The foundations of modern clinical psychiatry were laid in the early and middle part of the 19th century. The focus of interest among the 'alienists' responsible at that time for the care of the 'insane', was on persons with mainly psychotic forms of mental disorder who required admission to a mental hospital for treatment. Those with more benign forms of illness rarely came under the observation of the early psychiatrists.
The modern era in the classification of mental diseases began towards the end of the 18th century during the French Revolution with the concepts and humane practices of figures such as Philippe Pinel (1745–1826). William Cullen (1710–90) tried to subsume under the heading of 'neurosis' all forms of mental disorder including such conditions as tetanus, epilepsy, vesania, and a rough description of psychosis, but his concepts soon proved over-inclusive.
The term 'psychosis' was first formulated by Ernst von Feuchtersleben (1806–49) in his Principles of Medical Psychology. He considered that all psychoses belonged to a single class of mental disorder in which the neuroses were also included. But in German psychiatry of the time neuroses were regarded as non-illnesses and this concept survived during the century that followed.
The concept of unitary psychosis or Einheitspsychose arose from another source (Griesinger 1867). This view was challenged by the important contributions of French psychiatrists and at a later stage by the seminal work of Kraepelin, whose enquiries served to establish the distinct psychotic entities that have survived well into the modern period. The observations of the French psychiatrist Morel in 1852 were important because he isolated from unitary psychosis a distinct disorder, commencing in the second decade, leading to withdrawal from social contact, odd gestures and delusions, and later to increasing self-neglect and mental deterioration. He named this condition démence precise.
Another syndrome, named as 'catatonia', a state of rigid immobility and suspension of speech, was described by Kahlbaum (1863). The condition called 'hebephrenia' by Heller (1871) begins in the teens, marked by incoherence of speech, incongruity of emotion, social withdrawal, hallucinations, and delusions.
Kraepelin came onto the psychiatric scene during the last quarter of the 19th century. The early period of his work with Wilhelm Wundt had taught him the value of experimental method, and scientific approaches generally, for psychology. These experiences exerted a powerful influence on Kraepelin's later career. The achievements of Kraepelin stemmed from his personal qualities and his disciplined approach to psychiatric theory and practice. He was a painstaking observer and made copious notes on each patient. He attached considerable significance to the course and outcome of specific characteristics of disorders and set down a large corpus of clinical observation.
His account of dementia praecox in the fourth edition of his Textbook (1893) also appeared in the next edition (1897), as a disorder with features of disorganization of the personality leading to blunting and incongruity of the emotions and impoverishment of volition. The fifth edition of his Textbook (1897) included a more extensive account of each of the variants and he later added a fourth ('simple') version of the illness. His talent for identifying both unitary concepts and lines of demarcation enabled him to lay the foundations of the modern syndrome of schizophrenia by uniting three disorders: the catatonic, hebephrenic, and paranoid forms ('simple' schizophrenia was added later), of the disease. Paranoid schizophrenia was dominated by delusions of persecution. In the light of the clinical profile and observations during follow-up studies over long periods, these three syndromes appear to have similar properties in their clinical manifestations and prognosis in the long term.
Kraepelin had first accepted from the French school dementia praecox. He later accepted the term 'schizophrenia' as used by Eugen Bleuler (1857–1939), a professor in Zurich, who had been influenced by the teaching of Sigmund Freud and who spoke of the 'splitting' of mental functions. Bleuler adopted a more psychodynamic approach and a more optimistic view of the outcome of schizophrenia than other psychiatrists. The syndrome of paranoid schizophrenia continues to be unacceptable in France at the present time.
Another original contribution made by Kraepelin was the integration of a number of disorders of mood into a single entity. Some decades previously the French psychiatrist Falret had referred to the most specific psychiatric disorder of mood as 'folie circulaire' (Falret 1854) The central feature of this illness was fluctuation of the emotions, which varied between abnormal elation and sadness, both being of greater severity and depth than normal emotions so named. Pathological elation is associated with explosive anger and irritability and grandiose, paranoid and other delusions (Baillarger 1853). There were intervals between alternations of mood when the mental state returned to its normal form.
