The Transformation of American Psychiatric Nosology at the Dawn of the Twentieth Century

PERSPECTIVE The transformation of American psychiatric nosology at the dawn of the twentieth century

KS Kendler1,2

Between 1896, when Kraepelin published his first formulation of dementia praecox (DP), and 1917, when the American Medico- Psychological Association issued the first official American psychiatric nosology that contained DP and manic-depressive insanity (MDI)—Kraepelin’s key categories—psychiatric nosology in the United States underwent a transformation. I describe and contextualize historically this process using Thomas Clouston, a Scottish Psychiatrist and widely-read textbook author, as a representative pre-Kraepelinian diagnostician. Clouston used three major diagnostic categories based on symptomatic presentation —mania, melancholia and paranoia—all derived from the beginnings of modern psychiatry in the early nineteenth century. He observed that these categories contained good-outcome cases and those progressing to ‘secondary dementia’. Kraepelin designed his categories of DP and MDI to reflect putative distinct disease processes reflected in their course and outcome. Although Clouston and Kraepelin each saw similar patients, their nosologies started from different first principles: symptomatic presentation versus presumed etiology. Driven largely by social forces with American psychiatry, Kraepelin’s system spread throughout the United States in the succeeding decades replacing older diagnostic approaches typified by Clouston’s. In 1896, American psychiatry was demoralized as the idyllic asylums had become overcrowded, isolated scientific backwaters. Kraepelin’s nosology was derived from and was championed by individuals working in high-status research-based university psychiatric clinics. It brought excitement, the promise of subsequent research breakthroughs and the high prestige then associated with German biomedicine. Scientific research comparing the older and Kraepelinian diagnostic systems played little role in this transition. Using empirical methods to guide changes in our diagnostic system is a recent development in the history of psychiatry.

Molecular Psychiatry (2016) 21, 152–158; doi:10.1038/mp.2015.188; published online 22 December 2015

What books would a typical American alienist consult in 1896 Asylum under David Skae6 and was then appointed, at the age of if he or she were so inclined? The most commonly 23 years, as Medical Superintendent of the Cumberland asylum. available works from Europe were those of British alienists He rose rapidly in prestige becoming coeditor of the Journal of such as Thomas Clouston (1840–1915) [and] Henry Maudsley Mental Science (predecessor of the British Journal of Psychiatry)in (1835–1918) (Noll,1 p 47). 1872 and was appointed successor to Skae as Superintendent of the Royal Edinburgh Asylum (the most prestigious Scottish In 1896, Emil Kraepelin published the 5th edition of his textbook, asylum) in 1873. Responding to a long campaign by Scottish the preface to which declared a decisive turn away from a Psychiatrists, the University of Edinburgh instituted a lectureship 2 ‘symptomatic’ view of insanity (Engstrom, p 238). As a in Mental Diseases in 1879 to which Clouston was appointed. manifestation of this ‘turn’, this edition contained his first A contemporary wrote, ‘it was clear that he was a success in his 3 formulation of dementia praecox. Reading that edition convinced new position, and contemporaries were unanimous in their praise the then young and unknown Adolf Meyer to begin a successful of him as a gifted speaker’ (Beveridge,5 p 372). His book ‘Clinical campaign to introduce Kraepelinian nosology into American ’ fi 7 4 1 Lectures on Mental Diseases ( rst edition 1883, last (6th) edition psychiatry (Noll, p 64). In two decades, American psychiatry left 19048) was widely read and praised. A review of the first edition in the diagnostic world exemplified by Clouston, whose views were the Journal of Mental Science hailed it as ‘the best [psychiatric] traceable back to the beginnings of modern psychiatry in the early ’ 9 nineteenth century, for the new world of Kraepelin’s nosology that book from a clinical point of view published in Great Britain . influences us to this day. However, by the time he published his last edition in 1904, while admired as the ‘Grand Old Man’ of Scottish psychiatry, Clouston was criticized for falling behind newer developments from CLOUSTON German Psychiatry, then under the dynamic leadership of his Thomas Clouston, a graduate of Edinburgh Medical School, was an younger contemporary Emil Kraepelin (1856–1926). eminent Scottish psychiatrists of the late nineteenth century.5 He This essay describes this major turning point in the history of worked first as an assistant physician in the Royal Edinburgh American psychiatry and psychiatric nosology, and seeks to

