Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880

Abstract

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin’s chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin’s mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860–1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

In seeking to understand the roots of our current major psychiatric disorders, we are presented with a puzzle. The categories of melancholia and mania trace back to Greco-Roman times, albeit with a wide range of clinical features.^1,2 From the late 18th to mid-19th century, these syndromes were seen primarily as disorders of intellect described as, respectively, partial and complete insanity.^3,4 However, in the middle third of the 19th century, both disorders were reconceptualized as primary disorders of mood in which psychotic symptoms, if they occurred, emerged understandably from the affective disturbance.^3,4 Their key clinical features have been relatively stable from that point to the present.^5–8 However, for the preeminent psychiatric disorder of dementia praecox (DP) (aka schizophrenia), we have no such pedigree. The influential 1780 medical nosology of Cullen,^9,10 where melancholia and mania were prominently listed, contained no disorder with a clear historical link to DP.

Kraepelin’s mature concept of DP was articulated in 1899¹¹ and the roots of its three subtypes can be traced back to his earlier editions in the 1880–1890s^12–14 and, for catatonia and hebephrenia, to the works of, respectively, Kahlbaum^15,16 and Hecker^17–19 in the 1870s. While these texts are central to understanding the specifics of Kraepelin’s DP concept, they do not address the broader question: why did a new disorder with pervasive psychotic symptoms, chronic course, and the absence of primary mood disturbance emerge in Germany in the 1860s and 1870s? This disorder was called by most authors Verrücktheit and was carefully described by Kraepelin in the 1883 first edition of his textbook. Between 1883 and 1899, from his early description of Verrücktheit, Kraepelin developed his mature concepts of both paranoia and dementia paranoides (aka paranoid schizophrenia).¹²

This essay began as an effort to understand the origins of Kraepelin’s initial concept of Verrücktheit as articulated in his first edition.²⁰ I obtained all references Kraepelin cited and, then, translated and carefully studied them. However, as the story unfolded, it became clear that it could address the broader question of the historical roots of DP, providing parallels with my prior histories of the evolutions of melancholia³ and mania.⁴ Two concepts have been central to these histories. The first was faculty psychology, a popular perspective in the early 19th century that viewed the mind as a collection of modules or faculties each performing specific functions.^21–23 As in the histories of melancholia and mania, the two faculties on which we will focus are intellect and emotions. The second was understandability, a common-sense psychological perspective that could help nosologists decide on the causal relationship between disturbances in two faculties.²³ In the histories of melancholia and mania, understandability was used to determine whether delusions could be conceptualized as emerging from mood disorders.^3,4 In the history of Verrücktheit, the focus shifted to understanding how disturbances in mood could arise from delusional beliefs.

In Kraepelin’s first edition section on Verrücktheit,²⁰ he listed 5 references, all in German, which were, in the historical order: Snell,²⁴ Griesinger,²⁵ Sander,²⁶ Westphal,²⁷ and Mercklin.²⁸ The first four represent important original contributions, while the fifth, a doctoral thesis, is a review and is more briefly treated. From these texts, chosen by Kraepelin from a large literature, I tried to articulate the story they revealed about the evolution of the concept of Verrücktheit from roughly 1860 to 1880.

Two points of background are needed. First, the theory of unitary psychosis, especially influential in Germany in the middle decades of the 19th century and supported strongly by Zeller and, initially, Griesinger, postulated that only one true form of insanity existed with the specific syndromes representing stages in its course.²⁹ The ordering was relatively fixed, beginning with melancholy and, then, progressing through mania to Verrücktheit and often dementia. Within this nosologic framework, Verrücktheit was understood as a secondary disorder, arising from the prior melancholic and manic phases.

Second, in addition to Verrücktheit, several other terms were used for chronic nonaffective delusional insanity in Europe at this time. The most popular was monomania, first proposed by Esquirol in 1838³⁰ and largely fallen out of favor by the 1860s.^31,32 Its most common usage was for patients with delusions or delusions plus hallucinations typically of one theme who demonstrated none of the wildly agitated behavior associated with the “total insanity” of mania. However, over time, its utility diminished as it was applied to an increasingly very wide variety of psychiatric syndromes (eg, pyromania, demonomania, and nymphomania).

