Kraepelin’s Final Views on Dementia Praecox

Abstract

In 1921, at the age of 65, 6 years after completing the final edition of his textbook, 22 years after first proposing the concept of dementia praecox (DP), and 1 year before retiring from clinical work, Emil Kraepelin completed the last edition of his “Introduction to Clinical Psychiatry,” which contained a mini-textbook for students, 10 pages of which were devoted to DP. This work also included a series of new detailed case histories, 3 of which examined DP. This neglected text represents a distillation of what Kraepelin judged, near the end of his long career, to be the essential features of DP. The relevant text and case histories are translated into English for the first time. Kraepelin did not define DP solely by its chronic course and poor prognosis, acknowledging that remissions and even full recovery might be possible. His clinical description emphasized the frequency of bizarre delusions and passivity symptoms. He recognized the heterogeneity of the clinical presentations, outlining 6 subtypes of DP, including dementia simplex, depressive and stuporous dementia, and an agitated and circular DP. Kraepelin’s original concept of DP was not impervious to change and expanded somewhat, especially with the inclusion of Diem’s concept of simple DP. He also reviews several contributions of Bleuler, including his concept “latent schizophrenia.” He writes poignantly of the psychological consequences of DP. His 3 DP cases, for advanced students, included simple DP, “periodic catatonic,” and “speech confusion.”

Kraepelin completed the introduction to the final volume of the fourth edition of his “Einführung in die Psychiatrische Klinik¹” (“Introduction to Clinical Psychiatry”) on February 15, 1921, his 65th birthday. Eugen Bleuler’s major monograph on schizophrenia had been published in 1911.² The last volume of the final eighth edition of his textbook came out in 1915.³ Recent years had been tumultuous ones for Kraepelin. After the brutal fighting of WWI, the collapse of the German monarchy in late 1918, and the short-lived Munich Soviet Republic in 1919, he was writing a series of reflective articles on the nature of clinical studies and his own research methodology, defending himself from a range of criticisms leveled at him by younger contemporaries.^4–10 In 1922, he would retire from his position as Professor/Chair of Psychiatry at University of Munich, focusing on directing the German Psychiatric Research Institute in Munich, which he founded in 1917. He would die on October 7, 1926.

The 4 editions of Kraepelin’s Klinik published from 1901 to 1921 have received little scholarly attention. The first two editions (1901¹¹ and 1905¹²—both translated into English^13,14) consisted solely of vivid clinical lectures of a wide array of psychiatric syndromes. The third edition, published as a single 506-page volume in 1916,¹⁵ included for the first time a 99-page mini-textbook for students entitled “Die klinischen Formen des lrreseins” (“The Clinical Forms of Insanity”). While Kraepelin’s later textbook editions included very detailed chapters of all major psychiatric disorders, the mini-textbook was written with a different aim—to provide succinct summaries for beginning and advanced trainees.

Kraepelin’s fourth Klinik edition, published in 1921, greatly expanded to 3 volumes and 957 total pages.¹⁶ The mini-textbook, enlarged to 108 pages, was in the first volume along with other teaching materials. The second volume contained a selection of his earlier clinical lectures, while the third volume was all new case lectures.

Kraepelin’s forward to the first volume of this fourth edition includes a succinct summary of his goal: “…to make accessible to the student a representation of psychiatry which is as brief as possible, completely aligned to teaching purposes^16(pii).” I located two English reviews of this Klinik edition from the JNMD¹⁷ and Journal of Mental Science.¹⁸ Only the latter commented on the mini-textbook:

We should hardly have believed it possible to compress so much practical information into so small a volume of decent print. This book is a very striking example of what can be achieved in the way of sound brevity by one who is a master, not only of psychiatry, but of authorship. It puts all other small and medium-sized text-books of our subject deep in the shade; and besides being much better adapted to the requirements of students preparing for examinations … than any other psychiatric text-book that there is, it will be of great interest and convenience to experienced psychiatrists, however familiar they may be with its author’s other and more voluminous writings.^18(pp77,78)

In the mini-textbook in his fourth edition, the section on dementia praecox (DP) occupies 10 pages, a modest expansion from his third edition but far shorter than the 355 devoted to DP in his eighth edition.¹⁹ An English translation is provided in the supplementary appendix. Three of his new lectures in the third volume examine cases of DP and are translated in tables 1–3.

Table 1.