There followed a multiplication of disorders. It was Kraepelin who recognized the more attenuated period of affective disorder. He named this as 'cyclothymic temperament', which he regarded as minor mood variations of a single disorder he called 'manic–depressive' illness. The mild forms of 'cyclothymic' states may retain their character as a subclinical fluctuation of mood throughout life which constitutes the soil in which the more severe disorders develop.
A high proportion of those with a 'cyclothymic temperament', as conceived by Kraepelin, continue to have fluctuations of mood throughout their lives without ever crossing the frontier which leads many to develop psychotic illness. The relationship between cyclothymia and manic-depressive disorder closely resembles that between a proportion of those with neuroses such as obsessional or somatoform disorders and anxiety states with disabling hypochondriacal symptoms associated with constant self-scrutiny in seemingly normal subjects. The main classes of psychiatric disorder and an outline of the hierarchical systemThe main descriptive classes have been set down in Table 1, which represents the order of precedence of the conditions and the manner in which ambiguities are resolved when there is an overlap between different conditions. The order of precedence in hybrid cases is identified on the basis of the psychiatric clinical features alone. There is insufficient knowledge of causation to create a taxonomy based on established causal factors included in a clinical profile that do not necessarily decide the clinical diagnosis or position of the disorder in the hierarchical system.Level 1 Organic Syndrome At the head of the hierarchy are disorders that have organic features in clinical manifestations, namely states of 'delirium', 'clouding of consciousness', 'amnestic syndromes' (Korsakow), and 'dementia'. The rationale for placing the organic disorders at the head of the hierarchy is twofold.
The first is that if there is co-morbidity between the organic syndrome features and some features of other personality disorders or other psychiatric entities, the organic part of the total picture will often be the most severe and urgent component and also the one more likely to have a compelling need to be treated first. This refers to cases in which the symptomatology includes features suggestive of a stroke, a haemorrhage, or some cardiovascular emergency.
The second is that some of the organic features co-morbid with the organic disorder (so-called organic syndrome proper), which play a part in causation, might be relieved by treatment administered for alleviation of the organic cluster of features alone, for example paranoid symptoms and psychotic features arising from common independent contributors, and may prove beneficial for the control of one or more co-morbid features.Level 2 SchizophreniaSecond place in the hierarchy is allocated to schizophrenia, which is thereby given precedence in diagnosis over the clinical profile of the next step in the hierarchical order: the chronic paranoid psychoses (non-schizophrenic).
The clinical profile of schizophrenia represents a qualitative departure from normal mental functioning and in Jaspers's terms constitutes a break in continuity of psychic life.
The symptomatology comprises delusions, which are persecutory, grandiose, or derived from the realm of religion, or have a sexual content. There are hallucinations usually related to the delusional theme — most commonly auditory or are often visual, olfactory, or tactile. A female patient complained of being sexually violated by strangers working with 'atomic machines' distant from the hospital.
Speech and talk exhibit frequent derailment and incoherence. Negative symptoms include flattening of mood, and mental excitement in which violence to the self or to others nearby may occur. There is poverty of thought and impairment of initiative.
The criteria of Kurt Schneider (1897) are widely regarded, particularly in Europe, as being highly specific for and diagnostic of schizophrenia. They continue to be used and quoted but their value can be realized only in patients in whom a full psychiatric history and examination have been undertaken. Schneider's criteria are listed in Table 1.
Table 1. The hierarchical principle in psychiatric diagnosis (schematic and simplified)
In recent years complex syndromes, combining schizophrenic and affective psychotic features, have appeared with greater frequency. The illness is associated in a substantial proportion of cases with an addiction to cocaine, heroin, chronic alcoholism, or other groups of drugs. Criminal and other antisocial behaviour and a steep decline down the social scale or other forms of personality disorder are manifest in some cases.
