Personality and mental disorders: sensitive character,melancholic type,and addenda

Abstract

A traditional view in psychiatry is that personality disorders or traits are intimately related to primary mental disorders. Psychic functions with common roots might be constitutive of personality and psychosis or other disorders. Hoche held that paranoia, mania and melancholia lie in the normal psyche, and Kraepelin conceded such a view, explicitly implying personality. According to Carl Schneider, endogenous symptom complexes or associations and normal functional associations are fuzzy. Many other psychopathologists emphasize personality characteristics in connection with endogenous or functional psychoses, such as the sensitive and melancholic types. When adopting a continuum view of mental disorders, they behave in a unitary or systemic configuration, corresponding to endogenous-functional dispositions interacting with the milieu and composing personality.

Keywords

Melancholic type personality and psychosis/mental disorders sensitive character symptom/function complexes unitary psychosis

Introduction

Cartesian thinking often leads us to conceive that personality characteristics are derived from psychological, educational or sociocultural influences, while severe mental disorders are due to biological determinants. Similar reasoning applies in psychoanalysis, which conceives of neurosis as psychogenic. However, this Cartesian thinking does not apply in psychiatric clinical practice and research, where severe mental disorders, personality disorders, personality difficulties and traits frequently overlap. The conception of the mind–body problem underlies these issues and our view of psychiatry (Fulford, Thornton and Graham, 2006: 622).

However, either way, in dualistic or monist conceptions of personality, we should admit that there remains a ‘how?’. How do biological influences, usually referred to as temperaments when discussing personalities, relate to personal and general historical or sociocultural contexts?

This topic has been discussed since ancient times. When we say someone is choleric, melancholic, phlegmatic or sanguine, we are referring to Hippocratic writers, Galen, and Avicenna’s humour theory. Yellow bile (hot and dry), black bile (cold and dry), phlegm (cold and moist) and blood (hot and moist) were thought to lead to these personality types or temperaments when unbalanced and to diseases when more severely so. Hence, these personality types are dispositions to more profound mental disorders (Tellenbach, 1983: 5) or strong determinants of them (Tyrer, Mulder, Newton-Howes and Duggan, 2022). Furthermore, they correspond to the four cosmic elements (fire, earth, water, air) and are influenced by seasons, denoting an environmental interaction. Hippocrates also mentioned body characteristics or physiognomies in the context of personality types (Leibbrand and Wettley, 1961: 52–4). The types can mix and thus enrich the diversity of personalities.

These balanced–unbalanced and normal–pathological relations (sometimes also referring to hyper-normality related to genius) have often been discussed in psychiatry. According to Jaspers, the study of psychology is to psychopathology, in principle, what physiology is to pathology, without clear limits from one side to another. However, psychology does not offer the knowledge of ‘normal’ that psychopathology could take advantage of, i.e. we do not know how the mind works. Therefore, psychopathologists must often construct their own psychology (Jaspers, 1946: 2–3). It should be a psychology of a broad horizon conveyed through the psychological thinking of millennia, and that finds its way into the official psychology (p. 3).

The term ‘psychosis’ was initially related to the whole person in its psychophysical totality, preserving the psyche in a subjective-centric approach, as in Heinroth and Feuchtersleben (Schmidt-Degenhard, 1988: 51). The disposition, diathesis or vulnerability to psychosis was considered a personality disposition. Canstatt, influenced by Guislain, maintained that psychic sensibility was a disposition to psychosis, a term he introduced (pp. 49–50). He also referred to psychosis as ‘psychic neurosis’, emphasizing the ‘psychic’ alongside the then current view of ‘neurosis’ as a nervous system involvement (Bürgy, 2008: 1201). Psychosis designated psychological or experiential states at that point (Berrios and Marková, 2021: 14). Subsequently, after the Romantic period, a somatic-hereditary vulnerability concept for psychosis prevailed. Nevertheless, the question of a subject-centric perspective for psychosis, in contrast to a morbid-centric perspective, often reappears in psychiatry.

The present work aims to keep a balance between the subjective-personal and the biomedical morbid-centric views. Both of these views embed value-laden perspectives. The latter would reduce our scope to a meaningless nature (unless we see nature differently from how it is usually conceived), and the former would turn us into a sort of disembodied spirit. In this context, a dynamic dimensional and more holistic perspective is required instead of a reductionist static categorical perspective. The dimensional approach allows us to investigate the inner relations of various disorders (beyond simply comorbidities) and their possible links to the mind in general (Kendell, 1975: 136). Furthermore, it is a view of mental disorders that is consistent with empirical evidence (Balaratnasingam and Janka, 2015; Tamminga, Os, Reininghaus and Ivleva, 2021). The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) have adopted a more dimensional or spectral approach in their most recent editions, and the Research Domain Criteria have always adopted a transdiagnostic approach.

Two classical models of personality and psychosis

Kretschmer’s sensitive delusion of reference – a contribution to the paranoia question and the psychiatric character doctrine

Paranoia is traditionally a chronic delusion, usually non-bizarre, a psychosis that does not evolve into negative symptoms or mental dullness. In contrast, when it did show this kind of progression, it was named paranoid dementia and soon regarded as a subtype of dementia praecox by Kraepelin or, later, paranoid schizophrenia. On the other hand, nonpsychotic manifestations close to paranoia characterize the paranoid personality disorder or traits.

