Psychological Medicine, 1990, 20, 487-492 Printed in Great Britain
Ernst Kretschmer 1888-1964 HEINZ HAFNER1 From the Central Institute of Mental Health, Mannheim, FRG
Until his retirement in 1959 Ernst Kretschmer was Professor of Psychiatry at the University of Tubingen. He published eight monographs, five of which were of eminent importance and at least two exerted considerable influence on European psychiatry for several decades, namely Der sensitive Beziehungswahn (1918) and Korperbau und Charakter (1921). His theory on constitutional body types and character became an integral part of German schoolbooks. SYNOPSIS
INTRODUCTION A quarter of a century has passed since Kretschmer died. Looking through twenty volumes of two representative psychiatric journals published in Germany, Great Britain and the United States between 1965 and 1984, Kretschmer seems to be nearly forgotten in the UK and the USA, contrary to E. Kraepelin and K. Schneider (Fig. 1). Ernst Kretschmer was born in a small Swabian town in southern Germany. His father was a parson, his mother the daughter of a parson. He attended two renowned Protestant seminaries and subsequently studied philosophy at the University of Tubingen, which he gave up for medicine after one year. He spent a year at the Protestant College of Tubingen, where such eminent scholars as Melanchthon and Kepler, Holderlin and Hegel had been educated. In his opinion the Swabian Protestant elite of his ancestors represented a universal scholarly attitude, which he felt obliged to follow. Through his work he not only aspired to lay new foundations in psychiatry but to give 'an overall view of human nature from a biological perspective'. More than 25 years before, another psychiatrist, Sigmund Freud, had attempted to formulate the rules by which human nature could be comprehended by interpreting psychopathological phenomena within the context of a somewhat different culture, the Viennese Zeitgeist at the turn of the century. 1 Address for correspondence: Professor Dr. Dr H. Hafner, Central Institute of Mental Health, PO Box 12 21 20, D-6800 Mannheim 1, FRG.
Ernst Kretschmer was deeply impressed by psychoanalysis, but always retained a detached attitude towards it. He was much more devoted to the empirical sciences than Sigmund Freud. The most important roots of his work were Kraepelin's nosology and Eugen Bleuler's assumption of a continuum ranging from psychosis to specific personality disorder. KRETSCHMER'S WORK Kretschmer wrote his four most important books, Der sensitive Beziehungswahn (1918), Korperbau und Charakter (1921), Medizinische Psychologie (1922), and Hysterie, Reflex und Instinkt (1923), within six years unaffected by the rather chaotic circumstances of the time. The wide scope of knowledge and the treasure of original ideas he expounded in his work reflect his extraordinary productivity. Kretschmer wanted to ' run new adits into the large mine of human personality from a completely different side'. Der sensitive
Beziehungswahn
In 1914 Kretschmer's chairman and teacher Robert Gaupp published his monograph Zur Psychologie des Massenmords contending that a paranoid psychosis had emerged from the background of a 'psychopathic' personality precipitated by the shameful fear of having been watched when performing an act of sodomy. Kretschmer took up the issue and generalized the assumption of a psychogenic cause of sensitive delusions: the experience of shameful inadequacy - which he believed fitted like a key
487
H. Hdfner
488
100-
80-
I 60-
40-1 3
20-
0 -t-t—• 1965-69 1970-74 1975-791980-84 1965-69 1970-74 1975-791980-84 E. Kretschmer
K. Schneider
1965-69 1970-74 1975-79 1980-84 E. Kraepelin
FIG. I. Frequency of citations in two representative scientific journals in the USA, UK and the FRG, by five-year periods from 1965 to 1984. ( , FRG NervenarztIFortschritte der Neurologie, Psychiatrie; UK British Journal of Psychiatry/Psychological Medicine; , USA Archives of General Psychiatry]American Journal of Psychiatry.)
