Strömgren remembered


Erik Strömgren was born 28th of November 1909 in Copenhagen to Swedish parents. His father was professor of astronomy and his mother a distinguished dentist, both active in research with international contacts. During his childhood Erik Strömgren spent his summer vacations at his maternal aunt and her husband who was among the first practicing psychoanalytic therapists in Sweden. His engagement in psychotherapy and his devotion to his patients impressed Erik Strömgren and inspired an early interest in psychology and psychiatry. At the age of 15 he read Freud’s “Über Psychoanalysis'' (Five readings at the Clarke University, from 1909) and Bleuler's ``Lehrbuch der Psychiatrie'' which made a deep impression with its clarity of writing and strong dedication and warmth in the description of the patients.

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[  Erik Strömgren (1909–1993) was the leading figure in Danish and international psychiatry for many years. His biography and achievements are outlined and impressions of his almost mythical personality are described, based on his own contributions, on memorials and on personal memories. ]

From the age of 17 he studied medicine at the University of Copenhagen. Early in the study he had the opportunity to visit a friend working at a major mental hospital. He joined the rounds and was impressed by seeing patients corresponding to the descriptions in Bleuler’s textbook and by the humanitarian atmosphere in the hospital. The chief psychiatrist was a very learned and kind person with outstanding qualities. He personally knew each of his 800 patients, a quality Strömgren valued highly and tried to emulate.

The hospital received patients from the Danish island of Bornholm with about 46,000 inhabitants with a special dialect and characteristic surnames but otherwise representative of the general population. He soon realized that this was ideal for psychiatric epidemiological and genetic research. From follow-up visits to discharged patients in the island he saw that such a study was feasible in a population characterized by trust and open-mindedness, when approached respectfully and with proper explanation of the goal of the research. After his graduation as MD at the age of 24 he obtained a position at the general hospital in the island, and over the next few years managed to do the planned study, resulting in his doctoral thesis in 1938: ‘Beiträge zur Psychiatrischen Erblehre. Auf Grund von Untersuchungen an einer Inselbevölkerung” (Contributions to psychiatric genetics, based upon a study of an island population)(1).

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In 1935 he spent 3 weeks in Munich to visit the genealogical department of the German Psychiatric Research Institute founded by Kraepelin, to study methodological issues of psychiatric epidemiology and genetics. He was particularly interested in the methodology of correction for variable age of onset in calculation of the morbidity risk for the major psychotic disorders. Based on this visit he designed a refined method of age correction, which he published the same year: “Zum Ersattz des Weinbergschen ‘abgekürtzten Verfahrens’ (2), known as The Strömgren Method” which has been widely used in psychiatric genetics. In Munich Strömgren met Ernst Rüdin, the head of the department, a leading Nazi scientist and coauthor of the 1933 laws on eugenics, ideas not shared by Strömgren; Franz Kallmann, half-Jewish, who soon had to emigrate to USA because of increasing nazification of the institute; Hans Luxenburger who also had to leave for the army as he refused to join the Nazi party; Bruno Schultz who impressed him by a very conscientious approach to methodology and a personal integrity which brought him uncontaminated through the Nazi-period; and finally Eliot Slater, visiting post-doctoral fellow from the UK, who impressed Strömgren by his sharp and critical intelligence. The three weeks visit thus resulted in a valuable publication and a number of important international contacts (3).

