Karl Kleist (1879-1960)- a pioneer of neuropsychiatry

Historical and conceptual features of acute polymorphic psychosis: a myth of European psychiatry from bouffée délirante to ICD-11 acute and transient psychotic disorder

This paper deals with the history and epistemology of acute polymorphic psychosis. We undertook a comparative study of short-lived psychotic disorders used in different European countries since the late nineteenth century. The theory of degeneration offered a speculative basis to conceptualization of conditions such as bouffée délirante, cycloid psychosis and reactive psychosis, but it seems likely that different factors contributed to the profusion of clinical concepts with adverse effects on both nomenclature and classification. The resulting picture suggests that earlier nosological concepts tend to converge on common descriptive features and challenge the diagnostic categories for short-lived psychotic disorders listed in modern symptom-based psychiatric classifications.

Paratonia, Gegenhalten and psychomotor hypertonia Back to the roots

In the first half of the 20th century, well before the antipsychotic era, paratonia, Gegenhalten and psychomotor hypertonia were described as new forms of hypertonia intrinsic to particular psychoses and catatonic disorders. A series of astute clinical observations and experiments supported their independence from rigidity seen in Parkinson's disease. After World War II, motor disorders went out of fashion in psychiatry, with drug-induced parkinsonism becoming the prevailing explanation for all involuntary resistance to passive motion. With the 'forgetting' of paratonia and Gegenhalten, parkinsonism became the prevailing reading grid, such that the rediscovery of hypertonia in antipsychotic-naive patients at the turn of the 21st century is currently referred to as "spontaneous parkinsonism", implicitly suggesting intrinsic and drug-induced forms to be the same. Classical descriptive psychopathology gives a more nuanced view in suggesting two non-parkinsonian hypertonias: (i) locomotor hypertonia corresponds to Ernest Dupré's paratonia and Karl Kleist's reactive Gegenhalten; it is a dys-relaxation phenomenon that often needs to be activated. (ii) Psychomotor hypertonia is experienced as an admixture of assistance and resistance that partially overlaps with Kleist's spontaneous Gegenhalten, but was convincingly isolated by Henri Claude and Henri Baruk thanks to electromyogram recordings; psychomotor hypertonia is underpinned by "anticipatory contractions" of cortical origin, occurrence of which in phase or antiphase with the movement accounted for facilitation or opposition to passive motions. This century-old knowledge is not only of historical interest. Some results have recently been replicated in dementia and as now known to involve specific premotor systems.

[Transfer rates of the Psychiatric and Neurological University Hospital in Frankfurt am Main during National Socialism]

During the era of National Socialism around 300,000 people were murdered in the "euthanasia" programs. The majority of those killings took place in asylums, whereas no killings in psychiatric and neurological university (PNU) hospitals have so far been identified. Furthermore, there were no deportations from these hospitals to the gassing asylums. Nevertheless, the PNUs took part in the "euthanasia" by transferring patients to asylums, where many of them were either killed or deported to gassing asylums. There are only a few studies that empirically describe these transfers. In this study the rates of transfers of the PNU Frankfurt am Main are reported for the first time, thus allowing a judgment of the involvement in the "euthanasia" programs. The rate of patients transferred to asylums dropped from 22-25% in the years before to around 16% in the years after knowledge about the mass killings in the asylums spread in the PNU Frankfurt. Of the patients transferred between 1940 and 1945, 53% died in the asylums before 1946. The high mortality rate of the transferred patients underlines that the role of the PNUs in the "euthanasia" programs should be examined in more detail.

Historical review: the German Neurological Society and its honorary members (1952-1982)

BACKGROUND

As part of a larger project commissioned by the German Neurological Society (DGN), this paper focuses on the DGN's German and Austrian honorary members. In particular, the question of whether former membership in the National Socialist German Workers' Party (NSDAP) or other Nazi organizations was an obstacle to becoming an honorary member in the years 1952-1982, and whether victims of the Nazi regime were also considered for honorary membership.

