Klaus Conrad - History of Psychiatry

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Klaus Conrad (1905-1961) Detlev W. Ploog History of Psychiatry 2002 13: 339 DOI: 10.1177/0957154X0201305107 The online version of this article can be found at: http://hpy.sagepub.com/content/13/51/339

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Personalia

Klaus Conrad DETLEV W.

(1905-1961) PLOOG*

Klaus Conrad (1905-1961) was an internationally known figure in the field of Gestalt psychology to give a neuropsychology and psychopathology. He better understanding of the aphasias, the symptomatic psychoses and incipient

applied

schizophrenia. Klaus Conrad was born in Reichenberg in Sudetenland’ on 19 June 1905. His father, Otto, secretary of the Chamber of Commerce in Vienna, was a Dozent (lecturer) in economics at the Technical University in Vienna and became an internationally known scholar through his published books. His mother, Wilhelmine, nee Zwiauer, came from a Viennese family which was related by marriage to the family of the physiologist Thomas von Brucke. Conrad’s father’s family, originally from Siebenbtirgen but now living in Vienna, was related by marriage to the family of the surgeon Thomas Billroth. The family’s friendship over several generations with the Exners, a number of whom became well-known scientists, was also an important element in the environment in which Klaus Conrad grew up. Conrad was particularly impressed by the research on bees conducted by Karl von Frisch, whom he called Uncle Karl and whom he saw during his summer vacations in the now famous Brunnwinkel on Wolfgangsee.3 Influenced by this eminent scientist, at first Conrad wanted to become a zoologist; the subject of a long

* Originally published as: D. Ploog (1998). ’Klaus Conrad (1905-1961)’. In Hans Schliack and Hanns Hippius (eds), Nervenärzte. Biographien (Stuttgart: Georg Thieme Verlag), 75-85. Translated from the German by permission of the publisher. This paper is published in History of Psychiatry thanks to the great generosity of Mrs Martel Conrad and of Professor emeritus Ploog himself. The editor is very grateful to both. Address for correspondence: Prof. Dr. med. Dr. phil.h.c. Detlev Ploog, Max Planck Institute for Psychiatry, Kraepelinstrasse 2, D-80804 Munich, Germany. E-mail: [email protected]

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during his last year of I school was ’Die Sorgen den secondary Insekten fur ihre Nachkommenschaft’ (How insects take care of their offspring). But equally fascinating to him, if not more so, were butterflies and the markings on their wings. Because there was ’no money’ in zoology (eine ’brotlose Kunst’), his avuncular friend advised him to start off by studying medicine. In the summer the families from Vienna spent time together in Litzlberg on Attersee.’ Conrad often played music with them, as he did with others throughout his life. In secondary school and then as a young university student he was a sought-after clarinet paper he

wrote

player. Later, him for the

rest

the cello of his life.

captivated

The formal course of Conrad’s life be outlined briefly. After gaining KLAUS CONRAD his Abitur for classics at high school, he began to study medicine in Vienna in 1923 and completed his training there in 1929.’ It had already become clear to him after the first few semesters that he wanted to devote himself to neurology and psychiatry. Wagner von Jauregg, Pbtzl and Gerstmann were then teaching in Vienna, and Conrad worked with them as a volunteer, both as a student and then, after he had completed the state medical examination, from 1929 to 1931. He does not appear to have had personal contact with Sigmund Freud, although he later read Freud’s major works intensively and, for example, held an inspiring lecture series on the psychopathology of everyday life (Psychopathologie des Alltagslebens) . In 1924 Conrad spent a semester in Leipzig. At that time he may already have had his first experience of the holistic approach being promulgated there (Ganzheitspsychologie) . Excellent caricatures of his university instructors show his talent for capturing the essence of his subject. A clinical semester in London as a volunteer in a neurosurgical department established the foundation for his ongoing connection with the Anglo-Saxon world; later on, for example, the teachings of Henry Head and Hughlings Jackson had a strong influence on his scientific thinking. At that time the economic situation in Austria was desolate. As the result of an advertisement about a medical position, he went to the city neuropsychiatric hospital in Magdeburg, which was headed by Jacobi. Two papers can

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written by Conrad during this period already addressed what was to become the main topic of his scientific work, namely, analysis of neuropsychiatric syndromes using principles of Gestalt psychology. Starting with the idea that all psychic activity is based on Gestalt processes, he first formulated some of the laws governing the ’de differentiation of the Gestalt function’ (Entdi,fferen.zierung der Gestaltfwzktion) in a parietal syndrome. His love of neuropsychology - in those days called brain pathology (Gehirnpathologie) - probably developed while he was working with Otto Pbtzl. And his critical paper on Paul Schilder’s concept of the body image shows the Gestalt approach and Conrad’s pleasure in questioning existing views and looking for new

approaches. In February 1933,

at very short notice, Conrad decided to go to Paris to work with Guillain at the Salpetriere and to gain a deeper understanding of French neurology. Here again, as earlier in London, he had access to another culture, resulting later in the development of close contacts, especially through his friendship with Henry Ey. A stipend from the Rockefeller Foundation, followed by one from the Notgemeinschaft der Deutschen Wissenschaft (Emergency Fund for German Science6), enabled the young scientist - who now had a broad training - to work in Munich from 1934 to 1938 under the direction of Ernst Rudin in the genealogy department of the Deutsche Forschungsanstalt fur Psychiatrie (German Institute for Psychiatric Research’), founded by Kraepelin. Here he almost literally threw himself into his new field of research.

