Richard Noll, Ph.D. Dementia Praecox and Schizophrenia in America

Unitary Psychosis 4 Stages: 1. Neurasthenia (nervous exhaustion) 2. Melancholia 3. Mania 4. Confusion followed by Dementia In the US in the 1890s, laboratory research at McLean and the New York Pathological Institute (1896) framed by autointoxication

By 1860 European doctrine of disease specificity Distinct diseases specified by distinct biological mechanisms Typical signs, symptoms, courses, outcomes Exist outside of unique manifestations of individuals and places Enters American medicine slowly

Kraepelin’s Dementia Praecox (1896) Systemic or “whole body” madness Metabolic etiology (autointoxication) Vegetative nervous system signs (abnormal behavior of the pupils of the eyes, vasomotor disturbances, etc.), abnormal reflex responses Central nervous system signs and symptoms 1. Confusion (Zerfahrenheit) 2. Mental defect (Defekt) 3. Mental Weakness (Schwachsinn)

Kraepelin’s Dementia Praecox (1896) Course and Outcome: Age of onset 16 to 22 in half of cases Sudden onset and rapid deterioration associated with younger age Acute or subacute periods of mental disturbance Progressive deterioration processes (Verbl ödungsprocesse) Few recoveries, none without permanent defect

Adolf Meyer rejects Kraepelin (1902) 1902 Meyer heads 13 state hospitals and 25,000 patients in New York State Meyer tells hospitals diagnosis is unimportant Meyer is forced to introduce Kraepelin’s dementia praecox and manic-depressive insanity into state hospitals 1903-onwards Meyer rejects disease specificity in psychiatry and promotes a maladjustment model (habit deteriorations, reaction types)

Premorbid Personalities and Individual Case Histories By 1905, focus of US elite discourse and training begins shift to the historical recreation of premorbid functioning Rejection of disease specificity makes study of signs, symptoms, course and outcome of psychosis irrelevant to US psychiatry Mental hygiene focus on prevention is rationale

American eclectic reframing of chronic psychosis by 1911 Kraepelin’s disease functionalized Specific biological mechanisms rejected Typical “courses” rejected Linkage to premorbid forms of general vulnerability (Unlike Kraepelin and Bleuler) Psychoanalytic mental mechanisms also accepted by some Vegetative nervous system (dynamic physiology)

Eugen Bleuler’s Schizophrenia (1908 and 1911) A physical disease with flare-ups Vegetative nervous system signs Better prognosis, but still permanent defect between psychotic episodes Unlike Kraepelin, included latent and simple forms (not as vulnerability prodromes but as psychosis) Based on a dissociative metaphor (“splitting”)

Schizophrenia in America Hoch introduces schizophrenia to NY Psychiatrical Society in March 1912 Meyer uses “schizophrenic reaction type” at Phipps Clinic at Johns Hopkins in 1913 December 1925 conference in NYC enshrines schizophrenia as the preferred term for chronic psychosis 1927 Schizophrenia replaces dementia praecox in titles in psychiatric journals

DSM (1952) Dementia praecox is officially eliminated from diagnostic discourse “Schizophrenic reaction” is the new psychogenic term for chronic psychosis