German Psychiatry Research Articles

An Empirical-Phenomenological Exploration of Anderssein (Feeling Different) in Schizophrenia: Being in-between Particular and Universal

Introduction: In this paper, we wish to elucidate alterations of basic existential and intersubjective configurations in schizophrenia spectrum disorders (SSD) through the phenomenon of Anderssein (“feeling different”). Anderssein is an important yet neglected notion from German psychiatry, referring to a specific sense of feeling profoundly different from others occurring in SSD. Although phenomenological-psychopathological research mentions it as an aspect of the core disturbance of SSD (namely, “self-disorders”), the phenomenon has not yet been explored in empirical or theoretical detail. Method: We present material from a phenomenological-empirical study on the mode and onset of psychosis based on qualitative interviews with 25 patients with SSD. Results: Most of the participants in our study report having felt fundamentally and often ineffably different since childhood and articulate it as a sense of existing “outside” of the shared reality. Intersubjective reality appears progressively unreal or inauthentic, and simultaneously, the patient’s intimate, subjective sphere is permeated by an alien otherness. Importantly, this outside position should be understood carefully as it is often accompanied by the sense of being invaded by social rules, other people’s thoughts, or emotions. Incipient psychosis is described as a gradual extension of precedent alterations of the structures of (inter)subjectivity. Conclusion: We conceptualize the ontological feature of Anderssein as an altered “being in-between” – that is, some sort of halting of the dynamic movement between particularity and intersubjectivity. Finally, we discuss the critical implications of these results for research into the “onset” of schizophrenia.

«Hierarchical» and «Modular» Models of Psychopathological Syndromes and Mental Functions

The aim was to compare «hierarchical» and «modular» models of the mental functions and psychopathological syndromes.Material and method: a historical analysis is undertaken in the narrative review the works of thinkers of different times who put forward the concepts of mental deviations from the norm. Discussion and conclusion: hierarchical models go back to the concepts of the ancient Greek philosopher Plato, modular models – to the concepts of the German doctor F. Gall. The most famous hierarchical model of «circles» of positive and negative general psychopathological syndromes in Russian psychiatry by A.V. Snezhnevsky was preceded by the hierarchical model of M.O. Gurevich – M.Ya. Sereisky, in turn, based on the model of «levels» of the psyche of the English neurologist J.H. Jackson and E. Kraepelin’s «organ registers» model. In German psychiatry also K. Jaspers cited the «onion» model in the first edition of General Psychopathology, substantiating the complication of psychopathological symptoms depending on the nosology of mental disorders. Later, the American psycholinguist and philosopher J. Fodor proposed a «modular» model of the psyche, according to which the human psyche consists of relatively independent «modules» («encapsulated») that are specific to a certain area of stimuli, are genetically determined, correlate with certain neural structures and are «computationally autonomous». The concept of modular construction of the psyche was further developed in the works of psychologists and psychiatrists of the «evolutionary» direction (models of «massive modularity», which denied the «encapsulation» of modules according to J. Fodor), based, among other premises, on the modular construction of the brain of many animal species. Diversity turns out to be inherent not only in modular models of the psyche, but also in hierarchical ones, for example, the sequence of general psychopathological positive syndromes in A.V. Snezhnevsky’s model of «circles» differs from the correlation of psychopathological syndromes in the model of «registers» by E. Kraepelin, who at the final stage of his scientific activity postulated the principles of «comparative psychiatry», in many respects similar to the principles of the subsequent direction of «evolutionary» psychiatry.

Participatory Process Evaluation of Flexible and Integrative Treatment (FIT) Models in German Psychiatry – A Mixed Method Study

Flexible and integrative treatment (FIT) services in Germany make it possible to shift mental health inpatient care to day- and outpatient care. This paper presents the results of the mixed methods, participatory process evaluation (= PE) of the PsychCare clinical trial, which compares the outcomes of nine FIT departments to those of eight standard mental health care services. This PE integrates diverse data using a program theory and data transformation approach. It shows various implementation types of FIT services and how their processes and structures are distinct from those of control conditions, also experienced by service users. It contributes to mixed methods research by showing that the PE methodological frame is a valuable tool to effectively involve service users and other stakeholders.