At the beginning of the last century there was an interest in milder forms of paranoia, that is, paranoiac pictures that are not necessarily chronic. The medical disease model with a static, neuroanatomical view of mental disorders as delimited natural kinds was giving way to a more dynamic and transdiagnostic view. Even Kraepelin (1915: 1712–13) conceded that the boundaries between paranoia and psychogenic delusions, such as the querulous, might be tenuous. Jaspers (1913: 265–8, 270) preferred to talk of ideal types for endogenous psychoses, instead of disease species (which he applied to the exogenous psychoses), besides trying to differentiate more psychogenic developments from processes and phases. Bleuler drew attention to affective ideation complexes in paranoia (Bleuler, 1906: 97–137).

Ernst Kretschmer (1918) saw a continuum between all paranoia, paranoid psychosis, and personality, up to normality and hyper-normality (‘genius’). Another important continuum for Kretschmer was that between sthenic (strong, active) and asthenic (debilitated, weak). His concept of sensitive character with the sensitive delusion of reference is one of several relevant to paranoia, and he refers to his investigation as ‘type research, not boundary research’ (Kretschmer E, 1966: 155).

His description of the sensitive character is meticulous, as in this excerpt:

On the one hand, they show an extraordinary softness of temper, weakness, and delicate vulnerability; on the other hand, a certain self-confident ambition and obstinacy. The fully formed representatives of the character group are complicated, very intelligent, and high-quality personalities, fine and deeply feeling people of scrupulous ethics and overly tender, internalized emotional life, exposed to every hardship of life, locking up their sustained, tense affects deeply in themselves, of refined introspection and self-criticism, very touchy and obstinate, yet especially capable of love and trust, of resolute self-respect and yet shy and unsure of personal appearance, introverted and yet accessible and people friendly, modest but ambitiously striving and of marked social efficiency. (Kretschmer E, 1966: 146, original italics)¹

The sensitive personality is predominantly an asthenic character, which means that there is a conduction defect (Leitungsdefekt) from the centripetal to the centrifugal mental functions, lacking an ability for psychic discharge. Whereas the querulous paranoiac is instead expansive-sthenic and externalizes their thoughts or acts, the sensitive tend to ruminate consciously on their feelings and thoughts. This also differs from hysteric manifestations, which are engendered unconsciously. A variant of the sensitive character experiences more tension between sthenic and asthenic elements, which can lead to obsessive symptoms.

Besides the sensitive and expansive character types, as mentioned above, there are primitive and pure asthenic types. Someone with the primitive type of personality may manifest predominantly impulsive and explosive reactions with indifference as to the consequences, while the pure asthenic does not react or tends to experience reactive depression. The primitive character presents hysteric characteristics more often. The asthenic–sthenic axis and the primitive character form a triangle of possible intersecting manifestations. Kretschmer added at the other side of the axis, contrary to the primitive character, Kraepelin’s most characteristic paranoia (Kretschmer E, 1966: 181).

Kretschmer summarised his characterology as follows:

The most important guidelines of the character theory aimed here are that we replace the static and materializing point of view with the genetic and dynamic one, as it corresponds to the actual psychological facts. Following, we do not consider the character as a magnitude for itself but consequently in its living relation to the experience. We distinguish the characterological qualities, in the narrower sense, which the soul acquires reactively in a purely psychic way, from those which arise in it as part of the autonomous biological context of nature. Finally, above all, we project the scientific relations for character qualities into a logical plane in such a way that they become comparable with each other. (pp. 24–5, original italics)

However, Kretschmer’s most relevant contribution is not the description of a new personality type, but revitalizing, in mainstream psychiatry, the psychic components of psychosis. His book on the sensitive character and delusion of reference is considered a classic text on the historical personality–psychosis issue, whose relevance goes far beyond the paranoid syndrome sphere. Kretschmer demonstrated through exemplary clinical descriptions how a delusional state could emerge from a reactive psychological process. He saw an essential dynamic interrelationship between character, experience, and social environment in the development of paranoia (Schmidt-Degenhard, 1988: 53).

A fundamental requirement for the emergence of delusions is the person’s reaction to an external event, without which the delusion would not occur. This is not a simple reaction to a stimulus but the emergence of a personal experience (Erlebnis). A typical correlation exists between the event, character, experience, and delusion. Different characters give rise to different kinds of paranoia. Kretschmer emphasizes the interacting nature of this process: the milieu effects ‘are closely related to the character and ethical attitude of the patients, as far as these partly create the milieu, which in its turn affects them again’ (Kretschmer E, 1966: 147). Certain experiences are stimulated by certain milieu effects, leading the two components of the sensitive character, asthenic insufficiency feeling and sthenic self-consciousness, to be specifically provoked, thus increasing their mutual tension up to the outbreak of illness.

Although the delusional state cannot occur without an external event, biological causes are a latent disposition: ‘In the severe cases, there seems to be a good bit of the schizophrenic-schizoid or other endogenous load in the paranoid, which is strongly prominent in many cases’ (Kretschmer E, 1966: 7, original italics). Kretschmer maintains that process and psychologically empathic components, in Jaspers’ terms, are not mutually exclusive but, in many cases, interact in the genesis of the individual case. Again, continuities are everywhere, but in the most severe cases endogenous dispositions are likely to prevail:

The clinically careful observer can find all transitional forms and combinations in the field of paranoid psychoses: from the psycho-reactive cases of pure sensitives, querulous and desirous psychoses to the ‘multidimensional’ cases with a complicated interweaving of psychogenic and processual components up to the typical disintegrating paranoid-schizophrenic. (p. 6)

Thus, the diagnosis is always multidimensional, and each paranoia case is ultimately different – there would indeed be paranoiacs and not paranoia (p. 179).

