Paul Hoff

The introduction of the term and concept schizophrenia earned its inventor, Swiss psychiatrist Eugen Bleuler, worldwide fame. Prompted by the rejection of the main principle of Kraepelinian nosology, namely prognosis, Bleuler's belief in the clinical unity of what Kraepelin had described as dementia praecox required him to search for alternative characterizing features that would allow scientific description and classification. This led him to consider psychological, and to a lesser degree, social factors alongside an assumed underlying neurobiological disease process as constitutive of what he then termed schizophrenia, thus making him an early proponent of a bio-psycho-social understanding of mental illness. Reviewing Bleuler's conception of schizophrenia against the background of his overall clinical and theoretical work, this paper provides a critical overview of Bleuler's key nosological principles and links his work with present-day debates about naturalism, essentialism, and stigma.

In the history of psychiatry, "schizophrenia" has often been portrayed as the discipline's pars pro toto, which prototypically represents mental illness as such and which draws together the fundamental questions concerning psychiatric epistemology and practice. Taking a conceptual history approach, this essay examines how "schizophrenia" is represented in psychiatric discourse and what aspects of its representation account for the pars pro toto status. Three such aspects are identified: a pragmatic, an existential and a justificatory aspect. Following up these aspects in present day psychiatric discourse, it is concluded that "schizophrenia" is losing its special status as the representations of psychiatry and of mental illness have changed and become more diverse. Tentative conclusions regarding current debates about the abolition of "schizophrenia" are drawn.

Psychiatry has always been characterised by highly heterogeneous theoretical concepts regarding the etiology, diagnosis and treatment of mental disorders, but also concerning the appropriate scientific methods to be applied. A central issue is the question whether mental phenomena should preferably be explained (as in natural sciences), understood or interpreted (as in «Geisteswissenschaften») or described (with as few theoretical presuppositions as possible). This paper illustrates the main historical and actual arguments in this debate. The first conclusion is that no clear separation line exists between these three methods and that such a separation is not at all necessary for clinical or research purposes. What is needed, however, is a balanced combination of approaches, depending on the clinical or scientific questions to be answered. The second conclusion suggests a future strengthening of the role of psychopathology, a scientific field that clearly reaches beyond the reliable...

This chapter situates privacy and confidentiality as central ethical, legal, and anthropological concepts for psychotherapeutic practice. It first provides some conceptual background and clarification of the concepts before considering their specific relevance in the context of psychotherapy. In particular, it explores a unique significance that, it is argued, privacy and confidentiality acquire in the therapeutic process to do with the anthropological dimension of privacy, its psychological function, and the specific dynamics of the therapeutic relationship. Based on four case vignettes, potential ethical conflicts about privacy and confidentiality are then discussed. Finally, principles that can guide practitioners in responding to ethical conflicts about privacy and confidentiality in clinical practice are provided.

The introduction of the term and concept schizophrenia earned its inventor, Swiss psychiatrist Eugen Bleuler, worldwide fame. Prompted by the rejection of the main principle of Kraepelinian nosology, namely prognosis, Bleuler's belief in the clinical unity of what Kraepelin had described as dementia praecox required him to search for alternative characterizing features that would allow scientific description and classification. This led him to consider psychological, and to a lesser degree, social factors alongside an assumed underlying neurobiological disease process as constitutive of what he then termed schizophrenia, thus making him an early proponent of a bio-psycho-social understanding of mental illness. Reviewing Bleuler's conception of schizophrenia against the background of his overall clinical and theoretical work, this paper provides a critical overview of Bleuler's key nosological principles and links his work with present-day debates about naturalism, essent...

Ever since psychiatry emerged as a clinical discipline and field of scientific inquiry in the late 18th century, debates about diagnosis have been at its very heart. Considered by many a requirement for clinical communication as well as for systematic study, others have critiqued psychiatric diagnosis for being modeled on a medical conception of disease that is ill-suited to the specific nature of mental disorders. Based on a review of seminal positions in the conceptual history of psychiatry and an examination of their epistemological underpinnings, we propose to consider diagnosis as dialogue. Such understanding, we argue, can serve as a meta-framework that provides a conceptual and practical umbrella to encourage open-minded conversation across the diverse conceptual and experiential frameworks that are characteristic of psychiatry. In this perspective psychopathology will also reinforce the interpersonal realm as a necessary element of any clinical encounter, be it diagnostic in...

