What are the darkest truths in psychiatry

History of Psychiatry

Ancient medicine

The essential step that Greek medicine took compared to its forerunners is the conviction that diseases are to be viewed as natural phenomena and not as expressions of unknown and unaffected metaphysical forces. Of course, this does not apply to every representative of ancient Greek medicine, but it does to the most important, Hippocrates of Kos (460–377 BC). For this very reason, the then common name of epilepsy as "Morbus sacer", as a "holy disease", made no sense. He called for their empirically founded, factual and speculation-free research as far as possible.

Humoral pathology

Actual psychiatric teaching texts were not written in antiquity. The description of what we now call “mental disorder” was rather embedded in the presentation of general medicine, that is, primarily physical illnesses. This has to do with the "humoral pathology" widespread at the time, which was also represented by Hippocrates and which assumed a disturbed balance between the 4 body fluids as the cause of illnesses. In addition to Hippocrates, Galen (130–201 AD), Soranus of Ephesus, Celsus and Aretaeus of Cappadocia (all in the 1st century AD) are important representatives of ancient medicine who have also spoken out about mental illnesses.

Different meanings of technical terms

The basic understanding of these disorders was mostly somatic, even if the brain was not yet the focus of interest. The technical terms of that time, such as that of “phrenitis” in Soranus, are either no longer in use today or - as in the case of mania and melancholy - meant psychopathological issues that differ greatly from the current definition. The dichotomy of the two major forms of dementia praecox (schizophrenia) and manic-depressive illness (bipolar disorder) worked out by Emil Kraepelin at the end of the 19th century was not part of medical thought in antiquity. Until well into the 19th century, mania meant a form of psychosis in which the behavior of the person concerned was characterized by excitement and restlessness, whereas the melancholic hardly revealed his often existing psychotic content and appeared outwardly calm, inhibited or even stuporous.

therapy

Corresponding to the strong somatic orientation of ancient “psychiatry” - a separate subject with this designation did not yet exist - the therapeutic recommendations also pointed in this direction, such as bloodletting, laxatives, special dietary regulations. But rules of conduct for dealing with sick people, which could be described as psychotherapeutic in the broadest sense, such as a calm atmosphere in contact and removal from current sources of conflict, were also discussed.

Middle Ages and Renaissance

From a medical-historical point of view, there has been less progress than regression to report for this period.

The major advance of this era, not just in terms of psychiatry, was the emergence of clinics.

There are reports of very early founding of institutions for the treatment of mental disorders from the Arab cultural area, in Western Europe there are forerunners of psychiatric clinics or - in today's terminology - psychiatric departments at general hospitals from around the early 15th century (establishment of the department in Valencia / Spain 1409). This progress, which was based not least on the above-mentioned "enlightened", ie taking a naturalistic point of view, basic ideas of ancient medicine, is contrasted by a considerable step backwards, especially in dealing with mental disorders: Psychotic people, v. a. Women were described as possessed, as witches, socially excluded and in many cases were executed, mostly by cremation, referring to the notorious work Der Hexenhammer by Heinrich Krämer and Jakob Sprenger, published in 1486.

There were dissenting voices, for example when Paracelsus (1491–1541) - actually Philippus Aureolus Theophrastus Bombastus von Hohenheim - and Johann Weyer (1515–1588), no matter how much they were still committed to medieval thinking in many ways, the supernatural genesis of mental illnesses questioned and, following on from ancient traditions, drew attention to empirically recognizable physical or psychological causes.

From the 17th century to the "Enlightenment" and the French school of the early 19th century

Only a few of the renewal proposals by the renaissance authors were taken up in the period that followed. Although the willingness to denote and persecute the mentally ill as possessed and witches slowly declined, and a number of casuistic and clinically interesting books on psychiatric issues appeared, such as Felix Plater's (1536–1614) Medical Practice and Robert Burton's Anatomy of Melancholy (1621). But the emancipatory moment, for example in Paracelsus ’thinking, was increasingly counteracted by the increasing tendency to understand the mentally ill as mere marginal figures in society who, like criminals and" anti-social "people, should be excluded. The large psychiatric clinics in Paris, Bicêtre and Salpêtrière, were initially a mixture of poor house, prison, homeless asylum, orphanage and psychiatric clinic, but the latter was the least common, and the consultation of doctors was by no means the rule. In Michel Foucault's primarily philosophical and socio-critical, but also secondarily psychiatric-critical perspective, this fact occupies a central and therefore - in a negative sense - identity-creating place (Foucault 2005).

Enlightenment and Rationalism

It was not until the 18th century, shaped by the Enlightenment in terms of the history of ideas, that serious efforts were made to establish psychiatry as a medical science, to take psychiatric patients seriously as persons and both out of the orbit of belief in witches and spiritualism and out of their banishment to the to cut out the outermost edge of society (Leibbrand and Wettley 1961).

As a first approximation, rationalism can be seen as the mainstay of the Enlightenment. The word “science” was given a decidedly positive, even optimistic, meaning, since for the staunch rationalists of the 18th century there were only temporary problems, but not fundamentally unsolvable problems. These authors firmly believe that reason, ratio, will sooner or later permeate the entire field of human knowledge and action. Rationalism virtually created the conceptual construct that has been called science since then and that is specifically oriented towards mathematics and empirical natural research.