1The Virginia Institute of Psychiatric and Behavioral Genetics, Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA and 2Department of Human and Molecular Genetics, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA. Correspondence: Dr KS Kendler, The Virginia Institute of Psychiatric and Behavioral Genetics, Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Box 980126, Richmond, VA 23298- 0126, USA. E-mail: [email protected] Received 31 July 2015; revised 21 October 2015; accepted 26 October 2015; published online 22 December 2015 Transformation of American psychiatric nosology KS Kendler 153 explicate the nature and causes of these changes. Our entry point influenced by the German psychiatrist Snell who in 1865 proposed is Clouston’s Lectures. that monomania constituted a third primary form of madness Clouston's career included the decades of the 1880s and 1890s alongside mania and melancholia (Engstrom,2 p 128). As when Kraepelin was formulating his nosologic vision of major Clouston8 notes (pp 275–276), by the late nineteenth century, psychiatric disorders. Could Clouston’s lectures provide an the concept of monomania began to merge with the construct of alternative diagnostic perspective of an experienced and paranoia, then popular in Germany, which I use here (to avoid the respected psychiatrist in a different corner of Europe? Indeed, confusions associated with the controversial forensic application his ‘Clinical Lectures’ serves that purpose. It is a remarkable book. of monomania in mid-nineteenth century France18). This diag- His prose is clear and his perspective practical. The lectures nostic category of primary delusional insanity was much broader contain dozens of detailed case reports (45 and 28, respectively, in than the later Kraepelinian concept of paranoia19 (see also Krafft- his chapters on melancholia and mania in his 6th edition8). These Ebing20). For example, for Clouston, hallucinations were quite vivid cases, describing age at onset, presenting symptoms and common in patients with paranoia as were bizarre delusions of signs, and often detailed information about course, can be easily being ‘electrified’ or ‘mesmerized’. A major category of paranoia read, recognized and understood by a twenty-first century reported delusions of ‘unseen agency’ where individuals were clinician. Furthermore, the time period in which he was writing spoken to ‘by telephones’ and ‘persons read their thoughts, or 8 overlapped that of Ticehurst Asylum in England studied by have power over them to act on their thoughts’ (Clouston, p 259). 8 Turner,10 who showed that the clinical presentations of British In his section on diagnosis of paranoia, Clouston notes two key patients in those decades were nearly all easily diagnosable by diagnostic concepts: current diagnostic systems. Reading its 723 pages, one acquires from Clouston’s text a good sense both of what his patients were …1st, not to call any disease by that name that has not existed like and of his ‘nosologic world view’. His first edition, published 20 unaltered for at least 12 months; and 2nd, where there exists years earlier,7 presents virtually the same diagnostic perspective, along with the delusional condition any general brain which was, in the words of his teacher Skae, the ‘method of exaltation or excitement, or any general depression, not to classifying the insane … offered by Pinel, [and] modified by call it by that name till those have passed off (p 271). Esquirol’ (Skae,11 p 341 (1745–1826 and 1772–1840, respectively)). I focus on Clouston’s three major categories of insanity: mania, Critically, Clouston assigned the diagnoses of mania, melanch- melancholia and monomania/paranoia (see Supplementary Appendix olia and paranoia solely on the basis of symptoms and signs for brief comments on his other diagnostic categories). These without reference to course of illness or putative etiology. As 11 categories are so relevant for our story because the first large-scale Skae writes in 1873, this classification was founded solely on study of the prevalence of psychiatric illness in the United