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

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The Transformation of American Psychiatric Nosology at the Dawn of the Twentieth Century Molecular Psychiatry (2016) 21, 152–158 © 2016 Macmillan Publishers Limited All rights reserved 1359-4184/16 www.nature.com/mp 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
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