Wealth Psychology

Such a “rational” philosophy could of course not avoid including the psychological functions of humans in its concept: A “rational psychology” emerged, for example represented by the philosopher Christian Wolff (1679 - 1754). She wanted to distinguish herself clearly from the sensualistic theory of association, as it was advocated by the philosophers Hume and Condillac. The latter flourished again in the 19th and early 20th centuries, which also had an impact on psychiatry, albeit in a very different context - representatives were, for example, Pulling, Ebbinghaus, Wernicke, Freud. In contrast to this, “rational psychology” did not just take the empirical-inductive, but first the rational-deductive path: The human psyche is divided into various functions or “faculties”, which are the foundations of all human experience and behavior and thus also the scientific interpretation of empirical observations are to be recognized. As a result, numerous varieties of “asset psychology” emerged, which at least shared the distinction between thinking, feeling and willing. Immanuel Kant was most influential in advocating this approach in philosophy.

New psychiatric self-image

The great interest that the “enlightened age” aroused for the phenomenon of mental illness, especially for the psychotic manifestations, the “madness”, is a meaningful example of the necessary and close interlinking between the history of ideas and psychiatry: the human being as a rational being - this was the central postulate of Enlightenment thinking; the psychosis deprives him of precisely this moment, so hits him at a crucial point, which in turn results in the call to fellow human beings to help and restore the "reasonable" state.

Compassion for the sick, not their demonization in the truest sense of the word, the diagnosis and treatment of those affected, not their mere exclusion, increasingly became the focus of psychiatric self-image. New psychiatric clinics were built all over Europe, and in these clinics an attitude took hold that finally led to the often-described "liberation of the mentally ill from their chains" at the end of the 18th and beginning of the 19th centuries: Philippe Pinel in Bicêtre in Paris (1793; see below), William Tuke in York (1796), Johann Gottfried Langermann in Bayreuth (1805), to name just a few examples.

Two further innovations need to be mentioned in connection with psychiatry of the educational period:

Legal issues

On the one hand, from now on the psychiatrist was systematically included in the assessment of legal questions, in particular the sanity or culpability in criminal law and the judgment and legal capacity in civil law. This initially practical, i.e. inforo engagement of the psychiatrists generated numerous scientific questions over the course of time and led to the establishment of a separate field, which is of course closely related to clinical psychiatry, namely forensic psychiatry.

prevention

On the other hand, the Enlightenment emphasized for the first time the aspect of the prevention of mental disorders. Numerous contemporary works also dealt with questions of the course of mental illnesses as well as their connection with alcohol abuse and with their psychosocial development and environmental conditions.

The animism theory of steel

For a long time, medicine had been shaped by “iatrochemistry” and “iatrophysics”, ie theories that assumed the unproblematic transferability of chemical-physical principles and research methodologies to medicine and the completeness of such an approach. The most lasting challenge for this conception of the (healthy and sick) human being as a physical and chemical machine came from the Halle doctor and chemist Georg Ernst Stahl (1660–1734). He formulated the theory of "animism" and postulated that chemical-physical processes alone are not capable of producing and maintaining living processes. Rather, the soul, "anima", is the decisive factor that gives direction to the other moments that are necessary but not sufficient. He consequently understood illness primarily as an expression of the resistance of the "anima" to noxae that impair the functions of the human organism.

Although Stahl has hardly commented on specific psychiatric questions, the division of mental disorders he proposed fell into those that are caused by diseases of certain organs - "sympathetic mental diseases" - and those that occur without an organ disease - "pathetic mental diseases" -, on fertile ground in psychiatric literature. The clinical comparison of “organic” versus “psychogenic” or “functional” mental disorders, albeit in recent times increasingly questioned, has one of its numerous roots here.

Change in the meaning of psychiatric terms

The term “neurosis” shows how much clinical terms - especially the most common among them - are the products of complex processes of the history of ideas and have often changed or even changed their meaning. a. the psychoanalytical understanding, which saw in the "neurotic" symptoms the indirect expression of unconscious, but also sustainably effective psychological processes. Originally, namely at the end of the 18th century, coined by the Scottish clinician Cullen, the term "neurosis" referred to the neurophysiological theory of the sensitivity of neuronal structures and the irritability of muscle tissue developed by Albrecht von Haller. So it had a direct somatic background insofar as “neurosis” in this primary version was an expression of a disturbed excitability of the nervous system.

Today, in the context of operational psychiatric diagnostics, many authors ascribe so little consistency to the term “neurosis” that - like the term “endogenous” - it is viewed as a hindrance and scientifically dispensable.

However, it should not be overlooked that the abolition of a term does not at the same time eliminate the problem addressed by it, no matter how fuzzy it may have been. The term “psychiatry” also appeared for the first time during this period, namely in the work of the Halle city physician and later professor of medicine at the newly founded University of Berlin, Johann Christian Reil (1759–1813).

Barbaric therapeutic procedures

Particularly noteworthy is that the psychiatry of the Enlightenment period, with all its basic orientation towards the concept of reason as a central characteristic of human beings, i.e. towards rationality, in the practice of patient care nonetheless developed a series of "therapy procedures" that from today's perspective are extraordinarily irrational, even barbaric , propagated and applied. Many of these "treatments" were based on the principle of frightening the mentally ill or exposing them to physical stress in such a way that the symptoms of the psychosis either fade into the background or, at best, disappear completely: the patient was thrown around in the swivel chair, and when crossing a bridge suddenly opened a trap door, so that the patient fell into the water, starvation diets, even castrations were carried out.

