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.

On the Origins of MAOI Misconceptions: Reaffirming their Role in Melancholic Depression

The first monoamine oxidase inhibitors (MAOIs) used for the treatment of depression in the 1950-60s were credited with treating severe melancholic depression (MeD) successfully and greatly reducing the need for electroconvulsive therapy (ECT). Following the hiatus caused by the then ill-understood cheese reaction, MAOI use was relegated to atypical and treatment-resistant depressions only, based on data from insufficiently probing research studies suggesting their comparatively lesser effectiveness in MeD. The siren attraction of new 'better' drugs with different mechanisms amplified this trend. Following a re-evaluation of the data, we suggest that MAOIs are effective in MeD. Additionally, the broad unitary conceptualisation of major depressive disorder (MDD) in the DSM model diminished the chance of demonstrating distinctive responses to different antidepressant drugs (ADs) such as SSRIs, TCAs, and MAOIs, thereby further reducing the interest in MAOIs. More reliable categorical distinction of MeD, disentangling it from MDD, may be possible if more sensitive measuring instruments (CORE, SMPI) are used. We suggest these issues will benefit from re-appraisement via an inductive reasoning process within a binary (rather than a unitary) model for defining the different depressive disorders, allowing for the use of more reliable diagnostic criteria for MeD in particular. We conclude that MAOIs remain essential for, inter alia, TCA-resistant MeD, and should typically be used prior to ECT; additionally, they have a role in maintaining remission in cases treated with ECT (and ketamine/esketamine). We suggest that MAOIs should be utilized earlier in treatment algorithms and with greater regularity than is presently the case.

The first psychiatric pandemic: Encephalitis lethargica, 1917-27

Finding a link between COVID-19 and subsequent psychiatric symptoms has resulted in renewed interest in the psychiatric sequelae of pandemics. The first such instance was apparently the encephalitis lethargica pandemic which arose around the time of the First World War, moving in the shadow of a repiratory virus pandemic. The epidemic of encephalitis lethargica (EL), or Von Economo's Disease, in the years 1917-27 was the first pandemic involving the central nervous system. It moved in some places in parallel with the Great Flu Pandemic but does not seem to have been caused by it. Unlike the coronavirus, pandemic EL affected children heavily, leading often to bizarre changes in character and personality. It often left sequelae lasting for decades in the form of postencephalitic Parkinsonism (PEP). Unlike the coronavirus, it had a high mortality of around 20 percent. Although encephalitis lethargica involved a number of systems, psychiatric morbidity was most prominent and entailed severe depression, mania, catatonia and psychosis. It ended without therapeutic or public-health measures; today, sporadic cases of EL continue to be reported. The hypothesis is that we can derive from the EL psychiatric pandemic certain lessons that might be useful in studying tardive COVID symptoms today.

How amytal changed psychopharmacy: off-label uses of sodium amytal (1920-40)

In the early 1930s, American neurologist and psychiatrist William Bleckwenn used sodium amytal to render catatonic patients responsive, so that he could engage in talk therapy. Bleckwenn found a new, 'off-label' use for this anaesthetic and anxiolytic medication in psychiatry and, in doing so, allowed for important discoveries in the diagnosis and treatment of catatonia. Pharmacological textbooks reveal a 'label', while the Index-Catalogue of the Library of the Surgeon-General's Office reveals explorations 'off label' of barbiturates. The 'off-label' use of barbiturates facilitated talk therapy, heralding an important shift in psychopharmacy. Drugs previously only used as chemical restraints became a form of treatment for specific psychiatric diseases. The current strictures against off-label prescribing are overprescriptive and close off innovative new uses.

Does persisting fear sustain catatonia?

OBJECTIVE

To examine the psychological substrate of catatonia.

METHOD

Reviewing the historical descriptions and explanations of catatonic behaviours by clinicians from its delineation in the 19th century to the present.

RESULTS

Patients with catatonia are often haunted by fears and terrors; this has not been widely appreciated, and certainly was lost from view in the days when catatonia was considered a subtype of schizophrenia. The report contributes to resolving a major question in catatonia: is the mind in stupor inactive, as the blank state that we picture in anesthetized patients, or is the mind active, so preoccupied as to exclude all other influences.

THE MAIN FINDING

Persistent fear occupies the mind of catatonic patients.

CONCLUSION

The signs of catatonia are adaptations to persistent fear, akin to tonic immobilization. The relief afforded by sedation supports this interpretation.