States, the ‘mental symptoms’ and was ‘… in fact, not a classification of 1880 census, included only three categories of what we would now diseases, but a classification of symptoms (p 341). call psychotic illness: mania, melancholia and monomania.12 At the beginning of the nineteenth century, the concept of CLOUSTON’S VIEW OF PROGNOSIS AND PROGRESSION TO mania, quite different from our own, was defined by madness in DEMENTIA ‘… the presence of rage, aggression, excitement and lack of control’ (Beveridge,5 p 14). Melancholia was madness accompa- For Clouston, course of illness was a central subject for study and clinical care. Indeed, his textbook repeatedly emphasized the goal nied by reduced behavioral output, typically of psychomotor of preventing the development of ‘secondary dementia’ in mania retardation or prostration.13 During the nineteenth century, the and melancholia. Clouston7 writes, ‘The problem of what concepts of mania and melancholia were gradually narrowed secondary dementia means and how it can be averted is the under the influence of faculty psychology (which typically cardinal problem of psychiatry' (p 293). postulated three major mental functions of cognition, emotion He was well aware that a proportion of his cases of mania, and volition), and began their slow transformation into our melancholia and paranoia could end in ‘secondary, sequential or modern concept of the ‘emotional insanities’.14 terminal dementia’. His lectures contain a number of observations By the late nineteenth century, Clouston, along with most of his on the symptoms and signs that foretold this outcome. contemporaries, had recast the early more behavioral views of In the prediction of secondary dementia, Clouston8 notes the mania and melancholia as, respectively, agitated and retarded critical importance of early age at onset. ‘More than half of all psychotic states, into these more emotional terms. That is, he terminal dementia follows the insanity of adolescence’ (p 288). emphasized the importance, at initial presentation, of euphoria or The risk for dementia, he noted, also tends to increase with the grandiosity in mania, and of sadness and self-derogatory ideation number of episodes of illness. He observed signs of what we in melancholia. (In the words of Clouston’s contemporary, ‘ ’ fi ‘ would call subtle negative symptoms , which portend dementia Robertson, melancholia was best de ned as simply insanity might emerge early. He writes accompanied by mental pain or emotional depression’.15) 16 Writing in his 1916 textbook, Bleuler helpfully clarifies this In some cases a man shows mild dementia by slight degrada- terminological confusion: tions in his habits and feelings. I know such a man who is simply not so sensitive as he once was, not so particular in small things, The ‘mania’ and ‘melancholia’ of German psychiatry naturally is content with worse-fitting clothes, and is not so neat and clean belong to our disease [manic-depressive insanity after Kraepe- in his ways... I know many cases where it shows itself in deficit lin], but all diseases with this name of non-German authors inhibitory power … One might say that the ‘moral faculties’ are [e.g., English and French] do not; they include a large part of the first to be affected in dementia… (Clouston,8 p288). the excited and depressive forms of other psychoses also, especially of schizophrenia’ (p 487). And notes a few pages later It often happens that after a first attack of insanity certain Clouston’s paranoia can be traced to the diagnostic category of mental peculiarities are left, seen it may be only by the monomania, first proposed by Esquirol as a ‘partial insanity’.17,18 patient’s near relations and intimate friends. He is not ‘quite By mid-century, it had evolved into a psychotic syndrome without the same man’. Each succeeding attack that he has leaves him the marked behavioral disturbances typically accompanying the with more marked peculiarities or weaknesses until the final ‘total insanities’ of mania or melancholia. Clouston was likely breakdown of dementia is reached (Clouston,8 p 290).

