Emil Kraepelin. The Father of Modern Psychiatry

Emil Kraepelin. Introduction

In 1886 young German psychiatrist Emil Kraepelin hold inaugural lecture for his first lecturer chair in psychiatry at the University of Dorpat/Tartu outlining his vision for the future of psychiatric research and clinical care. This lecture marked a turning point in the history of psychiatry.

Kraepelin noticed that the predominant approach to psychiatry, which at that time focused on neuroanatomy and neuropathology found its dead end. Despite decades of slicing brains from dead corpses, there had been no achievements in explaining the nature of psychiatric illnesses.

Kraepelin rejected the reductionist view of mental illnesses as a simply organic brain disease and emphasised the complexity of mental processes and shifted his focus from neuroanatomy to psychology.

He noted that psychology had recently become a natural science and deserved the same respect and recognition as other scientific disciplines. Kraepelin recognized that the objective investigation of psychology had succeeded in creating strictly empirical research methods. He decided to apply these methods to the study of mental illnesses in particular in order to differente and classify different disorders. He argued that psychiatrists should not avoid the responsibility of describing mental processes and conditions in a manner consistent with the science of psychology.

Emil Wilhelm Georg Magnus Kraepelin. Biographical note

Freud’s psychiatric counterpart was born on February 15, 1856, in Neustrelitz, the residence city of the then North German Grand Duchy of Mecklenburg-Strelitz; he died on October 7, 1926, in Munich.

Early life circumstances

Kraepelin’s parents sought bourgeois respectability, which, however, was more difficult by the father’s profession from the perspective of the 19th century. He was an actor, operatic singer, and music teacher who repeatedly ran into financial difficulties and had a tendency towards excessive alcohol consumption. His marriage failed in the 1870s.

Kraepelin’s father withdrew more and more from the family due to the constant lecture tours, forcing his wife to raise her children largely on her own. A later aftermath of these family experiences can be suspected in his involvement in the anti-alcohol movement.

Despite the poor family circumstances and his father’s frequent absences, Kraepelin was a diligent and talented student.

Studies and career

He wrote a prize-winning essay on “The Influence of Acute Illness in the Causation of Mental Disorders.” In 1878, after the completion of his medical degree at the University of Würzburg, he worked at the University of Munich and then, in 1882 returned to the University of Leipzig.

In following years, he worked in Wilhelm Heinrich Erb’s neurology clinic and Wundt’s psychopharmacology lab. He completed his habilitation thesis on “The Place of Psychology in Psychiatry.” In 1884, he became senior physician in Leubus and director of the Treatment and Nursing Institute in Dresden the following year.

Two years later, he was appointed to Professor of Psychiatry at the University of Dorpat, where he held the mentioned inaugural lecture. In 1890, he became department head at the University of Heidelberg and in 1903, he moved to Munich to become Professor of Clinical Psychiatry at the University of Munich.

Development of evidenced based psychiatry

Kraepelin’s renowned nosology emerged amid significant developments in German psychiatry during the 1860s and 1870s. It arose as a response to the disintegration of the unitary psychosis concept, undermined by Kahlbaum and Hecker’s clinical studies. The hypothesis that all mental symptoms are manifestations of a single mental disorder was increasingly untenable since the late 1860s. Kraepelin rejected the generalization in diagnostics of mental illnesses and began to construct so-called disease units. At the same time, he rejected the complicated and barely empirically supported hypotheses of brain pathologists such as Flechsig, Meynert, or Wernicke. He critiqued Meynert and Flechsig for speculative attempts to link brain anatomy with clinical symptoms.

In Kraepelin’s opinion, psychiatry needed less speculative theories and more laboratory research on brain processes. He believed that psychiatry is a branch of medicine and should be studied through observation and experiments. He started to establish a classification system for mental disorders proclaiming high standards of gathering clinical information. His differentiation of dementia praecox and manic-depressive illness, especially his classification of affective disorders, permeates modern psychiatric thinking and practice.

Kraepelin continued to hold his views on Griesinger (another German psychiatrist), rejecting the latter’s efforts to unite psychiatry and neurology and instead, argued that they were separate spheres of medicine. Despite his awareness that psyche is not identical with body, he was able to recognize the influence of specific somatic changes based on mental disorders and vice versa. Even though his classification system was symptom focused he believed that psychiatric diseases were caused by biological and genetic malfunctions.

Classification of mental disorders

Kraepelin’s classification of mental disorders was based on symptoms and their patterns over time, instead of simply similarity of major symptoms. He recognized that any given symptom could appear in virtually any of these disorders. For instance, any symptom found in manic depression can also be seen in dementia praecox. Since there are no direct tests for each disease, differentiation is possible only through their specific symptom patterns. Therefore, Kraepelin’s system focuses on pattern recognition rather than grouping based on common symptoms.

