Psychiatric Movements

From Sects to Science

Leston Havens

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780765808400
  9781138530997
• eBook ISBN:
  9781351307826
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

In the early 1970s, the preeminence of psychoanalysis in the treatment of mental illness gave way to a number of other approaches. Yet, rather than practicing in cooperation, the different schools--existentialism, psychoanalysis, interpersonalism, behaviorism--each taught its own methods, convinced it was the true psychiatry. As a result, all too frequently, varieties of psychiatry have come and gone, wallowing in a battle of sects rather than progressing toward knowledge.

In Psychiatric Movements, Leston Havens posits that psychiatry must adopt a pluralistic stance, for only an inclusive psychiatry can bridge the traditional scientific quest of medicine with a humanistic interest in whole lives, inner states, and relationships with others. If for no other reason, from an ethical standpoint, the patient should get the treatment he needs, not the one treatment the doctor dispenses. This edition includes a new introduction explaining changes in the field during the last thirty years.

I
THE SCHOOLS

1
OBJECTIVE-DESCRIPTIVE PSYCHIATRY [1]

EMIL KRAEPELIN*

EMIL KRAEPELIN fell upon a psychiatric world exhausted with arranging and reordering symptoms along psychological lines largely without medical significance. He sought in psychological phenomena the key to disease states. Although an experimental psychologist and student of Wundt [2] and a lifelong investigator of what is today called psychopharmacology, he had little interest in psychological facts for themselves; he did not, for example, follow psychological facts to psychological processes, as Janet was to do. Nor was he a serious student of brain processes for themselves. His overriding interest was disease and disease processes in the pathological tradition of Virchow; it was to the discovery and elucidation of diseases that the greatest part of his work was directed. He brought to the task enormous energy, a long life, and the gift of marshaling large numbers of facts about a few, powerful ideas.

The most important of these was the disease concept itself. Incidence and distribution, anatomy, pathogenesis, etiology, symptoms and signs, differential diagnosis, course and outcome, prognosis, treatment, and prevention comprise its parts; complete knowledge of a disease implies knowledge of all these. The goal of medicine has been to place any bodily or mental disturbance in one such sequence, and this was Kraepelin’s goal for psychiatry. His pursuit of it, more than any other one thing, explains his enduring influence.

The Psychiatrie, first a Compendium, then a Short Textbook, and finally, in the Fifth Edition, A Textbook, carried the bulk of his observations and ideas [3]. It began modestly with distinctions along traditional clinical lines and with relatively little attention to organic states. Over the next three editions the material increased; more toxic and infectious states were included and gradually pushed to the front of the book. Several conditions, including “general neuroses,” previously handled separately, were brought together, and there were tentative efforts at classification by cause. The climax of these developments, with their emphasis on clinical concepts, the formation of new groupings, and efforts toward a causal structure, was the Fifth Edition, in 1896. The overwhelming tradition of psychiatric diagnosis by the symptoms of first prominence, whether arrived at clinically or from psychological or neurological presuppositions, was abandoned, and known organic states were used as the models for disease types. The new classification was to be by etiology, that is, by knowledge of cause. Diseases of known cause were most truly diseases; it was to be hoped that to this standard other conditions would someday repair. In the meantime, they were given provisional etiologies. Thus cretinism—thyroid idiocy—led off metabolic diseases. To this were added dementia praecox, hypothesized to be metabolic, and general paresis, an infectious process which Kraepelin then thought was metabolic. The final grouping, of manic-depressive psychosis, paranoia, neurotic conditions, and a few others, was more or less thrown together in desperation on a constitutional basis, as had so often been done in the past; these were diseases of inherited nature, the old French degeneracy concept.

In the last three editions of his text, Kraepelin placed dementia praecox and manic-depressive psychosis in separate categories of their own, without specification of cause. They were no longer one among metabolic or constitutional disorders, although these remained his hypotheses of first choice. Diseases of known cause, for example, infectious or toxic psychoses, still led the list. The largest categories were organic states, endogenous psychoses, and deviant personalities. In broad outline this remains the organization of the official American nosology and of most classificatory efforts since. (The principal change has been the insertion of a neurotic category between the psychoses and what are today called personality or character disorders; we will see how the neurotic category was developed by Janet.)