Case 46: Dementia Simplex

A few days ago, a 54-year-old former lawyer came to our clinic, because he was very emotionally and mentally disturbed. He asked therefore to be admitted. As you can see, the large, powerfully built, well-nourished man is prematurely gray and aged. His facial color is pale, his skull fairly large. Particularly on the left side, he has a substantially enlarged thyroid. His hands tremble. His pupils are in order. His corneal reflex is absent. His gag reflex is very weak. His heart is spread to the left, the first mitral tone is unclear. Pulse 65 beats. Emotional pupillary reflexes are present.The patient has 11 siblings, of which, beside him, six are still alive. A brother of the father was an alcoholic and shot himself. A brother of his mother died of tabes. As a child he had measles and scarlet fever, also later typhus. He twice failed a year in school. In the military he was weak, had to often exercise as punishment. Due to moderate giftedness studying was difficult, however, he always completed it. He drank 4–5 glasses of beer daily, once got the clap and masturbated into his 40s. Over-exertion in studying, as he admits, made him nervous. He often had flickering before his eyes, mild fainting, feelings of constriction, claustrophobia. After 4 years of working as a lawyer, which was not very remunerative, he went across to civil service, but there also did not feel well, again became afflicted with nervous conditions and took himself to a mental hospital, without seeking leave. As a result, he was fired. He now became a lawyer again, but not with autonomy. Since he let lie matters of the poor which he had been charged with representing, he was debarred from the legal profession. At that time, he had been suffering from a feeling of nervous weakness and general depression. When he crossed an open area, he became dizzy, as if he would fall over. He thought of suicide, but could not bring himself to do it.Then he opened a legal office. He quickly used up a few thousand marks which he had inherited from his mother, because he did not allow anything to be submitted to him. In the past few years, things had always gone bad for him. He was always worried about having food, could not pay the rent, lived from gifts which he received from relatives, friends, lawyers. For a few weeks now he has been completely breadless, stays with relatives who support him a bit, and upon their suggestion came to the clinic. As he indicates, he always tended to depression, had no right associations, no connection. He lived for the day, and did not think about the future. He found great joy in being in the coffee house. He smoked heavily, had few relations with the female gender. “My condition is half unconscious,” he says, “brought about by need and miserable circumstances. I cannot think a thought to the end anymore, cannot make any decisions anymore.” He is now very pleased that all worries have been taken from him and praises the activity of the doctors in exaggerated expressions. For now, at least, he is not concerned about his further fate. His knowledge and his judgment correspond to his level of education.

Relatives state that a foolish nature could be observed in him from a young age, apparently in connection with recovery from typhus. Later in work he was careless and indifferent, came late for appointments and declared that the gentlemen just would have to wait until he came. He suffered from a strange hypersomnia, and only got up at about 11 or 12. As soon as he inherited something, he frittered away all the money within a short time, also went to Italy. He was by nature an oddball, gloomy, did not socialize, did not work, made big plans, always sat in coffee houses reading newspapers, passionately played chess, otherwise had no interests. He was inordinately rough towards his mother, shouted at her in obscene language. Being debarred from the legal profession made little impression on him. In the past few years, he often undertook long walks, appeared completely tattered at one of his relatives and allowed himself to be endowed with gifts. He sold suits which he obtained, without wearing them. Once he appeared at his brother-in-law’s, took a suit from the cupboard and disappeared with it. According to the landlord, he brought home beer mugs and stored his feces in these. When he was given the right to reside in Munich, he could not decide to go to the townhall to sign, so that the matter remained undone. According to the judgment of the court of honor, in two cases he did not represent his parties even vaguely, came up with miserable pretexts and tried to lie his way out. It was determined that he neither had the moral fortitude nor the will to carry out the duties of a lawyer. At that time, he was 36 years old. Despite this, he installed a large sign on his apartment with the description “Lawyer.” Finally, he made ends meet miserably by means of writing work and mainly lived from assistance to the poor.

What is obvious here, is the contradiction between the education attained and his later lifestyle. The patient, who completed his education and today still retains corresponding knowledge as well as skill in verbal expression, has nevertheless proven to be quite incapable of carrying out his chosen career. In a completely incomprehensible way, he neglects his fundamental duties, lives for the day, commits obnoxious, degrading acts. Connected to this is a complete lack of sensitivity which allows him to indifferently accept his downfall. In a childish way he tries to avoid the results of being debarred from the legal profession, senselessly spends money provided to him, cannot pull himself together to improve his situation. We thus have a pervasive deterioration of emotional life and volition, accompanied by relatively well-preserved simple mental ability. The constitution of this clinical picture completely corresponds to dementia praecox. The first indications of the current mental deterioration in existence, seem to already be indicated by his foolish nature in adolescence. Whether “typhus” played any role in this, has to remain doubtful. We describe this peculiar dementia which form “without a song and a dance,” which is only expressed as a hopeless sinking down on the societal rungs, as “dementia simplex.” This is probably very frequent. Each of you will remember one or another such a failed personality from your circle of youthful acquaintances.1(pp190–193)

I first summarize Kraepelin’s mini-textbook section on DP and then briefly the 3 new DP cases. I then summarize his final systematic views on DP, a disorder central to the history of modern psychiatry, which he had first proposed 22 years earlier in 1899.^20,21

Introduction and Clinical Presentation

Kraepelin begins his summary of DP by noting the poor outcome and prominent personality “disintegration” he saw as central features of this syndrome:

The greatest number of uncured patients who accumulate in insane asylums are dementia praecox sufferers, whose clinical picture above all is characterized by more or less advanced disintegration of the mental personality with predominating emotional and volitional disturbances.^16(p59)

He then describes a typical pattern of onset using this approach to introduce its main signs and symptoms. First, there is the prodrome. From the baseline functioning of the individual: “there gradually develops, more rarely rapidly, a transformation of nature, with erratic, idiosyncratic, withdrawn, agitated behavior^16(p59).”

