|Fig 1: Emil Kraepelin, 1921 at the Department of Psychiatry, Munich. Source|
“Modern psychiatry begins with Kraepelin”1
The pages of history seen through the retrospectroscope often provide dull facts rather than insights into the personalities and driving forces of its famous subjects. Such is the case of Emil Wilhelm Kraepelin (1856-1926) (Fig 1), a German psychiatrist, widely acknowledged as the founder and pioneer of modern scientific psychiatry and classification.
Born in Neustrelitz, Mecklenburg, he studied medicine at Leipzig and Würzburg. As a student he had already determined his future was to be the study of mental illness. He graduated MD Würzburg in 1878 and was assistant to Flechsig in Leipzig, and in Munich to von Gudden (who was killed by mad King Ludwig when trying to stop him from committing suicide). He became Professor of Psychiatry in Dorpat, Estonia, and then moved to Heidelberg in 1890 where he worked with Nissl and Alzheimer. Finally he went with Alzheimer to Munich as Director of the Psychiatric Institute. He played a part in establishing the German Institute for Psychiatric Research, which was founded in 1917 in Munich.
In the nineteenth century, Theodor Meynert (1833-1892) and Carl Wernicke (1848-1905) had related mental disorders to organic brain diseases. Bastian published his The Brain as an Organ of Mind in 1880. The prevailing view was that mental illness was a unitary psychotic entity that Wilhelm Griesinger (1817–1868) called Einheitpsychosis in 1861. Refuting this notion, Kraepelin followed the Frenchman Morel who searched for separate and distinct illnesses, notably his demence précoce, 1852.
Kraepelin’s concepts of mental illness stemmed from medicine; he modified them as new information accrued. His work was original, a nosology based on an accurate delineation of symptoms based especially on the natural history of mental disorders, particularly manic-depressive insanity and dementia praecox. He described patients’ withdrawal in depressive stupor, the cyclothymic mood swings that predisposed to manic-depressive disorder—later to be named bipolar disorder—and he elaborated its prognosis and natural history. He recognized that catatonia, paranoia, and hebephrenia,2 previously thought separate disorders, should be classed as dementia praecox, which Bleuler labeled schizophrenia.
His new classification of insanity, differentiating dementia praecox from manic-depressive disorder, appeared in the fourth edition of his textbook in 1893.3 In spite of subsequent questioning, this important dichotomy persists in current psychiatric diagnosis.
Of equal prestige were his contemporaries Sigmund Freud (1856-1939) and Eugen Bleuler (1857-1959), who was director of the Burghölzli Clinic in Zurich. Kraepelin’s views were not universally accepted.4 Although Freud extolled Kraepelin’s role in European psychiatry and agreed with his separation of dementia praecox from manic-depressive insanity, he disagreed with his belief in a hereditary degenerative etiology. Kraepelin, however, sarcastically and stridently denounced much of Freudian psychology.
Bleuler too credited Kraepelin’s conclusions, but his own studies were concerned less with diagnosis and prognosis than with the mechanisms of symptoms. For instance, Bleuler thought dementia praecox was the “splitting of the mind,” hence he created the term schizophrenia. However, Kraepelin failed to differentiate neurotic and psychopathic states from psychosis. And, he largely ignored the notion of psychogenic reactions to stress and the importance of individual personality traits, subsequently established by Adolf Meyer and his psychobiological school of thought.1,4
It is often overlooked that Kraepelin was influenced by the experimental psychologist Wilhelm Wundt and used his tests to measure the mental deficits of his patients. He methodically studied sleep and fatigue, and the psychopharmacology of many drugs on human behavior. Throughout his career, he continued to refine his ideas and classification and was working on the ninth edition of his textbook when he died.
Essentially, Kraepelin was obsessed by objectivity and the measurable aspects of illness. He categorized mental illness and symptoms on the principles of Virchow’s anatomic-pathological basis for etiology—an organic rather than a functional approach. This left open the path for subsequent studies of neuroses and their more subtle accompaniments (if not causation) in modern neurochemistry, genetics, and imaging.5 These have added to our understanding of symptoms that do not neatly fall into Kraepelin’s classical categories.
Another aspect of Kraepelin is shown by his vehement battles against sexual excitability, homosexuality, alcoholism, and smoking, which he disliked for health and nationalistic reasons: he thought many patients were weak or lazy6 and rendered Germany less fit for international competition. He advocated “social Darwinism,” and supported a policy of racial hygiene, anti-Semitism, and Galtonian eugenics.7,8 Before the rise of the Third Reich, he mentored three prominent Nazi psychiatrists: Robert Gaupp, Paul Nitsche, and Ernst Rüdin.
To his credit, he fostered many doctors of distinction; in Munich, he was mentor to Alois Alzheimer and initiated the name Alzheimer’s disease. Another acolyte was Franz Nissl (1860–1919), who invented the method for staining neurons that bears his name. He trained Nicolás Achúcarro and Lafora, two distinguished pupils of Santiago Ramón y Cajal of the Spanish Neurological School.
After many years of engagement, Kraepelin married Ina Schwabe in 1884. They had eight children, four died in infancy. He died of pneumonia on 7 October 1926.
- Mayer-Gross Slater E. Roth M. Clinical Psychiatry. 3rd edn by Slater & Roth. Baillière, Tindall & Cassell, London 1969, pp. 10-16.
- Kraepelin E. Dementia praecox and paraphrenia. Edinburgh. Churchill Livingstone, 1919.
- Kraepelin E. Compendium der Psychiatrie: Ein kurzes Lehrbuch für Studirende un Aerzte. 4th ed. Leipzig: Abel; 1893. [Later editions were called Lehrbuch].
- Kendler KS, Engstrom EJ. Criticisms of Kraepelin’s Psychiatric Nosology: 1896–1927. American Journal of Psychiatry 2018;175:316–326.
- Falkai, P., Rossner, M., Schulze, T. et al. Kraepelin revisited: schizophrenia from degeneration to failed regeneration. Mol Psychiatry 2015;20:671–676.
- Decker H. The Psychiatric Works of Emil Kraepelin: A Many-Faceted Story of Modern Medicine. Journal of the History of the Neurosciences 2004; 13:248–76.
- Engstrom EJ, Weber MM, Burgmair W. “Emil Wilhelm Magnus Georg Kraepelin (1856–1926).” American Journal of Psychiatry 2006; 163 (10): 1710.
- Engstrom EJ. Emil Kraepelin: psychiatry and public affairs in Wilhelmine Germany. History of Psychiatry. 1991;2(6):111-132.
JMS PEARCE, MD, FRCP, is emeritus consultant neurologist in the Department of Neurology at the Hull Royal Infirmary, England.