American Madness: The Rise and Fall of Dementia Praecox

The tale of modern psychiatry's founder dominates this story of changing diagnoses, David Healy finds

December 8, 2011

Seventeen years ago, Richard Noll wrote a wonderful book about a German-speaking psychiatrist with nationalist, even proto-Nazi, sympathies. The Jung Cult: Origins of a Charismatic Movement plucked Jung out of an asylum in Switzerland and explained how his influence on 20th-century history has been much more important than had been recognised.

American Madness focuses on another German-speaking psychiatrist with nationalist, possibly proto-Nazi, sympathies - Emil Kraepelin. He spent much of his career out of the mainstream, but his writings are now the foundation of modern psychiatry and, as a result, he has a greater influence on all our lives today than Jung. A book on the man and his work has considerable potential to unsettle.

Kraepelin outlined two new illnesses - dementia praecox (schizophrenia) and manic depression. His approach to classifying psychiatric illnesses is, since 1980, supposedly embodied in the neo-Kraepelinian American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and underpins biological psychiatry. That is a lot of material for an author to work with! The book might have been called The Rise, Fall and Resurrection of the Kraepelin Cult.

American Madness: The Rise and Fall of Dementia Praecox sounds just as exciting. Unfortunately, whereas The Jung Cult soared and ruffled feathers, American Madness gets bogged down in the backwaters of US provincial asylums in the early 20th century. Noll describes some of Kraepelin's background, the emergence in 1896 of dementia praecox, and the transmuting of this cumbersome name into schizophrenia. He shows how Americans took to the new condition even more than the Germans, for whom Kraepelin remained just another psychiatrist. He pays no heed to the lack of impact Kraepelin had in France and Britain before 1950.

Part of the problem that Noll faces is that, compared with Jung, Kraepelin did not come festooned with mistresses or nerves. He favoured total abstinence. His autobiography is exceedingly dull - he is at his most passionate when he visits London which he "thoroughly disliked...the way of life with its endless uniform rows of houses, its lack of beautiful buildings and views, its confusing masses of people, its dull air, monotonous, tasteless cuisine and bleak Sundays". Kraepelin's interest in the US towards the end of his life centred on a pursuit of dollars. His concepts were largely stolen from another psychiatrist Karl Kahlbaum.

Hence, perhaps, the need to turn to US psychiatry for material of interest. But whereas what happens today in US psychiatry has consequences for the rest of us, in the early 20th century, US psychiatry was a backwater with no original contributions other than an enthusiasm for the detection of pre-psychosis. Telling the story of the terminology used by these psychiatrists before 1950 is as interesting as detailing bureaucratic procedures in the T'ang dynasty might be.

Fast-forward to 2007, when, having missed the 150th anniversary of his birth by a year, a symposium was held in Kraepelin's library in Munich attended by the senior figures of German psychiatry. These grandees, far from adopting his mantle, more or less dismissed him as an irrelevance and appeared to think there was no game in town other than the forthcoming 5th edition of the DSM.

Why the American DSM should be the only game in town is a mystery in need of answers. Noll indirectly might provide one in the story of Bayard Holmes, a surgeon who sought to save his son when he developed dementia praecox in 1905. Holmes spent a decade researching auto-intoxication theories of the type favoured by Kraepelin, and hit upon an operative intervention. Abraham-like, he took his son up the mountain. God did not intervene.

There is something about the US mania for madness that needs understanding, as it imperils us all. Noll clearly had to write this book - but there are others awaiting him.

American Madness: The Rise and Fall of Dementia Praecox

By Richard Noll

Harvard University Press

406pp, £33.95

ISBN 9780674047396

Published 28 October 2011

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