all ears…

Posted on Tuesday 30 April 2013

The debates about psychology versus biology as either the cause or the treatment of mental illness are probably as old as the topic itself:
Actually, that’s not bad, the blind giant and the dwarf psychologist are often heard modern criticisms – the heavy-handed psychopharmacologist and the impotent psychotherapist [although the italicized adjectives are sometimes reversed]. This dichotomy [psychology vs. biology] is frequently symbolized using the avatars of the giants of the early 20th century – Sigmund Freud and Emil Kraepelin – contemporaries but hardly colleagues. With these iconic figures, some of the gulf between them can be parsed away by recognizing that they saw a different group of patients – the neurotic outpatients of Vienna and the psychotic, institutionalized patients in Munich. They based their views of mental illness on different prototypic conditions – Conversion Hysteria for Freud and CNS Syphilis for Kraepelin. Of some interest, both conditions are now rarely if ever seen. But there were genuine basic differences beyond their disparate domains. Freud commented about the psychoses, but mainly to explain why they were untreatable by his methods. Kraepelin had little to say about neurotic illness, subjectivity, and he explained reactions to life’s stresses on something like innate constitution – anlage:
from TWO FACES OF EMIL KRAEPELIN
an·la·ge [äng]
noun
  1. Biology: The initial clustering of embryonic cells from which a part or an organ develops; primordium.
  2. A genetic predisposition to a given trait or personality characteristic.
  3. A fundamental principle; the foundation for a future development.

So how did I get here on a Monday? Well, the pollen count has fallen and my mind/brain is finally back. And I was thinking about something. After analytic training and years of teaching a "Freud Course," I can out·criticize Freud with the best of them, but what I realized is that while I am full of comments about the neoKraepelinians, I know very little about Emil Kraepelin himself. In training, I learned the textbook version – about his separation of Schizophrenia and Affective Psychosis, and about his work with Alois Alzheimer on presenile dementia. I’ve always accepted Kraepelin’s implied biological basis of the Major Psychoses. But I don’t know his story, his life and times at all.

So I started reading about him. The first thing I read was written by him in 1917 for the opening of a new research institute [100 years of Psychiatry, Emil Kraepelin, 1917]. It’s on the Internet, but it’s 174 pages long so I’m not pushing it. I found this nice review, but it’s not online. Here’s a comment and a quote:
by Hilde Bruch
Archives of General Psychiatry. 1969 21[3]:257-261.

The general atmosphere of the book is one of humanistic benevolence and scientific optimism. Some of his ideas sound amazingly modern, even contemporary, such as his emphasis on the need for better education and higher salaries for the auxiliary personnel in order to attract people of high caliber, or his awareness of the importance of the social milieu and of each patient’s position and role in the hospital community for his sense of dignity and well-being.

Kraepelin felt assured that nothing in the future would deflect from the progress that had been made. The foundation of the Research Institute indicated a further step forward. Though many things were still unclear and unknown, continued clinical investigations were expected to clarify the causes of mental illness and eventually to afford treatment for cases that thus far had been considered incurable. The Institute would attract scientific-minded psychiatrists in search of reward not afforded by psychotherapy, and give the opportunity for close collaboration of specialists in various fields. His concepts of progress was research in the organic field. He mentioned as shining achievements of the recent past the Wasserman test for the diagnosis of syphilis which had been recognized as the cause of general paresis, the malaria treatment for this condition, and thyroid medication for cretinism.

With all this benevolence there is also expression of a fatalistic pessimism. It seems rather tragic that Kraepelin’s name has become associated with this nihilistic attitude rather than his courageous forward-looking optimism. To quote:
    "Our satisfaction over the progress already made is tinged with regret. When we consider the extraordinary sacrifices made by those responsible for the evolution of psychiatry, we are constrained to lament the fact that all the hopes tied to it can never be fulfilled. We must openly admit that the vast majority of the patients placed in our institutions are according to what we know forever lost, that even the best of care can never restore them to perfect health. Our treatment probably makes life endurable for a vast number of mental cripples whose plight would otherwise be intolerable, but only rarely does it effect a cure… It is obvious that by itself even the best psychiatric therapy cannot eradicate the scourge of mental disease."