Then the positive symptoms (hallucinations and delusions) emerge:

In many cases hallucinations begin, especially auditory hallucinations, but also of the other senses, with delusional ideas linked to these, above all with a hostile or hypochondriacal content, but later also with a pleasurable content.^16(p59)

Thought disorder then sometimes develops “The train of thought can initially remain ordered, but later in many cases displays leaps, becomes disjointed, sometimes reaches complete incoherence^16(p59).” Next, volitional and emotional deficits begin to develop:

Soon the weakening of emotional reactions is very conspicuous, with dull apathy, indifference toward relatives, the environment, their own fate, loss of mental activity, inattentiveness, silence about wishes, hopes, fears.^16(pp59,60)

He comments about the frequent loss, in the course of DP, of normal “wishes, hopes and fears,” conveying sensitivity to the intra-psychic manifestations of the disorder. Kraepelin then notes the disturbed behaviors common in the early stages of illness:

…there can be outbreaks of angry agitation or foolish cheerfulness, mostly without discernible cause. Self-evident and everyday reactions (looking up when spoken to, taking an outstretched hand, answering a greeting, avoiding or defending against a threat) are absent.^16(p60)

Then follows a list of catatonic signs:

automatism, the limp submission to external influences, the long maintenance of an applied posture (… flexibilitas cerea), the repetition of words (echolalia), the imitation of movements (echopraxia)… especially important is the negativism, the impulsive, senseless resistance toward any influence … ^16(p60)

Kraepelin concludes this section with a discussion of the subtler signs of illness:

sometimes less pronounced disturbances of action are stereotypy … [the] recurrence of the same, senseless impulses … and the mannered behavior, incorrect convolution and alteration of simple actions...^16(p60)

He then reflects on the deeper nature of the symptoms and signs, again displaying an awareness of the subjective experiences of the affected individuals [references added]:

In this we evidence the expression of a loosening of inner fiber of mental processes (“intra-psychic ataxia” [²²]), which is represented by the name “schizophrenia” ². Often the patients themselves are aware of the feeling of inner lack of freedom, the dependence of thinking and actions on foreign influences, however, which then are interpreted as being due to persecution by means of telepathic and hypnotic effects. The emotional atrophy and disturbance of volition tend to soon bring the patients into conflict with their whole environment.^16(p61)

This is one of two references to work by Bleuler and the first of several descriptions of what we would call passivity or Schneiderian phenomenon.

Age at Onset

Kraepelin succinctly summarizes that “Dementia praecox as a rule starts in youth, most frequently in the third decade, exceptionally already in childhood…In later years, the illness occurs more rarely… ^16(p62).” He also here notes that “Often a number of members in a family are afflicted in a similar way.” He reports no other risk factors for DP, suggesting that regarded the familial/genetic influences on DP to be of particular importance.

Subtypes

In his sixth²⁰ and seventh²³ edition textbooks, Kraepelin’s subtyping system for DP included the 3 classic subtypes: hebephrenia, catatonia, and D paranoides. However, it expanded dramatically to 11 subtypes in his eighth edition,¹⁹ although only modest attention has been subsequently paid to this later more ornate system. Here, Kraepelin lists 6 subtypes, the ones he considered “only the most important.” Each of these subtypes was illustrated in case histories presented in the other two volumes of this work.

He introduces the subtypes with an approach that he adopted in his sixth edition,²⁰ wherein he emphasizes both the apparent distinctive features of their clinical pictures and the frequency with which the clinical pictures blend together²⁴:

From the above and some other symptoms of illness, a series of clinical pictures, which in many ways overlap, come together, which at first glance have little similarity in common.^16(p62)

The first subtype is dementia simplex as originally described by Diem, a student of Bleuler’s in 1903,²⁵ which he added in his eighth edition.

in or soon after the formative years, without any other obvious clinical phenomena, very gradually there occurs a failure of mental capability, which until then had been sufficient … and at the same time, a slow transformation of the entire mental personality, absent-mindedness, thoughtlessness, incomprehension, distractedness, on the other hand indifference to teasing and educational influences, defiant withdrawnness, estrangement from the family, aimlessness, lack of endurance for work and everyday life.^16(p62)

He calls the second subtype foolish or hebephrenic dementia. The description emphasizes the classical insidious onset, thought disorder, and affective deterioration often accompanied by childish silliness and mannerisms. Kraepelin notes the nonsensical letters considered to be diagnostic by Hecker in his first description of this syndrome.^26–29 Delusions and hallucinations are also present, and the outcome is typically severe dementia.

Kraepelin terms his third subtype depressive and stuporous dementia which begins with “a sad or anxious change of mood … in the absence of a deeper emotional reaction^16(p63).” Stupor is frequent, as well as features traditionally associated with the paranoid subtype, including auditory hallucinations, “voices made audible,” and a range of passivity symptoms, including “a feeling of being influenced electrically … the delusion of thinking and volition being influenced^16(p63).” Other catatonic features are common, including “command automatism, negativism, [and] stereotypy^16(p63).” Outcome is most commonly “simple mental impairment.”