© 2016 Macmillan Publishers Limited Molecular Psychiatry (2016), 152 – 158 Transformation of American psychiatric nosology KS Kendler 154 Turning to his three major syndromes, Clouston8 notes that nosology that turned away from a reliance on signs and dementia is a more likely consequence of mania than of symptoms toward the assessment of underlying disorders whose melancholia. He writes nature was reflected in course and outcome.2,21 In an early key document from 1871, Hecker argued, in agreement with the Attacks of melancholia may be followed by dementia, but this nearly contemporaneous comments by Skae is not nearly so common as in cases of mania… (Clouston,8 p 287). that the commonly accepted names for psychiatric illnesses, i.e., melancholia, mania …and dementia, are completely unsuitable and insufficient, because these names do not By his estimate, dementia supervenes in 30% of cases of 8 designate true disease forms but temporary conditions. mania admitted to his asylum (Clouston, p 213). He gives a Transferred to somatic medicine, they would correspond to a detailed description of poor prognostic signs in cases of mania, classification of diseases of headache, chest pain, abdominal including: (i) insidious onset, (ii) duration of attacks past pain, etc. Melancholia is a symptom like headache (Kraam,22 ‘ fi 12 months, (iii) persistence of xed delusions or delusional pp 349–350). states and especially of hallucinations’, (iv) ‘persistently dirty ’ ‘ habits , (v) deterioration in the facial expression, especially if it Recognizing that studies from brain pathology have been be towards vacuity’, (vi) ‘perversion or degradation of the natural fi ’ ‘ insuf ciently informative, Hecker argues that many medical affective, tastes, habits, and appetites , (vii) persistent insane diseases were discovered without knowledge of pathology from masturbation’ and (viii) ‘a tendency for the exaltation 8 careful clinical observation over time. He notes that psychiatry has to pass off and fixed delusions to take its place’ (Clouston, fi ‘ ’ — – identi ed one real disease what we would now call General pp 211 212). Paresis of the Insane (GPI)—‘which validates itself as a real clinical He also notes that for mania, the risk for dementia is in disease entity by displaying a peculiar and special course’ ‘ direct ratio to the length of the maniacal exaltation. This does (Kraam,22 p 353). not quite apply to melancholic depression, the existence of … which for long periods is not so damaging to function' 2 (Clouston,8 p 288). As described by Engstrom His views of the vulnerability to dementia as a consequence of ’ … mania are of substantial interest. He notes that in some cases To Hecker s mind the path to nosologic clarity lay in the clinical work of constant and unbiased observation of the There was probably a tendency … towards that weakening of entire course of the condition. Studying that course would the mental functions of the brain which we call dementia…; open the way to demarcating natural disease categories [that this can arise in] many cases where the previous (p 128). excitement was slight…. But it is useful also to keep in mind that there are brains of such quality that they may have In the 5th edition of his textbook, Kraepelin adopted the repeated attacks of acute excitement yet never sink into perspective of Hecker and Kahlbaum. This is clearly noted in the enfeeblement (Clouston,8 p 285). introduction where he wrote The significance of the external attributes of the disease must That is, the vulnerability to dementia may be a partially yield place to the viewpoints emerging from the conditions of independent dimension of liability, not directly related to the origin, course and outcome of the individual disorders liability to mania or melancholia. (Engstrom,2 p 238). Turning to melancholia, the list of predictors of poor outcome provided by Clouston is less thorough than for mania but is Meyer appreciated this key change of perspective in his 1896 fi relatively similar, including gradual onset, xed delusions, review of Kraepelin’s 5th edition published in the American Journal ‘ prolonged hallucinations, dirty habits and long continued of Insanity inattention to the calls of nature’. He was more optimistic about ‘ outcome in cases of melancholia, noting that he would almost An interesting anamnestic method of following the patients for ’ never pronounce a patient incurable while depression continues years after their discharge from the clinic has deeply influenced (p 123). However, he notes that the emergence of what we would Kraepelin. He found that the subsequent history is of the call delusions of passivity strongly predict a poor outcome: greatest value for the understanding of a clinical picture, Some delusions of annoyance or being worked on by electricity, because certain constant relations can be ascertained between magnetism or unseen agency, if they last long while the depres- features of the active psychoses and their outcome or 8 sion abates, are very unfavorable as regards prognosis (Clouston, residual… (Meyer,4 p 299). p 72). Although he gives far fewer details than in mania and 7 For his key concept of dementia praecox, Kraepelin regarded melancholia, Clouston is clear that the risks for secondary the dementia dementia in paranoia are high: not as a secondary condition which succeeds the psychosis The prospect of recovery is certainly very bad in cases of proper, but as an essential and more or less progressive delusional insanity that have lasted for over a year… There is a symptom of the disease, which is discoverable early in the tendency to mental enfeeblement as time goes on. Many cases course of the malady and which carries the distinctive and end in complete dementia after a few years (p 202). characteristic stamp …. (Farrar,23 p 261).

