Clinical Review & Education

JAMA Psychiatry | Special Communication

The Development of Kraepelin’s Concept of Dementia Praecox

A Close Reading of Relevant Texts
Kenneth S. Kendler, MD

In 1893 and 1896, in his fourth and fifth textbook editions, Emil Kraepelin brought together 3
syndromes to form the first and second of his 2 prequels to dementia praecox (DP), a
definitive version of which he would propose in his 1899 sixth textbook edition. These
syndromes, which would become hebephrenic DP, catatonic DP, and paranoid DP, each had
distinct histories. Hebephrenic DP was derived from syndromes first proposed by Hecker, and
catatonic DP was derived from syndromes first proposed by Kahlbaum, and then both were
substantially revised. Kraepelin created paranoid DP de novo from a division of his early broad
delusional syndrome Verrücktheit, distinguishing it from paranoia. Two of these syndromes
(catatonic DP and paranoid DP) were present in different forms in his earlier textbook
editions, and 1 syndrome (hebephrenic DP) was not. In his 2 prequels, the 3 syndromes were
listed together with a brief preface. In the sixth textbook edition, they became “clinical forms”
of DP with a lengthy integrative introduction. Much more than in his prequels, in his sixth
edition, Kraepelin stitched these 3 syndromes together, emphasizing their shared signs,
symptoms, and course. Hebephrenia was the core of Kraepelin’s DP concept, while the
paranoid subtype fitted least comfortably within his framework. His term dementia was Author Affiliation: Medical College
meant in a broad sense consistent with both short-term and rare long-term recoveries. of Virginia, Virginia Institute of
Psychiatric and Behavioral Genetics,
Kraepelin was a pragmatist, not a purist, in his nosologic work and focused both on clinical Department of Psychiatry, Virginia
features and course and outcome. He experimented with various nosologic categories, willing Commonwealth University,
to revise earlier formulations in the light of new data. He was more tentative about his Richmond.
conclusions than many who followed him. Corresponding Author: Kenneth S.
Kendler, MD, Department of
Psychiatry, Virginia Commonwealth
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.1266 University, PO Box 980126,
Published online June 10, 2020. Richmond, VA 23298 (kenneth.
kendler@vcuhealth.org).

O
n September 19, 1896, when Emil Kraepelin spoke to the
Annual Conference of the Association of German Psychia-
trists in Heidelberg on “Goals and Paths of Clinical
Psychiatry,”1 he had been professor of psychiatry in Heidelberg since
1890, where he established a clinical research program to support
the development of his new psychiatric nosologic classification. That
year, the fifth edition of his textbook2 was published containing a
tentative diagnostic category of Verblödungsprocesse (dementing
process). Three years later, the sixth edition of Kraepelin’s text-
book was published, containing the direct descendent of that cat-
egory: dementia praecox (DP).3-5 Kraepelin raised key issues about
psychiatric nosologic classification:
The difficulty…lies in distinguishing what is significant from what is
coincidental in each clinical picture…. More detailed analysis teaches
us to recognize very important differences between disturbances
which are externally very similar…. The consideration in all in-
stances of the further course and outcome allows what is essential
and fundamental of individual clinical processes to emerge clearly…,
it could be possible that different processes lead to the same end….
[and] the same process could lead to different outcomes…the most
important result of this research [was] the particular singling out of
the dementing processes (Verblödungsprocesse). This does not con-
cern the coincidental, “secondary” outcomes of other, simple men-
tal disturbances, but the outcome in mental weakness is certainly
predestined from the outset, as in paralytic dementia.1(pp842-843)
At this historical juncture, Kraepelin singled out a group of pa-
tients demonstrating a “predetermined,” “essential and fundamen-
tal” dementing process potentially detectable early in their course.
This effort began a decade earlier. Writing in his memoirs about
his time at University of Dorpat (1886-1890) when he began strug-
gling with the nosologic classification of insanity, Kraepelin wrote that
he was
…gradually forced to consider the importance of the course of ill-
ness with regard to the classification of mental disorder. However,
I did not come to any clear conclusions, because I had no opportu-
nity to survey the entire development of the disorder from the be-
ginning until the final result in a large number of patients…. It was
not until the last years of my time in Dorpat that I began to differ-
entiate more clearly between the cases which ended in dementia
faster than the others and I began to interpret them as Hecker’s
hebephrenia….6(pp43-44)
It was at this time, surely no accident, that Kraepelin commis-
sioned 2 students to do dissertations involving literature reviews and
clinical studies of catatonia and hebephrenia.7,8

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 Clinical Review & Education Special Communication The Development of Kraepelin’s Concept of Dementia Praecox

