The paper on paranoia was soon followed by others on a variety of topics, including a review of the role of intelligence testing in psychiatry, and further case studies, the last of which was published in 1913. During this period Jaspers was working on his only book on psychiatry, which was also published in 1913, two years before he became a professional philosopher.
General Psychopathology, completed when he was 30 years of age, attempted a grand sweep, bringing together the biological and the psychological. In it, Jaspers made a distinction between two apparently irreconcilable methods of comprehending mental symptoms: understanding and explaining. According to Jaspers, a patient’s experiences can be understood if they are seen to arise meaningfully from the person’s personality and life history. The key to a psychological analysis of a patient’s abnormal experiences is therefore the clinician’s empathetic understanding of the patient’s subjective world and life story. In some cases, however, symptoms arise in such a way that no amount of empathy can link them understandably to the patient’s background. Such symptoms, Jaspers asserted, cannot be understood but can only be explained as caused by an underlying biological disorder.16Ununderstandability was, of course, the hallmark of the psychoses, and allowed them to be distinguished from the less severe psychiatric disorders, which later became known as the neuroses.*
No where is this distinction clearer than in Jaspers’ account of abnormal beliefs. Such beliefs (which are discussed in more detail in later chapters) are often expressed by psychotic patients and usually follow particular themes, the most common of which are persecution (for example, ‘The Royal Family and the British Home Office are conspiring to kill me’) and grandiosity (for example, ‘I am Christ reborn’). Jaspers identified three key features of such beliefs. First, they are held with extraordinary conviction. Second, they are resistant to counterarguments or contradictory evidence. Third, they have bizarre or impossible content. However, according to Jaspers, these criteria are not sufficient to determine whether a belief is a true delusion. True delusions are ununderstandable because they arise suddenly without any context. The clearest case of this phenomenon is the delusional perception, in which the individual interprets a particular stimulus in a bizarre way. An example (described by Kurt Schneider) is of a young man who considers the position of a salt-cellar on his table and suddenly concludes that he will become the Pope.
The problem with this distinction is that, far from making the borderline between normality and madness more objective, it introduces an alarming degree of subjectivity. For Jaspers, the empathetic attitude of the psychiatrist towards the patient functions as a kind of diagnostic test. If the empathy scanner returns the reading ‘ununderstandable’ the patient is psychotic and suffering from a biological disease. However, behaviours and experiences may vary in degree according to how amenable they are to empathy. By not empathizing hard enough, we may fail to recognize the intelligible aspects of the other person’s experiences. Moreover, once we have decided that the patient’s experiences are unintelligible, we are given an apparent licence to treat the patient as a disordered organism, a malfunctioning body that we do not have to relate to in a human way.
A real-life example illustrates this danger. Some years ago, my research assistant, Sue Kaney, was administering a battery of psychological tests to patients suffering from delusions. One patient’s delusional belief, ‘Professor B has turned me into a portfolio’, had been dismissed by her doctors and nurses as meaningless. As Professor B was a well-known gynaecologist it seemed to us a good idea to check whether the lady had any unusual medical complaints. Investigation of her medical notes revealed that she suffered from a rare condition that the Professor was researching. ‘Professor B has turned me into a portfolio’ seemed an odd way for the woman to declare that she felt uncared for and an object of scientific scrutiny. Nonetheless this is what she appeared to be asserting.
This brief anecdote illustrates the central irony of Jaspers’ work. In his great book he tried to identify a role for psychological explanations in psychiatry. In the process, he gave madness to the biologists and inadvertently discouraged the psychological investigation of the psychoses.
Schneider and the ‘First-Rank Symptoms’
In 1913 Jaspers became a teacher of psychology in the Department of Philosophy at the University of Heidelberg. At first, he assumed the move would be temporary but in 1922 he was appointed to a full chair in philosophy, and he never returned to psychiatric practice.
Kurt Schneider’s career overlapped with Jaspers’ and was greatly influenced by it.17 Like Jaspers, he studied both medicine and philosophy and addressed the problem of deciding who was mad and who was not. Yet, unlike his predecessor, his approach was pragmatic rather than philosophical.
Born in 1887 in Crailsheim in the state of Württemberg, Schneider trained in medicine in Berlin and Tübingen. After military service in the First World War, he obtained his academic qualification in psychiatry in Cologne in 1919. In 1931 he was appointed director of the Psychiatric Research Institute in Munich, which had been founded by Kraepelin.
In the following years, Nazi policies were gradually embraced by the German psychiatric establishment, championed in particular by Ernst Rüdin, who had been recruited to the Institute by Kraepelin in order to develop the new field of psychiatric genetics. The eugenic theories that Rüdin proposed led, first, to the enforced sterilization and then, later, the killing of mentally ill patients.18 These developments horrified Schneider, who eventually left the Institute to serve as an army doctor during the Second World War.*
In 1945, the invading US army decided to reopen the famous university at Heidelberg and appointed a group of anti-Nazi academics to advise them. The group, led by Jaspers, attempted to identify fellow academics who could be safely entrusted with the rebuilding of the University. Schneider was sufficiently free of the taint of Nazism to be appointed Dean of the Medical School, a position he retained until his retirement in 1955. He died, aged 80 years, in 1967.