in its lock, the lock of a specific personality structure, the sensitive character - may trigger an episode of sensitive delusions. Kretschmer held the sensitive delusions, which may also be associated with productive psychotic symptoms like auditory hallucinations and thought disorder, to be the 'enhanced effect of specific traits of the sensitive character'. The assumption of a continuum between personality and psychosis provoked harsh criticism and controversies. Using pathological jealousy as an example, Jaspers (1910) demonstrated the assumed borderline between comprehensible 'development' and incomprehensible somatogenic 'process'. Schneider (1950) accentuated this psychogenic - somatogenic dichotomy by discriminating between the content of an experience, e.g. of a hallucination, which he considered to be based on biographical events, and the form of an experience, which in his mind was always based on biological causes. Kretschmer defended his assumption of a continuum: 1. In his opinion the strength of an assumed genetic load accounts for the severity of a specific personality disorder and for the occurrence of schizophrenic symptoms in a sensitive episode as well as for the transition from
an ' abnormal reaction' to a ' process', a chronic course with poor outcome. 2. In the second edition of his book (1927) Kretschmer demonstrated by means of impressive case reports that episodes of sensitive delusions can be made not only comprehensible but are thus successfully accessible to psychotherapeutic intervention. Korperbau und Charakter In his second book Korperbau und Charakter Kretschmer created a general psychology based on biological assumptions. His leading hypotheses were as follows: 1. Physique and character are genetically codetermined. Three homogeneous types can be identified: asthenic habitus associated with schizothymic personality, pyknic habitus with cyclothymic personality, and athletic habitus with an increased risk of epilepsy and irritable, 'enechetic' (dragging) personality. 2. The two endogenous psychoses, cyclothymia and schizophrenia, and the personality traits of genuine epileptics pass over continuously to milder grades of personality disorders, to normal characters and to specific forms of ingenuity without any observable leap.
Ernst Kretschmer 1888-1964
Kretschmer adapted this oligo-dimensional theory to the existing great variety of body types and characters by additionally assuming that: 1. numerous variations of genetically homogeneous types of physique exist, and; 2. moderating genetic, hormonal or environmental factors influence the development of physique and character. Even in his early book Der sensitive Beziehungswahn Kretschmer had opposed the unitary disease concept advocated by Kraepelin and had introduced the' multidimensional' view, a predecessor of multiaxial diagnostics: every individual case must be analysed with respect to each determining dimension, the genetic factors predisposing to a constitution, the traumatic or hormonal factors determining the development of brain and physique, as well as the biographical and environmental conditions essential for the development of the personality and for the type and course of a psychosis. The eminent success of Kretschmer's body type theory (the 26th edition of Korperbau und Charakter has meanwhile been published and it has been translated into seven languages) is probably due to its affinity to the daily experience of a correlation between temperament and physical appearance and to Kretschmer's extraordinary gift for observation and descriptive writing. Kretschmer's explanation of genius (Geniale Menschen 1929) as being due to an extreme physico-mental constitution was also based on experience: extraordinary or extreme characters have often played an outstanding role in history or held key positions in society because they were more gifted with specific faculties and less hampered by moral or other inhibitions. Medizinische Psychologie In his books Medizinische Psychologie (1922) and Hysterie, Reflex und Instinkt (1923) Ernst Kretschmer explains the patterns of behaviour associated with neuroses and psychoses, but also with lesions of the basal frontal lobe and of the hypothalamus and diencephalon on the basis of hierarchical levels of functions as advocated by J. Hughlings Jackson: if the psychophysical organism is overstrained, for example by a severe anxiety trauma or by specific life events,
489
given an existing constitutional disposition, the highest functional level of personality may fail. Consciousness and behaviour will then be governed by 'hyponoic' and 'hypobulic' processes. These are understood as ' stereotyped' patterns of behaviour derived from ontogenesis and phylogenesis. Kretschmer drew an analogy between a state of hysterical excitement or a psychogenic stupor, for instance, and the movement storm or the reflex of playing dead of animals in panic. This theory is so attractive because it provides simple models of explanation, which allow one to comprehensively interpret phenomena that had not been understood before. However, the animal models in general lack the close affinity to daily experience, which had essentially contributed to the acceptance of Korperbau und Charakter, and they were difficult to verify empirically. However, psychiatry has since undergone a change of paradigms. The interest in universalistic theories, even if only of medium scope, has worn off. PSYCHOTHERAPY The tools which Kretschmer provided were, contrary to psychoanalysis, derived from the treatment of war neuroses, psychogenic palsy, tremor, etc. in the psychiatric hospital. His theories are closely related to behaviour therapy. Later on called 'protreptics', they represent one track of Kretschmer's 'two-track standard method' including autogenous training and hypnosis, which he believed led direct to the constitutionally determined psychophysical processes of the so-called 'Tiefenperson'. The second track, the analysis of the individual personality and of the existing conflict situation forms the basis for the setting of new life goals adjusted to the constitutional and social perspectives of the patient. In his later years Kretschmer (1957) focused on the psychotherapy of schizophrenics as he had at the beginning of his work. In his endeavour to support mature personality traits of patients and their adaptation to reality he acted in opposition to the tendency of his time, which was to apply a radically analytical therapy on schizophrenia. This approach with its direct interpretation of delusions and fantasies