Psychiatry in the GDR as a "niche" - Between adaptation and autonomy

With the help of statements from contemporary witnesses, it shall be deduced, if and to what extent Psychiatry was experienced as a shelter for employees and patients in the state controlled society of the GDR and which effort of adaptation to the authoritarian regime was needed to organize protected and protective spaces, here called "niches". 74 guide-based interviews from subjects including former patients and different staff groups of the East german Psychiatry were analyzed qualitatively. Many quotations show, that Psychiatry in the GDR was experienced as a "niche" for dissenting people and could offer a certain amount of protection for patients. On the other hand, the autonomy of the psychiatric care was often violated by political intrusions regarding individual treatments. Moreover, treatment autonomy was restricted by harsh shortages in supplies. Psychiatrists in the GDR could protect their patients through their actings and so Psychiatry could establish a "niche" for patients and employees. However, establishing such protected spaces required efforts in adaptation. In reverse, Psychiatry has also been politically instrumentalised - either directly through unjustified admissions and exit restrictions or indirectly by a stigmatization of dissenters and removing them from society.

From the breakdown of psychiatry during nazism and the Nuremberg Code, to the materialist neuropsychological model in contemporary science and society: A bioethical analysis

The breakdown of German psychiatry with the coming to power of the National Socialist regime in 1933 resulted in a revival after the war of bioethical issues, the immediate effect of which was the enactment of the Nuremberg Code. In many ways, this breakdown was the result of the historical evolution of psychomedical knowledge and the mass dissemination of reductionist discourses and ideas that created a breeding ground for tragedy. The cyclical discourse of psychic materialism, which has been repeated for centuries in the history of science in different formulations, can, if not properly interpreted, lead to far-reaching appropriations and risks, to which due attention must be paid. The latest manifestation of this issue, the view of mental life as basically cerebral, neurological, biochemical, and determinist, a view that has not been managed or presented adequately to the public, could become the basis for perverse new perspectives and applications in the current context of research and academic activity.

The T4 Memorial for Patients Killed by their Doctors: A Personal View

This is the story of the murder, by psychiatrists, of patients with genetically based psychiatric disorders in Nazi Germany. It is told from the viewpoint of a person with bipolar disorder, reflecting on the suffering of people like herself. The various stages in the so-called “Euthanasia” programme are mentioned: sterilisation, forbidding marriage, gassing, poisoning, starvation. This dark page of German Psychiatry is lightened up by: Its contrast with the author’s experience of compassionate and professional psychiatric therapy today. The inspiring sermons of the Bishop of Munster in 1941 leading to protests among patients and their families, the largest protest movement in Nazi Germany. The informative and uplifting group of monuments in Berlin commemorating the victims. The speech by the chairman of the German association of psychiatrists in 2010 asking for the victims to forgive them. The incorrect use of the term ‘Euthanasia’ for the memorial and its correct use in a humane Dutch law, passed in 2002.

"РЕВОЛЮЦИОННЫЙ СУБЪЕКТ" В ПСИХИАТРИИ И ЛИТЕРАТУРЕ

This article examines the transformations taking place in German psychiatry and literature in the 1970 s. On the one hand, it traces the development of an anti-psychiatric “revolutionary subject” through the example of the Heidelberg Patient Socialist Collective led by Dr. Wolfgang Huber. On the other hand, in contrast to the marginality of Huber's circle, we analyze the somewhat different path taken by the “revolutionary schizophrenic subject” in literature, using Heinar Kipphardt's novel Marz as an example. With a number of similarities and differences, both phenomena transform cultural space in different ways.

De l’épistémologie de la psychiatrie à une épistémologie psychanalytique. Entretien avec Paul Bercherie, 17 avril 2021

