Karl Jaspers’ “General Psychopathology” In The Framework Of Clinical Practice

Karl Jaspers’ “General Psychopathology” is a monumental work. It encompasses all areas of psychiatry and delves intelligently and deeply into psychology and philosophy. Its influence in the German speaking world was immediate and remains so today. There is practically no work of psychopathology or even of general psychiatry written by a German author that is not inspired in, analyzes or criticises Jaspers. Its impact on the rest of the world has been directly dependent on the translations. The first one was into French, in 1933, the Spanish one appeared in 1955 and the Italian in 1964. The knowledge of his work in the English-speaking world had to wait for the excellent translation by Hoenig and Hamilton of 1963. However, its influence has been rather scarce, being limited in the USA to only some names, such as Paul McHugh (1983, 1987), Michael Schwartz (1985, 1987, 1988) and Nassir Ghaemi (2003), and in England, to the trace left by the German immigrant Wilhelm Mayer-Gross (1974), who was a member of the so called Heidelberg School until 1933. In Spain, the case we know best, Jaspers’ influence was felt prior to the translation, since the great masters of Spanish psychiatry of the first half of the 20^th century had studied in Germany and knew Jaspers’ work from their first editions. Examples of renowned Spanish psychiatrists with extensive training in Germany and who taught “General Psychopathology” in their universities are Juan José López Ibor Sr. (1966), from Madrid and Ramón Sarró (1987), from Barcelona. In Latin America his influence began to be noted as soon as the translation appeared, with the exception of Peru, where the doctor who was professor of generations of Peruvian psychiatrists, Honorio Delgado (1966), had been trained in Germany before the Second World War, and there he knew Jaspers’ work extensively.

 

Jaspers’ greatest achievement was to establish psychopathology as a hard science, the basis of psychiatry as professional practice. And he did this from a strictly methodological perspective, looking for the rigorous exploration and categorization of psychic disturbances in replacement of the pre-existing semiologies operating according to the model of medicine of that time. “Nobody before him was able to establish the relationship between the peculiarities of a methodology and the field of reality opened through it” (Blankenburg, 1984). Now, in order to give psychopathology a scientific character, Jaspers structured it adopting a deeply critical attitude, coinciding with modern epistemology, according to which “what distinguishes these two types of knowledge – scientific and common – is not so much rigour of scientific methods and submission to the epistemological rules, as the critical attitude of science faced with the naivety of common knowledge” (M. Bunge, 1980). But Jaspers goes beyond methodological criticism replacing the analytical attitude ─ proper for the science of that time ─ with a synthetic one, which is the paradigm at present. He always considers the patient and his psychopathological manifestations within the horizon of the totality of existence. “Whenever the object studied is Man and not man as a species of animal, we find that psychopathology comes to be not only a kind of biology, but also one of the Humanities. With psychiatry the doctor enters a world which lies outside the other disciplines with which he is already familiar. The fundamentals of his education generally consist of chemistry, physics and physiology, but here he is in need of a different basic training […] the psychopathologist, who is concerned with the human being as a whole and more especially the human being in times of sickness.” (GP, p. 36).

 

But our present question is about the effects of Jaspers’ psychopathology on clinical practice in the last 100 years. Let’s consider that this topic is so broad and deep that it would be practically impossible to summarize it in a few pages. The only way will be to focus on some of his contributions, such as for example the introduction of phenomenology and of the method of understanding, the concepts of process and development, the concept of situation and the dialectic perspective in psychopathology.

 

1. The introduction of phenomenology in psychopathology and in clinical practice

Conditioned by his time, Jaspers introduced the phenomenological method for grasping “the subjective manifestations of ill psychic life” (GP, p. 55). As is well known, he accepted only the first step of phenomenology, the descriptive moment and he declined to take the next step, in search for essences, considering it of a philosophic or metaphysic character and consequently, not scientific: “The term phenomenology was used by Hegel for the whole field of mental phenomena as revealed in consciousness, history and conceptual thought. We use it only for the much narrower field of individual psychic experience. Husserl used the term initially in the sense of ‘a descriptive psychology’ in connection with the phenomenon of consciousness; in this sense it holds for our own investigations also, but later on he used it in the sense of ‘the appearance of things’ (Wesensschau) which is not a term we use in this book. Phenomenology is for us purely an empirical method of inquiry…” (GP, p. 55)”. In a very striking study, Berrios goes beyond Jaspers himself, postulating that his phenomenology has little to do with that of Husserl: “It would seem, therefore that there is little evidence that Husserlian phenomenology had a major influence on Jaspers” (p. 320). We don’t completely share Berrios’ conclusions. We rather think that Jaspers’ philosophical intuition of Husserl’s phenomenological way opened the doors, in psychopathology, to overcoming both idealism of conscience on the one hand and sensorial empiricism on the other. Furthermore, several of Jaspers statements show proximity with respect to the intuition of essences. Thus, for example, he states: “Phenomenology, then, deals with what is actually experienced. It views psychic events “as from within”, and brings them into immediate realization*” (1912, 1968, p. 1322). Also in the phenomenological procedure of delimiting psychopathologic phenomena and isolating them, Jaspers established them “in order”: “an order** which will arrange psychic phenomena according to their phenomenological affinities with each other, somewhat in the way that infinite numbers of colours are arranged in the spectrum in a manner which is phenomenologically satisfying” (1912, 1968, p. 1320). Such order cannot but allude to a vision of the essence of what is observed. Other of Jaspers’ statements which show us how he, in spite of his prejudice faced with this transcendental moment of Husserl’s phenomenology, was quite close to his method, are the following: “Phenomenology only makes known to us the different forms in which all our experiences, psychic reality, take place” (1912, 1968, p. 1323). Or: “Close contemplation of an individual case often teaches us of phenomena common to countless others” (GP, 1963, p. 56). These forms, as well as this “common,” surely do not correspond to inductive generalizations of empirical findings, starting from the observation of a multiplicity of cases, but to the intuitive grasping of the eidos in the sense of Husserl.