Ludwig Snell, 1865: Ueber Monomanie als primäre Form der Seelenstörung (Regarding Monomania as a Primary Form of Mental Disturbance)

Snell, a prominent German asylum director (1817–1892), wrote this 13-page essay containing 8 case reports and 2 additional case sketches.²⁴ He begins:

I understand under … monomania the form of mental illness which is characterized by the emergence of single series of delusions with hallucinations, which, on the one hand, is distinguished from melancholia by the heightened self-awareness, and, on the other hand, from mania by the lack of flight of ideas and the general emotional turmoil, which … seizes the whole of mental life less than the other forms of mental disturbance.^24(p368)

Snell defines monomania by focusing on 3 features, which makes clear that he is using the term in its original narrow form synonymous with Verrücktheit as utilized by our later authors. First, the syndrome is characterized by delusions and hallucinations and is clinically distinct from mania and melancholy. Second, the disorder lacks the “emotional turmoil” of full-blown mania. Third, compared to other forms of insanity, the disorder has a more limited impact on the “whole of mental life.”

Snell then turns to a central point:

… the general view, especially of German psychiatrists, is that monomania is only a secondary form, which has developed out of melancholia and mania. For a long time, I also held this view. If I did not find any confirmation of this in the clinical histories, I consoled myself with the thought that there probably had been a preceding hidden melancholia or a short mania, unwitnessed by observers…. [Then,] I followed the course of the manias and melancholies which I was able to observe, so that in this way I could come closer to the pathogeny of monomania. But here too I was deceived. I saw the mentioned clinical forms transition to various conditions of mental weakness, to general confusion … but not to a pure, pronounced monomania. The idea thus immediately suggested itself that this form had to have a primary development, and … I gradually arrived at the conviction that one had to place it alongside melancholia and mania as a fundamental form.^24(p379)

Snell reports that the unitary psychosis theory, which requires delusional states to be secondary, arising from prior melancholic or manic episodes, was inconsistent with his clinical experience. He searched in cases of monomania for prior episodes of melancholia and mania but rarely found them. He failed to observe the classical case of monomania emerging from melancholia and mania. He concludes that monomania should be considered a primary disorder that should be considered, alongside melancholia and mania, an independent “fundamental” psychiatric disorder.

Table 1 contains summaries of the major symptoms seen in his cases with the most prominent being persecutory and grandiose delusions and auditory hallucinations. Bizarre and/or Schneiderian delusions are described in cases 1, 3, 5, and 7. No prominent affective signs or symptoms are noted. He writes that the grandiose delusions seen in monomania differ from those seen in mania “by their systematic, calculating character.” ^24(p377) In the two brief case sketches, Snell specifically comments “In both cases there was neither the anxiety nor the depressed sense of self of melancholia, and nor the flight of ideas and the general agitation of mania.” ^24(p379) Snell comments further about the psychotic symptoms:

Table 1.