In Kraepelin’s own words,

KRAEPELIN It gradually dawned on me that many patients who initially Beginning in the 1860s, Kahlbaum (1828–1899) and his student presented a picture of mania, melancholia or amentia [acute Hecker (1843–1909) developed a different approach to psychiatry confusional psychosis] showed progressive dementia. In spite

Molecular Psychiatry (2016), 152 – 158 © 2016 Macmillan Publishers Limited Transformation of American psychiatric nosology KS Kendler 155 of individual differences they began to resemble on another. It praecox. In his book review, Meyer states this explicitly summarizing seems as if the earlier clinical differences had little bearing on Kraepelin’s original view of his dementia praecox category the course of the illness. This evolution was similar to what was known with regards to [general] paralysis [of the insane] The secondary or terminal dementia of [other] writers is not an (Kraepelin,24 translated in Berrios and Hauser,25 p 817). end-stage of ‘mania,’ or ‘melancholia,’ or other psychoses, but of special psychoses which he calls Verblödungsprocesse Kraepelin, ever the empiricist, kept working on and revising his [dementia or ‘processes of mental enfeeblement’], and which nosology over the course of his long career, although his form real clinical entities… (Meyer,4 p. 299). fundamental vision of attempting to isolate disease entities based on course and outcome, expressed in his 5th and 6th editions, Among the patients with primary delusions, those without remained unaltered. deterioration, who typically had only non-bizarre delusions, he called paranoia—a much narrower category than Clouston’s A COMPARISON OF CLOUSTON’S AND KRAEPELIN’S paranoia. Those who developed symptoms of dementia typically NOSOLOGIC SYSTEM FOR THE MAJOR PSYCHOSES became his paranoid subtype of dementia praecox. Key features of Kraepelin’s system can be clearly seen from the Although oversimplified, Figure 1 presents a comparison of following two critical comments made by contemporary advo- Clouston’s and Kraepelin’s diagnostic approach to the major cates of a more traditional diagnostic perspective. Norman, writing psychoses. At its most fundamental, Clouston’s approach was in 1904 notes that in dementia praecox, Kraepelin symptomatic with the first a priori division of the group of insane patients into those with or without prominent behavioral/mood … points to the prognostic advantage of stringing together what symptoms (mania or melancholia versus paranoia). Second, may after all later on prove to be separate affections by the among those with major behavioral syndromes, they were divided common thread of their tendency to dementia (Norman,27 p972). into those who were underactive typically with sad mood and self- derogatory ideation and who were overactive, with elevated Farrar,23 a year later, noted that dementia praecox mood and grandiosity. As Clouston repeatedly points out, so constituted, these syndromes had very variable outcomes. Confounded in one disease-picture conditions generally Secondary dementia was common but, as he writes poignantly assumed to be distinct: it erased from the classification the cherished mania and melancholia of Pinel and Esquirol as disease There is no doubt that a man may fully and perfectly recover entities; it relegated to oblivion most of the so-called secondary from attacks of insanity. They may leave not a trace behind dementias which had held so important a place (p 259). them in any shape or form (Clouston,7 p 210).