Kraepelin sought to sharpen diagnostic boundaries and develop diagnoses that served critical clinical needs, such as predicting illness course, rather than searching for a single “true” diagnostic system. He was candid about the subjectivity of his clinical approach and relied on his own experiences in his search for natural truth. He put didactic aims ahead of professional consensus or collaboration in the demarcation of psychiatric disorders.

Kraepelinian diagnostic methodology is still vali and in use in such diagnostic manuals as ICD 10 and DSM 5.

Manic depression and dementia praecox

Kraepelin’s biggest achievement was the classification of psychoses into two distinct forms: manic depression (today’s bipolar disorder) and dementia praecox (today’s schizophrenia). He recognized that dementia praecox had a deteriorating course with a continuous decline in mental function.

On the other side he noticed that manic-depressive patients experienced an intermittent course of illness with relative symptom-free intervals between acute episodes. In one of his essays, “Patterns of Mental Disorder,” he discussed the difficulties in differentiating between dementia praecox and manic-depressive illness admitting at the same time that the differential diagnosis could be difficult.

Kraepelin believed that dementia praecox follows a deteriorating course where mental function gradually declines, while manic-depressive patients experience intermittent illness with symptom-free intervals between acute episodes.

In 1920 he admitted that distinguishing between the two diseases was increasingly challenging. On one hand, there were patients with irreversible intellectual deterioration and severe cortical lesions, and on the other hand, patients presenting hallucinations and delusions whose intellectual abilities and the core personality remained intact. Today we know that the second group would refer to patients with delusional disorders. Also, the symptoms of dementia praecox (schizophrenia) and manic depression (bipolar disorder) overlap which led in the modern diagnostic systems to a new category such as schizoaffective disorder to encompass the intermediate cases.

Kraepelin held to the speculation that the psychoses (dementia praecox and manic- depressive illness) would one day probably be found to be caused by a systemic or “whole body” disease process. He assumed that such process would be metabolic in its nature, affecting initially the organs and nerves and ending in a brain damaging cascade.

Kraepelin’s classification approach (nosology)

Throughout his career, Kraepelin made attempts aimed at quantifying and defining mental processes. In these experiments, he clearly differentiated between organic and psychological areas, which he believed had to be studied separately.

His nosological goals were practical, aimed at sharpening boundaries for educational purposes and developing diagnoses that served critical clinical needs. Kraepelin saw himself as a clinical researcher and believed his classification system would be surpassed by scientific progress. His contemporary reviewers praise especially Kraepelin’s dedication to clinical observations.

Over time, Emil Kraepelin’s views on his own classification criteria grew increasingly sceptical. He came to believe that a thorough differentiation between normal and pathological conditions was impossible due to the fundamental obstacle of categorizing life-processes. He also noted that there was no sharp distinction between mental health and illness and that the sheer diversity of endogenous conditions made it challenging to arrive at clearly defined disease categories.

Two paths of Kraepelin’s nosology

Seeking alternatives, Kraepelin pursued two paths. Firstly, he delved into Wilhelm Wundt’s experimental psychology, conducting stimulus-reaction experiments to establish quantifiable psychological norms for diagnosing mental abnormalities.

Secondly, he embarked on extensive clinical research, meticulously documenting the long-term courses of patients’ illnesses. Kraepelin amassed patient histories, creating diagnostic tools like his renowned “Zählkarten.”

From this clinical research, Kraepelin crafted a nosology that fundamentally reshaped 20th-century psychiatry. Kraepelin’s enduring influence doesn’t solely stem from valid categories but also his prowess as an educator. His textbook, with eight editions during his lifetime, left an indelible mark on an entire generation of students. Kraepelin’s dedication to robust psychiatric care within institutions further solidified his impact.

Foundation of German Institute for Psychiatric Research

Kraepelin published his major work, “Compendium of Psychiatry”, in 1883, and expanded it over the years. In 1912, he began plans for a research centre, which was established in 1917 in the middle of World War I, as the German Institute for Psychiatric Research. This was the predecessor of today’s Max Planck Institute for Psychiatry in Munich. In the objective of the research institute, international science and national interests merged. For Kraepelin, the research institute was a “place of strictest science”, where researchers from all over the world were to come together.

Kraepelin did not live to see the establishment of his final great project, which he devoted himself to mainly after his retirement in 1922. He died in 1926 during the planning of the new building for the research institute, which opened two years later.

