Dementia praecox
Encyclopedia
Dementia praecox refers to a chronic, deteriorating psychotic disorder characterized by rapid cognitive disintegration, usually beginning in the late teens or early adulthood. It is a term first used in 1891 in this Latin form by Arnold Pick
(1851–1924), a professor of psychiatry at the German branch of Charles University in Prague
. His brief clinical report described the case of a person with a psychotic disorder resembling hebephrenia (see below). It was popularized by German psychiatrist Emil Kraepelin
(1856–1926) in 1893, 1896 and 1899 in his first detailed textbook descriptions of a condition that would eventually be reframed into a substantially different disease concept and relabeled as schizophrenia
. Kraepelin, regarding the major psychoses as naturally occurring disease entities, simplified the complex psychiatric taxonomies of the nineteenth century by dividing them into two classes: manic depressive psychosis or dementia praecox. This division is commonly referred to as the Kraepelinian dichotomy
and it has had a significant impact on twentieth-century psychiatry.
The primary disturbance in dementia praecox is not one of mood
(as is the case in manic-depressive illness), but of thinking or cognition
. Cognitive disintegration refers to a disruption in cognitive or mental functioning such as in attention, memory, and goal-directed behavior.
From the outset, dementia praecox was viewed by Kraepelin as a progressively deteriorating disease from which no one recovered. The three terms that Kraepelin used to refer to the end state of the disease were "Verblödung" (deterioration), Schwachsinn (mental weakness) or Defekt (defect). Although "dementia" is part of the name of the disease, Kraepelin did not intend it to be similar to senile dementia and rarely used this term to refer to the end state of the disease. However, by 1913, and more explicitly by 1920, Kraepelin admitted that although there seemed to be a residual cognitive defect in most cases, the prognosis was not as uniformly dire as he had stated in the 1890s. Still, he regarded it as a specific disease concept that implied incurable, inexplicable madness.
is an ancient term which has been in use since at least the time of Lucretius
in 50 B.C.E. where it meant "being out of one's mind". Until the seventeenth century dementia referred to states of cognitive and behavioural deterioration leading to psychosocial incompetence. This condition could be innate or acquired and the concept had no reference to a necessarily irreversible condition. It is the concept in this popular notion of psychosocial incapacity that forms the basis for the idea of legal incapacity. By the eighteenth century, at the period when the term entered into European medical discourse, clinical concepts were added to the vernacular understanding such that dementia was now associated with intellectual deficits arising from any cause and at any age. By the end of the nineteenth century the modern 'cognitive paradigm' of dementia was taking root. This holds that dementia is understood in terms of criteria relating to aetiology, age and course which excludes former members of the family of the demented such as adults with acquired head trauma or children with cognitive deficits. Moreover, it was now understood as an irreversible condition and a particular emphasis was placed on memory loss in regard to the deterioration of intellectual functions.
The term démence précoce was used in passing to describe the characteristics of a subset of young mental patients by the French physician Bénédict Augustin Morel
in 1852 in the first volume of his Études cliniques. and the term is used more frequently in his textbook Traité des maladies mentales which was published in 1860. Morel, whose name will be forever associated with religiously inspired concept of degeneration theory
in psychiatry, used the term in a descriptive sense and not to define a specific and novel diagnostic category. It was applied as a means of setting apart a group of young men and women who were suffering from "stupor." As such their condition was characterised by a certain torpor, enervation, and disorder of the will and was related to the diagnostic category of melancholia
. He did not conceptualise their state as irreversible and thus his use of the term dementia was equivalent to that formed in the eighteenth century as outlined above.
While some have sought to interpret, if in a qualified fashion, the use by Morel of the term démence précoce as amounting to the "discovery" of schizophrenia, others have argued convincingly that Morel's discriptive use of the term should not be considered in any sense as a precursor to Kraepelin's dementia praecox disease concept. This is due to the fact that their concepts of dementia differed significantly from each other, with Kraepelin employing the more modern sense of the word and that Morel was not describing a diagnostic category. Indeed, until the advent of Pick and Kraepelin, Morel's term had vanished without a trace and there is little evidence to suggest that either Pick or indeed Kraepelin were even aware of Morel's use of the term until long after they had published their own disease concepts bearing the same name. As Eugène Minkowski succinctly stated, 'An abyss separates Morel's démence précoce from that of Kraepelin.'
Morel described several psychotic disorders that ended in dementia, and as a result he may be regarded as the first alienist or psychiatrist to develop a diagnostic system based on presumed outcome rather than on the current presentation of signs and symptoms. Morel, however, did not conduct any long-term or quantitative
research on the course and outcome of dementia praecox (Kraepelin would be the first in history to do that) so this prognosis was based on speculation. It is impossible to discern whether the condition briefly described by Morel was equivalent to the disorder later called dementia praecox by Pick and Kraepelin.
and symptoms of a given disease concept.
The dominant psychiatric paradigms which gave a semblance of order to this fragmentary picture were Morelian degeneration theory and the concept of "unitary psychosis
" (Einheitspsychose). This latter notion, derived from the Belgian psychiatrist Joseph Guislain
(1797–1860), held that the variety of symptoms attributed to mental illness were manifestations of a single underlying disease process. While these approaches had a diachronic
aspect they lacked a conception of mental illness that encompassed a coherent notion of change over time in terms of the natural course of the illness and based upon an empirical observation of changing symptomatology.