For Kraepelin, from the time of his 6th edition,26 cases with KRAEPELIN AND CLOUSTON prominent mood and behavioral syndromes with an episodic In 2015, we have a psychiatric nosology shaped by Kraepelin. remitting course were included in his overarching category of Hardly anyone has heard of Clouston and only a few more of his manic-depressive illness. Cases that began with retarded/depressive key nosologic predecessors. Why? or agitated/euphoric pictures but developed prominent negative In addressing this question, it is critical to differentiate between symptoms and secondary dementia were classiﬁed as dementia empirical and non-empirical sources of change.28 Empirical factors

Good

Paranoia Melancholia Mania (broad)

Manic Paranoia Depressive (narrow) Illness

Outcome

Dementia Praecox Poor

Clouston – Blue Kraepelin – Red

Figure 1. A schematic comparison of the nosologic approach to major psychotic syndromes of Thomas Clouston (1840–1915) and Emil Kraepelin (1856–1926). This ﬁgure depicts the broad relationship between the three major syndromes of Clouston (mania, melancholia and paranoia) and Kraepelin (manic-depressive insanity, dementia praecox and paranoia).

© 2016 Macmillan Publishers Limited Molecular Psychiatry (2016), 152 – 158 Transformation of American psychiatric nosology KS Kendler 156 lead scientists to prefer theories (or, for us, diagnostic systems) leading figure in American Psychiatry in the early twentieth with scientific successes as demonstrated by experimental or century: observational studies. Non-empirical factors that lead scientific communities to prefer one theory over another include social, When … Kraepelin’s classification, based on a new descriptive cultural or political forces. symptomatology and the course and outcome of the disease The triumph of Kraepelin’s nosology over that represented by process, came to be known, it was hailed everywhere with joy. Clouston was aided by six non-empirical influences. First, by the Here was a new lease on life for all of us, a new interest in late 1890s, Clouston and the views he presented were old news. psychiatry, new points of view. The whole subject was The stunning successes of the microbial revolution in medicine in revivified and made more alive, and the patients correspond- the late nineteenth century29,30 had increased the pressure on all ingly became more interesting (p 54). medical fields to develop etiologic theories. Symptomatic descriptions of clinical syndromes were seen as less and less That this was not an isolated observation is confirmed by a satisfactory. In 1886, this sentiment was articulated by Pliny Earle comment to Hill’s address by Charles Page, then Superintendent (1809–1892), one of the founding fathers of American Psychiatry: of the Connecticut Hospital for the Insane and an early advocate of Kraepelin’s nosology: In the present state of our knowledge, no classification of insanity … can be erected upon a pathological basis, for the simple reason I believe the Kraepelin system will eventually prevail Since ’ … that, with but slight exceptions, the pathology of the disease is [it s] adoption these gentlemen [his medical staff] have unknown.… Hence, for the most apparent, the most clearly found a fresh interest in the study of insanity, and more defined, and the best understood foundation for a nosological satisfaction than ever in classifying mental disease. All consider scheme for insanity, we are forced to fall back upon the the Kraepelin system a great advance over previous meth- … 36 symptomatology of the disease … as judged from the outward ods (Hill, p 290). manifestations (private correspondence, quoted in Grob12). Fourth, the idea of classifying psychiatric illness on the basis of course of illness that might reflect putative pathology was Second, the latter decades of the nineteenth century were conceptually appealing. Late nineteenth century American psy- fi 1,31 dif cult times for American Psychiatry. The moral therapy chiatry was struggling for scientific legitimacy and sought avidly movement had collapsed under the burden of chronic mental to align itself with brain-based biomedicine. Silas Weir Mitchell, a illness, rising population size and decreasing willingness for prominent American Neurologist, had delivered a blistering attack families to care for their own. The idyllic asylum had become an on the current state of American Psychiatry in his 1894 address to overcrowded, isolated backwater far removed from the new style the