    "We must therefore ask if there are other, more promising, approaches. The answer is a resounding yes. Most promising is the prevention of insanity, though this is possible today only to the extent that we are acquainted with the causes of the affliction and are capable of combating it. We know the basic causes of the three major diseases: hereditary defects, alcoholism, and syphilis. They constitute, according to the most conservative estimates, at least one third of all mental disorders treated in our clinic. Then comes addiction to morphine and cocaine. Traumatic neuroses can also be prevented. An autocrat in possession of our present knowledge would be able, if he showed no consideration for the lifelong habits of men, to effect a significant reduction in the incidence of insanity within a few decades"…
Changing Directions: I wrote everything above here before I read the next article. It was open on my desktop because I got that first Kraepelin quote from it, but I hadn’t read it all the way through. I had a twinge when I read about anlage and another with his pessimism. But the first jolt was the part about the autocrat reducing the incidence of insanity. I knew I was reading a book written by a German psychiatrist written in the year Germany was being defeated in World War I, and I certainly knew where German history was headed. But even at that, I wasn’t prepared for this next article. Every single one of you may already know the story it tells, but I didn’t have a clue – not a clue. Most of it’s available online as part of a collection. Here are just a few snippets from something that should be read thoroughly:
by MICHAEL SHEPHERD
British Journal of Psychiatry. 1995 167:174-183.
[most text on-line]

Kraepelin’s reputation, derived from a partial knowledge of the man and his work, is iconic. Icons exist to be worshipped, but a touch of iconoclasm is a safer bet. Histographical research is making it clear that, with a handful of exceptions, the leading figures in the history of psychiatry exhibit far too much clay below the ankles. Kraepein is one among many…

On the outbreak of the First World War Kraepelin’s nationalism became more intense and steadily grew as the outcome of the conflict became increasingly uncertain. Viewing venereal disease as a major threat to the health of the German army, he launched a personal campaign to establish a national screening programme which involved him in a tenacious but ultimately unsuccessful struggle with the Ministry of War. Frustrated by failure, he took up active politics. He joined the People’s Committee for the Rapid Subjugation of England, a body dominated by right-wing members of the academic community. He helped to draw up the annexationist Guidelines for Paths to Lasting Peace. And he campaigned for the overthrow of the Chancellor and the introduction of a more authoritarian rule in Germany…

