Posts Tagged ‘ Kraepelin ’

New issue: L’Évolution Psychiatrique

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The new issue of L’Évolution Psychiatrique includes multiple articles related to the history of psychiatry that could be of interest to H-Madness readers:

Jean Garrabé, La place de l’histoire dans l’enseignement de la clinique mentale

Jacques Hochmann, Réflexions sur les rapports entre l’histoire et la psychiatri

Thierry Haustgen, Les psychiatres historiens

Clément Fromentin, Pourquoi faire l’histoire de la psychiatrie ? Le cas de l’Évolution psychiatrique (1925–1985)

Hervé Guillemain, Le retour aux sources. Points de vue sur l’histoire sociale de la psychiatrie et de la maladie mentale

Thomas Lepoutre, La psychiatrie néo-kraepelinienne à l’épreuve de l’histoire. Nouvelles considérations sur la nosologie kraepelinienne

Loig Le Sonn, Le test d’intelligence Binet-Simon dans les asiles (1898–1908). L’invention d’une nouvelle pratique d’interrogatoire

Laurence Guignard, Crime et Psychiatrie. Antoine Léger, le lycanthrope : une étape dans la généalogie des perversions sexuelles (1824–1903)

Emmanuel Delille, Crise d’originalité juvénile ou psychose débutante ? Les représentations de l’adolescence « à risque » après-guerre en France et en Allemagne

Benoît Majerus, Fragilités guerrières – Les fous parisiens dans la Grande Guerre

Pierre Chenivesse and Manuella De Luca, Le théâtre du Grand Guignol et l’aliénisme

 

 

 

Book Review – Richard Noll, American Madness: The Rise and Fall of Dementia Praecox (Harvard 2011)

By Jesse Ballenger

As indicated by the controversies swirling around the proposed revisions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders due to be published next year, psychiatry is probably more concerned with the categorization of diseases under its purview than any other medical specialty. Yet solid knowledge of the causes and precise pathological mechanisms that might define mental illness remains more elusive than with any other sort of human affliction. In this richly detailed book, Richard Noll explores the historical predicament of psychiatry through the efforts of America’s early twentieth century psychiatric elite to integrate their field with the main currents of an emergent scientific medicine by creating a scientific classification of mental illness.

In the second half of the nineteenth century, culminating in the emergence of germ theory and the microbiological turn, medicine as a whole increasingly oriented itself around a concept of disease specificity. Disease was no longer thought of as a general process manifesting itself uniquely in each individual, but as a specific entity with distinctive signs, symptoms, cellular pathology, and a typical course and outcome. Medicine increasingly emphasized the rational investigation of biological mechanisms or physiological abnormalities in the laboratory or on the autopsy table.

By contrast, American alienism – the term used through the early twentieth century to describe the branch of medicine devoted to disorders of the mind – seemed left behind to grapple with the protean, inscrutable and seemingly intractable nature of insanity in increasingly overcrowded, understaffed and physically decaying asylums and state hospitals. Noll argues that by adopting and adapting the European concepts of dementia praecox to the American context, leading American psychiatrists transformed their field into a branch of modern medicine.

Historians of American psychiatry, pulled toward the historiographical black hole of conflicts between partisans of Freudian psychoanalysis and the bio-pharmacological turn of the past few decades, have paid far too little attention to the influence of German psychiatrist Emil Kraepelin in the first four decades of the twentieth century. Noll’s book goes a long way toward remedying that. He devotes an excellent chapter to describing how Kraepelin revolutionized psychiatry by replacing a static view of insanity as a single entity that could express itself in a number of characteristic forms in particular patients – melancholia, mania and finally terminal dementia – with the idea that mental disorders could be sorted into distinct categories based on a rigorous, quantitative study of how clinical symptoms manifested over time. This work established two main categories – manic-depressive inanity and dementia praecox – distinguished primarily on the basis of the deteriorating course and bleak prognosis of the latter. Manic depressives improved between acute episodes, and sometimes recovered completely. Patients with dementia praecox very seldom did.