Philippe Pinel and the "French School"

In 1801 the main work of the aforementioned French doctor Philippe Pinel (Fig. 1) was published with the title Traité médico-philosophique sur l’aliénation mental ou la manie. This brought about a breakthrough in a pragmatic, eclectic understanding of psychiatry, which was also advocated by earlier, mainly French authors, based on basic human values. Pinel expressed himself skeptically to openly negative about all speculative hypotheses about the genesis and v. a. the "seat" of mental illness. In his nosological classification of psychological disorders into mania, melancholy, dementia and idiocy, he too adopted many assumptions, some of which were ill-founded, from earlier authors, such as the assignment of mania to the abdomen, more precisely to disturbed functions in the visceral ganglia, but the basic tenor is always the demand for factual description of clinical facts in their individual biographical and social context. Unbalanced affects, wrong upbringing and educational methods, times of biographical crisis such as puberty or retirement from professional life can lead to a psychotic illness for Pinel just as much as purely somatic influences. In this respect, Pinel, like Reil, has a broad, person-centered and relatively undogmatic understanding of mental disorder - a few decades before the polarization between naturalistic and psychiatry in general, in the wake of the triumphant advance of scientific methods and findings in medicine in general and in psychiatry in particular, occurred to this day person-centered approaches came. We shall come back to that.
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"Liberation of the insane from the chains"

Pinel consistently rejected mechanical or other coercive means in the therapy of psychotic patients and polemicized against the already mentioned barbaric devices, whose underlying theoretical concepts he described as worse aberrations than the delusions of his patients. The "liberation of the insane from the chains", which he undertook, comprehensively justified and defended against attacks in the two Paris clinics he ran - Bicêtre had taken over in 1793 and Salpêtrière in 1795 - made his name internationally known. Weiner (1980) reported on these events and the significant involvement of Pinel's employee Pussin. Efforts to abolish coercive measures were made in early 19th century psychiatry.Century in many countries. In the English-speaking world, John Connolly (1794–1866) was the pioneer of this movement: He developed the concept of “no-restraint” and implemented it consistently.

Eclectic point of view

In the synopsis, Pinel and his most influential student Jean-Etienne Dominique Esquirol (1772–1861) were clinical pragmatists who set much in motion in contemporary psychiatry on the basis of enlightened humanism, took an eclectic point of view and, in particular, exercised restraint towards theoretical approaches if these appeared with dogmatic claims.

Concept of "moral insanity"

An important conceptual innovation should be mentioned here: The creation of the diagnostic category “moral insanity” by the English psychiatrist James Cowles Prichard (1785–1848). He used it to refer to people who disregarded the standards of value that are usually respected and applied in social contact, who asserted their interests in a ruthless and selfish manner and at the same time did not recognize the criticism of such behavior, at least for their own person. Clear echoes of this concept can be found in later teachings of psychopathy, and the "antisocial personality", which is much discussed today in forensic psychiatry and is controversial in its status as a mental disorder in need of treatment and capable of treatment, has many similarities with Prichard's approach.

From Enlightenment to "Romantic Psychiatry"

Franz Anton Mesmer

A peculiar intermediate position between the enlightenment rationalism of the 18th century and the subject and v. a. Affector-oriented, speculative natural philosophy inclined to romanticism in the early 19th century, as far as the medical and especially the psychiatric area is concerned, Franz Anton Mesmer (1734–1815). The theoretical core of his concept is the postulate that the cosmos consists of differently fine "flood rows" that are thought of as material. The finest of these series of tides is no longer divisible. Mesmer called their special effect in the organic field "animal magnetism". In doing so, he did not think of a rigid, atomistic corpuscular theory, but instead emphasized the aspect of the "interaction" of the tide rows with one another, which was not explained in detail. This conceptual fuzziness rightly called on many critics and founded the very complex history of the reception of mesmerism.

The decisive factor is that Mesmer saw himself as an “enlightener”, as the discoverer of a general scientific law that by no means only concerned medicine. Consistently - some critics called it supernatural or even fanatical - he championed this thesis and, clearly overshooting the target, expanded it into a theory of society par excellence. Such an application of fundamental philosophical considerations to concrete communities and to politics in general was not unusual at the time. One thinks of the political drafts of Kant, Fichte and Hegel. Mesmer's conception, however, in the opinion of most of his contemporaries, stood on such clay feet in medical and philosophical-political terms that, apart from a few stubborn and loyal supporters, it was rejected by the medical sciences and, in today's terminology, the social sciences was not received. It is noteworthy that Mesmer is by no means alone in psychiatry with his dubious overstretching of the validity of medical theories: Similar tendencies, i.e. the expansion of psychiatric terms to form the basis for whole worldviews - can be found in such decisive authors as JCA Heinroth, E. Kraepelin, E Bleuler and S. Freud. Even today's debate on the question of whether the rapidly growing neuroscientific knowledge (must) lead to a “new image of man” should be mentioned in this context. It will be discussed later.

mesmerism

"Mesmerism" in popular scientific form with its transitions into charlatanry - which cannot be chalked down by Mesmer himself - was a fad in major European cities for years. a. in Paris, Vienna and Berlin. In research on the history of psychiatry, mesmerism presents itself as a system that assigns itself to the Enlightenment, but is far more inclined to speculation in natural philosophy, but which can very well be regarded as a forerunner of modern auto- and heterosuggestive therapy methods (e.g. autogenic training, hypnosis). By sticking rigidly to the letter of his original concept, Mesmer himself permanently impeded objective research into the phenomena he described, ultimately suggestion (Darnton 1968; Hope 1989a).