And in 1919 he made his views explicit in a paper entitled ‘Psychiatric observations on contemporary issues’, in which he declared himself to be a psychiatrist who takes a stand on contemporary issues, reporting from the perspective of his professional experience. A few extracts illustrate his conclusions:
  • On war:… "there can be absolutely no talk whatsoever of a morbid disorder. The drive of self-assertion is the primal and most powerful force behind all individual and group action"
  • On the German emperor, William II:…" it is simply impossible in the case of William II to posit the existence of an acute mental disorder"
  • On sex-differences: "Based upon broad experience I believe we can view these apparently arbitrary upheavals of the will as the response of primal defence mechanisms to the dangers of life… In the case of the mature and emotionally well-anchored male, these antiquated defence mechanisms against overwhelming external pressures no longer have a role to play… it was the women who proved to be ill-prepared for the prolonged state of war and who tormented their sons and husbands at the front with their complaints and who at times breached the trust of those in the field"
  • On individuals with distinctly hysterical traits: … "among the leaders of current and past upheavals one also finds a surprising number of people who in one way or another fall outside the bounds of normality."
  • In this latter category he concludes… "dreamers and poets, swindlers and Jews. The active participation of the Jewish race in political upheavals has something to do with this [morbidity]. The frequency of psychopathic predisposition in Jews could have played a role, although it is their harping criticism, their rhetorical and theatrical abilities, and their doggedness and determination which are most important."
  • On the causes of social unrest: "What struck the informed observer was the wholesale ignorance of the collective psyche… Experience with accident neurosis has shown that providing pensions to those unwilling to return to work breeds an artificial work-disability which under certain circumstances can result in lasting mental decrepitation… The government measures presume that humans by nature tend to perform their duties, to work hard and to commit them selves to the common good. The development of every child teaches us that this conviction is false… we cannot escape the fact that the natural and self-evident drive behind all actions is selfishness and that in the case of popular rule this selfishness will seek its due with violent force as soon as the powers of the state designed to hold it in check are destroyed… It must be made absolutely clear that the stratification of human society is certainly far more the expression than the cause of the immeasurable inequality among humans. Accordingly, the emergence of classes of people would very much depend, if not for the individual then certainly for the succession of the lineages, on those abilities which come to be developed in them. And the proletariat would be chiefly a conglomeration of those countrymen whose ancestors could not, over the centuries, rise to the top true popular rule is entirely impossible. Invariably the masses submit to individual leaders who by virtue of certain qualities have risen to the top. They are true leaders; those led by them are left with only the appearance of sovereignty. It is not they who decide, but rather the superior leaders who understand how to force the others to follow."
  • On future measures: "We will have to work systematically and employ all of our resources in the physical, mental and moral regeneration of our people. The essential framework has already been explicated numerous times during the course of the war, especially by doctors. Attention must be focused above all on the fight against all those influences threatening to destroy future generations, in particular hereditary degeneration and genetic influences resulting from alcohol and syphilis. Furthermore, the following will be necessary: the greater possible encouragement of early marriage, the fostering and strengthening of the joys of parenthood, the protection of the younger generation from the changes of physical, mental and moral neglect, the strengthening of the body, of the mind, and in particular of the will, by means of their regular and appropriate engagement"…
Dying as he did in 1926, Kraepelin was spared involvement in these terrible events. We cannot know whether, like the overwhelming majority of German professors, he would have voted for Hitler in 1932. Or what he would have made of the version of his fatherland adopted by the Third Reich. Or how he would have responded to developments within his own Institute in the 1930s, when his close associate and successor - the psychiatric geneticist Ernst Rudin – joined the Nazi party and participated actively in the racial hygiene programme that was to lead to a policy of genocide and the nimiety of the gas chambers. Or if he could ever have accepted Fritz Stern’s considered verdict that from 1933 to 1945 the German academic profession, with medicine and psychiatry in the vanguard, furnished the most flagrant example of a trahison des clercs in the twentieth century…
This article was from a talk given by well-known British psychiatrist Dr. Michael Shepherd of the Maudsley Hospital in London in 1994 [six months before his own death]. We read about him recently as having done the first ever RTC [a fascinating tale…]. He was a renown clinician, a nosologist who wrote about conceptual issues in psychiatry, and was known as the "Hammer of Psychoanalysis" because of his keen criticisms of that discipline. His Wikipedia entry says, "Michael Shepherd was born on 30 July 1923 in Cardiff of a Jewish family with its roots in Odessa and Poland" which might give him a particular sensitivity to these issues, but I must say that his presentation of Kraepelin is balanced – presenting two faces as the title suggests.

I’m at something of a loss for words here. I started to flesh out the story the Emil Kraepelin who had essentially founded rational diagnosis in psychiatry by delineating Schizophrenia and Manic-Depressive Illness and who was the co·discoverer of Alzheimer’s disease, and now I find myself wondering about an altogether different topic – the kind of thinking in Germany that lead to the Nazi atrocities. As you read through Shepherd’s presentation, it is clear that Kraepelin’s intense nationalism and right wing views weren’t just a late life interest – they went back at least to his young adulthood in Heidelberg. So the question becomes, is it possible that his political views which were about degenerates, constitutional inferiority, and the need for authoritarianism could be kept separate from his psychiatric thinking? One might at least entertain that possibility if Kraepelin himself hadn’t written that he was speaking in these papers on politics and society as a psychiatric expert.