According to some authorities bipolar disorder should be given precedence in diagnosis as against melancholic and depressive disorders. This may be justified in practice but no evaluation of the proposal has yet been published.Level 5 Neurotic disorders.(The forms of the disorder are summarized in Table 1.) The psychotic and endogenous affective disorders take precedence in the hierarchy over the depressive and other neurotic disorders. There is an absence of psychotic features such as delusions and of the typical cluster of specific biological changes, such as a tendency to early waking and diurnal variation of depression. Many forms of neurotic disorder respond to treatment with psychotherapy often combined with supervised biological treatments.Level 6 Personality disordersPersonality disorders are characterized by a lifelong disturbance in behaviour, in personal relationships, social adjustment, and emotionality. The main features of maladjustment can be of disabling severity.
Neurotic disorders frequently appear in a setting of personality disorder. Neurotic breakdown is commonly manifest in the course of those with personality disorder. But those with compensating personality traits or high intelligence frequently respond to behavioural, cognitive, or dynamic therapy. The underlying personality disorder responds less favourably. The presence of alcohol, drug abuse, or unresolved sexual conflicts create further obstacles to improvement. But individuals with assets in the form of positive and constructive features can be helped to achieve a satisfactory adjustment.Recent developmentsThe new biological era from the 1950s onwardsDuring the 1950s the discovery of a number of powerful agents which exerted a therapeutic effect in psychiatric disorders marked the onset of the 'biological revolution'. ECT had appeared earlier but it had remained stationary over some decades. Pharmacological studies initiated a succession of significant findings regarding transmission of messages in the brain and the effects on it by a range of neurotransmitters.
The first discovery was that of lithium by Cade in Australia. This and other discoveries emerged, not as a result of research after a specific hypothesis about causation but as a result of serendipity. Cade's discovery was first observed in animals and proved to have a strikingly mitigating influence upon the alternating manic and depressive symptoms in bipolar disorder. This occurred in 1949. It was not until the long period of obstinate criticism had been overcome that this method of treatment, as described by Mogens Schou, began to spread among psychiatrists and in the process brought to light a wealth of discoveries regarding the phenomenology of this disorder.
Other treatments with the same effects emerged and were used as substitutes in cases inactive to lithium. These included carbamazpine whose effectiveness was discovered by Takasaki et al. and valpromide also used in bipolar disorder, another alternative against this form of mental turmoil. Imipramine was discovered as treatment for depressive illness in the course of open clinical observation by Kuhn in 1957. Within a short period and before clinical trials had firmly established its efficacy, its adoption in practice made rapid progress alongside other treatments for affective disorder.
Other new drugs were capable of inducing total remission in a small proportion of patients with schizophrenia, but induced a remission of a more limited kind in a larger group. These were far from cures but they mitigated the disease and opened up possibilities for rehabilitation and possible discharge of patients into the community.
In addition, advances were recorded in diagnosis and classification of psychiatric disorders.Progress in the development of classification and diagnosis of psychiatric disorders since 1950: a paradigm shift in the concept and diagnosis of psychiatric disorderOne of the most important factors in the revolution of what has come to be called the era of biological psychiatry (in the broad sense of the term) has been the advances achieved in the classification and diagnosis of psychiatric disorders. Surveys undertaken by national and international psychiatric organizations at the beginning of the period reveal wide differences in psychiatric diagnosis reflected in figures of prevalence elicited by epidemiological enquiries and in the results achieved in the treatment of psychiatric disorders since the early 1950s.
Professor Erwin Stengel was invited by the World Health Organization to survey the situation and make recommendations in respect of the unreliability of standardized tests for the examination and diagnosis of psychiatric disorders. This was held up by a grave impediment to the advancement of clinical practice and scientific progress in psychiatry. Professor Stengel had wide-ranging credentials for this task. He had been trained as a clinical psychiatrist by Schulder, also as an immunologist and as a Freudian psychoanalyst in Vienna. He quickly identified the conservatism of the inevitably large international committees, which failed to secure general agreement to all innovations. Their speed was dictated by their slowest members. His second insight would prove a more dynamic one. He met Professor Carl Hempel in the early 1950s, and he recommended the use of 'operational definitions' for all mental syndromes and separate features used to identify them. This proved a fruitful path to follow. Its beneficial effects were manifest in the improvement in the reliability of psychiatric diagnosis in clinical and epidemiological practice that was recorded at an early stage of this period.