On the concept of "romantic psychiatry"

A clear demarcation from the rationalism of the Enlightenment was made by authors mainly from the German-speaking area, who today are called representatives of "romantic psychiatry". Here, too, as with all scientific and historical science buzzwords, caution is appropriate: Of course, there was no romantic psychiatry, and not all psychiatrists included here held the same view, either theoretically or clinically; at the beginning of the 19th century by no means in the repeatedly abbreviated, even falsely quoted controversy between the two schools of "psychics" and "somatics". Nevertheless, the term romantic psychiatry is fundamentally justified and makes sense as a heuristic guideline for research on the history of psychiatry (Benzenhöfer 1993; Body burn 1956; Marx 1990, 1991).

The romantic attitude to life expressed itself on a broader social, v. a. artistic level (e.g. romantic painting, music and poetry) and initially had no direct contact with psychiatry. This connection came about naturally, as the Romantics were interested in the affective, the incomprehensible and the mysterious, which, like Ricarda Huch (1920) called it, "night side of the soul" - and many of the experience and behavioral phenomena included in this were and are particularly found in people with mental disorders.

Look at the individual

The central concern of the psychiatric authors of this time was to bring the individual, individual life course perspective into the teaching of the causation, clinical appearance, course and treatability of mental disorders. Great importance was attached to the area of ​​affects, the “passions”, as it is usually called in the original texts. The main criticism of Enlightenment rationalism was that in the search for generally valid "laws of nature" it had emphasized the supra-individual rule too much and neglected the individual in its uniqueness and personal - also personally responsible - "becoming".

Psychic vs. somatic

The “psychics” among the romantic authors took the view that the “soul” could become sick out of itself, that there were “diseases of the soul” in the narrower sense. Exactly this was disputed by the "somatics" such as M. Jacobi (1775-1858) and C. F. Nasse (1778-1851). Contrary to a widespread misunderstanding, however, these were by no means psychiatrists with a materialistic attitude, but instead - a typically romantic thought - considered the “soul” to be something as immaterial as it was immortal, even divine, which therefore could not become ill itself; only the body gets sick. Apparent “mental illnesses” are in truth the psychological expression of physical disorders which, by the way, do not necessarily have to affect the brain, but can also be located in the digestive, circulatory or respiratory systems.

Heinroth and Ideler

Major psychiatric authors of this epoch, and both psychics, if you want to label them, were J. C. A. Heinroth (1773–1843) and K. Ideler (1795–1860). On the one hand, her writings contain excellent psychopathological descriptions, supported by a genuine interest in the individual in psychological distress, which can still be seen in the texts even after almost 200 years. Heinroth also designed an instance model of the psychological that was in parts strikingly similar to the later psychoanalytic concept, in which he differentiated between “instincts”, “consciousness” and “about us”. On the other hand, psychopathological findings were often linked to a speculative natural-philosophical or moral-religious background. Serious mental illnesses were interpreted as the result of a wrong way of life or "sinful behavior" (Cauwenbergh 1991; Heinroth 1818; Schmidt-Degenhard 1985).

The idea of ​​personal responsibility for one's own life, and thus, to a certain extent, for one's own illnesses, played a central role in the thinking of romantic psychiatrists. With Heinroth, this had a seemingly radical consequence in forensic terms: Who, according to Heinroth, commits a criminal offense in a state of severe disorder, may not currently have known what he was doing, but was still responsible for the act, since he got into psychosis (at least in part) was due to accusable misconduct. This is reminiscent of the controversial - and mostly discarded - concept of “guilt of conduct”, which was controversially discussed in forensic literature much later, but which was not applied directly to the criminal responsibility of psychotically ill people.

A pioneering role in romantic psychiatry

In spite of all the strangeness of some of the beliefs of romantic psychiatrists - often based on linguistic reasons - recent research has impressively demonstrated that the earlier - v. a. towards the end of the 19th century - but also today the general disqualification of this psychiatric epoch is unfounded, quite apart from its, albeit not undisputed, pioneering function for later psychodynamic and especially psychoanalytic approaches (see below).

Other important authors of this time are Johann Reil (1759–1813), who not only introduced the term “psychiatry” - originally: “psychiatry” - but also in his doctrine of “community feelings”, which is an interesting basis for that today Understanding of psychotic disorders, Ernst von Feuchtersleben (1806–1849), who developed psychotherapeutic and psychoeducational forms of treatment, and Carl Gustav Carus (1789–1869), who himself, decades before Freud, called the “unconscious” for one central, but partly unrecognizable force in the realm of the psychic held.

From Griesinger to "brain psychiatry"

From around the 1830s, a counter-movement set in which sought to align psychiatric research with the growing “positive” natural sciences. This complex process should not be confused with the controversy already discussed between the romantic schools of psychics and somatics.

An outstanding figure in psychiatry at the time, Wilhelm Griesinger (1817–1868, Fig. 2), can be claimed as the most influential proponent of the claim that clinical psychiatry had to face the psychophysical problem empirically and not metaphysically, that is, it had psychophysiological research to operate. The quotation, which is just as well known as it is often without context and abbreviated, according to which mental illnesses are brain diseases, represents the greatest possible conceptual condensation of Griesinger's well-thought-out concept, for which clinical diagnostics do not disappear behind a flat "brain mythology" (Hoff and Hippius 2001).
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Psychiatry as an empirical science

Griesinger, who, according to Ludwig Binswanger, “gave psychiatry its constitution”, turned against any kind of uncritical speculation, both natural-philosophical-romantic and materialistic. His main goal was to establish psychiatry as an independent, empirically working science that is committed to a medical ethos, that is, it takes mentally ill people seriously. To put it bluntly, his psychiatry was, in terms of its self-image, both a predominantly biological research program and an applied medical anthropology.

materialism

It is not entirely wrong, but it invites misunderstandings to call Griesinger a materialist without looking at it. The crucial addition must be that his materialism was methodical and not metaphysical. This connected him with the then influential philosopher F. A. Lange (1828–1875). The central idea of ​​this methodical materialism was the thesis - in comparison to the uncompromising materialists of the late 19th century, almost modest - that in the given situation a cerebral substrate and in this respect a "materialistic" approach in terms of research methods is scientifically most promising for the time being . And if the psychic is seen as a "function" of the neurobiological substrate, but as an independent phenomenon and not fundamentally denied, then - the declared aim of psychiatric research since Griesinger - the psychic will also be accessible to empirical-quantifying research. So it no longer remains, as with some romantic psychiatrists, especially the somatics among them, sealed off behind the qualification as "holy" or "divine" (Verwey 1985; True-Schmidt 1985).