L'âge des premières règles en France, 1750-1950

Dans l'Europe de la fin du XIXe siècle, la baisse de l'âge aux premières règles est un fait général, et déjà bien connu. Ce qui est moins connu, c'est le moment où ce mouvement s'amorce. Question importante, car parmi les facteurs qui affectent l'âge de la première menstruation — l'affaiblissement du sujet par des maladies comme la tuberculose, l'âge de puberté de la mère, etc. —, celui qui pourrait avoir subi le plus de changements dans le temps est le régime alimentaire. Les chercheurs admettent aujourd'hui que la première menstruation résulte d'un processus de maturation plus général qui est sensible à la nutrition.

The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders

The current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 arose from a tradition filled with haphazard science and politically driven choices. The nosology of modern psychiatry began with the German classifiers of the late 19th century, especially Emil Kraepelin. Psychoanalysis then blotted out the classificatory vision for the next half-century, and most of this European psychopathological science failed to cross the Atlantic. The DSM series was a homegrown American product, beginning with Medical 203 in 1945, then guided by psychoanalytic insights through DSM-I in 1952 and DSM-II in 1968. In 1980, DSM-III represented a massive “turning of the page” in nosology, and it had the effect of steering psychoanalysis toward the exit in psychiatry and the beginning of a reconciliation of psychiatry with the rest of medicine. With the advent of DSM-5, however, questions are starting to be asked about whether this massive venture is on the right track.

The 25th anniversary of the launch of Prozac gives pause for thought: where did we go wrong?

The creation, in DSM-III, of the category 'major depression' can be linked to the launch, and success, of Prozac. The consequences of creating this broad diagnostic category are of concern in relation to the treatment of individuals with a diverse variety of depressive disorders.

The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders

The current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 arose from a tradition filled with haphazard science and politically driven choices. The nosology of modern psychiatry began with the German classifiers of the late 19th century, especially Emil Kraepelin. Psychoanalysis then blotted out the classificatory vision for the next half-century, and most of this European psychopathological science failed to cross the Atlantic. The DSM series was a homegrown American product, beginning with Medical 203 in 1945, then guided by psychoanalytic insights through DSM-I in 1952 and DSM-II in 1968. In 1980, DSM-III represented a massive "turning of the page" in nosology, and it had the effect of steering psychoanalysis toward the exit in psychiatry and the beginning of a reconciliation of psychiatry with the rest of medicine. With the advent of DSM-5, however, questions are starting to be asked about whether this massive venture is on the right track.

Traditional Chinese medicine and Western psychopharmacology: building bridges

This paper demonstrates that in the treatment of psychiatric disorders, there are striking similarities between the mechanisms of psychoactive agents used in Traditional Chinese Medicine (TCM) and those of western psychopharmacology. While western researchers search for new treatments and novel mechanisms of action, investigators in Asia are analyzing traditional remedies in order to understand the mechanisms responsible for their effectiveness. A review of contemporary pharmacologic studies of agents used in TCM for psychiatric indications reveals that virtually all of the active principles of drug action established in 20th century psychopharmacology were encountered empirically in Chinese herbal medicine over the past 2000 years. Building bridges between these two traditions may thus be of benefit to both cultures. In addition to providing western patients with a wider selection of treatment options, the effort may help Asian clinicians and researchers avoid some of the errors that have troubled their western counterparts.

Psychiatry and fads: why is this field different from all other fields?

Fads in psychiatry are little more than bad ideas with short half-lives. They have arisen because of the great discontinuities that have swept psychiatry unlike other specialties in the 20th century: the transition in the 1920s from asylum-based biological psychiatry to psychoanalysis, and the transition in the 1960s from psychoanalysis to a biological model based on psychopharmacology. In no other medical specialty has the knowledge base been scrapped and rebuilt, and then again scrapped and rebuilt. In these great transitions, when psychiatry each time has had to reconstruct from scratch, bad ideas have crept in with good. Psychiatry, in its heavy use of consensus conferences, is often unable to employ science as a means of discarding fads, which, once installed, are often difficult to remove. Each of the great paradigms of psychiatry in the last hundred years has given rise to fads, and psychopharmacology is no exception, with faddish uses of neurotransmitter doctrine claiming centre stage. Only when psychiatry becomes firmly linked to the neurosciences will its subjugation to the turbulence of faddism be moderated.

Childhood catatonia, autism and psychosis past and present: is there an 'iron triangle'?

OBJECTIVE

To explore the possibility that autism, catatonia and psychoses in children are different manifestations of a single underlying form of brain pathology - a kind of 'Iron Triangle' of symptomatology - rather than three separate illnesses.

METHOD

Systematic evaluation of historical case literature on autism to determine if catatonic and psychotic symptoms accompanied the diagnosis, as is found in some challenging present-day cases.