A Summary of Case Reports of Verrücktheit in Sander’s and Snell’s Reports

Snell	Case 1—“gradually ill with persecutory ideas and hallucinations… without any discernable cause….[an] acoustic apparatus has been set up … a prompter whispers into his ear … he includes everything in his milieu into the sphere of his delusions” 24(p370); case 2—“The delusion gradually developed in him that the family with whom he was living would poison him. [He later] developed grandiose delusions … spoke of his royal descent.24(p371); case 3—“withdrawn due to his [persecutory] delusions … his thoughts were known, since he could hear them repeated by other people, and that he could make dead people come alive again” 24(p372); case 4—“…persecutory ideas, which were based on auditory hallucinations. She accused her husband of unfaithfulness, believed that he had a lover, at night heard the wailing voices of her children on the street, believed that they were being mistreated” 24(p373); case 5—“Mistrust toward the people of his environment, who were persecuting him with poison and magnetic influences…. Constantly, day and night, magnetic batteries are used against him…. are trying to kill him and his friends. Hallucinations of all the senses.” 24(pp373–374); case 6—“Delusions … that he was the son of a king … [then] his enemies had tried to poison him.” 24(pp374–375); case 7—“persecutory ideas with hallucinations … His enemies poisoned him with a variety of poisons in different ways, especially in his food or while sleeping via all bodily orifices. [later] …, over-estimation ideas have arisen… chosen by god to convert the Catholics and Jews.” 24(p376); case 8—“… persecutory ideas and auditory and sensory hallucinations... Her persecutors also caused pain in her body and her head.”
Sander	Case 1—He suddenly displayed a variety of persecutory and poisoning delusions and lastly became so agitated that his admission into the clinic had become necessary … For four years now he had been tormented by the most varied persecutions... has been persecuted by the press for the last two years…; he has been influenced from afar by mysterious means, through animal magnetism. His heart was drawn against his ribs, his thoughts guessed, he had been forced to think certain thoughts. Poisonous fumes were released from afar… the deceased king was his father … remained entirely unoccupied and from his behavior it was clear that he was hallucinating…. By means of living images his thoughts are divined and shared with others., [He reports being] choked by means of animal magnetism… Over time greater disorientation set in, whereby the conceptions and hallucinations he produced became ever more peculiar.26(pp397–405)
	Case 2—He is being persecuted by many people, because a young lady is interested in him [and] … her family is attacking him. In the newspapers there are articles which relate to this matter…. people talk about him in the street; the innkeepers try to break into a castle to obtain documents about him; his only childhood friend is on the side of the persecutors. … he already saw significance in all manner of trivial things and coincidences … In the clinic he soon became calmer; however, he displayed very foolish and mentally incompetent behavior; often he laughed for no reason; did not recognize the people from his environment … His mood is very variable, sometimes cheerful without motivation, sometimes sad, however is always expressed in a very exalted way …. Participation in the machinations against him became ever more widespread and not only the whole of Germany, Poland and Italy were participating… today he comes to the conclusion that he is the grandchild of Frederick William IV or Napoleon I…. [his delusions] became ever more confused in the months that followed.26(pp405–409)
	Case 3—He avoided communicating about his delusions for a long time; he admitted that he had written to the queen; he believed that he was the son of the queen and the deceased king …[He reported seeing two very bright stars in the sky pointing toward Berlin which he took as a message that he was of high birth]. He occupied himself as best he could, and, even for a long time, was mostly able to speak clearly and coherently about actual things... It was of interest to now see how he, despite his apparent deliberation and clarity, organized all relationships according to this [delusional] system.
	Case 4—Hallucinated … indications … that God was interceding on his behalf and that God had chosen him … for great things…. He calls himself Apollo, emperor and lord of the earth. He has been bestowed title and power by God himself, initially due to his “faith.” All European monarchs have deposed themselves in his favor, they have all personally appeared to him (albeit naked), have given him their honors, their treasures and valuables…all the previous wives of all the monarchs and other royalty … in addition to all their possible daughters, are now his wives…. He writes constant letters … to all the powerful people in the world, in which he announces his decrees, until he no longer requires a written means, as he has other methods of making his thoughts and wishes known.... Now the “art” of people has caused him to do and say everything they want him to; all his physical movements are determined by “the art” of the people; he cannot fight it. At night he has peculiar attacks of twitching in his body, which he claims are caused by “the art” pulling at him.

The hallucinations in monomania are more general and more essentially connected to the illness than in any other form of mental disturbance…. In the rare cases, where these seem to be absent, the delusions, however, capture the sense of self with such direct force … Distinctive for monomania is that there is no awareness of being ill, which is often in evidence in mania and melancholia.^24(p378)

Hallucinations are central to the illness and in the rare case that they are absent, he notes, in a fascinating phrase, that the delusions strongly “capture the sense of self.” Affected individuals always lack insight.

Onset is typically insidious but can be acute. The prognosis is “known to be unfavorable.” ^24(p380) Recovery is rare but the delusions and hallucinations can fade, and the patient can become capable of “carrying out his duties to some extent.” ^24(p380) Snell concludes by emphasizing that the disorder “develops in its pure form as a primary mental disturbance …The persecutory ideas with elevated sense of self form the basic character of this form of illness.” ^24(p381)

Griesinger Vortrag zur Eröffnung der Psychiatrischen Klinik zu Berlin am 2. Mai 1867 (Lecture at the Opening of the Psychiatric Clinic in Berlin)

Griesinger (1817–1868), a central figure in the history of European psychiatry, assumed, in 1865, the position of professor of psychiatry at the Friedrich-Wilhelms-Universität in Berlin and head of the psychiatric and neurological wards in the Charité hospital. He held these posts until his death in 1868. Although he comments only briefly on what he termed Verrücktheit in this 15-page address,²⁵ what he says is of import because of his prominence and prior advocacy for the unitary psychosis concept. In discussing grandiose and persecutory delusions in patients with melancholia and general paresis of the insane, Griesinger writes