Course aspect of "insanity"

Not only this roughly outlined research program, but a psychopathological concept, namely the idea of ​​unit psychosis developed together with his teacher Albert Zeller, head of the Winnenthal institution at the time, linked Griesinger's name from the publication of his main work Pathology and Therapy of Mental Illnesses (1845, 2nd ed., 1861) firmly with the basic questions of psychiatric nosology (Berrios and Beer 1995; Crow 1990; Mundt and Sass 1992; Rennert 1982). Even before Kahlbaum and Kraepelin, the process aspect was recognized as a moment that differentiated and ordered any nosology that was merely symptomatologically oriented. However, Griesinger was not concerned with a nosographic breakdown into individual disease units, but on the contrary, the representation of "insanity" as a single disease (unitary psychosis) that legally goes through several stages (Viegen 1980): Primarily the affective disorder, then the delusional derailment ("madness") with paranoid-hallucinatory and possibly catatonic symptoms, and finally, unless standstill or remission occurs, the severe and irreversible deficit on the cognitive and action level, in today's terminology a dementia.

However, Griesinger later accepted - not dogmatically either - Snell's description of a "primary madness" (1865), which does not need to be preceded by an affective preliminary stage, and at this point revoked his earlier conception. This debate is also anything but “just” historically interesting: the question of what type of disease or even unit of disease we are dealing with in psychiatry, whether we are talking about distinct categories or overlapping dimensions, is a controversial subject of the current one and certainly the future discussion as well.

City asylums vs. large clinics

Griesinger dealt intensively, which is often overlooked, with "social psychiatry", to use the current term. He clearly distinguished himself from the opinion held by Roller, the head of the Badische Anstalt Illenau: Roller postulated that mentally ill people should be treated as secluded as possible in quiet rural areas and in facilities specially created for this purpose, i.e. strictly separated from all other patients . Griesinger, on the other hand, called for the integration of psychiatric care into medical care. Specifically, this included v. a. the establishment of so-called city asylums (Griesinger's expression) for the acutely ill who require a rather short inpatient treatment. According to Griesinger, such “community-based” care facilities should be operated in conjunction with the existing general city hospitals, since close interlinking between referring physicians, clinics, further treatment and living environment is decisive for the prognosis (Bergener 1987; Rossler 1992).

The second half of the 19th century was the time of the founding of numerous large and, Griesinger's intention, completely opposite, mostly outside of the large settlement areas of psychiatric clinics (Jetter 1981). Independently of this, chairs for psychiatry and nervous diseases were established at most medical faculties during this period.

Advances in science

During the same period, the natural sciences, including biology, developed rapidly.Particularly important for psychiatry were the advances in neuroanatomy, namely the teaching of the cerebral localization of certain services such as motor skills and sensitivity, but also language and memory. This research direction was significantly promoted by the development of new techniques: Examples are the microtome designed by Bernhard von Gudden (1824–1886) for the production of very thin brain slices and more specific histological staining methods such as that of Franz Nissl (1860–1919) (“Nissl- Coloring").

Unreflected materialism

However, this progress has been accompanied by the tendency of some authors to overstretch the recently successfully established neurobiological paradigm and to speak out against a materialism that has hardly been reflected on. For authors such as the Viennese psychiatrist Theodor Meynert (1833-1892), psychological, especially psychotic disorders were nothing more than “diseases of the forebrain”, as his characteristic subtitle was 1884 published, influential textbook on psychiatry. Contemporary and later critics called the (university) psychiatry of the late 19th century, not entirely wrongly, “brain psychiatry”, “psychiatry without a soul” or mockingly, such as Jaspers, “brain mythology”. If one disregards the terminology that seemed strange today, the parallel between the then and now, in the 21st century, the pressing fundamental questions of the subject remains astonishing, such as the connection between subjectivity and brain function or the term `` around '' not to say the "essence" of mental illness as such (Kronfeld 1920). We shall come back to that.

Degeneration theory

The "degeneracy" or "degeneration theory" is nothing less than a theory discussed only among psychiatric specialists. Rather, it shaped the intellectual profile of the late 19th and early 20th centuries through literature, the natural sciences and, last but not least, politics (Chamberlin and Gilman 1985; Pick 1989; Wettley 1959). The part of this teaching that is particularly relevant for psychiatry took up decisive impulses from French psychopathology, v. a. by B. A. Morel (1857) and V. Magnan (1896). The approach was based on the assumption that an increasing "mental degeneration" can occur within a family over generations, with the range of mild psychological abnormalities such as nervousness or reduced resilience, marked affective disorders and psychotic episodes up to the most severe dementia (Hermle 1986; Liegeois 1991).

