Madness Explained
Page 6
Prior to the 1970s, researchers studying mood disorders rarely distinguished between patients suffering from bipolar and unipolar illnesses. Following the publication of an English translation of The Classification of the Endogenous Psychoses in the 1970s, it became commonplace to do so. By the last quarter of the twentieth century, therefore, Kraepelin’s model had been substantially elaborated and yet remained, in most respects, intact. A consensus model of psychiatric classification, outlined in Figure 2.1, was widely embraced. It began with the distinction between the psychoses and the minor psychiatric disorders or neuroses, as outlined by Jaspers. The psychoses, in turn, were divided into two major categories, schizophrenia and manic depression as proposed by Kraepelin, and two perhaps more contentious categories, paranoia and schizoaffective disorder. Finally, manic depression was deemed to consist of two subtypes, unipolar depression and bipolar disorder.
Will the Real Concept of Schizophrenia Please Stand up?
In these first two chapters we have examined the development of the Kraepelinian approach to psychiatry from its beginnings in the last half of the nineteenth century through to the last quarter of the twentieth. Although I have presented no more than an outline sketch of this process, focusing narrowly on the work of four giants of psychiatry, the astute reader will already have recognized that Kraepelin’s ideas underwent a series of radical transformations as they progressed through the hands of Bleuler, Jaspers, Schneider and onwards. This was most obviously the case for the concept of dementia praecox. For Kraepelin the cardinal features of the disorder were intellectual, for Bleuler they were cognitive and emotional, whereas Schneider emphasized hallucinations and delusions. Indeed, we may be forgiven for wondering whether these explorers of the mind and its disorders were writing about the same illness. Writing in 1980, the psychiatric geneticist Seymour Kety had little doubt about this question, and argued that Schneider’s account of schizophrenia amounted to nothing less than a perversion of Kraepelin’s original concept:
Schneider, 50 years later… [after Bleuler] gave renewed support to those who preferred to think of schizophrenia as a benign process by simply redefining schizophrenia to make it so. Features regarded by Kraepelin and Bleuler as fundamental and characteristic (impoverishment of affect, disturbances of personal contact and rapport, ambivalence, lack of motivation, depersonalisation and stereotypes) were significantly rejected and the new criteria were restricted to particular kinds of hallucinations and delusions which Bleuler had regarded as accessory symptoms. Schneider
Figure 2.1 The consensus view of psychiatric classification, circa 1975.
established a new syndrome with features which are economically put into check lists and fed into computers. That syndrome may be more prevalent, have a more favourable outcome, and be more responsive to a wide variety of treatments, but it is not schizophrenia.29
British psychologist Mary Boyle has offered a different explanation for the apparent differences between modern schizophrenia patients and the dementia praecox patients of Kraepelin’s time.30 She has noted remarkable similarities between Kraepelin’s case studies and descriptions of people suffering from encephalitis lethargica, a viral disease that swept through Italy during the 1890s, and then through the rest of Europe between 1916 and 1927. In the epidemic of 1916–27, five million people were affected, about one third of whom died or fell into a coma after a period of intense sleeplessness. Many of those who survived went on to develop a form of post-encephalitic Parkinson’s disease (named after a London physician James Parkinson who, in 1817, first described the non-viral manifestations of this condition; symptoms include uncontrollable tremor, sudden accelerated movements interspersed with periods of stiffness or rigidity, and other crippling disorders of will and action). Sometimes, survivors would remain conscious but unable to move for years, frozen in their chairs without obvious motive, emotion or desire, apparently indifferent to the world around them.31 The biological basis of the illness was established by Constantin von Economo, a Greek-born neuropathologist who found characteristic lesions in the brains of victims at autopsy, and who demonstrated that a submicroscopic, filterable virus obtained from victims was capable of transmitting the disease to monkeys.32
So varied were the long-term symptoms observed following the epidemic, that encephalitis lethargica originally received a variety of other names, including ‘epidemic delirium’, ‘epidemic disseminated sclerosis’, ‘atypical poliomyelitis’ and ‘epidemic schizophrenia’. The last of these terms was sometimes used because the movement disorders of patients were similar to those recorded in patients thought to suffer from catatonic schizophrenia.
The important lesson of Boyle’s argument is not that Kraepelin was sometimes mistaken when assigning diagnoses (we will never know for certain whether some of his patients were suffering from a brain infection) but that the concept of dementia praecox was less certain than either he or his followers supposed. As we will see, this is not the only problem that has threatened to undermine the Kraepelinian system.
3
The Great Classification Crisis
If any man were bold enough to write a history of psychiatric classifications he would find when he had completed his task that in the process he had written a history of psychiatry as well.
