I agonized over that last post. I have no interest in discounting Emil Kraepelin or his legacy. I read that paper by Michael Shepherd in mid-morning and it didn’t get finished until after midnight – and it was on my mind the whole time. It felt like an unwanted hot potato – once in hand, it had to be dealt with and not ignored. I didn’t want to use it against the neoKraepelinian position with which I personally have little sympathy. I’d rather deal with that position directly. And Kraepelin’s contributions were nuclear to psychiatric nosology in a positive way. Schizophrenia, Affective Psychoses, Alzheimer’s Disease – all important concepts whether their unity stands the test of modern neuroscience or not.
His attitude towards alcohol paralleled the widely held thoughts of the era resulting in Prohibition in the US from 1920-1933. His opinion that Syphilis was a symbol of promiscuity and moral failing was also widely held. If you’ve ever seen Tertiary Syphilis, it’s a very bad disease and he had a hospital full of such patients. Prevention was the only treatment in his day and time. From Shepherd:
Basing his stand on his extensive experience of institutional psychiatry, he expressed himself forcibly on the prevention of alcoholism and syphilis, two of the indisputable causes of severe psychosis. In 1895 he advocated total abstinence from alcohol and thenceforward was a tireless, even a fanatical supporter of anti-alcohol campaigns…
His opinions about and contempt for the psychoanalysts of his day were certainly his to have, and were shared by many of his contemporaries:
We meet everywhere the characteristic fundamental features of the Freudian trend of investigation, the representation of arbitrary assumptions and conjectures as assured facts, which are used without hesitation for the building up of always new castles in the air ever towering higher, and the tendency to generalization beyond measure from single observations… As I am accustomed to walk on the sure foundation of direct experience, my Philistine conscience of natural science stumbles at every step on objections, considerations, and doubts, over which the likely soaring tower of imagination of Freud’s disciples carries them without difficulty.
But anything connected with early 20th century German Nationalism gives many of us an automatic startle because of what happened – the carnage of the World Wars, the Holocaust. It resides in the region of the unforgettable unimaginable. This whole notion of degenerates is too loaded with the Nazi brand to go unnoticed. But to be fair, guilt by association is not enough for an indictment. But there are some things along the way that do point specifically at his political views contaminating his science, like:
On the origins of hysteria, Kraepelin [1907: 458–9] wrote about ‘morbid’ constitution, ‘defective heredity’ and certain environmental conditions. He considered the possibility of uterine disturbances but said the role played by ‘the female sexual organs … is not clear’. In the eighth edition of Psychiatrie [1909–15], he considered at length [70 pages] the origins of paranoia: was it an outgrowth of ‘the hard blows life delivers to everyone’ or was it owing to innate degeneracy where ‘morbid germs … were already present in the disposition’ as in a genetic disease like Huntington’s chorea? [Kraepelin, 1921: 258, 264]. Kraepelin opted for degeneracy.
or maybe:
On individuals with distinctly hysterical traits: …among the leaders of current and past upheavals one also finds a surprising number of people who in one way or another fall outside the bounds of normality. In this latter category he concludes dreamers and poets, swindlers and Jews: The active participation of the Jewish race in political upheavals has something to do with this [morbidity]. The frequency of psychopathic predisposition in Jews could have played a role, although it is their harping criticism, their rhetorical and theatrical abilities, and their doggedness and determination which are most important.
or perhaps:
While still at Heidelberg he had formed the opinion that mental illnesses were above all social disorders and his views on the body politic [Volkskorper] are set out in his early paper on "Crime as a Social Disease", in which he extrapolated from his clinical experience and attributed most criminal behaviour to what he called a congenitally inferior predisposition [1906]…
That is a rhetorical fallacy, a Tautology. If a person does bad things, they have a "congenitally inferior predisposition." The action, or rather one’s judgement of the action, defines the person’s essence? their predisposition? The mental patient’s social functioning degenerates, ergo they have a degenerative disorder? No thanks. And then there’s this:
Attention must be focused above all on the fight against all those influences threatening to destroy future generations, in particular hereditary degeneration and genetic influences resulting from alcohol and syphilis.