 

Now, why was Jaspers’ introduction of phenomenology to psychopathology and to psychiatric practice so important? First, because he introduced into the empirical study of psychopathologic phenomena the subjective experiences of the patients without objectifying them in sensorially perceivable data, that is to say, without converting them into mere signs to be grasped by a semiologist. This was all the more significant, as the scientific attitude of that time consisted of eliminating the patient as observer and as subject of judgements about his own psychic phenomena; an intention to discard symptoms and be guided only by signs. Jaspers tells us: “An experience is best described by the person who has undergone it. Detached psychiatric observation with its own formulation of what the patient is suffering is not any substitute for this.” And shortly afterwards, he says: “The patients themselves are the observers…” (GP, p. 55). This is very much in accordance with Husserl’s phenomenological attitude and, on the other hand, is very much in accordance with the new paradigm of science, as for example, with the transition from classical ethnology to cultural anthropology, which distinguishes between a primary observer – a member of the observed culture - and a secondary observer, who participates in the cultural world being studied so that he can grasp the real sense of the behavioural features in the life of “that” culture.

 

The phenomenological approach to patients, introduced by Jaspers, became established in clinical practice as a new general operating framework. Clinical psychiatrists could no longer ignore a patient’s subjective experiences because they were not scientifically reliable, as in the previous semiology. Moreover, these experiences became the fundamental object of phenomenological investigation both in the field of endogenous psychoses and of neuroses. From the feeling of threat in the phobic situation and the formal obsessions of an obsessive-compulsive disorder up to the experience of destruction of the world in catatonia or of loss of natural evidence in some schizophrenias (Blankenburg, 1971), all of these fields deal with subjective experiences. Thus, all clinicians, in order to be able to differentiate a psychopathologic structure from another and these from normality, study the personal and intimate way in which patients constructed their forms of relationship with objects and with other persons. The personal forms of intentionality – the intimate way of affecting or being affected by life situations – are what determine the specific pathologic character of each symptom.

 

This reciprocal respectivity between the human individual and his situation constitutes precisely the central concept of Husserl’s phenomenological intentionality, which inaugurated the replacement of the gnoseologic objectivist vision for a dialectic-communicational one. Jaspers introduced it explicitly in his work: “In all developed psychic life we find the confrontation of a subject with an object and the orientation of a self towards a content as an absolutely basic phenomenon (GP, p. 57). This is a bi-univocal relationship: “But the state of self-awareness and the objective aspects of that ‘other’, to which the self directs itself, interlock in a mutual movement whereby the ‘self’ is caught up by what is given externally and is at the same time driven internally to grasp at what is there. Description of what is objective leads on to the meaning of this for the self and a description of the states of the self (emotional states, moods, drives) turns into a description of the objective aspects under which these states become apparent.” (GP, p. 57, 58). Here “the self” and “the object” are not entities “in themselves”, constituted prior to the ulterior relationship between them. Rather, the form of interaction subject/object, “intentionality”, is the one that constitutes the way of being of the comprehensive phenomenon of experience.

Psychiatric phenomenology introduced by Jaspers opened the way, in the second half of the 20^th century, for some notable psychopathologists, who incorporated elements from the late Husserl – that of the life-world – from Heidegger and from Merleau-Ponty, and applied a hermeneutic phenomenology. This meant an advance from the subjective experiences of the patient up to the essential structures underlying psychopathological manifestations. In the phenomenological-anthropological and/or phenomenological-existential orientation, authors such as L. Binswanger (1947, 1957), E. Straus (1960), v. Gebsattel (1954), H. Tellenbach (1961) and W. Blankenburg (1971) stand out. In a previous paper (Doerr-Zegers, 2000) we showed in detail some of the extraordinary contributions these authors have made to psychopathology and to psychiatry. But none of this would have been possible without the fundamental change launched by Jaspers when he introduced into psychopathological sciences both the subject of the patient and the subject of the explorer. His psychopathology introduced a dia-logic, interactive way, in the exploration as well as in the conception of psychopathological structures. “The symptoms are structures of the meaning of life built and interpreted by the patient” (Pelegrina, 2006). However, Jaspers could not overcome some prejudices of his time. Thus, he insists, for example, on differentiating “form” from “content” too strictly. And he adds that “phenomenologically we are interested only in forms”, while “the psychologist who looks for meaning will find content essential and the form at times unimportant” (GP, p. 59). This distinction has tended to disappear and thus, investigations into the perception of Gestalt psychology have showed the intimate relationship and the mutual influence of content (or meaning) over perceptual forms and of forms over content. Something similar occurs in Phenomenology of Perception by Merleau-Ponty (1945). Other works of phenomenological-anthropological orientation have also demonstrated the intimate relationship existing between the content and the form. Thus, Haefner and Wieser (1953) could show the formal conditions under which a given theme ceases being experienced as desire, thought or representation and is transformed into a hallucination (change of form), which would be conceived as a perception separated from the Self. For his part, Kisker (1960), through psychotherapeutic experiences with schizophrenics, was able to prove in an almost experimental way how through the recovery process the hallucination began to be transformed into thought hearing, then into forced thinking, finally ending as normal and fully accepted representations.