Most of the remainder of the book explores how American psychiatrists like Adolph Meyer introduced and adapted Kraepelin’s methods and concepts into American psychiatry. From a series of increasingly influential positions – first as head of pathology at the Worcester Hospital in Massachusetts, then director of the New York Pathological Institute, and finally professor of psychiatry and head of the Phipps Psychiatric Clinic at Johns Hopkins, Meyer trained nearly every psychiatrist who rose to a senior administrative position in American asylums in the first half of the twentieth century.

Meyer learned Kraepelin’s methods and nosological system during a six week visit to his clinic in Heidelberg in 1896 just as the revolutionary fifth edition of Kraepelin’s textbook was published, and returned to the United States a confirmed Kraepelinian. He was enthusiastic about Kraepelin’s methods and concepts not only because they provided a scientific basis for psychiatric research, but because they provided a rationale for asylum doctors to take a more active interest in the patients who crowded their wards. Thanks to the influence of Meyer and a few other elite psychiatrists like August Hoch and E.E. Southard, dementia praecox, which did not exist in American psychiatry in 1895, became in the space of a decade the mental disorder most widely written about in American medical journals and most frequently diagnosed in American psychiatric institutions.

Although Noll’s book mostly focuses on the thought-world of elite psychiatrists, he recognizes that most American alienists practiced in a much different world in which limitations in their training, and the lack of resources and clinical demands of the institutions they worked in, made it very difficult for them to follow the psychiatric literature published in English, let alone read Kraepelin’s original work in German. Noll argues that in their hands, Kraepelin’s classification scheme became something of a diagnostic blunt instrument – with mixed results for patients. To the good, Kraepelin’s emphasis on clinical observation restored interest in patients and their symptoms, and Noll thinks it likely that some patients benefitted simply from the increased attention. Moreover, since the major categories of mental disorder were distinguished by prognosis, giving patients a diagnosis allowed alienists to say something about the future to patients and their families, and a diagnosis of manic-depressive insanity gave grounds for some hope of recovery. To the bad, Noll argues that the rising prominence of dementia praecox facilitated continued neglect. The dire prognosis of dementia praecox, which Noll estimates to have been the diagnosis for between one quarter to one half of institutionalized patients during this period, justified non-treatment or mistreatment.

Noll shows that American psychiatrists began to stretch the concept of dementia praecox almost from the moment it entered American psychiatry in 1896. In part, this reflected the relative isolation of workaday asylum alienists described above. But even elite American psychiatrists were dissatisfied with several ambiguous aspects of Kraepelin’s concept, and by 1904 Noll finds prominent neurologists and psychiatrists complaining that the term was so malleable that it could be applied to any young person with a serious mental disturbance. The imprecision with which psychiatrists used the term dementia praecox became an embarrassment to the profession when it was mocked in the sensational murder trial of Henry Kendall Thaw in 1907. As widely reported in newspapers around the world, numerous prominent alienists testified as expert witnesses for both sides in the trial and offered conflicting diagnoses, and the strange new term dementia praecox that many had used was lampooned in the closing statement of the defense attorney as “dementia Americana.”

In addition to the slipperiness of diagnosing dementia praecox, many leading psychiatrists, including Meyer, were frustrated that it implied nothing about the cause of mental illness. Kraepelin had rejected the “brain psychiatry” that developed in Germany in the 1860s and ‘70s because he thought its focus on finding the cause of mental illness in specific brain pathology was reductionist and premature. He thought that the first priority of a scientific psychiatry had to be using rigorous clinical observation to establish disease concepts that corresponded to natural disease entities. Kraepelin assumed that dementia praecox had a biological basis, probably in systemic autointoxication, but thought psychiatry should resist etiological speculation in favor of classification based on clinical observation.

Leading American psychiatrists could not easily abide such restraint. In the first two decades of the twentieth century, dozens of articles appeared in the psychiatric literature trying to establish a specific neuropathology for dementia praecox, or compiling laboratory data of various bodily functions of praecox patients to try and identify evidence of autointoxication or “endocrinopathy.”  Despite initial enthusiasm, none of these studies shed much light on the causes of madness, but Noll argues they did serve to demonstrate that psychiatry shared the sort of methods and concerns that characterized modern medicine as a whole. They also encouraged some unfortunate adventures in therapeutics. Convinced that the cause of dementia praecox was autointoxication, Bayard Taylor Holmes, a Chicago surgeon whose son was stricken with the disorder, developed a surgical treatment that involved removing part of the appendix and maintaining an open appendicostomy to allow for frequent direct irrigation of the bowel to remove the infectious material that he believed was the cause of mental derangement. Holmes’s first patient – his son – died of complications following the treatment, but he claimed modest success in the more than twenty patients he and his associates operated on. Others, most notably Henry Cotton at the Trenton State Hospital, developed similar surgical treatments that generated initial excitement, but ultimately failed to produce meaningful results. Hundreds of patients suffered the painful and often fatal consequences of the therapeutic optimism fostered by biological theories of dementia praecox.