The

genetics of mental disorders After only a year, the first in a series of related papers on heredity and epilepsy appeared, based on studies of 253 sets of twins. Papers then followed on the progeny of individuals with epilepsy, on the question of epileptoid psychopathy and on the genetic environment of individuals with epilepsy and their social class. Conrad quickly became well known. At the third annual conference of the Gesellschaft deutscher Neurologen und Psychiater in Munich in September 1937, he was the principal speaker; at the end of his address on heredity and constitution in epileptics he made a statement about legislation on eugenics, which for listeners at that time was very clear and unambiguous, namely, that it must be based solely on scientific knowledge: ’But knowledge must never be guided by legislation, otherwise progress would be impossible’ (Die Erkenntnisse aber dürfen sich niemals nach der Gesetzgebung richten) sonst wäre ein Fortschritt unmöglich). Conrad’s key research findings - a high concordance rate (86%) in identical twins with idiopathic epilepsy and a low percentage of affected individuals with children (only 6-8%) - are, as far as I know, still uncontested. Meanwhile, under the influence of young National Socialists, the Munich research institute became increasingly politicized. Jewish researchers had to

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leave the institute. Conrad, who had just completed his postdoctoral dissertation in Munich and was now eligible for a university teaching position, applied for a post as senior physician at the university hospital for neuropsychiatry in Marburg on the river Lahn. In May 1938 Ernst Kretschmer asked the young Reader to join him as senior physician at his hospital in Marburg. Two years later and shortly before being called up to serve as a military physician in Russia, Conrad quietly completed a comprehensive monograph addressing the problem of constitution and character from a new angle. Kretschmer’s masterful description of this subject had fascinated Conrad and stimulated him to consider the constitutional types as genetically determined products of diametrically opposed growth tendencies. The book, which was published by Springer in 1941, was entitled Der Konstitutionstypus als genetisches Problem. The Constitutional

Type

as a

Genetic Problem

In Conrad’s constitutional theory, the inherent relationship of certain body types with certain basic personality structures is based on the principle of the quantitative gradation of hereditary factors and the hierarchical structure of genetic effects. Diametrically opposed conservative and propulsive types of growth, with their associated basic psychic structures, are the result of different determining steps in the ontogenetic process of progressive individuation. In Conrad’s theory the growth tendencies are entered into a system of coordinates, with a leptomorphic-pyknomorphic range of variation and a hyperplastic-hypoplastic range of variation. In the leptomorphicpyknomorphic range of variation, growth tends towards length at the expense of breadth, and breadth at the expense of length. In metromorphic types there is balance in growth between length and breadth - these are the classic body proportions. The hyperplastic-hypoplastic growth tendencies are based on too much or too little development of tissue; the more extreme types correspond to Kretschmer’s athletic and asthenic types. In the middle of this polarity is the metroplastic type. In addition, there are dysplastic types of growth of endocrine origin (e.g., eunuchoid gigantism and certain types of obesity). Conrad calls the leptomorphic-pyknomorphic polarity primary variations of humans and the hyperplastic-hypoplastic polarity secondary variations. In this way he refers to embryonal development, in which the primary type begins earlier and therefore has more marked effects, with the secondary type beginning later ontogenetically and therefore having less marked effects. The primary and secondary variations refer not only to somatic processes, however, but also to the associated psychic differentiation. The pyknomorphic type, with its slower shifts in proportions, is closer to children (and the feminine body type), whereas the leptomorphic type - with its greater ’developmental force’ (Entfaltungstemperament) and more rapid

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shifts in proportions through the body shape - changes in the sense of Zeller and is closer to a pubescent individual than to a child. The reception of Conrad’s theory of constitutional types was varied. After its initial publication in 1941 the theory attracted a great deal of attention. Jaspers discussed the ’excellent work’ (das ausgezeichnete Werk) for ten pages in the fourth edition of his Allgemeine Psychopathologie (1946)8 and conferred upon it the status of a ’radical reformation’ (radikale Neugestaltung) of constitutional theory, but in the end concluded that ’in spite of its brilliant nature the whole theory will sink into oblivion without any consequences’ (das Ganze trotz seines geistreichell Zuges folgenlos versinken wird). Three decades later a leading researcher on constitution, Rainer Knuf3mann,9 recognized that the leptomorphic-pyknomorphic range of variation and the growth phases as bodily variations during ontogenesis were confirmed by empirical data. (For me personally, the book was a milestone on the road to a biologically-oriented psychopathology in which the ’causal connections’ play a stronger role than the ’meaningful psychic connections’.’° My reading of the book resulted in a request for a topic for a doctoral dissertation.) Two decades later Conrad, at the request of Springer-Verlag - and related to his comprehensive contribution to Psychiatrie der Gegenwart (Current Psychiatry)&dquo; on the different constitutional theories - wrote a slim second edition of his 1941 book. In it he evaluated his early work in his own impartial, unassuming way: ’For much of what the author considered irrefutable twenty years ago,’ he wrote in the Preface, ’doubts are now noted; the apodictic certainty no longer exists.’ (Zu vielem, ’Was dem Autor vor 20 3‘ahren unbezweifelbar erschien, werden jetzt Zweifel angemerkt, die apodiktische Sicherheit besteht nicht mehr. ) But the basic ideas, the genetic-dynamic approach to the problem of constitution, he still considered fruitful. The second edition is entitled Der Konstitutionstypus. Theoretische Grundlegung und praktische Bestimnaung (The Constitutional Type. Theoretical Foundations and Practical Determination). It was completed in 1961 shortly before his death. At the start of the war against the Soviet Union, Conrad was drafted to serve at the reserve military hospital in Marburg and soon afterwards marched with his unit from Ukraine into the Caucasus. While there, in December 1942, he received orders to set up a special hospital for brain injuries in Marburg. Between 1943 and the end of the war in 1945, 808 soldiers with brain injuries passed through his department, 216 of them with aphasia. Conrad examined every single patient himself. His careful documentation in the medical records and with ’diagnostic cards’ (Zdhlkarten, literally ’counting cards’) enabled a scientific evaluation of these valuable findings, which was begun even before the war was over. When Marburg was occupied by the American front-line troops, the whole hospital was taken over and everyone in it became a prisoner of war, but without any changes being made in the internal structure of the hospital. By then I had completed