490
H. Hafner
promoted confusion and a loss of reality in patients. ATTEMPTS AT EMPIRICAL VALIDATION Contrary to Sigmund Freud, who was very sensitive to criticism, Ernst Kretschmer saw himself as a scientist whose task it was to test his hypotheses. As Jaspers, among others, criticized his constitutional body types as being merely artistically created ideal types (Jaspers, 1946), he made every effort to validate empirically his theories. He studied the quantitative distribution ratio of the different types of physique to types of character in large populations. In 1950, in the 20th edition of his book, he reported the evaluation of as many as 65000 cases studied in Germany and abroad. However, validation could not be achieved only by studying a great number of subjects. CRITICISM Controversies surrounded Kretschmer's first publications, stemming in particular from followers of Kraepelin. Schneider, on the other hand, despite his reservations, called Korperbau und Charakter a 'book of extraordinary importance'. The essential argument against Kretschmer's constitutional body type theory was, as von Zerssen (1980) put it, that he had 'overlooked the fact that patients with affective psychoses generally have a later onset and are therefore on average older when the examination of their physique takes place'. Between the third and the fourth decade of life a 'relative pyknomorphisation of the physical habitus' can be observed due to the growing layer of fat. As von Zerssen was able to prove, there was no evidence for a significant correlation between schizophrenia or affective psychoses and Kretschmer's body types when the age variable was taken into account. Kretschmer's just defence of his theory, which found little response, was: 'One cannot set two things against each other if one of them is already an integral part of the other.' He wanted to point out that there is a considerable difference in the mean age of onset in the case of schizophrenia and affective psychoses independent of the body type. The vanishing positive
correlations between the two types of physique and the two functional psychoses when age is accounted for, therefore, cannot disprove the constitutional theory. Nonetheless, being largely related to age, the measurements of the body chosen by Kretschmer were not adequate to prove his theory, either. If age-independent body type measurements were available, as Kretschmer expected, it would be possible to test the correlation between stable characteristics of the body, personality traits and disease risks. This, however, is the task of future research. KRETSCHMER'S INFLUENCE ON FUTURE GENERATIONS Kretschmer's Der sensitive Beziehungswahn and his theory on paranoia have become common knowledge in psychiatry. His model of vulnerable personality structures has continued to exert considerable influence, although the assumption of specificity has retained only limited validity. Kretschmer's assumption that there is a continuity of functional psychoses has met with new interest (Baron, 1986; Hafner, 1987), though his own contribution is almost forgotten today. His hypothesis of a manifest dimension of personality as a diluted form of the schizophrenic psychosis has not been generally accepted due to the great variety of psychopathological syndromes in the genetic environment of schizophrenia. The concept of a continuity of affective disorders, on the other hand, has been the topic of numerous studies. These obtained above all specific personality traits associated with unipolar disorders (von Zerssen et al. 1969; Nystrom & Lindegaard, 1975; von Zerssen, 1976; Hirschfeld & Klerman, 1979; Akiskal et al. 1983; Angst & Clayton, 1986; Krober, 1988). Kretschmer's triadic theory of physique and character was resumed and modified by Sheldon et al. (1940). Based on photographs of 4000 college students, he identified three main types of physique, which he classified as endomorph, mesomorph and ectomorph. He derived these three primary components of physique from the three primary germinal layers, namely the endoderm, mesoderm and ectoderm. This concept, though speculative, allowed to develop a three-dimensional scaling of measurements of the body and to classify every individual
Ernst Kretschmer 1888-1964
