Janusz Rybakowski: 120 years of the Kraepelinian dichotomy of "endogenous psychoses" in historical perspective

Carlos Morra’s Comment

         I enjoyed your essay,“120th Anniversary of the Kraepelinian Dichotomy of Psychiatric Disorders,” very much, but I have a question.

         I always hear our colleges discussing Kraepelin’s work without paying attention to the real evolution of his thinking from the first to the ninth edition of his textbook, Psychiatrie. Ein Lehrbuch für Studirende und Aerzte. He moved from a syndromic classification (1883, 1887 and 1889 editions) to a clinical point of view in the fourth edition (1893). He had a real evolution of his thinking since the first to the ninth edition of his manual (Psychiatrie Ein Lerbuch fur studierende und Aertze). He moved from a syndromic classification (1883, 1887 and 1889 editions) to a more clinical point of view (1893); he grouped catatonia, paranoid dementia and dementia praecox in the group of “the mental degeneration processes” (Die Psychischen Entartungsprocesse). In the sixth edition he crystalized the concept of dementia praecox, integrating the group of paranoid dementia, hebephrenia and catatonia into a single entity. He classified disorders in 15 classes, one of them dementia praecox and another manic-depressive psychosis. As you mentioned before, here we can trace the birth of the “Krepelinian dicothomy” (a term introduced by Möbius).

         His classification, in general terms in the seventh edition (translated to English in 1915), remained untouched until his eighth (1908) and ninth editions (1915) where he abandoned his dichotomy and created a third class in which he included the paraphrenias, that were arguably extracted from the paranoid forms of dementia praecox and paraphrenias, extracted from manic- depressive psychosis. Would it not be correct to say that at the end of his life he introduced a new concept - “The Kraepelinean Trichotomy” - by describing a third group of patients different from the other two groups in terms of symptomatology and outcome, a group that never reached to a dementia?

         The multiple clinical implications of a third group of patients with psychotic manifestation without any signs of deterioration may introduce a possible alternative to the problem that Kendell and Gourley (1970) presented in their paper “The Clinical Distinction between the Affective Psychoses and Schizophrenia” in which they faced some problems while separating both groups of patients by their symptomatic profile.

         Similar results were obtained by Häfner in 2010 when he concluded that depression does not represent comorbidity, but an integral part of psychosis. He suggested that this constitutes “a dimensional disease model based on hierarchical symptom patterns of the human brain with increasing brain dysfunction in the course of schizophrenia.”

         Nevertheless, Roth (1978) suggested that the variables identified by Kendell and Gourley (1970) were not correct and found certain differences between both groups in terms of personality, inheritance, evolution, treatment response and outcome.

         Kraepelin´s point of view in his last editions may indeed show a possible but still not perfect solution to this problem: “schizophrenic patients have different age of onset, different clinical manifestations and different outcomes.”  Thus, in general terms they might have different illnesses.

What do you think?

References:

Häfner H. The early Kraepelin’s dichotomy of schizophrenia and affective disorder. Evidence of separate diseases? Eur. J. Psychiat, 2010; 24:98-113.

Kendell RE, Gourlay J. The clinical distinction between the affective psychoses and schizophrenia. Br J Psychiatry, 1970; 117:261-6.

Kraepelin E. Psychiatrie: Ein Kurzes lehrbuch fur studierende und aerzte. Leipzig. 1887. Abel.

Kraepelin E. Psychiatrie: Ein Kurzes lehrbuch fur studierende und aerzte. Leipzig. 1893. Abel. (Arthur Meiner)

Kraepelin E. Psychiatrie: Ein lehrbuch fur studierende und aerzte. Leipzig: Barth; 1896.

Kraepelin E. Psychiatrie: Ein lehrbuch fur studierende und aerzte. Leipzig: Barth; 1899.

Kraepelin E. Psychiatrie: Ein lehrbuch fur studierende und aerzte. Leipzig. 1909. Barth.

Kraepelin E. Psychiatrie: Ein lehrbuch fur studierende und aerzte. Leipzig. 1913. Barth.

Kraepelin E. Psychiatrie: Ein lehrbuch fur studierende und aerzte. Leipzig. 1915. Barth.

Kraepelin E. Clinical Psychiatry. New York. 1902.  The Macmillan Company.

Kraepelin E. Psychiatry. A textbook for students and physicians. Canton. 1990. Science History Publications.

December 19, 2019