Table 1. Timeline and Summary of the Developments of Kraepelin’s

syndrome paranoia and use Verrücktheit for his earlier broader syn-
Concept of Dementia Praecox From 1883 to 1899a drome [roughly, chronic, nonaffective delusional psychoses].9)

Source Content
Kraepelin first Contained section on Verrücktheit (chronic nonaffective
edition,15 delusional psychoses) without subforms
1883 1893: Fourth Edition
Kraepelin Contained section on Verrücktheit now with physical, Kraepelin drafted 2 prequels to DP in his fourth and fifth editions.
second hallucinatory, and referential subforms of Verrücktheit;
edition,16 catatonic form of Verrücktheit also noted His introductions to these sections are particularly informative. In
1887
the 1893 fourth edition,12 his 126-word introduction to “The Pro-
Kraepelin [While at Dorpat] … gradually forced to consider the
autobiography,6 importance of the course of psychotic illness with regard to cesses of Mental Degeneration” (Psychische Entartungsprocesse)
1886-1890 the classification of mental disorder, with a particular focus read as follows:
on Hecker’s concept of hebephrenia
Kraepelin third Section on Verrücktheit little changed from second edition
edition,17 The clinical pictures which we will summarize here under the name
1889 of mental processes of degeneration (Entartung), have in com-
Daraszkiewicz8 Kraepelin initiates dissertation research by Daraszkiewicz on mon the profoundly rapid development of a permanent condition
and Behr,7 hebephrenia and Behr on catatonia in Dorpat, likely
1890-1891 prompted by his increased interest in these syndromes; of mental impairment, the origin of which can usually be clearly dis-
Kraepelin leaves Dorpat and moves to Heidelberg to establish cerned by the individual accompanying symptoms. In contrast to
his nosologically oriented research program
Kraepelin First prequel for Dementia Praecox: The Processes of Mental
other psychoses which result in secondary mental impairment, here
fourth Degeneration (Psychische Entartungsprocesse) with the 3 the mental invalidism of the patient is clearly apparent from the out-
edition,12 classical subtypes. First described syndromes of hebephrenia
1893 and dementia paranoides in Kraepelin’s writings. He begins set or within a very short time. Permanent, formed delusional sys-
his introduction, “The clinical pictures which we will tems never occur… Depending on the particular way in which the
summarize here …have in common the profoundly rapid
development of a permanent condition of mental mental disorders develop, we may distinguish three main types,
impairment.” He notes “no major delusional subforms.” namely dementia praecox, catatonia and dementia paranoides.
Kraepelin fifth Second prequel for Dementia Praecox: Dementing Processes There are numerous transitions between these forms.12(p435)
edition,2 1896 (Verblödungsprocesse) with same 3 subtypes and same
introductory sentence; Kraepelin creates the fantastical
subform of Verrücktheit and anticipates its possible transfer From the beginning, Kraepelin saw the syndrome that became
to his category of dementia paranoide
Kraepelin In describing his nosologic work in Heidelberg, he notes that
DP as demonstrating rapid development of mental impairment. This
address,1 1896 “the most important result of this research [was] the text includes the surprising claim that “permanent, formed delu-
particular singling out of the dementing processes”
sional systems never occur”12(p435) in this syndrome. At this time,
Aschaffenburg Kraepelin’s main assistant, anticipating his mentor’s
address,14 conclusions, states that “the diseases of hebephrenia and Kraepelin assumed that such syndromes would remain in Verrück-
1897 catatonia form a unified disease process. The name theit.
‘dementia praecox’ seems to me to be the most suitable.”
His list of subtypes is familiar, with 1 expected term—
Kraepelin sixth Kraepelin’s classic formulation of dementia praecox – “three
edition,3 1899 principal groups of dementia praecox which, however, are hebephrenia—missing. In its place, we find, for the first time in Krae-
connected to each other by fluid transitions.” He transfers pelin’s writings, dementia praecox. In his fourth and fifth editions,
the fantastical subform of Verrücktheit to the dementia
paranoides subtype of dementia praecox, with the Kraepelin used this term to refer not to the entire syndrome, but to
“referential” form of Verrücktheit becoming his mature the subtype that he would rename hebephrenia in this sixth edi-
concept of paranoia. He increasingly emphasized the wide
sharing of symptoms, signs, and course across the 3 tion. (Here, when dementia praecox is used as a subtype, it is in ital-
dementia praecox subtypes as well as his new data on the
better short-term prognosis for catatonia.
ics.) However, in these 2 editions, Kraepelin did use hebephrenia to
Kraepelin In an address focused on “the results of many years of describe the severe form of this subtype.
address,13 detailed clinical research” on dementia praecox, he Kraepelin saw the hebephrenic syndrome—first articulated by
1899 emphasized its “peculiar state of mental impairment,” but
also discussed the key diagnostic role of “nonsensical Hecker,18-20 but substantially modified by Kraepelin10—as the core
delusions,” dullness, apathy, and stereotypy. He provides a of DP. Although Kraepelin distinguished the 3 familiar types of DP,
list of poor prognostic features for dementia praecox: (1)
dull mood and lack of interest, (2) senseless delusions transitions between them were common, a theme he emphasized
without affect, (3) enduring mannerisms, (4) recurring more strongly with each edition.
changes of mood with dullness in between, and (5)
disappearance of negativism without return of emotional
responsiveness.
a
Not all events are described in this article, as some are covered in detail in
earlier articles in this series. 1896: Fifth Edition
In Kraepelin’s fifth edition,2 the introduction to his second DP pre-
In 3 previous articles, through a close reading of Kraepelin’s rel- quel, expanded to 223 words, begins
evant editions and articles cited therein, I traced the development
of the 3 DP subtypes proposed in his sixth edition.9-11 Here, I pro- The clinical pictures which we will summarize here under the name
vide an overview and synthesis aided by reviews of critical parts of of “Dementing Processes” (Verblödungsprocesse) have in com-
his fourth, fifth, and sixth editions2,3,12; his autobiography6; pub- mon the rapid development of peculiar conditions of mental weak-
lished lectures of Kraepelin from 18961 and 189913; and his student ness. Mostly this process proceeds with the appearance of lively
Aschaffenburg in 1897.14 I outline the main features of this story in symptoms in various spheres of mental life; the mental impair-
Table 11-3,6-8,12-17 and the Figure.9-11 (Table 23,5,13 contains supple- ment very soon clearly comes into effect and becomes increas-
mentary quotes. I call Kraepelin’s mature sixth edition Verrücktheit ingly foregrounded in the further course of the illness. In my opin-