according to his rating in the three components. However, the great importance that was accorded to Sheldon's typology during the 1940s and 1950s did not last. Doubts concerning the stability of the somatotypes and the failure of empirical validation (cf. Rees, 1960), which also apply to Kretschmer's constitutional theory, caused a shift of the focus of interest. Nonetheless, the two principal assumptions of Ernst Kretschmer, namely that there exist a limited number of body types as a result of different combinations of genetically determined growth tendencies and that specific body types or features are closely associated with specific personality traits and susceptibility to disease, are still of topical interest to psychiatric as well as to genetic research of human behaviour and disposition to disease. But even studies with considerably improved methodology, for instance by Rees & Eysenck (1945), have not provided sufficient stimulation for further research in this field. Kretschmer's importance lies not only in his work but also in his sincere attitude during the Third Reich. In 1933 he resigned from his position as President of the General Association for Medical Psychotherapy of German-Speaking Countries, when Nazi infiltration became obvious. C. G. Jung was elected his successor. Kretschmer strongly objected to euthanasia. In many lectures during the Third Reich he repeated one sentence, 'The psychopaths are always there, but in good days we examine them and in bad days they rule us', which alone was a brave statement in those days and indeed led to sanctions against him. After the war, Kretschmer and Schneider were among the few leading German psychiatrists who had retained their respect throughout the national catastrophe and were able to set an example and to teach a new generation of students. In 1956, on the occasion of Sigmund Freud's 100th birthday, Ernst Kretschmer delivered a remarkable address. He paid tribute to Freud's eminent achievements and their influence on psychiatry and Western civilization. Although only fragments of Freud's theories have been validated so far, Freud became a household word. According to Kretschmer, Freud woke a sleeping world and confronted it with what had long been forgotten. In fact, Freud called
491
people's attention to many things which Western civilization at the turn of the century ignored although they were essential parts of human life, pleasure, and fear. Instead of using the everyday way of thinking, Kretschmer tried to make use of the scientific way of his time in order to obtain a comprehensive understanding of human behaviour in its pathological as well as normal forms. He had his intellectual roots in the scholarly attitude of academic Protestant tradition and in the sciences of his time, which were basically only known to scientists. In the course of a change of paradigms in psychiatry, the holistic biologism governing Kretschmer's thinking was superseded by a way of thinking which is fragmentary and lacks theories. As a consequence, access to Kretschmer's work has become difficult for us today. Nevertheless, his achievements have been more fruitful for psychiatric research and practice than psychiatrists are as yet willing to admit. REFERENCES Akiskal, H. S., Hischfeld, R. M. A. & Yerevanian, B. I. (1983). The relationship of personality to affective disorders. A critical review. Archives of General Psychiatry 40, 801-810. Angst, J. & Clayton, P. (1986). Premorbid personality of depressive bipolar and schizophrenic patients with special reference to suicidal issues. Comprehensive Psychiatry 27, 511-532. Baron, M.(1986). Genetics of schizophrenia: I. Familial patterns and mode of inheritance. Biological Psychiatry 21, 1051-1066. Gaupp, R. (1914). Zur Psychologie des Massenmordes: Hauptlehrer Wagner von Degerloch. Eine kriminalpsyehologisehe und psychiatrische Studie. Springer: Berlin. Hafner, H. (1987). Epidemiology of schizophrenia. In Search for the Causes of Schizophrenia (ed. H. Hafner, W. F. Gattaz and W. Janzarik), pp. 47-74. Springer: Berlin. Hirschfeld, R. M. A. & Klerman, G. L. (1979). Personality attributes and affective disorders. American Journal of Psychiatry 136, 67-70. Jaspers, K. (1910). Eifersuchtswahn. Ein Beitrag zur Frage 'Entwicklung einer Personlichkeit' oder 'Prozess'. Zeitschrift fur Neurologie 1, 567. Jaspers, K. (1946). Algemeine Psychopathologie, 4th revised edn. Springer: Berlin. Kretschmer, E. (1918). Der sensitive Beziehungswahn. Springer: Berlin. Kretschmer, E. (1921). Korperbau und Charakter. Springer: Berlin. Kretschmer, E. (1922). Medizinische Psychologie. Thieme: Stuttgart. Kretschmer, E. (1923). Hysteric, Reflex und Instinkt. Thieme: Stuttgart. Kretschmer, E. (1929). Geniale Menschen. Springer: Berlin. Kretschmer, E. (1949). Psychotherapeutische Studien. Thieme: Stuttgart. Kretschmer, E. (1957). Die mehrdimensionale Struklur der Schizophrenic in bezug auf ihre Therapie. Paper read at the International Congress for Psychotherapy. Krober, H.-L. (1988). Die Personlichkeit bipolar manischdepressiv Erkrankender. Nervenarzt 59, 319-329. Nystrom, L. & Lindegard, B. (1975). Predisposition for mental syndromes. A study comparing predisposition for depression, neurasthenia and anxiety state. Ada Psychiatrica Scandinavica 51, 69-76.
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Rees, L. (1960). Constitutional factors and abnormal behaviour. In Handbook of Abnormal Psychology (ed. H. J. Eysenck), pp. 487-539. Pitman: Belfast. Rees, L. & Eysenck, H. J. (1945). A factorial study of some morphological and psychological aspects of human constitution. Journal of Mental Science 91, 8. Schneider, K. (1950). Klinische Psychopathologie, 3rd edn. Thieme: Stuttgart. Sheldon, W. H., Stevens, S. S. & Tucker, W. B. (1940). The Varieties of Human Physique. Harper: New York.
Zerssen, D. von (1976). Der 'Typus melancholicus' in psychometrischer Sicht. Teil I und 2. Zeilschrift fur Klinische Psychologie und Psyclwtherapie 24, 200 220; 305 316. Zerssen, D. von (1980). Konstitution. In Psychialrie der Gegenwart, vol. 1/2, 2nd edn. Springer: Berlin. Zerssen, D. von, Koeller, D.-M. & Rey, E.-R. (1969). Objektivierende Untersuchungen zur pramorbiden Personlichkeit endogen Depressiver. In Das depressive Syndrom (ed. H. Hippius and H. Selbach), pp. 183 205. Urban & Schwarzenberg: Munchen.