 

In any case, Jaspers’ phenomenology, for the reasons stated above, is much closer to the modern developments of ontology and epistemology of the life sciences, from biology itself (H. Jonas, 2001; P. L. Luisi, 2006) up to the cognitive (F. Varela, 2003) passing through ethology (K. Lorenz, 1978) and linguistics (K. O. Apel, 2003). His phenomenology also coincides with contemporary philosophy, which does not happen with the prevailing psychiatry of pragmatic-empiricist orientation. Under the sway of the later, “logical positivistic” constructs predominate, with each symptom objectified and transformed into a sign caused by a supposed brain disease or dysfunction. The consequence is a blurring of the profile of the nosologic unities or entities and an inordinate increase of comorbidities (A. Farmer & P. McGuffin, 1989; R. C. Kessler et al, 1996; G. Parker, 2006; J. Cole et al, 2008). In psychopathology it is impossible to know what the structures of the symptoms of a particular patient mean without exploring the entire situation in which the symptom appears. Only from the totality of sense of behaviour is it possible to unveil and to discover the processes of the genesis of psychopathologic structures, be these of a biological, psychological or sociological nature. This perspective, which starts from the “self-constructive (autopoietic) unity of life” (Pelegrina, 2006), as a general system and behaviour generator, can today represent Jaspers’ key concept of the totality of human being and his life, as the horizon of all psychopathologic research.

 

2. The introduction of the method of understanding

Every experienced psychiatrist will be able to recognize how often psychopathological phenomena surpass the possibilities of natural sciences, e. g. by attempting to “explain” delusion with the energetic theory of psychoanalysis or through measurement of neurotransmitters. Following Dilthey, Jaspers (1912, 1968; GP, 1913, 1963, p. 301 ff.) was early to recognize this particularity of the psychopathological world when he separated precisely what is explainable from what is understandable. With the method of explanation we approach clinical reality in the manner in which physicists study matter, and thus we calculate the size of cerebral ventricles, quantify intellectual capacity or measure the concentration of catabolites of neurotransmitters in urine, etc. With the method of understanding, by contrast, we have access to phenomena which resist all attempts to quantify them, such as feelings and emotions, the experience of art in general, the world of interpersonal atmospheres, etc., that is, all the world of meaning. How one psychic phenomenon arises from another is something very different from the linear causality of the physical world, and the method of understanding intends to do justice to that difference. To be able to understand the biographic sense of a given illness, or to interpret a delusion within itself and not from supposed extraconscious causalities, are two typical tasks where the psychiatrist has to employ the methods of understanding and hermeneutics in their purest forms. But we have to warn that Jaspers’ understanding-explanation distinction is not so valid anymore if one looks at it from the perspective of the new paradigm of natural sciences, also called the paradigm of “complexity”. The historical evolution of epistemology in the 20^th century has drawn the explanatory methods close to the one of understanding (Hawking and Mlodinow, 2010; Kuhn, 2000, 2002).

 

To be able to appreciate the value of the introduction by Karl Jaspers of the method of understanding in psychopathology, it is necessary to consider the theoretical postulates of psychiatry of his time. Starting from the 19^th century and following a period of romantic medicine where passions, faults and feelings had been crucial in interpreting the genesis of mental diseases, a change of paradigm toward positivism and empiricism took place, which reached its greatest development with Griesinger (1817-1868). This author, already when he was only 25 old, had proclaimed: “Medical practice has taken leave of empty speculation and finally overcome romantic medicine” (cited by Schifferdecker & Peters, 1965) and years later he would formulate his famous principle: “Mental diseases are brain diseases”. This psychiatry dealt with defining syndromes and then searching for their localization in some brain area. Progressive General Paralysis became, consequently, the perfect model, the idea of disease which was completed when its cause, the treponema pallidum, was discovered in 1905. Now, in the framework of this organicistic psychiatry arose the figure of Kraepelin, who went beyond the mere register of symptoms, up to the intuition of nosologic entities, whose differences he tries to establish on the basis of following the outcome of the disease. And thus he distinguishes dementia praecox from manic-depressive illness, because besides the different symptomatology the first evolves toward deterioration and the other toward more or less spontaneous healing. The great nosologic problem posed to Kraepelin was that of paranoia, because this illness consisted in a delusion which evolved progressively, such as dementia praecox, but which did not cause deterioration and in that sense resembled manic-depressive illness although with none of its other symptoms.

 

In reality, Karl Jaspers introduced his concept of understanding and of meaningful psychic connections in 1910, in a work prior to the first edition of “General Psychopathology” (1913), referring specifically to paranoia. It is here where he for the first time distinguishes between static and genetic understanding, on which he would elaborate extensively in his “General Psychopathology.” The first is equivalent to descriptive phenomenology, to which we have already referred and the second would take two forms, the rational and the psychological. Rational understanding allows us to grasp the reasons for which someone acts in one way or another. Psychological understanding, by contrast, captures or intuits how the psychic arises from the psychic: “When somebody knows that his beloved has been unfaithful with him […], and he falls into a deep desperation and thinks of suicide, we cannot invoke any rational context, there is no purpose to reach for, there are no means to which one appeals with some rationality, and instead, we understand everything by empathy” (1910, 1963, p. 113). To these two forms of understanding Jaspers juxtaposes the “grasping” (Begreifen) of causal relationships, which is analogous to causal relationships prevailing in nature. The maturative processes would be an example of it. Writing prior to the famous work by Gaupp about the Wagner case (1914) and of the description of the Sensitive Delusion of Reference by Kretschmer (1918), Jaspers states in this foundational article the notion that unlike dementia praecox, which would not be an understandable process, paranoia belongs to the developments category, since delusional ideas, for example jealousy, would be “understandable” from the previous personality and also from certain biographic situations. He does acknowledge that there are cases of paranoia that lie between the incomprehensibility of process and the comprehensibility of development. In the next chapter we will delve deeply into the question of Jaspers’ distinction between process and development in. In any case, it is of some interest that in an environment that largely ignored psychology (at least in the field of psychoses) as that prevailing in German psychiatry at the beginning of the 20^th century, Jaspers affirmed the possibility of understanding a psychosis. The only precursor of this more “psychological” vision of paranoia is the German psychiatrist Heinrich Schüle, who in the first edition of his treatise of 1878 ignores paranoia, but in an 1894 work states, “the nature and essence of these processes is purely psychological; they are based on thought itself and consequently, they are only psychologically explainable” (cited by Schifferdecker & Peters, 1995).