In 1863, the Danzig based psychiatrist, Karl Ludwig Kahlbaum
(1828–1899), published his text on psychiatric nosology Die Gruppierung der psychischen Krankheiten (The Classification of Psychiatric Diseases). Although with the passage of time this work would prove profoundly influenital, when it was published it was almost complete ignored by German academia despite the sophisticated and intelligent disease classification system which it proposed. In this book Kahlbaum categorized certain typical forms of psychosis (vesania typica) as a single coherent type based upon their shared progressive nature which betrayed, he argued, an ongoing degenerative disease process. For Kahlbaum the disease process of vesania typica was distinguished by the passage of the sufferer through clearly defined disease phases: a melancholic stage; a manic stage; a confusional stage; and finally a demented stage.
In 1866 Kahlbaum became the director of a private psychiatric clinic in Görlitz
(Prussia
, today Saxony
, a small town near Dresden
). He was accompanied by his younger assistant, Ewald Hecker
(1843–1909), and during a ten-year collaboration they conducted a series of research
studies on young psychotic patients that would become a major influence on the development of modern psychiatry.
Together Kahlbaum and Hecker were the first to describe and name such syndrome
s as dysthymia, cyclothymia
, paranoia
, catatonia
, and hebephrenia. Perhaps their most lasting contribution to psychiatry was the introduction of the "clinical method" from medicine to the study of mental diseases, a method which is now known as psychopathology
.
When the element of time was added to the concept of diagnosis
, a diagnosis became more than just a description of a collection of symptoms: diagnosis now also defined by prognosis
(course and outcome). An additional feature of the clinical method was that the characteristic symptoms that define syndromes should be described without any prior assumption of brain pathology (although such links would be made later as scientific knowledge progressed). Karl Kahlbaum made an appeal for the adoption of the clinical method in psychiatry in his 1874 book on catatonia. Without Kahlbaum and Hecker there would be no dementia praecox.
Upon his appointment to a full professorship in psychiatry at the University of Dorpat (now Tartu
, Estonia
) in 1886, Kraepelin gave an inaugural address to the faculty outlining his research programme for the years ahead. Attacking the "brain mythology" of Meynert
and the positions of Griesinger
and Gudden
, Kraepelin
advocated that the ideas of Kahlbaum, who was then a marginal and little known figure in psychiatry, should be followed. Therefore, he argued, a research programme into the nature of psychiatric illness should look at a large number of patients over time to discover the course which mental disease could take.
It has also been suggested that Kraepelin's decision to accept the Dorpat post was informed by the fact that there he could hope to gain experience with chronic patients and this, it was presumed, would facilitate the longitudinal study of mental illness.
Kraepelin believed that by thoroughly describing all of the clinic's new patients on index cards, which he had been using since 1887, researcher
bias could be eliminated from the investigation process. He described the method in his posthumously published memoir:
The fourth edition of his textbook, Psychiatrie, published in 1893, two years after his arrival at Heidelberg, contained some impressions of the patterns Kraepelin had begun to find in his index cards. Prognosis (course and outcome) began to feature alongside signs and symptoms in the description of syndromes, and he added a class of psychotic disorders designated "psychic degenerative processes", three of which were borrowed from Kahlbaum and Hecker: dementia paranoides (a degenerative type of Kahlbaum's paranoia, with sudden onset), catatonia (per Kahlbaum, 1874) and dementia praecox, (Hecker's hebephrenia of 1871). Kraepelin continued to equate dementia praecox with hebephrenia for the next six years.
In the March 1896 fifth edition of Psychiatrie, Kraepelin expressed confidence that his clinical
method
, involving analysis of both qualitative
and quantitative
data derived from long term observation of patients, would produce reliable diagnoses including prognosis:
In this edition dementia praecox is still basically hebephrenia, and it, dementia paranoides and catatonia are described as distinct psychotic disorders among the "metabolic disorders leading to dementia".
still uses "hebephrenic" to designate the third type. These subtypes may be dropped from the next edition of the DSM, DSM-V, due to be published in May 2013.
reported in 1908 that in many cases there was no inevitable progressive decline, there was temporary remission in some cases, and there were even cases of near recovery with the retention of some residual defect. In the eighth edition of Kraepelin's textbook, published in four volumes between 1909 and 1915, he described eleven forms of dementia, and dementia praecox was classed as one of the "endogenous dementias". Modifying his previous more gloomy prognosis in line with Bleuler's observations, Kraepelin reported that about 26% of his patients experienced partial remission of symptoms. Kraepelin died while working on the ninth edition of Psychiatrie with Johannes Lange (1891–1938), who finished it and brought it to publication in 1927.
Adolf Meyer was the first to apply the new diagnostic term in America. He used it at the Worcester Lunatic Hospital in Massachusetts in the fall of 1896. He was also the first to apply Eugen Bleuler's term "schizophrenia" (in the form of "schizophrenic reaction") in 1913 at the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital.