Robert Kendell1
The philosopher Thomas Kuhn2 has observed that sciences do not develop by the mere accumulation of knowledge (although the accumulation of knowledge is important). Rather, scientific progress sometimes occurs in abrupt leaps or shifts, for example when Newton justified a Copernican model of the solar system by proposing his law of gravitation, or when Einstein abolished the concept of absolute motion by introducing his theory of special relativity. In each of these examples (and many others from the physical and biological sciences that can be easily invoked) one theoretical framework was eventually abandoned in favour of another, incompatible, framework. During this process, according to Kuhn, researchers are usually reluctant to accept the evidence in favour of the new approach until limitations of the old approach become so obvious that they can no longer be avoided.
Kuhn argued that these sudden theoretical leaps could be understood, at least in part, in sociological terms. According to his account, each science begins in fits and starts until researchers eventually accept a common paradigm (framework or set of assumptions about the nature of their subject matter). During the subsequent phase of normal science, researchers work within the paradigm, even though they may be hardly aware that they are doing so (for example, after Newton physicists assumed that space was best described by the principles of Euclidean geometry, until Einstein showed that non-Euclidean geometries were required to describe the curvature of space under the influence of gravity). Over time they begin to accumulate observations that cannot be understood within the existing framework and this leads, eventually, to a scientific revolution in which a replacement paradigm is accepted. Afterwards there follows another period of normal science.
Although Kuhn’s model has sometimes been criticized for oversimplifying the processes involved in the growth of scientific knowledge,3 it allows us to understand Emil Kraepelin’s position within the history of psychiatry. It is a position that bears some resemblance to that of Newton within the history of physics. Like Newton, he established a paradigm or a set of assumptions that would guide the activities of successive generations of researchers, but which were so ingrained that they have been difficult to question. According to this paradigm, psychiatric disorders fall into a finite number of types or categories (dementia praecox, manic depression, paranoia, etc.), each with a different pathophysiology and aetiology. Of course, modern psychiatrists and psychologists have sometimes quibbled with details of the system (for example, arguing whether the true number of psychotic illnesses is three or more than three). Often they have also acknowledged the multifactorial origins of particular illnesses (‘schizophrenia is caused by an interaction of biology and the environment…’). Nonetheless,
the practice of most psychiatrists and clinical psychologists – the way that they assign diagnoses and decide treatments for their patients, the way that they conduct their research into the causes of madness – reveals that the Kraepelinian paradigm remains almost unchallenged within the mental health professions as a whole. That this is so is evident from four observations.
First, modern textbooks of psychopathology, whether written by psychiatrists or psychologists, almost without exception, are organized according to some variant of Kraepelin’s system, with chapter headings on ‘schizophrenia’, ‘manic depression’ and so on. Second, as we will see later in this chapter, the official diagnostic systems currently advocated by influential bodies such as the World Health Organization (WHO)4 and the American Psychiatric Association (APA),5 are similarly organized in a way that reflects Kraepelin’s assumptions about the nature of madness. Third, most research in psychiatry (whether conducted by psychiatrists or psychologists) is based on Kraepelin’s paradigm. Usually, patients with a particular diagnosis are compared with other people, on the assumption that those with the diagnosis have something in common that makes them different. And finally, clinicians throughout the world typically employ Kraepelin’s diagnostic concepts during their routine work, for example when explaining to patients what is wrong with them (‘I’m afraid you suffer from manic depression, Mr Smith’) and when deciding what treatment should be offered (‘so you should therefore take lithium carbonate’).
Because Kraepelin’s paradigm remains the main organizing principle for psychiatric practice and research, any evidence that draws it into question has revolutionary implications for both the understanding and treatment of madness. Evidence of this kind would undermine most of the research into psychiatric disorders conducted since Kraepelin’s death. (After all, the attempt to find the cause or causes of schizophrenia is doomed to failure if the diagnosis does not pick out a group of people who suffer from the same disorder.) It would also undermine any routine clinical decisions – for example, advice about whether patients are likely to recover, or to benefit from particular kinds of medication – that are based on Kraepelinian diagnoses.
These disastrous consequences of a poorly founded method of classification point to the necessity of evaluating Kraepelin’s system. There are many different ways of approaching this problem. However, in this chapter we will be concerned only with the first and most obvious test that a diagnostic system must pass in order to be deemed useful. This test is known as reliability, and concerns the consistency with which diagnoses are employed by different clinicians or on different occasions. If two psychiatrists met the same patient, we would expect both to make the same diagnosis. Similarly, we would expect a patient to be assigned the same diagnosis on two different occasions (unless the patient recovered and later developed a separate illness altogether). Without this kind of diagnostic consistency, there would be no way of agreeing about who suffers from a particular disorder and who does not.