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doctorate, and I had the good fortune to work there under Conrad during this time. It was most impressive how patiently, systematically and at the same time imaginatively he worked with the patients. Time after time he found new methodological approaches to understanding the laws governing the different aphasic disorders, the word-finding disturbances and alexia. Through his professional but very personal approach, he kept the patients’ attention so well that they never tired of co-operating with him, often for periods of many months. In other areas of his field, too, especially psychiatry-psychotherapy, my

in the examination process, he was able to win over the him and to share the responsibility. This was the basis of his patients help success as a clinician. In the treatment of neuroses his efforts were centred on the reduction of ’egocentricity’ (Ichhaftigkeit), a key concept of Fritz Künkel, whom he greatly admired. This therapy, based on a partnership, would today be considered a form of client-centred therapy. In early 1946, after the oppressive final months of the war and the sad spring and summer in captivity as a PO«1, his wife and four children were with him again after a long separation following their evacuation. But, while playing music with friends, Conrad was suddenly taken away by American officers and put in the Zuffenhausen camp for war criminals. 12 In September, after months of unsuccessful attempts, his bright and courageous wife managed to get him released. The reason for his arrest and internment never came to light. From this period of many months without any charges or interrogations, in a state of total uncertainty and despair, there are letters and poems that bear witness to Conrad’s inner strength and human greatness.

masterful

as

he

was

to

Sonett

Von meinem Fenster seh ich ein Stiick Straj3e Ein kurzes Stiick, das sich zum Dory verliert. Auf diesem Wege Groj3 und Klein spaziert. Lustwandelnd abends zwischen Busch wzd Grase. .

’

Sie fiihlen nichts von jenem Ubermaj3e Der Freiheit, die sie haben, höchster Lust Und keiner ist sich wohl des Glücks bewuJ3t So hinzugehn - iiber eine StraJ3e. O daj3 wir niemals es vergessen mögen) Wenn alles, was ein jeder hier ertrug, Ihm wieder ferne und verblasst genug.

DaJ3 jedes freie Gehn auf freien Wegen, Ach, daj3 in Freiheit jeder Atemzug Ist Gottes immer wieder

neuer

Segen.

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Sonnet 13 From my window I see a bit of the street A short stretch that vanishes towards the village. On this path people large and small are walking. Promenading in the evening between bushes and grass. .

They feel nothing of the plenitude of Freedom which they have, the greatest joy And no one seems aware of his So to stroll - along a street.

good fortune

Oh that we may never forget it, When everything that each of us endured here Is again distant and dim enough. That every unhampered walk on paths of choice, Oh, that in freedom every breath Is God’s blessing, new each time.

The tyranny of fate that he experienced in prison left its mark on this reflective and sensitive man. Nevertheless, as if he had gone away only the day before, he took up his work again as head of the military hospital and as a senior physician at the university hospital. In the meantime, Ernst Kretschmer had gone to Tubingen in 1946, and Werner Villinger was now head of the university department and the hospital. For Conrad another fruitful period of scientific work began, and this was to be a central element for everything that came later.

Structural analyses of cases

involving brain pathology In 1947/48, Conrad published a total of 300 pages on these cases, in six articles: four in Deutsche Zeitschnft fiir Nervenheilkunde and two in Archiv fiir Psychiatrie, followed later by four additional contributions. Based on subtle case studies of different forms of aphasia and diagrams with statistics on the localization of the brain damage, Conrad showed that the classical system of brain pathology, with its highly concentrated expression found in Lichtheim’s scheme, no longer did full justice to the large amount of newly observed data available. ’The foundation, the notion of a reflex arc that underlies the classical concept, has become shaky and is in need of revision’, he wrote (Das Fu71dament, die Vorstellung vom Reflexbogen, das der klassischen Lehre zugrunde liegt, schwankt und ist revisionsbedürftig). This had been acknowledged in many valuable papers, but an urgently-needed new model, which would explain the phenomena better, was lacking. Conrad presented such a model and referred to the great founder of the classical concept, Carl Wernicke,

