Karl Jaspers, 1883-1969
Should we add an antipsychotic, or stop the stimulant?
STUDY: Harland R et al, British Journal of Psychiatry 2026
STUDY TYPE: Editorial
FUNDING: Independent
Background
In 1913, Karl Jaspers set out to solve a problem we encounter every day. How do you make a diagnosis when multiple symptoms overlap in the same patient? His resolution, in General Psychopathology, was to lay out a hierarchy emphasizing disorders with biological causes:
- Med-Psych: Conditions with a clear biological or medical cause, like brain injuries or drug effects
- Major Psychoses. Rather than arising out of personality or temperament, these represented a fundamental break with the person’s baseline, as in schizophrenia or mania. It’s difficult for those close to the patient to empathize with the change.
- Neuroses and Personality Disorders. Here, others can empathize with the symptoms, and they may be understood as a reaction to stress or arising out of the patient’s temperament. Anxiety disorders, affective temperaments, and mild stress-related disorders are examples.
When psychiatrists rewrote the DSM in the 1970s, they tried to preserve this system with the “do not diagnose if better explained by” clause, but the idea got buried in the text. In a recent podcast, I revisited the book that inspired DSM-III, still updated today as Psychiatric Diagnosis, which does a much better job of clarifying which disorders are valid and which ones are lower in the hierarchy.
Here, a team from Maudsley Hospital and King’s College describe three cases that illustrate how things can go wrong when Jasper’s idea gets lost.
Stimulant-Induced Psychosis
A woman with an ADHD history on stimulants develops psychotic symptoms. Her doctors keep the stimulant and add an antipsychotic; reasoning ADHD is the underlying condition. The authors argue psychosis should take precedence. Stop the stimulant first, then reassess ADHD once she’s stable.
Medical Causes
A boy with ADHD grows more irritable after an elbow injury, so his stimulant dose is raised. The real cause is a wound infection causing delirium. Once treated, his behavior returns to baseline, “diagnostic overshadowing” masking a more urgent problem.
Personality and Environment
A teenage girl seeks an autism diagnosis to secure school accommodations, illustrating how personality traits or an environment mismatch gets relabeled as neurodevelopmental disorder.
Postpartum Depression?
I’ll add another example. A woman experiences severe changes in thinking and behavior two weeks after delivering a baby. She is started on zuranolone for postpartum depression, or in a famous case of postpartum psychosis the news, sertraline and mirtazapine.
Medical and public education focuses more on postpartum depression than psychosis, and with newly approved medications for the depressed side (and non for the postpartum psychosis), the imbalance is likely to tilt more. DSM amplifies the problem. Not only does the book neglect to place postpartum psychosis on a higher rung, it does not even give the disorder its own diagnostic category.
For women and families with postpartum psychosis, the lapse is devastating (at a rate of 1:500 to 1:1,000). Anxiety and depression are prioritized and treated with antidepressants that worsen the bipolar nature of postpartum psychosis. Guidelines recommend lithium and antipsychotics acutely, with continuation of lithium longer term, and efforts are underway to reclassify it more clearly in the DSM.
Practice Implications
- Social media, the pharmaceutical industry, and profit-driven healthcare emphasizes problems that affect a lot of people but are at the bottom of the diagnostic hierarchy.
- While that helps destigmatize, it carries a cost for those with severe, biological disorders where stimulants, benzos, and sometimes antidepressants are not the answer.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
