Overview
To describe an approach as “Kraepelinian” is to mean that it views mental illnesses as distinct biologically-driven neurological conditions that can be identified through their progression rather than just the current presentation of symptoms. This is in contrast to Freudian psychoanalysis, which located the source of symptoms within someone’s fluid, subconscious emotional conflicts that could not be standardized in manuals or diagnostic guidelines.
History and Context
In the 1960s, Freudian psychoanalysis of the subconscious was the dominant form of psychiatry, but this psychodynamic perspective made it incredibly difficult to produce reliable diagnoses. Different doctors could examine a patient and arrive at entirely different theories about the emotional conflicts responsible for a set of symptoms.
In 1972, the Cross-National Project for the Study of the Diagnosis of Mental Disorders in the United States and the United Kingdom (or the US-UK Diagnostic Project for short) initiative was conducted to compare the diagnostic processes between American and British psychiatrists. A group of each watched the same videotaped clinical interviews and were asked to provide diagnoses independently. The psychiatrists from New York were more than twice as likely to diagnose patients with schizophrenia than their London counterparts, whereas the London doctors diagnoses depressive psychoses or mania twice as often as the New York doctors. This dealt a blow to the legitimacy of psychiatry as a field by highlighting the subjective and arbitrary elements of clinical evaluations under a psychodynamic framework, as it was inferred that American psychiatrists used “schizophrenia” as a catch-all bucket for significant psychological distress that couldn’t be cleanly identified as anything else.
Insurance companies and government healthcare programs like Medicaid and Medicare were not pleased that they were being asked to pay for open-ended talk therapy that targeted fluid subconscious conflicts that were lumped into “schizophrenia.” The rapid breakthroughs in the psychiatric drugs, which were designed to address biological or physiological mechanisms, required more clarity in a patient’s disorder to be properly prescribed. Otherwise, patients with bipolar disorders were being labeled as schizophrenic and being prescribed antipsychotics that were ineffective rather than lithium.
The confluence of these circumstances led to a revival of Kraepelinian ideas about building a taxonomy of disorders as discrete entities with unique progressions and biological mechanisms to replace the notion of fluid subconscious conflicts. In the same year that the US-UK project published its findings, a team of psychiatrists include Eli Robins, Samuel Guze, Robert Woodruff Jr., George Winokur, Rodrigo Munoz, and John Feighner published a paper called “Diagnostic Criteria for Use in Psychiatric Research”, which contained operationalized criteria for 14 psychiatric disorders. These are referred to as the Feigher Criteria after the lead author of the paper, and it served as a major influence for the DSM-III and the ICD-9. Cognitive-Behavioral Therapy (CBT) arose alongside this pivot to addressing observable symptoms from current, conscious thoughts and behaviors rather than digging into underlying trauma and personality constructs, which insurance companies readily embraced as well for its predictable, manualized delivery and quantitative metrics to show improvements.
Let’s consider depression as an example.
In the DSM-II, we have the diagnosis “300.4 Depressive neurosis”:
This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession. It is to be distinguished from Involutional melancholia (q.v.) and Manic-depressive illness (q.v.). Reactive depressions or Depressive reactions are to be classified here.
“Internal conflict” is not a readily observable phenomenon; it requires a clinician to make a qualitative assessment that a patient is suffering from an internal conflict based on what they say or do. Similarly, the clinician could subjectively or even arbitrarily determine that one of the thousands of life events a patient had was the “identifiable event” in question.
The DSM-III has a lengthy entry titled “Major Depressive Episode” that includes a section title “Diagnostic criteria for major depressive episode”:
A. Dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. The dysphoric mood is characterized by symptoms such as the following: depressed, sad, blue, hopeless, low, down in the dumps, irritable. the mood disturbance must be prominent and relatively persistent, but not necessarily the most dominant symptom, and does not include momentary shifts from one dysphoric mood to another dysphoric mood, e.g., anxiety to depression to anger, such as are seen in states of acute psychotic turmoil. (For children under six, dysphoric mood may have to be inferred from a persistently said facial expression.)
This still calls on some subjective judgment of whether someone’s mood disturbance is “prominent and relatively persistent”, but a mood is more easily observed through someone’s external affect than an “internal conflict.” Plus, we have at least some quantitative guidelines laid out in the next section:
B. At least four of the following symptoms have each been present nearly every day for a period of at least two weeks (in children under six, at least three of the four).
(1) poor appetite or significant wait loss (when not dieting) or increased appetite or significant weight gain
(2) insomnia or hypersomnia
(3) psychomotor agitation or retardation (but not merely subjective feelings of restlessness or being slowed down)
(4) loss of interest or pleasure in usual activities, or decrease in sexual drive not limited to a period when delusional or hallucinating
(5) loss of energy; fatigue
(6) feelings of worthlessness, self-reproach, or excessive or inappropriate guilt (either may be delusional)
(7) complaints or evidence of diminished ability to think or concentrated, such as slowed thinking, or indecisiveness not associated with marked loosening of associations or incoherence
(8) recurrent thoughts of death, suicidal ideation, wishes to be dead, or suicide attempt
There are more stipulations to the diagnosis after this, but this should suffice to demonstrate the differences between the Kraepelinian approach that laid out consistent diagnostic criteria for distinct illnesses and the Freudian psychodynamic approach that located the sources of distress in unobservable internal conflicts.
This solved the problem of doctors arbitrarily or subjectively giving different diagnoses for the same presentation of symptoms, but it introduced a new problem around whether the diagnoses themselves are actually valid as distinct biological diseases. There are no blood tests, genetic markers, brain scans, or anomalies that can deterministically demonstrate a defined diagnosis, which has led to the criticism that ordinary distress from life becomes pathologized and assigned a diagnosis. Studies find that patients often meet multiple disorders at the same time, with Major Depressive Disorder and Generalized Anxiety Disorder being particularly common as a pairing, which brings into question whether these are truly distinct biological diseases. The threshold system also creates strange outcomes. For instance, if you must meet 5 out of 9 symptoms to be clinically diagnosed with a disorder, then two patients might have the same diagnosis while only having one symptom in common.
One of the efforts to remedy the new problems introduced by Kraepelinian frameworks is the Research Domain Criteria (RDoC) framework led by the National Institute of Mental Health (NIMH). The RDoC framework focuses on brain circuits and behavioral dimensions across a continuous spectrum that builds a bottom-up picture of someone’s mental health through empirical neuroscience. In the case of an overlap between say, MDD and GAD, the RDoC framework would explore the shared neural circuity that produces the symptoms of both diagnoses, whereas the Kraepelinian framework would explore both as distinct diseases with distinct progressions.
Psychodynamic therapists haven’t become irrelevant by any means either. Instead, they argue that RDoC is simply revealing the physiological mechanisms through which the unconscious mind operates, but that mental patterns are still necessary to explore to facilitate change within a person’s lived experiences by interpreting the meaning of their inner world and perspectives. For instance, two people can both present with MDD according to the DSM’s Kraepelinian-style checklists, but if one has a personality we might describe as high in narcissistic traits while another has a personality we might describe as high in dependent traits, the delivery of any therapeutic modality will fundamentally be different to address the symptoms in each patient. In fact, there’s an entirely separate Psychodynamic Diagnostic Manual (PDM) from the DSM. Those like Jonathan Shedler are strong critics of CBT being treated as a gold standard treatment, raising the argument that patients who undergo psychodynamic therapy continue to improve after the therapy ends because they’ve made deeper changes to their personality functions while patients who undergo traditional CBT primarily learn to manage symptoms that emerge on the surface as a result of those functions.