Although Schneider’s work was to have a profound impact on the way in which English-speaking researchers thought about schizophrenia, his approach became known to the English academic world largely via accounts provided by British and American psychiatrists who had studied him in German. Indeed, the English translation of his famous textbook on Psychopathology, published in 1959, was allowed to go out of print after one edition, and has never been reissued. It is doubtful whether Schneider himself felt his analysis of schizophrenia to be his most important contribution; he also wrote extensively about disorders of personality, and about forensic problems that lay at the boundary between legal and psychiatric practice.
According to Canadian psychiatrist J. Hoenig, ‘Schneider’s work… was not in the area of system design, but it was firmly planted at the bedside’ (a curious description, as psychiatrists almost never see their patients when they are lying in bed). Applying Jaspers’ phenomenological approach, he addressed himself to the problem of diagnosing schizophrenia and differentiating it from more general problems of personality. He hit on the strategy of identifying those characteristics that were peculiar to schizophrenia, and which would therefore provide the best guide for the practising clinician. In this way, he identified what he believed to be the first-rank symptoms of the disorder, which are listed in Table 2.1. These symptoms, which were to be distinguished from other symptoms of the second rank, were all forms of hallucination, delusion, or passivity experience. For example, the patient might hear an auditory hallucination in the form of a voice speaking about him in the third person and commenting on his actions, or he might feel that his will was being controlled by some external force or agency.
When trying to determine whether patients suffered from any of these symptoms, Schneider believed that it was more important to pay attention to the form rather than the content of the patient’s experience:
Diagnosis looks for the ‘How?’ (form) not the ‘What?’ (the theme or content). When I fin
d thought withdrawal, then this is important to me as a mode of inner experience and as a diagnostic hint, but it is not of diagnostic significance whether it is the devil, the girlfriend or a political leader who withdraws the thoughts. Wherever one focuses on such contents, diagnostics recedes; one sees then only the biographical aspects or the existence open to interpretation.19
For Schneider therefore, the meaning of first-rank symptoms was irrelevant to the diagnostician. Moreover, he was careful to deny that these symptoms were crucially important features of schizophrenia. They were chosen purely for convenience, because they were easy to recognize. Accordingly, any patient who showed any of these symptoms would, more likely than not, be suffering from schizophrenia,
Table 2.1 Schneider’s first-rank symptoms of schizophrenia (adapted from K. Schneider (1959) Clinical Psychopathology. New York: Grune & Stratton)
Symptom as described by Schneider
Example given by Schneider
1 Audible thoughts
A schizophrenic woman, for instance, replied to the question about hearing voices with the answer, ‘I hear my own thoughts. I can hear them when everything is quiet.’
2 Voices heard arguing
Another schizophrenic heard his own voice night and day, like a dialogue, one voice always arguing against another.
3 Voices heard commenting on one’s actions
A schizophrenic woman heard a voice say, whenever she wanted to eat, ‘Now she is eating, here she is munching again’, or when she patted the dog, she heard, ‘What is she up to now, fondling the dog?’
4 Experience of influences playing on the body
A schizophrenic woman speaking of electrical influences said, ‘The electricity works of the whole world are directed on to me.’
5 Thought withdrawal
A definite schizophrenic disturbance may only be supposed when it is recounted that ‘other people’ are taking the thoughts away… A schizophrenic man stated that his thoughts were ‘taken from me years ago by the parish council’.
6 Thoughts are ascribed to other people who intrude their thoughts upon the patient
A skilled shirtmaker knew exactly how large the collars should be, but when she proceeded to make them, there were times when she could not calculate at all. This was not ordinary forgetting; she had to think thoughts she did not want to think, evil thoughts. She attributed all this to being hypnotized by a priest.
7 Thought diffusion
The diffusion of thoughts is illustrated by a schizophrenic shopkeeper who said, ‘People see what I am thinking; you could not prove it but I just know it is so. I see it in their faces; it would not be so bad if I did not think such unsuitable things – swine or some other rude word. If I think of anything, at once those opposite know it and it is embarrassing.’
8 Delusional perception
Another schizophrenic woman said: ‘The people next door were strange and offhand; they did not want me; perhaps I was too quiet for them. The previous Sunday my employers had a visitor who embarrassed me. I thought it was my father. Later on, I thought it was only the son of the house in disguise. I don’t know if they wanted to find out about me.’