However, there are also highly interesting cases, where the two kinds of primordial delusions develop very slowly alongside each other, where at this slow speed stretching over a number of years, the contradictory conceptions (grandiose and persecutory delusions), have time to gradually become organized, to become enmeshed and become fixed thought connections, a so-called system of delusional ideas … Here there often forms a most peculiar melded together mixture of persecutory and grandiose ideas: These patients own great possessions and inheritances, out of which they have been swindled, due to which they are being persecuted, they are children of nobles, but are not acknowledged, and their rights have been contravened, etc. I no longer consider this peculiar, very chronic disturbance to be secondary (as I did in my textbook), rather I am convinced of the protogenetic (protogenetisch) formation of these conditions and now describe them as primary.^25(p148)

The last sentence, where he cites Snell, is critical. He rejects his prior theory of a unitary psychosis and secondary Verrücktheit and throws his considerable prestige behind Snell’s argument that Verrücktheit should be considered a key primary psychiatric disorder.

Going beyond the comments of any other of our authors, Griesinger offers an etiologic theory for the origins of delusions in the cases of primary “Verrücktheit”:

To be poisoned, to be emperor, would never occur to a healthy person, such completely foreign conceptions, without any links, break into our continuous series of usual conceptions, into thinking and feeling, into our everyday work, into the joys and pains of healthy life. The patients in whom this occurs are mentally ill, and naturally the brain disorder is the cause for the emergence of these thoughts. But how does this content arise? … Previously I was more inclined to differentiate primordial delusions as logical products from emotional foundations. Today I place more emphasis on their direct emergence from a cerebral disturbance. In the ganglia cells of the grey cerebral cortex, according to our current assumptions, the processes occur which trigger ideas… In the event of anomalous action of these cerebral cortex cells, images, words ideas of all kinds will be elicited which no longer correspond to reality.^{25(pp148–149)}

Rather than seeking the origin of delusions in their “emotional foundations,” Griesinger turns to consider the disturbed functioning of cortical cells.

Sander 1868 “Über eine Specielle Form der Primären Verrücktheit” (Regarding a Special Form of Primary Verrücktheit)

Sander (1838–1922) worked from 1862 to 1870 as an assistant doctor at the Charité, where he was influenced by Griesinger. His 31-page essay,²⁶ including 4 case reports, begins the problem as Sander understood it:

As general interest has in recent years turned more toward paralytic insanity, which promises a valuable yield for pathological anatomy … the more the study of so-called Verrücktheit has receded into the background. Mostly the numerous forms belonging to this large category are … all conceived in the same way, as the resulting conditions of so-called primary mental disorders, namely melancholia or mania. However, the time may have come to challenge this summary conception, which has resulted in the understanding of paranoid (Verrückten) patients remaining far behind that of other mental disorders, and to turn our attention to the study of this extensive group [of] paranoid (Verrückte) patients who fill the mental hospitals … ^26(p387)

He describes his path to this perspective:

According to the viewpoint taught in most handbooks, it is usually assumed that all paranoid patients have, a short or longer time previously, found themselves in a stage of a primary mental disorder. In my opinion this is a mistake. Precisely the converse is true, that by far the minority of individuals display a verifiable transition from the primary form of mania or melancholy … Following this general conception…, I tried in vain, sometimes by examining the patients for hours, to determine the primary illness and the point at which the transition to Verrücktheit occurred…. I never succeeded.^26(p388)

He then describes the developmental history of individuals with Verrücktheit, emphasizing their sensitive nature, social isolation, and a tendency to get lost in their own imagination “their own fantastical thoughts and daydreams.” ^26(p389) It is this “picture of the mental peculiarity of these predisposed individuals,” ^26(p391) which forms the substrate of the disorder. He describes a typical onset of Verrücktheit:

The mental disturbance gradually develops from the predisposition described [and] … if it results in admission to a clinic, is usually already very advanced and can be described as Verrücktheit. The first hallucinations combine directly with the “imaginations” … described above, or rather the latter become more intensive …. The patients see and hear that they are being slighted, that others want to harm them; this has not been said directly, but it has been made clear. The most usual and simplest things are interpreted in a singular and notable symbolic manner … Soon the hallucinations increase: behind every random event, the patient finds an insinuation about himself, he is jeered at in the street, he is given meaningful looks, or people spit in front of him, and there are reports about him in the newspapers, etc…. In a relatively short time…, all these “persecutory ideas” have been put into a system. It is an organization or a secret society persecuting the patient, because he is in their way (not because he is unworthy and deserves to be punished, in the ways expressed by melancholics!).^26(p392)

