Close Reading of Old Texts—Towards a Psychiatric Hermeneutics

In the current issue of Schizophrenia Bulletin, Ken Kendler traces the development of catatonia from Kahlbaum’s 1874 monograph to the 1899 edition of Kraepelin’s psychiatry textbook.¹ It complements 2 recent manuscripts in which he reviewed the development of the diagnostic concepts hebephrenia² and dementia paranoides/paranoia.³ Kendler’s publications are a detailed analysis of texts by Emil Kraepelin, who merged 3 previously separate clinical syndromes into a new diagnostic entity, dementia praecox, later renamed schizophrenia by Eugen Bleuler.⁴

In addition to the 3 dementia praecox pieces, Kendler has also published historical reviews (which he calls genealogies) of depression, mania, and delusional psychoses prior to Kraepelin’s dementia praecox concept^5–7 and a prehistory of Schneider’s first-rank symptoms.⁸ Finally, in a joint effort with Eric Engstrom, an eminent authority on German psychiatry in general and Kraepelin in particular⁹, Kendler has reviewed Kraepelin’s influence on the concept of psychiatric disorder.^10–12 These publications can be viewed as the most recent instantiation of Kendler’s longstanding interest in psychiatric nosology.^13–16

The story of catatonic dementia praecox that Kendler tells in this issue¹ has 2 protagonists, Karl Kahlbaum (1828–1899) and Emil Kraepelin (1856–1926), and a supporting cast of alienists and psychiatrists from the second half of the 19th century. They were all male physicians, who published articles in German (many of which Kendler had translated into English for the first time) and were entirely devoted to one cause: make psychiatry a rigorous academic discipline.

These were early days for academic psychiatry. Most physicians who cared for the mentally ill were working as alienists in mental asylums, often large institutions, away from urban areas. Psychiatry was a new discipline in German universities, the first chair of psychiatry having been appointed in 1864 (Wilhelm Griesinger in Berlin).⁹ After the German states were unified into the German Empire in 1871, and Otto Bismarck created the first welfare state, 2 important developments accelerated the emergence of academic psychiatry. First, natural sciences, especially microbiology, put clinical medicine on a solid foundation.¹⁷ Second, a national health insurance system provided access to mental health care. Kraepelin entered psychiatry in the early 1880s, determined to climb the academic ladder and make important contributions.¹⁸

Kendler refers to his 3 dementia praecox articles^1–3 as a “close reading of relevant texts.” This is akin to the scholar who pores over ancient, sacred texts. The science that emerged from this long tradition of text interpretation is known as hermeneutics. Well-known examples of such scholarship are biblical, legal, and constitutional hermeneutics. They are concerned with the question: What did the authors (of Bible or Constitution) mean to say and how do we best interpret them now?

The Diagnostic and Statistical Manual of Mental Disorders (DSM), especially the DSM-III.¹⁹, has often been called the bible of psychiatry. But the DSM is no bible at all. The DSM is to psychiatry what catechism is to Christian churches and the Federal Register is to the US government. These publications disseminate official rules and regulations that are supposed to be true to the urtext.

What Kendler is doing for psychiatry, especially for the English-speaking community of clinicians and researchers, is an important first step: getting to the urtexts of contemporary psychiatry. He is doing the yeoman’s work: finding the texts, translating them, and putting them into a historical context. Many of these texts are from German-speaking psychiatrists in the second half of the 19th century.

In his foundational work towards a psychiatric hermeneutics, Kendler has chosen schizophrenia as his first topic.^1–3 He has also begun similar close readings of the relevant texts for mania and depression. Schizophrenia and manic-depressive illness (bipolar disorder) are the paradigmatic illness of psychiatry, introduced by Kraepelin in the last century of the 19th century. He had hoped that these 2 diagnostic categories would be helpful to clinicians (in their effort to predict course and outcome) and researchers (in their effort to discover neural mechanisms, genetic etiology, and effective interventions).

Among the 3 syndromes that gave rise to schizophrenia, catatonia is a particularly contentious diagnosis. Some have considered a slow separation of catatonia from schizophrenia.²⁰ Others have argued for catatonia to be reclassified as a medical condition.^21,22 There is even the charge that Kraepelin hijacked Kahlbaum’s catatonia and forced it into dementia praecox.²³

The DSM-5 took a first step towards revision, by removing the schizophrenia subtypes (including the catatonic subtype) and by recognizing catatonia as a condition that can be coded independently.²⁴ The ICD-11 classification goes 1 step further and recognizes catatonia as a new diagnostic class, at the same level as psychotic disorders and mood disorders.²⁵

These recent changes in the nosology of catatonia reverse the trend that Kraepelin began in the 1890s. Rather than merging catatonia with other syndromes into dementia praecox, we are now seeing a growing effort to redefine catatonia in its own right, at the level of brain circuitry²⁶ and novel mechanisms, such as inflammation.²⁷ If we do not want to repeat the mistakes of previous nosological battles, we need to understand its history.

Like the religious and legal communities that turned to hermeneutics to establish the proper text interpretation, psychiatry is known for considerable controversy about core principles. It is fair to say that psychiatry is more sectarian than any other medical specialty, giving rise to a panoply of languages and cultures. Over the last 150 years, some have assumed a dominant role, creating schools and occupying positions of power (not just in academia, but also in popular culture).²⁸ The sectarian nature of psychiatry is both a consequence of and a contributor to the still unenlightened view of mental illness, resulting in stigma and prejudice.

It is particularly noteworthy that Kendler, a highly accomplished genetic researcher and major contributor of the DSM revision process, has engaged in the close reading of all the relevant texts for a scholarly analysis of schizophrenia. Is it necessary for a researcher to read psychiatric texts that are more than 100 years old? It turns out that our core concepts of psychiatry, including psychiatric research, are steeped in philosophical concepts of the 18th and 19th centuries. The power of genetics (or any other contemporary method of basic and clinical neurosciences) will not be realized if we do not know the historical limits of our scientific concepts. If we do not join Kendler in his ambitious project of psychiatric hermeneutics, we will experience a silent spring.²⁹