Links to normality remain important. In some cases, there is a tendency to find assurance in an over-individual modus operandi, the ‘escape into the super-individual’, as in religion (with possible mystic delusions), overidentification with special personalities, or resolution of the conflict tension by its elevation into a fateful human theme (p. 10). Ideas of reference that fall short of psychosis, also termed reference neurosis, are a milder form of the sensitive delusion of reference, and may precede or be secondary to the sensitive delusion (p. 151). The development of the delusion mirrors the struggles of the psyche of normal people, where a long-silenced love, or an unresolved grievance, disturb the mind inwardly until an external encounter suddenly causes a severe discharge of affect (p. 155). In referring to geniuses with an expansive–sensitive character mixture, Kretschmer talks of ‘character study, not pathography’, even though the character is not normal, that is, different from that of an average person (p. 159). He explicitly mentions psychic connections as being ‘in an indissoluble web’ between the ‘psychogenic’ delusions and those which Kraepelin calls ‘genuinely paranoid’, which Kraepelin had already conceded (pp. 176–80).

Kretschmer was also in tune with the psychoanalytic dynamic view and valued some psychoanalytic clinical observations, though expressing concerns about its general theory. Notably, Kretschmer was probably a strong influence on Lacan, whose thesis on paranoiac psychosis and personality mentioned Kretschmer around 100 times, comparable only to Kraepelin (Lacan, 1932/1975; see section on sensitive character: pp. 88–102). According to Lacan, without an adequate conception of the ‘psychic synthesis’ functioning, psychosis will always remain an enigma, and this synthesis is the personality (p. 14). The ample space dedicated to Kretschmer is justified as an elaborate expression of the thesis chapter ‘Conceptions of paranoiac psychosis as a personality development’, for considering paranoia ‘as a reaction of a personality and as a moment of its development’ (p. 98, original italics).

Unsurprisingly, as with psychoanalysis, Kretschmer was sometimes criticized for being too psychological (Engstrom, 2008). However, overall, scholars have been very positive in his favour. Wolfgang Kretschmer praised the emphasis on psychic causation, which dates back to the Romantic period, and he pointed out that even Griesinger had emphasized that psychic causes can shake the nervous system (Kretschmer W, 1966: 205) or the psychophysiological schema (Daker, 2021: 16–26). Griesinger (1861: 55) also mentioned the emotionally weak (gemütsschwach) man or self, which seems close to the sensitive character.

Appraising the patient’s life history, as advocated by Kretschmer, became consonant with phenomenological–anthropological psychopathology (Schmidt-Degenhard, 1988: 53). Among this group, Kretschmer influenced Tellenbach, who likewise argued for abandoning a constitutional predetermined view of personality in favour of a more dynamic view of characterological reactivity (Tellenbach, 1967).

Tellenbach’s melancholic type

In every true depression or melancholy, there is a tendency (endogenous disposition) and a situation that breaks the equilibrium and triggers the depressive transformation. However, melancholy will occur only in those possessing some personality characteristics, which Tellenbach called Typus melancholicus (Dörr Zegers, 2021: 21). It is not a true dysthymic or subsyndromal depression, but a personality given to some obsessive or anankastic traits and other characteristics. As a personality, it is ego-syntonic (in contrast, for example, to ego-dystonic obsessive disorder).

In his phenomenological–anthropological approach, which considers the whole person irrespective of being pathological or normal, Tellenbach considers this type of personality as ‘too normal’ or a ‘pathological normality’ (Tellenbach, 1983: 148–9), a ‘normopathy’ (Dörr Zegers, 2021: 20). The pathological element can be traced back to healthiness, but even so a state of health may turn pathological. There are dialectic or polar anthropological proportions in this interplay of psychopathological and normal or hyper-normal instances (Kraus, 2015: 315). For example, there may be an overidentification with an objective self, attached to social norms, at the expense of a spontaneous and constantly redesigning or changing subjective self (Kraus, 2014: 126–8). Thus, the attachment to a social role and the need to take control of situations result in an inability to deal with spontaneity. When this control collapses, endogeny – the endogenous melancholy – emerges. The melancholic type attaches rigidly to some values, indeed positive values such as a sense of justice and what is socially important, providing a world vision and an existential sense; it is how the person relates with themself, others, and the world (Ambrosini, Stanghellini and Langer, 2011: 303). However, under certain circumstances, this rigidity may become a disadvantage.

The basic characteristics of this melancholic premorbid personality are orderliness and conscientiousness. The exaggerated orderliness directed to taking refuge in a safe, stable world leads to a high demand that may exceed the person’s capabilities. Conscientiousness aims at seeking the acceptance of others – including social norms – and preventing the feeling of guilt. These characteristics come along with the above-mentioned social role attachment or hypernomie and ambiguity intolerance due to the person’s pre-established image of themself and others (Ambrosini et al., 2011).

Therefore, the melancholic type can fall into a self-contradiction, trying to overcome it (Inkludenz) but possibly not handling it (Remanenz), into a state of despair (Verzweiflung) – ultimately not wishing to live, though not especially wishing to be dead either. Under these conditions, loss of affective resonance, the delusion of guilt, devitalization, and psychomotor slowness appear (Ambrosini et al., 2011: 306–8; Tellenbach, 1983: 126–47, 153–6).

Underlying all the above is Tellenbach’s refined understanding of endogeny. The term was initially used in psychiatry, in contrast to ‘exogenous’, by Möbius (1892). It carried the burden of Morel’s degeneration theory. Later, it assumed the meaning of cryptogenic or something somatic to be still discovered; used in this sense, endogenous would be doomed to become exogenous. However, Tellenbach inverts this equation and considers endogeny as something positive and necessary. It would not vanish through the discovery of its somatic or any other basis since it would still be endogenous.