In daily clinical work, coercion continues to be highly prevalent, with rates differing between countries and sometimes even within countries or between wards of the same hospital. Previous research found inconsistent characteristics of individuals who underwent coercive measures during psychiatric treatment. Furthermore, there continues to be a lack of knowledge on the clinical course of people after being involuntarily committed. This study aimed to describe the rate and duration of different coercive measures and characterise a cohort of involuntarily committed patients regarding sociodemographic and clinical variables. In this observational cohort study, we analysed clinical data from the patients' medical files, the use of coercive measures (seclusion, restraint, coercive medication) and other procedural aspects in involuntarily hospitalised patients (n = 612) at the University Hospital of Psychiatry Zurich. For analysis, we used cross-tabulation with chi-square tests for c...

Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures. In a sample of involuntarily hospitalized patients ( = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion ( = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression. In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients...

... Paul Hoff und Anastasia Theodoridou ... Eine herausragende Erscheinung in diesem Zusammenhang, Wilhelm Griesinger, forderte nachhaltig, die klinische Psychiatrie habe sich dem psychophysischen Problem empirisch und nicht metaphysisch zu stellen, sie habe also ...

1. One aspect of using MAO-inhibitors - combining them with tricyclic antidepressants in the treatment of therapy resistant depression - has always been controversely discussed in regard to its unusual toxicity and efficacy. 2. To obtain detailled information about safety and efficacy of such a combined treatment, the charts of 94 inpatients treated with a tranylcypromine - tri- (tetra) cyclic antidepressant combination were reviewed. 3. Within a mean treatment period of 21.9 days, 68% of the patients demonstrated a very good or good improvement to combined treatment, the most effective combination being tranylcypromine + amitriptyline. 4. The incidence of side effects among the patients on the combined regimen was slightly, but not significantly lower as compared to the patients on single tri- (tetra) cyclic antidepressant treatment. 5. Our retrospective study supports the general safety and efficacy of combined MAOI-TCA treatment and suggests that combined treatment, if properly administered, leads to neither serious complications nor an inordinate number of side effects.

Probably few psychiatrists would spontaneously associate Emil Kraepelin’s name with philosophy. Nevertheless, I think it is necessary to look at this relationship for the following reasons: During recent years, several authors have described a crisis in psychiatry, particularly in psychiatric diagnosis. It is not purely coincidental that in such a “critical” era, many concepts and ideas are “re-discovered” which previously have been regarded as of merely historical interest. This is especially true of Emil Kraepelin’s psychiatry. The influence of what is often called the “neo-Kraepelinian movement” is well-known, an influence which manifests itself, for example, in the operationalized diagnostic criteria of DSM-III-R, and which proves the profound relevance of Kraepelinian ideas for present-day psychiatry (Blashfield 1984). Given this situation, it seems appropriate to critically reevaluate Kraepelin’s nosological positions as they changed over time (which cannot be further discussed here), and—our present topic—to highlight the philosophical implications of this nosology, although—as will be shown—they often are quite well hidden.1

Emil Kraepelin (1856-1926) was an influential figure in the history of psychiatry as a clinical science. This paper, after briefly presenting his biography, discusses the conceptual foundations of his concept of mental illness and follows this line of thought through to late 20th-century "Neo-Kraepelinianism," including recent criticism, particularly of the nosological dichotomy of endogenous psychoses. Throughout his professional life, Kraepelin put emphasis on establishing psychiatry as a clinical science with a strong empirical background. He preferred pragmatic attitudes and arguments, thus underestimating the philosophical presuppositions of his work. As for nosology, his central hypothesis is the existence and scientific accessibility of "natural disease entities" ("natürliche Krankheitseinheiten") in psychiatry. Notwithstanding contemporary criticism that he commented upon, this concept stayed at the very center of Kraepelin's thinking, and t...

In the history of psychiatry, "schizophrenia" has often been portrayed as the discipline's pars pro toto, which prototypically represents mental illness as such and which draws together the fundamental questions concerning psychiatric epistemology and practice. Taking a conceptual history approach, this essay examines how "schizophrenia" is represented in psychiatric discourse and what aspects of its representation account for the pars pro toto status. Three such aspects are identified: a pragmatic, an existential and a justificatory aspect. Following up these aspects in present day psychiatric discourse, it is concluded that "schizophrenia" is losing its special status as the representations of psychiatry and of mental illness have changed and become more diverse. Tentative conclusions regarding current debates about the abolition of "schizophrenia" are drawn.