In providing a development picture of Verrücktheit distinct from that of melancholia and mania, Sander supports his thesis that this syndrome is an independent disorder. While in melancholia, the delusions arise from cognitive beliefs (eg, worthlessness) that are, in turn, due to the primary mood disorder, in Verrücktheit, the delusions emerge independently. Further development of the disorder commonly includes intense ideas of reference and grandiose and increasingly bizarre delusions:

… as the hallucinations increase, which soon falsify the patient’s entire social intercourse, all actual events and emerging memories from the past are symbolically connected with statements and facts which are also interpreted in light of the dominant conceptions… the patient soon develops the idea that he does not belong to this family, that he is merely an adopted child…. The patient is actually of noble descent, mostly was born to a ruling monarch, was stolen or abducted in early childhood … Once the delusional system has grown to this extent, it continues to develop. Every event is connected with the patient, occurs in his favor or against it … Political occurrences mentioned in the newspapers, natural events of greater or lesser significance, accidents, and all other things are either punishments from those opposed to the patient, or they serve to announce his imminent victory over his adversaries…. The patient comes ever closer to a condition of complete disorientation and produces the most astonishing delusions … ^{26(pp393–394)}

The course is variable, and remissions can occur. Mental weakness often develops but is not inevitable. He, then, reviews the prior literature, including a detailed account of Snell’s article. He does not favor Snell’s use of monomania, however, and “would thus like to propose ‘Verrücktheit’ as the most fitting description” ^26(p396) of the syndrome.

He summarizes his nosologic position on these delusional/hallucinatory syndromes: “We thus have secondary Verrücktheit, which develops from the primary forms (mania and melancholia), and primary Verrücktheit.” ^26(p373) He, then, proposed a subtype of primary Verrücktheit that is of special interest to him, which he terms “original” Verrücktheit, particularly characterized by the developmental precursors he mentions earlier in his article.

Sander provides 4 detailed case reports. Selected features of these cases are presented in table 1. While they all include prominent delusions, in other ways they are quite variable. Cases 1 and 4 include bizarre passivity delusions and auditory hallucinations, case 2 includes foolish, hebephrenic-like behaviors and case 3 has only a single nonbizarre grandiose delusion without hallucinations.

Westphal 1878 Über die Verrücktheit (Concerning Verrücktheit)

Westphal (1833–1890) worked as an assistant physician at the Berlin Charité from 1858 and took over as director after Griesinger’s death. This 5-page article, without case reports, summarized a talk given in September 1876 to the Psychiatric Section of the Natural Sciences Convention in Hamburg.²⁷ Such summaries, often written by the speaker, refer to him/her in the third person. It begins with a formal nosologic issue:

“Verrücktheit” is not found listed among the diseases acknowledged by the Society of German Psychiatrists in their admission cards (Zählblättchen). He considers this to be a mistake, which obviously results from a false understanding of Verrücktheit, which has been subsumed under the concept of “secondary” mental disorders.^27(p252)

Both Westphal and Snell follow in the footsteps of their mentor Griesinger in arguing that Verrücktheit deserves independent status as a “primary” psychiatric disorder. Westphal, then, summarizes the developments of his views on Verrücktheit noting that Griesinger had begun to doubt his prior position on Verrücktheit 6 years before he published his formal change of opinion:

After the speaker mentioned an 1862 discussion with Griesinger, in which he already expressed his reservations with regard to the positioning of Verrücktheit under the “secondary” mental disorders, after pointing out Griesinger’s later changed viewpoints … and the works of Snell and Wilhelm Sander, he pointed out that, nevertheless, most German psychiatrists still seem to have the undeterred view that Verrücktheit develops out of melancholia, and that cases of so-called primary Verrücktheit are something quite exceptional. The speaker asserts that Verrücktheit never develops from pure melancholia.^27(p252)

Westphal proposed 4 etiologic pathways to Verrücktheit from hypochondriacal concerns, spontaneous delusional thoughts, auditory hallucinations, and the original form as described by Sander. However,

In none of these kinds of development of Verrücktheit is there a mood state corresponding to melancholia, with its particular delusions, which have an intrinsic relationship to the mood state. Instead, what is essential to Verrücktheit, is the abnormal process of conceptions. The [disease] process unfolds in the sphere of conceptions … ^27(p253)

Consistent with historical developments,³ Westphal recognizes that the delusions in melancholia have an intrinsic relationship to the depressed mood. That is, the psychosis in melancholia can be understood as emerging from the depressed mood of melancholia. For Verrücktheit, by contrast, the etiology of the delusions results from an independent process, a dysfunction in the “sphere of conceptions.” He states explicitly “This form of mental illness [Verrücktheit] … does not begin with a disturbance in the feeling sphere.” ^27(p255)

Westphal presses this point further: “Concerning the moods, feeling and affects of Verrücktheit, they are essentially dependent on the content of the conceptions (and the delusions).” ^27(p254) That is, in Verrücktheit, the anxiety and depression that typically accompanies persecutory delusions and the elation that often occurs with grandiose delusions arise as a result of, and not as a cause of, the delusional beliefs.