The psychiatric degeneration theorists - in the German-speaking world, for example H. Schüle and R. von Krafft-Ebing - relied on extensive observations and based their empirical data on a theory that was partly scientific (Magnan) and partly moral-philosophical (Morel). Other authors, on the other hand, linked the theoretical level of the thought of degeneracy with the empirical level in an even more direct way: Above all, the Italian school of criminal anthropology by Cesare Lombroso emphasized the diagnostic, indeed prognostic, value of somatic characteristics ("stigmata"), from their presence both on psychopathological relationships and the level of “degeneration” that has already been reached can also be deduced (“the born criminal”, Lombroso 1887).

Degeneration and race theory

The basic ideas of the theory of degeneration can be found in almost all psychiatric or neurological teaching texts of the turn of the century in a more or less clearly recognizable form. One example is Emil Kraepelin, a particularly influential psychiatric author, to whom we will come back in another context. The example is intended to demonstrate the widespread use of the doctrine of degeneration as well as the self-evident - for today's readers irritating - with which the corresponding terminology was recognized as scientifically acceptable, indeed required.

It is important to emphasize the need to deal carefully with this emotionally charged matter, which is important in terms of psychiatry history. Not every author at the turn of the century who uses the language of the “doctrine of degeneracy” may eo ipso be discredited as a direct intellectual forerunner or even proponent of National Socialist terror against the mentally ill.

Nevertheless - and this makes the situation so complex - the doctrine of degeneration and National Socialism are related to the concepts of social Darwinism and “racial hygiene” (see below) in a complex historical context. A simple cause-and-effect relationship is certainly not present here, but the degenerative theoretical doctrine, which is scientifically grounded, made it particularly easy for the even more speculative, even absurd, racial theories of the National Socialists to scientifically disguise their ideological distortions.

Use of the term degeneration using the example of Kraepelin

Many psychiatrists at the turn of the century, including Emil Kraepelin, made extensive use of the term degeneration: Kraepelin, who was anything but an apolitical scientist (Engstrom 1991), speaks again and again of "degeneration", also of the "degenerate", of "degenerative basis" and "inferiority". This becomes particularly clear in his description of - as we would say today - personality disordered, but also dysthymic or sexually deviant people. Nevertheless, it would be wrong to conclude that German-speaking psychiatry around 1900 had a completely uncritical attitude towards the theory of degeneration. In particular, after the “rediscovery” of the laws of inheritance described by Mendel, the rather vague concept of “degeneration” increasingly lost ground. In Kraepelin's case, for example, the extensive application of the degeneration theory contrasts in a peculiar way with his criticism of the conceptual vagueness of the concept, which he has repeatedly made. He speaks of the “uncertain and fluctuating boundary” of the term degeneracy (Kraepelin 1915, P. 1973). In 1918 he rejects the comprehensive explanatory claim of the theory advocated by Magnan: Even if, according to Kraepelin, his “efforts to fundamentally contrast the mental disorders of the degenerate with those of the healthy predisposition…, the close relationships between certain forms of insanity and hereditary disposition are shined in a clear light the sharp separation of those two groups has proven to be impracticable. ”(Kraepelin 1918, P. 253).

Differentiation between "healthy" and "sick"

Kraepelin's use of relevant terms such as “hereditary degeneration”, “pathological predisposition”, “mental developmental inhibitions” or “innate basic conditions” is anything but uniform. Sensing this very well, when differentiating between “healthy” and “sick”, especially in the case of the not clearly psychotic clinical pictures, he ultimately refers to the quantitative factor, namely the degree of severity, v. a. in terms of the psychosocial consequences of a mental disorder:

If, in the strictest sense, we were to regard all those innate properties as the result of degeneration which prevent the attainment of general purposes of life, we would nowhere miss their traces. We can only ascribe the importance of the morbid to the personal deviations from the predetermined direction of development when they gain considerable importance for physical or psychological life; the delimitation is therefore purely by degree and therefore arbitrary to a certain extent (Kraepelin 1915, P. 1973).

Ethical considerations

Consequently, Kraepelin has repeatedly warned against the careless implementation of such concepts in concrete measures. For example, he was skeptical of the American practice he mentioned of performing sterilization for certain mental disorders, pointing to the inevitable ethical dilemma:

The measure would undoubtedly be effective, but it seems difficult to determine with whom it should stop (Kraepelin 1903, P. 386).

Hereditary factors vs. personality and environment

Heimann (1989): When the later Tübingen professor for psychiatry and convinced National Socialist HF Hoffmann spoke in July 1920 at a meeting of the German Research Institute for Psychiatry led (and founded) by Emil Kraepelin about his racial hygiene and hereditary biological theses, Kraepelin expressed his approval for genetic research In psychiatry in general there are considerable reservations about uncritical conclusions from symptoms to underlying disease processes in particular. He emphasized that "the disease" does not lead directly to the clinical symptoms, but that personality and environment - that is, factors that are not or not decisively inherited - are of striking importance.

Degeneration theory as a conceptual background

For the author Kraepelin selected here as an example, the degeneration theory became a comprehensive, but not dogmatically applied grid, the conceptual background for the understanding of numerous mental disorders (Hoff 2008). This had the least effect with regard to dementia praecox (schizophrenia), most clearly with manic-depressive illness, paranoia and personality disorders.

Despite this poorly reflected general affirmation of the idea of ​​degeneration, Kraepelin clearly rejected biological abbreviations - for example in the sense of the "stigmata degenerationis". His attitude - and that of other contemporary authors - remained vague here in a similarly strange way as that of the relationship between the neuronal and mental level (“body-soul question”) or other fundamental questions of the theory of science, although Kraepelin, viewed superficially, in all editions of the textbook as well as in a study specially dedicated to this topic (Kraepelin 1908) commented on this several times in detail. In the German-speaking world, Bumke's study "On nervous degeneration" (1912) is seen as the decisive critique of the traditional form of the theory of degeneration.