RESULTS

From the early 1950s to the early 1980s, the DGN awarded honorary membership to 55 individuals. Of these, 27 were German or Austrian citizens who were physicians during the Nazi era, and 17 of the 27 (63%) were members of the NSDAP, Storm Troopers (SA), or Schutzstaffel (SS). In the early postwar period, honorary membership was much less frequently awarded to former Nazi Party members than in the years around 1980. Sir Ludwig Guttmann, the only neurologist forced to emigrate, received his honorary membership in 1971. Brief biographies of Hans Jacob, Gustav Bodechtel, Karl Kleist, and Ludwig Guttmann outline exemplary careers and life histories, in addition to highlighting key issues such as concurrent research on "euthanasia" victims, denazification procedures, forced emigration, and the contemporary mindset in the Federal Republic of Germany.

CONCLUSIONS

Apparently, a "Nazi past" did not play a decisive role in the selection process for honorary members within the DGN until at least the 1980s. Aside from Guttmann, no other neuroscientist expelled from Germany was honored. With these practices, the Society marginalized its Jewish colleagues for a second time.

Altered effective connectivity in sensorimotor cortices is a signature of severity and clinical course in depression

Research into neurobiology of depression primarily focuses on its complex psychological aspects. Here we propose an alternative approach and target sensorimotor alterations—a prominent but often neglected feature of depression. We demonstrated using resting-state functional MRI data and computational modeling that top-down and bottom-up information flow in sensory and motor cortices is altered with increasing depression severity in a way that is consistent with depression symptoms. Depression-associated changes were found to be consistent across sessions, amenable to treatment and of effect size sufficiently large to predict whether somebody has mild or severe depression. These results pave the way for an avenue of research into the neural underpinnings of mental health conditions.

Functional neuroimaging research on depression has traditionally targeted neural networks associated with the psychological aspects of depression. In this study, instead, we focus on alterations of sensorimotor function in depression. We used resting-state functional MRI data and dynamic causal modeling (DCM) to assess the hypothesis that depression is associated with aberrant effective connectivity within and between key regions in the sensorimotor hierarchy. Using hierarchical modeling of between-subject effects in DCM with parametric empirical Bayes we first established the architecture of effective connectivity in sensorimotor cortices. We found that in (interoceptive and exteroceptive) sensory cortices across participants, the backward connections are predominantly inhibitory, whereas the forward connections are mainly excitatory in nature. In motor cortices these parities were reversed. With increasing depression severity, these patterns are depreciated in exteroceptive and motor cortices and augmented in the interoceptive cortex, an observation that speaks to depressive symptomatology. We established the robustness of these results in a leave-one-out cross-validation analysis and by reproducing the main results in a follow-up dataset. Interestingly, with (nonpharmacological) treatment, depression-associated changes in backward and forward effective connectivity partially reverted to group mean levels. Overall, altered effective connectivity in sensorimotor cortices emerges as a promising and quantifiable candidate marker of depression severity and treatment response.

Myelo- and cytoarchitectonic microstructural and functional human cortical atlases reconstructed in common MRI space

The parcellation of the brain's cortical surface into anatomically and/or functionally distinct areas is a topic of ongoing investigation and interest. We provide digital versions of six classical human brain atlases in common MRI space. The cortical atlases represent a range of modalities, including cyto- and myeloarchitecture (Campbell, Smith, Brodmann and Von Economo), myelogenesis (Flechsig), and mappings of symptomatic information in relation to the spatial location of brain lesions (Kleist). Digital reconstructions of these important cortical atlases widen the range of modalities for which cortex-wide imaging atlases are currently available and offer the opportunity to compare and combine microstructural and lesion-based functional atlases with in-vivo imaging-based atlases.