These recommendations slowly began to exert a radical influence upon the two main diagnostic scales employed in the classification of psychiatric disorders. In the United States, whose psychiatric populations were the largest and most influential in the world at the time, one scale was the Mental Health Section of the International Classification of Diseases. In 1959 Stengel, working for the World Health Organization, reported a poor level of reliability in studies undertaken for the 8th edition of the International Classification of Diseases. The second was the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
In 1972 Feighner et al. in the United States used operational criteria developed for psychiatric research and applied them in the form of clear, specific inclusion and exclusion criteria for a clinical trial. This study came from the Department of Psychiatry in St. Louis, Mo., which was under the direction of Sam Guze and Eli Robins. The results of this limited study were the first step in the rapid development that led to the American system of diagnostic practice employed by the American Psychiatric Association.
1980 saw publication of the first full edition of the 3rd version of the Diagnostic and Statistical Manual (DSM-III). The next stage was to eliminate errors and make other modifications to the script that had not been completed for the 1980 edition. The final completed edition (DSM-IV) appeared in 1994.
An important outcome of the close collaboration on DSM-IV was with the investigators of the 10th edition of the International Classification of Diseases (ICD-10), whereby each of the teams appointed representative members of each of their most important working committees to function alongside the corresponding committee of the other organization.
In consequence, DSM-IV and ICD-10 were similar in all essential respects. DSM-IV, with both the teams working on diagnostic problems in the World Health Organization and in the American Psychiatric Association, suddenly acquired access to a greatly expanded potential readership, with opportunities for developing a greater range of joint international enquiries into a range of epidemiological, social, biological, and therapeutic problems.The hierarchical order of psychiatric clinical syndromesIt was noted that in the disorders described so far and the theoretical disputes about their classification, virtually all the conditions were major psychiatric illnesses, such as schizophrenia or manic-depressive psychosis and disorders related to them. Leading clinicians and investigators who laid the foundations of clinical psychiatry towards the end of the 19th and the beginning of the 20th centuries, in Germany, France, and to some extent the Scandinavian countries, seemed to evince little interest in the neuroses and personality disorders. Their scientific papers were devoted to schizophrenia, paranoid and other delusional states, manic-depressive illness, general paralysis of the insane — their classification, diagnosis, and treatment and the philosophical and legal problems they posed.
One reason for this exclusiveness was that in the mental hospitals in which they conducted their work, the majority of those who had been admitted for psychiatric reasons were suffering from mental disorders that fell into one of the psychotic diagnostic groups cited. A high proportion had been admitted on a compulsory order and had to spend many months or years in hospital. Kraepelin, who was familiar with these disorders and referred to neuroses and personality disorders as 'psychopathies', made it clear in firm sentences that these patients were not suffering from psychiatric illness, or indeed any other medical disorder.
It was well into the modern era, in the 1950s, that Kurt Schneider, the famous German psychiatrist and pupil of Kraepelin, wrote a letter to German psychiatrists stating with a certain emphasis that neurotic and personality disorders did not constitute a medical illness. These patients, he stated, did not require medical treatment although psychotherapy might be useful for them.
However, towards the end of the 19th century a gifted young neurologist named Sigmund Freud moved into a field in which he had already published some works of distinction, to study patients with such conditions as 'hysteria', 'phobias', 'anxiety states', and 'personality disorders'. Moreover, he began to treat these patients at first with hypnosis and later with the aid of psychoanalysis. He interpreted it as testifying to the consensual correctness of his theories of causation of mental disorders, such as those which emanated from the vicissitudes of unresolved conflicts, generated during the period of development between the early formative years of childhood and the adult mature personality.
