Psychopathology and the Classification of Mental Disorders

1. Psychopathology and the Classification of Mental Disorders Henning Sass Aachen / Aix la Chapelle

2. Pro-Con-Debate EPA Congress Munich 2010 (Möller vs. Sass) Thesis: Traditional phenomenological descriptive psychopathology is no longer relevant in the new era of biological psychiatry

3. Neuroscience and Psychopathology Which impact do the proceedings of brain research have on our idea of man, on the treatment of patients with psychic disorders and on the assessment of offenders? Are feelings,thoughts and decisions determined by causal laws of neuronal processes, or is there space for subjectivity and freedom of will? How important is the „inner perspective“ of the patient‘s experience? Maier, Helmchen, Saß, Hirnforschung im 21. Jahrhundert, Nervenarzt 2005

4. Wilhelm Griesinger (1817-1868) His aim: To establish psychiatry as an empirical science. Concept of unitary psychosis Landmark publication: „Die Pathologie und Therapie der psychischen Krankheiten“ (1845) (English translation 1867) Methodical, but not metaphysical materialism. “Mental illness is an illness of the brain“ (“Geisteskrankheiten sind Gehirnkrankheiten“)

5. Brain and Soul • „Even if we knew all the things going on in the brain, all chemical electrical processes in detail – what would it be good for? All oscillations and vibrations, everything electrical and mechanical is still no mental state, no vizualisation. How it can become like that – this riddle will remain unsolved till the end of time, and I believe if an angel would be coming down from heaven and would explain everything to us, our intellect would not be able to comprehend.“ „Die Pathologie und Therapie der psychischen Krankheiten (1845)“

6. Founded and established the “clinical method“ in psychiatric research: looking for common etiology, histopathology, symptomatology and clinincal course. • First to describe: • “Catatonia“ (1874) • “Hebephrenia“ (1871) (together with Ewald Hecker) Karl LudwigKahlbaum (1828 – 1899)

7. Emil Kraepelin (1856–1926) “Natural disease entities“ (“Natürliche Krankheits-Einheiten“), main focus on symptomatology and course Nosological dichotomy (1899) Manic-Depressive Illness Dementia Precox Quantifying (i.e. experimental) research, together with Wilhelm Wundt in Leipzig Textbook: Psychiatrie - Ein Lehrbuch für Studirende und Ärzte.9 editions between 1883 and 1926

8. Alois Alzheimer (1864-1915) His aim: To define “histopathology of endogenous psychoses“ In Munich, co-worker of Emil Kraepelin, who suggested to name “presenile dementia“ after Alzheimer (first description in 1907)

9. Eugen Bleuler (1857-1939) “Group of Scizophrenias“ with different courses and outcomes (1911) Psychodynamic approaches in clinical psychiatry (cooperation with S. Freud and C.G. Jung) Vitalistic theory in his later publications

10. Carl Gustav Jung (1875-1961) Psychoanalyst and for some years close collaborator of Sigmund Freud Developed “analytical psychology„ after his separation from Freud “Collective Unconscious“ “Archetypes“ Dimensional Personality Traits Introversion Extroversion

11. Karl Jaspers (1883-1969) Founder of psychopathology as methodologically reflected science “General Psychopathology“, 1913 (“Allgemeine Psychopathologie“) Differentiation between Explanation and Understanding Later existentialist philosopher.

12. Phenomenological-descriptive psychopathology • …“sorting out, defining, differentiating and describing specific psychic phenomena, which are thereby actualized and are regularly described in specific terms.“ • …“grouping related phenomena on a purely phenomenological basis“ – i.e. by those aspects of phenomena which can be clearly differentiated by the patient‘s self-descriptions, excluding any notion or theory, focusing on ‚the modes in which the experience comes to expression‘ G Stanghellini (2009) The meanings of „psychopathology“. Curr. Opin. Psychiatry, 22(6), 559-564

13. Subjective Symptoms by Jaspers (1913) Subjective symptoms are: emotions, inner processes, sensory manifestations (expression) like fear, grief and cheerfulness. They include all mental experiences that patients describe to us only Indirectly (interpretation). and finally interpreted mental processes from fragments of the two proceding facts, from actions, life style etc. They cannot be perceived by sensory organs but only by Putting ourselves into the others soul, by empathy. Thus we can visualize them internally only by co-experiencing, not by thinking. Translation in: Saß H, 2007, Anthology of German Psychiatric Texts