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who arrived at his theory of mental illness on the basis of observations of people with aphasia. In this way, as we shall see, Conrad indicated the path he himself would take in the future. It is clearly difficult to describe, in the space available, the new, much more complex fundamental concept which was capable of supporting brain pathology and, in fact, psychopathology as a whole. But without such an attempt, which should at the very least stimulate the reader to mine the veins of gold in the original papers, the essence of Conrad’s way of thinking and conducting research would be lost. Two principles are the structural pillars. The first is the principle that psychic phenomena, which appear to us as wholes or Gestalten, have a developmental aspect. This means that, underlying every psychic phenomenon, for example, a perception, a thought, a word, a word-finding disturbance, is a developmental process. Everything that is present has become. As a model for this process Conrad chose the then familiar tachistoscopic experiments of Sander on the microgenesis (Aktualgenese) of Gestalten, whereby the development of perception goes from the stages of pre-Gestalt ( horgestalt) to those of the final Gestalt (Endgestalt), a process which usually takes place in a split second and is not conscious, but which, if it is disturbed, is suitable for shedding light on psychopathological ways of experiencing. Today, through recording of event-related potentials in the range 30-500 ms, evidence in support of this theory is available. The term pre-Gestalt is used for those forms of perception that lie between the first appearance, the nucleus of an experience, and its full formation in the final Gestalt. They are in no way limited to visual or acoustic perceptual Gestalten, but also include movement Gestalten and processes of speech production, of understanding speech, of memory and of thought. The question arises: is what we describe as a given pathological phenomenon merely a consequence of a protracted microgenetic process at different stages of the Gestalt formation? With the introduction of principles of Gestalt theory into psychopathology, Conrad departed from the then (and to some extent probably still) prevailing psychology of association, according to which everything psychic results from complicated mechanisms of association of individual impressions or from stimulus traces, which the cerebrum, as a mnemonic-associative apparatus, combines. Any damage in this apparatus must sever numerous connections and bring certain functions to a standstill, especially if the nodes of connection (centres) are affected. Conrad countered that it was not the loss of a function localized at a particular place but rather a change in the process of mental performance that could be disturbed from a certain location. These changes in performance had characteristic features that were subject to laws of Gestalt theory. To discover and describe in detail these laws by studying different syndromes associated with brain pathology was the goal of the structural analyses. The second principle on which Conrad’s psychopathology is based is the

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relationship between object and subject. The commonly held view of the time, based on the stimulus-response model, that a subject, with the aid of his or her basic functions of perception, thinking, feeling and will; can understand the objective world as a primarily independent state or - in the case of pathology, because of an interruption of this subject-object relationship can no longer understand - was in his eyes obsolete. Instead of this model, the idea of a Gestalt-circle-like connection (gestaltkreisartige Verbundenheit) of the subject with his or her world was introduced. The subject changes with the objects, and the objects change with the subject; subject and object can be understood only in their interactive relationship. The achievements of the organism cannot be understood without the introduction of the subject. Here Conrad refers to Viktor von Weizsdcker’s theory of the Gestaltkreis.14 He also takes from it the neurophysiologically-grounded concept of change in function, which underlies change in performance. Originally Weizsacker was concerned with the hand that must feel in order to recognize objects and with the disturbances of stereognosis the subject experiences in disorders of the posterior funiculus of the spinal cord, which lead to a (neurophysiologically definable) change in function - which in turn underlies the change in performance (inability to recognize objects). Related concepts that have gained better acceptance in modern sensory physiology are expressed in the reafference principle (von Holst and Mittelstaedt), in corollary discharge (Teuber) and most recently in the complex re-entry concept of Edelman. In the end the modern biologically-oriented schools of the philosophy of consciousness are united in the new understanding of the subject-object relationship that Conrad developed in his case analyses of brain pathology and later used in his research on psychoses. To understand the change in function that underlies the change in performance, two additional concepts were necessary, which were taken from Henry Head’s studies on sensitivity and then applied to psychic processes in general. These are the epicritic forms of experience, in which the given field of experience is completely formed, and the protopathic forms of experience, in which the experiences are of the pre-Gestalt type. Their most important feature is the blurring of the ’internal structure’ (Binnengliederung) of what is experienced and the emergence and dominance of the physiognomic qualities of expression (e.g., grotesque faces in wallpaper). One has to look carefully at the individual protocols and the long series of experiments for the different types of aphasia to grasp the force of the argumentation and to understand that the speech problems in each type of aphasia are, on the one hand, characteristic for that type of aphasia, but that underlying these problems are common rules of incorrect formation processes or, in other words, that the mistakes of people with aphasia are strongly predetermined. The disturbance is to be sought in the developmental process that leads from the preverbal existence of the thought content to the verbal form. This developmental process has a temporal course that is

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slowed down by the change in the function of the damaged brain tissue, as Conrad showed in studies of the duration of excitation and of the refraction time in the Gestalt change. The example of a conduction aphasia will be used to illustrate this disturbed developmental process. This is a typical syndrome of difficulty in finding words, with literal and verbal paraphasias and a disturbance of the

grammatical structure including expressive and impressive paragrammatisms, and finally also an impaired ability to repeat words despite retained comprehension and a relatively good ability to read. The syndrome is discussed in its component parts. The paragrammatic disorder develops because, although the motor structures for speech are completely intact, the microgenesis of developing speech from the preverbal stage is not fully completed but gets stuck halfway through, and thus the result shows all the characteristics of the pre-Gestalt. The epicritic, that is, clear grammatical structuredness of the sentence is lost. Word finding shows the same type of disturbance; the paraphasic errors show all the characteristics of the absence of epicritic detail. Because the process is slowed down, the search for a word can be followed through the individual developmental phases, which are quite similar to the individual phases of a microgenetic developmental process. The disturbance of impressive performance corresponds to that of the expressive performance. The intact grasp of meaning paired with a disturbed grasp of speech sounds is a typical feature of the protopathic change in Gestalt in the sense of physiognomization of perception. The underlying change in function leads to a change in the temporal processes, with the result that the time from reception of a stimulus until the meaning is grasped is lengthened. The manifestation is more pronounced with acoustic performance (which is normally tachistoscopic performance) than with visual performance. The conduction aphasia (which, according to Goldstein, would be better termed ’central’ aphasia) is thus the form of aphasia in which the protopathic change in the Gestalt of speech performance affects both expressive and impressive performance components; it attacks at a place in the pre-verbal stage which is before the separation into expressive and impressive components. If one studies modern psycholinguistic models of the flow of activation in speech production, which are based on experiments with event-related potentials and other registration techniques, one is surprised by the similarity of the concepts.&dquo; There no longer appears to be any doubt that the ’final Gestalt’, the articulated word, stands at the end of a process, the duration of which can be measured. With this approach grammatical processes, too, can be demonstrated that are not already available in the language apparatus, but must be generated anew each time, i.e., that must go through a Gestalt process.