Unlike clinical psychiatrists at the beginning of the 19th century, whose work was mainly devoted to the care of chronic psychotic patients and those with organic mental disorder, Freud devoted much of his time to the care of patients suffering from neuroses and personality disorders. They included eating disorders, drug dependence, and some with aggressive behaviour whose symptoms showed paths of continuity with their previous personality traits.
Personality disorder is much more often a predisposing factor in a cluster of psychiatric symptoms and signs rather than the actual cause of the presenting disorder. (In DSM-IV it is classed on Axis II as a concomitant contributory factor.)
By the second half of the 19th century systems of classification had developed to the stage at which classification of psychiatric disorders was already beginning to resemble the psychiatric classifications implemented in our time and used in the majority of countries that provide services for psychiatric patients. There was a variety of causal theories regarding the origin of the different syndromes with little evidence or knowledge. At present, descriptive terms of the phenomena of mental illness fall into six groups of disorder which are shown in Table 1. It will be noted from the ground covered earlier, that most of these groups were already recognized by the last few decades of the 19th century. The two main groups of psychotic disorder were widely accepted and the area of neurotic and personality disorders had been noted.
An early system of classification was that of Philippe Pinel, an intrepid and compassionate psychiatrist who had liberated the insane from their chains. His classification was simple and did not survive, but the force of the example he had set at the Salpetrière had inspired leading psychiatrists in France, where a beginning had been made in defining, for example, the two main groups of psychosis, and provided the early foundations for Kraepelin's major contributions.
The terms used by Jaspers to define the main phenomena of mental disorder were not purely descriptive. He amalgamated aetiological and descriptive criteria and included genuine epilepsy as a major 'functional' psychosis. He was in advance of his time in grouping neuroses with 'abnormal personalities' and combining them under the heading of 'psychopathies'.Axis classificationA number of modern classifications have included multi-axial sections comprising several headings in respect of which information has to be provided. For example DSM-III and its successors (DSM-III-R, DSM-IV, etc.) include axes under five different headings.Axis IIn both the DSM and ICD systems of classification Axis I is derived from application of the clinical diagnostic criteria to the history and the findings recorded by examination of the patient. The character of the clinical items that have to be provided in relation to Axis II differ from those which have to be specified under Axis I. In the latter all items form part of the clinical profile of the illness under examination and the patient's experience of it. There is no specific link between the items other than the first (which represents the clinical diagnosis derived from Axis I). The items in Axis II relate to associated features that may be relevant for the causation, treatment, and management of the patient and for the prognosis of his condition. They may stem from such items as physical illness due to the age of the patient or his social status, employment, or religious affiliation. They do not necessarily discriminate the patient from other psychiatric disorders and may have no link with any operational inclusion criteria for diagnosis.
The information on the other axes helps to complete the clinical picture and may be relevant for management and prognosis of the patient's illness. But they differentiate the patient less sharply from those with other illnesses than the lists of operational criteria defined within schedules such as DSM-III and IV and ICD-10.Axis IIThis is an associated feature only of some 40–45 per cent of those who present with obsessive-compulsive neurotic disorder as recorded on Axis I. But the personality disorder under this heading may occur in depressive, anxious, obsessional, and many other forms of illness. It also occurs as a normal variant that does not call for treatment. It may in fact be one of the patient's most valuable assets as an individual. It may occur in mentally normal individuals.
A similar statement can also be made with regard to schizoid personality. It is a feature in a proportion of those with current or prior schizophrenic illness. Something similar can be found in other disorders, as in obsessive-compulsive neurosis, paranoid psychoses, in socially isolated individuals who are, despite this, not schizophrenic.Axis IIIrequires specification of a general medical condition. Such information needed to be added and taken into account and set down in the patient's record. Here again physical illness is a common co-morbid condition in psychiatry and gains increasing prevalence with age.
