Psychopathology

   (as a movement)

   Because the term "psychpathology" springs so readily to the lips, it is difficult to ascertain the priority for its first use. It is mentioned in passing in some of the psychiatric writing of the early nineteenth century. The Viennese psychiatrist Ernst von Feuchtersleben (1806–1849), in commenting on the somaticist views of his colleague at the University of Würzburg, Johann Baptist Friedreich (1796–1862), said about the supposed physical causation of mental illness: "Psychopathology has not yet been able to cast enough light on these critical processes" (Textbook of Medical Psychology [Lehrbuch der ärztlichen Seelenkunde], 1845, p. 69). The importance of psychopathology lies in the belief of its proponents that a disease is constructed from symptoms (the proponents of nosology, on the other hand, claim that there is a prior disease, and the disease determines the symptoms). After the work of Karl Jaspers, it would be the abnormal forms of symptoms, rather than the abnormal symptoms themselves (for example that hallucinations are taking place rather than the content of the hallucinations), that are relevant to the disease.

   Guislain introduced the term "phenomenology" into psychiatry (1852). Within psychiatry, phenomenology came to have a meaning equivalent to psychopathology. The German philosopher Georg Wilhelm Friedrich Hegel (1770–1831) first gave the term "phenomenology" its currency in the Phenomenology of Spirit (Phaenomenologie des Geistes) in 1807. Thus, the word was in the air when Belgian psychiatrist Joseph Guislain (1797–1860), offering the medical students at Ghent University detailed guidance on how to investigate a patient, coached them on how to pose questions: "When did you get married? When are you getting out of here?" Guislain told the students, "if you know how to formulate your questions along these lines, you will know how to address your patients in order to determine the phenomenology of the illness. . . . You will have taken a step ahead in the practical science of mental illness" (p. 45). Guislain published his lectures under the title, Oral Lectures on the Phrenopathies, Or a Practical and Theoretical Treatise on the Mental Illnesses (Leçons orales sur les phrénopathies, ou traité théorique et pratique des maladies mentales, 1852).

   Concept of "general pathology" applied to the psyche (1859). Adolph Wachsmuth (1827–1865), having trained in medicine at Göttingen University, decided in the mid-1850s to go over to psychiatry. After a study trip to some of the larger asylums, he started to lecture on the subject in Göttingen (while remaining an assistant in the medical clinic), and in 1859 wrote General Mental Pathology (Allgemeine Pathologie der Seele), saying that psychiatry was now open to the same kind of progress that internal medicine had been making: "Our understanding of somatic physiology and pathology now permits no doubt that a scientific physiology and pathology of mind [Seele] are possible in exactly the same manner" (pp. 4–5). He broke down psychic illnesses into those affecting mood (Gemüt), hallucinatory illnesses (Sinnestäuschungen), thought disorder (Wahnsinn), and the "conditions of psychic weakness" (psychische Schwächezustände).

   The launching manifesto of the psychopathology movement: Kahlbaum’s Catatonia (1874). In his book on Catatonia (die Katatonie), Karl Kahlbaum said at the outset that all previous psychiatry textbooks, despite their stated intentions of moving beyond such fixed categories as "mania" and "melancholia," had nonetheless arrayed their case material upon this traditional disease scaffolding. For the sake of the "clinical method," it was time to "evaluate as many as possible of the individual patient’s symptoms for the sake of the correct diagnosis and to ascertain the prognosis." Then, one might see which symptoms could empirically be grouped into psychiatric diseases, with the understanding that the symptom picture down the road might be very different from the picture at the beginning. Furthermore, previous efforts to link clinical pictures with brain lesions had largely failed, and now it was time to concentrate on careful clinical observation rather than on postmortem microscopy. "Only the comprehensive and intensive application of the clinical method can serve here and advance the science of psychiatry to ever deeper insights into psychopathic processes" (p. viii). Kahlbaum rejected the previous psychology of the Romantic psychiatrists (see German "Romantic" Psychiatry) as filled with useless moralizing. "But there exists a whole world of individual psychological phenomena that currently . . . remain terra incognita and that may only be discovered through meticulous investigation" (p. xi). Kahlbaum concluded: "The penetrating observation and frequent analysis of psychological phenomena of mentally-ill individuals—as well as the launching of a disease-specific psychological symptomatology—are the next urgent agenda of clinical psychopathology" (pp. xi–xii). Many younger psychiatrists now responded to this clarion call with the same enthusiasm that had once drawn earlier generations of physicians to identify the basic organic diseases of the human body using the same clinical method.