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 The Development of Kraepelin’s Concept of Dementia Praecox Special Communication Clinical Review & Education

Figure. Development From 1883 to 1899 by Emil Kraepelin of His Classical Formulation of Dementia Praecox (DP) in His Sixth Edition

Hallucinatory Hallucinatory Hallucinatory

Verrücktheit with Fantastical
Verrücktheit and Physical and Physical and Fantastical
no subforms Verrücktheit
Verrücktheit Verrücktheit Verrücktheit

Dementia Dementia Dementia

Dementia
Development of subtypes

paranoides paranoides paranoides

paranoides
subform of PE subform of DV subtype of DP

Catatonic Catatonic
Verrücktheit Verrücktheit
Catatonic Catatonic
Catatonic subform of DV subtype of DP
Catatonia Catatonic Catatonic
Verrücktheit
Wahnsinn subform of PE

Hebephrenic Hebephrenic Hebephrenic

Hebephrenia
subform of PE subform of DV subtype of DP

Second Classical form

Drafts of DP First prequel-PE
prequel-DV of DP

Daraszkiewicz
Key on hebephrenia
dissertations
Behr on catatonia

Textbook
First Second Third Fourth Fifth Sixth
editions

Professorships Dorpat Heidelberg

1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899
Year

From bottom to top, the figure, presents (1) the timing of Kraepelin’s 2 first
professorships in Dorpat (now Tartu, Estonia) and Heidelberg; (2) the year of
publication of the first 6 editions of his textbook; (3) the timing of the 2 key
dissertations by Kraepelin’s students in Dorpat on catatonia and hebephrenia,
likely from 1890 to 1892, that likely paved the way for Kraepelin’s focused work
on these syndromes in his fourth edition; (4) the publication in editions 4
through 6 of his first 2 prequels (or drafts) psychischen entartungsprocesse
(PE) in the fourth edition, and die verblödungsprocesse (DV) in the fifth edition,
and his classical conceptualization of DP in his sixth edition; (5) the simple
evolution of his concept of hebephrenia as a subform of PE and DV in the fourth
and fifth editions (called dementia praecox in those editions) and hebephrenia
as the classic DP subtype in the sixth edition; (6) the more complex evolution of
the concept of catatonia beginning as a subtype of Verrücktheit and Wahnsinn
in the second and third editions evolving into the classic catatonic DP in the
sixth edition; and (7) the intricate evolution of dementia paranoides beginning
as hallucinatory and physical Verrücktheit in the second and third editions that
merge into fantastical Verrücktheit by the fifth edition. Dementia paranoides is
independently proposed in the fourth edition, and that merges with fantastical
Verrücktheit to create the classical DP subtype in the sixth edition. Many of the
specifics in this figure (somewhat simplified for presentation here) are
presented in detail in the first 3 articles from this series.9-11