Dr. Shepherd wrote:
An historical study may be undertaken either as a self-contained inquiry in its own right or with the aim of having the past illuminate the present. This one belongs to the second of these two categories.
I’ll say. And with me, this one needs to sit for a while. If anyone has any references or commentary to add, I’m all ears…
  1.  
    April 30, 2013 | 1:16 AM
     

    My dear Dr. Nardo: I love reading your blog, but I’d love reading it more if it were more readable. I just posted some practical tips here.

  2.  
    woody
    April 30, 2013 | 11:44 AM
     

    “De gustibus non disputandem est . . . .”

    I like your site just fine.

  3.  
    wiley
    April 30, 2013 | 12:06 PM
     

    I’m pretty sure that Richard P. Bentall touched on this in Madness Explained. The relationship between psychiatry and eugenics in mid-19th Century Europe and the U.S. is too close for comfort and probably needs to be reexamined and excised in order to remove some of the stench of authoritarianism in the field.

    So, there’s the “blind giant” of biology and the “dwarf psychologist”— what would we call sociology? The book “Worlds of Pain,” by Dr. Lillian Rubin described my family— working class/”hard settlers”— so vividly and accurately, that I finally understood their self-hatred and internalized shame. Knowing where it came from and how truly impersonal it was helped me to overcome it in myself without having to make any appointments. My woefully emotionally wounded family was a textbook case. There’s something oddly comforting about that— it means being “normal” and having a normal response to social stress.

    While researching civil disobedience for a college project, I ran across a tome with the word “Obedience” embossed in gold letters on the spine, and thought, ‘Ah-ha!’
    To my surprise, there was an entire chapter in the book about overseas military units during peace time. My last unit was so neurotic and near-psycho that when a counselor in lock-down asked me if I’d ever been around someone that was suicidal, I thought ‘Yeah. Quite a few. And don’t forget setting fires. (And college for that matter)’ The most bizarre little society I had ever been in—- worse than my twisted little family— was a textbook case.

    It appears that Kraepelin saw the “mentally ill” as a threat to society rather than seeing society as a creator of “mental illness.” For the time, that was perfectly understandable, and he was fortunate to have been practicing at a time when the relationship between syphilis and psychosis was being established, but that too can be seen as “degenerate.” Regardless of how much he may or may not have felt sympathetic toward his patients, or how accurate his classifications may or may not have been, the classifications themselves were damning; which may have simply reflected a perception based on what little information and few resources was available.

    The urge to see hope in biology, and to see problems of mental distress in biological terms is understandable. Neuroscience is a booming field, which, like any field in the cradle looks full of potential; but it’s childish to pin too many hopes on something so young and imprudent to see potential as a promise.

  4.  
    jamzo
    April 30, 2013 | 12:19 PM
     

    FYI

    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/30/kathleen-frydl-on-the-drug-war-here-we-have-total-and-complete-failure/

    interview with historian kathleen frydl about her new book “The Drug Wars in America, 1940-1973″ provides some interesting context on the historical relationship between the regulation of narcotics and the development of prescription medicine….

  5.  
    Annonymous
    April 30, 2013 | 12:47 PM
     

    More reasons that patients and physicians, rather than regulators, need to do most of the heavy lifting:
    http://www.pharmalive.com/ema-ordered-not-to-release-trial-data-for-now
    Will this hurt AbbVie and Intermune brands with patients and physicians? Are they tired of being infantilized by these companies?
    Will it impact in any way the reputation of the non-industry researchers who chose/are choosing to participate in the trials where the data won’t be released?
    If patient “advocacy” groups could pull themselves away from the money trough long enough to target the worst offending companies and their brands we might see some movement on these issues. Instead of this 20 year holding pattern.