   A psychologist lays the basis of psychopathology in France: Ribot (1875 onwards). Théodule Armand Ribot (1839–1916), whom Pierre Pichot calls the "father of French scientific psychology," was keen to break with past metaphysical traditions in psychology about whether the mind had knowledge of itself and put the discipline on a scientific basis in order to classify mental phenomena, normal and pathological. (He recommended that psychologists should begin as psychiatrists.) In 1875, he described in Contemporary English Psychology (La psychologie anglaise contemporaine) the recent empirical contributions of the English. His own principal contributions to psychopathology were Disorders of Memory (Maladies de la mémoire, 1881), Disorders of Will (Maladies de la volonté, 1883), and Disorders of Personality (Maladies de la Personnalité, 1885). In 1885, he began teaching a course in experimental psychology at the University of Paris and in 1888 was appointed professor of experimental and comparative psychology at the Collège de France.

   The term "general psychopathology" becomes current (1878). In the same year that Hermann Emminghaus (1845–1904) became the professor of psychiatry in Dorpat (Tartu), 1878, he published his psychiatry textbook, General Psychopathology: An Introduction to the Study of Mental Illness (Allgemeine Psychopathologie: Zur Einführung in das Studium der Geistesstörungen). Yet, the work was more a general psychiatry textbook than a discussion of symptoms as such.

   Kraepelin: psychopathology and psychiatric diseases (1909). The eighth edition of Emil Kraepelin’s classic textbook represents the most elaborate classification in his work of diseases and symptoms. In the first volume of this edition, published in 1909, Kraepelin turned his hand—more so than in previous editions—to the fine description and differentiation of psychiatric symptoms, to objective psychopathology in other words, although Kraepelin did not use the term "psychopathology" and preferred to speak of "the manifestations of insanity" (die Erscheinungen des Irreseins). He divided symptoms into "disorders of perception," "disorders of mental activity," "disorders of emotional life," and "disorders of will and activity," for each domain describing how normal psychological function is distorted in illness. Indeed, Kraepelin made ample use of the kinds of psychometrics he had learned when studying with Wilhelm Wundt (1832–1920) in Leipzig. In the following volumes of this edition, published in 1910 and after, Kraepelin went on to a nosology of disease.

   Reconciling psychopathology and psychoanalysis: an English attempt (1912). On the face of it, Sigmund Freud’s psychoanalysis was more concerned with limning unconscious processes than with the fine description of symptoms as such. Yet in 1912, Bernard Hart (1879–1966), an English psychiatrist then at Long Grove Asylum in Epsom (who advanced to a consulting room on London’s Harley Street), defined psychopathology in his little book, The Psychology of Insanity, as "the science which attempts to explain the problems of mental disorder by psychological principles" and suggested that psychoanalysis qualified under that rubric because "Freud slowly and tentatively built up his theoretical conceptions in accordance with the facts which were continuously elicited by investigation of his patients" (p. xxviii). Yet, most psychopathologists held psychoanalysis at arm’s distance, and vice versa.

   Jaspers’s textbook General Psychopathology (Allgemeine Psychopathologie) (1913) as the most important milestone in the history of the psychopathology movement. Karl Jaspers was influenced by the German philosopher Georg W. F. Hegel’s (1770–1831) concept of "phenomenology," by which Hegel meant the sum total of the productions of the mind. More specifically, Edmund Husserl’s (1859–1938) "descriptive phenomenology," articulated in Husserl’s 1890 book, Logical Investigations (Logische Untersuchungen), shaped Jaspers’s thinking (see Husserl, I, p. 212). Jaspers later wrote in his autobiography (1977) of Husserl’s impact: "Describing what patients innerly experienced as phenomena of consciousness turned out to be possible, and productive. Not only hallucinations, but delusions as well, the ways in which patients experienced their consciousness of themselves [Ichbewusstsein] and their feelings, could be described so clearly in the patients’ self-reports as to make sure that the phenomena would be recognizable again in other cases. Phenomenology became a research method" (p. 23). Phenomenology for Jaspers and the Heidelberg school did not therefore mean the objective classification and description of symptoms, as others often understood the term, but the subjective phenomena of pathological mental experiences.