 

But the problem of understanding, as Jaspers states it, has several weaknesses. In the first place, the fact that it assumes that a community of supposedly healthy persons feel in a similar way in a given sets of circumstances and for that reason they can empathize with what others feel. Second, although the dichotomy comprehensibility / incomprehensibility is based on a “subjective” incapacity, not being able to understand is transformed into a diagnostic criterion pretending to be “objective”. Different authors of the psychoanalytical, anthropological and existential-analytical tradition have questioned this dichotomy (Binswanger, 1955, pp. 67-104; 1961, pp. 190-217; Kisker, 1963), because psychotherapeutic experiences with schizophrenic patients, for example, have shown that what initially seemed incomprehensible is shown in all its biographic sense in the course of the treatment. But the biggest difficulty with Jaspers’ concept of understanding and/or of comprehensibility is that it remains stuck in something like a day to day or “average” understanding. It would be possible, for example, to broaden that horizon and to understand the delusion from the perspective of the psychology of Gestalt psychology, as Conrad did (1958) or from that of existential analysis, in the sense of Binswanger (1957). For this author, the schizophrenic can be shown to us as the specific modification of the a priori structures of Dasein and what in empiricist or even in Jaspers’ psychiatry is called symptom, will acquire from the perspective of the Self-world unit the character of the phenomenon containing the world and the Self, since in transcendence not only is the aim of transcending the world constituted, but also the transcended itself, the entity we are in each case. And thus complex and central phenomena of schizophrenia, namely eccentricity (1956) or catatonic postures can be open to understanding. But as transcendence takes root in time, in its evolution from the past to the future, life history acquires great importance in existential analysis. And thus, not only the clinical picture of schizophrenia appears to us as a single meaningful structure, but we can also look into the past for the genesis of these progressive limitations ending in that new image of the world which is psychosis. Existential analysis wonders about lighting, consistency, harmony, temporality and the spatiality of psychosis and about the characteristics of the world projects which were the condition of possibility of the respective psychotic worlds (see Doerr-Zegers, 1997). The authors of the phenomenological-anthropological school have also made fundamental contributions to the knowledge of psychoses insofar as they broke through the limits of Jaspers’ comprehensibility, but without the absolute commitment of Binswanger to Heidegger’s philosophy. These authors have applied the phenomenological method to the study of psychotic forms in the search for underlying disturbances of fundamental anthropological structures of human being and also of meaningful correlations between life history, previous situation and psychotic symptoms themselves in a double hermeneutic and psychotherapeutic eagerness. Examples of it are the studies by Zutt (1958) about the paranoid syndrome, by Kulenkampff (1964) about the psychotic crises of adolescence, by Haefner (1959) about hypochondria, by Tellenbach (1961) and Kraus (1977) about melancholy, by Mundt (1984) and Fuchs (2005) about intentionality in schizophrenia.

 

A way to broaden Jaspers’ concept of comprehensibility without having to appeal to other paradigms, such as the psychoanalytical or the analytical-existential ones, has been proposed by Blankenburg (1984) in his critical comment to Karl Jaspers’ Psychopathology. He wonders: “To what exactly are we referring by speaking of incomprehensibility when faced with a schizophrenic patient?” And he answers himself that this does not mean an impossibility to interpret something, but rather that a person “does not know how to relate” to the other and consequently is not able to “make somebody understand”. To be “mad” or “insane” (verrückt) does not mean that a given behaviour is not intelligible, but only that it is not inter-subjectively referred. This being inter-subjectively referred as criterion of comprehensibility or incomprehensibility would represent a great advantage, since it restores to these concepts their value in differential diagnosis (between the psychotic and the not psychotic, for example), but without limiting the attempts of psychotherapeutic understanding. And Blankenburg concludes: “Then, justice could be done to Jaspers’ theorem in the sense that it becomes a starting point of a differentiated study of the modifications of inter-subjective reference of human experience and/or behaviour” (p. 456).

 

3. The concepts of process and development

Jaspers introduced the dichotomy process/development in the already mentioned article of 1910, in relation to the detailed clinical and biographical study of several cases of jealousy. It is in this article where he also introduces, as we saw, the method of understanding. Strictly, the concept of process comes from somatic medicine. Its application to psychopathology does not pose difficulties when it is a matter of organic-cerebral diseases, such as Alzheimer Disease or Progressive General Paralysis. What occurs here at a psychological level is understood as epiphenomenon of a destructive corporal process. Psychiatry prior to Jaspers also applied this concept to Dementia Praecox, since this had in common with the organic diseases the beginning in a given moment and the evolution toward some degree of defect or residual state. Moreover, many of the symptoms of what later was called schizophrenia, such as affective flattening or social deterioration, showed certain similarities with what is observed in organic diseases. The fact that the corresponding anatomical-pathological alteration had not yet been proven did not seem a problem, because it was expected to be found later on. Paranoia is what posed a problem, because on the one hand, it gave the impression of “primary madness”, but on the other, it compromised only the content of some ideas (delusions), leaving the remaining functions undamaged.

