Dementia praecox ("premature
dementiaDementia is a serious cognitive disorder. It may be static, the result of a unique global brain injury or progressive, resulting in long-term decline in cognitive function due to damage or disease in the body beyond what might be expected from normal aging...
") 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 PickArnold Pick was a German 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 PragueCharles University in Prague is the oldest and largest university in the Czech Republic. Founded in 1347, it was the first university in the Holy Roman Empire and in Central Europe in general...
. 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 KraepelinEmil Kraepelin was a German psychiatrist. The Encyclopedia of Psychology by H. J. Eysenck identifies him as the founder of contemporary scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological...
(1856-1926) in 1896 in his first detailed description of a condition that would eventually be reframed and relabeled as
schizophreniaSchizophrenia , from the Greek roots skhizein and phrēn, phren- is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality...
.
The primary disturbance in dementia praecox is not one of
moodA mood is a relatively long lasting emotional state. Moods differ from simple 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
cognitionCognition is the scientific term for "the process of thought". Usage of the term varies in different disciplines; for example in psychology and cognitive science, it usually refers to an information processing view of an individual's psychological functions...
. 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 degenerating disease from which no one recovered. 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.
First use of the term
The term
démence précoce was used to describe a psychotic disorder by the French physician
Benedict-Augustin MorelBénédict 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 1853, and later used in his 1860 textbook,
Traité des maladies mentales. Morel used the term to define a disorder that first struck men in their teenage or young adult years, after which their intellectual functioning rapidly deteriorated. Morel saw this mental disorder as being within the larger context of his theory of
degenerationThe 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...
. These young men were beginning a rapid intellectual deterioration that would result in total disability and possible death.
Morel described an entire category of 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
quantitativeQuantitative research is the systematic scientific investigation of quantitative properties and phenomena and their relationships. The objective of quantitative research is to develop and employ mathematical models, theories and/or hypotheses pertaining to natural phenomena...
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 brief description of the disorder described by Morel was equivalent to the disorder later called dementia praecox by Pick and Kraepelin. Nor is there any reason to conclude that either of these men used Morel as a source of inspiration for their concepts.
The time component
In 1863, Karl Kahlbaum (1828-1899) of Danzig published
Die Gruppierung der psychischen Krankheiten (The Classification of Psychiatric Diseases). In this book, Kahlbaum described a class of progressively degenerating psychotic disorders that he grouped under the term "Vesania typical" (typical insanity). In 1866 Kahlbaum became the director of a private psychiatric clinic in
GörlitzGörlitz is a town in Germany 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 belongs to the region of Upper Lusatia and Silesia. Today it is the easternmost town in Germany...
(
PrussiaPrussia was a historic state originating out of the Duchy of Prussia and the Margraviate of Brandenburg. For centuries this state had substantial influence on German and European history...
, today
SaxonyThe Free State of Saxony is a federal state of Germany, located in the southeastern part of present-day Germany. It is the tenth-largest German state in area and the sixth largest in population , of Germany's sixteen states.Long in the heart of German-speaking Europe, Saxony became one of the new...
, a small town near
DresdenDresden is the capital city of the Free State of Saxony in Germany. It is situated in a valley on the River Elbe. The Dresden conurbation is part of the Saxon Triangle metropolitan area....
). He was accompanied by his younger assistant,
Ewald HeckerEwald 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 together they conducted a series of
researchResearch can be defined to be search for knowledge or any systematic investigation to establish facts. The primary purpose for applied research is discovering, interpreting, and the development of methods and systems for the advancement of human knowledge on a wide variety of scientific matters of...
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
syndromeIn medicine and psychology, the term syndrome refers to the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one feature alerts the physician to the presence of the others...
s as
dysthymiaDysthymic Disorder is a chronic mood disorder that falls within the depression spectrum. It is considered a chronic depression, but with less severity than major depressive disorder. This disorder tends to be a chronic, long-lasting illness....
,
cyclothymiaCyclothymia is a mood disorder and a form of bipolar disorder. It is defined in the bipolar spectrum. Specifically, this disorder is a milder form of bipolar II disorder consisting of recurrent mood disturbances between hypomania and dysthymic mood. A single episode of hypomania is sufficient to...