Tellenbach’s Endon is traced back unilaterally neither from the physical nor from the psychic; it permeates the human organism’s nature, including mental normality or the anthropological norm (Gebsattel, 1983: xii). It concerns constitutional dispositions as already intended in the Corpus Hippocraticum, temperament or personality types, leading in Plato and Aristotle to a loss of measure or Ametria in diseases, but also symmetry or Meson in the case of genius (Tellenbach, 1983: 5, 7–15).

Tellenbach (1983) was aware of new data concerning the internal biological rhythms and mentioned chronobiology and one of its pioneers, Jürgen Aschoff. Even though he was not using this terminology in the first edition of 1961, he was already mentioning the sleep–wake cycle and other rhythms in the context of ‘Rhythmic manifestations of the untransformed Endon’ (Tellenbach, 1961: 20). Endogenous chronobiological dispositions synchronize in life with geophysical rhythms or Zeitgebers. There is an endocosmogenic periodicity, which also includes ecological-sociological Zeitgebers (Tellenbach, 1983: 19; see also Daker, 2021: 153–4). As a subtle example of how the endogenous corresponds to the cosmic nature – such correspondence is often emphasized – Tellenbach (1983) says that sleeping and being awake do not occur because there is night and day, but in unison with day and night, one wakes and sleeps (even if there is no night and day, as in a cave, circadian rhythms will still operate). It means that the cosmos is not causally entangled with the organism but correlatively (pp. 21, 181). For the sake of survival, the organism must be intrinsically prepared for its environment (‘prepare’ is etymologically ‘set in order or readiness for a particular end’; Harper, 2022), which embeds a projection or developing trend (Geworfenheit).

Genuine melancholic depression is a decompensated disproportion of being-in-the-world, whereby the melancholic distinctive and hardly communicable supra-individual endogeny emerges, and all personal differences seem to become erased (Tellenbach, 1983). It is an incomprehensible global transformation of the existential gestalt. This transformation can express itself in facets, ‘but in each of them the whole is always contained. In other words: all phenomena constitutive of an endogenous transformation are equally original’ (p. 27, original italics). The distinctiveness of typical psychotic manifestations, such as melancholy, points to a uniform, specific origin, the Endon.

The Endon is a third field of causation, apart from the dichotomic physical and psychic, a ‘metabiological/transobjective’ and ‘metapsychological/transsubjective’ instance (p. 52). It makes possible the biological and psychological characteristics of personal development or maturation, as in the case of the melancholic type. The Endon bridges the psychophysical parallelism (in our understanding, through the endocosmogenic person). Although the endogenous has a genetic root, it was sustained that the gene is not deterministic but acts as a possibility (p. 33), mirroring current data on epigenetics and environment relations.

After mentioning Janzarik on types or ‘structures that are solidified responses of hereditary dispositions to formative situational forces’ (p. 34), the concept of ‘situation’ emerges. With the development of the melancholic type, there is a growing tendency to specifically ‘situate’ others and the environment. Kretschmer, as mentioned above, had already detected this situational instance, which can be related to enactivism, a dynamic interaction between the organism and its environment. It differs from reactions as in mechanistic physiology, which assumes that a subject, somehow separated from the world, reacts to an object in the world that stimulates it. Conversely, we situate ourselves in the world. We co-constitute the situation in dynamic reciprocity of our being or personality and the world, and two interrelated courses arise: to be projected and to be the projector (Dörr Zegers, 1995: 50). A person with a melancholic personality has an increased tendency to situate close people and everything available as part of their environment. Suppose the other person or, in the case of a move, the house withdraws from this inclusion. In that case, the once constituted stable and reassuring situation becomes pathogenic (‘endotrophic’ pre-melancholic situation), possibly resulting in endogenous alteration (‘endokinetic’ melancholic transformation).

Concerning the Endon, this means:

We understand the Endon then neither as the nonpersonal of the biological nor as the personal in the sense of existence, its vivification of spiritual reality. The Endon is before these because it makes them possible and shapes them; it is after these because it can be influenced, inhabited, formed by them because, as Goethe says, man can ‘teach his organs,’ in the sense in which Goethe speaks of becoming as the formation and transformation of organic natures.

Just as human reality cannot be imagined at all without reference to the world, so also the endogenous development can be realized only in the full entanglement of Endon and the world. (Tellenbach, 1983: 38)

Regarding the connections between personality, situation, and psychosis, Tellenbach (1983) lastly resumes Kraus’s existential analysis of the social behaviour style of people with manic-depression. Instead of the affective–full cyclothymic personality, Kraus emphasizes how such people are bound to social roles. It is thus not precisely a mood disorder but a disorder of the self, whereby the overidentification with the social role effaces the self. In other words, it is depersonalization, a fugue in the role, and an inability to feel how to transcend the person’s own bonds. It corresponds to a warm-hearted but sentimental stickiness, a flood of feelings of characterless emotional sloppiness, which would mean a flattening of affective life rather than deep feelings. All distinct role and identity modifications would not be based, according to Tellenbach, on freedom and choice (as per Sartre), but on what he postulates as the endogeneity sphere (p. 120).

Kretschmer’s sensitive and Tellenbach’s melancholic types are in-depth examples of multidimensional relations comprising endogenous dispositions that involve personality development and psychosis.

Additional historical support for the interrelatedness of personality and mental disorders

It is well known in psychiatry that Kahlbaum distinguished symptoms and symptom complexes from diseases. It is noteworthy that besides thoroughly investigating and classifying mental diseases, he also investigated the symptoms and symptom complexes regardless of diseases, thus, in a sense, regarding them only as a changeable garment of the diseases. He developed a general scheme of symptoms and symptom complexes according to afferent, central, and efferent continuous physiological pathways and different intensities (Daker, 2019: 227–9; 2021: 72–7). The question arises: if these symptom complexes are not diseases, what should they be?