American Medico-Psychological Association (the predecessor fi fi 38 of scienti c medicine imported from Germany and typi ed by the of the APA). The major success story of nineteenth century university-based Johns Hopkins Medical School. Effective treat- neuropsychiatry was the identification of General Paresis of the ments for psychiatric illness lay decades in the future. Psychiatry Insane as a distinct syndrome.39,40 By the middle of the century, its was facing stiff competition from the rising specialty of neurology, downhill course and its distinct gross and later histopathological which championed its scientific base. It was time for a change. changes were identified, although the pathological agent was not Third, Kraepelin was a skilled and persuasive author who spoke identified until 1913.41 As intended by Kraepelin, identifying a with great prestige and authority as the leading figure in German ‘dementing process’ disorder that would capture the poor out- and, indeed, European, psychiatry. In the late nineteenth century, come cases clinicians like Clouston had been seeing for decades German science was world dominant and United States was had obvious appeal. scientifically backward. Kraepelin’s nosology was seen Fifth, a diagnostic system focused on the prediction of as more scientific than its predecessors and more closely tied prognosis had pragmatic benefits. University-based Psychopathic to the key advances in disease description associated with the Hospitals, in direct imitation of German models, were being recent advances in pathology, endocrinology and medical established in the United States around the turn of the century at microbiology.29 Emerging evidence that ‘internal disorders in the major universities such as Columbia, Johns Hopkins and University metabolism of the body (Kraepelin,32 p 29) could cause illness and of Michigan (Grob,31 pp 135–142) and these institutions trained deficiencies in the resulting secretions could be treated by many of the leaders of the next-generation of American supplementation33 provided impetus for Kraepelin’s autointoxica- Psychiatry. Similar to Kraepelin in his clinic in Heidelberg, they tion theory of dementia praecox (Kraepelin,34 p 154). This theory faced the problem of needing to predict prognosis quickly to keep proved quite popular in the United States in subsequent decades, their small clinics from filling up with poor outcome patients on leading, unfortunately, to a series of ill-fated therapeutic efforts.35 whom the limited moral and vocational therapeutic methods then at their disposal had little chance to work.2 The importance of the scientific promise of Kraepelin’s system is fi Sixth, Kraepelin had enthusiastic and skilled advocates in the well conveyed in what may be its rst public discussion in the United States in the critical decades after 1896 who contributed United States.1 In 1900, Hill,36 then superintendent of the Iowa ’ ‘ substantially to the rapid and widespread acceptance of his Hospital for the Insane, advocated for Kraepelin s system: The diagnostic system.1 Most important was Adolf Meyer who within object of this paper is to suggest that alienists ought to persevere ’ fi 20 years of writing his positive review of Kraepelin s 5th Edition in their efforts to secure a scienti c nomenclature for the different headed, in succession, the Pathological Institute of the New York forms of insanity’ (p 285). 23 State Hospital system (soon renamed the Psychiatric Institute) and In 1905, Farrar noted that the newly opened Phipps Psychiatric Clinic at Johns Hopkins.42 fl fi The time-honored, all embracing, receptacles—mania and Surely the most in uential gure in American psychiatry in fi melancholia, have in many representative American institu- the rst third of the twentieth century, he was, especially in his ’ tions gradually been losing prestige … Most conspicuous early years, a determined and forceful advocate for Kraepelin s among the diagnoses which have grown at the expense of the diagnostic system. August Hoch was also a resolute promoter. He mania-melancholia group is that of dementia praecox (p 270). worked with Kraepelin and upon accepting a position in 1894 at McLean Asylum, insisted on introducing and using Kraepelin’s That the adoption of Kraepelinian nosology generated sub- diagnostic system (Noll,1 p 83). In 1910, he followed Meyer as stantial excitement is well captured by William Alanson White,37 a director of the New York Psychiatric Institute where Hoch