The Problem of Reliability
In order to achieve reliable psychiatric diagnoses it is first necessary to reach a consensus about the main features of each disorder. Although early attempts to create the required standard definitions were made elsewhere (the first being a list of eleven mental diseases agreed at a Congress of Mental Science in Paris in 1889),6 it is fair to say that this process of mass-producing psychiatric diagnoses has been mostly an American enterprise. From our vantage point at the beginning of the twenty-first century, it therefore seems almost paradoxical that American psychiatrists working in the middle years of the last century were mostly sceptical about the value of diagnoses. This scepticism reflected the influence of Adolf Meyer, a Swiss-born psychiatrist who played a leading role in shaping American thinking about madness during the first decades of the twentieth century.
Meyer was born in 1866 in Niederweingen, near Zurich, and studied medicine in Switzerland before undertaking postgraduate work in Paris, London, Edinburgh and Berlin. In 1892, he migrated to the United States where, after working in a series of neurology posts, he eventually became director of the Pathological Institute of the New York State Hospitals. In 1909 he received an honorary doctorate from Clark University at the same time as did Sigmund Freud and Carl Jung, who were mid-way through a lecture tour of the United States.
During this early period of his career, Meyer was a firm advocate of Kraepelin’s approach and has been credited, along with a few other émigrés, for introducing the concept of dementia praecox to the United States. Indeed, the only book he published in his lifetime was entitled Dementia Praecox. It attempted (with somewhat less success than Bleuler’s book of the same title) to integrate Kraepelin’s ideas with those of Freud. On being appointed to a chair in the Department of Psychiatry at Johns Hopkins University in Baltimore in 1910, where he was to remain until retiring in 1941, Meyer intended to model the new University clinic on Kraepelin’s Institute in Munich. The Henry Phipps Psychiatric Clinic, as it became known, was housed in an elegant building, with a roof garden and unbarred windows. Like the Munich Institute, the clinic was run along medical lines, so that patients usually arrived in ambulances, physical restraints were employed as rarely as possible, and few patients were compulsorily detained. It is therefore all the more remarkable that Meyer’s subsequent reputation was as an anti-Kraepelinian.
Historian Edward Shorter was probably unfair when he described Meyer as, ‘a second-rate thinker and verbose writer, [who] was never, in his own mind, able to disentangle schools that were absolutely incompatible, and ended up embracing whatever new came along’.7 However, Meyer was certainly enthusiastic about Freud’s theories, and therefore shares some responsibility for the success of psychoanalytic ideas in the United States. He also supported the psychologist J. B. Watson’s first attempts to apply the theory of Pavlovian conditioning in a psychiatric setting, and therefore can also be credited with encouraging the psychological doctrine of behaviourism* (an approach to psychology that is usually regarded as the antithesis of psychoanalysis). Meyer’s later writings, mostly published after his death in 1950, advocated a holistic approach to psychiatry in which biological, psychological and sociological approaches were considered to be equally important. Despite his earlier enthusiasm for Kraepelin’s system, he became pessimistic about the value of psychiatric classification, arguing that ‘We should give up the idea of classifying people as we do plants.’ He felt that psychiatric categories did little justice to the complexity of patients’ problems, their individual histories, and the social circumstances in which their problems arose. He also objected to the superstition that a diagnosis led automatically to a choice of treatment and suggested that, rather than grouping different behaviours under one name, clinicians should base their treatment decisions on a concrete specification of the various problems from which the patient suffered.
Despite Meyer’s influence, the American Psychiatric Association contributed a section on psychiatric disorders to a nationally accepted Standard Classified Nomenclature of Disease organized by the New York Academy of Medicine, which was published in 1933. It was the attempt to use this classification during the Second World War that led both military and civilian psychiatrists to reconsider their attitudes towards the whole process of diagnosis. During the war, nearly 10 per cent of all discharges from the armed forces were for psychiatric reasons. However, the range of disorders contained within the Nomenclature, based largely on clinical experience within asylums, was inadequate to describe many of the problems suffered by the returning men. In particular, stress reactions, psychosomatic problems and problems of personality were inadequately described. To make matters worse, the US army, the US navy and the Veterans Administration (responsible for providing medical care to ex-service personnel and their families) all employed their own idiosyncratic systems of classification alongside the Nomenclature.8 It was in order to bring an end to this chaos that the American Psychiatric Association in 1948 formed a task force to create a new standardiz
ed diagnostic system. The result, published in 1952, was the first edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders.
DSM-I (as it became known) was a triumph of the doctrine of truth by agreement. Great care was taken to represent the broad spectrum of contemporary psychiatric opinion in the USA. One tenth of the Association’s members were sent a questionnaire, which elicited their opinions about an early draft of the manual, allowing revisions to be made before it was officially adopted by a vote of the entire membership. The final version came as a handy-sized book with a grey cover. Within its pages, each diagnosis was given a simple definition, usually accompanied by a thumbnail description of the disorder. The impact of this simple and practical system proved to be as great outside the United States as within, shaping attempts to produce an international consensus about psychiatric classification.