The clinicians at the turn of the 19th and 20th centuries

Clinical-pragmatic progress research

Parallel to the development of the concept of degeneration, and in some areas clearly influenced by it, the clinical-pragmatic progress research came to the fore in continuation of the studies by Wilhelm Griesinger and Karl Ludwig Kahlbaum (1828–1899, Fig. 3) with Emil Kraepelin (1856–1926). Above all, Kahlbaum and Kraepelin found earlier systematics to be unsatisfactory, especially because too much weight was attached to the fluctuating clinical picture compared to the long-distance course. Both authors can be called “pragmatic” insofar as they were concerned with the most comprehensive and detailed clinical recording of the course of the disease, so that theoretical-systematic considerations could only be made on the basis of such empirical knowledge. With Kraepelin in particular, there is a clear skepticism towards in-depth scientific-theoretical considerations in psychiatry. Kahlbaum, on the other hand, designed a theoretically complex, but later forgotten nosological system that cannot be considered here. Clinically, Kahlbaum's name is v. a. associated with the description of catatonia, "tension insanity" as he called it (Kahlbaum 1874; Lanczik 1992).
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Emil Kraepelin

Emil Kraepelin (Fig. 4) continued the clinical research project begun by Griesinger and Kahlbaum in some aspects, but shaped it strongly through his own concepts. Like Kahlbaum, Kraepelin repeatedly expressed himself critically, even disparagingly, about the purely symptomatic approach to psychiatric diagnostics that many authors of the 19th century had. Although he did not fail to recognize that Griesinger had also worked out the course aspect, his already discussed concept of a “unitary psychosis” could not convince the pragmatic clinician Kraepelin. The decisive factor for the great influence of his work, which continues to this day, is likely to have been that Kraepelin legitimized and also legitimized psychiatry, which suffered from the terminological confusion of the 19th century, based on decades of clinical experience and thus "intra-psychiatric" - that is, not philosophically or neuroanatomically still provided a prognostic and thus pragmatically oriented nosological reference system.
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Concept of "natural disease units"

Against the background of the theory of degeneration, which he accepted to a high degree, but not uncritically, psychophysical parallelism, strict, if hardly discussed, philosophical realism and an unconditional orientation towards observable clinical reality were the cornerstones that made it possible for Kraepelin to use different methodological methods To align approaches towards a common research goal, namely the recognition of what he called “natural units of disease”. The central hypothesis of this approach is that in psychiatry, as in other medical disciplines, there are disease units that are predetermined by nature - in today's terminology: biological - which exist in exactly this way, regardless of which person is sick with them and whether or not the research deals with them.

According to Kraepelin, these units are by no means "constructed" by psychiatrists; they are not mere psychopathological conventions, but objectively existing and clearly separable entities, similar to what is possible with objects from the outside world, such as different types of plants. The very far-reaching postulate advocated by Kraepelin was that the psychiatric researcher, regardless of his respective research methodology - pathological anatomy, etiological-pathogenetic research or symptomatology, including the course - with sufficiently refined technology will necessarily move towards the discovery of the same nosological units, the “natural units of illness” that are already established before any research.

Psychiatric research and philosophy of science

Kraepelin was of course aware, and he also expressed this, the high standards he was articulating on psychiatric research. Far less clearly, however, he brought up the epistemological concepts that he explicitly or more often implicitly introduced, namely realism (here in the epistemological sense, in contrast to idealism), parallelism, naturalism and the methodological orientation of psychiatry on the experimental psychology of Wundt .

However, he discussed the fact that in clinical reality the boundaries between the individual mental illnesses can often hardly be drawn, although this is exactly what his model should demand. In his later programmatic works from 1918–1920, he tried to take this objection raised by himself, but also by numerous other authors, into account. Here are formulations that indicate a gradual weakening of the previously uncompromising conception of natural and principally recognizable disease units and the v. a. those of Birnbaum (1923) Weight factors called “pathoplastic” significantly more, such as the personality of the sick person, their living conditions and the quality of interpersonal relationships.

Nevertheless, if one examines Kraepelin's texts specifically with regard to this point, over the five decades of his psychiatric research there is no fundamental shift from the central idea of ​​the natural unit of disease to be ascertained (Hoff 1994).

The dichotomy of endogenous psychoses (dementia praecox / schizophrenia vs. manic-depressive illness), which is essentially based on progressive characteristics, is only one of many results of his diagnostic research, albeit without a doubt a particularly lasting one, namely effective up to the current operational diagnostic manuals (see below ).

Alfred Erich Hoche

A not fundamental, but clear alternative to Kraepelin's understanding of psychiatry comes from Alfred Erich Hoche (1865–1943), an important figure in psychiatry history in several respects. In the current context, it is about Hoche's stubborn criticism of Kraepelin's concept of "natural units of disease", which Hoche considered too speculative, or at least far premature.He spoke of the “hunt for the phantom” disease unit and, with an unmistakable allusion to Kraepelin's numerous small and large changes in the nosological limits, scoffed at the fact that a cloudy fluid - namely the clinical picture and the course of mental disorders - cannot be made clearer by pour them from one vessel into the other - so just give the disturbances new names (summarized in Hoche 1912).