 

Kraepelin began to change his definition of paranoia throughout the eight editions of his “Treatise,” but already in the fourth he states the contradiction inherent in this illness of being manifested by “the chronic development of a persistent delusional system with normal presence of mind”. In the eighth and last edition, in 1915, he would specify this contradiction, saying: “with perfect conservation of clarity and the order of thought, will and action” (cited by Schmidt-Degenhard, 1998). Two years later Krüger (1917) would add new elements to this definition, and it has not been surpassed. He also speaks of a delusional system, but “which is constructed and developed logically, which does not occur outside the realm of possibility, which does not generally alter the subject personality apart from a narrowing of his sphere of interest […] which finally does not affect the subject’s perception in areas which are not important to the delusional system […] A complete transformation or destruction of the personality does not occur […] even within the delusion, however, the subject’s thought remains as comprehensible and logical as the thought of a healthy person and his decisions and actions are logically and clearly derived.” But the great investigator of paranoia was Gaupp, who studied and followed the evolution of a particular case, Ernst Wagner, throughout almost 30 years. At the end of his monograph of 1914 he affirms that Ernst Wagner suffers from “paranoia”, that is, “a form of mental perturbation gradually developing from the personality and on the basis of degeneration” (p. 185). As we stated above, Gaupp expressly considered paranoia, following Jaspers, as a “psychologically understandable” development.

 

In his article, and after an introduction in which he talks about the different forms of jealousy, Jaspers first reports two cases in great detail. In the comment, he states: “These two clinical histories seem to demonstrate what has frequently been denied, that there are cases which match the definition of paranoia provided by Kraepelin” (1910, 1963, p. 112). Then he proceeds to develop his method of understanding by empathy, previously mentioned, and to establish the differences between a process and a development: “There where we are not able to grasp the single nature of the development of a personality, there where we find out something new, something heterogeneous with respect to the original disposition, something that does not correspond to the development [of a personality], then it is a process” (1910, 1963, p. 116). And later he adds that “we call not all pathologic diseases process, but only those leading to a persisting and incurable change” (1910, 1963, p. 117). To provide a distinction from process, he defines development as follows: “We speak of a development when from an interaction of psychological and rational connections we can understand or explain phenomena which for some reason have been considered pathologic and that in spite of their lack of consistency and harmony are integrated in a uniform psychological context”. And he continues: “It may be that we have an extreme variation, but the unity of personality in its peculiarity, from growing up to involution, appears conserved” (1910, 1963, p. 116).

 

Now, the problem Jaspers faced was that when analysing the above two mentioned cases of jealousy, he found that delusional jealousy appears accompanied by delusional ideas of persecution and of poisoning and that there is no continuity between life history and psychosis. It is then that he creates his concept of “psychic process”, which forms a boundary concept between the physic-psychotic process inherent in organic-cerebral syndromes and the development of a personality as it is observed in some “psychopathies” (generic name given then to personality disorders). In this original work the relationship of nosologic entities schizophrenia and paranoia with the concepts of process and development is not clear. In a first approach and as we stated with respect to the introduction of the method of understanding, it seemed that schizophrenia is a process and paranoia more a development. But it occurs that the symptomatology of the first two cases described by Jaspers greatly exceeds the clinical picture of Kraepelin’s paranoia and besides, they do not present that fundamental element of development of a personality, which is the sense of continuity with the life history. On the other hand, they do not present auditory hallucinations nor formal alterations of thought, and thus cannot be diagnosed as schizophrenia. Furthermore, cases 3 and 4 present many of the characteristics of paranoia and would fit well into the concept of development, but in a given moment the “meaningful connections” disappear and “unconnected delusional ideas” arise (1910, 1963, pp. 130, 131). Only case number 7, identified as Friedmann’s “light paranoia” by Jaspers himself, seems to match the concept of development of a personality. At the end of the article Jaspers becomes a little sceptical and states: “And thus, it seems that the criteria for considering delusional jealousy as ‘development of a personality’ or ‘process’ mingle with the predominance of the latter”. And he adds: “This cannot surprise us, since, as we saw, every life development is a process in which meaningful and rational connections are integrated, but ‘the process’ of normal life can be conceived as a development to the degree that one can grasp in it the unity of the personality” (1910, 1963, p. 140).

 

In any case, in spite of the fact that these concepts depend on other things, acknowledged, as we saw, by Jaspers himself, they are still used in clinical practice up to the present. And thus, even when they do not appear in the modern systems of classification and diagnosis, such as DSM-IV TR and the ICD-10, many psychiatrists who treat psychotic patients continue speaking of “process” to refer to schizophrenia and of “development” to refer to those pictures, now called “delusional disturbances” that correspond approximately to the different forms of classical paranoia. Notably, five decades ago, German psychiatrist Heinz Haefner proposed a new and interesting way of conceiving of the concepts of process and development, which unfortunately has not gained the publicity it deserves. Haefner starts by pointing out the inadequacy for pathology of the term “development,” given its positive connotation. Next, appreciating its fickleness and ambiguity in the court of somatic medicine, he sets aside Jaspers’ concept of a physico-psychotic process. Then, he looks for the broadest possible definition of the concept of process in psychopathology: “Psychic process is a progressive event necessarily leading to a pathologic defect in the functional capacity of the individual” (1910, 1963, p. 408). Finally, basing himself on Viktor von Gebsattel’s important work (1954), Haefner states that addictions, some personality disorders, sexual perversions, and in a certain way obsessive-compulsive neurosis can also represent a form of process, since all these pictures lead to an important, progressive and somehow irrevocable limitation of the ability of an individual to realize his existence. Haefner does distinguish two types of processes, the “modifying” and the “restrictive” ones. The former are accompanied by modifications of basic structures of the human, such as interpersonality, spatiality or temporality. This is what occurs in schizophrenias, in schizo-affective psychoses and in paraphrenias. The second, by contrast, lead to a narrowing of the existence around a theme, such as paranoid delusional jealousy, severe addiction to drugs or to alcohol, etc. The concept of a modifying process is self-explanatory. The manifestations of schizophrenia, for example, cannot be reduced to auditory hallucinations or to delusional ideas. Several authors of the phenomenological-anthropological orientation have been able to demonstrate up to what point the anthropological and constitutive structures of human being are altered in this disease (V. von Gebsattel (1954), L. Binswanger (1957), K. P. Kisker (1963), W. Blankenburg (1971) and O. Doerr-Zegers (1972, 1997)). The restrictive processes, by contrast, require clarification which we will summarize here. Why apply the concept of process to certain forms of addiction or “philias”, as Pelegrina (2006) calls them? What drugs do is to fill an existential emptiness or deficiency. However, drowsiness and the illusory satisfaction of the sensation of void do not last long, and with their end, the same emptiness - which generally occurs upon either the omission of a task or of an actual achievement - is again manifest in an even clearer way. Furthermore, unlike the initial surrender to drugs, feelings of guilt are now added to the emptiness and therefore, the feeling of failure or uneasiness is greater. The compulsion to again consume a drug arises as a consequence. Haefner comments: “The longer the empirical performance of tasks and possibilities is omitted and emptiness is covered only in an illusory way, the more pronounced will be the distance between real failure (for example, social decline or isolation) and the apparent satisfaction brought by the drug. Herewith this destructive condition, which at the beginning still left some room for a certain freedom, gradually becomes need and compulsion, that is to say, process.” (1963, p. 403).