9-ii Feelings, impulses (drives) and volitional acts that are experienced by the patient as the work or influence of others
A schizophrenic student said, ‘I cannot respond to any suggestion; thousands and thousands of wills work against me.’
but ‘We often have to base our diagnosis of schizophrenia on the second rank symptoms, in exceptional cases now and then even merely on expressional [behavioural] symptoms, provided they are adequately distinct and present in large numbers.’20
Despite these qualifications, many English-speaking researchers assumed that Schneider had found a more precise way of identifying ‘real cases’ of schizophrenia. The term ‘Schneider-positive schizophrenia’ – to refer to a group of patients suffering from his first-rank symptoms – was first used in 1965 by a group of investigators searching for metabolic abnormalities in psychotic patients.21 Somewhat later, Schneider’s account was used to define a core group of schizophrenia symptoms by a British team, led by John Wing, which was attempting to find more reliable ways of defining and diagnosing psychiatric disorders.22 As we will see in the next chapter, subsequent definitions of schizophrenia developed in Britain and the United States, and now employed throughout the world, have all emphasized hallucinations and delusions rather than the intellectual deficits described by Kraepelin or the so-called fundamental symptoms described by Bleuler.
It is likely that Schneider himself would have been shocked by these developments. As we have seen, his goal in defining the first-rank symptoms was merely to make the task of the clinician more straightforward. Indeed, Schneider the pragmatist denied that psychiatric diagnosis identified cases with a common aetiology as supposed by Kraepelin. In an essay celebrating Kraepelin’s influence on psychiatry published in 1956 he remarked that:
Today no one will any longer attempt a sharp differential diagnosis between cyclothymia [manic depression] and schizophrenia (as they are now called). There is only a differential typology, that means there are transitions… One should really no longer argue about such cases: ‘this is a cyclothymia, no, this is a schizophrenia’. One can argue this about GPI versus a cerebral tumour. Here the ‘is’ can be verified. With the endogenous psychoses, which are purely psychological forms, one can make assessments only according to one’s own concepts. One can only say: this is for me, or I call this a cyclothymia or a schizophrenia. The crucial point in such an argument is merely to make it clear that in a descriptive psychopathology of this kind Kraepelin’s forms are still basically accepted.23
The sceptical reader may be forgiven for wondering whether the two main assertions in this quotation (that ‘one can make assessments only according to one’s own concepts’ and that ‘Kraepelin’s forms are still basically accepted’) are entirely consistent with each other.
The Evolution of Manic Depression
Just as the concept of dementia praecox evolved, and even changed dramatically in the years following Kraepelin’s original formulation, so too the concept of manic depression underwent a series of transformations. These transformations followed the growing perception among psychiatrists in Europe and North America that Kraepelin’s account created problems of two kinds. The first problem was the embarrassment for psychiatric classification presented by patients who suffered from a mixture of schizophrenic and manic-depressive symptoms. The second problem was the apparent over-inclusiveness of the manic-depression concept, which demanded that it be broken down into several subtypes.
As we have seen, Bleuler believed that psychotic patients could be more or less schizophrenic or manic depressive depending on the extent to which schizophrenia symptoms were more evident than abnormal mood. Extending this idea to its logical conclusion, in 1933 the American psychiatrist Jacob Kasanin proposed the concept of schizoaffective disorder to describe a kind of illness which combined symptoms of both disorders, but which was distinct from both.24 According to Kasanin, schizoaffective patients usually suffered from ‘marked emotional turmoil’ and ‘false sensory impressions’ (hallucinations) but rarely experienced the passivity symptoms (delusions of control) usually seen in cases of schizophrenia. These symptoms most often appeared suddenly after a stressful experience, and there was usually evidence of good premorbid adjustment (in other words, patients showed little evidence of social or personality difficulties prior to their illness). Recovery was often rapid, although many patients went on to suffer further episodes.
A similar but not identical concept of cycloid psychosis was proposed in 1926 by Karl Kliest, professor of psychiatry at Frankfurt University. His student Karl Leonhard, who, in 1936, became head of the Frankfurt University Mental Hospital, later elaborated this concept.25 In a series of papers published in the 1950s, Kliest and Leonhard grouped together under this term all those disorders that appeared to have such a variable course tha
t patients appeared schizophrenic at one point in time and manic depressive at another.26 Despite the apparent similarities with Kasanin’s account, Leonhard denied that the two proposals were the same. The essential feature of cycloid psychosis was the change in symptomatology observed over time. In contrast, the schizoaffective patients described by Kasanin appeared to experience symptoms of schizophrenia and manic depression simultaneously.
It was Leonhard who introduced a final modification to Kraepelin’s system that appeared to solve the second problem of over-inclusiveness. Leonhard undertook an analysis of the varying symptoms of a large group of manic-depressive patients, which he summarized in his book on The Classification of the Endogenous Psychoses, which was published in 1957. He observed that some patients experienced both episodes of mania (characterized by euphoria, excitement and irritability) and episodes of depression, whereas others appeared to suffer only from episodes of depression.27 He therefore proposed the term bipolar disorder to describe the first type of illness, because patients appeared to experience at different times two opposite types of extreme mood. (The term ‘manic depression’ is now often used exclusively to describe this bipolar type of illness.) The term unipolar depression was suggested for the second type of illness, in which episodes of mania never occurred. Importantly, Leonhard and subsequent investigators observed that mania in the absence of a history of depression is extremely rare. For this reason, it is usually assumed that apparently ‘unipolar manic’ patients either have experienced episodes of depression which they have forgotten about, or will go on to develop depression in the future.28
Madness Explained Page 5