Meanwhile, many other American psychiatrists, led by Meyer, grew scornful of narrow laboratory approaches to psychiatry and began to approach dementia praecox as a psychodynamic disorder whose origins could be found in a pre-morbid personality type marked by psychosocial introversion, disorganized habits, and maladaptive psychological reactions to the biological, social and emotional challenges of life. The search for psychogenic causes of dementia praecox led Meyer and his followers to pay increasing attention to the peculiarities of individual patients, thus moving them away from mainstream medicine’s concept of diseases as discrete entities that could be isolated from the particularities of individual patients. By the late 1920s, most psychiatrists intent on finding the psychogenic roots of insanity began to use the term schizophrenia rather than dementia praecox. Noll argues that this represents more than a simple change in nomenclature, as is often suggested, but a fundamentally different approach to psychiatry that emphasized psychological reactions as holding both the key to diagnosis and a potential means of treatment. The concept of schizophrenia proved especially attractive to more doctrinaire followers of Freudian psychoanalysis who became the dominant force in American psychiatry in the 1940s.

In an epilogue, Noll makes explicit the critique of eclecticism in American psychiatry implicit throughout the book. During the period in question, psychiatric elites like Adolf Meyer embraced ambiguity, making room under Meyer’s capacious notion of “psychobiology” for conflicting theories and practices, ranging from psychosurgery to psychoanalysis. Noll acknowledges that Meyer’s eclecticism was in part at least a “pragmatic response to clinical perplexities” that “imposed a fragile peace on rivals in the service of “the greater goal of restoring maladjusted individuals to society” (276). Though Meyer and even more the early psychoanalysts were committed to a psychogenic approach, they understood that biological research and somatic treatments were essential for the prestige of the profession.

But Noll argues that this eclecticism kept alive a tendency to emphasize the peculiar expression of disease in each individual rather than identifying the general characteristics that other branches of medicine used to demarcate specific disease entities, and ultimately marginalized laboratory research and statistical methods, and inhibited psychiatry’s integration into the increasingly powerful and prestigious modern medicine. The enforcement of doctrinaire psychoanalysis in the 1940s and ‘50s was an attempt to solve the problem by constructing a rigorous theory of psychogenic disease that could rival the explanatory and therapeutic power of biomedicine. But psychoanalysis was plagued by ambiguity and paradox and ultimately failed. From the 1960s on, progress in biomedical research into brain chemistry, psychopharmacology and genetics provided the basis for the rationalization of psychiatry that culminated in the triumphant return of Kraepelinian psychiatry as embodied in the DSM-III of 1980.

Many historians will take issue with some or all of Noll’s critique. I tend to take the clinical perplexities psychiatry has always faced more seriously than Noll, and find grounds for skepticism whenever psychiatric theories of any stripe have arrogantly asserted that the fundamental ambiguity of mental disorder has finally been vanquished by science. But the great strength of this book is that it invites intellectual engagement. Noll does not allow his own interpretive commitments to overwhelm the narrative; his representation of the world of American psychiatry during this critical period is so rich and nuanced that readers are able to develop alternative interpretations even as they consider his. In other words, it generates much more light than heat and should be widely read by historians, neuroscientists, clinicians, social scientists and educated general readers interested in understanding medicine’s efforts to come to terms with mental illness. Given the issues at play in the upcoming revision of the DSM, a work of mature, responsible historical scholarship is a timely and valuable contribution to the broad discussion we need to be having about what is at stake in psychiatric classification.

 

Jesse Ballenger is an associate professor in the Science, Technology, and Society program at Penn State University. He is the author of, among other works, Self, Senility and Alzheimer’s Disease in Modern America: A History (Johns Hopkins University Press 2006).