RESULTS

It is clear from the historical literature that by the 1920s all three diagnoses in the Iron Triangle - catatonia, autism and childhood schizophrenia - were being routinely applied to children and adolescents. Furthermore, it is apparent that children diagnosed with one of these conditions often qualified for the other two as well. Although conventional thinking today regards these diagnoses as separate entities, the presence of catatonia in a variety of conditions is being increasingly recognized, and there is also growing evidence of connections between childhood-onset psychoses and autism.

CONCLUSION

Recognition of a mixed form of catatonia, autism and psychosis has important implications for both diagnosis and treatment. None of the separate diagnoses provides an accurate picture in these complex cases, and when given single diagnoses such as 'schizophrenia', the standard treatment options may prove markedly ineffective.

A brief history of placebos and clinical trials in psychiatry

The history of placebos in psychiatry can be understood only in the context of randomized controlled trials (RCTs). Placebo treatments are as old as medicine itself, and are particularly effective in dealing with psychosomatic symptoms. In psychiatry, placebos have mainly been featured in clinical drug trials. The earliest controlled trial in psychiatry (not involving drugs) occurred in 1922, followed by the first crossover studies during the 1930s. Meanwhile the concept of randomization was developed during the interwar years by British statistician Ronald A Fisher, and introduced in 3 trials of tuberculosis drugs between 1947 and 1951. These classic studies established the RCT as the gold standard in pharmaceutical trials, and its status was cemented during the mid-1950s. Nevertheless, while the placebo became established as a standard measure of drug action, placebo treatments became stigmatized as unethical. This is unfortunate, as they constitute one of the most powerful therapies in psychiatry. In recent years, moreover, the dogma of the placebo-controlled trial as the only acceptable data for drug licensing is also being increasingly discredited. This backlash has had 2 sources: one is the recognition that the US Food and Drug Administration has been too lax in permitting trials controlled with placebos alone, rather than also using an active agent as a test of comparative efficacy. In addition, there is evidence that in the hands of the pharmaceutical industry, the scientific integrity of RCTs themselves has been degraded into a marketing device. The once-powerful placebo is thus threatened with extinction.

Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature

Catatonia is a motor dysregulation syndrome described by Karl Kahlbaum in 1874. He understood catatonia as a disease of its own. Others quickly recognized it among diverse disorders, but Emil Kraepelin made it a linchpin of his concept of dementia praecox. Eugen Bleuler endorsed this singular association. During the 20th century, catatonia has been considered a type of schizophrenia. In the 1970s, American authors identified catatonia in patients with mania and depression, as a toxic response, and in general medical and neurologic illnesses. It was only occasionally found in patients with schizophrenia. When looked for, catatonia is found in 10% or more of acute psychiatric admissions. It is readily diagnosable, verifiable by a lorazepam challenge test, and rapidly treatable. Even in its most lethal forms, it responds to high doses of lorazepam or to electroconvulsive therapy. These treatments are not accepted for patients with schizophrenia. Prompt recognition and treatment saves lives. It is time to place catatonia into its own home in the psychiatric classification.

Darwin's contribution to psychiatry

This November we celebrated the sesquicentennial of the Origin of Species, a landmark in the history of biology. Yet Darwin's chief contribution to psychiatry appears in The Expression of the Emotions in Man and Animals (1872), where he describes 'the grief muscles', later identified as a sign of melancholic illness.

The history of lithium therapy

The use of lithium in psychiatry goes back to the mid-19th century. Early work, however, was soon forgotten, and John Cade is credited with reintroducing lithium to psychiatry for mania in 1949. Mogens Schou undertook a randomly controlled trial for mania in 1954, and in the course of that study became curious about lithium as a prophylactic for depressive illness. In 1970, the United States became the 50th country to admit lithium to the marketplace. Meanwhile, interest in lithium for the prophylaxis of depression was growing apace and today the agent is widely prescribed for that indication, even though it has not been accepted by the Food and Drug Administration. Lithium was almost derailed by a small group of opponents from the Maudsley Hospital and its status today is threatened by the "mood stabilizers."

Are patients with depression at heightened risk of suicide as they begin to recover?

It has long been taught and believed that patients with depression and suicidal tendencies are at heightened risk of suicide as they begin to recover and their energy and motivation return. What are the data behind this enduring belief? More than a century ago, eminent clinicians noted that some patients with depression committed suicide just as their depression seemed to be improving. The clinicians went on to warn that early recovery carries a high risk of suicide. Although no studies have tracked suicide along with symptomatic change in depression, recent large-scale studies of suicide and phase of treatment do not indicate that suicide is more likely to occur early in recovery than at other times. Our forebears helpfully pointed out that patients with depression may commit suicide as they are beginning to recover. But the idea that these patients are at particular risk of suicide at this time, intuitively plausible as it is, remains to be substantiated.