,
paranoiaParanoia is a thought process heavily influenced by excessive anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs concerning a perceived threat towards oneself. In the original Greek, παράνοια simply means madness...
,
catatoniaCatatonia is a syndrome of psychological and motorological disturbances. Karl Ludwig Kahlbaum first described it in 1874: Die Katatonie oder das Spannungirresein...
, 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
psychopathologyPsychopathology is a term which refers to either the study of mental illness or mental distress, or the manifestation of behaviors and experiences which may be indicative of mental illness or psychological impairment, such as abnormal, maladaptive behavior or mental activity.Psychopathology is that...
.
Other than Morel’s description of his degeneration theory, the element of time had largely been missing from definitions of mental disorders. Psychiatrists made assumptions about prognosis that were not based on careful observation of the changing symptoms of patients over time. Psychiatrists and other physicians who wrote about the insane arbitrarily invented names for insanities and described their characteristic
signsA 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 based on a short-term, cross-sectional
observationObservation is either an activity of a living being , consisting of receiving knowledge of the outside world through the senses, or the recording of data using scientific instruments. The term may also refer to any datum collected during this activity.-Observation in science:A scientific method...
period of their lunatic patients.
When the element of time was added to the concept of
diagnosisIn medicine, diagnosis is a label given for a medical condition or disease identified by its signs, symptoms, and from the results of various diagnostic procedures...
, a diagnosis became more than just a description of a collection of symptoms: diagnosis now also defined
prognosisPrognosis is a medical term to describe the likely outcome of an illness. When applied to large 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 previous...
(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 first made his 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.
The quantitative component
In 1891 Emil Kraepelin left his position at the university in Dorpat (now
TartuFor the French captain, see Jean-François TartuTartu 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....
,
EstoniaEstonia , officially the Republic of Estonia , is a country in 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 the Russian Federation...
) to become a professor and director of the psychiatric clinic at the University in Heidelberg,
GermanyGermany , officially the Federal Republic of Germany , is a country in Central Europe. It is bordered to the north by the North Sea, Denmark, and the Baltic Sea; to the east by Poland and the Czech Republic; to the south by Austria and Switzerland; and to the west by France, Luxembourg, Belgium,...
. Convinced of the value of Kahlbaum’s suggestions for a more exact qualitative clinical method in psychiatry, Kraeplin realized that by adding a quantitative component to such a research program he could place
psychiatryPsychiatry is a medical specialty officially devoted to the treatment and study of mental disorders. The term was first coined by the German physician Johann Christian Reil in 1808....
on a more scientific foundation.
Quantification helped to eliminate any
subjectiveSubjectivity refers to a person's perspective or opinion, particular feelings, beliefs, and desires. It is often used casually to refer to unsubstantiated personal opinions, in contrast to knowledge and fact-based beliefs. In philosophy, the term is often contrasted with...
biasBias is a term used to describe a tendency or preference towards a particular perspective, ideology or result, especially when the tendency interferes with the ability to be impartial, unprejudiced, or objective.. In other words, bias is generally seen as 'one-sided'. The term biased is used to...
es on the part of the
researcherA 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.-Job titles:...
. He began the first such research program of this nature in the history of psychiatry at Heidelberg in 1891, collecting
dataThe term data means groups of information that represent the qualitative or quantitative attributes of a variable or set of variables. Data are typically the results of measurements and can be the basis of graphs, images, or observations of a set of variables...
about every new patient that was admitted to the clinic (not just interesting cases, as had been the case in the past) and summarizing them on specially prepared index cards, his famous Zahlkarten. He had been keeping data on such cards since 1887. In his posthumously published
Memoirs (first published in German 61 years after his death) Kraepelin described his method:
. . . after the first thorough examination of a new patient, each of us had to throw in a note [in a "diagnosis box"] with his diagnosis written on it. After a while, the notes were taken out of the box, the diagnoses were listed, and the case was closed, the final interpretation of the disease was added to the original diagnosis. In this way, we were able to see what kind of mistakes had been made and were able to follow-up the reasons for the wrong original diagnosis (p. 61).
Kraepelin was obsessed with finding patterns in the data on these cards, at times taking them home with him or on vacation. In 1893, two years after starting his more rigorous research program in
HeidelbergHeidelberg is a city in Baden-Württemberg, Germany. As of 2008, over 145,000 people live within the city's area. Heidelberg is a unitary authority...