ObjectiveThis interview with the psychiatrist and psychoanalyst Dr. Paul Bercherie attempts to mobilize the major questions that traverse the epistemology of psychiatry and of psychoanalysis. Our conversation covers his work on classical psychiatric knowledge–the subject of his doctoral dissertation–as well as more recent work that questions the conceptual geography of the contemporary psychoanalytic field. MethodIn this open conversation, Paul Bercherie speaks about his training at the end of the 1960s, his various experiences of analysis, and his research path, which led him to develop a singular method of investigation at the interface between practice and theory. The richness of this unique journey is also supported by numerous references to the intellectual context of the time. ResultsReturning to the foundations of psychiatry allows us to revisit the complexity of these texts and illustrates the fruitfulness of the dialogue between French and German psychiatry, which nevertheless has the same objectivist and organicist basis. The author also sheds light on the inconsistency of certain nosographic elaborations. A second series of works serves to resituate Freud in his theoretical context. It results in the demonstration that the discovery of the unconscious is developed within a dated theoretical framework that is poorly suited to its innovation. DiscussionThe Freudian subject of autonomy, the perceptive, cognitive subject, which was that of classical psychology and philosophy, will be called into question by the theories of structuralism, which bases the subject on a heteronomous theory, in which the latter is conceived as a response to the linguistic and social structures which determine it. ConclusionsContemporary psychoanalysis unfolds in the form of separate currents, based on different ethical and theoretical conceptions. However, an analysis shows that the four main currents are individualized from different dimensions already included in the Freudian text. Paul Bercherie argues that these currents should not only be opposed but, instead, that they could benefit from being integrated into a multi-referential clinical orientation. This makes it possible to offer differential but complementary approaches for the patient.

Die Zukunft der deutschen Psychiatrie

The Future of German Psychiatry. An (un)realistic reform proposal for psychiatry From the existing deficits and undesirable developments in German psychiatry, more or less realistic recommendations for the future are derived here and their chances are assessed. The current psychiatric paradigm has not yet fulfilled many of its promises; extensive institution-centredness still allows for profit extraction on a considerable scale. In order to develop a psychiatric help system that meets the legitimate expectations of those affected, a paradigmatic shift is needed so that contexts can be created in which recovery is systematically possible, coercion is avoided and human rights are no longer violated, as well as the promise of social and work inclusion is seriously fulfilled. For this, concepts such as recovery and trauma-informed treatment as well as outpatient team-based treatment models such as Open Dialogue and Supported Employment are available, which are quite demanding for professionals. Effective psychiatry, especially for people with so-called severe mental illnesses, must be offered in the living environment, competently, relationship-oriented and long-term.

Historical path of paraphrenia

IntroductionParaphrenia is a psychotic disorder characterized by an insidious development of a vivid and exuberant delusional system, accompanied by hallucinations and confabulations, without a personality deterioration. It is considered to be an intermediate entity between the disorganization of schizophrenia and the systematization of a delusional disorder.ObjectivesDevelop knowledge about paraphrenia as an individualized diagnostic entity and its historical path through the classical authors’ texts.MethodsExtensive research on the historical path of the paraphrenia diagnostic entity was carried out, as well as the current situation of the term.ResultsIn the German psychiatry it was Karl Kahlbaum who first introduced the term of paraphrenia. Later many authors of the German psychiatry delved into this diagnostic entity. Emil Kraepelin described four different subtypes of paraphrenia: paraphrenia systematica, expansiva, confabulans and phantastica. However, other authors such as Kleist or Bleuler, considered paraphrenia should not be judge as an individualized diagnostic entity as it should be considered inside schizophrenia, so the term disappeared in the German psychiatry. In the French psychiatry, unlike the German, the independence of chronic psychosis from schizophrenias was recognized, so the term had a longer path. Henry Ey recognized four important clinical features in this disorder: paralogical thought dominance, megalomania, confabulation and integrity of relation with reality.ConclusionsCurrently the term paraphrenia is no longer considered an individualized diagnostic entity. In fact, in today’s textbooks of psychiatry paraphrenia is considered a psychotic disorder that has nothing in common with the one described by the classical authors, and it is part of the late-onset psychosis.