 

4. The concept of situation

In Jaspers’ time substantialism was still the dominant thought, which meant that entities, things, were considered realities “in themselves”, whose being is constituted by their inalterable, atemporal “essence”, which in its essence is identical in appearing and metamorphosing. Things would eventually have the capacity of relating to others as external causes of effects on them. This ontology also included, of course, the human being, who was considered as “in himself” and “from himself”. Man as substance had been viewed for many centuries as a spiritual being, removed from the materiality of things and who could relate to them, or rather, whose agreement with the world was sustained by God. During the 19^th century science began to replace God with the absolute universality of scientific laws, and the spiritual essence of man was in turn replaced by an entity, “consciousness”. The latter confers form to the material given by the senses, thus constructing its “objects” of consciousness. This consciousness is exposed to the world and is somehow affected by it, provoking in each case a “reaction”. Strictly, the I-world, subject-object, consciousness-situation relationship was conceived according to the physiologic model of stimulus and response. In fact, at that time and until a few decades ago, one talked about “abnormal experiential reactions”, and Jaspers himself used that terminology.

 

However, in his work “Philosophy” (1932) Jaspers elaborates a new concept of situation, which he later complements with another very important one for his philosophy of liberty, which is that of the “limit situation”. Even earlier, in his “General Psychopathology” (1913, 1959) he had dedicated a page to the concept of situation in the chapter about the relationship man-world: “All life takes place in its own particular surroundings. In abstract physiological terms we say stimulus causes reaction. In real life, the situation releases activity, and gives birth to performance and experience” (GP, p. 325). Jaspers goes on to explain the manner in which the behaviour of the individual with respect to typical situations becomes an object of the psychology of meaning, and “the way in which coincidence, opportunity and destiny come to us through the situation itself and how to grasp or lose them” (GP, p. 325). In these handful of quotes one can appreciate the manner in which Jaspers’ concept of situation moves away from the scheme stimulus-reaction. There is a participation of the subject both in the creation and in the overcoming of it: “Situations have urgency, their sequence is changeable and unfixed, and the human being can contrive them” (GP, p. 325). In his “Philosophy,” Jaspers adds new elements to his concept of situation, for example stating: “Although, as empirical existence, I am always in situations in which I act or let myself be carried, nonetheless, not for that reason do I know the situations in which in fact I am” (1958, p. 65). Later he emphasizes this idea, when he writes: “Empirical existence is a being in situation, I can never get out of a situation without immediately entering into another […] My action is presented to me with its consequences, in turn as a situation created by me, which is already given” (1958, p. 66). These considerations are fully in accordance with the deployment of phenomenology starting since the 40s.

 

The importance of Jaspers’ concept of situation relies on the fact that it is going to represent the model on the basis of which both E. Kretschmer and H. Tellenbach would eventually construct their respective concepts of “key situation” and “pre-melancholic situation”. In his book “The Sensitive Delusion of Self-reference,” (1918) Kretschmer proposes the idea of the existence of an essential relationship between previous personality, psychosis and triggering situation, which he calls key situation: “The sensitive delusion of self-reference arises by the accumulative action of typical experiences or life situations, upon typical characterological and constitutional bases, and frequently under the complementary effect of equally typical social constellations” (p. 148). Jaspers (1910) and then Gaupp (1914) had already posed the connection or rather the continuity between personality and psychosis in relation to paranoia, but Kretschmer added the concept of a specific triggering situation, which he defines as of “bashful insufficiency” which was to be crucial in pathogenesis: “In typical cases the experience or life situation underlying it means everything and without it the illness would be reduced to nothing” (p. 148). It was clearly a big step for psychiatry that Kretschmer proposed that a person’s key situation has a leading and even causal role in the genesis of a psychosis, since previous authors, such as Kraepelin and Gaupp himself, spoke only of the possibility of understanding the content and not the form, that is, the existence itself of the psychosis. Thus, Kraepelin writes: “Its content [of paranoia] shows, although in a pathologic way, a notable correspondence with fears, wishes and hopes also arising in healthy persons from the feeling of insecurity and the aspiration to freedom” (1915, p. 1758).