ion, this behavior indicates that we are most probably dealing with
organic changes in the brain…The progress of the illness may halt
at any stage of the dementia, so we encounter a series of condi-
tions in the end states of this form of insanity, ranging from the mild-
est impairment of mental functions to the deepest dementia. In
some cases, this may be accompanied by certain remnants from the
development of the illness. Insofar as these forms can be sur-
veyed, I believe to be justified in initially distinguishing between three
main groups of dementing processes, namely Dementia praecox,
Catatonia and Dementia paranoides. Nonetheless there seem to be
numerous transitions between these forms. In addition, I think it is
probable that some other clinical pictures should also be included
among the dementing processes, which at present we classify dif-
ferently, especially some of the Verrücktheit groups.2(pp425-426)
Dementia (Verblödung) in 1800 referred to cases of “psycho-
social incompetence,” often accompanied by cognitive impair-
ment and psychotic symptoms.21 This term narrowed during the 19th
century, but “irreversibility and old age were not features of the con-
dition, and, in general, dementia was considered to be a terminal
state to all sorts of mental, neurological and physical conditions.”21(p15)
Writing in the 1890s, Kraepelin was using the term dementia more
broadly than our current usage.
Consistent with this, Kraepelin outlines a range of possible end
states. As in his fourth edition, he notes “numerous transitions” be-
tween the subforms of DP. He warns of a coming shift—a subgroup
of Verrücktheit might get transferred into dementia paranoides. He
does not repeat his claim that patients with “permanent, formed de-
lusional systems” are not part of proto-DP.
Aschaffenburg: 1897
Gustav Aschaffenburg (1866-1944),22 then Kraepelin’s assistant in
Heidelberg, lectured to a session chaired by Kraepelin on Novem-
ber 7, 1897, at the Conference of South-West German Alienists. His
lecture, “The Catatonia Question,” was a “detailed study and the most
careful comparison of 227 case histories” admitted to Kraepelin’s

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 Clinical Review & Education Special Communication The Development of Kraepelin’s Concept of Dementia Praecox