Hoche proposed to postpone the question of natural disease entities as - temporarily or fundamentally - unanswerable and to devote himself to the development of empirically proven symptom complexes that fully meet the needs of practice and research. This approach, later called “syndromal”, has largely gained acceptance, although this does not in principle exclude the existence of disease units “behind” the syndromes. It is worth mentioning that Hoche was one of two authors of a book published in 1920 in which the "killing of life unworthy of life" is discussed from a legal and psychiatric point of view and is definitely approved (Binding and Hoche 1920). We shall come back to that.

Robert Gaupp and Ernst Kretschmer

Some other important conceptual contributions that appeared at the beginning of the 20th century should be mentioned: Robert Gaupp (1870–1953), Kraepelin's senior physician in Munich until 1906, and Ernst Kretschmer (1888–1964), both in Tübingen, devised a psychopathologically sound approach with which they diverged from Kraepelin's thinking in some ways, if not fundamentally.

Understanding access to the “incomprehensible” of madness

Gaupp felt v. a. to the question of the extent to which an understanding approach that emphasizes biography and personality development could at least in individual cases be able to resolve the “incomprehensible” of the madness, the madness thus as a psychologically understandable, albeit unusual reaction to a very specific constellation of psychological and social, but also understand physical conditions. Gaupp masterfully developed this subject on the basis of the “principal teacher Wagner” who he examined and who, as a result of psychotic experiences, killed his family and several uninvolved people in 1913 and started various fires. Gaupp kept in contact with Wagner until Wagner's death in 1938 and published numerous papers on the case (Gaupp 1920). Neuzner and Brandstätter (1996) have comprehensively reviewed Wagner's medical history, paying particular attention to his longstanding relationship with Gaupp and the plays and other literary texts he wrote.

Constitutional Approach

This research direction was supplemented and significantly expanded by Gaupp's student Ernst Kretschmer. Noteworthy in this context is v. a. his monograph on Sensitive Relationship Mania (1918). He took a constitutional approach, so he tried to identify certain physical characteristics, v. a. to bring the physique into a possibly even causal connection with psychological characteristics and disorders. Kretschmer called for a “multi-dimensional” diagnosis and thus also an assessment of the findings in what appears to be the most up-to-date today.

Carl Wernicke, Karl Kleist and Karl Leonhard

The important clinician and researcher Carl Wernicke (1848–1905) designed a psychiatric system that saw the endogenous psychoses in many respects analogues of the neurological systemic diseases. He dealt intensively with the psychotically disturbed expressive motor skills, especially with the catatonic symptoms. The school he founded was continued by Karl Kleist (1879–1960) and Karl Leonhard (1904–1988). These authors defined - far beyond Kraepelin's classification, which was perceived as too crude, v. a. rejecting his nosological dichotomy of endogenous psychoses - distinct mental illness units, which are to be sharply separated with regard to their genesis, familial burden, symptoms, course and therapy. Karl Leonhard expressed this idea most succinctly in his classification of endogenous psychoses (1980) worked out. This approach represents the opposite of the unified psychotic concept of Griesinger and Rennert.

Karl Bonhoeffer

Karl Bonhoeffer (1868–1948), after his time in Breslau from 1912–1938, for 26 years, director of the Clinic for Mental and Nervous Diseases at the Berlin Charité, postulated the “nosological non-specificity” of psychopathological symptoms by making the thesis that is still accepted today established that the brain realizes only a limited number of possible reactions to the theoretically unlimited number of noxae. This means that any direct conclusion from the symptom to the cause becomes obsolete (Bonhoeffer 1910).

Eugen Bleuler

The Swiss psychiatrist Eugen Bleuler (1857–1939, Fig. 5) was one of the few university psychiatrists who tried to integrate Freud's psychoanalysis into clinical psychiatry. Later, however, after increasing substantive discrepancies between Bleuler's and Freud's basic convictions had become apparent, he moved away from this position again, albeit by no means completely (Bleuler 1913; Küchenhoff 2001). After a critical summary of the available research results, Bleuler suggested following a lecture from 1908 (Maatz and Hoff 2014), no longer to speak of "dementia praecox" like Kraepelin, but in view of the symptomatological, but possibly also etiological-pathogenetic heterogeneity of these diseases, to speak of the "group of schizophrenias" (Bleuler 1911), a proposal that was widely accepted. Bleuler's distinctions between basic symptoms and accessory symptoms as well as between primary and secondary symptoms became important for the systematic recording of psychopathological phenomena: basic symptoms are present in every schizophrenic illness, while accessory symptoms can or do not have to be added. The second distinction is conceived quite differently, namely etiologically: According to Bleuler, primary symptoms resulted directly from the neurobiological disease process he suspected, while the secondary symptoms already represented psychological reactions of the person concerned to the disease. Bleuler's contributions on the course of schizophrenic diseases were trend-setting insofar as he abandoned Kraepelin's downright pessimistic view of the necessarily poor course of "dementia praecox" and described groups of partially or completely remitted patients. Christian Scharfetter (2006) has subjected Bleuler's work to a comprehensive and critical appraisal from a psychopathological and epistemological perspective. The volume also contains a text by Manfred Bleuler (1903–1994), son and (not immediate) successor of Eugen Bleuler in the management of the Zurich University Clinic “Burghölzli”, which is remarkable in terms of psychiatry history. Recently, there has been a remarkable increase in scientific interest in “classical” positions in the history of psychiatry, including those of Eugen Bleuler (Bernet 2013; Berrios 2011; Dalzell 2010; Kuhn and Cahn 2004; Maatz et al. 2015; Schott and Tölle 2006; Stam and Vermeulen 2013).