Conrad With one

decades ahead of his time with his developmental model. exception, all his papers on brain pathology (neuropsychology) was

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published in German shortly after the war and were therefore hardly noticed internationally. The one exception of which I am aware and which is cited occasionally, is a paper published in Brain (1954); in it, the main questions addressed are those of localization. The analysis of 51 cases of motor aphasia, 48 of which involved right-handed individuals, showed that the closer the injury was to the sylvian fissure the more devastating the effect on speech performance. Neither small injuries localized in Broca’s area proper nor large areas of destruction at a greater distance led to permanent speech impairment. Once again, with this finding and the localization of other types of aphasia, for example, the word-finding disturbance and amnestic and sensory aphasia, Conrad was ahead of his time. For Conrad, the immense project on the structural analysis of cases of brain pathology, completed in barely two years, was a preliminary study for projects he planned to do later, among them the analysis of dreams based on Gestalt theory (in which he discussed Freud’s theories extensively), studies on the symptomatic psychoses, including Korsakoff’s psychosis and, were

especially, incipient schizophrenia. In 1948 a new period began in the life of the Conrad family of six. Conrad was offered the newly established professorship for psychiatry and neurology at the International University of Saarland, with a medical school located in Homburg. In those days this meant that a window to the world opened for them. The Federal Republic of Germany had not yet been founded. Even after the currency reform in June 1948 the economic situation was still di~cult. With very few exceptions, contacts with scientists abroad did not yet exist. But Saarland, under French administration, was completely integrated into the West. Because of his prewar acquaintance with French neurology and psychiatry and thanks to his language skills, Conrad could quickly reestablish the long-prohibited connection and begin a fruitful exchange of ideas with clinicians working in neuropsychology, for example Henri H6caen (Paris) and Oliver Zangwill (Oxford). And this in turn led to publications because of the symposia of the aphasia researchers, which he helped establish. Conrad was brilliant in discussion, always amiable and courteous, but very rigorous in his argumentation. I remember one of the symposia, held in an old abbey near Oxford with MacDonald Critchley as moderator, at which the official topic was the function of the parietal lobe but where there was also a heated discussion about visual agnosia and thus, in fact, about perceptual disorders. Such debates, some of which were continued in journals, were also extremely instructive and enlightening for young researchers. Today, in both spirit and style they seem to have died out. Through trips within Europe Conrad established new relationships, built bridges between neurology and psychiatry, gave talks in 1949 at the First International Congress of Neurology and in 1950 at the First International Congress of Psychiatry, both in Paris, at a time when the official languages at congresses were those of the ’Big Four’ Allied Powers only, and long before

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.

English had become the lingua franca of science. Conrad became an honorary member of the Paris Neurological Society. In Henry Ey, whose work first became known to a wide audience in Germany through Fortschritte der Neurologie und Psychiatrie (then edited by Conrad, Scheid and Weitbrecht), Conrad found a friend and colleague with the same desire to trace psychiatric disorders back to an organodynamic foundation that treats the psychopathological not as an epiphenomenon of organic processes but as psychic structures that change according to a particular pattern. Current psychopathology, dominated today by surveyors who keep surveying the land but never dig in it, would probably have been a horror for him. Conrad’s universal spirit did not allow him to restrict himself to his specialty. His ongoing concern for his time is shown by his articles and talks, for example, on the psychopathology of international tensions, on developmental stages of mankind, on modern art, on Jugend und Alter als überindividuelles Problem (Youth and old age as a problem beyond the individual), and on Das Geistige und das Gehirrz (The mind and the brain). His article Der zweite Siindetifall - psychiatrische Betrachtungen zur modernen Kunst (The second fall of man - psychiatric observations on modern art), which appeared in 1953 in Annales Universitatis Saraviensis, contains a penetrating analysis of abstract and surrealist painting. The pointed critique of our culture that appeared in 1961 in the Göttinger Universztdtsreden entitled Die neurotischen Züge unserer Zeit (The neurotic aspects of our times) was a talk he was not able to deliver because of his sudden illness. Challenging, original, sometimes polemical and critical of fashionable views, Conrad expressed his thoughts in polished language. He even avoided well-worn paths in his lectures for students, revising them regularly. In the spring of 1958 Conrad had accepted the position he was offered in G6ttingen, succeeding Ewald as head of what was then the most modern Nervenklinik, opened in 1955. As in Homburg, he covered the specialties of neurology and psychiatry (which would later be separated). He built his first house; chamber music at home flourished, with all four of his children participating; hospitality was written large, and his wife was an unparalleled hostess. In the autumn of the same year Conrad was offered the position of head of the psychiatric department at his old hunting ground, the Deutsche Forschungsanstalt fur Psychiatrie in Munich (now the Max-Planck-Institut fur Psychiatrie), and was asked to be a consultant on rebuilding the Institute. Along with him, Richard Jung was to be appointed head of the neurophysiology department. ’Herr Conrad’, it is reported, ’considers a future biochemistry department to be the most important one; in his view the problem of the major psychoses is a biochemical problem.’ (Herr Conrad hiilt eine zukiinftige biochemische Abteilung fiir die wichtigste; das Problem der groj3en Psychosen sei ein biochemisches.) In December 1960 the president of the MaxPlanck-Gesellschaft (Max Planck Society), Adolf Butenandt, asked Conrad