Table 2. Selected Quotes From Kraepelin’s Work Relevant to the clinic from 1891 to 1897.22(p1004) In concluding his clinical and fol-
Development of His Concept of Dementia Praecox low-up study, Aschaffenburg writes
Quote
No. Text …my knowledge does not allow any other conclusion other than the
1 The sensory experience of our patients very frequently suffers serious assumption that the diseases of hebephrenia and catatonia form a
disturbances due the occurrence of hallucinations… The patients’ train unified disease process. The name “dementia praecox” seems to me
of thought always tends to suffer seriously sooner or later… On this
basis it is extremely common for delusions to develop temporarily or to be the most suitable. It indicates the characteristic of the illness,
permanently…. Very striking and pervasive disturbances generally take
place in the emotional life of our patients…3(pp140-142)
the premature development of mental weakness, without, unlike
2 What all these, externally so different, clinical pictures of dementia the description hebephrenia…a [specific] relationship to pubes-
praecox have in common, is the outcome of a peculiar state of mental cent development, nor, as in the name catatonia, indicating the ten-
impairment. The characteristics of it lie therein that rationality and
orientation remain intact for a notably long period and that memory is sion conditions of the musculature…22(p1017)
relatively meagerly disturbed. However, usually judgment suffers, as
can be seen especially from the adherence, without any insight, to
completely nonsensical delusions. In the sphere of mood, a distinct Perhaps this was Aschaffenburg’s opinion, but more likely he was
dullness and apathy develop. The healthy, deeper emotional reflecting the evolving views of his professor.
connections fade, even if great momentary irritability exists. The most
severe disturbances are finally suffered in behavior and actions.
Besides the loss of mental independence, and the own incentive to act,
we here find the various symptoms, which we know as negativism,
command automatism, impulsivity, stereotypy and stiltedness.13(p257)
1899: Sixth Edition
3 Dullness of mood, and lack of interest and mental activity, with
retained intellectual grasp. Determining this disturbance can be
simulated by dazedness on the one hand, which is not unusual at the In his sixth edition,3 Kraepelin expanded his introduction to the DP
start of illnesses, by negativism on the other hand, which may make edition to more than 4000 words. It begins:
the patient seem more indifferent than he is.13(p258)
Pronounced, senseless delusions without affect or agitation. These can
recede, however they tend to leave behind a significant degree of lack The clinical pictures which we will summarize here under the name
of judgment.13(p258) of “Dementing Processes” (Verblödungsprocesse) have in com-
Enduring uniform mannerisms and movement stereotypes without mon the rapid development of peculiar conditions of mental weak-
agitation. These can also disappear again, however, mostly with the
continued existence of clear mental weakness (Psychische ness. Although it seems that this unfavorable outcome need not oc-
Schwäche).13(p259) cur in all cases without exception, it is so extremely common that
Regular recurring changes of mood (Verstimmungen) or agitations of a
short duration with dullness of mood in the intervals. As these are very we would like to continue to keep to the conventional designation
frequent with disturbances in their end stages with accompanying for the time being…. In view of the clinical and anatomical facts
transitory hallucinations or delusions, their occurrence may have a
particularly unfavorable significance.13(p259) known so far, I cannot doubt that we are dealing here with serious
Disappearance of negativism or agitation without return of emotional and, as a rule, at the most only partly reversible damage to the ce-
responsiveness, of involvement in the environment or with their rebral cortex…. From the clinical standpoint, it is perhaps to be rec-
relatives, of mental activity, or the wish to be occupied. Conversely, it
seems that one need not yet give up hope of significant recovery ommended…to distinguish between three principal groups of de-
completely, as long as there is still enduring agitation or strong mentia praecox which, however, are connected to each other by fluid
negativism.13(p259)
transitions. We shall call these forms hebephrenic, catatonic and
4 Their ears perceive…. the whispering voices of all of mankind. The
Edison phonograph speaks; accusations and threats are uttered (“she paranoid. The first one is identical with the dementia praecox which
eats and does not work,” “she is to be skinned,” “she’s going to be put
in an asylum”); the patients’ thoughts become audible and everyone
I described earlier, the second with catatonia, and the third em-
can perceive them, they are discussed and gossiped about by those braces paranoid dementia and, in addition, those cases otherwise
around…. Everything is the patient’s fault, he is a great sinner, a
murderer and traitor… He is stared at, observed, gossiped about, counted as Verrücktheit which lead rapidly to a considerable de-
bewitched; he is to be killed; to be declared a spy, to be shot…. his gree of mental weakness. The whole field of dementia praecox ba-
blood is taken, his hair dirtied, his face disfigured, his thoughts are
formed for him, his actions are influenced artificially, and words are sically corresponds to the clinical pictures that used to be called “de-
put in his mouth… The patient has come into a huge inheritance, has a menting processes”; I would like to propose this change of names
lot of money to claim, a whole room full of gold, is descended from the
German emperor… He has been sent by God, speaks with him, has a because paralysis and senile dementia as well as a series of other
high calling, is to save mankind….3(pp150-151) diseases could possibly also be included under the name of “de-
5 In many cases, catatonic characteristics are observed, such as pulling menting processes”. The diversity of the clinical pictures which we
faces, mannerisms in eating and shaking hands… slobbering, grunting,
rhythmic… rocking, catalepsy, echolalia and echopraxia.3(p155) observe in the course of dementia praecox is very great, so that it
6 People know his thoughts, talk about him, speak of “murder and such is often very difficult to detect the internal homogeneity by super-
stories,” “he has to come along.” There are revelations, spiritual
voices, “vocal interventions,” ventriloquists; when the patient thinks
ficial examination. Nevertheless, we meet certain basic disorders
of something, he immediately hears it being related to others. In the again everywhere in a more or less pronounced form, though they
room there is vapor, foul air; a smell of death; in the meal there is
human flesh and garbage… his genitals are removed. Female patients are at their purest in the final conditions in which more incidental
are robbed of their honor; they give birth to dead children. The and transitory accompaniments of the process of disease have re-
patient’s thoughts are weakened, his mind is drawn from his brain like
a rag, his brain torn up, his head sawed through the middle and a gas ceded behind the permanent and characteristic changes in mental
tap screwed into his skull.3(p161) life.3(pp137-138)
7 [Later in the course] more and more peculiarities and eccentricities
usually appear: making grimaces, queer gestures and habits, affected
movements, mannerisms, in shaking hands, eating, walking and The phrase “the rapid development of peculiar conditions of
talking, and traces of negativism. The patients speak… with words of mental weakness,” seen with small changes in the first sentence of
their own invention, and they like wordplays and rhyming; it may even
come to total confusion of language.5(pp147-150) all 3 editions, reflects a central tenet of Kraepelin’s view of DP. How-
ever, this definition does not apply to all cases. We have a stronger
statement about the “organic” cause of DP than seen in his earlier