The dissemination of Kraepelin's disease concept to the Anglo-phone world was facilitated in 1902 when Ross Diefendorf, a lecturer in psychiatry at Yale, published an adapted version of the sixth edition of the Lehrbuch der Psychiatrie. This was republished in 1904 and with a new version, based on the seventh edition of Kraepelin's Lehrbuch appearing in 1907 and reissued in 1912. Both dementia praecox (in its three classic forms) and "manic-depressive psychosis" gained wider popularity in the larger institutions in the eastern United States after being included in the official nomenclature of diseases and conditions for record-keeping at Bellevue Hospital in New York City in 1903. The term lived on due to its promotion in the publications of the National Committee on Mental Hygiene (founded in 1909) and the Eugenics Records Office (1910). But perhaps the most important reason for the longevity of Kraepelin's term was its inclusion in 1918 as an official diagnostic category in the uniform system adopted for comparative statistical record-keeping in all American mental institutions, The Statistical Manual for the Use of Institutions for the Insane. Its many revisions served as the official diagnostic classification scheme in America until 1952 when the first edition of the Diagnostic and Statistical Manual:Mental Disorders, or DSM-I, appeared. Dementia praecox disappeared from official psychiatry with the publication of DSM-I, replaced by the Bleuler/Meyer hybridization, "schizophrenic reaction".
Schizophrenia was mentioned as an alternate term for dementia praecox in the 1918 Statistical Manual. In both clinical work as well as research, between 1918 and 1952 five different terms were used interchangeably: dementia praecox, schizophrenia, dementia praecox (schizophrenia), schizophrenia (dementia praecox) and schizophrenic reaction. This made the psychiatric literature of the time confusing since, in a strict sense, Kraepelin's disease was not Bleuler's disease. They were defined differently, had different population parameters, and different concepts of prognosis.
The reception of dementia praecox as an accepted diagnosis in British psychiatry came more slowly, perhaps only taking hold around the time of World War I. There was substantial opposition to the use of the term "dementia" as misleading, partly due to findings of remission and recovery. Some argued that existing diagnoses such as "delusional insanity" or "adolescent insanity" were better or more clearly defined. In France a psychiatric tradition regarding the psychotic disorders predated Kraepelin, and the French never fully adopted Kraepelin's classification system. Instead the French maintained an independent classification system throughout the 20th century. After 1980, when DSM-III totally reshaped psychiatric diagnosis, French psychiatry began to finally alter its views of diagnosis to converge with the North American system. Kraepelin thus finally conquered France via America.
The term "schizophrenia" was first applied by American alienists and neurologists in private practice by 1909 and officially in institutional settings in 1913, but it took many years to catch on. It is first mentioned in The New York Times
in 1925. Until 1952 the terms dementia praecox and schizophrenia were used interchangeably in American psychiatry, with occasional use of the hybrid terms "dementia praecox (schizophrenia)" or "schizophrenia (dementia praecox)".
(RDC) in the 1970s that were independent of any clinical diagnostic manual, Kraepelin's idea that categories of mental disorder should reflect discrete and specific disease entities with a biological basis began to return to prominence. Vague dimensional approaches based on symptoms—so highly favored by the Meyerians and psychoanalysts—were overthrown. For research purposes, the definition of schizophrenia returned to the narrow range allowed by Kraepelin's dementia praecox concept. Furthermore, after 1980 the disorder was a progressively deteriorating one once again, with the notion that recovery, if it happened at all, was rare. This revision of schizophrenia became the basis of the diagnostic criteria in DSM-III (1980). Some of the psychiatrists who worked to bring about this revision referred to themselves as the "neo-Kraepelinians".
Arnold Pick
Arnold Pick was a Czech neurologist and psychiatrist. He is known for identifying the clinical syndrome of Pick's Disease and the Pick bodies that are characteristic of the disorder. He was the first to name reduplicative paramnesia. He was also to use the term dementia praecox .- External links...
(1851–1924), a professor of psychiatry at the German branch of Charles University in Prague
Charles University in Prague
Charles University in Prague is the oldest and largest university in the Czech Republic. Founded in 1348, it was the first university in Central Europe and is also considered the earliest German university...
. His brief clinical report described the case of a person with a psychotic disorder resembling hebephrenia (see below). It was popularized by German psychiatrist Emil Kraepelin
Emil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
(1856–1926) in 1893, 1896 and 1899 in his first detailed textbook descriptions of a condition that would eventually be reframed into a substantially different disease concept and relabeled as schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
. Kraepelin, regarding the major psychoses as naturally occurring disease entities, simplified the complex psychiatric taxonomies of the nineteenth century by dividing them into two classes: manic depressive psychosis or dementia praecox. This division is commonly referred to as the Kraepelinian dichotomy
Kraepelinian dichotomy
The Kraepelinian dichotomy refers to the division of the major endogenous psychoses into the disease concepts of dementia praecox, which was reformulated as schizophrenia by Eugen Bleuler in 1911, and manic-depressive psychosis, which has now been reconceived as bipolar disorder. This division was...
and it has had a significant impact on twentieth-century psychiatry.
The primary disturbance in dementia praecox is not one of mood
Mood (psychology)
A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
(as is the case in manic-depressive illness), but of thinking or cognition
Cognition
In science, cognition refers to mental processes. These processes include attention, remembering, producing and understanding language, solving problems, and making decisions. Cognition is studied in various disciplines such as psychology, philosophy, linguistics, and computer science...
. Cognitive disintegration refers to a disruption in cognitive or mental functioning such as in attention, memory, and goal-directed behavior.
From the outset, dementia praecox was viewed by Kraepelin as a progressively deteriorating disease from which no one recovered. The three terms that Kraepelin used to refer to the end state of the disease were "Verblödung" (deterioration), Schwachsinn (mental weakness) or Defekt (defect). Although "dementia" is part of the name of the disease, Kraepelin did not intend it to be similar to senile dementia and rarely used this term to refer to the end state of the disease. However, by 1913, and more explicitly by 1920, Kraepelin admitted that although there seemed to be a residual cognitive defect in most cases, the prognosis was not as uniformly dire as he had stated in the 1890s. Still, he regarded it as a specific disease concept that implied incurable, inexplicable madness.
