One Century of Allgemeine Psychopathologie (1913 to 2013) by Karl Jaspers

Karl Theodor Jaspers (born February 23, 1883, in Oldenburg, Germany) was a German psychiatrist and philosopher, who had a profound influence on modern psychiatry, philosophy, and theology. Although Jaspers entered the University of Heidelberg in 1901, enrolling in the faculty of law, in the following years, he transferred to medicine at the universities of Berlin, Göttingen, and eventually, Heidelberg again. After completing the state examination to practice medicine (1908), he registered as a doctor (1909). During this time, Jaspers worked on the development of psychiatry at a period very similar to our own in that there were dramatic advances in the neurosciences of the day (the period became known as psychiatry’s first biological phase). He worked at a psychiatric hospital in Heidelberg—where Emil Kraepelin had worked some years earlier—which was headed by the renowned neuropathologist Franz Nissl. In 1911, when Jaspers was only 28 years old, he was requested by Ferdinand Springer, a well-known publisher, to write a guide for students, doctors, and psychologists; he completed the Allgemeine Psychopathologie (General Psychopathology) 2 years later.¹ During his life, Jaspers continued working on his textbook, producing 4 different editions of the same with significant additions and changes.² In 1915, Jaspers gained a post as a psychology teacher at Heidelberg University, after which he never returned to clinical practice. At the age of 40, he turned from psychiatry to philosophy and existentialism, drawing upon the roots of Nietzsche and Kierkegaard. After the Nazi seizure of power, Jaspers was forced to retire from teaching (1937) and was placed under a publication ban (1938). In 1948, Jaspers moved to the University of Basel in Switzerland, where he remained prominent in the philosophical community until his death (February 26, 1969, in Basel, Switzerland).

General Psychopathology by Karl Jaspers is one of those major works that have become a classic in psychiatric literature, at least in Europe. The present special issue of Schizophrenia Bulletin is devoted to the centenary of its publication (1913 to 2013). The aim of this themed issue is to address why, after such a long period of time, this work should still be studied and read by trainees, experienced psychiatrists, psychologists, neuroscientists, and researchers working in neuropsychiatry. The principal reasons for its success are critically addressed in each of the 3 articles published in the present issue, thanks to the valuable contributions of leading experts in the field. The first article by Parnas et al addresses conceptual Jaspers’ issues underlying psychiatric psychopathology and nosography. Next, Mishara et al discuss Jaspers’ contributions in the context of the neurobiology of delusion onset. In the third article, Fulford et al describe Jaspers’ psychopathology as a prime contributor to the development of person-centered medicine.

First, General Psychopathology raised core questions concerning both the ontology and epistemology of the “psychiatric object” (symptoms and signs), which are at the forefront of current concerns of psychiatry as a clinical science (see the article by Parnas et al).³ As described above, psychiatry at the time of Jaspers was dominated by academic neuroscientists who favored natural–scientific models (“Mental illnesses are brain illnesses” [^{4 (p459)}]). For example, during that period, Jaspers’ mentor Franz Nissl showed that the neurohistological changes in general paralysis were different from the changes described by Alois Alzheimer in dementia, proving that general paralysis was a form of neurosyphylis. Although Jaspers shared the general natural–scientific optimism of psychiatry’s first biological phase, he became dissatisfied with the way the medical community of the time approached the study of mental illness. He felt that the underlying biological approaches were pushed too far: “These anatomical constructions, however, became quite fantastic (eg, Meynert, Wernicke) and have rightly been called ‘Brain Mythologies’” [^{4 (p18)}]. He felt that both neurobiological and psychological reductionism (at that time, psychoanalysis was starting to become popular) were fully grounded in the Cartesian dichotomy between mind (res cogitans) and body (res extensa). This dualism was at the root of the modern positive sciences, thus prohibiting any comprehensive psychopathology that attempted to address the whole person. Jaspers’ reservations about the contemporary emphasis on a natural–scientific approach to psychiatry were driven by an epistemological debate about whether the human sciences should try to emulate their far more successful cousins the natural sciences or whether they should follow their own methods. Jaspers adopted the intermediate option suggested by the German philosopher and sociologist Max Weber, who believed that some sciences may involve a distinctive and hybrid approach, living partly within the natural and partly within the human sciences. Thus, Jaspers set himself the task of establishing psychopathology as a comprehensive science that could overcome the original Cartesian dualism. Developing a language that was capable of describing the symptoms of disease well enough to facilitate positive recognition in other cases, approaching the subject from the human concern with her/his own existence. Some authors⁵ think that the most important contribution of Jaspers to psychiatry is this attempt to define a scientific method based on a pluralistic model. In practical words, General Psychopathology tried to bring the methods of phenomenology—the direct investigation and description of phenomena as consciously experienced by the patients suffering disorders, without theories about their causal explanation—into the field of clinical psychiatry.

Second, Jaspers’ General Psychopathology had a specific influence on our understanding of psychosis, in particular during its earliest phases (see the article by Mishara et al).⁶ His 3 indicators, the “subjective certainty,” the “imperviousness to other experiences and counter-arguments,” and the “implausibility” are still used for the diagnosis of delusions. However, as Jaspers recognized, these “criteria” are only external. It is only possible to differentially diagnose primary or genuine delusions indicating a schizophrenia process from merely delusion-like ideas through the clinical interaction. Primary delusions cannot be derived from any prior psychological content or motivation, they are “new” and nonderivable from the psychological or cultural background of the subject. Thus, Jaspers not only emphasizes the psychological understanding of psychosis, he also affirms the value of explanatory physiological and neurobiological approaches, especially in the research and diagnosis of delusions. The phenomenological approach may thus lead to neurobiological hypotheses, which can be tested experimentally. For example, Jaspers’ approach to delusions and its subsequent development by phenomenological psychiatrists supports contemporary neurobiological models of delusion formation in early psychosis, which involve aberrant salience processing, dysfunctional cortical networks, and altered dopamine neurotransmission. Of particular importance, Jaspers also believed that psychiatrists should diagnose symptoms of psychosis by their form rather than by their content. For example, in diagnosing a hallucination, the fact that a person experiences visual phenomena when no sensory stimuli account for it (form) assumes more importance than what the patient sees (content).

Third, General Psychopathology emphasized the psychological understanding of mental disorders as narrative-based and contextual occurrences, anticipating a person-centered medicine (see the article by Stanghellini et al).⁷ Jaspers drew attention to the active role that the person, as a self-interpreting agent engaged in a world shared with other persons, has in interacting with his/her basic disorder and in the shaping of the psychopathological syndromes. This person-centered approach helps contemporary psychiatry see patients as meaning-making, rather than passive, individuals, participating in their own healing as empowered agents and their efforts at self-understanding as not necessarily pathological but potentially adaptive. This has crucial implications for clinical psychiatry. For example, on the basis of this work, it is possible to develop a theoretical framework and practical resources for understanding the diversity of the schizophrenic psychosis phenotypes, including symptom presentation, course, and outcome, as a consequence of the different ways people with psychosis seek to make sense of the basic changes in their self- and world experiences.