Kraepelin’s fourth DP subtype was an agitated and circular form. These cases typically have a sudden onset, with hallucinations and “preposterous” grandiose delusions accompanied by disorganized agitation. The mood is typically elevated or agitated but superficial (a comment likely added to help differentiate this syndrome from psychotic mania). He notes that “depressive” phases can occur and so comments about some similarity to “circular courses of manic-depressive insanity.” The course is often not entirely progressive. Improvements can occur, but the final outcome most frequently involves substantial impairment.

His fifth subtype—catatonia or “tension insanity”—features both stupor with classical signs, such as “muteness, inaccessibility… complete lack of reaction, remaining in the same position, [and] rigid resistance to any change…,” and excited periods marked by “sudden senseless impulsive actions, carried out extremely quickly and with great violence, such as rushing out, dancing about, destruction, monotonous screaming, singing^16(p65).” Delusions and hallucinations occur but are infrequently prominent. Contrary to his general emphasis on the deteriorating course of DP, Kraepelin here emphasizes the more variable course of catatonic DP noted in earlier editions³⁰: “Frequently (in about 1/3 of the cases) the course of the illness is interrupted by one or more improvements which are similar to recovery^16(p64).”

His sixth subtype is dementia paranoides characterized by a later age at onset and “delusions and hallucinations are strongly foregrounded compared to the volitional disturbances^16(p65).” The positive psychotic symptoms include prominent hallucinations and delusions that are bizarre, far different from those seen in paranoia, which reflect more common human concerns³¹:

In connection with suspicious observations and premonitions, gradually a bizarre persecutory delusion develops, which finds rich nourishment in misperceptions, especially auditory ones (hearing their thoughts spoken, thought transferal)… Very often the delusion is of physical influencing (electrical, hypnotic, especially also sexual), which joins the nonsensical hypochondriac ideas and the feeling of a lack of inner freedom.^16(pp65,66)

At least 3 symptoms later judged by Schneider to be first rank in the diagnosis of schizophrenia³² are noted by Kraepelin in this short passage.

Outcome

Kraepelin describes a picture of variable outcomes for DP:

The overwhelming majority of pronounced cases of illness end in chronic mental infirmity, often of a high degree (permanent need for institutionalization). Whether full, enduring recovery occurs in some cases, is uncertain, but cannot be denied with regard to a reliably observed improvement which resembles recovery and has lasted for more than a decade. Often the degree of change brought about by the illness remains moderate (lack of insight into the illness, dulling of interests and enjoyment of work, lack of vigor and striving, withdrawnness, a quiet, depressed nature, lack of controllability, dependence, indications of command automatism, small peculiarities in behavior)…. The severe dementing states brought about by dementia praecox fill the insane asylums.^16(pp66,67)

In a short passage initially about outcome, Kraepelin outlines what we might now call schizotypal symptoms, which, he notes, can occur before onset, late in the course of the illness, and in relatives of DP patients. This is the second time he refers explicitly to Bleuler’s work:

Some milder symptoms which remain after recovery from dementia praecox, we observe as personal peculiarities already long before onset of the illness, also in the relatives of the patients and other persons who never display severe disturbances (“latent schizophrenia”).^16(p67)

Treatment

Kraepelin completes his section on DP with two major comments about treatment. First,

Since the causes of dementia praecox still are completely obscure, an effective combatting of the illness is at this time not possible. Treatment is of necessity limited to the lessening of illness symptoms… ^16(p67)

Second, he emphasizes his concern about the importance of rehabilitative efforts

After waning of the more stormy clinical phenomena, the most important task in the clinic or at home, is to guide the patients to an occupation relative to their condition, which alone is capable of enabling them to retain the remnants of their mental personalities.^16(p67)

Case Reports

In this brief section on DP in his mini-textbook from the fourth edition of his Klinik,¹⁶ Kraepelin refers to 12 detailed case reports appearing in volumes 2³³ and 3.¹ Of these, 9—all in volume 2—were reported in the earlier editions of the Klinik (previously translated [see chapters III, IV, and XVI¹⁴]). The 3 new cases in volume 3 have not been translated and are seen in tables 1–3. Kraepelin’s introduction to volume 3 began:

The following lectures have arisen from the clinical discussions for advanced students, which were only interrupted temporarily by the war, and which I have been holding for many years. They contain a selection of cases which either represent rarer occurrences or those which provide particular difficulties. However, between these there are also observations which serve to round off the discussion in the prior lecture.^1(piii)

We may conclude that the cases of volume 2 were meant for beginning students and present relatively classical and clear clinical presentations. By contrast, the cases of volume 3, designed for advanced students, were less typical and more challenging.