Many psychopathologists, including Jaspers, considered this question about symptom complexes, arguing for their investigation irrespective of the notion of disease. A tendency was to see them as part of the personality and psychism, or in a special framework of psychiatric pathogenesis. These psychopathologists led Kraepelin to reconsider his assumptions about endogenous psychoses being clear-cut diseases. He conceded the possibility that ‘the affective and schizophrenic manifestation forms of insanity do not represent, in themselves, the expression of certain disease processes, but merely reveal those areas of our personality in which they take place’ (Kraepelin, 1920: 27; 1992: 528).

Kraepelin’s division of endogenous psychoses according to a strict disease model might have given the impression that other mental disorders or psychism would be apart from endogeny. That is not the case, as is well known with the clinical manifestation of neurosyphilis and other exogenous mental diseases (disorders due to another medical condition, in DSM terms, or secondary mental or behavioural syndromes associated with disorders or diseases classified elsewhere, in the ICD). They can present similar symptoms to those of endogenous psychoses. Fauser (1905), from a case report of paralytic dementia, had anticipated Hoche’s (1912) historically acknowledged work on the meaning of symptom complexes. Fauser considered the endogenous constitutional manifestations associated with the normal mind as ‘coordinated symptom complexes’ or ‘psychic functions already preformed in healthy lives’. To be clear: ‘All of us – even we completely healthy people – have these symptom complexes in us by predisposition’ (Fauser, 1905: 174–5). Accordingly, the clinical picture will vary depending on how these endogenous manifestations are prominent in relation to other symptoms of paralysis or exogenous diseases.

Hoche introduces an anthropological–personal perspective into psychopathology: symptom complexes are preformed or lie ready in the normal psyche. He equates melancholy, mania and chronic paranoia to the hysteric, hypochondriac, neurasthenic, suspicious, querulant and other mental dispositions or personality reaction forms:

In the occurrence of these special, lasting, and largely accompanying forms of reaction, each of them from the union of elementary dispositions [. . .] lies the pressing indication that in the normal psyche as well as in the degenerative [functional] predisposed certain symptom couplings are preformed, which partly constitute what we call the character of a human being, partly in the case of special pathogenic influences determine how the pathologically deviating form of the personality reaction turns out. (Hoche, 1912: 549)

Bumke (1909) also considered a continuum between manic-depressive, paranoia, and the above conditions, stating that they have healthy analogues that we can understand. Later he states:

We should certainly assume that there are deviations in the function of the brain tissue, but these deviations will rise from the normal somatic disposition in just the same way as their mental counterparts are related to normal behaviour. Mental disorders which are ‘functional’ in this sense can and must shade off into normal human psychology. (Bumke, 1924/1993: 134, original italics)

Bumke tended not to include schizophrenia in this functional spectrum, differing from Bleuler and Kretschmer regarding its functional continuum with normality, that is, their view of schizophrenia as a morbid condensation of normal mental reactions (Bumke, 1924/1993: 134). However, in addition to seeing schizoidia as premorbid to schizophrenia, Bleuler (1922) indeed uncovered its probable relevant ‘biological functions’ (p. 381) in ‘normal character’ (p. 378), in his words: ‘independence from the environment’, ‘adaptation through inventions/creations’, ‘opportunity for reflections and modifications’, ‘can postpone or sublimate a drive’, ‘can vigorously pursue ideal aspirations’, ‘the most important innovations in our cultural life’, ‘a perception distance and a perception slope/gradient’, ‘can fragment himself and observe in detail’, ‘able to confront his own feelings’, ‘the same expressed in poetry and art’, ‘capable of much finer and more differentiated (up to refined) feelings’, ‘having an idea represented by symbols’, ‘abstraction’, ‘philosophical thinking’, ‘sharp logicians’, ‘originals’, ‘tenacity’ and ‘powerful people’ (pp. 381–4). Hence, what makes up the schizoid personality and relates to schizophrenia would also lend itself to essential mental functions. Bleuler considered self-evident the positive functions of syntony, a term he preferred over Kretschmer’s cyclothymia, i.e., the cyclothymic temperament related to manic-depressive insanity.

Carl Schneider followed similar thoughts. He sometimes named his investigated schizophrenic symptom complexes as functional complexes or associations; that is, a dynamic correspondence exists between symptom associations and normal function associations. His symptom complexes represent more condensed and researchable mental functions, while the normal psyche is difficult to comprehend for being more diluted or fluid (Schneider, 1942: 133, 136, 237). He maintained, along with Fauser and Hoche, that the symptom association ‘is already preformed in a healthy functional association and is only its pathological deviation. The disease, therefore, consists of the alteration of the normal functional associations’ (p. 142). Alternatively, ‘the symptom couplings present in the symptom associations are not first produced by the schizophrenic process but are already formed in the norm’ (p. 142). He warned against regarding the identified associations as static constructions in the sense of rigid categorizations but as expressions of an ever-fluid process of life with dynamic effects and changeable responsiveness (p. 194). Schneider’s investigations resulted in a new hypothesis of the structure of mental life (p. 156; Jaspers, 1946: 491; see also Daker, 2019).

Schneider often speaks of ‘wholeness’ or ‘totality’, concepts with which many psychopathologists were concerned when approaching personality and mind. For Minkowski, psychiatry as a branch of medicine is supposed to address symptoms and syndromes, but the notion of psychic reality poses special problems. This is because we tend to view psychic manifestations in the context of the whole person. Thus, mental syndromes are not simple associations of symptoms but ‘the expression of a profound and characteristic modification of the whole human personality’ (Minkowski, 1933/1968: 211). Indeed, many phenomenological psychopathologists, such as Minkowski, follow these lines.

