1 Boring Old Man

DSM-5 and the Research Domain Criteria: 100 Years After Jaspers’ General Psychopathology

by Jose de Leon, M.D.

American Journal of Psychiatry. 2014 171:492-494.

In 1913, 30-year-old German psychiatrist Karl Jaspers published the first edition of General Psychopathology, in which he summarized current psychiatric knowledge and included his ideas regarding the methodological and scientific issues then facing psychiatry. In the words of his biographer, Jaspers thought the discipline of psychiatry “was crying out for a systematic clarification of current thinking” and that “to make real progress psychiatrists must learn to think,” but his book was not well received by more senior German psychiatrists. Jaspers subsequently became better known as a philosopher. In 1922, when writing the third edition, Jaspers was no longer in direct contact with psychiatry and asked for suggestions from Kurt Schneider, an excellent young psychiatrist, who then probably updated the later editions of the book.

The first English translation of General Psychopathology, more than 900 pages long, was published in 1963, reflecting the seventh German edition. Jaspers’ book defined psychiatry as a hybrid scientific discipline that must combine the methods of the natural and the social sciences which, respectively, provide an explanation of psychiatric diseases that follows the medical model and an understanding of psychiatric abnormalities that are variations of human living. General Psychopathology has had a continuous influence on psychiatry in the United Kingdom, including psychiatric research and resident training, but has had very limited direct impact on U.S. psychiatry. General Psychopathology’s English translator described a visit to a Philadelphia psychiatry department, where the chairman told him, “Nobody reads it, but it is obligatory to have it seen on your shelf.” The American Journal of Psychiatry has published only two articles on Jaspers. In 1967, Havens commented on the publication of the General Psychopathology translation and hoped that U.S. psychiatrists would be open to Jaspers, who “provides a systematic rationale for eclecticism.” In 1986, Schwartz and Wiggins used Jaspers’ “explaining” and “understanding” concepts in the context of Engel’s biopsychosocial model.

At 100 years, we might speculate on what Jaspers would think about the current differences in diagnostic strategy between the National Institute of Mental Health’s Research Domain Criteria [RDoC] and DSM-5. The RDoC appears reminiscent of Karl Wernicke’s attempt to consider all mental disorders as brain disorders, and DSM-5 follows Emil Kraepelin’s dictum that all psychiatric disorders follow the medical model of disease. Jaspers had strong critiques of both Wernicke and Kraepelin.

According to Insel et al., “the RDoC framework conceptualizes mental illness as brain disorders. In contrast to neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of brain circuits.” At the beginning of the 20th century, Wernicke, already famous for describing the sensory speech center, also wrote a textbook including a pathophysiological model of the relationship between brain and behavior, which became one of the most important competitors of Kraepelin’s textbook. According to Jaspers, Wernicke believed that all mental illnesses are “cerebral illnesses in the sense that they can be wholly comprehended in terms of cerebral processes”. If Wernicke had not died young, we psychiatrists might be living in a “Wernickian world” instead of a “Kraepelinian world”. Although Jaspers acknowledges that Wernicke’s pathophysiological model applied well to aphasia and other neurological disorders, Jaspers thought Wernicke erred in extending it to all psychiatric disorders. Jaspers contrasted Wernicke and Sigmund Freud, who were both disciples of the same Viennese mentor, Theodor Meynert, saying that they were positioned at opposite extremes in psychiatry. In Jaspers’ view, Wernicke thought that “explaining” was the only methodology needed in psychiatry. On the other hand, Freud thought that “understanding” was the only methodology needed in psychiatry. The RDoC’s focus on brain disorders implies a view similar to Wernicke’s that explaining is the only methodology needed in psychiatry.