From 1935 Erik Strömgren continued his clinical training at the University psychiatric department in Copenhagen chaired by professor August Wimmer, who had introduced the concept of psychogenic psychoses in Denmark. Elaborating on this concept, Strömgren developed a hypothesis of the pathogenesis of the various subtypes of psychogenic psychoses. It was based upon experiences and ideas he had entertained during his last year as medical student. He then had to spend half a year in a hospital sanatorium due to an unconfirmed suspicion of a tuberculous lunginfection. Here he found an opportunity to obtain an impression of the personalities of mentally normal persons, his co-patients. During conversations he asked them what they considered their goal in life. From their responses he got an impression of important parts of their self-image of which they often were unaware. They invariably ended up with expressing a strong wish to be the best in some area, even if very special or narrow. From these experiences and from reading Kretschmer’s monograph ‘Der sensitive Beziehungswahn, he provided a description of the ‘image of self’, the knowledge and beliefs of whom you are, what makes you different from other people, your qualities, abilities, capacities and possibilities. This self-image may be more or less unrealistic with misjudged ambitions or self-esteem to which a traumatic confrontation with reality might produce an unbearable revision with defensive projection, resulting in psychogenic delusions: a psychogenic paranoid psychosis. Similarly he described the ‘image of the environment’, of the world surrounding the self, of things and persons, relatives and relations, to which a traumatic event may cause an intolerable reorientation resulting in a dissociative disorder of consciousness: a psychogenic confusional psychosis. The psychogenic emotional disorders he assumed to be caused by simple situational traumas. Erik Strömgren published his ideas in a Danish monograph and later on in several publications (4). This concept of psychogenic psychoses dominated Danish psychiatry for many years. Through Strömgren’s international influence as adviser for WHO the psychogenic or reactive psychoses also obtained categories under ‘other psychoses’ in the 8th and 9th revisions of the WHO ICD (International Classification of Diseases), but they almost disappeared in the non-etiological classification of ICD-10.

In 1943 Erik Strömgren took up a position at the state mental hospital in Risskov, a suburb of the main city of Jutland: Århus. As a student he had been on a one month practicum visit to Århus. He had already then observed that the mental hospital with about 800 beds for all kinds of mental disorders, located near a large city with a young university, provided unique opportunities for creating a major center for psychiatric training and research. In 1945 at the age of 35 he became head of the hospital and university professor of psychiatry, a chair he retained for the following 35 years.

He immediately began long range planning for such a center, which he managed to accomplish over the next two decades. At that time the hospital was secluded in a fenced-in area, which he now opened, removing the fences and a huge cast iron gate. Departments were erected for outpatient treatment with satellite offices in nearby cities, for childhood psychiatry, for psychotherapy including psychoanalysis, for psychology with special interest in neuropsychology, for forensic psychiatry, and for treatment of alcoholics.

He then developed institutes for research, with the departments of the Munich Psychiatric Research Institute in mind, seeking out talented doctors to head the institutes: First an institute for neuropathology, with a unique collection of postmortem brain specimens, many from the time before the era of psychopharmaca. Later an institute for psychopharmacology and biological psychiatry with a modern laboratory, in which Mogens Schou conducted his world renowned studies of Lithium treatment of manic-depressive disorders. An institute for cytogenetics was for many years the lead in research on chromosomal abnomalities. The psychiatric library with an almost complete collection of early European psychiatric literature was expanded and developed into one of the most comprehensive research libraries in northern Europe, with more than 300 journals and periodicals and some ten thousand books.

Finally, Erik Strömgren created an institute for research in psychiatric epidemiology and genetics, the Institute for Psychiatric Demography. Here was placed the nationwide Central Psychiatric Register of inpatient admissions. This register has been an extremely valuable resource for many internationally distinguished epidemiological and genetic investigations, including epidemiological surveys and twin and adoption studies. This institute also became the center of a new epidemiological study of an island population, the Samsø Island project, including a community psychiatry model. The institute further included a WHO Collaborating Center for Research and Training in Mental Health, which took part in WHO coordinated international epidemiological studies: The Pilot study of Schizophrenia 1968–73 with 2 and 5 years follow-ups, The Study of the Determinants of Outcome of Severe Mental Disorders 1978–82, and the Study of Acute Psychoses 1981–85. Erik Strömgren was appointed as a consultant to the Mental Health Division of WHO in Geneva. He was a member of the WHO advisory committees on psychiatric classification for the 8th, 9th and 10th revisions of the WHO ICD, and a member of several other WHO scientific committees and boards.

Gradually the psychiatric research center became a ‘Mecca’ for visits from all over the world. Guest psychiatrists worked for shorter or longer times on research projects or participated in training courses. Many came for one-or two days visits to become acquainted with what was going on in ‘Risskov’. Strömgren then arranged that the guests were taken care of by his co-workers. Every one or two hours a new person guided them through the center research activities so that by the end of the day they just wanted to be left alone. Meetings and symposia were arranged at the center and the participants often were invited as guests to his beautiful home in which he was a generous host together with his wife, Lizzie, who was also a psychiatrist, working at the same hospital.