Die Fallschilderung beeindruckt aus zwei Gründen: (1) Sie adressiert in authentischer Weise das schwierige Gebiet medizinischer Zwangsmaßnahmen, speziell bei der Behandlung psychischer Erkrankungen. (2) Das persönliche Engagement der Autorin wird deutlich spürbar, hat sie doch die 19-jährige (und damit gleichaltrige) Patientin über Monate erlebt, teils selbst in der Rolle der „1:1-Betreuerin“. Als im akutpsychiatrischen Bereich tätiger Psychiater und Psychotherapeut möchte ich auf vier thematische Facetten eingehen.

Die sorgfaltige Anamneseerhebung ist Voraussetzung, ja sogar integraler Bestandteil jeder psychiatrisch-psychotherapeutischen Diagnostik und Therapie. Die hier vorgestellte Systematik spricht die wesentlichen Bereiche an; im Interesse einer moglichst vollstandigen Datenerhebung empfiehlt sich die konsequente Anwendung eines derartigen Schemas. Jenseits dieses formalen Aspekts kommt es aber entscheidend darauf an, die Balance zu halten zwischen umfassender Datensammlung auf der einen und Respekt vor der Individualitat und Intimitat des Patienten auf der anderen Seite. Hier wird jeder Untersucher mit wachsender Erfahrung einen eigenen „Stil“ entwickeln mussen. Dies steht keineswegs im Gegensatz zu einem strukturierten Vorgehen. Im Gegenteil: Erst die personliche Ausgestaltung der vorgegebenen Struktur stellt die dem individuellen Patienten angemessene und damit respektvolle Weise der Anamneseerhebung dar.

The "Association of Methodology and Documentation in Psychiatry" (AMDP) has developed the 2nd version of a new observer-rated scale for a quick and precise assessment of obsessive-compulsive symptoms. The first version of the scale comprised 20 items on the dimensions "description", "distress and impairment" and "emotion and cognition". The item pool of the 2. version was enlarged to 44 items to accomplish a differentiated assessment of obsessions and compulsions and to assess the associated passive avoidance behaviour. The results of an empirical study (n = 141) demonstrated excellent internal consistency (Cronbach's alpha = 0,93), a split-half reliability of 0,83 (Spearman-Brown), a test-retest reliability of r = 0,84, a high interrater-reliability, a high differential validity and good convergent validity with the Hamburger Zwangsinventar (HZI) and the SCL-90-R. The results are presented and their implications on the final steps of the development of the scale will be discussed.

Deskriptive psychopathologische Befunderhebung – dieser Begriff meint zum einen ein methodenkritisches Vorgehen mit dem erklarten Ziel der Vermeidung impliziter theoretischer Vorannahmen. Zum anderen aber stost er seinerseits an methodische und konzeptionelle Grenzen, an die es zu denken gilt, um bei der Untersuchung und Beschreibung der abnormen psychischen Phanomene keine Vorurteile und unzulassigen Verkurzungen wirksam werden zu lassen. Der Begriff der deskriptiven Psychopathologie ist viel alter als die heute gebrauchlichen Diagnosesysteme, doch heben diese ganz wesentlich auf den von ihnen praktizierten deskriptiven Zugangsweg ab. Freilich sind operationale Diagnostik und deskriptive Psychopathologie keineswegs deckungsgleich. Ein groser Vorteil jedes deskriptiven Ansatzes liegt in der deutlich verminderten Gefahr der Verquickung ungeprufter atiopathogenetischer Hypothesen mit dem diagnostischen und therapeutischen Prozess sowie in einer hoheren Reliabilitat. Wird Deskription allerdings zu eng gefasst, etwa als eindeutiges Abbilden eines objektiven Tatbestandes beim Patienten durch ein ebenso objektives Medium, den Untersucher, so werden rasch die Nachteile deutlich, namlich das Uberwiegen der formalen zuungunsten der inhaltlichen Aspekte, die zwar unumgangliche, aber eben problematische Reduktion der klinischen Gesamtheit auf das deskriptiv Erfassbare und das Unterschatzen, ja Vernachlassigen von komplexen subjektiven Erlebensweisen, die oft die Beziehungsebene betreffen und in den Kriterienkatalogen nicht oder nur verkurzt vorkommen (konnen). Sei nun die Rede von der ursprunglichen deskriptiven Psychopathologie im Sinne Karl Jaspers’ („phanomenologische Richtung“) und Kurt Schneiders („deskriptiv-analytische Methode“) oder von den zum Teil uber sie hinausgehenden, z. T. hinter sie zuruckfallenden aktuellen operationalisierten Befunderfassungs- und Diagnosesystemen, in jedem Fall ist eine empathisch-verstehende, von Respekt getragene Grundhaltung die wesentliche Basis einer sorgfaltigen und damit patientengerechten Erhebung des psychopathologischen Befundes.