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 The Development of Kraepelin’s Concept of Dementia Praecox
editions. He introduces for the first time hebephrenia as a sub-
type, as in this edition the term DP is “promoted” to describe the
entire syndrome. He comments specifically on the expansion of
the concept of dementia paranoides predicted in the fifth edition.
Finally, he again reemphasizes the “fluid transitions” between
subtypes.
Later in this introduction, Kraepelin notes key features most
closely associated with his paranoid and hebephrenia subtypes that,
he argues, are seen across all patients with DP (Table 23,5,13; quote
1). He follows with a discussion about the frequent “deep distur-
bances…in the domain of behavior and action,”3(p143) which he il-
lustrates with discussions of excitation, stupor, negativism, and
“manifold stereotypic movements and postures,”3(p144) all features
particularly associated with his catatonic subtype.
1899 Address to the Assembly of the South-West
German Alienists
In this 1899 address “On the Diagnosis and Prognosis of Dementia
Praecox,” Kraepelin summarized “the results of many years of
detailed clinical research.”13(p262) It began
In recent years, a large group of cases have stood out from the va-
riety of clinical diseases, the outcome of which tends to be a
peculiar condition of mental weakness. The development of this
impairment is not a coincidental, “secondary” event, but it evi-
dently is founded in the nature of the illness process. This can
thus be predicted with certain probability, if one knows this dis-
ease category. Initially it is irrelevant whether this category,
which for now it is probably best to describe as dementia prae-
cox, concerns a unified disease process or not. As experience has
demonstrated to us, it is possible to distinguish dementia prae-
cox in its first stages from other forms of mental disturbance,
even if in individual cases the practical difficulties in determining
it can be considerable.13(p254)
We again see the phrase “a peculiar condition of mental weak-
ness,” now described as a primary feature “in the nature of the ill-
ness process.” Kraepelin emphasizes the ability to recognize the dis-
order in its early stages and is uncertain about the causal
homogeneity of the syndrome.
In a later passage, Kraepelin addressed the key commonalities
of the DP syndrome (Table 23,5,13; quote 2). Although he begins with
the paradigmatic phrase “peculiar state of mental impairment,” he
expands his descriptive domain considerably, including “nonsensi-
cal delusions” and other features including dullness, apathy, and ste-
reotypy.
Kraepelin then reports the short-term outcome of 300 cases
of DP, noting better outcomes in patients with catatonic DP than
those with hebephrenic DP. In a final section, he reviews the
prognosis of the disorder, noting the underlying uncertainty of its
course and citing stupor or agitation as good prognostic features.
Supporting the breadth of his “dementia” concept, he writes,
“Furthermore, we know from surprising late recoveries we have
observed, that even after a very long duration of severe illness
Finally, Kraepelin lists 5 symptoms and signs associated with poor
outcome: (1) dull mood with lack of interest, (2) senseless delu-
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Special Communication Clinical Review & Education
sions without affect, (3) enduring mannerisms, (4) recurring changes
of mood with dullness in between, and (5) disappearance of nega-
tivism without a return of emotional responsiveness (Table 23,5,13;
quote 3). In his concluding remarks, he notes that, “despite all ef-
forts, [I] have not been able to determine sharp boundaries be-
tween the individual clinical manifestations of dementia
praecox.”13(p282)
The Constituent Subtypes
From the first of his DP prequels in his fourth edition, Kraepelin pos-
tulated that proto-DP consisted of 3 syndromes. Reviewing the evo-
lution of these syndromes9-11 suggests 4 lessons. First, for 2 DP sub-
types—hebephrenia and catatonia—Kraepelin was working from a
literature and clinical tradition more than 2 decades old estab-
lished by Kahlbaum and Hecker. 23 Although Kraepelin subs-
tantially departed from some of their views,10,11 any prehistory of
DP must turn first to these writers and their foundational
monographs.18-20,24-26 However, 1 of his DP subtypes had no such
historical tradition. Although nonaffective chronic delusions syn-
dromes generated a large amount of literature in the latter half of
the 19th century, no precedent existed for Kraepelin’s concept of
dementia paranoides.9,27 It was his de novo creation.
Second, 2 of the DP subtypes—catatonia and dementia para-
noides—evolved out of syndromes that appeared in earlier editions
of Kraepelin’s textbook. From his first to sixth editions, his text-
book had sections on Verrücktheit from which dementia para-
noides developed.9 In the second and third editions, Kraepelin had
2 categories (Verrücktheit and Wahnsinn) that contained catatonic
subforms. By contrast, hebephrenia (as a severe form of dementia
praecox) made its first entry as a category in Kraepelin’s fourth edi-
tion. That his interest in this syndrome predated his fourth edition
is noted by the above quote from his memoirs and his assignment
of his student Daraszkiewicz to study hebephrenia for his disserta-
tion in 1890 or 1891.8 Kraepelin’s serious study of this syndrome,
which formed the core of his concept of DP, can be dated to his work
with Daraszkiewicz in Dorpat in the early 1890s.
Third, the birth of dementia paranoides was inextricably bound
up with the development of Kraepelin’s mature concept of para-
noia. They were each defined in contrast to one another, with the
fission of Verrückheit into paranoia and dementia paranoides. Krae-
pelin reworked his concepts of hebephrenia and catatonia from his
fourth to sixth editions, but he was just “fine-tuning.” By contrast,
between his fifth and sixth editions, Kraepelin detached a large part
of the category of Verrücktheit and placed it within dementia para-
noides. Finally, the evidence suggests that, among these 3 sub-
types regarding both the nature of their evolution and their clinical
presentations, hebephrenia and catatonia were more closely asso-
ciated with each other than either was with dementia paranoides.
The Stitching Together of DP
Although Kraepelin sought to interrelate the 3 constituent syn-
dromes in the 2 prequels of DP in his fourth and fifth editions, this
“stitching together” accelerated in his sixth edition. In his sixth edi-
tion description of hebephrenia (which Hecker18 conceptualized as
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 Clinical Review & Education Special Communication
having minimal positive psychotic symptoms), Kraepelin empha-
sized the prominence of bizarre delusions and hallucinations of the
kind common in dementia paranoides (Table 23,5,13; quote 4). Al-
though Hecker18 did not record catatonic features in his patients with
hebephrenia, Kraepelin noted them in his sixth edition (Table 23,5,13;
quote 5). In Kraepelin’s sixth edition, he enlarges on his earlier de-