History
First use of the term
The term dementiaDementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
is an ancient term which has been in use since at least the time of Lucretius
Lucretius
Titus Lucretius Carus was a Roman poet and philosopher. His only known work is an epic philosophical poem laying out the beliefs of Epicureanism, De rerum natura, translated into English as On the Nature of Things or "On the Nature of the Universe".Virtually no details have come down concerning...
in 50 B.C.E. where it meant "being out of one's mind". Until the seventeenth century dementia referred to states of cognitive and behavioural deterioration leading to psychosocial incompetence. This condition could be innate or acquired and the concept had no reference to a necessarily irreversible condition. It is the concept in this popular notion of psychosocial incapacity that forms the basis for the idea of legal incapacity. By the eighteenth century, at the period when the term entered into European medical discourse, clinical concepts were added to the vernacular understanding such that dementia was now associated with intellectual deficits arising from any cause and at any age. By the end of the nineteenth century the modern 'cognitive paradigm' of dementia was taking root. This holds that dementia is understood in terms of criteria relating to aetiology, age and course which excludes former members of the family of the demented such as adults with acquired head trauma or children with cognitive deficits. Moreover, it was now understood as an irreversible condition and a particular emphasis was placed on memory loss in regard to the deterioration of intellectual functions.
The term démence précoce was used in passing to describe the characteristics of a subset of young mental patients by the French physician Bénédict Augustin Morel
Bénédict Morel
Bénédict Augustin Morel , was a French physician born in Vienna, Austria. He was an influential figure in the field of psychiatry during the mid-19th century....
in 1852 in the first volume of his Études cliniques. and the term is used more frequently in his textbook Traité des maladies mentales which was published in 1860. Morel, whose name will be forever associated with religiously inspired concept of degeneration theory
Degeneration
The idea of degeneration had significant influence on science, art and politics from the 1850s to the 1950s. The social theory developed consequently from Charles Darwin's Theory of Evolution...
in psychiatry, used the term in a descriptive sense and not to define a specific and novel diagnostic category. It was applied as a means of setting apart a group of young men and women who were suffering from "stupor." As such their condition was characterised by a certain torpor, enervation, and disorder of the will and was related to the diagnostic category of melancholia
Melancholia
Melancholia , also lugubriousness, from the Latin lugere, to mourn; moroseness, from the Latin morosus, self-willed, fastidious habit; wistfulness, from old English wist: intent, or saturnine, , in contemporary usage, is a mood disorder of non-specific depression,...
. He did not conceptualise their state as irreversible and thus his use of the term dementia was equivalent to that formed in the eighteenth century as outlined above.
While some have sought to interpret, if in a qualified fashion, the use by Morel of the term démence précoce as amounting to the "discovery" of schizophrenia, others have argued convincingly that Morel's discriptive use of the term should not be considered in any sense as a precursor to Kraepelin's dementia praecox disease concept. This is due to the fact that their concepts of dementia differed significantly from each other, with Kraepelin employing the more modern sense of the word and that Morel was not describing a diagnostic category. Indeed, until the advent of Pick and Kraepelin, Morel's term had vanished without a trace and there is little evidence to suggest that either Pick or indeed Kraepelin were even aware of Morel's use of the term until long after they had published their own disease concepts bearing the same name. As Eugène Minkowski succinctly stated, 'An abyss separates Morel's démence précoce from that of Kraepelin.'
Morel described several psychotic disorders that ended in dementia, and as a result he may be regarded as the first alienist or psychiatrist to develop a diagnostic system based on presumed outcome rather than on the current presentation of signs and symptoms. Morel, however, did not conduct any long-term or quantitative
Quantitative research
In the social sciences, quantitative research refers to the systematic empirical investigation of social phenomena via statistical, mathematical or computational techniques. The objective of quantitative research is to develop and employ mathematical models, theories and/or hypotheses pertaining to...
research on the course and outcome of dementia praecox (Kraepelin would be the first in history to do that) so this prognosis was based on speculation. It is impossible to discern whether the condition briefly described by Morel was equivalent to the disorder later called dementia praecox by Pick and Kraepelin.
The time component
Psychiatric nosology in the nineteenth-century was chaotic and characterised by a conflicting mosaic of contradictory systems. Psychiatric disease categories were based upon short-term and cross-sectional observations of patients from which were derived the putative characteristic signsMedical sign
A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....
and symptoms of a given disease concept.
The dominant psychiatric paradigms which gave a semblance of order to this fragmentary picture were Morelian degeneration theory and the concept of "unitary psychosis
Unitary psychosis
Unitary psychosis refers to the 19th-century belief prevalent in German psychiatry until the era of Emil Kraepelin that all forms of psychosis were surface variations of a single underlying disease process...
" (Einheitspsychose). This latter notion, derived from the Belgian psychiatrist Joseph Guislain
Joseph Guislain
Joseph Guislain was a Belgian physician and a pioneer in psychiatry.-Education:Guislain started his medical studies at Ecole de Médicine and he was one of the first students to the University of Ghent; he graduated as a medical doctor in 1819.-Career:In 1828 Guislain became head of the psychiatric...