 

But undoubtedly we owe to Hubertus Tellenbach (1961, 1983) his magnificent contribution to the relationship between mental illness, personality and life situation. Tellenbach’s starting point is Jaspers’, in the sense that a human situation does not consist only of the action of environmental circumstances over the subject, but also in the action of the subject over the circumstances. According to Jaspers: “The decision whether a situation is made by a surrounding world or by the individual derives mainly from his knowledge and will: whether he is affected without knowledge by the situation or whether his self-confident will effect it” (p. 132). But Tellenbach goes farther when he states: “We take the situative as that originality in which the individual and his inner surround are still united […] Situation is always a cross-section through the existing context of I and world.” (1980, p. 132). For Tellenbach it is not only that I voluntary can face a situation caused by the environment and alter it (Jaspers’ idea), but that I am creating specific typical situations starting from my way of being, from my personality. And thus, the pre-depressive personality of unipolar patients, which he called typus melancholicus, fundamentally characterized by a fixation to order (orderliness), by a peculiar way of having an order and of being in an order, will tend to go downhill in those situations in which that order is menaced. Tellenbach adds: “[…] always when this order is seriously threatened, this threat will affect the existence itself”. And he continues: “The specific situation of order is then ready to revert into a situation of disorder, a phase we have occasionally and as yet indeterminately termed ‘the pre-melancholic situation’” (p. 135). And this will constitute the starting point of the endogenous-melancholic transformation. This way of framing the situation has allowed us to understand those cases where the pre-depressive situation is presented to a person with an average understanding as something positive, for example, a move to a better house or a promotion at work. The vision of melancholy which Tellenbach poses for us is very comprehensive, from the previous personality and its genesis up to a new understanding of the symptoms of illness, passing through certain characteristic triggering situations that he typifies with the neologisms of includence and remanence. An excellent interpretation of Tellenbach’s ideas can be found in Stanghellini’s book “Disembodied Spirits and Deanimated Bodies” (2004, p. 105 ff.). In our opinion, this psychopathologic richness of Tellenbach’s contributions to pathogenesis of depression would have not been possible without Jaspers’ visionary depiction of human situations.

 

5. Dialectic thinking in psychopathology

Dialectics dates back to the beginning of philosophic thinking, appearing in different forms in the two great pre-Socratic philosophers: Parmenides from Elea and Heraclitus from Ephesus. For Parmenides dialectics is a method which allows one to prove the falsehood of appearances that the senses give us and, in this way, to purify the thinking of irrationalities. For Heraclitus, on the contrary, dialectics represents the basic principle which structures and directs all that exists, since reality is ordered in polarities which need one another. Plato uses dialectics as a method to get to the truth through dialogue and by proving the contradictions inherent in nature as well as in thinking. In Hegel the concept of dialectics reaches its greatest universality. Both reality and knowledge would be one and the same process, but the truth of a process is only reached at the end of it, since every cross section will show its internal contradiction: the contradiction between the bud and the blossom that refutes it will be resolved in the fruit; this is the so called dialectic moment, when the synthesis overcomes the contradiction between the thesis and its denial, the antithesis. Today, dialectic interpretation of reality is present in all of the natural sciences, which deal with the dialectics of contrary elements constituting a unity and not the dialectics of contradictory elements nullifying themselves (see Jasinowski, 1957). In the same sense, the Nobel Prize winner in chemistry Ilya Prigogine (1996) asserts that “the no balance is the fundament of all stability”.

 

Karl Jaspers was the first to apply dialectic thinking to psychiatry. For Jaspers “psychic life and its contents are polarized in opposites. It is through the opposites, however, that everything is once more re-connected. Image calls forth counter image, tendencies call forth counter-tendencies and feelings other feelings in contrast.” (p. 340). Jaspers distinguishes categorial, biological, psychological and intellectual opposites. These opposites manifest themselves in different ways: 1. They reverse through time without consciousness taking part, as inspiration changes into expiration, grief into cheerfulness, etc. 2. The opposites fight with each other, the one hurling itself against the other. 3. The self decides between the opposites, excluding one in favor of the other. “The two latter modes lead to radically different dialectical movements: in the one, a synthesis of ‘this as well as that’, in the other a choice – ‘either-or’” (p. 342). In the first form a synthesis is produced between the opposites and a new movement arises, which opens the way to the whole. In the second, dialectics engages to the limits of the decision. Both forms carry a special risk for the psyche. Aiming at the whole, the psyche can lose its ground and “be enticed into pleasing generalities” (p. 242). On the other side, when the psyche endeavors to reach the sure ground of decision, sacrificing one of the opposites, it may become unnaturally and psychically impoverished.

 

Among the many contributions of Jaspers to dialectic perspectives, the most interesting is perhaps his attempt to apply it to the understanding of opposites in psychopathology. In schizophrenic patients, for example, the phenomenon of a drastic emancipation of a tendency without its counter-tendency is given: automatism to the command, echolalia, echopraxia. Likewise, there are examples of failures in the union of the opposites, as it is the case of ambivalence. The emancipation of the counter-tendency can also be produced as occurs in negativism. Jaspers also describes how in most studies of the character and personality of humans opposites have been described: introversion / extraversion, narcissism / object-cathexis, schizoid character vs. hyperthymic character, etc. He warns, however, about the risks of the absolute generalization of the opposites and remembers that “the deeper we grasp the understandable meaning, the more we are directed into the non-understandable, extra-conscious ground of life and the non-understandable, historical absolute of Existence itself” (p. 345).

 

But it was Wolfgang Blankenburg (1962, 1965, 1974, 1981) who definitely introduced dialectic thinking into psychiatry. Blankenburg’s starting point is the hypothesis that certain positivity can be enclosed in what is negative (the abnormality or illness). The question of the positivity of what is negative is found in many forms in daily life and also in the religious world, e. g. in Christianity: “the last will be the first”, “it is necessary to die in order to resurrect”, etc. And thus Blankenburg underlines the positive aspects of schizophrenia, like the depth of the perception these patients have of the world, their nearness to genius, their metaphysical sense, their authenticity, etc. (1965) and later the positive aspects of hysteria, as for example, the lack of rigidity, the easy adaptability, the capacity for entertaining, etc. of hysterical patients, (1974). But the relationships between dialectic thinking and schizophrenia do not end in the question of a possible positivity of the negative. And so, Blankenburg states: “The modifications of the psychic life that we label as ‘schizophrenic’ show themselves something dialectic insofar ones understands it […] as the openness and sensitivity for every ‘it is and it is not’, for every questioning of the principle of contradiction”. And then he remembers that Bleuler (1911) has defined ambivalence as a fundamental symptom of schizophrenia.