The historical Kraepelin

Our understanding of Kraepelin might reflect the interests of 20th-century U.S. psychiatry more than the historical figure himself. The neo-Kraepelinian psychiatry in the U.S. was a reaction to psychoanalytic and social psychiatry schools and saw him as a standard-bearer. However, Kraepelin himself struggled with the relationship between brain and mind-based approaches to psychiatric illness and recognized the limitations of clinically based nosology. Despite controversies about his personality and his own objections Kraepelin still has much to offer to modern psychiatry than the icon created by the neo-Kraepelinians.

Interrelating brain and mind

Psychiatric historians and Kraepelin scholars seek to correct misperceptions of Kraepelin. The historical Kraepelin, who struggled with interrelating brain and mind-based approaches to psychiatric illness and appreciated the strengths and limitations of his clinically based classification system.

A recent study by Richard Noll further underscores the limitations of viewing Kraepelin’s writings from a solely brain-focused perspective. Noll argues that Kraepelin adopted a larger, systemic, whole-body approach that took account of metabolic, serological, endocrinological, and other potential etiologic factors.

Changing the paradigm of psychiatry

Kraepelin’s general perspective on mental illness relied heavily on internal medicine because at the time, psychiatry was still in the process of demarcating itself as a medical specialty. In Kurt Kolle’s 1956 tribute to Kraepelin 100th birthdays, he described Kraepelin as a sober researcher dedicated only to “facts”. He emphasized his great merits for the development of psychiatry, but also some barely understandable idiosyncrasies, such as fanatical anti-alcoholism with tendencies towards world improvement.

Undoubtedly, the aspects highlighted by Kolle were important parts of Kraepelin’s life and work. However, as the biographical sketch shows, this perspective also requires differentiation, as does the widely held view among psychiatrists that Kraepelin’s nosology was constructed as an unshakable system.

The critical researcher

Kraepelin himself would have wondered about the long-term success of his classification method, as he always considered his theory of diseases to be a working hypothesis and hoped for more scientifically grounded insights into mental disorders in the future, beyond what was possible for his generation. Behind this attitude he was a researcher who reflected many of the tendencies of his time, pursued his scientific and scientific-political intentions with confidence, but also represented a lively personality.

Two faces of Emil Kraepelin

Despite Kraepelin’s rejection of the mistreatment of the mentally ill, he promoted social Darwinism evolving to eugenics in his late career.

Based on his secure scientific authority, Kraepelin began to focus on social issues around 1903. He revisited his early criminological interests and advocated for prison reform that would grant psychiatrists greater influence in the determination and enforcement of court-imposed sentences.

He intensified his involvement in the anti-alcohol movement by criticizing the Munich brewing industry, through numerous public lectures, and by actively working to establish so-called cure institutions for drinkers.

The degeneration theory

In all these areas of social political engagement, Kraepelin’s approaches were heavily influenced by the degeneration theory as well as the Darwinian and somatic assumptions of his time. In his eyes, many social ills were expressions of “degenerative forces” that hindered the “struggle for existence.” Therefore, he called for the elimination of some socio-cultural deformations of the “struggle for existence,” such as by reforming the education and higher education systems or by abolishing certain social welfare benefits that contributed to the “effeminization of the population.”

Preventive eugenics

Kraepelin advocated for preventive eugenic measures to “raise” public health. After the start of World War I, his political engagement went far beyond “psychic public hygiene.” His involvement in the “People’s Committee for the Swift Defeat of England” and the founding of the Bavarian Land Association of the “German Fatherland Party” during the war clearly showed his advocacy for a military victory.

Kraepelin’s concern for “psychic public hygiene” also shaped his science. At this time, Kraepelin also wrote his self-portrait “Personal,” which showed a complex image of his worldview and political convictions, as well as his emotions and weaknesses.

The controversies

Kraepelin is the key figure, in particular because of his psychiatric classification systems. Today’s nosology still relies on his classification of the mental illnesses. Kraepelin’s concept of a clinically oriented, fundamental research, including the models he designed for institutional implementation in psychiatry, remains current.

On the other hand, Kraepelin is often evaluated in medical historical discussions as a typical representative of the national-conservative academic elite of the late Wilhelmine era. The political views developed in this period helped pave the way for the collapse of the Weimar Republic and, as a result, National Socialism after World War I.

Kraepelin’s humanistic and progressive convictions contradict his national-conservative and Darwinian views. For this reason, the English psychiatrist Michael Shephard postulated the existence of “two faces of Emil Kraepelin”.

Conclusion

In 2006, not only did the 150th birthday of Sigmund Freud prompt reflection, but also that of Emil Kraepelin. Historical assessments have created a distorted view of Kraepelin as a reductionist and biological psychiatrist. However, this image as a hard-nosed, brain-focused psychiatrist fails to capture the full complexity of his personality and his work.