Ernst Kretschmer 1888-1964 HEINZ HAFNER1 From the Central Institute of Mental Health, Mannheim, FRG
Until his retirement in 1959 Ernst Kretschmer was Professor of Psychiatry at the University of Tubingen. He published eight monographs, five of which were of eminent importance and at least two exerted considerable influence on European psychiatry for several decades, namely Der sensitive Beziehungswahn (1918) and Korperbau und Charakter (1921). His theory on constitutional body types and character became an integral part of German schoolbooks. SYNOPSIS
INTRODUCTION A quarter of a century has passed since Kretschmer died. Looking through twenty volumes of two representative psychiatric journals published in Germany, Great Britain and the United States between 1965 and 1984, Kretschmer seems to be nearly forgotten in the UK and the USA, contrary to E. Kraepelin and K. Schneider (Fig. 1). Ernst Kretschmer was born in a small Swabian town in southern Germany. His father was a parson, his mother the daughter of a parson. He attended two renowned Protestant seminaries and subsequently studied philosophy at the University of Tubingen, which he gave up for medicine after one year. He spent a year at the Protestant College of Tubingen, where such eminent scholars as Melanchthon and Kepler, Holderlin and Hegel had been educated. In his opinion the Swabian Protestant elite of his ancestors represented a universal scholarly attitude, which he felt obliged to follow. Through his work he not only aspired to lay new foundations in psychiatry but to give 'an overall view of human nature from a biological perspective'. More than 25 years before, another psychiatrist, Sigmund Freud, had attempted to formulate the rules by which human nature could be comprehended by interpreting psychopathological phenomena within the context of a somewhat different culture, the Viennese Zeitgeist at the turn of the century. 1 Address for correspondence: Professor Dr. Dr H. Hafner, Central Institute of Mental Health, PO Box 12 21 20, D-6800 Mannheim 1, FRG.
Ernst Kretschmer was deeply impressed by psychoanalysis, but always retained a detached attitude towards it. He was much more devoted to the empirical sciences than Sigmund Freud. The most important roots of his work were Kraepelin's nosology and Eugen Bleuler's assumption of a continuum ranging from psychosis to specific personality disorder. KRETSCHMER'S WORK Kretschmer wrote his four most important books, Der sensitive Beziehungswahn (1918), Korperbau und Charakter (1921), Medizinische Psychologie (1922), and Hysterie, Reflex und Instinkt (1923), within six years unaffected by the rather chaotic circumstances of the time. The wide scope of knowledge and the treasure of original ideas he expounded in his work reflect his extraordinary productivity. Kretschmer wanted to ' run new adits into the large mine of human personality from a completely different side'. Der sensitive
Beziehungswahn
In 1914 Kretschmer's chairman and teacher Robert Gaupp published his monograph Zur Psychologie des Massenmords contending that a paranoid psychosis had emerged from the background of a 'psychopathic' personality precipitated by the shameful fear of having been watched when performing an act of sodomy. Kretschmer took up the issue and generalized the assumption of a psychogenic cause of sensitive delusions: the experience of shameful inadequacy - which he believed fitted like a key
487
H. Hdfner
488
100-
80-
I 60-
40-1 3
20-
0 -t-t—• 1965-69 1970-74 1975-791980-84 1965-69 1970-74 1975-791980-84 E. Kretschmer
K. Schneider
1965-69 1970-74 1975-79 1980-84 E. Kraepelin
FIG. I. Frequency of citations in two representative scientific journals in the USA, UK and the FRG, by five-year periods from 1965 to 1984. ( , FRG NervenarztIFortschritte der Neurologie, Psychiatrie; UK British Journal of Psychiatry/Psychological Medicine; , USA Archives of General Psychiatry]American Journal of Psychiatry.)
in its lock, the lock of a specific personality structure, the sensitive character - may trigger an episode of sensitive delusions. Kretschmer held the sensitive delusions, which may also be associated with productive psychotic symptoms like auditory hallucinations and thought disorder, to be the 'enhanced effect of specific traits of the sensitive character'. The assumption of a continuum between personality and psychosis provoked harsh criticism and controversies. Using pathological jealousy as an example, Jaspers (1910) demonstrated the assumed borderline between comprehensible 'development' and incomprehensible somatogenic 'process'. Schneider (1950) accentuated this psychogenic - somatogenic dichotomy by discriminating between the content of an experience, e.g. of a hallucination, which he considered to be based on biographical events, and the form of an experience, which in his mind was always based on biological causes. Kretschmer defended his assumption of a continuum: 1. In his opinion the strength of an assumed genetic load accounts for the severity of a specific personality disorder and for the occurrence of schizophrenic symptoms in a sensitive episode as well as for the transition from
an ' abnormal reaction' to a ' process', a chronic course with poor outcome. 2. In the second edition of his book (1927) Kretschmer demonstrated by means of impressive case reports that episodes of sensitive delusions can be made not only comprehensible but are thus successfully accessible to psychotherapeutic intervention. Korperbau und Charakter In his second book Korperbau und Charakter Kretschmer created a general psychology based on biological assumptions. His leading hypotheses were as follows: 1. Physique and character are genetically codetermined. Three homogeneous types can be identified: asthenic habitus associated with schizothymic personality, pyknic habitus with cyclothymic personality, and athletic habitus with an increased risk of epilepsy and irritable, 'enechetic' (dragging) personality. 2. The two endogenous psychoses, cyclothymia and schizophrenia, and the personality traits of genuine epileptics pass over continuously to milder grades of personality disorders, to normal characters and to specific forms of ingenuity without any observable leap.