It should be added that far beyond softening the Kraepelinian dichotomy and rigid classification principles, as did many authors, Kretschmer evolved his work on endogenous psychoses into a kind of general anthropology. In his laborious book Körperbau und Charakter (Physique and Character), he statistically related schizophrenia and manic-depressive illness to typical personalities or temperaments and personality disorders, respectively: schizothymic-schizoid and cyclothymic-cycloid (Kretschmer, 1961). These personality types would even correspond to body shapes or physiognomies: leptosomic and pyknic (there is also the medium-term athletic, besides the dysplastic). The psychophysical constitutional types can mix, leading to a spectrum of possibilities. Indeed, the constitutional types have a fixed core that empirical group correlations can determine, but no fixed boundaries (p. 419). True or scientific types, according to Kretschmer, allow for the expression of the relation between isolated functions and the whole personality (p. 415). As advertised by Kraepelin’s ‘areas of our personality’, it is not a specific cause that leads to schizophrenic or affective manifestations, but rather one’s personality.

Unitary psychosis: a further twist in the plot

Unitary psychosis (Einheitspsychose) is a term used by Jaspers (1913: 257) as opposed to categorical disease unities or entities (Krankheitseinheiten). Therefore, the term was introduced after the Kraepelinean dichotomy of dementia praecox/schizophrenia versus manic-depressive insanity. Historical-conceptual overviews (Berrios, 1994; Berrios and Marková, 2021; Daker, 2021) have shown how the concepts of unitary psychosis not only pre-date Kraepelin but also provide a challenge to the dichotomy, since they merge schizophrenia and manic-depressive insanity into a continuum. Furthermore, a unitary view can be extended to other disorders, including personality disorders, corresponding to a systemic and dynamic view of mental disorders. In Aristotelian terms, it is a heterogeneous continuum (Daker, 2021: 9–10).

Guislain (1833) is considered the founder of unitary psychosis. He regarded an increase in psychic sensitivity as the baseline symptom of insanity (Schmidt-Degenhard, 1988: 50). Griesinger, among others, followed Guislain’s hierarchical evolution of psychosis in a continuum from affective to intellectual disorders and referred to emotionally weak, as mentioned above, and other personality characteristics. His psychophysiological assumptions explained essential aspects of mental life (emotions, affects, mood, ideation, impulses, volition, freedom) and some personality disorders, besides mental diseases arranged in a continuous hierarchical order (Griesinger, 1861; see also Daker, 2021: 16–26, 42).

After the Kraepelinian dichotomy, the unitary conceptions changed from a vertical hierarchical to a prevailing horizontal relation between schizophrenia and manic-depressive insanity (though authors such as Ey, Conrad, Llopis, and Crow kept hierarchical views). This horizontality corresponds to ‘a pendular movement’ (Jaspers, 1946: 475) swinging between attempts at their division. Leonhard’s many subdivisions of the endogenous psychosis denoted the proximity between the neighbouring entities, paradoxically inducing Rennert to propose an all-inclusive unitary endogenous psychosis with a universal genesis (Kumbier and Herpertz, 2010; Leonhard, 1980; Rennert, 1982). This also recalls Möbius’s original view of endogenous engendered disorders as naturally continuous (Daker, 2021: 89–90; Möbius 1892). Rennert’s unitary conception includes personality disorders and neurosis. Kretschmer, in his constitutional approach, and Bleuler also did not believe that schizophrenia and manic-depressive insanity were unconnected. Llopis (1960) also included exogenous psychosis (due to another medical condition) in unitary psychosis as its emergence depends on endogenous mechanisms as well exogenous precipitating causes.

Kahlbaum, in his scheme of symptom complexes, also regarded them in a continuum, such as a unitary psychosis, even though he also searched for discrete, distinct forms of mental disease. Even Kraepelin (1920), in his later work, indicated a continuous hierarchical human disposition of symptom complexes, an anthropogenetic ordering in stages: (1) delirious (clouding of consciousness, as in dreams), paranoid, affective, hysteric, and impulsive forms; (2) schizophrenic and perhaps auditory hallucinatory forms; (3) encephalopathic, idiotic, and spasmodic forms.

These stages, according to Kraepelin (1920), correspond to a phylogenetic organization of the human organism tied to the personality and are pre-formed dispositions with which the organism reacts to different causes. They are located between causes and clinical manifestations. This therefore blurs Kraepelin’s former linear law of corresponding cause, anatomo-pathological finding, and clinical manifestation, although indeed Kraepelin had already recognized the shortcomings of this law, which he referred to as a ‘contradiction with the basic laws of natural science’ (Kraepelin, 1909: 15). Kraepelin seems to use the various forms of human disposition as a mediating effect in this regard (Daker, 2021: 94–9). Each of us would embed such continuous dispositions interacting with the environment and enmeshed in our personality. They may be disturbed and manifest in unitary psychosis.