 

Special issue of the Journal História, Ciências, Saúde – Manguinhos

Special issue of the Brazilian journal História, Ciências, Saúde – Manguinhos is dedicated to “Hospice and Psychiatry in the First Republic – Diagnosis in Historical Perspective”.

Grand mal seizures in the Cemetery of the Living: the diagnosis of epilepsy at Brazil’s National Hospital for the Insane by Margarida de Souza Neves. The abstract reads:

This study in the social history of medical thought analyzes the articles on epilepsy published in the journal Archivos Brasileiros de Psychiatria, Neurologia e Medicina Legal in 1915 and 1918. Through these texts, I identify some of the ways in which early twentieth-century Brazilian medicine addressed this syndrome, particularly the direct association that medical science then drew between epilepsy and a propensity to violence and crime. The texts, which contain clinical observations on patients diagnosed as epileptics, also afford us a brief glimpse into these individuals’ life stories.

Nervousness as a nosographic category in the early twentieth century by Luiz Fernando Duarte The abstract reads:

The paper presents the conceptual framework surrounding the category of nervousness in Brazilian psychiatry in the early twentieth century as represented in an article by Henrique Roxo published in Arquivos Brasileiros de Psiquiatria, Neurologia e Medicina Legal in 1916, and contextualizes it in the history of psychiatric classifications and representations about nerves and the nervous system. As such, it intends to contribute towards mapping out physicalistic naturalism (or epiphenomenalism), which can be seen throughout the representations of the human person and their disturbances in modern western culture.

Classifying differences: the dementia praecox and schizophrenia categories used by Brazilian psychiatrists in the 1920s by Ana Teresa A. Venancio. The abstract reads:

This article analyzes how the Brazilian psychiatrists Henrique Roxo and Murillo de Campos understood and differentiated between the diagnostic categories dementia praecox and schizophrenia at the end of the 1920s in scientific articles published in the principal psychiatric journal of the time. We note how the aforementioned psychiatrists incorporated the European knowledge that created these diagnostic categories and how they represented them in the context of the institutionalization of psychiatry in Brazil. We seek to understand how this scientific diagnostic naming and defining process developed in conjunction with the definition of the difference between what should and should not be considered phenomena, with respect to mental pathologies.

The emergence of manic depressive psychosis as a diagnosis in Brazil by Joel Birman. The abstract reads:

This essay examines the early twentieth-century interpretation of manic depressive psychosis in Brazil, during a moment when Brazilian psychiatry witnessed a theoretical shift from the French to German traditions. It calls special attention to how the problem of hysteria was replaced by manic depressive psychosis within this historical context.

Hysteria and psychiatry under Brazil’s First Republic by Sílvia Alexim Nunes. The abstract reads:

The article problematizes Brazilian psychiatric thought on hysteria in the early decades of the twentieth century, a time when a biopolicy of population management was lending impetus to the growth of social medicine. This notion is situated within the context of the nineteenth-century debate on hysteria that took place in major European centers and served as the main reference for Brazil’s fledgling field of psychiatry. The debate found expression in Brazilian psychiatric discourse as part of the era’s project for medical reform and prevention in Brazil. The work of Brazilian neurologist Antônio Austregésilo (1876-1960) within this project is also addressed, since he played a fundamental role in dismantling hysteria as a diagnostic category in psychiatry, a process that continued through the entire Old Republic.

Syphilis and the aggiornamento of organicism in Brazilian psychiatry: notes on a lesson by Dr. Ulysses Vianna by Sérgio Carrara and Marcos Carvalho. The abstract reads:

Taking as its point of departure the lesson published by Brazilian psychiatrist Ulisses Vianna in the Arquivos Brasileiros de Neuriatria e Psiquiatria in 1919, the article analyzes the development of that day’s medical discussions about ‘syphilis of the nervous system’ and ‘cerebral syphilis,’ situating Vianna’s work within its broader intellectual scenario. The article also examines the impact of this disease category on psychiatric thought, especially how it strengthened the organicist or somatological concepts of mental illness and adjusted them to the new scenario created by bacteriology.