August Mercklin (1855–1928) 1879: Studien über die Verrücktheit (Studies on Verrücktheit)

This 102-page monograph was a doctoral dissertation at the University of Dorpat. Upon completion of his studies at Dorpat, Mercklin went to work under Westphal in Berlin. Mercklin does not contribute novel insights into the nature of Verrücktheit but rather provides a summary and synthesis of previous material. We, here, focus on his first two chapters, relevant quotes from which are seen in table 2. In his introduction (quote 1), he re-emphasizes the critical role the demise of the unitary theory of psychosis played in the rise of Verrücktheit as an independent primary delusional syndrome. In quotes 2 through 4, he presents his views of the essays of Snell, Griesinger, and Sander, assigning them key roles in the transformation of the Verrücktheit concept. In quotes 5 and 6, he presents relevant work of two psychiatrists not cited by Kraepelin (Hertz and Samt), who both focused on cases of hallucinatory psychoses where the hallucinations were understood as primary and unrelated to prior mania or melancholia. Quote 7 presents the lecture of Westphal and quote 8 a brief summary of views on Verrücktheit similar to those described here by the major German neuropsychiatrist Hans Schule in his 1880 handbook.³³ Quote 9 summarizes his literature review when he refers to the fundamental abnormality in Verrücktheit as occurring in the “life of ideas.”

Table 2.

Comments from the Thesis of Mercklin

# 1	Included among the advances which are able to bring psychiatry as a science on a par with the other clinical disciplines … are the efforts to reform the classification of the psychoses. In these endeavors, it has been recognized that it is only possible to penetrate the nature of mental disturbances if the same method is used that elevated the rest of clinical medicine to its current standing … which can briefly be described as empirical or clinical. Before psychiatry could own this method, many old theories had to be rejected. Firstly, the theory that stated that all mental illness phenomena are the expression of one illness, of insanity, and which viewed the variety of individual clinical pictures as stages of this single illness, had to be relinquished. The conviction that there are essentially different mental illnesses replaced this theory ….28(pp9–10)
# 2	I believe that a short historical sketch about the development of primary Verrücktheit cannot be avoided, because in the following observations, the existing descriptions in the literature have to be constantly considered. When Snell in 1865, under the title of “Monomanie als primäre Form der Seelenstörung” made the first contribution on this subject, Griesinger’s theory dominated in Germany, namely that Verrücktheit was a secondary psychopathic condition, a state of mental impairment which always developed out of a preceding melancholia or mania.28(p17)
# 3	How much Snell’s representation is based on objective facts, is proven by the circumstance that the acceptance of this form which he delineated found no opposition, and that even Griesinger in 1867 openly recognized it.28(p18)
# 4	The theory of primary Verrücktheit entered a new stage with the publication in 1868 of the essay by W. Sander: “über eine specielle Form der primären Verrücktheit.” Sander fully acknowledges the statements by Snell and is only disagrees with the description of these primary psychopathic symptom complexes, which do not arise from melancholia or mania, as Wahnsinn or monomania. Like Griesinger, he uses the description Verrücktheit.28(p19)
# 5	At the convention of the Psychiatric Society of the Rhine Province on 14 June 1873, Hertz made statements about “idiopathic hallucinations.” Based on his clinical experience he has arrived at the conviction that a whole number of psychoses do not commence either as melancholia, nor as mania, therefore not with a depressive or exalted alteration of mood, but that the hallucinations without any pathic change of mood with a peculiar [which] throughout the entire course this is preserved purely as sensory insanity.28(p21)
# 6	Samt in 1874 also speaks in favor of the primary nature of Verrücktheit, and joins Sander, in that he accepts that “the different forms of Verrücktheit form a clinical illness group, in which further different forms can be clinically determined,” depending on the development and the total course. Samt describes two such forms under the description “hallucinatory Verrücktheit”… The patients are only mentally impaired (schwachsinnig) with regard to their delusions and hallucinations. The development of the illness is chronic.28(pp21–22)
# 7	Now follows what in the history of primary Verrücktheit is epochal, namely Westphal’s lecture, held at the Natural Sciences Conference in Hamburg in 1876. It is only at this lecture, in which he provided a delineation of the entire concept of primary Verrücktheit and new insights to the development of the individual forms, that there arose all-round interest in this mental disturbance and the break with the old classification system became complete.28(p22)
# 8	Corresponding to the reformed understanding of Verrücktheit, Schüle [in 1880] … described it as a primary, independent psychosis group. “The pathological premises have here taken up primary position in the life of ideas.” 28(p26)
# 9	From this short overview of German literature about this subject of study, that generally the existence of a group of psychoses is acknowledged, which, without an affective foundation, captures the life of ideas primarily, is characterized by sensory delusions and delusional ideas and can continue for a long time … 28(p26)