On the national level Strömgren soon became the adviser to the governmental department or directorate in charge of the state mental hospitals. In this position, which he held for more than 20 years, he came to exert a decisive influence on the innovative planning and development of Danish psychiatry. After World War II he also became an adviser to the West German government for the re-establishment of German psychiatry, and he helped to reintegrate German psychiatry into the international forum of psychiatry. He was a member of the World Psychiatric Association Executive Committee from 1961 and chairman of the Committee for Nomenclature and Classification 1972–77, and was one of the founding members of the European Psychiatric Association.

Erik Strömgren was frequently invited as lecturer or chairman at congresses or meetings all over the world. He was invited to give honorary lectures and received a number of international prizes and awards, including the Anders Jahre Award 1975, the Kraepelin Gold Medal 1976, the Wagner von Jauregg Award 1982, and the Stanley R Dean Award also 1983. He received two honorary doctorates, 1976 from the University of Rochester, New York, and 1984 from the University of Lund, Sweden; he especially appreciated the latter because of his family connections with this university, where his parents and other family members had studied and worked.

As a teacher, Erik Strömgren was esteemed by his colleagues, registrars and students. His lectures were always well-attended and enjoyed because of his clear and accurate presentations in a beautiful and elegant language, which made them an aesthetical pleasure to a degree that you almost forgot to listen to the content. He mastered several foreign languages and spoke English, German, and Swedish fluently. It was also a pleasure to read his well-formulated articles and the psychiatric textbook he updated and revised through 13 editions, also in use in Norway and Sweden. He had an immense capacity for reading and an extraordinary, almost scary memory. During his first years at the hospital he was able to read and provide abstracts from the leading international journals and books, available from the research library. He was a book lover and had a most beautiful private collection with many unique specimens. He took for granted that his co-workers and colleagues were well-acquainted with the classical psychiatric literature. Realizing that this was not always the case he might let out a sigh that, ‘well, some people lie, some steal, and some do not read books’. He also wondered why the young doctors did not cultivate their language but often displayed ‘only hear-say knowledge of vocabulary and grammatical rules’.

Erik Strömgren was the editor of the present journal, the Acta Psychiatrica Scandinavica from 1961 to 1981 and the editor of the psychiatric part of Acta Neurologica et Psychiatrica Scandinavica from 1954 to 1960. He was always ready to help young contributors with their often somewhat clumsy presentations and was open to accepting articles from developing countries. Some manuscripts, however, ‘were beyond repair’, but he was reluctant to send rejection letters to the authors, especially if they included international acquaintances or contacts, and would leave this job to his assistant. He was member of the editorial board of quite a number of international journals and co-editor of three editions of the German ‘Psychiatrie der Gegenwart’ (Contemporary Psychiatry). His own contributions to the psychiatric literature numbered more than 300 articles and textbook chapters, among which were several ‘classics’ (6).

In formal discussions Erik Strömgren was an attentive listener who did not say much when not explicitly asked, until at the end of the discussion. At that point he provided a short and clear concluding statement formulated with delicate diplomacy so that everybody agreed, that this was what could be said about the issue in question. His thinking was logical, analytic with sharpened critical sense, not only seeing what might be incorrect, but also what was missing or ought to be taken into consideration. He was a keen observer of people, but hesitated to come forward with his impressions and was sparing with both praise and criticism.

His nature was not for informal conversation or small-talk and he therefore could give a false impression of being cold or distant. His highly structured use of his time did not leave many pauses, but sometimes, e.g. on travels you might try to engage him in some less formal conversation, bringing up some issue of interest. He then gave a comprehensive answer, completely exhausting the issue and leaving no room for further questions. Then you had to find another topic, with a similar result, and eventually you ran out of topics. He then looked at you, nodded shortly and took up a book and began reading. In fact he was a bit shy, modest and did not want to bother others with unnecessary talk, but perhaps he also wanted to avoid empty and superficial communication. He knew that it might cause others to be insecure and anxious so that, at times, he would try to overcome this impediment and become more talkative.