, the 4th edition of Kraepelin’s textbook,
Psychiatrie, reflected some preliminary impressions derived from the analysis of his cards. Clinical syndromes involved not only a diagnosis according to signs and symptoms, but also included course and outcome. In that edition he introduced a class of psychotic disorders he called "psychic degenerative processes." Three of these came directly from the work of Kahlbaum and Hecker: dementia paranoides (a sudden-onset, degenerative form of Kahlbaum’s paranoia; catatonia (directly from Kahlbaum’s 1874 monograph on the subject); and dementia praecox, which was essentially Hecker’s hebephrenia (as described in 1871). Dementia precox was hebephrenia and would remain so in Kraepelin’s thinking for 6 more years.
In March 1896 the 5th edition of Kraepelin’s textbook appeared. In it, Kraepelin stated that he was confident of the value of his
clinicalClinical trials are conducted to allow safety and efficacy data to be collected for new drugs or devices. These trials can only take place once satisfactory information has been gathered on the quality of the product and its non-clinical safety, and Health Authority/Ethics Committee approval is...
methodScientific 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 observable, empirical and measurable evidence subject to specific...
of using
qualitativeThe term qualitative is used to describe certain types of information. Qualitative data are described in terms of quality...
and
quantitativeQuantitative research is the systematic scientific investigation of quantitative properties and phenomena and their relationships. The objective of quantitative research is to develop and employ mathematical models, theories and/or hypotheses pertaining to natural phenomena...
data collected over a long period of observation of patients as a way of developing a diagnosis that included prognosis (course and outcome):
What convinced me of the superiority of the clinical method of diagnosis (followed here) over the traditional one, was the certainty with which we could predict (in conjunction with our new concept of disease) the future course of events. Thanks to it the student can now find his way more easily in the difficult subject of psychiatry. (preface, p. v)
In the 1896 5th edition, dementia praecox (still essentially hebephrenia), dementia paranoides, and catatonia are separate psychotic disorders included among "metabolic disorders leading to dementia."
Kraepelin's influence on the next century
In the 6th edition of Psychiatrie of 1899, Kraepelin reordered the psychiatric universe for the next century by grouping most of the insanities into two large categories, dementia praecox and manic-depressive illness. They were distinguished by the following characteristics: (1) dementia praecox was primarily a disorder of intellectual functioning, manic-depressive illness was primarily a disorder of affects or mood; (2) dementia praecox had a uniformly deteriorating course and a poor prognosis, manic-depressive insanity had a course of acute exacerbations followed by complete remissions with no lasting deterioration of intellectual functioning; and (3) there were no recoveries from dementia praecox, whereas in manic-depressive illness there were many complete recoveries. In 1899 dementia praecox took its now-familiar form as a heterogeneous class of psychotic disorders comprising hebephrenic, catatonic, and paranoid forms. These forms have persisted until today through Eugen Bleuler’s schizophrenia of 1908 (to which he added a fourth form, dementia simplex, or simple schizophrenia], and the main types of schizophrenia in DSM-IV-TR (the paranoid, catatonic and disorganized types, with the latter retaining its historical designation as the hebephrenic type in
ICD-10The International Statistical Classification of Diseases and Related Health Problems10th Revision is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization...
[1992]).
Change in prognosis
In the 7th edition of 1904 there was little change in the description of dementia praecox, but Kraepelin does admit for the first time that in a small number of cases that recovery from dementia praecox might occur.
The 8th edition of Kraepelin’s
Psychiatrie was a four-volume opus, each of which appeared in different years between 1909 and 1915. In this edition dememtia praecox became one of the "endogenous dementias." It is in the 1913 third volume (second part) of this edition that Kraepelin adjusts his concept of prognosis to admit that a partial remission of symptoms occurred in approximately 26 percent of his patients.
This brought dementia praecox in line with Eugen Bleuler’s claims about schizophrenia, which he had insisted from the start (in 1908) that (a) in many cases there was no fateful progressive deterioration, that (b) in some cases the symptoms did indeed remit for periods of time, and (c) that there were cases of complete recovery.
The 8th edition of 1913 is also notable for the fact that Kraepelin increased the number of forms of dementia to 11. However, the three classical original subtypes would remain as the most influential description of this disorder for the century that followed.