Chapter XVI of volume 3, entitled “Dementia Praecox,” begins with this introduction:

Dear Sirs! The viewpoint which originally led to the delineation of dementia praecox was the common outcome of a peculiar mental deterioration. Due to this perspective, all cases which went over into recovery were excluded from the frame of the illness. However, it is now an open question whether this exclusion is justified. In any case, reasons can be cited which indicate the contrary. On the other hand, a long series of clinical pictures have been grouped together which often deviate considerably from each other. Fundamental concerns cannot be raised when one sees that even in unitary illnesses such as paresis, the clinical phenomena turn out extraordinarily differently. Here we can, however, keep to the physical symptoms, especially the serological findings [e.g., the Wasserman test], whereas in dementia praecox we are still reliant merely on the deceptive mental clinical picture. All things considered, we are nevertheless able to find our way to an extent, however, we have to admit that there is an element of doubt remaining, which we cannot satisfactorily eliminate.^1(p190)

He directly addresses the degree to which a poor outcome should be definitional for DP, expressing clear doubts on this critical point, and clearly admits the wide variation in cases seen within the rubric of DP. He notes how much simpler these problems are with the syndrome of general paresis, where diagnoses are made much easier by classical physical signs and, more recently, the Wasserman test, developed in 1906.³⁴

Case 46 (table 1), a 54-year-old former lawyer with dementia simplex, fits well into Diem’s clinical description.³⁵ No positive psychotic symptoms are noted. Instead, we see a gradual decline in social and occupational functioning accompanied by affective changes (“deterioration of emotional life and volition”) and some bizarre behaviors. This picture certainly differs dramatically from the more classical forms of catatonic, hebephrenic, and paranoid DP that Kraepelin emphasized in his initial descriptions of DP.

Case 47 (table 2) is a 36-year-old academic with “Periodic Catatonia,” whom Kraepelin describes as “not easy to assess.” He has a remitting–relapsing course with episodes of agitation, thought disorder, a range of catatonic signs, regressed behaviors (eg, fecal smearing), wide weight fluctuations, and some features (eg, verbosity and euphoria) suggestive of “manic agitation.” Kraepelin notes that catatonia is often episodic and argues that a number of features of the case, including thought disorder in the absence of psychomotor activation and substantial residual volitional impairment and affective flattening, suggest that DP is the correct diagnosis.

Table 2.

Case 47: Periodic Catatonia (Course in Episodes With Weight Fluctuations)

Not easy to assess, was the case of a 36-year-old private academic, whom I coincidentally can only show you briefly today. The very large, powerfully built man, as you can see, has his forehead bandaged, because two days ago, suddenly jumping out of bed, he forcefully fell against the edge of the table. He has one longer and three smaller injuries through his scalp. He forcefully resisted the protective actions of the nurses. Subsequently he became calm for a short while, to then run off again. During the course of the day, the agitation repeated itself, whereby the patient threatened to throw himself head-first out of the bathtub into which he had been placed. Yesterday and today he was calmer. Now he lies in a rigid, bound position, stares ahead, does not look at me when I speak. He sensibly answers the questions posed to him after a long pause. He is clear about where he is. He indicates that he sinned badly in his youth and now longs for punishment. Destiny unstoppably runs its course. He has to take the path of suffering, which a high power predestined for him. I need to add that a physical examination did not yield any disturbances and that the Wasserman reaction was negative. Pupillary restlessness and mental pupillary reflexes are present.The patient came to us 5 months ago for the first time, after having become afflicted with insomnia, speech and writing compulsion, as well as lively agitation. In a private asylum, from which he escaped, he had smashed his bed, disrupted the room arrangement, screamed senselessly and had become very violent. Initially he was also very restless with us, sang and spoke a lot, did somersaults, took up strange postures, stuck his tongue out, slapped his thighs. In his speeches he was very verbose, spoke in a lieutenant’s tone and bragged about campaign experiences, even though he had only served in the garrison during the war. After only a few days he became calm. The patient now discussed his life history and his illness condition in a somewhat stilted way. He does not remember the first more severe outbreak. Later he had given in to his restlessness because it is easiest for him to get over it that way, he explained. His mood was somewhat agitated. Gradually, however, he became very calm and communicative, but retained a degree of restraint, peculiar circular hand movements while talking and unfree nature. Once he cried without any discernible reason, said they were men’s tears, triggered by his memories of his time as a soldier. One could also say the aftershocks after an earthquake. He mostly stares ahead while talking.