In the hospital Erik Strömgren was highly committed to the patients and managed to show his respect for their individual personalities by learning their names, whereabouts and detailed clinical history. Over the years this included ten thousands of patients and he was always able to recognize or remember them when he later heard about them or met them, also after many years. He was a great clinician and a keen diagnostician, mainly following the Bleulerian tradition. He set high standards for his coworkers, requiring accurate descriptions of the psychopathology, social background and family history of the patients and clear and logical conclusions in a precise and correct language. More than usual engagement and interest was expected. ‘A true psychiatrist is something you are, not something that you may become, just by learning’. He did not tolerate discrimination or lack of respect for the patients and could be quite furious when somatic colleagues refused to treat a patient because he was mentally disturbed. When angry, Strömgren never raised his voice; on the contrary, he lowered his voice, so that you, standing up on the other side of his desk, could hardly hear what he said, against the tick-tock from the big long-case clock in his office. To co-workers or personnel who had health or other problems, he was most helpful; he saw to it that they got proper treatment and rehabilitation, sometimes in sheltered jobs at the hospital. Gradually his time became increasingly occupied with administration, teaching and research, leaving little time for the patients, which he very much regretted.

Erik Strömgren’s working capacity was extraordinary. He was highly self-disciplined, organizing his time to the last minute, but always appearing quiet and at ease. He was ascetic and hardworking, able to work harder and for longer hours than most others. His memory was legendary and his thinking logical and penetrating and he had an amazing ability to get to the core of problems, find relevant literature and reach clear and precise conclusions.

He was tall in stature with an erect posture and an aristocratic appearance. He was soft-spoken and unobtrusive, moderate and reticent, which sometimes was mistaken for coolness. Actually, he was a very kind person, understanding and considerate. His strong personality, however, might induce a feeling of respect and awe, which could have a paralyzing effect on others, making them feel inadequate like unprepared pupils before their school-master. He was aware that he might give this impression which he regretted and tried to make up for. He was socratically modest, was tolerant of human failings and had learned not to expect the same from others as he expected from himself. He had a highly developed sense of humor, often expressed in a subtle way, in sentences with a double meaning or by fine irony, including self-irony. Once traveling abroad he wanted to discuss a serious problem with the present author, which was: ‘I have a contact problem’ (in Danish language ‘contact’ is the same word for interpersonal communication as for an electric outlet or switch). As it turned out he wished to borrow my device for adaption to the foreign electric ‘contacts’. Confronted with emotional or irrational arguments he might jokingly suggest that he would comment upon them in a future monograph on ‘the logic of emotions’. The deterioration in teaching and research following the 1968 political youth revolution at the universities made him sigh upon the ‘active and performing ignorance’, which tended to appear also in psychiatry.

After his retirement at the age of 70 Erik Strömgren was allowed an emeritus work-room in the Demographic Institute, from which he continued his research, particularly a 50-year follow–up of his epidemiological investigation of the island population of Bornholm (6). He continued at a high level of activity, traveling to congresses and centers, giving lectures and writing papers. He was often asked to write his memoirs, but he refused. They would have been extremely interesting because of all the activities in which he had taken part and the many significant persons he had met. He stated that if he could not write truthfully without the risk of hurting anybody, he should not write at all. He gave interviews to Michael Shepherd (7) and to Mogens Schou (8), to which the majority of the biographical information presented in this paper is indebted. I happened to know Erik Strömgren through 25 years as an illustrious example, a mentor and a friend. He died 15.march 1993, at the age of 83, unimpaired by age, after a short serious illness.

At his retirement he had accepted that a memorial plaque was set up in the hospital auditorium, with only his name, dates, and four nouns for his major areas of functioning engraved: physician, teacher, researcher, and planner. Simple words for areas in which he had contributed with unique achievements to Danish and international psychiatry. In this auditorium he is remembered by the annual Strömgren lectures by internationally distinguished psychiatric researchers, awarded with the Strömgren medal, containing a miniature of the memorial plaque. It is my hope that the present memorial for the centennial of his birth also may contribute to keep the memory of Erik Strömgren alive among future generations of Danish psychiatrists.