   In his 1913 book, Jaspers was hostile to Kraepelin’s big disease concepts (the task of nosology) and differentiated the various areas of psychopathology: phenomenology, objective performance, the psychology of expression, and so forth. He recognized the distinction between meaningful connections (verstehen) and causal explanation (begreifen); yet, psychopathology cannot be understood as the science of empathic understanding alone: some additional dimension of grasping the issues was involved. In particular, Jaspers distinguished between the form of psychosis and its content, saying the former was the more important. "The mode in which the experience appears is the form (whether as a perception, an image, or a thought.) Thus hypochondriacal ideas, for example, are contents of [such forms as] calling voices, compulsive ideas, or . . . delusions. The form of psychosis may be contrasted with its particular contents: for example, the periodic episodes of depression represented the form of the illness but its various contents may be suicide, alcoholism . . . and so forth" (p. 19). Jaspers-style psychopathology would thus lose interest in what the patients were actually saying, or hallucinating, in favor of studying the form of the psychosis—yet with the nuance that Jaspers and his school were highly interested in empathically placing themselves in the patients’ shoes for the sake of determining whether the patients’ psychology before the illness had been roughly congruent with the content of the illness—or whether the symptoms had come out of the blue. (See Paranoia: Jaspers’s "pathological jealousy" [1910].)

   After Jaspers, phenomenology came to be used in two senses: (1) as by Jaspers, meaning the inner life of the patient, (2) as descriptions of clinical phenomena. Determing which phenomena are commonly held makes it possible to close in on causes of psychiatric diseases.

   The first monograph of the Heidelberg phenomenology school (1924): Willi Mayer-Gross on Self-Descriptions of Confusion: Oneiroid Experiences (Selbstschilderungen der Verwirrtheit: die oneiroide Erlebnisform). He attempted to let the patients describe events occurring in their conscious processes. (See also HEIDELBERG.)

   Ludwig Binswanger’s study of "flight of ideas" (Ideenflucht), the beginning of existential psychiatry (1933). Binswanger (1881–1966), director of his family’s private nervous clinic "Bellevue" in Kreuzlingen, Switzerland, had been interested in phenomenology since 1917, when he published an article in a Swiss medical weekly on that subject. In 1933, he took a careful look at mania from the manic patient’s viewpoint, excerpting long passages of manic speech. The book is generally considered the beginning of a version of phenomenology, or of existential analysis, that Binswanger called in 1942 Daseinsanalyse (pronounced DA-zines-anah-loo-zuh), after the German philosopher Martin Heidegger’s (1889–1976) concept of "Dasein," or being-in-the-world.

   Freyhan’s concept of "target symptoms" (1956). Fritz A. Freyhan (1912–1982), a young German-Jewish medical graduate who qualified in Berlin in 1937, then fled the Nazis and trained in psychiatry at the Delaware State Hospital in Farnhurst, remained imbued with German concepts of psychopathologic thinking. At Delaware, he presided over early trials of some of the new antidepressants and antipsychotics, realizing that for highly heterogeneous groups of "depressed" and "psychotic" patients the drugs were rather ineffective. In a paper given at a National Institute of Mental Health conference in 1956 that launched the Psychopharmacology Service Center, he spoke of his experiences with chlorpromazine and reserpine, arguing that research in psychopathology should be shifted from a Kraepelinian interest in outcome to responsiveness to drugs. "What we have to decide first and foremost is the effect of a pharmacological agent on behavior. This we can study clinically and measure in terms of the modifiability of specific psychopathological symptoms. To do so, we have to record all clinical observations in ‘double-bookkeeping’ fashion, listing target symptoms as well as clinical diagnoses" (in Cole, Psychopharmacology, p. 375). Freyhan expanded his views in an article in Neuropsychopharmacology in 1961: "To think in terms of ‘anti-schizophrenic’ or even ‘anti-psychotic’ action impresses me as reckless. There is certainly no evidence of correlations between response to drugs and assumed entities labeled schizophrenia or psychosis" (p. 193). Psychopathologic thinking, he said, demanded that these patients be sorted into treatment-responsive syndromes on the basis of "target symptoms"; the syndromes would then be more responsive to the new drugs: "melancholic syndrome" in depression, consisting of the target symptoms of psychomotor retardation, apathy, sadness, somatic disturbances, and insomnia, was more responsive to the new antidepressant drugs than an "ideational" syndrome consisting of hypochondriasis, phobias, guilt, and delusions.

   Phenomenology: current understanding in U.S. psychiatry (1998). In the second edition of their book Perspectives of Psychiatry (1998), Paul R. McHugh (1931–) and Phillip R. Slavney (1940–), both professors of psychiatry at Johns Hopkins University in Baltimore, explain that phenomenology represents the patient’s answers to such queries as "What is your mood today?" "Are your thoughts clear?" Acknowledging Karl Jaspers’s views of phenomenology as, in their words, "the results of eliciting and describing the personal mental experiences of patients," the authors continue, "We can learn how another person is thinking and feeling by talking to that person." Thus, the mental status examination is merely "a systematic way of talking to patients" (pp. 9–10). The phenomenological aspect of such an interview is not the content of the patient’s answers but how the patient processes his thoughts.