To illustrate this, we may consider an interplay between endogenous psychoses. The overinclusion and ambiguity intolerance of the melancholic type means an overinclusion into common sense, contrasted to the characteristic schizophrenic loss of common sense (Blankenburg, 1988: 66; Cutting, 2013: 27–9; Tellenbach, 1983: 112). It corresponds closely to Bleuler’s syntony and schizoid (Bleuler, 1922; Kapfhammer, 2017). In the context of a ‘predominantly syntonic’ or a ‘predominantly schizoid’ came Bleuler’s notorious dimensional assertion: ‘The diagnostic question would then, as far as the manifestation is concerned, no longer be: manic-depressive or schizophrenic? but: to what extent manic-depressive and to what extent schizophrenic?’ (Bleuler, 1922: 374–5, original italics). For example, Kretschmer’s sensitive paranoid delusion lies largely within the schizophrenic circle or spectrum. However, it also includes a strong influence from the depressive pole, resulting in some personality characteristics that resemble the melancholic type, such as marked social efficiency and scrupulous ethics. Furthermore, paranoia is a stable and coherent picture or polarity in contrast to the disorganized or thought-dissociated (Spaltung) typical of schizophrenia. Such views open the possibility of speculating about polarities among symptom complexes with potentially intermediate/mixed cases in a unitary configuration (Daker, 2019: 236–7; 2021: 109).

Conclusion

This paper has explored the mental structure underlying personality and primary mental disorders, linked by their endogenous origin in a fluid and dynamic process. This framework allows for a bio-endo-anthropological structure interacting continuously with the environment, including social Zeitgebers (time givers) and, conceivably, Sinngebers (sense or meaning givers).

As we saw in Tellenbach’s Endon, this mental activity contributes both to personality maturation or development and to endogenous manifestations (symptoms or symptom complexes), which are preformed or functional, according to Hoche, C. Schneider, and many others. The psychopathological manifestations from this structure result in unitary psychosis. Personality disorders would be deviant and fixed; ‘normality’ or the normal range corresponds to more malleable people who are better adapted and live in better harmony with their environment.

This historical survey favours an intimate and iterative relationship between psychopathological manifestations and the person. Therefore, developing empathy with our patients is important, not just to facilitate a good doctor–patient relationship as in general medicine, but to get us closer to understanding the diagnosis.

Footnotes

Acknowledgements

The author would like to dedicate this work to Alfred Kraus.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship and/or publication of this article.

Notes

References

Ambrosini

Stanghellini

Langer

(2011) El Typus melancholicus de Tellenbach en la actualidad: una revisión sobre la personalidad premórbida vulnerable a la melancolia. Actas Españolas de Psiquiatría 39: 302–311.

Balaratnasingam

Janka

(2015) Normal personality, personality disorder and psychosis: current views and future perspectives. Current Opinion 28: 30–34.

Berrios

(1994) The notion of unitary psychosis: a conceptual history. History of Psychiatry 5: 13–36.

Berrios

Marková

(2021) Historical epistemology of the “Unitary Psychosis”. In: Tamminga

, et al. (eds) Psychotic Disorders: Comprehensive Conceptualization and Treatment. New York: Oxford University Press, 12–20.

Blankenburg

(1988) Das Problem der prämorbiden Persönlichkeit. In: Janzarik

(ed.) Persönlichkeit und Psychose. Stuttgart: Enke, 57–71.

Bleuler

(1906) Affektivität, Suggestibilität, Paranoia. Halle: Carl Marhold.

Bleuler

(1922) Die Probleme der Schizoidie und der Syntonie. Zeitschrift für die gesamte Neurologie und Psychiatrie 78: 373–399.

Bumke

(1909) Über die Umgrenzung des manisch-depressiven Irreseins. Zentralblatt für Nervenheilkunde und Psychiatrie 32: 381–403.

Bumke

(1993) The dissolution of dementia praecox (Classic Text No. 13). Introduction and translation by Dalén

Per

. History of Psychiatry 4: 129–139; originally published in German in 1924.

10.

Bürgy

(2008) The concept of psychosis: historical and phenomenological aspects. Schizophrenia Bulletin 34: 1200–1210.

11.

Cutting

(2013) The psychiatric concept of causation: philosophical and semiotic contributions. Appraisal 9: 13–32.

12.

Daker

(2019) The theory of symptom complexes, mind and madness. History of Psychiatry 30: 227–239.

13.

Daker

(2021) The Continuum of Mental Disorders and Unitary Psychosis: History and Perspectives. Newcastle upon Tyne: Cambridge Scholars Publishing.

14.

Dörr Zegers

(1995) Psiquiatría antropológica: contribuciones a una psiquiatría de orientación fenomenológica-antropológica. Santiago de Chile: Editorial Universitaria, S.A.

15.

Dörr Zegers

(2021) En torno a la vida y obra del psiquiatra y humanista Hubertus Tellenbach (1914–1994). Psicopatologia Fenomenológica Contemporânea 10: 13–28.

16.

Engstrom

(2008) Book Review: Martin Priwitzer (2007) Ernst Kretschmer und das Wahnproblem (Stuttgart: Franz Steiner). History of Psychiatry 19: 239–241.

17.

Fauser

(1905) Endogene Symptomkomplexe bei exogen Krankheitsformen. Allgemeine Zeitschrift für Psychiatrie und Psychisch-Geschichtliche Medizin 62: 165–175.

18.

Fulford

KWM

Thornton

Graham

(2006) Oxford Textbook of Philosophy and Psychiatry. Oxford and New York: Oxford University Press.

19.

Gebsattel

VE von

(1983) Geleitwort. In: Tellenbach

, Melancholie: Problemgeschichte, Endogenität, Typologie, Pathogenese, Klinik, 4th edn. Berlin, Heidelberg, New York, Tokyo: Springer-Verlag.

20.

Griesinger

(1861) Die Pathologie und Therapie der psychischen Krankheiten, 2nd edn. Braunschweig: Friedrich Wreden.

21.

Guislain

(1833) Traité sur les phrénopathies. Bruxelles: Établissement Encyclographique.

22.

Harper

(2022) Online Etymologic Dictionary; accessed (2 June 2022) at: https://www.etymonline.com

23.