Kraepelin’s reductionist understanding was influenced by the success of his classification method. However, a closer examination of his work shows a different picture of this remarkable man as more psychologically oriented, less brain-focused, and more sceptical of nosology.

Kraepelin and psychology

Despite his rejection of Freudian psychoanalysis Kraepelin was far more psychologically inclined than his contemporary image suggests. Contemporary reviews of his writings showed that he had adopted a psychological standpoint that challenged psychiatry’s foundations. He was sensitive to the role of psychological factors in the aetiology of psychiatric illness and acknowledged that the clinical picture was a product of the causal relationship between bodily and mental phenomena.

Kraepelin’s scientific modesty can be seen in his own scepticism about the validity of his categories considering them as provisional and of no scientific value. He saw them as of practical and didactic relevance only.

Social and political views

In later years, Kraepelin focused on public health, championing alcoholic abstinence and promoting eugenics and racial hygiene. He believed urbanization negatively affected mental health, and social systems undermined natural selection.

Kraepelin appears to many as a typical representative of the national-conservative academic elite. He was the child of the founding years of the German Empire and the Wilhelmine Period. His social and political views were formed during his academic years in Würzburg, Munich, and Leipzig in the late 1870s and early 1880s. This was the time after reunification of Germany, an era of intellectual, cultural, and political ferment.

We do condemn Kraepelin’s views and actions from our current time perspective, but his life reflects the spirit of the late 19th and early 20th century. We do not know how he would have had behaved seeing Darwinism and eugenics put in action one decade later.

Despite his questionable social and political views, Kraepelin’s significance to the development of modern psychiatry since 1900 is undeniable.

Biographical facts

1. Emil Kraeplin was born in 1856 in Neustrelitz, Germany.

2. At the age of eighteen, he decided on a career in psychiatry.

3. Kraepelin returned to the University of Leipzig in 1882. His main work, the Compendium of Psychiatry, was first published in 1883.

4. In 1885, he was appointed director of the Heil- und Pflegeanstalt in Dresden and in 1886, at the age of thirty, he became a professor of psychiatry at the University of Dorpat.

5. Kraepelin received his doctorate in 1878. He went to Bernhard von Gudden at the University of Munich, where he completed his dissertation with the title “The Place of Psychology in Psychiatry”.

6. In 1908, he was elected a member of the Royal Swedish Academy of Sciences.

7. Kraepelin took over the department at the University of Heidelberg in 1890 and remained there until 1904.

8. In 1912, a research center was established at the request of the German Society for Psychiatry, which was founded in 1917.

9. With the help of a generous donation from the Rockefeller Foundation, a new building dedicated to the institute was inaugurated in 1928, according to Kraepelin’s specifications.

10. At the age of sixty-six, he retired from teaching. The last edition of Emil Kraepelin’s textbook of psychiatry was published in 1927, approximately one edition after his death in 1926.

Sources

Engstrom, E. J. (1 September 2007). “On the Question of Degeneration’ by Emil Kraepelin (1908)1”

Shepherd, M. (1 August 1995). “Two faces of Emil Kraepelin”. The British Journal of Psychiatry.

On Kraepelin’s early life and family, see Burgmair et al., vol. I, as well as his Memoirs (Berlin: Springer, 1987).

“Klinik für Psychiatrie und Psychotherapie, Historie”. LMU Klinikum München. Retrieved 10 June 2021.

Shepherd, Michael (1990). Conceptual Issues in Psychological Medicine. London: Tavistock/Routledge.

Decker Hannah S (2007). “How Kraepelinian was Kraepelin? How Kraepelinian are the neo-Kraepelinians?—from Emil Kraepelin to DSM-III” (PDF). History of Psychiatry.

Teodoro T, Durval R (October 2022). “Emil Kraepelin’s taxonomic unitary view of manic-depressive insanity in the 21st century: the never-ending diagnostic conundrum of bipolar depression”

Ebert, Andreas (2010). “Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology”. Indian Journal of Psychiatry.

Noll, Richard. “Whole Body Madness”. Psychiatric Times. Retrieved 26 September 2012.

Noll, Richard (2011) American Madness: The Rise and Fall of Dementia Praecox. Cambridge and London: Harvard University Press.

Engstrom, Eric; Weber, Matthias; Burgmair, Wolfgang (2016). “Psychiatric Governance, völkisch Corporatism, and the German Research Institute for Psychiatry in Munich (1912–1926)”. History of Psychiatry. 

Briole G (2012). “Emil Kraepelin: The Fragility of a Colossal Oeuvre”.