Molecular Psychiatry (2016), 152 – 158 © 2016 Macmillan Publishers Limited Transformation of American psychiatric nosology KS Kendler 157 continued not only to display interest in Kraepelin but also turned Kraepelinian nosologic vision, the historical evidence suggests much of his attention to psychoanalysis.43 that social and cultural forces were largely responsible. No Both Meyer and Hoch read German and therefore had access to definitive empirical studies compared the performance of the Kraepelin’s teachings years before the first translation of his two diagnostic systems, finding Kraepelin’s to be superior. Indeed, textbook in 1904.44 The culmination of their efforts came in the the idea that empirical methods should have a central role in the first official American psychiatric nosology, issued by the American choice of psychiatric diagnostic categories is of recent origin, first Medico-Psychological Association in 1917, which contained the formally proposed in 1970.50 The degree to which changes in two key Kraepelinian categories of dementia praecox and manic- official nosology should be governed by scientific evidence versus depressive insanity.45 This nosology, largely derived from the clinical judgment or public health needs was actively debated as classification introduced into all New York state hospitals by 1909, recently as the Diagnostic and Statistical Manual of Mental was strongly advocated for by Hoch who was, between 1910 and Disorders, Fifth Edition.51 Although we might be embarrassed by 1917, chief of those hospitals. the recency of the application of science to psychiatric nosology, What about empirical influences? Well-conducted scientific the rise of statistical methods for systematics—the study of studies that contrasted the performance of Kraepelin’s nosology species assignments in biology—is also of recent origin and still with alternatives (e.g. Clouston’s) and showed the Kraepelinian controversial in some quarters.52 Indeed, while we in psychiatry system to be superior played little to no role in the adoption of often look with envy on the harder sciences thinking they have all Kraepelin’s diagnostic system (Noll,1 p 144; G Berrios, personal these classification issues long since answered, the recent debate written communication, May 2015). Noll documents a number of over the planetary status of Pluto was eerily similar to psychiatric often poorly conducted biological studies of autointoxication and diagnostic controversies.53 metabolic abnormalities in patients with dementia praecox The systematic application of science to psychiatric nosology is appearing in the United States literature as well as some positive a new and precarious enterprise. We stand atop a long tradition of clinical reviews1 (pp 124–131), which he concludes contributed clinical descriptive research and ‘authority-based’ diagnostic substantially to the ‘reification’ of the concept of dementia systems,54 in which, in the struggle for dominance of psychiatric praecox in the United States. More systematic efforts in Germany nosologies, the most famous and articulate professor won. As our to ‘validate’ the diagnosis of dementia praecox in Kraepelin’s field matures, both our interest and those of our patients will likely research program had mixed results. Alois Alzheimer attempted to be served by reducing the social influences on psychiatric define a definitive neuropathology as early as 1897 but without nosology and, in a commensurate manner, increasing our use of success.46,47 Years later, in 1916, Rüdin attempted to find the empirical evidence. Mendelian basis of dementia praecox,48 but also failed. Indeed, only after Second World War did quantitative studies of psychiatric CONFLICT OF INTEREST diagnostic systems begin appearing. Several of the new United States Psychopathic Hospitals, including the Phipps clinic, began The author declares no conflict of interest. clinical research programs that could have validated Kraepelin’s 1 key longitudinal observations. None tried. Although many factors ACKNOWLEDGMENTS were involved in a turning away from the longitudinal research Noll’s recent book (ref. 1) was important in pointing me toward relevant primary model advocated by Kraepelin, the rise of the mental hygiene and sources. child guidance movements was particularly important in drawing the interest of United States psychiatry toward the identification and treatment of the not-yet-psychotic.1,31 REFERENCES The historical record suggests non-empirical factors were the 1 Noll R. American Madness: The Rise and Fall of Dementia Praecox. Harvard major reason for the widespread adoption of Kraepelin’s views in University Press: Cambridge, MA, USA, 2011. the United States at the dawn of the twentieth century. It was not 2 Engstrom EJ. Clinical Psychiatry in Imperial Germany: A History of Psychiatric science as we now understand it that was responsible for our Practice. 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