About 5 weeks after admission he again rapidly became agitated, tore up books, washed his face with milk. In conversations he suddenly became halting, contorted his face, imitated animal voices. He lost coherence, said senseless things, such as: “Boredom is the best remedy for bad teeth.” He sang and prayed through the nights and became violent toward other patients. His body weight reduced by about 9.5 kg in 2 weeks. Then with renewed calmness, his body weight increased by about 10 kg in 14 days. The patient said senseless things, sometimes softly, lisping, sometimes shouting, contorted his face, mixed up the food, tore his clothes and became violent. At the same time his body weight decreased by 12 kg in 3 weeks, to then increase again by 13.5 kg with increasing calmness. The patient became polite, approachable and ordered, still tended to long, somewhat disjointed and contentless discourses, but after 5 months he could be discharged to his home. He showed insight into his illness. His knowledge was in line with his education. His intention was, as previously, to occupy himself with gardening and studies in political economy. He also said that he had written a few small essays which, however, had not been published.Already after 4 days the patient returned, because he felt that things were not right with him. His weight had decreased by 1.5 kg again. He gave an unfree, tense impression, stared ahead of himself, yawned convulsively and contorted his face. He did not shake hands when a hand was proffered to him. On the 6th day of his stay he injured himself.An uncle and the mother of the patient had apparently been mentally ill. He was considered to be very gifted, also poetically. He easily became agitable, enthusiastic, but without endurance, and was subject to frequent mood swings. After having studied law and having taken articles, he twice failed the assessor exams and gave up his career to only occupy himself with art, literature and political economy. He then could only ever work mentally for short periods. He had married 3 years previously and has two children.At the age of 21, a rapidly passing mental disturbance occurred for the first time in our patient. He wrote confused letters, however, he calmed down again. He again became ill 7 years ago. He became restless, travelled, made confused statements, threw valuables in the water for “legal reasons,” walked some steps into the sea and then became very agitated, which necessitated his admission to the hospital. Here he was very restless, sang, whistled, made dancing movements, spoke with a disguised voice and was often violent. His mood was elevated, he tended to jest and banter, in between he was also angry, more rarely depressed. He spoke a lot, was easily distracted, intrusive, pestered the other patients, and got up to all kinds of mischief. Notable was that he often smeared with feces, carried out his needs into the crockery, washed himself in the toilet bowl, once also ate feces. He often broke objects and threw them out of the window because they were superfluous. In his expressions he was coarse in a labored manner. After many fluctuations of the condition, he could be discharged after 5 months as “recovered.” He became ill again in a similar way 5 years ago. In the beginning he expressed poisoning ideas, then became cheerful, agitated, very talkative, pulled faces, went down on his haunches boomingly, whistled and sang, smeared feces and urine. After 4 months he was calm and had “become insightful to an extent” and could be released. At the start of the war he was drafted, but soon became ill and was hospitalized. No details are known to us about this episode.

This illness has occurred in a series of episodes. This one is the fifth. Except for the first, which passed quickly, the condition seems to display similar characteristics. The verbosity and distractibility, the elevated, in many cases agitated mood, and the urge to activity, which is discharged in all kinds of mischief, suggests manic agitation. Which is how the affliction had previously been construed. Notable is the derailment of the patient, who despite good aptitude, quit every career and was satisfied with a meaningless existence. It therefore seems that a degree of mental insufficiency has remained. After the severe illness phenomena had completely receded, we could not deny the impression that understanding and judgment of the patient were superficial, his emotional life colorless and his volition without impetus. A degree of unfreedom and restraint, disjointedness in speech, the contortion of his face and the compulsivity of his self-injuries emerged in the clinical picture. From the past, his severe uncleanliness and eating of feces are notable. Finally, the rapid, unexpected fluctuations of the condition and especially the strong fluctuation of body weight have to be pointed out, which, although in a less pronounced manner, occurred in the previous illnesses.Nevertheless, we have been able to establish that mental pupillary reflexes exist. However, it has to be emphasized that conclusions can only be drawn from their absence, and that the enduring loss of these seems to be far rarer in dementia praecox than has hitherto been assumed.Therefore, taking all the cited circumstances into account, we come to the conclusion that in the case of our patient it does not concern manic-depressive insanity, but dementia praecox. We have to, however, remember that in catatonia, individual episodes are not uncommon. Although mental deterioration soon occurs in that case, which has been indicated in our patient. Such cases can create considerable difficulties in assessment, since we must always keep in mind that even in indubitably manic clinical pictures, sometimes other traits are mixed in which can create a catatonic impression. Precisely for this reason I wish to particularly emphasize the behavior of body weight. We know dementias with agitations of short duration, which recur periodically, which are characterized by accompanying weight fluctuations which are determined by the accumulation and loss of water and which could belong to the sphere of dementia praecox. It therefore seems that precisely this affliction provides the precondition for such radical changes.1(pp193–198)

Case 48 (table 3) is a 43-year-old saw-mill owner described as manifesting “Speech Confusion,” a case that provides “A further contribution to the variability of dementia praecox.” The most prominent sign of this case is thought disorder, which, with substantial quotes demonstrates many derailments and, at times, approaches a classical “word salad.” He also demonstrates bizarre delusions, hallucinations, and a substantial decline in social/occupational functioning.

Table 3.