Alcoholism and psychiatric medicine in early twentieth-century Brazil by Fernando Sergio Dumas dos Santos and Ana Carolina Verani. The abstract reads:

Based on a study of the construction of psychiatric knowledge and practices regarding alcoholism, the article explores the development of psychiatry in Brazil from the close of the nineteenth century through the first three decades of the twentieth. It examines both the role that psychiatry assigned to alcohol in manifestations of madness as well as the hypothesis that the concept of “alcoholic psychosis” was an attempt to encompass the symptoms and problems triggered within someone with chronic alcoholism. Defining the latter as a “social disease” tended to link it with the lower classes and their customs, practices, and living conditions. In an analysis of confinement to asylums, the article also captures echoes of the era’s medical discussions and uses the reflections of writer Lima Barreto as a counterpoint to medical knowledge at that time.

Psychasthenia by Rafaela Teixeira Zorzanelli. The abstract reads:

The article analyzes the medical category of psychasthenia, used by French psychiatry from the late nineteenth through the early twentieth centuries. It describes the clinical profile of psychasthenia and the main hypotheses meant to account for symptoms as defined and advanced by Pierre Janet, the central figure in systematization of this category. The article also looks at how this diagnosis was used in Brazil and how it related to the profile of neurasthenia within the context of Brazilian psychiatry.

Neurasthenia by Rafaela Teixeira Zorzanelli. The abstract reads:

The article addresses the medical category of neurasthenia, developed in the United States by neurologist George Beard at the close of the nineteenth century. Points of discussion include the principle features of the category’s clinical presentation, the main hypotheses advanced to account for symptoms, and the treatment alternatives suggested in Beard’s works. The article also looks at how the diagnosis was received outside the United States, both in Europe and, more specifically, in Brazil.

The degenerate by Octavio Domont de Serpa Jr. The abstract reads:

The article discusses the theory of degeneration as presented in the works of Benedict-Augustin Morel, situating it within the scientific and cultural context of its day. It underscores the roles played by the notions of heredity and environment in grounding this theory and how it related to the mid-nineteenth century French understanding of psychiatric medicine. It also explores the ramifications of this theory, particularly the works of Valentin Magnan, with the ultimate progressive transition from the notion of degeneration to that of degenerate. Other points of analysis include French psychiatry’s concepts of imbalance and constitution and German psychiatry’s concept of endogeneity as heirs to degeneration in twentieth-century psychiatry, as well as the Neo-Lamarckian appropriation of this debate in Brazil.

Emil Kraepelin and the problem of degeneration by Sandra Caponi. The abstract reads:

When Kraepelin laid the foundations of what we now understand as psychiatry, he was faithful to the nineteenth-century hygienist’s penchant for approaching social problems in terms of medical categories. With Kraepelin’s writings on the issue of degeneration as a backdrop, the article analyzes how the methodology he introduced for researching psychiatric illnesses is indebted to Morel’s theory of degeneration. The article explores not only Kraepelin’s concern with defining a classification of mental pathologies just as well grounded as the classifications of biological pathologies, but also his use of comparative statistics and his explanations of morbid heredity.

Bringing order to the Babel of psychiatry: Juliano Moreira, Afrânio Peixoto, and paranoia in Kraepelin’s nosography (Brazil, 1905) by Ana Maria Galdini Raimundo Oda. The abstract reads:

The article explores the meanings of paranoia and its use as a disease category. Juliano Moreira and Afrânio Peixoto’s article “A paranoia e as síndromes paranoides” is used to show how these two scientists differentiated between this clinical construct and dementia praecox. Delineating the diagnostic boundaries of “legitimate” paranoia was their way of demarcating their theoretical stances and their alignment with Kraepelin, thereby justifying the scientific stance that they deemed essential to making Brazilian psychiatry modern. The article also discusses aspects of the conceptual history of paranoia (its relation to personality) in terms of the theoretical references used by the Brazilian authors of the article.

This study in the social history of medical thought analyzes the articles on epilepsy published in the journal Archivos Brasileiros de Psychiatria, Neurologia e Medicina Legal in 1915 and 1918. Through these texts, I identify some of the ways in which early twentieth-century Brazilian medicine addressed this syndrome, particularly the direct association that medical science then drew between epilepsy and a propensity to violence and crime. The texts, which contain clinical observations on patients diagnosed as epileptics, also afford us a brief glimpse into these individuals’ life stories.

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