[Between affirmation and negation: Karl Kleist and Viktor von Weizsäcker between 1933 and 1945]

In 1954 Karl Kleist (1879-1960) became an honorary member of the German Neurological Society (DGN), an honor that was granted 2 years earlier to his colleague Viktor von Weizsäcker (1886-1957). The attempt to classify and assess their careers between 1933 and 1945 led to diametrically opposed results in historical research. This article summarizes the main lines of argumentation and draws a preliminary conclusion. After 1933 Kleist is said to have felt more and more accountable for his non-Aryan colleagues and that he treated his Jewish patients as long as he could. Publications and third party testimonies confirmed that he circumvented at least occasionally the Law for the Prevention of Genetically Diseased Offspring (GzVeN). Furthermore, he is said to have saved patients from "euthanasia" actions by prudently formulated diagnoses. Simultaneously, he worked as an expert at the Appelate Hereditary Health Court in Frankfurt am Main, in 1940 he joined the National Socialist German Workers' Party (NSDAP) and in 1942 the NS Medical Association. Von Weizsäcker used his scope of action in a similarly contradictory way. Certainly, he kept away from central Nazi organizations and was considered "politically unreliable" by those colleagues who had a penchant for the system. But as professor of neurology he formally headed from 1941 onwards exactly that Neuropathological Research Institute in Breslau (Wroclaw) where one of his colleagues examined the brains of minors who had been killed in the course of "child euthanasia", in what was called "concomitant research". To a certain extent von Weizsäcker was also an advocate of the GzVeN. In his lectures and publications between 1933 and 1935 he chose the pertinent NS terminology and he was the first to speak of a "theory of extermination". In either case, even meticulous research could not answer the question where to exactly assign both biographies in a spectrum between criticism and affirmation of National Socialism.

Current Challenges in Translational and Clinical fMRI and Future Directions

Translational neuroscience is an important field that brings together clinical praxis with neuroscience methods. In this review article, the focus will be on functional neuroimaging (fMRI) and its applicability in clinical fMRI studies. In the light of the "replication crisis," three aspects will be critically discussed: First, the fMRI signal itself, second, current fMRI praxis, and, third, the next generation of analysis strategies. Current attempts such as resting-state fMRI, meta-analyses, and machine learning will be discussed with their advantages and potential pitfalls and disadvantages. One major concern is that the fMRI signal shows substantial within- and between-subject variability, which affects the reliability of both task-related, but in particularly resting-state fMRI studies. Furthermore, the lack of standardized acquisition and analysis methods hinders the further development of clinical relevant approaches. However, meta-analyses and machine-learning approaches may help to overcome current shortcomings in the methods by identifying new, and yet hidden relationships, and may help to build new models on disorder mechanisms. Furthermore, better control of parameters that may have an influence on the fMRI signal and that can easily be controlled for, like blood pressure, heart rate, diet, time of day, might improve reliability substantially.

Constructional apraxia from the roots up: Kleist, Strauss, and their contemporaries

The concept and the term of constructional apraxia have been proposed by Karl Kleist and described in his impressive book "Gehirnpathologie", published in 1934. However, the first ever paper under the heading of constructional apraxia was written by Hans Strauss, one of Kleist's pupils, and published in 1924. Nowadays, the term constructional apraxia is still in use to refer to all disorders observed in drawing and assembling activities; its assessment, performed as it was in early studies, is part of common practice in behavioral neurology and neuropsychology. Nonetheless, the concept and the neural underpinnings of constructional apraxia have been deeply revisited with respect to the original proposal. Modern studies demonstrated that drawing and assembling are based on very large and complex brain networks extending in both hemispheres, including the left angular gyrus (as hypothesized by Kleist) but well beyond the original ideas about localization of constructional apraxia. From a clinical point of view, constructional apraxia has poor localizing value but provides valuable diagnostic information for conditions of cognitive impairment.

The Research Domain Criteria (RDoC) and the historical roots of psychopathology: A viewpoint

In this article we aim at conceptual reconstruction of the historical background behind RDoC project. It incorporates some elements that have not heretofore been included in frameworks for psychopathology research. At the same time, however, RDoC - like any approach to mental illness - must grapple with longstanding challenges in addressing issues about the roles and relationships of mind, brain, and patients' reports in considering the nature of disorder. In this respect, the historical roots of psychopathology remain as relevant as ever.