The 8th edition of
Psychiatrie was that last Kraepelin would produce in his lifetime. He was working on a 9th edition with Johannes Lange (1891-1938) but died in 1926 before it could be completed. Lange finished the bulk of it and published it in 1927.
Addition of etiology
Kraepelin realized that the state of scientific knowledge was such that definitive claims about the cause of dementia praecox could not be made.
HeredityHeredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause a species to evolve...
clearly played a role, as Kraepelin and his research associates had demonstrated this in their quantitative research. As a result of following the clinical method suggested by Kahlbaum, Kraepelin set aside claims about underlying brain disease or specific neuropathology in diagnostic descriptions of mental disorders. However, from the 5th edition of 1896 to the third volume of the 8th edition of 1913 it was clear that Kraepelin believed that dementia praecox was caused by a poisoning of the brain, and “autointoxication,” probably arising from the sex glands after puberty.
Universality of the disease
Kraepelin believed that dementia praecox was not a culture-bound syndrome and that it represented a disease process that could be found all over the world. Kraepelin himself loved to travel, and in Asia he observed that dementia praecox was similar to the European form of the illness in Chinese, Japanese, Tamil and Malay patients, leading him to suggest in the 8th 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
Without knowing the cause of dementia praecox or manic-depressive illness, Kraepelin repeatedly stated that there could be no treatments specific to these conditions. Treatment for these insanities was the same for any institutionalized patient with any diagnosis: the occasional use of drugs (opiates, barbiturates, and so on) to alleviate acute episodes of distress, prolonged baths (greatly admired by Kraepelin as a humane method of calming patients), and occupational activities (if possible). Kraepelin himself had experimented with hypnosis early in his career and found it lacking. Psychotherapy as such was not part of the medical cognition of Kraepelin. In fact, Kraepelin detested both Freud and Jung for introducing diagnostic terms and forms of treatment that had no empirical basis. Kraepelin did, however experiment for a while with organotherapy -- the injection of glandular extract from the thyroid, gonads and other organs -- but without success. This experimental therapy was a rational treatment based on his presumed cause of dementia praecox -- an autointoxication arising from the sex glands.
Use of term spreads
By 1899 Kraepelin himself had counted almost 20 German-language publications which made reference to his new diagnostic term, dementia praecox. In the decade after 1899 the number of German-language publications using Kraepelin’s categories of dementia praecox and manic-depressive illness as a basis for clinical speculation and experimental research exploded. 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 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.
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 of 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.’
The reception of dementia praecox as an accepted diagnosis in British psychiatry came much slower, perhaps only taking hold around the time of the First World War. 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 an older 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
Because so many influential American physicians began to take psychoanalysis seriously after Freud and Jung attended a conference at
Clark UniversityClark University is a private research university and liberal arts college in Worcester, Massachusetts.Founded in 1887, it is the oldest institution founded as an all-graduate university. Clark now also educates undergraduates...
in 1909, psychogenic theories of dementia praecox and, by 1920, Bleuler’s schizophrenia were openly accepted. Until 1910 Bleuler had been peripherally connected through Jung to Freud’s psychoanalytic movement, and this eased the adoption of his broader version of dementia praecox (schizophrenia) in America over Kraepelin’s more narrow and prognostically more negative one.
The term "schizophrenia" was first applied by American alienists and neurologists in clinical settings around the year 1918. It is first mentioned in
The New York TimesThe New York Times is an American daily newspaper founded in 1851 and published in New York City. The largest metropolitan newspaper in the United States, "The Gray Lady"—named for its staid appearance and style—is regarded as a national newspaper of record...
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 1968 in which the symptoms of schizophrenia were interpreted as "psychologically self-protected"). The diagnostic criteria were 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 treatable than either Kraepelin or Bleuler would have allowed.
Conclusions
As a direct result of the effort to construct
Research Diagnostic CriteriaThe 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 ideas began to return to prominence. For research purposes, the definition of schizophrenia returned to the narrow range allowed by Kraepelin’s dementia praecox. Furthermore, 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. Some of the psychiatrists who worked to bring about this revision referred to themselves as the "neo-Krapelinians."
Additional Resources
- Bibliography of scholarly histories on schizophrenia and dementia praecox, part 1 (2000-mid 2007).