Historical path of paraphrenia

IntroductionParaphrenia is a psychotic disorder characterized by an insidious development of a vivid and exuberant delusional system, accompanied by hallucinations and confabulations, without a personality deterioration. It is considered to be an intermediate entity between the disorganization of schizophrenia and the systematization of a delusional disorder.ObjectivesDevelop knowledge about paraphrenia as an individualized diagnostic entity and its historical path through the classical authors’ texts.MethodsExtensive research on the historical path of the paraphrenia diagnostic entity was carried out, as well as the current situation of the term.ResultsIn the German psychiatry it was Karl Kahlbaum who first introduced the term of paraphrenia. Later many authors of the German psychiatry delved into this diagnostic entity. Emil Kraepelin described four different subtypes of paraphrenia: paraphrenia systematica, expansiva, confabulans and phantastica. However, other authors such as Kleist or Bleuler, considered paraphrenia should not be judge as an individualized diagnostic entity as it should be considered inside schizophrenia, so the term disappeared in the German psychiatry. In the French psychiatry, unlike the German, the independence of chronic psychosis from schizophrenias was recognized, so the term had a longer path. Henry Ey recognized four important clinical features in this disorder: paralogical thought dominance, megalomania, confabulation and integrity of relation with reality.ConclusionsCurrently the term paraphrenia is no longer considered an individualized diagnostic entity. In fact, in today’s textbooks of psychiatry paraphrenia is considered a psychotic disorder that has nothing in common with the one described by the classical authors, and it is part of the late-onset psychosis.DisclosureNo significant relationships.

Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880.

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin's chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin's mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860-1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

'The schizophrenic basic mood (self-disorder)', by Hans W Gruhle (1929).

During the first half of the twentieth century, German psychiatry came to consider 'Ich-Störungen', best translated as self-disorders, to be important features of schizophrenia. The present text is a translation of a chapter by the German psychiatrist Hans Gruhle, which is extraordinarily clear and emblematic for this research line. Published in 1929, it was part of a book co-written with Josef Berze, The Psychology of Schizophrenia (concerning its subjectivity). Gruhle claims that the essential core of schizophrenia is of an affective nature, a 'mood' manifesting itself as self-disorder, an unstable, incomplete pre-reflective self-awareness. His impact on contemporary psychiatry was probably limited due to his confrontational style, but this text has great significance for the modern revival of phenomenological research in schizophrenia.

Berufliche Teilhabe am Arbeitsleben von Menschen mit schweren psychischen Erkrankungen: gestern und heute eine Herausforderung

Throughout its history, German psychiatry has been aware of the challenge it imposes to capacitate persons with severe mental disorders to participate in the job market. In the past, it was above all work therapy that was seen as an instrument to overcome this problem. The reform efforts of the Rodewisch Propositions can serve as an example. In Germany, social law legislation favored the classic rehabilitation sector to provide labor market participation benefits. Aiming at reintegrating patients in labor was not regarded a primary task of acute psychiatry. This approach should be altered to maintain the employability of mentally ill people and to prevent early retirement because of mental illnesses.

Karl Jaspers' General Psychopathology (Allgemeine Psychopathologie) and Its Implication for the Current Psychiatry.

Karl Jaspers is a psychiatrist, philosopher, and humanist. In 1913, he published the General Psychopathology (GP; Allgemeine Psychopathologie), the first edition. Despite the passage of one hundred years after the GP was published, GP still has a potential value to present a phenomenological and comprehensive viewpoint for psychiatry to overcome Kraepelinian-biological absolutism. The philosophical backgrounds of a Jaspersian phenomenological sense have been related to both the transcendence and the immanence roots. Partly under the influence of a Husserlian distinction between the natural and phenomenological attitudes, a rigid distinction between explanation and understanding has been proposed as the proper epistemological method in Jaspers' GP. Further, the fact that a distinction between process and development has been presented as the psychical phenomenon is understandable. The integrated and comprehensive viewpoint establishment for the state of "Babylonian confusion of tongues" in German psychiatry as well as the newly initiating phenomenological trend in psychiatry have been the legacies of Jaspers' GP. Moreover, the common theoretical backgrounds may be shared by the Jaspersian sense and humanitarian approaches in Korean psychiatry. Also, the Jaspersian sense may help the current molecular psychiatry to have a chance to overcome its solipsism and limitations.