scriptions, emphasizing the importance of bizarre delusions and hal-
lucinations in catatonia (rarely noted in Kahlbaum’s monograph25)
(Table 23,5,13; quote 6). In new sixth edition text on catatonia, Krae-
pelin notes that patients’ speech and thought is often disturbed in
ways typical for hebephrenia: “The sequence of ideas is muddled and
incoherent, and thought is in most cases seriously impaired, as is
shown by the patients’ nonsensical and contradictory
utterances.”3(p162) He comments on the close association between
the early forms of catatonia and hebephrenia: “This first phase of the
disease [catatonia]…in all principal features resembles that of cer-
tain hebephrenic forms….”3(p163)
In his sixth edition description of dementia paranoides, Krae-
pelin notes how often symptoms and signs strongly reminiscent of
hebephrenia and catatonia occur both early in the illness (“they quite
often…present [with]…agitation, mannerisms, play on words, ne-
ologisms and confusion of language”5(p137)) and much later in their
course (Table 23,5,13; quote 7).
Discussion
From the materials we have reviewed here and the prior 3 essays in
this series,9-11 we can extract 7 major lessons about Kraepelin’s path
to DP. First, his approach must be contextualized within the noso-
logic traditions of late 19th-century German psychiatry. Kahlbaum
and Hecker were important influences on Kraepelin’s work. They ar-
ticulated the paradigm of clinical research that he pursued: to iden-
tify disease-like entities through an iterative process of careful clini-
cal observation and follow-up.23 However, Kahlbaum and Hecker also
defined 2 of the 3 syndromes that constituted the starting point for
Kraepelin’s DP concept. Other developments in German psychia-
try that led to an opening of the “diagnostic space” for DP is an im-
portant subject for future historical inquiry.
Second, hebephrenia was the core around which the proto-DP
concept was first built, followed by catatonia. Dementia para-
noides was the least central. In his fourth edition introduction, Krae-
pelin stated that permanent delusional systems were not part of the
DP’s clinical picture. Kraepelin’s ambivalence about the association
of dementia paranoides with DP is illustrated not only by the late sub-
stantial enlargement of this category in his sixth edition, but also,
in his eighth edition, his removal from DP of the large group of chronic
delusional-hallucinatory syndromes he called paraphrenia.28,29
Third, confusion remains about the meaning of the term de-
mentia in DP. Kraepelin was likely using the term in its earlier, less
specific form, not its narrower modern sense.21 This explains why
he found nothing contradictory in noting both short-term recover-
ies (most common in catatonic DP) and rarer longer-term full recov-
eries. Kraepelin’s views are not as inconsistent as commonly claimed,
with evidence from long follow-up studies that a proportion of pa-
tients with DP truly recover.30
Fourth, a careful reading of Kraepelin’s texts belies the com-
mon assumptions that he defined DP solely on poor outcome. His
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The Development of Kraepelin’s Concept of Dementia Praecox
views of psychiatric illness were more multidimensional. When he
was separating his 2 mature delusional syndromes—paranoia and de-
mentia paranoides—from his earlier broader version of Verrücktheit,9
the nature of the delusions was important. He distinguished be-
tween delusions that reflected misinterpretation of actual events vs
those that were bizarre and arose from what he saw as a deeper form
of pathologic illness within the mind-brain system. As Kraepelin dif-
ferentiated his concept of hebephrenic and catatonic DP from Heck-
er’s and Kahlbaum’s initial conceptualizations, he increasingly em-
phasized, for both syndromes, the importance of positive and bizarre
psychotic symptoms.10,11 The diversity of his perspective on this syn-
drome is mirrored in his list of poor prognostic features in DP, which
included senseless delusions, mannerisms, and negativism, along
with flatness of mood and avolition.13
Fifth, Kraepelin was a nosologic experimenter, willing to ques-
tion and revise his earlier formulations in the light of new clinical ex-
periences and data. His own categories were far from sacrosanct in
his own mind. Despite his desire to emphasize the similarities of cata-
tonia and hebephrenia in his sixth edition, new results available to
him in the mid-1890s showed the much better short-term out-
come of catatonia, which he included in his text. At the same time,
he launched a longer-term follow-up effort showing that many of
the patients with apparent recovery had relapsed.31 Although out-
side the temporal window of this review, Kraepelin entirely revised
and substantially expanded his subtypes of DP in his eighth
edition.28,29 Kraepelin was more tentative about his nosologic sys-
tem than many who followed him. He was repeatedly willing to re-
vise his diagnostic categories but usually preferred to make these
changes based on empirical data rather than armchair speculation.32
Sixth, the unfolding story of general paresis of the insane was a
key influence in Kraepelin’s development of DP. By the 1890s, the
syphilitic origin of general paresis of the insane was increasingly rec-
ognized, as was its status as the preeminent success story of the Ger-
man school of “biological” psychiatry started by Griesinger. Distinc-
tive early clinical signs were by then well characterized, as were the
characteristic course and outcome. The Wasserman test—the most
successful “biomarker” ever developed in psychiatry—was pub-
lished only 7 years after Kraepelin’s sixth edition.33 Kraepelin
believed that the clinical features, cause, and pathologic charac-
teristics of DP would eventually coalesce in defining a natural dis-
ease entity. General paresis of the insane was the paradigm
toward which he was striving, the criterion standard that he
hoped DP would emulate.
Seventh, while Kraepelin was a positivist and believed in psy-
chiatric diagnosis as natural kinds, as a nosologist he was a pragma-
tist, not a purist. He worked inductively from patient observations
to draft clinical constructs. Although informed by prior diagnostic
concepts, he was not bound by them. He did not work deductively,
beginning with one thesis (ie, DP is defined by poor outcome) and
then finding cases to fit his concept. He had a depth of knowledge,
an incisive intellect, and a writing ability that go a long way to ex-
plain his persistent influence on our field.
Although inferring opinions from historical figures relevant to
present-day problems should be treated with skepticism, I risk some
concluding remarks regarding what we can learn about Kraepelin’s
approach to the development of DP. Kraepelin would be optimistic
about the goals of psychiatric nosologic classification, believing that,
for at least some disorders, real disease-like entities were in the world
jamapsychiatry.com
 The Development of Kraepelin’s Concept of Dementia Praecox Special Communication Clinical Review & Education