Ernst Kretschmer 1888-1964
Kretschmer adapted this oligo-dimensional theory to the existing great variety of body types and characters by additionally assuming that: 1. numerous variations of genetically homogeneous types of physique exist, and; 2. moderating genetic, hormonal or environmental factors influence the development of physique and character. Even in his early book Der sensitive Beziehungswahn Kretschmer had opposed the unitary disease concept advocated by Kraepelin and had introduced the' multidimensional' view, a predecessor of multiaxial diagnostics: every individual case must be analysed with respect to each determining dimension, the genetic factors predisposing to a constitution, the traumatic or hormonal factors determining the development of brain and physique, as well as the biographical and environmental conditions essential for the development of the personality and for the type and course of a psychosis. The eminent success of Kretschmer's body type theory (the 26th edition of Korperbau und Charakter has meanwhile been published and it has been translated into seven languages) is probably due to its affinity to the daily experience of a correlation between temperament and physical appearance and to Kretschmer's extraordinary gift for observation and descriptive writing. Kretschmer's explanation of genius (Geniale Menschen 1929) as being due to an extreme physico-mental constitution was also based on experience: extraordinary or extreme characters have often played an outstanding role in history or held key positions in society because they were more gifted with specific faculties and less hampered by moral or other inhibitions. Medizinische Psychologie In his books Medizinische Psychologie (1922) and Hysterie, Reflex und Instinkt (1923) Ernst Kretschmer explains the patterns of behaviour associated with neuroses and psychoses, but also with lesions of the basal frontal lobe and of the hypothalamus and diencephalon on the basis of hierarchical levels of functions as advocated by J. Hughlings Jackson: if the psychophysical organism is overstrained, for example by a severe anxiety trauma or by specific life events,
489
given an existing constitutional disposition, the highest functional level of personality may fail. Consciousness and behaviour will then be governed by 'hyponoic' and 'hypobulic' processes. These are understood as ' stereotyped' patterns of behaviour derived from ontogenesis and phylogenesis. Kretschmer drew an analogy between a state of hysterical excitement or a psychogenic stupor, for instance, and the movement storm or the reflex of playing dead of animals in panic. This theory is so attractive because it provides simple models of explanation, which allow one to comprehensively interpret phenomena that had not been understood before. However, the animal models in general lack the close affinity to daily experience, which had essentially contributed to the acceptance of Korperbau und Charakter, and they were difficult to verify empirically. However, psychiatry has since undergone a change of paradigms. The interest in universalistic theories, even if only of medium scope, has worn off. PSYCHOTHERAPY The tools which Kretschmer provided were, contrary to psychoanalysis, derived from the treatment of war neuroses, psychogenic palsy, tremor, etc. in the psychiatric hospital. His theories are closely related to behaviour therapy. Later on called 'protreptics', they represent one track of Kretschmer's 'two-track standard method' including autogenous training and hypnosis, which he believed led direct to the constitutionally determined psychophysical processes of the so-called 'Tiefenperson'. The second track, the analysis of the individual personality and of the existing conflict situation forms the basis for the setting of new life goals adjusted to the constitutional and social perspectives of the patient. In his later years Kretschmer (1957) focused on the psychotherapy of schizophrenics as he had at the beginning of his work. In his endeavour to support mature personality traits of patients and their adaptation to reality he acted in opposition to the tendency of his time, which was to apply a radically analytical therapy on schizophrenia. This approach with its direct interpretation of delusions and fantasies
490
H. Hafner