14. Objective Symptoms by Jaspers (1913) Objective symptoms are all the processes that can be perceived with the senses: reflexes, visible movements, the photographable face, motor agitation, speech utterances, written products, actions, life style etc. The objective symptoms also include all measurable performances such as fitness for work, fitness for exercise, memory performance etc. There are also included: delusions, memory distortions etc., in shortthe rational contents of speech related manifestations which can only be understood by thinking i.e. rationally. Translation in: Saß H, 2007, Anthology of German Psychiatric Texts

15. The polarity of Explanation and Understanding • Because of the junction between mind and brain, the phenomenal world must be viewed from several different perspectives if it is to be fully appreciated • The polarity of explanation and understanding was intruduced into psychiatry by Karl Jaspers. • Philosophical forerunners were: Johann Gustav Droysen, Wilhelm Dilthey, Max Weber • For Jaspers there could be no choice between explanation and understanding, since his patients were both agents and organisms … they had both mind and brain (Slavney, McHugh (1987) Psychiatric Polarities)

16. Scientific analysis of connections (Jaspers 1913) Saß and Hoff in: Möller, Laux, Kapfhammer, 2010 Natural Sciences Humanities Perception of causal connection Explanation (Erklären) Perception of meaning Understanding (Verstehen) (Psychopathology) static understanding (Phenomenological Psychopathology) genetic understanding (Psychopathology of understanding)

17. Kurt Schneider (1887-1967) Descriptive and “non-speculative“ psychopathology, influential for modern operationalized diagnostic systems. Postulated “somatogenesis of endogenous psychoses“. “First and second rank symptoms“ of schizophrenia. Concept of “Psychopathic Personalities (1923)” Two step definition of delusional perception. Main textbook: “Clinical Psychpathology” (1959) last edition (1967)

18. Definition of schizophrenia as a convention in „Clinical Psychopathology“ „When symptoms of first rank undeniably are present and no underlying somatic illness can be found we speak clinically in all modesty of schizophrenia“ K. Schneider, Psychischer Befund und psychiatrische Diagnose, 1938

19. The „four perspectives“ of psychiatry (McHugh and Slavney, 1983)

20. Establishing diagnostic validity in psychiatric diagnosis (Robins & Guze 1970) first: • careful clinical description • laboratory studies • clear delineation of one disorder from another then: • long term follow up for establishing stability and natural history and diagnoses • family studies to establish familial aggregation

21. Principles of „operational“ diagnoses • descriptive approach • explicit inclusion- and exclusion-criteria • algorithms for the criteriology of every single diagnosis • nominalistic (and not realistic) understanding of psychiatric diagoses • etiological neutrality („free of theories“) • comorbidity principle • multiaxial (realized, until now, mainly in the DSM-system) • focus on severity („quantitative approach“)

22. Shortcomings of modern Classification Systems • inflation of diagnostic categories (DSM-III 229; DSM-IV 395) • consensus-politics and scientific imperialism • rarification of psychopathological differentiations and symptomatology • danger of reification of verbalized syndroms based on conventions • abandoning crucial concepts (neurosis, endogene depression, psychosis) • abandoning conceptual history and psychopathological traditions • abandoning psychodynamic and psychostructural factors • disregarding aspects of subjective experience and biography • lack of predictive validity, e.g. therapeutic response and course • horizontalisation instead of verticalisation via comorbidity-principle („Schichtenregel“) • restriction to observable behaviour

23. The Chinese Classification of Mental Disorders (CCMD) creating CCMD, chinese psychiatrists blended worldwide used terms with more traditional terms problem: how to deal with vast size of the country and heterogeneity of language and traditions, e.g. • „qi gong induced mental disorder“ means: a condition believed to arise from inappropiate practice of qi gong • „traveling psychosis“ as term for an acute psychotic episodes with anxiety, impulsivity and potential for self harm in migrant workers • certain personality disorders not seen as pathological (i.e. avoidant and dependent) but as part of Confuzianism Blum J, Jauhar S. (2011) Portrayals of mental illness in different cultures; how it influences training.