Scholz 1892 Lehrbuch der Irrenheilkunde: Für Aerzte und Studirende (Textbook of Psychiatry: For Doctors and Students)

To assess the influence of these authors on key psychiatric figures in Germany other than Kraepelin, I reviewed the introductory section of the Verrücktheit chapter in the 1892 first edition of the well-known textbook by Dr Friedrich Scholz (1831–1907),³⁴ then Director of the hospital and the St Jürgen Asylum in Bremen. The publication date of this text precludes any influence by Kraepelin’s 1893 fourth edition,³⁵ where he began to transform his nosologic system toward his eventual DP concept. Scholz uses the English term “paranoia” interchangeably with Verrücktheit in this text, an approach that Kraepelin adopted from his second edition³⁶ onward. Scholz’s text went through 7 editions, first of which was one of the select group of general psychiatry textbooks referenced in Kraepelin’s introduction to his fourth, fifth, and sixth editions.^11,35,37 Scholz writes:

Paranoia (Verrücktheit) is a non-affective psychoneurosis, which mainly influences thought processes and is characterized by the predominance of delusions. There is a distinction between primary and secondary paranoia. Secondary paranoia (Verrücktheit), as has already been demonstrated, is an outcome stage for the unhealed affective insanity … In the following, paranoia always refers to the primary form. Paranoia is distinct from melancholia and mania mainly in its lack of affect. This, of course, does not mean that there is no change in mood at all. Instead, all perceptions as a whole and the vehemence with which they impose themselves onto consciousness are always determined by the contents of the delusions… pathological affects with inhibition or acceleration of psychological activity do not occur [in Verrücktheit]. Due to the lack of affective foundation, paranoid delusions are distinct from melancholic and manic delusions. In particular, they are never, as are these, attempts to explain their own condition, or of their own perceptions as a whole. When they impel the patient to an action, this does not occur because fear, anxiety or presumptuousness are the driving forces. Instead they occur simply according to psychological laws, according to which every conception brings about desires and actions.^{34(pp122–123)}

Scholz expressed key concepts about Verrücktheit covered by previous authors. It is a primary disorder that influences “thought processes,” not secondary to melancholia or mania. Any mood changes that occur in the disorder result from the contents of the delusions and not from mood disturbances. In distinguishing between delusions in Verrücktheit and in mood disorders, Scholz refers to theories presented by earlier writers positing how profound mood changes can drive delusions.³ They posit that melancholic and manic patients can delusionally distort perceptions of the world around them in a highly negative and positive way, respectfully, or develop these beliefs in an effort to explain to themselves the origins of their altered mood. By contrast, the delusional beliefs in Verrücktheit drive the behavior and actions “according to psychological laws.”

Discussion

This historical inquiry sought to gain insight into the historical antecedents of Kraepelin’s concept of DP. The story focused on the origin of primary Verrücktheit, which was, in turn, the antecedent syndrome from which Kraepelin developed dementia paranoides (aka paranoid schizophrenia). Our primary approach was to follow-back the 5 references cited by Kraepelin in his section on Verrücktheit in his 1883 first edition. Parts of this history have been explored in modern German literature, albeit not as part of an effort to understand the origins of Kraepelin’s DP concept.^38,39 Of the many features of our story, 5 points are particularly noteworthy.

First, this story revolves critically around the concept of primary and secondary psychiatric syndromes and within syndromes, primary and secondary clinical features. Although none of our authors directly define these terms, they use them in an etiologic sense—that one disorder or symptom can cause another. Furthermore, they infer these causal processes from both the temporal and psychological association of the 2 syndromes/symptoms. The structure of the unitary psychosis concept best encapsulates the chronological views of the primary–secondary distinction. The major mood disorders occur first and are etiologically primary to the later delusional-hallucinatory syndromes.