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whether he would accept the position as head of the Institute when the hospital building had been completed, at the latest. Conrad assured him that ’of course’ he would accept the position at that time; he had already been much involved in the Munich project. But he did ask Butenandt to bear in mind that it would still be several years before the hospital building was completed. (And in fact it was more than five years.) ’None of us know’, he wrote, ’how long we will be able to work, but we certainly know that it will not be forever.’ Conrad was 55 years old at the time. A few months later he was dead. While he was still in Homburg, Conrad had completed what was probably his most influential work, Die beginnende Schizophrenie (Incipient Schizophrenia). In G6ttingen he began tackling the whole field of the symptomatic psychoses. He had already done a great deal of work on describing individual disorders, e.g. chronic tactile hallucinosis, subacute panencephalitis and the diabetic psychoses; Gestalt analysis of Korsako~’s psychosis has already been mentioned. But now he tried to present a comprehensive description and restructuring of this central group of psychopathological disorders. The

symptomatic psychoses Conrad took advantage of the invitation to prepare the chapter ’Die symptomatischen Psychosen’ (The symptomatic psychoses) for the handbook Psychiatrie der Gegenwart (Current Psychiatry), which was published in 1960 (the second edition, 1972, also included his chapter). In it Conrad rued the fact that, in spite of important advances in the understanding of the mind, little had been added to Bonhoeffer’s concept of ’exogenous reaction types’. Conrad proposed that the view of the mind as an association of memory links be replaced by a model that conceived of it as a whole (Ganzheit), as an integrated totality which from the start appeared as a ’given’ to subjective experience (Erlebera) . The method for gaining a better understanding of the problem of the symptomatic psychoses was to study various aspects of experiencing: content and components, field structure and dynamics. Conrad’s method was again Gestalt analysis. In such a phenomenological perspective we do not find a perceptual function, but only the perceived, and here the goal is to study the laws governing the perceived, which constitute the perceptual field. Thus, Conrad describes the change in the Gestalt of the experiential field as a process that, from the prodromal manifestations of the psychosis to clouding of consciousness and the delusional phenomena, passes through characteristic states that can be described in terms of Gestalt psychology. To this end he uses the model of the control of sleep and wakefulness (Table 1). From being wide awake to being in deep, dreamless sleep, there is a broad physiological transition zone, the area with which we are concerned in some of the psychoses with a physical basis. The only difference is that instead of the physiological change in the function of sleep

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352 TABLE 1.

From Psychiatrie der Gegenwart, Vol. permission of the publisher.

2

The

symptomatic psychoses

(Berlin: Springer, 1960), 379; translated from the German by

pathological change in function resulting from a noxa. But there are specific noxious substances that produce specific symptoms. Accordingly, Conrad describes the obligatory characteristics of the organic psychoses and the different clinical syndromes in terms of Gestalt theory. He concludes that there is no psychotic state that cannot also be found in psychoses with a physical basis. In fact, the current nosology of psychiatry became a problem for him; and from the perspective of human genetics, too, he found the sharp differentiation between schizophrenia and cyclothymia, as if they were completely different types of illness, to be highly questionable. Finally, let us turn to the publication, also translated into Spanish and Japanese, which is of most interest to psychiatrists today. we

have

a

no

Die

beginnende Schizophrenie (Incipient Schizophrenia) The subtitle of the book is Versuch einer Gestaltanalyse des Wahns (Attempt at a Gestalt Analysis of Delusion). Conrad saw that psychopathology after

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353

Jaspers was in a dilemma. Either one tried to ’explain’ psychopathological phenomena causally by tracing them back to an organic substrate and thus transforming a psychopathological problem into a physiopathological problem that was susceptible to medical treatment (’The causal connections of psychic life’’6), or one attempted to ’understand’ the phenomenon by tracing it back to some other aspect of the psyche (’Meaningful psychic connections&dquo;’) and looking for relationships to other aspects of the individual’s life history, thus transforming the psychopathological problem into a hermeneutic problem. Conrad proposed a third approach, the subtle description and analysis of the psychopathological phenomenon experienced. Here again, the method is Gestalt analysis. For everything that is experienced has a Gestalt, and the analysis of given phenomena is always the analysis of forms and configurations. With this in mind, Conrad studied 107 soldiers who during the war, in 1941/42, had suffered a ’fresh episode of schizophrenia’, two-thirds of whom were between 20 and 31 years old. The fact that all those affected were soldiers in uniform when the psychosis broke out turned out to be an advantage, because the effect of being uniformed was that what was experienced was also ’uniformed’ and this reinforced what was typical of the illness, and what was typical for the individual became less important. The aim of the study was to identify the laws governing the phases within an individual episode of schizophrenia and to replace the past unrelatedness of schizophrenic symptoms and courses with a structural relationship in which everything that was happening can be seen in terms of uniform laws compatible with Gestalt theory. Conrad called the first phase Trema. It is a strange state that precedes the delusions. With increasing affective tension (Bodenaffektivität, to use Kurt Lewin’s term), the individual’s environment gains a strange, never-beforeexperienced physiognomic trait. ’It looks coldly and hostilely at the person experiencing it, as if at someone who has been condemned.’ (Es sieht kalt und feindselig auf den Erlebenden wie auf einen, fiber den man den Stab gebrochen hat.) This trema phase can go on for a long time. It is followed by the apophany phase, the experience of abnormal awareness of meaning and the sense of being at the centre of what is happening in the world. These types of experience, which always occur together, form the central feature of schizophrenic experience. The cause is a severe disturbance of the ability to change systems of reference. Although all healthy individuals are the centre of their ’world’, they are still able to see themselves as one among others, stand next to others or put themselves in someone else’s shoes. In contrast, people with schizophrenia have in their psychosis lost the possibility of ’changing perspectives’ ( Uberstieg) . They are no longer able to change the system of reference. Therefore everything is related to them no matter where they direct their attention.