Where etiology was obscure, Kraepelin arranged the syndromes, largely handed on from nineteenth-century predecessors, by their signs, course, and outcome—other parts of the disease concept. His assumption of underlying physical processes encouraged the study of signs and symptoms over time, for a disease process implied longitudinal effects. Just before the writing of the Fifth Edition, Ziehen, Kraepelin’s near-contemporary and rival, had reached the university pinnacle of German psychiatry and brought psychological formalism to a sterile perfection. The clinical material was arranged by academic categories: Were the phenomena primarily intellectual, volitional, or emotional; was the location of distortions outside the patient, in the mind, or in the body? As a medical man concerned with prognosis, Kraepelin escaped this symptom-splitting petty warfare of his time by collecting clinical signs under broad distinctions of outcome, distinctions which were useful clinically. The clinician, if not given something to do, was at least given something to expect. This was the second guiding idea. His location at Heidelberg made its application possible. The numbers of patients were manageable, and the district was accessible and well organized; he was able to follow patients for years after discharge. Every scientific revolution depends upon a fresh idea and method; Kraepelin’s revolution depended on the disease concept and the method of case study his clinical situation made possible. Almost in the same year the Freudian revolution was also beginning, with its conviction that psychological events, however obscure, were understandable and with the methods of case study Freud’s clinical situation made possible. Freud was to lead psychiatric attention to the earliest and most remote crannies of childhood experience; Kraepelin was to lead it to later courses and eventual outcome, at the other end of time. Both were also to produce genetic psychiatries, one a theory of psychological development, the other on the basis of physical genetics.

Kraepelin traveled clinically with an extraordinary small baggage of psychological ideas. Perhaps the most important is the concept of volition. In the first case that follows he describes an impediment to will; in the second case, a lost or indifferent will. It is important to have in mind that such phenomena as lack of responsiveness or delayed responsiveness need not call up this idea of will. Energy or life force or libido will do for other investigators. As a student of Wundt, however, Kraepelin would not reduce mental life to a hypothetical energy; it must be reduced to some product of introspection. Will is something we feel in ourselves; whatever empirical roots it has are introspective. You feel “willfull” or “willing”; also, the term is used when some obstruction to action is experienced. Similarly, we suspect Wundt’s influence on Kraepelin’s concern with the “disunities” of much pathological mental life; the concept of dissociation is a natural outgrowth of the dominant psychology of the nineteenth century, associationism. His attention to the phenomena of “splitting” is not great, however, and may owe as much to Bleuler as to Wundt. Nowhere in Karepelin’s clinical work is his psychological background very obvious. He does not reduce clinical material to a few elements, for example, sensations, and build it up again as in the mental chemistry of Wundt’s Leipzig school. Medical interests predominate. There is the same considerable gulf between laboratory and clinical ideas, as well as methods, that persists in psychiatry to this day.

Manic-Depressive Insanity

The first of his cases to be discussed is taken from the Lectures on Clinical Psychiatry, a collection of demonstrations before students. Each lecture contains a series of case examples, the general points interpolated between observations. A “clinical picture” is first presented, and then dissected, in the search for crucial features. The material is all pointed toward diagnosis and the closely related prognosis; the suspense lies in his gradual working forward through the clinical details to the apparently decisive signs. These are “signs” to a particular disease. The disease in turn suggests a prognosis which is tested against the clinical facts. With the arrival at diagnosis and prognosis the interest of each case is largely dissipated. We are then brought up to the present.

He takes us immediately to the psychological examination: what the physician observes standing before the patient. Even the patient’s complaints (symptoms) are little heeded. First attention is to “objective” signs. Similarly, history is incidental and almost all history of the course of the signs. It is to the obvious manifestations of disease—to the disease rather than the host—that our concern is directed. His was an unsurpassed interest in what patients presented to an intensely curious, persistent, and objective academic physician in a hospital setting, with no special concern for developing a therapeutic or confidential relationship. Throughout, the content of the patient’s communications and behaviors is of less interest than their form, the contour, pace, and unity of the stream of life.

The patient is brought into the lecture hall and Kraepelin begins his description.

The patient you see before you today is a merchant, 43 years old, who has been in our hospital almost uninterruptedly for about five years. He is strongly built, but badly nourished, and has a pale complexion, and an invalid expression of face. He comes in with short, wearied steps, sits down slowly, and remains sitting in a rather bent position, staring in front of him almost without moving. When questioned, he turns his head a little, and, after a certain pause, answers softly, and in monosyllables, but to the point. We get the impression that speaking gives him a great deal of trouble, his lips moving for a little while before the sound comes out. The patient is clear about time and place, knows the doctors, and says that he has been ill for more than five years, but cannot give any further explanation of this than that his spirits are affected. He says he has no apprehension. He gives short and perfectly relevant answers to questions about his circumstances and past life. He does exercises in arithmetic slowly but correctly, even when they are fairly hard. He writes his name on the blackboard, when asked to do so, with firm though hesitating strokes, after having got up awkwardly. No delusions, particularly ideas of sin, can be made out, the patient only declaring that he is in low spirits, without knowing of any cause for it, except that his illness has lasted so long, and worries him. He hopes, however, to get well again [4, p. 11].

We have to do here, he asserts, with emotional depression or “low spirits.” Straightaway he sets about the differential diagnosis. These are not the low spirits of the melancholy patients he had discussed in an earlier lecture. The present patient is not apprehensive, does not gesticulate, lament, or even complain, as they did. Indeed, it is difficult to draw any response from him, whether the subject be of interest or indifference, or the questioning emphatic or gentle. The dominant impression he conveys is of being under some constraint. This is a broad inhibition and suggests to Kraepelin “some general obstacle to utterance of speech,” in fact to “all action of will.” If it were fear alone that constrained him, why should he be silent on matters of indifference? Comprehension of even complex trains of thought is intact, and the patient seems to try to comply with requests, but something retards him. Between the will and action there is an impediment. This, Kraepelin maintains, is by far the most prominent feature of the case.