24. Other Examples of culturally specific symptoms • Neurasthenia (ICD-10 and CCMD-3) • described in the late 1800, meets in many cases the DSM-criteria for a somatoform, mood or anxiety disorder on Axis I and / or chronic fatigue-like syndroms • Ataque de nervios (Spain) • means literally „an attack of the nerves“ an refers to various manifestations of stress • Amok (South East Asia) • has elements of mental distress found in many cultures Blum J, Jauhar S. (2011) Portrayals of mental illness in different cultures; how it influences training.

25. WPA-Proposal for ICD 11 • Person centered Integrative Diagnostic Model (PID) • Idiographic Personalized Formulation • Jointly made by clinican, patient, and family • Incorporates contextualized perspective and positive aspects of health cf. Mezzich, 2007

26. DSM V – Issues under Discussion • Axes I, II and III are collapsed into one axis containing all psychiatric and general medical diagnoses. • This brings DSM V into greater harmony with the single-axis approach of ICD-10 • Axis IV is currently containing psychosocial and environmental problems • Working group on axis IV is examining codes that are comparable to ICD-10 • Axis V allows clinicians to rate a patients level of functioning • Disability and distress should be better assessed in DSM V, should follow more closely the outlines of the WHO http://www.dsm5.org/ProposedRevisions/Pages/ClassificationIssuesUnderDiscussion.aspx

27. Conclusions • Psychic disorders occur in the „inner perspective“ of the patients. • They suffer from changes due to their self experience, in feelings, emotions, intentions, hopes, expectations, plans, in self-estimation and estimation of other persons, thus they suffer from modifications of subjectivity and interpersonality. • These correlate indeed with brain-processes, but they do have also an autonomy that goes beyond and is nevertheless natural. Maier, Helmchen, Saß, Hirnforschung im 21. Jahrhundert, Nervenarzt 2005

30. Sigmund Freud (1856-1939) Early neurophysiological studies From hypnosis to psychoanalytical treatment (together with Breuer) Psychoanalysis as anthropological framework and as a general perspective to interpret social and historical phenomena and the arts

31. Scientific value of subjective and objective symptomatology Sass and Hoff in: Möller, Laux, Kapfhammer 2010

32. Philippe Pinel 20/04/1745 in Saint-André † 25/10/1826 in Paris • Main Work: «Traité médico-philosophique sur l’aliénation mentale, ou la manie», published in 1801 (second edition in 1809). • Five nosological categories: • - melancholia • - mania without delirium • - mania with delirium • - dementia • - idiotism • Manie sans délire (Mania without delirium) •  in some disorders emotions are primarily involved •  personality disorder as a nosological entity •  mania without delirium exhibits emotional instability and social drift • is caused by inadequate education or a perverse unrestrained constitution

33. Jean Etienne Dominique Esquirol *03/02/1772 in Toulouse † 12/12/1840 in Paris Favourite student of Philippe Pinel, he saw the question of madness as institutional Became the main architect of the national law of 1838 that instituted departmental asylums for all needy French mental patients and that is still in force today Introduced „Monomania“ as a distinct daignostic categorie, e.g.: • Pyromania • Kleptomania • Erotomania • Phonomania (homicidal monomania) Main work: << Des Maladies Mentales considérées sous les Rapports médical, hygiénique et médico-légal >> published in 1838 in Paris

34. Bénédict Augustin Morel • 22 /11 /1809 Vienna † 30/03/1873 • First to use the term « démence précoce », which refers to what is now known as schizophrenia. • Launched the notion of degeneration on its fateful trajectory: • Degenerative alterations are pathological deviations from normality • Mental diseases are mostly hereditary • the degeneration is both quantitative and qualitative • nosological classification according to the degree of degeneration • the less disordered group presents eccentricity, unstable emotions, untrustworthiness and sparing of cognitive functions = folie morale • Main Work: «Traité des dégénérescences physiques, intellectuelles, et morales de l’espèce humaine », Paris 1860. Henning Sass, AEP 2005/2006