to be found. However, he would not underestimate the difficulty of
that task. He would avoid pathognomic symptoms, arguing that dis-
orders are best identified by a coalescence of symptoms, signs, and
course. Similarly, while Kraepelin saw poor outcome as a key feature
of DP, he did not believe that patients with a good outcome, by defi-
nition, could not have the disorder. He would advocate for a middle
ground in setting thresholds for nosologic revision, avoiding most
changes based solely on conceptual concerns. However, he would
equally oppose reification and be quite willing, given good data, to re-
vise criteria. Finally, he would not restrict himself to a single concep-
tualization of psychiatric illness. In his struggle to divide Verrücktheit
into more coherent entities, he distinguished what he saw as a brain
disorder with expected “pathological-anatomical changes” (demen-
tia paranoides) and a syndrome best understood as a psychological
disorder evolving from common human fears and ambitions where
the search for “a pathological anatomy” would be futile (paranoia).9

ARTICLE INFORMATION
Accepted for Publication: April 6, 2020.
Published Online: June 10, 2020.
doi:10.1001/jamapsychiatry.2020.1266
Conflict of Interest Disclosures: None reported.
Additional Contributions: Eric Engstrom, PhD,
Department of History, Humboldt University, and
Stephan Heckers, MD, Department of Psychiatry
and Behavioral Sciences, Vanderbilt University
Medical Center, provided helpful comments on an
earlier draft. The German translations presented
here were done in collaboration with Astrid Klee,
MA; she was compensated for her contribution.
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