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354

Using an example of Gestalt perception, Conrad demonstrates the ability of healthy individuals to change their system of reference constantly. The diagram in Fig. 1 can be seen in two ways: if we interpret it as two squares that intersect each other, then the small rhombus in the middle ’means’ the area common to both of the large squares; but if we see two angular figures that touch each other at their corners, Fig. 1. Diagram from Die then the rhombus in the middle ’means’ simply beginnende Schizophrenie, p. 48 part of the background. Analogously, the delusional individual is unable to achieve the shift from one system of reference to another. The first manifestation of schizophrenic delusion occurs at the instant when changing perspectives has become impossible. But it is not just the environment, the exterior space, that is affected by the apophany; the internal space is also changed by it. Each ’idea’ (Einfalv becomes ’inspiration’ (Eingebung), one’s own thoughts can be read by anyone, and so forth. The wall separating the world and me becomes porous. The more advanced the destruction process, the more the general properties (Wesenseigenschaften) prevail in the perceptual field, with the result that the perceptual connection begins to weaken. With the severing of the situational connection, the contact to the affected individual also ceases. The apocalyptic phase begins. The field of experience is flooded with pictures, the order in thinking is lost, ’voices’ dominate the internal field. The point of culmination is catatonia. In the slow consolidation process the individual goes through the phase of apophany in reverse. As on the way to catatonia, a brief paranoid phase reappears until the delusions begin to disappear. Consolidation can go as far as to a ’Copernican change’: the affected individuals are again able to achieve the ’crossing-over’ process and can recognize that the change was not in the outside world but rather in themselves. This would mean that the psychosis was healed. If residual symptoms remain, Conrad attributes them to the reduction in the energy potential. In this loss of potential - with different degrees of severity - he sees the specific (organic) schizophrenic change, the pathological change in function due to a problem in the brain that underlies schizophrenia in the different phases described. ’It must be a change in function in those parts of the cerebral organization through which the human brain is distinguished from the brains of the highest primates, that is, those parts that are peculiar to humans.’ (Es muss sich um einen Funktionswandel jener Anteile der cerebralen Organisation handeln, durch die sich das menschliche von den höchsten Primatengehimen unterscheidet, die also speziell dem Menschen eigentiitnlich sind.) It is worth ’continuing the search for the pathological substrate of this process’. Conrad’s phase model, whose far-reaching consequences for psychiatric nosology cannot be discussed here, was tested by Hambrecht and Hafner’8

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355

representative sample. Their results supported Conrad’s assumption of prepsychotic phase (trema) followed regularly by a psychotic-productive phase (apophany), and they also showed that Conrad’s findings could be on a a

extended to include both sexes and an age range of 12-59 years. But the strict succession of apophany and apocalypse could not be demonstrated. For methodological reasons, however, a conclusive statement on this issue could not yet be made. One must appreciate the very close relationship between the publications Strukturanalysen hirnpathologischer Fdlle, Die symptomatischen Psychosen and Die beginnende Schizophrenie in order to understand that they represent the development of a reformatory psychopathology that was closely related to the classical-empirical foundations of our field, but also marked a radical break with their theoretical prerequisites, namely, with the psychology of the nineteenth century. Central concepts, such as consciousness, the unconscious, recent memory and attention take on a new meaning through Gestalt analysis. Conrad was convinced that the only way to an understanding of the psychosis problem was that of brain pathology (neuropsychology). With this view, he led phenomenological psychopathology back to a basis in science and medicine. Unceasingly active, but at peace with himself and without haste, Conrad fashioned his life and his work, both in rare accord with each other. His path in life seemed straight and always headed for the peak. But in early 1961 a myeloma was discovered, and six weeks before his fifty-sixth birthday he died, on 5 May 1961. Klaus Conrad was a remarkable individual both intellectually and as a person. For those who knew him personally, he was a shining example - as a clinician, as a researcher and as a human being. The originality of his thinking, his passion and his wide-ranging thoughts were fascinating, and they stimulated not only his field of specialization but also related disciplines in science and the humanities. His courageous analyses of apparently unshakeable teachings in psychiatry brought changes in the phenomenological psychopathology of his time. The question of what influences he would have had on psychiatry if he had lived longer is unanswerable. The only thing that is certain is that he would have been very actively involved in its further development. For those looking for a model of how clinical work with patients can be conducted as basic science, an in-depth study of Klaus Conrad’s work would be rewarding.

Selection of Conrad’s The

following are

publications

selected from

more

than

one

hundred.

Monographs and contributions to handbooks 1939. Erbkreis der Epilepsie. In G. Just (ed.), Handbuch Menschen, Vol. 5 (Berlin: Springer), 932-1020.

der

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Erbbiologie des

356 1941. Der Konstitutionstypus als genetisches Problem (Berlin: Springer). 1951. Contribution for Germany. In G. W. Kisler (ed.), World-tension: The Psychopathology of International Relations (New York), 87-105. 1958. Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns

(Stuttgart: Thieme). 1958. Das vierte Zeitalter und die moderne Kunst. In H. Ehrhardt et al. (eds), Psychiatrie und Gesellschaft (Bern/Stuttgart: Huber), 102-13. 1960. Die symptomatischen Psychosen. In H. W. Gruhle, R. Jung, W. Mayer-Gross and W. Mfller (eds), Psychiatrie der Gegenwart, Vol. II (Berlin/Gottingen/Heidelberg: Springer), 369-436; 2nd edn 1972. Theoretische Grwzdlegung und praktische 1963. Der Konstitutionstypus. 2nd rev. edn (Berlin: Springer). Bestimmung, 1967. Konstitution. In H. W. Gruhle, R. Jung, W. Mayer-Gross and W. Muller (eds), Psychiatrie der Gegenwart, Vol. I/1 (Berlin/G6ttingen/ Heidelberg: Springer), 70-151. Publications in journals

psychologischen Analyse des Parietalsyndroms. Monatsschriftfiir Psychiatrie und Neurologie, 84, 28-97. 1933. Das K6rperschema. Eine kritische Studie und der Versuch einer Revision. Zeitschrift fiir die gesamte Neurologie und Psychiatrie, 147, 346-69. 1938. Epilepsie. Vererbung und Konstitution. Zeitschrzft fiir die gesamte Neurologie und Psychiatrie, 161, 280-92. 1939. Der Begriff der Erbanlage und ihre quantitative Stufung. Allgemeine Zeitschrzft für Psychiatrie, 112, 126-37. 1947/1948. Strukturanalysen hirnpathologischer Fdlle: Part 1, Part 2 in Deutsche Zeitschrift fiir Nervenheilkunde, lS8 (1947), 344-71, 372-434; Part 3, Part 4 in Archiv fiir Psychiatrie vereinigt mit Zeitschrift fiir Neurologie, 179, 180 (1948), 502-67, 54-104; Part 5, Part 6 in Deutsche Zeitschrift fiir Nervenheilkunde, 158, IS9 (1948), 132-87, 1932. Versuch einer

.

188-228. 1948. 1949.

Über differentiale und integrale Gestaltfunktion und den Begriff der Protopathie. Der Nervenarzt, 19, 315-23. Das Problem der gest6rten Wortfindung in gestalttheoretischer Betrachtung. Schweizer Archiv fiir Neurologie und Psychiatrie, 63, 141-92.

1951.

Jugend

und Alter als uberindividuelles Problem. Studium

Generale, 4,

580-7.

Gestaltanalyse in der Psychiatrie. Studium Generale, 5, 503-14 [contains list of publications on brain pathology up to 1949]. Über einen Fall von ’Minuten-Geddchtnis’. Beitrag zum Problem des amnestischen Symptomenkomplexes. Archiv fiir Psychiatrie und Zeitschrift für Neurologie, 190, 471-502. Zur Psychopathologie des amnestischen Symptomenkomplexes. Gestalt-

1952. Die

1953.

1953.

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357

1953.

analyse einer Korsakowschen Psychose. Deutsche Zeitschrift fur Nervenheilkunde, 170, 35-60. Über Erregungsnachdauer und Refraktdrphase im Gestaltwandel h6herer Leistungen. Analyse eines Syndroms der parieto-occipitalen Übergangsregion. Archiv fiir Psychiatrie und Nervenk rank heiten, 190, 196-220.

1953. Der zweite Sundenfall. Annales Universitatis Saraviensis, 1/2, 3-20. 1954. New problems of aphasia. Brain, 77, 491-509. 1954. Das Geistige und das Gehirn. Deutsche Universitdts-Zeitung, 5, 6 (8 and 22 March). 1955. Zum Problem der chronischen taktilen Halluzinose. Archiv fur Psychiatrie und Nervenkrankheiten, 193, 601-6. 1957. Das Unbewuf3te als phdnomenologisches Problem. Fortschritte der Neurologie, - Psychiatrie, 25, 56-73. 1959. Gestaltanalyse und Daseinsanalytik. Der Nervenarzt, 30, 405-10. 1959. Das Problem der ’nosologischen Einheit’ in der Psychiatrie. Der Nervenarzt, 30, 488-94. 1960. Die Gestaltanalyse in der psychiatrischen Forschung. Der Nervenarzt,

31, 267-73. TRANSLATOR’S NOTES 1. Then part of Austria-Hungary, now in the Czech Republic. 2. Then also part of Austria-Hungary, now in Romania. 3. A lake near Salzburg; it became well-known among scientists, especially behavioural scientists, through von Frisch. 4. A lake near Wolfgangsee. 5. Six years was normal. 6. Now the Deutsche Forschungsgemeinschaft (German Research Foundation). 7. Now the Max-Planck-Institut fur Psychiatrie (Max Planck Institute for Psychiatry). 8. English translation: Karl Jaspers (1963). General Psychopathology (Manchester: Manchester

University Press). 9. Rainer Knußmann (1978). Konstitution,

Vererbung und

Umwelt.

Collegium Anthropologicum,

2, 154-67. 10. Karl Jaspers (1946). Allgemeine Psychopathologie, 4th edn (Berlin: Springer-Verlag). 11. H. W. Gruhle, R. Jung, W. Mayer-Gross and M. Müller (eds) (1960/1967). Psychiatrie der Gegenwart. Forschung und Praxis, 3 vols (Berlin/Heidelberg/New York: Springer). 12. Near Stuttgart. 13. Translation, without rhymes. 14. Viktor von Weizsäcker (1940). Der Gestaltkreis. Theorie der Einheit von Wahrnehmen und Bewegen

(Leipzig: Thieme). J. M. Levelt (1989). Speaking: Press); 5th print 1998. op. cit., Jaspers, General Psychopathology (

15. Willem

From Intention

16. 17. Ibid., part 2. 18. Martin Hambrecht and Heinz Häfner Phasenmodell empirisch begründbar?

Note 8), part 3.

to

Articulation

(Cambridge, MA:

MIT

(1993). ’Trema, Apophänie, Apokalypse’ - Ist Conrads (’Trema, apophany, apocalypse’ - Can Conrad’s phase model be substantiated empirically?). Fortschritte der Neurologie - Psychiatrie, 61, 418-23.

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