(1797–1860), held that the variety of symptoms attributed to mental illness were manifestations of a single underlying disease process. While these approaches had a diachronic
Diachronic
Diachronic or Diachronous,from the Greek word Διαχρονικός , is a term for something happening over time. It is used in several fields of research.*Diachronic linguistics : see Historical linguistics...
aspect they lacked a conception of mental illness that encompassed a coherent notion of change over time in terms of the natural course of the illness and based upon an empirical observation of changing symptomatology.
In 1863, the Danzig based psychiatrist, Karl Ludwig Kahlbaum
Karl Ludwig Kahlbaum
Karl Ludwig Kahlbaum was a German psychiatrist. In 1855 he received his medical doctorate at Berlin, and subsequently worked as a physician at the mental asylum in Wehlau. For a period of time he was also a lecturer at the University of Königsberg , and from 1867 was director of the mental...
(1828–1899), published his text on psychiatric nosology Die Gruppierung der psychischen Krankheiten (The Classification of Psychiatric Diseases). Although with the passage of time this work would prove profoundly influenital, when it was published it was almost complete ignored by German academia despite the sophisticated and intelligent disease classification system which it proposed. In this book Kahlbaum categorized certain typical forms of psychosis (vesania typica) as a single coherent type based upon their shared progressive nature which betrayed, he argued, an ongoing degenerative disease process. For Kahlbaum the disease process of vesania typica was distinguished by the passage of the sufferer through clearly defined disease phases: a melancholic stage; a manic stage; a confusional stage; and finally a demented stage.
In 1866 Kahlbaum became the director of a private psychiatric clinic in Görlitz
Görlitz
Görlitz is a town in Germany. It is the easternmost town in the country, located on the Lusatian Neisse River in the Bundesland of Saxony. It is opposite the Polish town of Zgorzelec, which was a part of Görlitz until 1945. Historically, Görlitz was in the region of Upper Lusatia...
(Prussia
Prussia
Prussia was a German kingdom and historic state originating out of the Duchy of Prussia and the Margraviate of Brandenburg. For centuries, the House of Hohenzollern ruled Prussia, successfully expanding its size by way of an unusually well-organized and effective army. Prussia shaped the history...
, today Saxony
Saxony
The Free State of Saxony is a landlocked state of Germany, contingent with Brandenburg, Saxony Anhalt, Thuringia, Bavaria, the Czech Republic and Poland. It is the tenth-largest German state in area, with of Germany's sixteen states....
, a small town near Dresden
Dresden
Dresden is the capital city of the Free State of Saxony in Germany. It is situated in a valley on the River Elbe, near the Czech border. The Dresden conurbation is part of the Saxon Triangle metropolitan area....
). He was accompanied by his younger assistant, Ewald Hecker
Ewald Hecker
Ewald Hecker was a German psychiatrist who was an important figure in the early days of modern psychiatry. He is known for research done with his mentor, psychiatrist Karl Ludwig Kahlbaum ....
(1843–1909), and during a ten-year collaboration they conducted a series of research
Research
Research can be defined as the scientific search for knowledge, or as any systematic investigation, to establish novel facts, solve new or existing problems, prove new ideas, or develop new theories, usually using a scientific method...
studies on young psychotic patients that would become a major influence on the development of modern psychiatry.
Together Kahlbaum and Hecker were the first to describe and name such syndrome
Syndrome
In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one or more features alerts the physician to the possible presence of the others...
s as dysthymia, cyclothymia
Cyclothymia
Cyclothymia is a mood and mental disorder in the bipolar spectrum that causes both hypomanic and depressive episodes. It is defined medically within the bipolar spectrum and consists of recurrent disturbances between sudden hypomania and dysthymic episodes. The diagnosis of cyclothymic disorder is...
, paranoia
Paranoia
Paranoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...
, catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....
, and hebephrenia. Perhaps their most lasting contribution to psychiatry was the introduction of the "clinical method" from medicine to the study of mental diseases, a method which is now known as psychopathology
Psychopathology
Psychopathology is the study of mental illness, mental distress, and abnormal/maladaptive behavior. The term is most commonly used within psychiatry where pathology refers to disease processes...
.
When the element of time was added to the concept of diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
, a diagnosis became more than just a description of a collection of symptoms: diagnosis now also defined by prognosis
Prognosis
Prognosis is a medical term to describe the likely outcome of an illness.When applied to large statistical populations, prognostic estimates can be very accurate: for example the statement "45% of patients with severe septic shock will die within 28 days" can be made with some confidence, because...
(course and outcome). An additional feature of the clinical method was that the characteristic symptoms that define syndromes should be described without any prior assumption of brain pathology (although such links would be made later as scientific knowledge progressed). Karl Kahlbaum made an appeal for the adoption of the clinical method in psychiatry in his 1874 book on catatonia. Without Kahlbaum and Hecker there would be no dementia praecox.
Upon his appointment to a full professorship in psychiatry at the University of Dorpat (now Tartu
Tartu
Tartu is the second largest city of Estonia. In contrast to Estonia's political and financial capital Tallinn, Tartu is often considered the intellectual and cultural hub, especially since it is home to Estonia's oldest and most renowned university. Situated 186 km southeast of Tallinn, the...
, Estonia
Estonia
Estonia , officially the Republic of Estonia , is a state in the Baltic region of Northern Europe. It is bordered to the north by the Gulf of Finland, to the west by the Baltic Sea, to the south by Latvia , and to the east by Lake Peipsi and the Russian Federation . Across the Baltic Sea lies...
