cortex.
Literature over a century ago, and more contemporaneously, has demonstrated the correlation of histology and mental illness. The study of TBI has permitted predictive clinical consequences. Specific mitochondrial errors in metabolism predict clinical outcome such as in the synucleinopathies. I am not pessimistic for future achievements in biological sciences; but, the more we learn, the more we may question.
Robert Waelder referred to psychoanalysis as an unending search light for truth. The biological sciences do not have a different standard. The lack of a biological marker has permitted conjectures that do not pass the crucible of probity.
The most alarming aspect of the last quarter century has been the desertion of the patients not only in psychiatry and psychology but in medicine in general.