He has found, in this constraint and in the absence of “apprehensive restlessness,” his keys to diagnosis. We have already reached the climax of the presentation. The diagnosis is maniacal-depressive insanity [5], “an entirely different disease” from melancholia. The patient is in a depressed stage of “circular stupor,” the older French term for one type of the same condition. And diagnosis implies prognosis.

This disease generally runs its course in a series of isolated attacks, which are not uniform, but present either states of depression of the kind described or characteristic states of excitement. . . . The isolated attacks are generally separated by longer or shorter intervals of freedom [4, p. 13].

The conclusion is promptly tested by reference to the patient’s history. He first became depressed when he was 23 (that age or a little earlier would be typical) and entered a state of excitement the next year. Again, at age 26, 31, and 36 years, there were depressed and excited episodes. From these we are given the first bits of history that are not solely the history of the patient’s signs. At age 26 and 31 his depression followed disappointments in love. In fact, “his relations held his depression to be the result of the melancholy experiences he had been through.” Kraepelin places their view in sharp contrast to his own. Both disappointments followed periods of excitement, he states, during the first of which the patient had married “a person very much beneath him” and in the second fallen into the hands of an “adventuress.” It is the illness which precipitates the apparently stressful experiences. For the first time Kraepelin has made assumptions of fact; both the predisposing excitements were “probable”; neither could be documented.

This is a point at which to pause, for in Kraepelin’s handling of “psychic causes,” what are today called traumata or stresses, we see his viewpoint stated most baldly. He was to write at a later time:

Profound changes have marked the development of our theory of the physical causes and bases of insanity. Though our attitude toward the influence of psychic forces on the development of mental disorders has changed but slightly, our assessment of their importance has fluctuated. While the old psychic school assigned them a dominant role, the somatic school tended to consider them unimportant. Popular opinion steadfastly championed the importance of psychic influences in the etiology of insanity, and even Griesinger held that they were generally more decisive than physical injuries. Today we have apparently arrived at a clearcut definition. We know that frequently so-called psychic causes—unhappy love, failure in business, overwork—are the product rather than the cause of the disease, that they are but the outward manifestations of a preexisting condition, and finally that their effects depend for the most part on the subject’s anlage [6].

“The patient’s father, as well as his two brothers, were drunkards, while his sister was ill in the same way as himself.” Here is the family history. There are as yet no intensive investigations of the home, school, jobs, or the personalities of parents. Nor are we asked to pause long over the melancholy facts he gives us. Kraepelin is the farthest thing from being a sentimental physician. Even in his less formal, less academic writings, from which his energetic activities in behalf of the patients become evident, there is no stepping down from his objective position. The transmission of parental sickness is assumed to be by physical inheritance. The tough-minded approach to inheritance would remain for several decades nonpsychological.

From the brief family history we are taken to the history of medical illnesses and then to the patient’s state on admission to the hospital. At first he had suffered from diabetes insipidus. “A doctor advised him, presumably on this account, to take a little wine, as too much water was not good for him. The patient followed this advice, and about five and one-half years ago suddenly fell ill of delirium tremens, immediately followed by a state of excitement, gradually and continually growing worse, which only disappeared slowly after two years.” Thus the episode before the present one was said to be ushered in by delirium tremens, the trembling hallucinatory delirium of heavy drinkers. (It was named and given one of its first descriptions by Thomas Sutton in 1813, who practiced on a section of the English coast through which much smuggled wine and liquor were passed and sampled [7]). We are not told whether this diagnosis was Kraepelin’s or a predecessor’s: In some cases mania and the “d.t.’s” may be difficult to distinguish, especially when the acute illness passes into a chronic mania. Only a few weeks separated the end of the manic period from the sudden onset of an “extraordinarily severe impediment of volition,” which led to the present hospitalization.

The patient remained motionless in bed, would not eat, was wet and dirty in his habits, could hardly speak, and expressed apprehensive ideas. ... In spite of the most careful nursing, his condition has improved only very slowly and immaterially in the course of the last three years. Yet we may expect that this attack also will end in recovery, like those which have preceded it, if only the patient can live through so severe a disturbance.

The follow-up is given in a footnote. Six months later the patient died, of acute tuberculosis, the common scourge of mental hospitals until recent times. There was no opportunity to test Kraepelin’s further prediction that the patient would again fall ill of depression and excitement.

The case report closes with a discussion of the patient’s “fluctuatio...

Table of contents

• Cover
• Half title
• Title Page
• Copyright Page
• Dedication
• Contents
• Transaction Introduction
• Introduction
• Part I. The Schools
• Part II. Main Currents of Psychiatric Development
• Part III. Toward a Pluralistic Psychiatry
• Notes
• INDEX