promoted confusion and a loss of reality in patients. ATTEMPTS AT EMPIRICAL VALIDATION Contrary to Sigmund Freud, who was very sensitive to criticism, Ernst Kretschmer saw himself as a scientist whose task it was to test his hypotheses. As Jaspers, among others, criticized his constitutional body types as being merely artistically created ideal types (Jaspers, 1946), he made every effort to validate empirically his theories. He studied the quantitative distribution ratio of the different types of physique to types of character in large populations. In 1950, in the 20th edition of his book, he reported the evaluation of as many as 65000 cases studied in Germany and abroad. However, validation could not be achieved only by studying a great number of subjects. CRITICISM Controversies surrounded Kretschmer's first publications, stemming in particular from followers of Kraepelin. Schneider, on the other hand, despite his reservations, called Korperbau und Charakter a 'book of extraordinary importance'. The essential argument against Kretschmer's constitutional body type theory was, as von Zerssen (1980) put it, that he had 'overlooked the fact that patients with affective psychoses generally have a later onset and are therefore on average older when the examination of their physique takes place'. Between the third and the fourth decade of life a 'relative pyknomorphisation of the physical habitus' can be observed due to the growing layer of fat. As von Zerssen was able to prove, there was no evidence for a significant correlation between schizophrenia or affective psychoses and Kretschmer's body types when the age variable was taken into account. Kretschmer's just defence of his theory, which found little response, was: 'One cannot set two things against each other if one of them is already an integral part of the other.' He wanted to point out that there is a considerable difference in the mean age of onset in the case of schizophrenia and affective psychoses independent of the body type. The vanishing positive
correlations between the two types of physique and the two functional psychoses when age is accounted for, therefore, cannot disprove the constitutional theory. Nonetheless, being largely related to age, the measurements of the body chosen by Kretschmer were not adequate to prove his theory, either. If age-independent body type measurements were available, as Kretschmer expected, it would be possible to test the correlation between stable characteristics of the body, personality traits and disease risks. This, however, is the task of future research. KRETSCHMER'S INFLUENCE ON FUTURE GENERATIONS Kretschmer's Der sensitive Beziehungswahn and his theory on paranoia have become common knowledge in psychiatry. His model of vulnerable personality structures has continued to exert considerable influence, although the assumption of specificity has retained only limited validity. Kretschmer's assumption that there is a continuity of functional psychoses has met with new interest (Baron, 1986; Hafner, 1987), though his own contribution is almost forgotten today. His hypothesis of a manifest dimension of personality as a diluted form of the schizophrenic psychosis has not been generally accepted due to the great variety of psychopathological syndromes in the genetic environment of schizophrenia. The concept of a continuity of affective disorders, on the other hand, has been the topic of numerous studies. These obtained above all specific personality traits associated with unipolar disorders (von Zerssen et al. 1969; Nystrom & Lindegaard, 1975; von Zerssen, 1976; Hirschfeld & Klerman, 1979; Akiskal et al. 1983; Angst & Clayton, 1986; Krober, 1988). Kretschmer's triadic theory of physique and character was resumed and modified by Sheldon et al. (1940). Based on photographs of 4000 college students, he identified three main types of physique, which he classified as endomorph, mesomorph and ectomorph. He derived these three primary components of physique from the three primary germinal layers, namely the endoderm, mesoderm and ectoderm. This concept, though speculative, allowed to develop a three-dimensional scaling of measurements of the body and to classify every individual
Ernst Kretschmer 1888-1964
according to his rating in the three components. However, the great importance that was accorded to Sheldon's typology during the 1940s and 1950s did not last. Doubts concerning the stability of the somatotypes and the failure of empirical validation (cf. Rees, 1960), which also apply to Kretschmer's constitutional theory, caused a shift of the focus of interest. Nonetheless, the two principal assumptions of Ernst Kretschmer, namely that there exist a limited number of body types as a result of different combinations of genetically determined growth tendencies and that specific body types or features are closely associated with specific personality traits and susceptibility to disease, are still of topical interest to psychiatric as well as to genetic research of human behaviour and disposition to disease. But even studies with considerably improved methodology, for instance by Rees & Eysenck (1945), have not provided sufficient stimulation for further research in this field. Kretschmer's importance lies not only in his work but also in his sincere attitude during the Third Reich. In 1933 he resigned from his position as President of the General Association for Medical Psychotherapy of German-Speaking Countries, when Nazi infiltration became obvious. C. G. Jung was elected his successor. Kretschmer strongly objected to euthanasia. In many lectures during the Third Reich he repeated one