In the treatment programme of psychiatric patients most include a detailed record of physical illness and disability. But it fails to discriminate in the form of disorder diagnosis under Axis I. In dealing with patients in old age it will be found in a high proportion of subjects, either in chronic or acute form. The diffuseness of its prevalence disqualifies it from inclusion among the operational cluster of clinical symptoms and signs which have to be evaluated in order to make a diagnosis.Axis IVA response to Axis IV calls for information regarding psychosocial and other environmental problems. The information gathered under this heading is clearly of relevance. But there will be considerable variation in prevalence of these psychosocial and environmental problems and it is necessary to make a general statement regarding all psychiatric conditions in respect of this axis. It has no precise diagnostic value except for the genesis of maladjustment and conflict for which certain characteristic features of the patient's basic personality may be manifest.Axis VGlobal assessment of function is a basis for assessment of progress or deterioration of the individual's mental health and social achievement. In the course of the disease it may be of crucial importance in accordance with Kraepelinian criteria. The school of Kraepelin which continues to exert a major influence on German psychiatry yields information that makes, as Kraepelin insisted, a specific contribution to diagnosis; in true schizophrenic illness the patient's personality deteriorates according to this school. This is probably the case in a high proportion of patients with hebephrenic schizophrenia or one that arises in a setting of a markedly abnormal personality. Recovery from the illness can be treated, according to some European psychiatrists, as an unequivocal refutation of the diagnosis of schizophrenia.Neurosis and PsychosisDuring the past fifteen years the terms 'psychosis' and 'neurosis', which were previously used in most systems of classification of psychiatric disorder, have been gradually eliminated from the main systems of classification, namely those embodied in ICD-10 and DSM-IV to which reference has been made above.
It has been claimed that use of such words as 'neurosis' and 'psychosis' add little or nothing to the information conveyed by the specific disorder from which the patient is judged to suffer, namely anxiety neurosis or schizophrenia. It is also stated by critics that criteria which are cited as discriminating between these two concepts are vague and unreliable. These views fail to take account of the role played by neurosis and psychosis as organizing concepts in clinical diagnosis and prediction.
The great majority of cases of neurosis can be understood as a quantitative measure of the patient's emotional life, intellectual functioning, confidence, and self-esteem. In psychosis, the contrast changes and qualitative delusions and hallucinations have no antecedents in the patient's premorbid mental life, whereas anxiety, depression, social phobia, agoraphobia, and obsessional neuroses are found to have premorbid antecedents in a circumscribed and non-disabling form. If compelled, the patient seeks help simply because the corresponding traits with which they could cope have undergone an incapacitating change in severity.
When a full history has been taken of the patient's development and adaptation of the premorbid state and an assessment has been made of the personality and the circumstances in which the neurotic disorder evolved, his/her illness can, with the help of empathy, usually be understood. This is not the case in psychotic disorders. There may have been a stepwise experience in the form of adverse circumstances, but the auditory hallucinations, the feelings of passivity, the incongruous emotions, the incoherent speech, have no understandable connection with the appearance of the first symptoms and signs. Jaspers brought these features of schizophrenic psychosis together by referring to them as a break in the continuity of psychic life. There is no such break in cases of neurosis. The continuity of mental life is maintained. With the exercise of empathy it is possible in neurosis to establish contact with the inner life of the patient and a therapeutic relationship can be established with the aid of the contact achieved. In psychotic illness, attempts at empathy usually fail.
Finally, in the great majority of civilized countries and some relatively primitive societies, the law makes a clear distinction between psychotic and neurotic disorder in its attitude towards responsibility for and treatment of those accused of serious offences such as murder. If an individual charged with killing or taking part in the killing of another person had an abnormality of mind which impaired his mental responsibility for his acts, he would not to be convicted of murder. 'Insanity', which invariably refers to psychosis, defends him from conviction of a charge of murder.