  6.  
    Richard Noll
    April 30, 2013 | 1:01 PM
     

    Mickey,

    Most of the good biographical and critical stuff on Kraepelin is in German (aand is causing my bookshelf to sag). In English, some of the best historical and critical articles were written by Hannah Decker (including a good one on “how Kraepelinian was Kraepelin?”). However, her new book on the making of DSM-III was just released the other day and I am awaiting for my copy to arrive in the mail. Photographs of Bob Spitzer and Emil Kraepelin are on the cover, so I suspect that will have her most up-to-date thoughts on Kraepelin.

    http://www.amazon.com/Making-DSM-III%C2%AE-Diagnostic-Conquest-Psychiatry/dp/0195382234/ref=sr_1_1?s=books&ie=UTF8&qid=1367340144&sr=1-1&keywords=hannah+decker

    Alas, we are all historical beings, and even our innermost thoughts and feelings are given shape by our historical era and our place in it. Kraepelin’s racist and anti-semitic remarks are well documented, especially in the German literature. Racialist thought dominated Anglo-American-European science and culture a century ago, and it is not hard to find evidence of these sorts of attitudes and statements from many prominent persons in the historical record of those times. It has always been a dilemma for historians as to how to present and interpret them with respect to our era and its very different sensibilities. Kraepelin died at age 70 in 1926, and in his ardent German nationalism and racialism and racism he reflected the opinions of many in the culture of his time. Most historians would not go so far as to make an explicit link between Kraepelin , his psychiatric classification or his methods of treatment to the rise of Nazism or the Holocaust, but the culture that inspired these later events certainly was in existence during the last decades of his life.

  7.  
    Annonymous
    April 30, 2013 | 1:10 PM
     

    1BOM, to me what is most striking in your post is how if you replaced “Anlage” with “neurobiology” or “neural circuitry” …etc that that statement could easily have been made by any number of thought leaders in American mental health today.

  8.  
    April 30, 2013 | 1:13 PM
     

    Annon,
    Eerie, isn’t it?

  9.  
    Annonymous
    April 30, 2013 | 1:23 PM
     

    1BOM,
    It really is.

  10.  
    Richard Noll
    April 30, 2013 | 1:33 PM
     
  11.  
    May 1, 2013 | 3:10 PM
     

    I have to say, I come to your blog to read opinions and alternative insights, but sometimes your posts are exhausting. It is your blog, but, I have to ask this truly sincerely and inquisitively, who is your audience?

    I guess sometimes your subject matter is beyond my scope.

    Be well and be safe, especially in these times.

  12.  
    May 4, 2013 | 7:40 AM
     

    I did not understand the local brand of Norwegian psychiatry until I started to read the history of psychiatry and found it wasn’t at all local, but dominant in the USA and Europe, aiming for global dominance, biological views logically leading to eugenics, sterilizations, then the gas chambers for the inmates of Polish and German asylums starting immediately after the attack on Poland in 1939, then, with technology refined by health personel on persons judged, by doctors, unfit to live, these “experts” went on to work the Final Solution, the Holocaust. Logical inhumanity, logical ambitions, logical elitist thinking and devotion to abstractions, science, racial purity and elitist superiority…

    Closing the asylum, by British psychologist Peter Barham was a first that helped me step to get a grip on horrible contradictions within “helping” professions that were reating suffering people cruelly – even in front of relatives – mouthing good intentions.

    Robert Jay Lifton next – and more psychiatrists/writers/historians on how the ideologues of the Nazi state, Hitler’s totalitarian Reich needed the cover of science provided by ambitious doctors and psychiatrist, the majority were members of the Nazi party, joining freely the then vehicle to money, prestige, power. Then British historian of medicine Roy Porter on the long lines, in smaller doses, Robert Gerwarth’s book “Hitlers Hangman”, the life of Reinhard Heydrich.

    Long after WWll we could believe “the problem” was solved, Germany beaten. We know better. It’s never solved, only kept at bay. Vigilance, resistance, democracy, justice for all.

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