sentence, 'The psychopaths are always there, but in good days we examine them and in bad days they rule us', which alone was a brave statement in those days and indeed led to sanctions against him. After the war, Kretschmer and Schneider were among the few leading German psychiatrists who had retained their respect throughout the national catastrophe and were able to set an example and to teach a new generation of students. In 1956, on the occasion of Sigmund Freud's 100th birthday, Ernst Kretschmer delivered a remarkable address. He paid tribute to Freud's eminent achievements and their influence on psychiatry and Western civilization. Although only fragments of Freud's theories have been validated so far, Freud became a household word. According to Kretschmer, Freud woke a sleeping world and confronted it with what had long been forgotten. In fact, Freud called
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people's attention to many things which Western civilization at the turn of the century ignored although they were essential parts of human life, pleasure, and fear. Instead of using the everyday way of thinking, Kretschmer tried to make use of the scientific way of his time in order to obtain a comprehensive understanding of human behaviour in its pathological as well as normal forms. He had his intellectual roots in the scholarly attitude of academic Protestant tradition and in the sciences of his time, which were basically only known to scientists. In the course of a change of paradigms in psychiatry, the holistic biologism governing Kretschmer's thinking was superseded by a way of thinking which is fragmentary and lacks theories. As a consequence, access to Kretschmer's work has become difficult for us today. Nevertheless, his achievements have been more fruitful for psychiatric research and practice than psychiatrists are as yet willing to admit. REFERENCES Akiskal, H. S., Hischfeld, R. M. A. & Yerevanian, B. I. (1983). The relationship of personality to affective disorders. A critical review. Archives of General Psychiatry 40, 801-810. Angst, J. & Clayton, P. (1986). Premorbid personality of depressive bipolar and schizophrenic patients with special reference to suicidal issues. Comprehensive Psychiatry 27, 511-532. Baron, M.(1986). Genetics of schizophrenia: I. Familial patterns and mode of inheritance. Biological Psychiatry 21, 1051-1066. Gaupp, R. (1914). Zur Psychologie des Massenmordes: Hauptlehrer Wagner von Degerloch. Eine kriminalpsyehologisehe und psychiatrische Studie. Springer: Berlin. Hafner, H. (1987). Epidemiology of schizophrenia. In Search for the Causes of Schizophrenia (ed. H. Hafner, W. F. Gattaz and W. Janzarik), pp. 47-74. Springer: Berlin. Hirschfeld, R. M. A. & Klerman, G. L. (1979). Personality attributes and affective disorders. American Journal of Psychiatry 136, 67-70. Jaspers, K. (1910). Eifersuchtswahn. Ein Beitrag zur Frage 'Entwicklung einer Personlichkeit' oder 'Prozess'. Zeitschrift fur Neurologie 1, 567. Jaspers, K. (1946). Algemeine Psychopathologie, 4th revised edn. Springer: Berlin. Kretschmer, E. (1918). Der sensitive Beziehungswahn. Springer: Berlin. Kretschmer, E. (1921). Korperbau und Charakter. Springer: Berlin. Kretschmer, E. (1922). Medizinische Psychologie. Thieme: Stuttgart. Kretschmer, E. (1923). Hysteric, Reflex und Instinkt. Thieme: Stuttgart. Kretschmer, E. (1929). Geniale Menschen. Springer: Berlin. Kretschmer, E. (1949). Psychotherapeutische Studien. Thieme: Stuttgart. Kretschmer, E. (1957). Die mehrdimensionale Struklur der Schizophrenic in bezug auf ihre Therapie. Paper read at the International Congress for Psychotherapy. Krober, H.-L. (1988). Die Personlichkeit bipolar manischdepressiv Erkrankender. Nervenarzt 59, 319-329. Nystrom, L. & Lindegard, B. (1975). Predisposition for mental syndromes. A study comparing predisposition for depression, neurasthenia and anxiety state. Ada Psychiatrica Scandinavica 51, 69-76.
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Rees, L. (1960). Constitutional factors and abnormal behaviour. In Handbook of Abnormal Psychology (ed. H. J. Eysenck), pp. 487-539. Pitman: Belfast. Rees, L. & Eysenck, H. J. (1945). A factorial study of some morphological and psychological aspects of human constitution. Journal of Mental Science 91, 8. Schneider, K. (1950). Klinische Psychopathologie, 3rd edn. Thieme: Stuttgart. Sheldon, W. H., Stevens, S. S. & Tucker, W. B. (1940). The Varieties of Human Physique. Harper: New York.
Zerssen, D. von (1976). Der 'Typus melancholicus' in psychometrischer Sicht. Teil I und 2. Zeilschrift fur Klinische Psychologie und Psyclwtherapie 24, 200 220; 305 316. Zerssen, D. von (1980). Konstitution. In Psychialrie der Gegenwart, vol. 1/2, 2nd edn. Springer: Berlin. Zerssen, D. von, Koeller, D.-M. & Rey, E.-R. (1969). Objektivierende Untersuchungen zur pramorbiden Personlichkeit endogen Depressiver. In Das depressive Syndrom (ed. H. Hippius and H. Selbach), pp. 183 205. Urban & Schwarzenberg: Munchen.