Case 48: Speech Confusion

A further contribution to the variability of dementia praecox can be provided by this case of the 43-year-old sawmill owner. The fairly large, powerful, but somewhat pale man, whose expressionless features are notable, initially gives sensible, applicable answers to questions. We hear that he has six living siblings, trained in a bank, attended agricultural college, then finally joined his father’s business, which he subsequently took over. He served for 2 years, married 17 years ago, has a good marriage, and six healthy children. He never drank much. He is clear about place, time, environment. In the war he was drafted, once had a fainting spell, came to the military hospital and was discharged due to nervousness.If left to tell his own story, instead of asking him short questions, he starts to become involved in stranger turns of phrase which become increasingly incomprehensible the more one asks him for further explanations. He declares: “Militarism takes a big word, turns it around, gives it a big hold, and due to this a few cattle-nerves are twisted, and this is where the nervousness comes from. The mood of the cattle is the same. The meat of the cattle is dispersed across heaven and earth. I know this from politics. The sun, this is the part, which moves on the surface, and the reflection of the sun, which we see, is the distance of the sun to the middle of the earth. The earth and the sun seek greater hold and, for example, phone France, but this is not possible here at all. When there is lightning, the institute is such that the one stops and the other calls and the third one pulls. I have after all participated in this stupidity. I caught the lightning. As the sergeant commanded, how he gave out the guard, there it came down. The word Hohenzollern was spoken there three times, and there the word was shattered. It was just so tautly tensed that it burst. The emperor, by means of the drawing power of the English language, got the throat affliction. The nerves phone mountains or ships or airships to distract themselves a bit.” If he is told that it is all incomprehensible, he responds: “That is the cattle sense. The cattle sense just lays out the dignity of people into larger and wider forms. The cattle sense catches every word.”

All these statements are made with familiarity and with quiet self-evidence. He never becomes agitated when he is told that he is mentally ill and that he is producing horrendous nonsense, instead he simply says: “But that is self-evident,” and then just carries on in the same confused manner. On the other hand, at any time by means of strict questions it is possible to distract him from his flow of talking, and to obtain ordered information about different things, especially his business matters, which he had also been able to discuss correctly with his son a short time ago. Furthermore, he has compiled an excellent resume, to which he only at the end added that he was now in Munich to overcome his past history, his parents. His past history could not be found in the violent instruction of the military organization. It had brought him to the hospital in a deceitful way, so that his past history did not need to taste the flavor of military physical activity. “It now wants to help with word rhetoric, that which in my past history contravenes against general humanity.”When one has a longer conversation with the patient, certain confused ideas again emerge in the thought processes of the patient, which, however, are difficult to capture, since they take on a changeable form and are continuously embellished with new details. He speaks of an influence from the animal world, which he had been subjected to in his youth due to a kick from a hoof. All animals are connected by blood, male and female. The latter is completely rotten. The animals which hear and understand everything, act through the kick from a hoof. What the horses stamp with their hooves and the cows want is transmitted to the patient through “hoof-voices” in whispers. He feels weak because he has to work through the animal blood in him. Sometimes many thoughts well up in him, at other times they are suddenly cut off. Other times he has to do things he does not want to do, especially in agriculture, not in the forest where he has the power of the wood. He understands the influence of militarism, the unified power of 60 million soldiers of the world war, which can hang a person in a bell like a clapper. Also, the animal world, which had suffered a lot in the war, and his wife, influence him. Which is why he had to buy property. He has to work on pulling together and re-enlivening the animal and female forces which are spread all over the world. He is supported in this by the carbide. Under the ground of his house there are large iron deposits from former smithy operations which he has absorbed into himself. This iron draws the chalk from the walls to itself and in him unites as carbide, which works out of him.

In his external behavior the patient does not present anything notable. He adapts to his current stay at the clinic without any objections and does not express the wish to be discharged. He has no inclination to occupy himself. He can stand around for hours with his hands in his pockets or lies on his bed. On the other hand, he does talk to his co-patients, sometimes ordered, sometimes in his confused statements. His mood is composed. No physical disturbances can be discerned. His knee reflexes are very lively. There is pupillary restlessness. The other mental reflexes are weak. The Wasserman Reaction is negative in his blood.The development of the affliction started about 4 years ago. The patient was in a spiritist group, also then read the relevant books, thought that he was Jesus, and stopped eating. For this reason, he was at an asylum for 2 months. He heard an inner voice, believed he could save the world, gave away his possessions to the poor, undressed himself. He refused to eat due to a divine command. His condition improved rapidly. He took over his business again, but gradually lost his will to work, went for many walks. When he was admitted, he had numerous fainting spells. After his discharge he thought a lot about how everything was connected, wanted to unite the Protestant and Catholic church, spoke and wrote incomprehensible things. He became withdrawn, did not want any strangers around him and did all kinds of wrong things, for example, he put his watch in water, buried gramophone records, did not feed the cattle enough, and could not be convinced to do otherwise. Sometimes he was agitated, threatened his family, hit the cattle, spoke of suicide. Earlier he slept for a long time, explained that he was being held in bed. When the carbide lamp flickered, he thought his relatives were to blame.