) in 1886, Kraepelin gave an inaugural address to the faculty outlining his research programme for the years ahead. Attacking the "brain mythology" of Meynert
Theodor Meynert
Theodor Hermann Meynert was a German-Austrian neuropathologist and anatomist who was born in Dresden.In 1861 he earned his medical doctorate, and in 1875 became director of the psychiatric clinic associated with the University of Vienna. One of his better known students in Vienna was Sigmund...
and the positions of Griesinger
Wilhelm Griesinger
Wilhelm Griesinger was a German neurologist and psychiatrist born in Stuttgart. He studied under Johann Lukas Schönlein at the University of Zurich and physiologist François Magendie in Paris....
and Gudden
Bernhard von Gudden
Johann Bernhard Aloys von Gudden was a German neuroanatomist and psychiatrist born in Kleve.In 1848 he earned his doctorate from the University of Halle, and became an intern at the asylum in Siegburg under Carl Wigand Maximilian Jacobi...
, Kraepelin
Emil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
advocated that the ideas of Kahlbaum, who was then a marginal and little known figure in psychiatry, should be followed. Therefore, he argued, a research programme into the nature of psychiatric illness should look at a large number of patients over time to discover the course which mental disease could take.
It has also been suggested that Kraepelin's decision to accept the Dorpat post was informed by the fact that there he could hope to gain experience with chronic patients and this, it was presumed, would facilitate the longitudinal study of mental illness.
The quantitative component
Understanding that objective diagnostic methods must be based on scientific practice, Kraepelin had been conducting psychological and drug experiments on patients and normal subjects for some time when, in 1891, he left Dorpat and took up a position as professor and director of the psychiatric clinic at Heidelberg University. There he established a research program based on Kahlbaum's proposal for a more exact qualitative clinical approach, and his own innovation: a quantitative approach involving meticulous collection of data over time on each new patient admitted to the clinic (rather than only the interesting cases, as had been the habit until then).Kraepelin believed that by thoroughly describing all of the clinic's new patients on index cards, which he had been using since 1887, researcher
Researcher
A researcher is somebody who performs research, the search for knowledge or in general any systematic investigation to establish facts. Researchers can work in academic, industrial, government, or private institutions.-Examples of research institutions:...
bias could be eliminated from the investigation process. He described the method in his posthumously published memoir:
The fourth edition of his textbook, Psychiatrie, published in 1893, two years after his arrival at Heidelberg, contained some impressions of the patterns Kraepelin had begun to find in his index cards. Prognosis (course and outcome) began to feature alongside signs and symptoms in the description of syndromes, and he added a class of psychotic disorders designated "psychic degenerative processes", three of which were borrowed from Kahlbaum and Hecker: dementia paranoides (a degenerative type of Kahlbaum's paranoia, with sudden onset), catatonia (per Kahlbaum, 1874) and dementia praecox, (Hecker's hebephrenia of 1871). Kraepelin continued to equate dementia praecox with hebephrenia for the next six years.
In the March 1896 fifth edition of Psychiatrie, Kraepelin expressed confidence that his clinical
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
method
Scientific method
Scientific method refers to a body of techniques for investigating phenomena, acquiring new knowledge, or correcting and integrating previous knowledge. To be termed scientific, a method of inquiry must be based on gathering empirical and measurable evidence subject to specific principles of...
, involving analysis of both qualitative
Qualitative research
Qualitative research is a method of inquiry employed in many different academic disciplines, traditionally in the social sciences, but also in market research and further contexts. Qualitative researchers aim to gather an in-depth understanding of human behavior and the reasons that govern such...
and quantitative
Quantitative research
In the social sciences, quantitative research refers to the systematic empirical investigation of social phenomena via statistical, mathematical or computational techniques. The objective of quantitative research is to develop and employ mathematical models, theories and/or hypotheses pertaining to...
data derived from long term observation of patients, would produce reliable diagnoses including prognosis:
In this edition dementia praecox is still basically hebephrenia, and it, dementia paranoides and catatonia are described as distinct psychotic disorders among the "metabolic disorders leading to dementia".
Kraepelin's influence on the next century
In the 1899 (6th) edition of Psychiatrie, Kraepelin established a paradigm for psychiatry that would dominate the following century, sorting most of the recognized forms of insanity into two major categories: dementia praecox and manic-depressive illness. Dementia praecox was characterized by disordered intellectual functioning, whereas manic-depressive illness was principally a disorder of affect or mood; and the former featured constant deterioration, virtually no recoveries and a poor outcome, while the latter featured periods of exacerbation followed by periods of remission, and many complete recoveries. The class, dementia praecox, comprised the paranoid, catatonic and hebephrenic psychotic disorders, and these forms are still found today in the DSM-IV-TR's paranoid, catatonic and disorganized types of schizophrenia. The ICD-10ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
still uses "hebephrenic" to designate the third type. These subtypes may be dropped from the next edition of the DSM, DSM-V, due to be published in May 2013.
Change in prognosis
In the seventh, 1904, edition of Psychiatrie, Kraepelin accepted the possibility that a small number of patients may recover from dementia praecox. Eugen BleulerEugen Bleuler
Paul Eugen Bleuler was a Swiss psychiatrist most notable for his contributions to the understanding of mental illness and for coining the term "schizophrenia."-Biography:...
reported in 1908 that in many cases there was no inevitable progressive decline, there was temporary remission in some cases, and there were even cases of near recovery with the retention of some residual defect. In the eighth edition of Kraepelin's textbook, published in four volumes between 1909 and 1915, he described eleven forms of dementia, and dementia praecox was classed as one of the "endogenous dementias". Modifying his previous more gloomy prognosis in line with Bleuler's observations, Kraepelin reported that about 26% of his patients experienced partial remission of symptoms. Kraepelin died while working on the ninth edition of Psychiatrie with Johannes Lange (1891–1938), who finished it and brought it to publication in 1927.