Historical and conceptual aspects of motor disorders in the psychoses

Historical epistemology is a useful method to understand the longitudinal construction of the movement disorders in psychiatry. Four periods can be identified in such a process. The first, extending from Classical times to the work of Griesinger, included disorders such as catalepsy, crocidism, epilepsy and paralysis. The second period, stretching from Griesinger to Kahlbaum, concentrated on the study of melancholia attonita, stupor and catatonia. The third period, covering the time from Kahlbaum to WWI, witnessed important conceptual shifts such as: the transformation of madness into psychoses; the redefinition of movement and motility in psychiatry; the appearance of self-contained syndromes as dyskinesias, tics, akathisia, complex disorders like the cases of encephalitis lethargica, etc.; the advent of functional and psychodynamic explanations; and the description by Wernicke, Kleist and others of the motility psychoses. The fourth period stretches from WWI to the present and since it corresponds to the views and work reported in the rest of this Special issue it has not been touched upon in this paper. In spite of an increasing methodological refinement, empirical research is yet to clarify what is the clinical meaning of the movement disorders in the context of the psychoses and to explain whether such disorders are primary (i.e. issuing directly from the brain and parallel to the rest of psychotic symptomatology) or secondary (i.e. mediated by cognitive and emotional phenomena characteristic of the psychoses).

New revelations about Hans Berger, father of the electroencephalogram (EEG), and his ties to the Third Reich

Hans Berger was a German neuropsychiatrist and head of the neurology department at the University of Jena, who discovered the human electroencephalogram (EEG). Many sources state that Berger was forced into retirement and suicide by the Nazis because he was at odds with the regime. In fact, Berger helped select his Nazi successor Berthold Kihn (complicit in "euthanasia" murders), financially supported the Nazi Schutzstaffel (SS), and was a willing participant on Nazi genetic health higher courts that reviewed appeals for forced sterilizations of neuropsychiatric patients. His motivations could be related to avoiding Nazi harassment, indoctrination by Nazi ideology, or less likely, career opportunism. His actions stand in contrast to colleagues who partially resisted the Nazis, and hopefully will serve as an example to future generations of neurologists regarding the danger of allowing one's professional standing to be used as a tool to support the policies of tyranny and oppression.

The neuropathology of morality: Germany 1930-1960

This article analyzes brain scientists' attempts to trace morality in the brain in Germany from 1930 to 1960. The debate around Karl Kleist's localization of the Gemeinschafts-Ich [community-I] in the 1930s is depicted in order to illustrate the central arguments for and against localizations of morality. The focus of this article is on the period 1936-1960 in which experts put forth specific ideas on morality's cerebral underpinnings that mirror the larger theoretical shift from strict localization doctrine to a more holistic understanding of the brain. As a result of this shift, experts avoided exact localizations of morality. Instead, they posited correlations between brain areas and morality. The analysis illustrates the dependence of neuropathological research on morality on general theories of brain functioning and marks a first contribution to the history of the neuroscience of morality for the time after 1930.

What is a'mood-congruent' delusion? History and conceptual problems

This article investigates the history of the concept of mood-congruent delusions and the problems accompanying this concept. In the late nineteenth century, there were conflicting views regarding the relationship between the contents of an individual's delusional thought and his/her affective state. The differentiation between delusion-like ideas secondary to affective state and incomprehensible primary delusions was introduced in the early twentieth century; this differentiation is the origin of the present-day distinction between mood-congruent and -incongruent delusions. Although the themes of delusions are clearly described in the operational diagnostic criteria for mood-congruent psychotic symptoms, the concept of mood congruence inevitably involves ambiguity. This article argues that a dilemma between reliability and validity emerges when diagnosing mood-congruent (and -incongruent) psychotic symptoms.

Cycloid psychoses revisited: case reports, literature review, and commentary

Emil Kraepelin proposed to separate psychiatric disorders with psychotic features into two major categories, dementia praecox (later schizophrenia) and manic-depressive insanity (later bipolar disorder and major depression). Over the past century, there have been many efforts to categorize conditions that do not fit readily in either group. These conditions include many cases of acute psychotic illnesses of limited duration, with recovery between recurrences. For some of these conditions, Karl Kleist proposed the term cycloid psychosis: acute features were psychotic, as in schizophrenia, but the course was episodic, as in manic-depression. His concept was later elaborated by Karl Leonhard and Carlo Perris, and validated by modern studies. Leonhard described three overlapping cycloid subtypes (anxiety-beatific, excited-inhibited confusional, and hyperkinetic-akinetic motility dysfunction forms); Perris proposed a more unitary syndrome with operational diagnostic criteria; and recent investigators have considered relatively affective versus thought-disordered subtypes. The cycloid concept is not explicitly included in standard international diagnostic schemes, but both DSM-IV and ICD-10 have broad categories for acute, recurrent psychotic disorders, whose validity remains insecure. We present two cases of probable cycloid psychosis, review the history of the concept, and propose that it be reconsidered as a clinically useful category whose validity and utility for prognosis and treatment can be further tested.