The most remarkable phenomenon in this clinical picture is the contrast between sensible and incomprehensible behavior of the patient and his completely confused talking, which stands in contrast to his comprehensible and correct answers to specific questions. Additionally, the patient was until now able to carry out his business correctly, although he did carry out some senseless actions in between. This strange behavior is described as speech confusion (Sprachverwirrtheit), to indicate that obviously mainly his speech expression is disturbed by the illness. We are justified in such an understanding, not only because the patient must be far more ordered in his thinking than is suggested by his fuzzy speeches, but because from our own experience we also know conditions in which words only express our thoughts in an incomplete way, especially in dreams. Dream speech in an almost perplexing manner resembles the statements of those with speech confusion. However, here we can often be accountable for the fact that our claims do not coincide with the ideas we have in mind. Therefore, the connection between our thinking and its speech expression must be loosened in some way. Something similar can probably be assumed about our case. Besides this, there obviously exist all kinds of bizarre delusions, which apparently emerge in changing forms. From these it is evident that the patient feels influenced in various ways and believes to stand in a mysterious relationship to his environment. At the beginning he seems to also have had hallucinations, at least to have heard inner voices. Now none of that can be established. There is an additional deterioration of his emotional life and volition. All the latter traits correspond to the clinical picture of dementia praecox. In fact, speech confusion is not a frequent phenomenon of dementia praecox. We can perhaps assume that this corresponds to a peculiar spread of the underlying pathological changes.1(pp98–202)

Conclusions

The greatest value of this heretofore neglected text, and its associated case reports, is that it represents a distillation of what Kraepelin judged, near the end of his long clinical and research career, to be the essential features of DP that should be conveyed to both beginning and more advanced students of psychiatry. Much of the historical work on Kraepelin’s writings on DP has, appropriately, focused on the 1899 sixth edition²⁰ in which he presents, after 2 “trial-runs” (which he termed, respectively, Psychischen Entartungsprocesse [The Processes of Mental Degeneration] and die Verblödungsprocesse [The Dementing Processes]) in his fourth³⁶ and fifth³⁷ editions, respectfully), the full DP syndrome for the first time. While the sixth edition contained what might be called the opening chapter of Kraepelin’s writings on his mature DP syndrome, the texts reviewed here represent his final summary chapter, written for beginning and advanced students.

Of the many interesting points that might be made about this material, I focus on 7. First, the text shows that Kraepelin did not, at the end of this career, define DP solely by its chronic course and poor prognosis. He recognized episodic courses, especially in catatonia, and a substantial proportion of patients whose final state included only moderate impairment. He expressed the probability that full recovery can occur in patients with DP. Second, Kraepelin made, in this text, repeated references to bizarre delusions and a range of passivity symptoms, which we now commonly refer to as “Schneiderian symptoms,” although they actually have a long history in descriptive psychiatry back to the early nineteenth century.³⁸ Kraepelin’s interest in these specific symptoms as characteristic of DP, particularly the paranoid subtype, were first evident in his writings in the late 1890s when he was using them to help divide the broad delusional syndrome of Verrücktheit into what would become his mature concept of paranoia and paranoid DP.³¹

Third, despite the addition of new subtypes, this final summary of the key features of DP continues to strongly reflect its origins in the syndromes of Kahlbaum’s catatonia,³⁰ Hecker’s hebephrenia,²⁹ and his own syndrome of dementia paranoides, which arose from his division of primary Verrücktheit after the removal of his mature form of paranoia.^31,39–41 While he spent considerable effort in his sixth edition to stitch these diverse clinical forms together into a coherent whole,²⁴ he here ponders the success of that effort when he concludes that the syndromes seen within DP “often deviate considerably from each other.”

Fourth, Kraepelin’s vision of DP, especially as articulated in his subtyping, expanded from his sixth textbook edition to the fourth edition of his Klinik. He emphasized for the students 2 addition subtypes, “depressive and stuporous” and “agitated and circular,” which, despite having poor outcomes, contained some features reminiscent of manic-depressive illness. Perhaps more dramatically, he added dementia simplex, a form of DP with no positive psychotic symptoms at all. Kraepelin’s concept of DP seems to have broadened in the years between 1899 and 1921, a point not lost on some of his critics.⁴

Fifth, although early in his career, Kraepelin was quite skeptical of the neuropathologic focus on much psychiatric research⁴²; later in his life, he invested heavily in such research, recruiting at various times, key luminaries in the field, including Nissl, Alzheimer, and Brodmann. In volume 3 of his eighth edition,⁴³ published in 1913, in his section on “Morbid Anatomy,” he presents photomicrographs showing changes in both neurons and glia from postmortem samples of DP patients. It is, therefore, striking when he summarizes his final views on the etiology of DP to students of psychiatry; he concludes “…the causes of dementia praecox still are completely obscure...”

Sixth, we can see that Kraepelin’s concept of DP was not firmly fixed and impervious to change in the 22 years since its publication. He accepted Diem’s concept of simple DP. He cites several points of Bleuler’s, including his concept of “latent schizophrenia.” He uses the adjectival form of the term “schizophrenia.”

Finally, Kraepelin is often seen as having little to no interest in the role of psychological mechanisms in the etiology of psychiatric illness. This might be true but, as conveyed at several points in his short chapter on DP, he could be aware of the psychological consequences of severe psychiatric illness. Associated with an increased interest in occupational psychology late in his career (having work-benches and machines installed in his laboratory setting in order to study work-place fatigue), he notes the importance of what we would now call occupational therapy to help get work for the patient, which helps critically in “enabling them to retain the remnants of their mental personalities.” He poignantly notes the degree the “wishes, hopes and fears” of normal individuals fade in the background with the development of DP.