Neurosis, no matter how severe, is virtually never accepted as a condition that means an individual is not held to be mentally responsible for an act such as murder, though it might serve to mitigate the sentence. The law therefore recognizes a clear distinction between neurotic and psychotic persons. The abolition of the psychosis/neurosis dichotomy does nothing to limit the punishment of those with neurosis, and threatens to eliminate the compassion which once protected those who in their mental turmoil can neither form intent nor recognize the difference between right and wrong, from inhumane and unjust punishment.Summary and conclusions and possible future paths of enquiryIn psychiatry, as in other medical and scientific disciplines, advances in classification have been generally followed by progress in the recognition and treatment of mental disorders. A critical turning point was marked in the 1950s when the unreliability of the existing methods of discriminating between those with psychiatric disorder and those unaffected was recognized.
Erwin Stengel played a leading role at that time. He was quick to identify the defects in the instruments for establishing clinical diagnoses in psychiatry. He recommended the use of operational diagnostic definitions for all psychiatric syndromes and the features of their clinical profile. Each feature of the disorders had to be specified and described in lucid, unambiguous, and consistent language to ensure consistency by different participants.
Increasing expertise in Great Britain and the United States in particular from the 1950s onwards endowed the findings with greater authority. They also gave impetus to psychiatric research into neuropharmacological, biological, neurochemical, and genetic origins of the diseases. The influence of 'biological psychiatry' evolved in an exponential manner.
It is perhaps in the affective disorders that the course of the disease is transformed as compared with what was achieved in the past, for example, the discovery of effective treatments for manic–depressive (bipolar) disorder in the 1950s and drugs which improved the prognosis in schizophrenia. To a more limited extent there were advances in relation to some neurotic disorders, those with predominantly depressive or anxiety symptoms in particular. This ignited scientific enquiries into the mode of action of new pharmacological compounds, research to define the fundamental cerebral mechanisms and the neuronal pathways involved, and the neurotransmitters and their interconnections which mediated them.
Hypotheses were also investigated in attempts to define the normal function of the newly discovered drugs and the role of the underlying cerebral functional systems that came to light in normal mental functioning.
The new knowledge has transformed the chances of relief or recovery in manic depression ('bipolar disorder'), schizophrenia, and paranoid psychoses. Special mention is perhaps deserved by the mental disorders of old age. This area has been transformed during the period from one of general gloom and despondency to one in which a number of disorders formerly regarded as due to 'senile' cerebral degeneration have been shown to respond well to treatment. This has led to scientific developments which show high promise of coming to fruition (Roth and Iversen, 1986, Wischik et al. 1997).
In contrast to these achievements there is a whole range of disorders in psychiatry presenting challenges not only to families but to societies where the progress of enquiry and understanding has stood relatively still. No significant advances have been made in countering the growing problems of addiction to hard drugs such as cocaine, heroin, and dextroamphetamine, established addictions developed against a background of personality disorders.
'Histrionic personality disorder', 'paranoid personality disorder', 'narcissistic personality disorder', 'antisocial personality disorder', 'borderline personality disorder', schizotypal personality, and psychopathic personality with addiction to cocaine and heroin, and personality disorders with chronic alcoholism, are some of the disorders of personality which have become increasingly prominent in psychiatric practice.
Nor has there been progress in research into conditions more in the clinical stream, such as anorexia nervosa, a state of self-induced starvation, often seen in the setting of high intelligence or other gifts, alcoholism, or addiction to hard drugs. There is no decrease either in the number of those who simulate disease in order to gain the comfort they derive from medical care and attention. These are individuals who simulate surgical emergencies or fabricate haemorrhages or other states resembling medical crises to gain admission to hospitals for medical attention. A disturbing aspect of the phenomenon of Munchausen syndrome by proxy has been the infliction of artefact injuries, or the addition of insulin or other potentially lethal substances into blood or other fluid being administered to patients by intravenous drips, a crime for which several parents and nurses have received sentences of imprisonment.Jaspers's contributionLong before the concept of phenomenological psychiatry there was theoretical consideration of the relationship between psychotic disorders on the one hand and personality and related disorders on the other. Jaspers, a pioneer of modern psychiatry, had devoted considerable effort to drawing a sharp distinction between the two types of psychiatric disorder. There were those suffering from disorders that could be understood with the aid of empathy into the patient's mental processes and attitudes. The presenting disorder is found to emerge as a result of a continuous 'developmental' process which culminates in the emergence of a neurotic and/or personality disorder in adult life.