Background: Involuntary admission (IA) for psychiatric treatment has a history of controversial discussions. We aimed to describe characteristics of a cohort of involuntarily compared to voluntarily admitted patients regarding clinical and socio-demographic characteristics before and after implementation of the new legislation. Methods: In this observational cohort study, routine data of 15’125 patients who were admitted to the University Hospital of Psychiatry Zurich between 2008 and 2016 were analyzed using a series of generalized estimating equations. Results: At least one IA occurred in 4’560 patients (30.1%). Of the 31’508 admissions 8’843 (28.1%) were involuntary. In the final multivariable model, being a tourist (OR = 3.5) or an asylum seeker (OR = 2.3), having a schizophrenic disorder (OR = 2.1), or a bipolar disorder (OR = 1.8) contributed most to our model. Male gender, higher age, prescription of neuroleptics (all OR < 2.0) as well as having a depressive disorder, pres...

Die Verlaufsforschung nimmt eine zentrale Stelle bei der Entwicklung und Validierung von Konzepten zur Klassifikation endogener Psychosen ein. Kahlbaum und Kraepelin postulierten fur die Vielfalt psychiatrischer Syndrome sogenannte Zustands-Verlaufseinheiten, die unterschiedliche, klar voneinander abgrenzbare Krankheitsentitaten reprasentieren sollten (Kraepelin 1896). 1911 loste das von E. Bleuler entwickelte Schizophrenie-Konzept das Konzept der „praecox“ ab und gestand der Schizophrenie eine potentiell gute Prognose zu. Die in der Psychiatrie weit verbreitete Dichotomie von schizophrenen versus affektiven Storungen mit dem fur die jeweilige Storung charakteristischen Verlauf und Ausgang bestand jedoch weiterhin. Diese traditionelle, auch heute noch allgemein anerkannte Verknupfung von diagnostischer Kategorie und typischem Verlauf muβ aufgrund bisheriger Verlaufsstudien relativiert werden. Schizophrene Sturungen weisen nicht in jedem Fall ungunstige Verlaufe auf, was bereits von ...

Elliot Abemayor, MD, PhD Jason L. Acevedo, MD Eugenia Allegra, MD, PhD Jacqui E. Allen, MBChB, FRACS Petra Ambrosch, MD Vinod K. Anand, MD Jennifer Anderson, MD, FRCSC Simon I. Angeli, MD Samantha Anne, MD Jack B. Anon, MD Rony K. Aouad, MD, FACS Oneida A. Arosarena, MD Karthik Balakrishnan, MD, MPH Donald D. Beahm, MD Joshua Bedwell, MD Mathieu Bergeron, MD, BPharm, FRCSC Simon R.A. Best, MD Brian W. Blakley, MD, PhD Jonathan M. Bock, MD Sarah N. Bowe, MD Jennings R. Boyette, MD Joseph P. Bradley, MD Michael J. Brenner, MD Scott E. Brietzke, MD, MPH Christopher D. Brook, MD Clifford S. Brown, MD J. D. Browne, MD Kevin T. Brumund, MD Nicolas Y. Busaba, MD Matthew L. Bush, MD, PhD Cristina Cabrera-Muffly, MD Trinitia Y. Cannon, MD Erika M. Celis-Aguilar, MD Mohamad R. Chaaban, MD, MSCR, MBA Raymond L. Chai, MD Philip G. Chen, MD Jeffrey Cheng, MD Neil N. Chheda, MD David H. Chi, MD Steven B. Chinn, MD, MPH Do Cho, MD Richard A. Chole, MD, PhD John D. Clinger, MD David M. Cognetti, MD...

The epistemic processes leading to a practically viable “knowledge” in psychopathology are traced back from the transcendental-philosophical premises and antecedents through various epistemic steps to the empirical recognition and systematisation into a scientific theory. Psychopathology should serve empirical procedures in diagnostics, epidemiology, etiological conditions. However, it should also produce viable advices for the interpersonal therapeutic transaction. This is illustrated by an example of a catatonic syndrome.