The diagnostic scheme for psychiatric disorders developed by the Department of Psychiatry at Washington University, which led to DSM-III, DSM-IV, and DSM-5, is a Kraepelinian nosological model where mental disorders follow the medical model of disease as a set of identifiable symptoms. Jaspers was critical of Kraepelin’s idealization of the medical model of general paralysis of the insane [neurosyphilis] as a model for psychiatric disorders, with each disorder having a unique cause, set of symptoms, course, outcome, and neuropathology. In General Psychopathology, Jaspers proposed that some psychiatric disorders follow the traditional medical model, principally those that were called organic mental disorders in DSM-III. Jaspers called them “known somatic illnesses with psychic disturbances” [“Group I”]. Other psychiatric disorders, he proposed, were not medical disorders but variations of normality; Jaspers called these disorders of personality, including “abnormal reactions, neurosis and neurotic syndromes, as well as abnormal personalities and their developments” [“Group III”]. Situated between them were the psychoses [“Group II”], which, according to Jaspers, could be distinguished from normality but were not clearly separated from each other—e.g., intermediate cases between schizophrenia and manic-depressive illnesses. Jaspers felt that Kraepelin’s denial of the heterogeneous nature of mental disorders failed to capture some psychiatric disorders correctly.

Jaspers’ critiques a century ago of Wernicke’s brain pathophysiological model and Kraepelin’s medical model might thus be applied contemporarily to RDoC and DSM-5. We still struggle 100 years later with the issues that Jaspers raised: psychiatry is a hybrid scientific discipline that must include in its research enterprise patients’ beliefs and culture, influences not captured by traditional scientific reductionism, and  psychiatry encompasses heterogeneous disorders, not just those that follow the traditional medical model.

When I discovered Jaspers a year ago, I revisited the history of that era. These days, we talk a lot about ideologies, biases, and conflicts of interest, but by the standards of a century ago in Europe, we’re rookies in dealing with outside forces. I’d made my peace with Freud in analytic training and teaching the "Freud Course" in our Psychoanalytic Institute – what he got right, where he was dead wrong, how his persona influenced his work, and the  impact of the anti-semitism of those times on so many things in his life. While I can join in eruditely with those who never tire of criticizing many of his theories, his clinical acumen and his contributions to listening and understanding were unequaled in my experience, and I wouldn’t have missed the chance to study Freud’s thinking for anything.

But I knew next to nothing about Kraepelin. As I read about him, his views on mental diseases and his sociopolitical views merged and were a major surprise to me [see all ears…, an open question…, see also Dr. Noll’s comments to those posts]. He was as complicated as Freud and very much a man of his times. His theories were all about a "congenitally inferior predisposition," "hereditary degeneration," and "genetic influences" result from "alcohol and syphilis." Candidly, he was into eugenics and had he lived long enough, I fear he would gotten caught up in the craziness that swept German under Hitler. That’s a harsh thing to say and I’m no expert, but it’s not said lightly. A couple of the softer quotes [from Shepherd, see also all ears…, an open question…]:

On the origins of hysteria: [Kraepelin] wrote about ‘morbid’ constitution, ‘defective heredity’ and certain environmental conditions. He considered the possibility of uterine disturbances but said the role played by ‘the female sexual organs … is not clear’. In the eighth edition of Psychiatrie [1909–15], he considered at length [70 pages] the origins of paranoia: was it an outgrowth of ‘the hard blows life delivers to everyone’ or was it owing to innate degeneracy where ‘morbid germs … were already present in the disposition’ as in a genetic disease like Huntington’s chorea? Kraepelin opted for degeneracy.

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.

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.

When the DSM-III came along, we suddenly had a new group – the neoKraepelinians – who following Kraepelin generalized the medical model which had kind of worked for the Major Psychoses to all mental illnesses – classifying based on symptoms. They included the neurotic patients, the behavioral syndromes, everything. It didn’t work for the psychoanalysts, the psychotherapists, the psychologists, the social workers, the counselors, etc. It did work for the insurance carriers, the medicare architects, the hospitals, the FDA, PHARMA, etc. because they had pigeon-holes to put people into [DRGs in medical parlance]. The medical justification was Kreapelin AKA neoKraepelin who apparently thought all mental illness was biological degeneracy of some kind and who had some weird ideas about how heredity worked. After reading more about Kraepelin, I find myself thinking that the neoKraepelinian Emil Kraepelin was a creation of the St. Louis psychiatry group – not the historical figure I’ve read about more recently. And I’m thinking now that the real Kraepein’s opinions about Jaspers Group III were more socio/political prejudice than medical/psychiatric observation.