Classification Matters for Catatonia and Autism in Children

Despite its chequered history, Kahlbaum's 1874 description of catatonia (tension insanity) and its categorization as a clinical illness is in outline still valid. Kahlbaum also acknowledged the existence of catatonia in children. Corresponding case studies have also been analyzed. The originators and disciples of the Wernicke-Kleist-Leonhard school proved catatonia in early childhood as a discrete entity with specific psychopathology. This does not mean that catatonic symptoms do not occur in other illnesses and in particular in organic psychoses. These are, however, of a totally different nature. Autism, as first described in connection with schizophrenic negativism by Bleuler in 1910, is one of the key symptoms of schizophrenia. As identified by Kanner in 1943, abnormal social interaction and communication, together with retarded development, are the main characteristics of autism in early childhood. Asperger's concept of autistic disorder (1944), although based on psychopathological theory, did not include retardation in development as an aspect. Consequently, autistic behavior can occur in a variety of mental disorders. Research into possible etiological and pathogenetic factors has been undertaken, but no clear link found as yet.

Georg N. Koskinas (1885-1975) and his scientific contributions to the normal and pathological anatomy of the human brain

Georg N. Koskinas is invariably recognised by neuroanatomists as Constantin von Economo's co-author on the celebrated Die Cytoarchitektonik der Hirnrinde des erwachsenen Menschen, published 80 years ago in Vienna and Berlin. That text and Atlas are generally accepted as a monumental landmark in the evolution of morphological brain research. A number of neuroanatomists and neurophysiologists continue to use to this day the parcellation scheme of the cerebral cortex into 107 areas, proposed by von Economo and Koskinas (and logically denoted by alphabetical characters from the initials of the respective lobes), despite the commoner adoption of Brodmann's scheme of 52, randomly numbered, areas. Several works have been written about the life and work of von Economo; on the other hand, virtually nothing can be found in the biomedical literature about Koskinas. This study aims at posthumously restoring part of the fame due this illustrious man of 20th century science -- and giant figure of brain anatomy -- whom history has not treated in the fairest of ways. We present newly gathered biographical data, as well as lesser known aspects of his scientific productivity. Koskinas' neuropathological studies, in collaboration with Ernst Sträussler -- of Gerstmann-Sträussler-Scheinker disease fame -- include findings from patients inoculated with malaria as a form of therapy for progressive general paresis (research related to psychiatrist Wagner von Jauregg's 1927 Nobel Prize), colloid degeneration, and the laminar distribution of status spongiosus lesions. Koskinas' neuropsychiatric activities in Greece upon his return from Vienna in 1927, and until his parting in 1975, are further related, including his successful -- and "Hippocratic" -- practice in the suburbs of Athens, his association with the Vogt Institute for Brain Research at Neustadt, and lesser known neuroanatomical works.

Karl Kleist and his refusal of an appointment at Leipzig in 1923

Further to the study of Newmärker and Bartsch (2003) of Karl Kleist (1879-1960), this short contribution based on archive material, cited for the first time, looks into Kleist's motives for refusing an appointment as Professor of Psychiatry and Neurology at Leipzig University. This study comes to the conclusion that Kleist thought seriously of moving to Leipzig. However, the Saxony Ministry of People's Education refused to make a definite financial commitment to the reconstruction and building work that Kleist considered essential. On the other hand, the authorities in Frankfurt am Main, where Kleist had been appointed 3 years earlier, evidently agreed to the funding he required if he was to remain there. This finally prompted him to turn down the Leipzig offer.