History of psychiatry

PURPOSE OF REVIEW

The present review examines recent contributions to the evolving field of historical writing in psychiatry.

RECENT FINDINGS

Interest in the history of psychiatry continues to grow, with an increasing emphasis on topics of current interest such as the history of psychopharmacology, electroconvulsive therapy, and the interplay between psychiatry and society. The scope of historical writing in psychiatry as of 2007 is as broad and varied as the discipline itself.

SUMMARY

More than in other medical specialties such as cardiology or nephrology, treatment and diagnosis in psychiatry are affected by trends in the surrounding culture and society. Studying the history of the discipline provides insights into possible alternatives to the current crop of patent-protected remedies and trend-driven diagnoses.

Károly Schaffer and his school: the birth of biological psychiatry in Hungary, 1890-1940

In the first third of the twentieth century, neuropathology seemed to offer the key to unlock the causes of psychiatric illness. Among the top centers devoted to the microscopic anatomy of the brain was that of Károly Schaffer in Budapest. Schaffer, a pioneer in the histopathology of Tay-Sachs-Schaffer disease, was also a charismatic teacher, bringing forth a school of investigators in psychopathology. Among them was László Meduna, who originated convulsive therapy. Despite the importance of the Schaffer school, it is almost unknown outside of Hungary, largely the result of the introduction of neurophysiological, neurochemical and molecular genetic methods that distracted attention away from histopathological contributions in psychiatry after the Second World War. The microscopic study of the brain and its diseases seemed increasingly less important. The present biographical account of Károly Schaffer and his school seeks to bring this important story in the early history of biological psychiatry to a wider audience and explain why it has since been forgotten.

The liberal state and the rogue agency: FDA's regulation of drugs for mood disorders, 1950s-1970s

The theory of the liberal state does not generally contemplate the possibility that regulatory agencies will turn into "rogues," regulating against the interests of their clients and, indeed, the public interest. In the years between circa 1955 and 1975 this seems to have happened to one of the prime regulatory agencies of the US federal government: the Food and Drug Administration (FDA). Intent upon transforming itself from a traditional "cop" agency to a regulatory giant, the FDA campaigned systematically to bring down some safe and effective drugs. This article concentrates on hearings in the area of psychopharmacology regarding several antianxiety drugs, namely meprobamate (Miltown), chlordiazepoxide (Librium) and diazepam (Valium). In addition, from 1967 to 1973 this regulatory vengefulness occurred on a broad scale in the Drug Efficacy Study Implementation (DESI), an administrative exercise that removed from the market almost half of the psychopharmacopoeia. The article explores possible bureaucratic motives for these actions.

Chronic fatigue in historical perspective

Chronic fatigue as a presenting complaint, in the absence of other evident organic illness, was seldom reported historically before the second half of the 19th century. Its first eruption was the so-called 'bed cases' or 'sofa cases' among middle-class females in the period from 1860 to about 1910. 'Neurasthenia' does not necessarily represent an early forerunner of chronic fatigue. Many patients receiving that diagnosis did not complain of fatigue. Others with functional fatigue did not receive the diagnosis 'neurasthenia'. Both medical-anecdotal and quantitative sources make it clear that by the time of the First World War, chronic fatigue was a common complaint in Europe and North America. Medical concepts of chronic fatigue since the 1930s have run along four separate lines: (1) 'postinfectious neuromyasthenia', going back to an atypical 'poliomyelitis' epidemic in 1934; (2) 'chronic Epstein-Barr virus' infection, an illness attribution that increased in frequency after the discovery in 1968 that this virus caused mononucleosis; (3) 'myalgic encephalomyelitis', dating from an epidemic at the Royal Free Hospital in London in 1955; and (4) 'fibrositis', or 'fibromyalgia', used as a rheumatological description since the turn of the century. Recently, these four separate paths have tended to converge into the diagnosis of 'chronic fatigue syndrome'.

About the history of sexuality

About 50 years of demolition work, it's time now for a return to the grand syntheses. Two of the great syntheses of the 19th century have now been shattered. Marxism lies in fragments. And psychoanalysis has largely drifted outside of psychiatry to find a new and doubtless temporary home in departments of literary studies. To be sure, the third of the great syntheses, Darwin's theory of evolution, remains intact. But otherwise, as far as the eye can see, there is rubble. The time for new attempts at synthesis is now nigh. After decades of pioneering work in the neurosciences, the fundamental importance of brain biology in the human condition has now become evident. Surely one of the new syntheses will draw upon neurochemistry and neurophysiology, and it is to the great credit of the Hungarian neurosciences that pharmacologist Joseph Knoll has now ventured a first attempt. This attempt will be widely discussed and will form the platform for other work that may end up building firm bridges between "neuroenhancers" and behavior - and, what's more, to show how this relationship has shaped the evolution of thousands of years of human destiny, a great synthesis indeed.

