Kraepelin was the founder of modern scientific psychiatry, the first to identify the two major psychoses, schizophrenia (dementia praecox) and manic-depression, and also the great reformer of the modern psychiatric institution. In spite of these unparalleled achievements, Kraepelin’s name is virtually unknown to the public and the details and extent of his achievements are equally unknown even to the vast majority of clinicians in the fields of psychiatry and psychology. In spite of his status as the unrecognized “Mendel of Psychiatry,” Kraepelin has been ranked in a recent reference text as one of the 100 greatest scientists in history in recognition of the fact that in large measure Kraepelin’s diagnostic system forms the basis for the American Psychiatric Association’s DSM-IV, the Diagnostic and Statistical Manual of Mental Disorders, on which all psychiatric diagnoses of patients are based.
Mozart had his Salieri, Plato had his Aristotle, Schopenhauer his Hegel, and Kraepelin…his Freud. Freud referred disorders of the mind principally to early childhood experiences and mysterious psychic forces, while Kraepelin believed such disorders could only be explained by the controlled experimental methods of neuroscience and genetics and the tried and true diagnostic techniques of biological medicine. Kraepelin dominated psychiatry through the first decades of the 20th century, and then faded into near-complete obscurity. In contrast to Kraepelin’s acknowledgment that psychiatry has no effective treatments or cures for most psychiatric disorders, Freud’s star rose when he claimed to be able to cure psychiatric disorders. Only in the last couple of decades has Kraepelin’s work been rediscovered by the leading researchers in psychiatry, who in large measure based the DSM-III and DSM-IV on Kraepelin’s approach to the classification of mental disorders.
It is Kraepelin, not Freud, who is the central figure in the history of psychiatry. Freud…did not see patients with psychotic illness. His doctrine of psychoanalysis, based on intuitive leaps of fantasy, did not stand the test of time. By contrast, Kraepelin…provided the single most significant insight that the late nineteenth and early twentieth centuries had to offer into major psychiatric illness: that there are several principal types, that they have very different courses, and that their nature may be appreciated through the systematic study of large numbers of cases.
This was a brilliant classification that has stood the test of time. In Kraepelin’s system, there were the psychoses mentioned above, the Dementias [brain diseases like Senile Dementia, Alzheimer’s Disease] and the syndromes of known etiology [toxic brain syndromes like DTs, and at that time Tertiary Syphilis]. It was an elegant piece of work. Add in the time honored Melancholia, and it constituted a system that contained the major psychiatric disorders. Kraepelin’s conditions live today in my head almost unmodified from his original descriptions. Kraepelin thought these were biological disorders. I do too, though proof remains elusive. And I would’ve written the above before the coming of the DSM-III if I had been asked.
Although Adolf Meyer [1866-1950] was essentially the father of American Psychiatry, we didn’t teach him in the medical school course, or for that matter, in the residency program – even though his thinking had dominated the Nomenclature for Mental Illness before the 1980 DSM-III revision. It’s because there wasn’t a whole lot to teach that hadn’t been incorporated by psychiatry proper. I had the opportunity to read the book that was compiled by his students, Common Sense Psychiatry, because there was a copy in the base hospital library when I was in the Air Force [as an Internist]. His focus was on collecting very detailed case histories from patients and insisted that they could best be understood through consideration of their life situations. It was called the biopsychosocial model which essentially meant "look everywhere." The patient is a novel. Read it, and the symptoms [and life] will make sense. The more you learn, the more sense things will make. That approach remains the bedrock of psychiatry as practiced by 1boringoldman. And Meyer classified illness by symptoms – e.g. anxiety reaction, depressive reaction, psychophysiological gastrointestinal reaction, etc.
Sigmund Freud [1858-1938] was a contemporary of both Kraepelin and Meyer. His ideas are difficult to summarize because they changed over the course of the forty years of his career. His formal theories are easily criticized, particularly his earlier theories. I have no interest in defending this guy who I consider a brilliant pioneer. He was a Darwinian who saw humans as animals with biological instinctual motivations similar to our non-human ancestors – sex, aggression, self preservation. He conceptualized our developing mind as carrying "structures" developed over time that were dependent on our unique experience and could get us in big trouble in later life if they were formed in conflict. He developed techniques to understand the forces in the mind like repression and transference. He made lots of misfires along the way, but initiated a process still ongoing to understand the illness generated by the mind, not the brain. I’m not a strictly "Freudian" Analyst having focused my attention of the later work of the British Object Relations analysts and on traumatic illness, but I give Freud the credit for looking at the "mind" – that’s the part I wanted to look at myself.
All of this is to say that when I read about Kraepelin being unknown, eclipsed by Freud’s promises of "cure" with "leaps of fantasy," it doesn’t make any immediate sense to me. Freud wasn’t talking about the Major Psychiatric Illnesses as defined by Kraepelin. He was talking about people who hurt in other ways. It feels like a false dichotomy. I was sure around when the DSM-III came out and felt the wave of anti-psychoanalytic furor that followed. But feeling it and understanding it are two different things. What I’ve later understood is that in America, psychoanalysts had dominated psychiatry for years and, importantly, were filing for insurance reimbursement for long, and optional analyses. That I understand. It was about money and about power. Frankly, I have no interest in engaging that conflict. I expect non-analyst psychiatrists had a plenty legitimate beef in the 1980s, maybe still do. Psychoanalysts have become increasingly focused on teaching psychodynamic psychotherapy to an eclectic group of therapists, including psychiatrists, which is fine with me. It’s what I did in my practice, and I found it to be an effective and productive way of approaching the non-major mental illnesses. That’s not why I’m going on about this right now.
Sunday morning: a walk with the dog, fresh cantalope, good coffee and reflections from 1boringoldman. Still wondering about that teenage girl I saw on the PBS special: so did she have “true” melancholia, a real Karepelinian psychosis??? If so, was trying five classes of psychotropic drugs and multiple ECTs warranted? Clearly, she wasn’t suffering from poverty or neglect. Or, has our world just become so twisted that we’ve made it virtually impossible from some of our more sensitive adolescents to navigate through it? A psychologist I used to work with referred to it as “being it this world disorder”.
‘…he came up with a classification based on conditions.’
Kraepelin also saw how conditions are related. He formulated the concept of ‘a single morbid process’ underlying the various presentations of manic-depressive illness, from mild or temperamental forms to psychotic and incapacitated forms. He was able to do that because he accorded due weight to family history and past history and prospective course of illness. These key factors are absent in the DSM-III criteria for mood disorders.
This is how DSM-III criteria came to be decontextualized symptom lists.