How do "hereditary degeneration and genetic influences" result from "alcohol and syphilis"? That’s backwards! By the time Kraepelin wrote this, Gregory Mendel had come and gone and Mendelian Inheritance was taught everywhere. And finally:
Each of these examples starts with a premise – that "congenitally inferior predisposition," anlage, leads to social ills and/or mental illness – and the distinction between the two is hopelessly blurred. Even his critique of the Freudian "generalization beyond measure from single observations" is suspect, in that Kraepelin’s general assumption of constitutional inferiority is a priori, not even based on "observation" at all. It just is. When a scientist begins with an unproven assumption and uses it in an explanatory concept central to his scientific opinions, one must assume bias.
I’m always in dangerous waters with a topic like this. For my whole career, I’ve heard, "you’re just saying that because you’re a therapist, an analyst, a Freudian, a liberal, a dufus" – something not so savory. In this case, I think I’m saying it because it’s true. But I’m not saying to Kraepelin, "You’re just saying that because you’re a German, a Nazi, a Fascist, a right-winger, a dufus." I’m saying that Kraepelin was a man of his times, a German Nationalist devoted to his Fatherland and injured by its plight, by its defeat in World War I. I am saying that he obviously held the view that people were born as degenerates, constitutionally inferior. How could such a belief not color his view of people – mentally ill or not? Would he have participated in the racial policies along with his followers had he lived? If I had to guess from the things he said, he might have gone along with sterilization, considering his enthusiasm about prevention [and autocrats]:
Most promising is the prevention of insanity, though this is possible today only to the extent that we are acquainted with the causes of the affliction and are capable of combating it. We know the basic causes of the three major diseases: hereditary defects, alcoholism, and syphilis. They constitute, according to the most conservative estimates, at least one third of all mental disorders treated in our clinic. Then comes addiction to morphine and cocaine. Traumatic neuroses can also be prevented. An autocrat in possession of our present knowledge would be able, if he showed no consideration for the lifelong habits of men, to effect a significant reduction in the incidence of insanity within a few decades"…
But did Kraepelin’s notion of constitutional inferiority impact his legacy? our current nosology? I don’t know the answer to that and it’s the worst of things for idle speculation. It is an open question…
Mickey,
Perhaps one way to sort through possible answers to these sorts of questions is to try to understand why, after 1896, with all of the alternative “experts” in the treatment of nervous and mental disease in Europe and North America, was Kraepelin’s approach adopted? What about it was viewed as so new and clinically useful, and what perspetives did it replace? There are multiple angles of approach to answering this question, and I’ve thrown my hat into the ring with my assessment.
We see Kraepelin as a “turning point” in the historical narrative. We are fascinated by “turning points” because they seem so dramatic in retrospect, perhaps even causally incomprehensible. Just as with the changes in psychiatry since 1980, those of us who are old enough to have witnessed this look back and wonder: how did this happen? From the “here” of today we can see the multiple external economic (managed care in medicine, the rise of Pharma), social and intra-disciplinary forces that were at work, but while all this was going on we were busy with our own lives and careers and did not fully comprehend how profound they were until decades later. We always end up resorting to analogies and metaphors, and my favorite is Neurath’s boat rather than Kuhn’s paradigm shift.
Now, with respect to American psychiatry’s turn from “brain chemistry” to “brain circuitry,” I suspect a new mythic icon might be needed for marketing purposes, and also to signal a “new approach.” One of Kraepelin’s most prominent opponents was Carl Wernicke, who was doubtful about disease entities in psychiatry and promoted views that might be more consistent with the current “brain circuitry” buzz. I would not be surprised to see him anointed in the literature and a new marketing blitz led by “neo-Wernickean” members of a younger medical generation. No more totems such as Freud and Kraepelin.
Sigh. Welcome to the Generation Gap.
“Imagine sailors, who, far out at sea, transform the shape of their clumsy vessel from a more circular to a more fishlike one. They make use of some drifting timber, besides the timber of the old structure, to modify the skeleton and the hull of their vessel. But they cannot put the ship in dock in order to start from scratch. During their work they stay on the old structure and deal with heavy gales and thundering waves. In transforming their ship they take care that dangerous leakages do not occur. A new ship grows out of the old one, step by step—and while they are still building, the sailors may already be thinking of a new structure, and they will not always agree with one another. The whole business will go on in a way that we cannot even anticipate today. That is our fate.”
Otto Neurath, Foundations of the Social Sciences, 1944: 47.
FYI..
The anointing of Carl Wernicke as the RDoC totem for a post-neo-Kraepelinian age has already begun:
http://www.ncbi.nlm.nih.gov/pubmed/16353368?dopt=Abstract
http://schizophreniabulletin.oxfordjournals.org/content/37/6/1131.full#ref-12