Rerun: A Kraepelin Appreciation (Why his 1921 opus is way ahead of the psychiatry of 2011)

I've been running a series of pieces on Hagop Akiskal. This is the dude Akiskal looks up to. From June last year ...

I've just been reading Emil Kraepelin's classic "Manic-Depressive Insanity." Never heard of him? Bet you heard of Freud, who was born the same year. All Kraepelin did was "discover" manic-depression, schizophrenia, co-discover Alzheimers, and found diagnostic psychiatry. His body of work, based on meticulous observations of thousands of patients in German asylums, spans from 1893 to 1927. "Manic-Depressive Insanity" was published in English in 1921, extracted from his much larger "Compendium."

Kraepelin's pioneering approach to classifying mental disorders inspired the modern DSM-III and IV, though - ironically - he has to be rolling in his grave over how both editions got manic-depression all wrong. Let's hear from the source what manic-depression really is:

Manic-depressive insanity ... includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia.

Plus "colorings of mood" that embrace both pathology and personality.

All these diverse elements, claims Kraepelin, "represent manifestations of a single morbid process."

In other words, someone who cycles up and down, gets depressed, flips into mania, has messed up thinking, and has stuff going on with moods is suffering from one illness, not  five, not twenty-five. Equally important, the depression itself (even without evidence of mania) is strong evidence of manic-depression, not something else. All this was revolutionary thinking way back in the first part of the previous century, and still remains ahead of the curve in the first half of this one.

Kraepelin's view of manic-depression, then, is vastly more inclusive than the modern DSM's "bipolar disorder," which does not recognize recurrent unipolar depression. Modern psychiatry, instead, lumps recurrent depression with chronic depression, which explains why antidepressants don't work for a good many individuals and can even cause harm.

You would think the DSM-5 would fix this, but do psychiatrists listen?

In addition to offering finally-detailed clinical descriptions of depression and mania, Kraepelin identified transient "mixed" states. Here, we can truly appreciate the master at work.

Kraepelin asks us to conceptualize not just mood cycling up and down, but also intellect and volition, but not necessarily in sync. Thus, instead of pure mania (flight of ideas, exalted mood, pressure of activity) or classic depression (inhibition of thought, mournful moodiness, irresoluteness) we variously have:

• Depressive or anxious mania (where depression takes the place of a cheerful mood).
• Excited depression (where flight of ideas is replaced by inhibited thought).
• Mania with poverty of thought (instead of flight of ideas).
• Manic stupor (a depression with cheerful mood).
• Depression with flight of ideas (instead of inhibited thought).
• Inhibited mania (flight of ideas with cheerful mood and psychomotor inhibition).

If you find, say, "manic stupor" confusing, don't worry, Kraepelin has your back. Sample:

The patients are usually quite inaccessible, do not trouble themselves about their surroundings, give no answer, at most speak in a low voice straight in front, smile without recognizable cause, lie perfectly quiet in bed or tidy about at their clothes and bed-clothes, decorate themselves in an extraordinary way, and all this without any sign of outward restlessness or emotional excitement. ...

The reason you probably haven't heard about all this is because the DSM flies in the face of reality by categorizing a mixed state as full-blown depression coexisting with full-blown mania. The DSM-5 would partially redress this, but comes nowhere near to restoring Kraepelin.

Kraepelin has been referred to as the father of modern psychiatry, but that does him a grave injustice. If Kraepelin were alive today, he would take a match to the DSM and start over - I've heard that sentiment expressed by a good many reform-minded psychiatrists. His "Manic-Depressive Insanity" from 1921 remains state-of-the-art. The psychiatry of 2011 has a lot of catching up to do.

The Year That Was - Almost Over, But Not Letting Go: Part II

My second (first here) idiosyncratic installment in looking back on how 2010 unfolded:

Old Movie of the Year: Groundhog Day

Updating the DSM is an exercise that affords us that rare opportunity to think mental illness afresh. The last time this happened was in the late seventies with the publication of the ground-breaking DSM-III of 1980. Think of the DSM-III as the old DOS operating system. Its successor editions (the last one was 1994) were essentially DOS updates. In Feb this year, the American Psychiatric Association unveiled its draft to DOS-5 - um DSM-5 - due for publication in 20013.

In sticking to DOS, as I reported here on numerous occasions, those responsible for the next DSM - which sets the scene for the next 20 years - are keeping us stuck in 1980 Groundhog Day forever.

If nothing else, a soul-searching discussion would have been useful. Hell, I would have settled for an instant message. An instant message where numerals pose as words, even. Is this asking too much? Yes, apparently.

Psychiatrist of the Year: Emil Kraepelin

Okay, he’s sort of dead - well, completely dead - which is a rather large technically. But even dead, this guy leaves the live psychiatrists for dead. (Wait, let me rephrase that.) Kraepelin, who was born the same year as Freud, coined the term, manic-depression, which - contrary to conventional thinking - is not synonymous with bipolar.