Etiology
Though his work and that of his research associates had revealed a role for heredity, Kraepelin realized nothing could be said with certainty about the etiology of dementia praecox, and he left out speculation regarding brain disease or neuropathology in his diagnostic descriptions. Nevertheless, from the 1896 edition onwards Kraepelin made clear his belief that poisoning of the brain, "autointoxication", probably by sex hormones, may underlie dementia praecox – a theory also entertained by Eugen Bleuler. Both theorists insisted dementia praecox is a biological disorder, not the product of psychological trauma. Kraepelin, recognizing dementia praecox in Chinese, Japanese, Tamil and Malay patients, suggested in the eighth edition of Psychiatrie that, "we must therefore seek the real cause of dementia praecox in conditions which are spread all over the world, which thus do not lie in race or in climate, in food or in any other general circumstance of life..."Treatment
Kraepelin had experimented with hypnosis but found it wanting, and disapproved of Freud's and Jung's introduction, based on no evidence, of psychogenic assumptions to the interpretation and treatment of mental illness. He argued that, without knowing the underlying cause of dementia praecox or manic-depressive illness, there could be no disease-specific treatment, and recommended the use of long baths and the occasional use of drugs such as opiates and barbiturates for the amelioration of distress, as well as occupational activities, where suitable, for all institutionalized patients. Based on his theory that dementia praecox is the product of autointoxication emanating from the sex glands, Kraepelin experimented, without success, with injections of thyroid, gonad and other glandular extracts.Use of term spreads
Kraepelin noted the dissemination of his new disease concept when in 1899 he enumerated the term's appearance in almost twenty articles in the German-language medical press. In the early years of the twentieth century the twin pillars of the Kraepelinian dichotomy, dementia praecox and manic depressive psychosis, were assiduously adopted in clinical and research contexts among the Germanic psychiatric community. German-language psychiatric concepts were always introduced much faster in America (than, say, Britain) where émigré German, Swiss and Austrian physicians essentially created American psychiatry. Swiss-emigree Adolf Meyer (1866–1950), arguably the most influential psychiatrist in America for the first half of the 20th century, published the first critique of dementia praecox in an 1896 book review of the 5th edition of Kraepelin's textbook. But it was not until 1900 and 1901 that the first three American publications regarding dementia praecox appeared, one of which was a translation of a few sections of Kraepelin's 6th edition of 1899 on dementia praecox.Adolf Meyer was the first to apply the new diagnostic term in America. He used it at the Worcester Lunatic Hospital in Massachusetts in the fall of 1896. He was also the first to apply Eugen Bleuler's term "schizophrenia" (in the form of "schizophrenic reaction") in 1913 at the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital.
The dissemination of Kraepelin's disease concept to the Anglo-phone world was facilitated in 1902 when Ross Diefendorf, a lecturer in psychiatry at Yale, published an adapted version of the sixth edition of the Lehrbuch der Psychiatrie. This was republished in 1904 and with a new version, based on the seventh edition of Kraepelin's Lehrbuch appearing in 1907 and reissued in 1912. Both dementia praecox (in its three classic forms) and "manic-depressive psychosis" gained wider popularity in the larger institutions in the eastern United States after being included in the official nomenclature of diseases and conditions for record-keeping at Bellevue Hospital in New York City in 1903. The term lived on due to its promotion in the publications of the National Committee on Mental Hygiene (founded in 1909) and the Eugenics Records Office (1910). But perhaps the most important reason for the longevity of Kraepelin's term was its inclusion in 1918 as an official diagnostic category in the uniform system adopted for comparative statistical record-keeping in all American mental institutions, The Statistical Manual for the Use of Institutions for the Insane. Its many revisions served as the official diagnostic classification scheme in America until 1952 when the first edition of the Diagnostic and Statistical Manual:Mental Disorders, or DSM-I, appeared. Dementia praecox disappeared from official psychiatry with the publication of DSM-I, replaced by the Bleuler/Meyer hybridization, "schizophrenic reaction".
Schizophrenia was mentioned as an alternate term for dementia praecox in the 1918 Statistical Manual. In both clinical work as well as research, between 1918 and 1952 five different terms were used interchangeably: dementia praecox, schizophrenia, dementia praecox (schizophrenia), schizophrenia (dementia praecox) and schizophrenic reaction. This made the psychiatric literature of the time confusing since, in a strict sense, Kraepelin's disease was not Bleuler's disease. They were defined differently, had different population parameters, and different concepts of prognosis.
The reception of dementia praecox as an accepted diagnosis in British psychiatry came more slowly, perhaps only taking hold around the time of World War I. There was substantial opposition to the use of the term "dementia" as misleading, partly due to findings of remission and recovery. Some argued that existing diagnoses such as "delusional insanity" or "adolescent insanity" were better or more clearly defined. In France a psychiatric tradition regarding the psychotic disorders predated Kraepelin, and the French never fully adopted Kraepelin's classification system. Instead the French maintained an independent classification system throughout the 20th century. After 1980, when DSM-III totally reshaped psychiatric diagnosis, French psychiatry began to finally alter its views of diagnosis to converge with the North American system. Kraepelin thus finally conquered France via America.