Hoche

(1912) Die Bedeutung der Symptomkomplexe in der Psychiatrie. Zeitschrift für die gesamte Neurologie und Psychiatrie 12: 540–551; translated in 1991 as Classic Text No. 7 in History of Psychiatry 2: 329–343.

24.

Jaspers

(1913) Allgemeine Psychopathologie. Berlin: Springer.

25.

Jaspers

(1946) Allgemeine Psychopathologie, 4th edn. Berlin: Springer.

26.

Kapfhammer

H-P

(2017) Das Schizoidie-Konzept in der Psychiatrie. Von der Schizoidie über die Schizotypie zu den Cluster-A-Persönlichkeitsstörungen. Neuropsychiatrie 31: 155–171.

27.

Kendell

(1975) The Role of Diagnosis in Psychiatry. Oxford: Blackwell Scientific Publications.

28.

Kraepelin

(1909) Psychiatrie. Ein Lehrbuch für Studierende und Aerzte, Vol. 1, 8th edn. Leipzig: Johann Ambrosious Barth.

29.

Kraepelin

(1915) Psychiatrie. Ein Lehrbuch für Studierende und Aerzte, Vol. 4, 8th edn. Leipzig: Johann Ambrosious Barth.

30.

Kraepelin

(1920) Die Erscheinungsformen des Irreseins. Zeitschrift für die gesamte Neurologie und Psychiatrie 62: 1–29.

31.

Kraepelin

(1992) The manifestation of insanity (Classic Text No. 12). Introduction and translation by Beer

. History of Psychiatry 3: 509–529.

32.

Kraus

(2014) Antinomische Struktur des Daseins und “Gehäuse” im Sinne von Karl Jaspers mit Hinblick auf Melancholie und Manie. In: Engelhardt

Kick

(eds) Lebenslinien – Lebensziele – Lebenskunst. Medizingeschichte, Vol. 6. Berlin: LIT Verlag, 117–133.

33.

Kraus

(2015) Psychiatry: anthropological aspects. International Encyclopedia of the Social & Behavioral Sciences 19: 313–319.

34.

Kretschmer

(1918) Der Sensitive Beziehungswahn. Ein Beitrag zur Paranoiafrage und zur psychiatrischen Charakterlehre. Berlin: J. Springer.

35.

Kretschmer

(1961) Körperbau und Charakter: Untersuchungen zum Konstitutionsproblem und zur Lehre von den Temperamenten, 24th edn. Berlin, Göttingen, Heidelberg: Springer-Verlag.

36.

Kretschmer

(1966) Der Sensitive Beziehungswahn. Ein Beitrag zur Paranoiafrage und zur psychiatrischen Charakterlehre, 4th edn (ed. Kretschmer

). Berlin: Springer.

37.

Kretschmer

(1966) Begriff, Geschichte und wissenschaftliche Stellung des sensitiven Beziehungswahnes. In: Kretschmer

, Der Sensitive Beziehungswahn. Ein Beitrag zur Paranoiafrage und zur psychiatrischen Charakterlehre, 4th edn (ed. Kretschmer

). Berlin: Springer, 203–226.

38.

Kumbier

Herpertz

(2010) Helmut Rennert’s universal genesis of endogenous psychosis: the historical concept and its significance for today’s discussion on unitary psychosis. Psychopathology 43: 335–344.

39.

Lacan

(1975) De la psychose paranoïaque dans ses rapports avec la personnalité. Paris: Éditions du Seuil; reprint, originally published in 1932.

40.

Leibbrand

Wettley

(1961) Der Wahnsinn. Geschichte der Abendländischen Psychopathologie. Freiburg, München: Akademie.

41.

Leonhard

(1980) Aufteilung der endogenen Psychosen, 5th edn. Berlin: Akademie.

42.

Llopis

(1960) Das allen Psychosen gemeinsame Axialsyndrom. Fortschritte der Neurologie-Psychiatrie 28: 106–129.

43.

Minkowski

(1968) Le temps vecú: études phénoménologiques et psychopathologiques. Neuchâtel: Delachaux et Niestlé; reprint, originally published in 1933.

44.

Möbius

(1892) Ueber die Eintheilung der Krankheiten. Centralblatt für Nervenheilkunde und Psychiatrie 15: 289–301.

45.

Rennert

(1982) Zum Modell “Universalgenese der Psychosen” – Aspekte einer unkonventionellen Auffassung der psychischen Krankheiten. Fortschritte der Neurologie-Psychiatrie 50: 1–29.

46.

Schmidt-Degenhard

(1988) Disposition und Vulnerabilität in der Problemgeschichte von Persönlichkeit und Psychose. In: Janzarik

(ed.) Persönlichkeit und Psychose. Stuttgart: Enke, 47–56.

47.

Schneider

(1942) Die schizophrenen Symptomverbände. Berlin: Springer.

48.

Tamminga

Reininghaus

Ivleva

(2021) Psychotic Disorders. Comprehensive Conceptualization and Treatment. New York: Oxford University Press.

49.

Tellenbach

(1961) Melancholie: zum Problemgeschichte, Typologie, Pathogenese und Klinik. Berlin, Göttingen, Heidelberg: Springer Verlag.

50.

Tellenbach

(1967) Endogenität als Ursprung der Melancholie und als Ursprung des Typus melancholicus. Psychiatry and Clinical Neurosciences 21(4): 241–249.

51.

Tellenbach

(1983) Melancholie: Problemgeschichte, Endogenität, Typologie, Pathogenese, Klinik, 4th edn. Berlin, Heidelberg, New York, Tokyo: Springer-Verlag.

52.

Tyrer

Mulder

Newton-Howes

Duggan

(2022) Editorial. Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated. British Journal of Psychiatry 220: 309–310.