Kraepelin saw all forms of depression (even unipolar depression) in an obvious relationship with clear overlap. This translates into a lot of unipolar depressions behaving like bipolar, even if mania is not involved. This may also explain why antidepressants do not work for a good many people, and may indeed be harmful. The DSM-III of 1980 can be forgiven for getting this wrong. The DSM-5, due out in 2013, cannot.

No doubt about it: If we could somehow “undead” Kraepelin, he’d be saying take a match to the DSM and start over. Instant message: "G8 stuff, homey! All 4U! :) :)"

Person of the Year: You

That’s right, you - patients and loved ones. In April this year, I delivered a keynote to DBSA Kansas. As part of my talk, I asked my audience to come up with a one-sentence description of depression. The answers bore some relationship to the DSM, but were much more insightful and in touch with reality:

“Like having two doberman pinschers waiting for you to get out of bed in the morning.”

“You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.”

“It's like trying to walk through mud up to your neck.”

These were just some of the responses, very much in line from what I have been hearing from fellow patients and loved ones for years. But then again, only we know what we have to live though. Too bad psychiatry isn’t interested in hearing from us. “Is that a better list than the DSM list?” I asked my audience. “Congratulations,” I concluded, “you guys have beat the best psychiatrists in the world. Give yourselves a round of applause.”

More to come ...

A Kraepelin Appreciation (Why his 1921 opus is way ahead of the psychiatry of 2010)

I've just been reading Emil Kraepelin's classic "Manic-Depressive Insanity." Never heard of him? Bet you heard of Freud, who was born the same year. All Kraepelin did was "discover" manic-depression, schizophrenia, co-discover Alzheimers, and found diagnostic psychiatry. His body of work, based on meticulous observations of thousands of patients in German asylums, spans from 1893 to 1927. "Manic-Depressive Insanity" was published in English in 1921, extracted from his much larger "Compendium."

Kraepelin's pioneering approach to classifying mental disorders inspired the modern DSM-III and IV, though - ironically - he has to be rolling in his grave over how both editions got manic-depression all wrong. Let's hear from the source what manic-depression really is:

Manic-depressive insanity ... includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia.

Plus "colorings of mood" that embrace both pathology and personality.

All these diverse elements, claims Kraepelin, "represent manifestations of a single morbid process."

In other words, someone who cycles up and down, gets depressed, flips into mania, has messed up thinking, and has stuff going on with moods is suffering from one illness, not  five, not twenty-five. Equally important, the depression itself (even without evidence of mania) is strong evidence of manic-depression, not something else. All this was revolutionary thinking way back in the first part of the previous century, and still remains ahead of the curve in the first half of this one.

Kraepelin's view of manic-depression, then, is vastly more inclusive than the modern DSM's "bipolar disorder," which does not recognize recurrent unipolar depression. Modern psychiatry, instead, lumps recurrent depression with chronic depression, which explains why antidepressants don't work for a good many individuals and can even cause harm.

You would think the DSM-5 would fix this, but do psychiatrists listen?

In addition to offering finally-detailed clinical descriptions of depression and mania, Kraepelin identified transient "mixed" states. Here, we can truly appreciate the master at work.

Kraepelin asks us to conceptualize not just mood cycling up and down, but also intellect and volition, but not necessarily in sync. Thus, instead of pure mania (flight of ideas, exalted mood, pressure of activity) or classic depression (inhibition of thought, mournful moodiness, irresoluteness) we variously have:

• Depressive or anxious mania (where depression takes the place of a cheerful mood).
• Excited depression (where flight of ideas is replaced by inhibited thought).
• Mania with poverty of thought (instead of flight of ideas).
• Manic stupor (a depression with cheerful mood).
• Depression with flight of ideas (instead of inhibited thought).
• Inhibited mania (flight of ideas with cheerful mood and psychomotor inhibition).

If you find, say, "manic stupor" confusing, don't worry, Kraepelin has your back. Sample:

The patients are usually quite inaccessible, do not trouble themselves about their surroundings, give no answer, at most speak in a low voice straight in front, smile without recognizable cause, lie perfectly quiet in bed or tidy about at their clothes and bed-clothes, decorate themselves in an extraordinary way, and all this without any sign of outward restlessness or emotional excitement. ...

The reason you probably haven't heard about all this is because the DSM flies in the face of reality by categorizing a mixed state as full-blown depression coexisting with full-blown mania. The DSM-5 would partially redress this, but comes nowhere near to restoring Kraepelin.

Kraepelin has been referred to as the father of modern psychiatry, but that does him a grave injustice. If Kraepelin were alive today, he would take a match to the DSM and start over - I've heard that sentiment expressed by a good many reform-minded psychiatrists. His "Manic-Depressive Insanity" from 1921 remains state-of-the-art. The psychiatry of 2010 has a lot of catching up to do.