But the psychological approach of understandability also plays a role in their primary–secondary distinction. In the history of melancholia³ and mania,⁴ this was a positive role. An important phase in the development of the mood-based models for these syndromes was the recognition that, when accompanying psychotic symptoms were found, they could be seen as arising understandably from the underlying mood disorders. In the history of Verrücktheit, the concept of understandability was applied negatively. That is, the concept of primary Verrücktheit was based on the argument that the delusions and hallucinations of this syndrome did not understandably arise from mood disorders. So, when Snell wrote that “The hallucinations in monomania are more general and more essentially connected to the illness than in any other form of mental disturbance,” he was arguing that the hallucinations arose directly from the disease process and not in an understandable manner from some other forms of psychopathology. Westphal put it more directly: “In none of these kinds of development of Verrücktheit is there a mood state corresponding to melancholia, with its particular delusions, which have an intrinsic relationship to the mood state … This form of mental illness [Verrücktheit] … does not begin with a disturbance in the feeling sphere.” Finally, Scholz emphasizes that point: “Due to the lack of affective foundation, paranoid delusions are distinct from melancholic and manic delusions.”

Second, the role of faculty psychology is also central to this history. Griesinger, Westphal, and Scholz note that the symptoms in Verrücktheit cannot be explained by mood disturbances. Many of our authors state explicitly that Verrücktheit is a disorder of cognition. Snell writes: “The persecutory ideas with elevated sense of self form the basic character of this form of illness.” The latter authors use more abstract terms. Westphal describes the disturbances in Verrücktheit as “the abnormal process of conceptions.” Mercklin refers to the disturbance as residing in the “life of ideas,” and Scholz in the “thought processes.” Westphal comments: “Concerning the moods, feeling and affects of Verrücktheit, they are essentially dependent on the content of the conceptions (and the delusions).”

Third, our history begins with the dominance in German psychiatry of the theory of unitary psychosis in which psychotic syndromes were understood to emerge secondarily from prior melancholic and manic phases. The revision of this position seen most clearly in our earliest authors—Snell and Sander—was driven not by theoretical concerns but rather by their own clinical experience of Verrücktheit cases where they could not find evidence of prior and primary episodes of melancholia and mania.

Fourth, from the case reports of Snell and Sander, we obtain a sense of the clinical syndromes included in their concepts of Monomania/Verrücktheit. Similar to the descriptions presented by Kraepelin in his first edition,²⁰ the cases are diverse and included individuals who today might be diagnosed with delusional disorder, paranoid and nonparanoid schizophrenia. Table 3 contains quotes from Snell and Westphal suggesting that Verrücktheit could include cases with prominent catatonic and/or hebephrenic symptoms. This is consistent with Kraepelin’s second–fourth editions of his textbooks containing catatonic subforms of Verrücktheit.¹⁴ Further scholarship will be needed to trace the influence on this line of work on Kraepelin’s development of hebephrenic and catatonic DP compared to that of, respectively, Hecker¹⁷ and Kahlbaum.¹⁵

Table 3.

Quotes from Sander and Westphal Suggesting that Some Cases of Verrücktheit Might Demonstrate Features of Hebephrenic and/or Catatonic Dementia Praecox

Sander

Some of them [cases of Verrücktheit] lose, already at a young age (toward the end of adolescence), external composure, they quickly succumb to hallucinations and conceptualize delusions, which in the case of others only develop later and will be described further on. They sink rapidly into a condition of mental weakness, which can easily be distinguished from other terminal conditions.26(p391)

Westphal

Westphal describes two possible “sub-forms” of Verrücktheit. The first involves substantial motoric symptoms: “The “catatonic” patients of Kahlbaum, in the sense of the speaker, suffer from Verrücktheit, with a different kind of development and course…. [In the second] “The picture of Verrücktheit [can be] ... further modified …by a more or less considerable disturbance of formal thinking. This can …increase to complete confusion.” 27(p. 256).

Finally, our review suggests a broad narrative within German psychiatry that begins with the demise of the theory of unitary psychosis. Our authors, particularly Snell through Westphal, in advocating for Verrücktheit as a primary nonaffective psychotic syndrome, opened up a novel “nosologic space.” It was this space that Kraepelin filled with his mature concepts of paranoia and DP.

Funding

No grant support for this paper.

Conflict of Interest

The author reports no conflicts of interest.