The doctrine of the two depressions in historical perspective

OBJECTIVE

To determine if the concept of two separate depressions - melancholia and non-melancholia - has existed in writings of the main previous thinkers about mood disorders.

METHOD

Representative contributions to writing on mood disorders over the past hundred years have been systematically evaluated.

RESULTS

The concept of two separate depressions does indeed emerge in the psychiatric literature from the very beginning of modern writing about the concept of 'melancholia'. For the principal nosologists of psychiatry, melancholic depression has always meant something quite different from non-melancholic depression. Exceptions to this include Aubrey Lewis and Karl Leonhard. Yet the balance of opinion among the chief theorists overwhelmingly favors the existence of two quite different illnesses.

CONCLUSION

The concept of 'major depression' popularized in DSM-III in 1980 is a historical anomaly. It mixes together psychopathologic entities that previous generations of experienced clinicians and thoughtful nosologists had been at pains to keep separate. Recently, there has been a tendency to return to the concept of two depressions: melancholic and non-melancholic illness. 'Major depression' is coming into increasing disfavor. In the next edition of DSM (DSM-V), major depression should be abolished; melancholic mood disorder (MMD) and non-melancholic mood disorder (NMMD) should become two of the principle entities in the mood disorder section.

Hysteria and catatonia as motor disorders in historical context

It is difficult to imagine motor symptoms in psychiatry as different as hysteria and catatonia. The mechanism of hysteria is presumed to be psychogenic, while catatonia has always been considered to be among the most organic syndromes in psychiatry. Yet hysteria and catatonia have historically been regarded as allied conditions, an observation borne out by recent developments in neuroscience as well as by a growing awareness that the presentation of both conditions has changed over the years. In hysteria, the main shift has been from motor symptoms to sensory complaints such as chronic fatigue; in catatonia, the major change has been the virtual disappearance of negativistic or oppositional behaviour. It is possible that catatonia as well as hysteria may be responsive to changing cultural norms.

From railway spine to whiplash--the recycling of nervous irritation

The search for a specific structural basis for chronic whiplash and other chronic pain and fatigue syndromes has been in progress for decades, and yet currently there remains no "structural" solution to these enigmata. In light of the failure of research to identify the chronic "damage" or pathology as lying in a muscular, bony, or "connective tissue" sites for many chronic pain syndromes like whiplash, fibromyalgia, et cetera, more recent attention has been paid to nervous system structures. Nerve irritation has been implicated as the basis for the pain and other symptoms that are common to many chronic disability syndromes. We postulate here, however, that the concept of nervous irritation has been prostituted for centuries whenever more concrete structural explanations for chronic pain and other controversial illness have been untenable. We suggest that, after each cycle of nervous irritation as a disease, and subsequent dismissal of the notion, the doctrine of irritation as a disease was too good to go away. First, with the hypersthenic and asthenic diseases of the nineteenth century, then railway spine, whiplash, thoracic outlet syndrome, and now brachial plexus irritation, we detect the same pattern: patients with symptoms, but no objective evidence of nerve disease. Nervous irritation has repeatedly served this purpose for the last 200 years. It is our intent that bringing an understanding of this trend will encourage current clinicians and researchers to appreciate the need to abandon this form of speculation without historical insight when dealing with today's controversial syndromes.

Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease

No new drugs for mood and anxiety disorders have reached the market for over a decade. Why is there so little innovation in a sector that accounts for the largest proportion by far of sales of psychiatric drugs?

Notes on antipsychiatry

The present paper aims to provide a review of the history and basic principles of the antipsychiatric movement, as well as to discuss the work of its most important theorists. The authors searched recent literature, as well as drawing upon some of the basic antipsychiatric texts. Antipsychiatry emerged as an international movement during the 1960s as part of the historic tumult of the period rather than as a result of the evolution of scientific ideas. Antipsychiatrists radically opposed what they understood as a hospital-centered medical specialty legally empowered to treat and institutionalize mentally disordered individuals. Indeed, many antipsychiatrists argued against the very existence of mental disorders themselves. After the 1970s, the antipsychiatry movement became increasingly less influential, due in particular to the rejection of its politicized and reductionistic understanding of psychiatry.