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV

Robert Spitzer and the DSM - Part II

In Part I, I mentioned how I found myself seated next to Robert Spitzer, the architect of the ground-breaking DSM-III, and the inadequacies of the earlier versions. To pick up where I left off:

In an article published in Science in 1973, Stanford University psychologist David Rosenhan described dispatching eight healthy associates to various mental hospitals, each claiming to have heard voices. All eight were admitted, seven with the diagnosis of schizophrenia, one with manic-depression.

Following admission, all eight behaved normally. Although many of the real patients suspected a ruse, hospital staff interpreted even routine behavior on the part of the impostors as pathological, such as “writing behavior.” To obtain release, the “patients” had to acknowledge their diagnosis and agree to take meds. The “patients” were held on average for 19 days.

In the second part of his experiment, Dr Rosenhan let it be known at a particular hospital that more fake patients were on the way. The hospital was aware of the results of the first experiment, and were confident they could weed out the impostors. Out of 193 patients, 41 were singled out as phonies and another 42 were considered suspect. In reality, no bogus patients had been dispatched. All the patients were genuine.

According to Dr Rosenhan: “Any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.”

A year later, Robert Spitzer MD of Columbia University drew the assignment of leading a new revision of the DSM, the so-called diagnostic Bible that no one paid any attention to at the time.

Dr Spitzer drew his inspiration from the pioneering German diagnostician, Emil Kraepelin (pictured here), who was born the same year as Freud. It was Kraepelin who coined the term, manic-depression and separated out the illness from schizophrenia, thus giving psychiatry a basic navigating system. Kraepelin believed that mental disorders were best understood as analogues of medical disorders.

In other words, you don’t treat a heart attack as if it were cancer, or as if the two were somehow related. For one, an individual in the throes of cardiac arrest and someone with a specific organ system under siege have entirely different symptoms.

But psychiatry, which back in the seventies was still in thrall to Freud, viewed things totally differently. To Freud’s followers, symptoms (such as depression) were merely maladaptive reactions to inner turmoil. You didn’t treat the depression; you dug deeper to root out the underlying neurosis. To a Freudian, diagnostics didn’t matter.

The old-timers have no end of horror stories. At the 2004 APA in New York, I heard Jack Barchas MD of Cornell University - the man who pioneered research into serotonin’s connection to behavior - relate how an early mentor actually challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Dr Spitzer lined up support from the one university of the day not under the spell of the Wizard of Id, Washington University (St Louis), an outpost of intellectual sanity fairly crawling with Kraepelinians. In 1972, John Feigner, then a resident there, came up with a classification scheme that Spitzer adopted as the template to block out a first draft, which was completed in a year. In addition, Spitzer used his unlimited administrative control to establish 25 committees peopled with psychiatrists who despised Freudian dogma and who viewed themselves as scientists.

The catch was that there was precious little that could pass for psychiatric science at the time. Meetings often degenerated into free-for-alls where the loudest voices tended to prevail. Nevertheless, a working draft was thrashed out, which was tested by the NIMH for reliability. In other words, if presented with a basic set of symptoms, could different psychiatrists agree on the diagnosis? Or, at least, kinda come close?

One problem in the past was that one psychiatrist’s view of depression could be very different from that of another psychiatrist. Dr Spitzer’s solution was the “checklist,” something we all take for granted these days. (For instance, a diagnosis of major depression requires checking off at least five of nine listed symptoms.)

Something else we take for granted: ADD, autism, anorexia nervosa, bulimia, panic disorder, and PTSD - these illnesses and others debuted during Spitzer’s watch, and no one these days seriously challenges their legitimacy.

Finally, a “multi-axial” system separated out major mental illnesses (such a depression, bipolar, anxiety, and schizophrenia) from personality disorders such as borderline personality disorder (which made its debut in the DSM-III).

The draft copy that got circulated amongst the profession totally eliminated that Freudian article of faith, “neurosis.” To Spitzer and his task force, neurosis was an emperor with no clothes. Basically, if depression were a reaction to neurosis, then show me the neurosis. The depression was visible, tangible, treatable. But what was this underlying neurosis crap? Where was the scientific evidence?

By the end of the seventies, Freudians were in retreat, but they still had the clout to sabotage Spitzer’s efforts. The term, neurosis, was restored, but relegated to parenthesis. In 1979, following some more strategic compromises, the DSM-III came up for approval before the APA. According to an eyewitness account from an article by Alix Spiegel in the Jan 3, 2005, New Yorker:

“People stood up and applauded. Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts, and instead he gets a standing ovation.”

The DSM-III became an instant runaway success worldwide. Finally, no more Freudian muck. Clinicians, researchers, and other stakeholders had a common language, could actually talk to one another. Patients for the first time could enter a clinician’s office with the reasonable expectation of an accurate diagnosis and the appropriate treatment. Imagine that.

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. What do I say?

To be continued ...