On the other hand there were those suffering from disorders that were beyond the reach of comprehension. Insight and understanding into the condition manifest could not be gained by any such effort. Conditions such as schizophrenia and manic-depressive psychosis entailed a break in the continuity of psychic life, to advance beyond comprehension into intervals of illness, or into a state sustained for the rest of the lifespan, even after the patient had suffered and displayed many attacks, and bore no relationship to any progressive, dynamic sequence which could provide an explanation.
The first of the two forms was given the name 'development' by Jaspers. This issued from his observation that these states evolved gradually and continuously to manifest in adolescent or adult life. With the aid of empathy he had achieved entry into the inner life of his subject during years of investigation in attempts to understand how the vulnerable facets in the personality evolved. In contrast, psychotic disorders such as schizophrenia, which he named as 'process', were impervious to enquiry to deepen understanding or attempts at treatment by psychological means.
Jaspers's concept of mental disorder was wide but consistent with his general theory, unlike some psychiatrists who regard anti-social forms of personality disorder as being more a problem for the law and police than psychiatry. Those who covertly inflict injuries on themselves or those who harm or kill others are not psychiatric problems; anorexia nervosa is not a disease, but it has complications of disease and episodes of self-display and narcissistic excess. Eating disorders simply reveal immature or hysterical personalities. The addictive gambler ruins himself and his family and the personality disordered alcoholic dies of liver or cardiac disorders.
With some of the disorders listed here psychiatrists have a compelling duty to collaborate with the police and the law. But they cannot neglect clinical and scientific interests in these phenomena, which cannot be omitted from consideration in attempts to gain insight into the psychopathology of personality disorders.
In recent years cognitive and behavioural therapies have achieved significant results and some significant findings in patients with neuroses have been recorded. These are less expensive, more effective and dynamic than psychoanalytic methods. Very little has been written about phenomenological methods of psychotherapy, which approach the patient through empathy and identification carried out by an experienced and sensitive psychotherapist. This would prove to be a valuable task by trying to map the landscape of inner experiences and observe the results of the course of treatment.
The German psychiatrists who exerted a powerful influence on European clinical and therapeutic psychiatry regarded personality disorders and neuroses as being out of the scope of medical practice. Jaspers's concepts were far wider. He was the first psychiatrist to state boldly that personality disorders, including whatever repugnant offences had been committed by psychopathic criminals, had an important place in psychiatric theory and practice. His writing, as embodied in his classical work (Jaspers 1913), conceived psychiatry in particular terms, enabled to do this by his wide interest in literature and art and his philosophical training and originality. His contributions to philosophy before and after his departure from psychiatry have been widely regarded as original, lucid, and profound.
His views of psychoanalysis took account both of its contributions and shortcomings. His wisdom and compassion for those who suffer in mind and the breadth of his intellect endow his reading with deep interest. His book General Psychopathology (1913; trans. into English 1963) was widely acclaimed but very few psychiatrists proceeded to carry his contributions further with the aid of fresh research. There has been only a thin trickle of papers and Jaspers has described the methods in use in empathic approaches to patients as crude. Other contemporary variants of psychotherapy, namely cognitive and behavioural psychotherapy, have failed to make any deep or lasting contribution to those with personality disorder whether anti-social or neurotic in its expression.
As the few cases described by Jaspers and some of his colleagues are stimulating and of profound interest, there is a need to carry his work into contemporary psychiatric research and clinical practice. Initial work would have to be on an individual basis. This would not be scientific in character but would form the basis of a preliminary classification of psychopathology as detected by empathic approaches to the relationship with the patients and to the techniques employed in treatment. There is good reason to anticipate that such studies would bring order and understanding to the personality disorders in particular, and also to neuroses and their relationships to normal states of mental distress and suffering.
(Published 2004)
— Martin Roth
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