 

Following the line suggested by Blankenburg, we tried to advance in the dialectic perspective of the great psychopathological syndromes. As the initial model we took the manic–depressive diad, where the polar and dialectical character is evident: mania is the reverse of depression and vice versa. But at the same time each emphatically needs one another so that in some way the one is contained in the other and vice versa. How frequently we perceive, behind the joy and hyperactivity of the manic, infinite sorrow and, inversely, behind the sorrow and inactivity of the depressive patient, feelings of envy and aggressiveness which are almost impossible to emanate from his weakened and harmless appearance. Additionally, what draws one’s attention is the fact that situations triggering the two illnesses would seem to be inclined to produce the opposite effect; they are marked by an inverse sign: what would result in joy for any normal person (a move to a better house, the happy marriage of a daughter, the birth of a child who is wanted, promotion at work, etc.), may trigger a depression, while those precipitating mania generally represent intolerable setbacks (the death of a beloved person, financial bankruptcy, the diagnosis of a serious or mortal illness, situations of great pressure, etc.). In other words, the manic develops his mania against depression, while the depressive patient develops his depression against the mania. What is manic can be seen as what is positive with respect to depression, as a defense against that inability, that congealed anguish, that stopping of time. And conversely, what is depressive can be conceived as what is positive with respect to mania, as being saved from exhausting hyperactivity, from continuous disrespect for others or from an inability to maintain both thinking and behavior within rational and socially acceptable limits. We also observe a dialectic structure in the polarity established between the “not being able” (das Nicht-Können) of the depressive phase and a total ability and availability in the manic phase.

 

But all the formerly called endogenous conditions can also be seen as distributed between the depressive pole and the schizophrenic pole. The extremes would be represented by unipolar depression on the one side and disorganized schizophrenia on the other. The schizo-affective psychoses would be equidistant from both poles. From these in direction towards the schizophrenic pole we observe the deployment of the rest of the forms of this illness: catatonic, paranoid and hebephrenic schizophrenia. In the other direction we find cycloid psychoses, delusional manias, delusional depressions, bipolar forms and finally, unipolar depression. Something similar is suggested by Janzarik (1959) in his description of “dynamic constellations in endogenous psychoses”. This conceptualization allows a greater fidelity to the clinical fact of the multiple transitions among the different psychopathologic syndromes and resolves the old dispute between the theory of “unique psychosis” and the one postulating the existence of perfectly different nosological entities (Doerr-Zegers, 1987, 1991, 1992).

 

These structures are not simple reifications as is the case for categorial diagnoses, but “ideal” types, in the sense of Jaspers (GP, p. 560 ff.). For Jaspers “dialectics is the form in which a basic aspect of meaningful connections becomes accessible to us” (GP, p. 345) and that is precisely a structure in the style of the ones we are describing. The ideal types are for Jaspers always self-evident, they do not lead to theories, but rather correspond to patterns through which particular events can be measured. An excellent treatment of this subject matter and of the transcendence of ideal types in daily clinical practice we owe to Michael Schwartz and Osborne Wiggins (1987, 1995).

 

But Jaspers brings dialectic thinking beyond psychopathology, up to human existence itself, explaining how difficult it is for man to achieve the synthesis between the many contradictions in which we are inserted. And so, he states: “It is fundamentally characteristic of our temporal human situation that we cannot accomplish such a synthesis. This means that in life we select and realize our destiny from among the chances and risks of historical events, while all correct resolutions disappear at the frontiers of tragedy and in the presence of our transcending possibilities.“ (GP, p. 343).

 

6. Conclusions

Jaspers’ “General Psychopathology” constituted, in its moment, the creation of an authentic psychopathology at the forefront of medical semiology, and additionally the start of an enhanced clinical praxis from the methodological vantage. Together, the volume continues to have significant heuristic value for clinical as well as theoretical investigation in psychiatry and medicine. Jaspers’ work was the fruit of his training as a physician and a philosopher and also his genius for engagement with the issues of his times. These authors have attempted to show some of Jaspers’ main contributions and also the way in which he anticipated future developments in psychopathology with regard, for example, to the concept of situation or to the introduction of dialectic thinking into psychiatry.

 

From theoretical point of view, Jaspers knew how to grasp the essentials of the great revolution that was being initiated – at the turn of the century – in the scientific and philosophical vision of reality. This consisted in passing from the “substantialist paradigm”, which saw unities “in themselves”, composed of elements, to the grasping of complex systems, whose connective, communicational dynamics makes the local structures “emerge”, in daily life, as entities or things separate and preexisting to their causal relations. Thus, the substantialist vision requires a method of analytic-reductionist knowledge and the second demands a dialectic synthetic method. In the end, this overcoming of substantialism has constituted, according to Gastón Bachelard (1934), the greatest intellectual effort of the 20^th century.

 

Jaspers incarnates in his work the intuition of this revolution of knowledge, with the incorporation of phenomenology as an exploratory method implying a synthetic vision of human existence. This is understood as embodied dialectics stemming from a symbolic communication – of meanings and senses – between the situation and the subject, which simultaneously constructs both the structure of the world and of the subject’s personality (see Minkowski, 1927). Given the earliness of his work, Jaspers did not reach his objective of grasping the essence of nosological unities, but he undoubtedly opened the way through which this goal has been attained.

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* Michael Schwartz has proposed “representation” for the German word Vergegenwärtigung, with which we completely agree.

** In the English version appeared in the British Journal of Psychiatry, 114, 1968, the word “Ordnung” is  translated as “classification”. We widely prefer the word “order”, because it fits much more the sense of the German word.