From dementia praecox to schizophrenia
Due to the influence of alienists such as Adolf Meyer, August Hoch, George Kirby, Charles Macphie Campbell, Smith Ely Jelliffe and William Alanson White, psychogenic theories of dementia praecox dominated the American scene by 1911. In 1925 Bleuler's schizophrenia rose in prominence as an alternative to Kraepelin's dementia praecox. When Freudian perspectives became influential in American psychiatry in the 1920s schizophrenia became an attractive alternative concept. Bleuler corresponded with Freud and was connected to Freud's psychoanalytic movement, and the inclusion of Freudian interpretations of the symptoms of schizophrenia in his publications on the subject, as well as those of C.G. Jung, eased the adoption of his broader version of dementia praecox (schizophrenia) in America over Kraepelin's narrower and prognostically more negative one.The term "schizophrenia" was first applied by American alienists and neurologists in private practice by 1909 and officially in institutional settings in 1913, but it took many years to catch on. It is first mentioned in The New York Times
The New York Times
The New York Times is an American daily newspaper founded and continuously published in New York City since 1851. The New York Times has won 106 Pulitzer Prizes, the most of any news organization...
in 1925. Until 1952 the terms dementia praecox and schizophrenia were used interchangeably in American psychiatry, with occasional use of the hybrid terms "dementia praecox (schizophrenia)" or "schizophrenia (dementia praecox)".
Diagnostic manuals
Editions of the Diagnostic and Statistic Manual of Mental Disorders since the first in 1952 had reflected views of schizophrenia as "reactions" or "psychogenic" (DSM-I), or as manifesting Freudian notions of "defense mechanisms" (as in DSM-II of 1969 in which the symptoms of schizophrenia were interpreted as "psychologically self-protected"). The diagnostic criteria were vague, minimal and wide, including either concepts that no longer exist or that are now labeled as personality disorders (for example, schizotypal personality disorder). There was also no mention of the dire prognosis Kraepelin had made. Schizophrenia seemed to be more prevalent and more psychogenic and more treatable than either Kraepelin or Bleuler would have allowed.Conclusions
As a direct result of the effort to construct Research Diagnostic CriteriaResearch Diagnostic Criteria
The Research Diagnostic Criteria are a collection of psychiatric diagnostic criteria published in late 1970s . As psychiatric diagnoses widely varied especially between the USA and Europe, the purpose of the criteria were allow diagnoses to be consistent in psychiatric research...
(RDC) in the 1970s that were independent of any clinical diagnostic manual, Kraepelin's idea that categories of mental disorder should reflect discrete and specific disease entities with a biological basis began to return to prominence. Vague dimensional approaches based on symptoms—so highly favored by the Meyerians and psychoanalysts—were overthrown. For research purposes, the definition of schizophrenia returned to the narrow range allowed by Kraepelin's dementia praecox concept. Furthermore, after 1980 the disorder was a progressively deteriorating one once again, with the notion that recovery, if it happened at all, was rare. This revision of schizophrenia became the basis of the diagnostic criteria in DSM-III (1980). Some of the psychiatrists who worked to bring about this revision referred to themselves as the "neo-Kraepelinians".
Further reading
- Burgmair, Wolfgang & Eric J. Engstrom & Matthias Weber, et al., eds. Emil Kraepelin. 7 vols. Munich: Belleville, 2000-2008.
- Vol. VII: Kraepelin in Munich, Teil II: 1914-1926 (2008, forthcoming)
- Vol. VI: Kraepelin in Munich, Teil I: 1903-1914 (2006), ISBN 3-933510-95-3
- Vol. V: Kraepelin in Heidelberg, 1891-1903 (2005), ISBN 3-933510-94-5
- Vol. IV: Kraepelin in Dorpat, 1886-1891 (2003), ISBN 3-933510-93-7
- Vol. III: Briefe I, 1868-1886 (2002), ISBN 3-933510-92-9
- Vol. II: Kriminologische und forensische Schriften: Werke und Briefe (2001), ISBN 3-933510-91-0
- Vol. I: Persönliches, Selbstzeugnisse (2000), ISBN 3-933510-90-2
- Engels, Huub (2006). Emil Kraepelins Traumsprache 1908-1926. annotated edition of Kraepelin's dream speechDream speechIn 1906 the famous German psychiatrist Emil Kraepelin published a monograph titled Über Sprachstörungen im Traume . In his psychiatry textbook Kraepelin used the shortcut Traumsprache to denote language disturbances occurring in dreams...
in the mentioned period. ISBN 978-90-6464-060-5. - Kraepelin, EmilEmil KraepelinEmil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
. Psychiatrie: Ein kurzes Lehrbuch fur Studirende und Aerzte. Vierte, vollstandig umgearbeitete Auflage. Leipzig: Abel Verlag, 1893. - Kraepelin, Emil. Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte. Funfte, vollstandig umgearbeitete Auflage. Leipzig: Verlag von Johann Ambrosius Barth, 1896.
- Kraepelin, Emil. Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte. Sechste, vollstandig umgearbeitete Auflage. Leipzig: Verlag von Johann Ambrosius Barth, 1899.
- Pick, Arnold. Ueber primare chronische Demenz (so. Dementia praecox) im jugendlichen Alter. Prager medicinische Wochenschrift, 1891, 16: 312-315.
Additional resources
- Bibliography of scholarly histories on schizophrenia and dementia praecox, part 1 (2000-mid 2007).