Current clinical practice of electroconvulsive therapy and repetitive transcranial magnetic stimulation in psychiatry, a German sample

The purpose of the study was to evaluate the current clinical practice of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation in German psychiatry. Case-based data (> 1.000.000 cases) were collected according to §21 of the German hospital remuneration law from January 2015 to December 2017. The study cohort comprises approximately 35–40% of the annual psychiatric cases and hospitals in Germany. Frequency of ECT and rTMS cases were investigated considering main diagnoses according to ICD-10 and treatment settings (inpatient vs. day-care). ECT cases with short-term hospitalization (≤ 4 days) were supposed to be maintenance ECT cases. A linear regression analysis was conducted to estimate trends in the use of ECT and rTMS. Different groups were compared using Chi-square tests. ECT and rTMS cases appear to increase in total during the observation period possibly due to facilities newly introducing ECT and rTMS but also to increased frequency of treatments. Both treatments were rarely performed in day-care settings (0.89% and 11.25%). ECT was performed in 1.72% of all cases with affective disorders and in 1.48% with major depressions, respectively. Age ≥ 65 years, females, severe and psychotic depression were significantly associated with a higher rate of ECT cases. > 40% of all ECT cases were possibly maintenance ECT cases. Only 0.60% of these were performed in day- care settings. rTMS was primarily performed in major depression (86,7% of all rTMS cases). This study suggests a growing demand for ECT and rTMS. Nevertheless, the use of ECT is still low compared to the high prevalence of treatment resistant depression. The use of rTMS is even lower and seems to be restricted to specialized institutions. Maintenance ECT is frequently carried out in an inpatient setting. Limitations of this study are the case- and group-based analysis, missing data on outpatient services and treatment sessions per case. Therefore, the database is not necessarily representative for the entire German healthcare system. Further studies are needed to verify the presented findings and should address the feasibility of ambulatory and day-care ECT services.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder.

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms. Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed. Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses. These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

The introduction of leucotomy in Germany: National Socialism, émigrés, a divided Germany and the development of neurosurgery.

Thinking about the chronology of the introduction of leucotomy in Germany sheds new light on the hypothesis of a special 'radical' approach of German psychiatry to the treatment of the mentally ill during the period of National Socialism. Moreover, it offers new insights into the transnational and interdisciplinary conditions of the introduction of leucotomy in early divided post-war Germany.

Karl Jaspers' General Psychopathology (Allgemeine Psychopathologie) and Its Implication for the Current Psychiatry.

Karl Jaspers is a psychiatrist, philosopher, and humanist. In 1913, he published the General Psychopathology (GP; Allgemeine Psychopathologie), the first edition. Despite the passage of one hundred years after the GP was published, GP still has a potential value to present a phenomenological and comprehensive viewpoint for psychiatry to overcome Kraepelinian-biological absolutism. The philosophical backgrounds of a Jaspersian phenomenological sense have been related to both the transcendence and the immanence roots. Partly under the influence of a Husserlian distinction between the natural and phenomenological attitudes, a rigid distinction between explanation and understanding has been proposed as the proper epistemological method in Jaspers’ GP. Further, the fact that a distinction between process and development has been presented as the psychical phenomenon is understandable. The integrated and comprehensive viewpoint establishment for the state of “Babylonian confusion of tongues” in German psychiatry as well as the newly initiating phenomenological trend in psychiatry have been the legacies of Jaspers’ GP. Moreover, the common theoretical backgrounds may be shared by the Jaspersian sense and humanitarian approaches in Korean psychiatry. Also, the Jaspersian sense may help the current molecular psychiatry to have a chance to overcome its solipsism and limitations.

“Man is made to fathom what is human.”

This article is a contribution to the theoretical and philosophical foundations of the West German psychiatric reform. I argue that the phenomenological anthropological approach played a crucial role for changes in psychiatry during the late 1950s and early 1960s (the so-called “reform before the reform”, cf. Kersting) and that this approach gave rise to the specific anthropological attitude of German social psychiatry towards mental illness. To show this in detail, I will focus on four key figures of the aforementioned reform: Walter von Baeyer, Heinz Häfner, Caspar Kulenkampff and Karl Peter Kisker. I will first give a short summary of their phenomenological anthropological concepts and then reflect upon the relevance of these concepts for the reform. In the following, I will highlight the critiques made by Erich Wulff, Klaus Dörner and Karl Peter Kisker to further indicate the problematic relation between social psychiatry and anthropological psychiatry. Finally, I will discuss the impact of what I call the <italic>anthropological social-psychiatric attitude</italic> on the reform of West German psychiatry.