An overview on Hebephrenia, a diagnostic cornerstone in the neurodevelopmental model of Schizophrenia

Pre-Kraepelinian observations converged in Kahlbaum’s and Hecker’s description of Hebephrenia. For Kraepelin, Hebephrenia was an ‘idiopathic incurable dementia whose onset is in adolescence’. It became the core of ‘Dementia Praecox’, and then Bleulerian ‘Schizophrenia’. In recent decades, the resurgence of the ‘late neurodevelopment’ hypothesis of schizophrenia has brought into focus Hecker’s clinical reports of adolescents who, as a result of a putative loss of psychic energy, showed a rapidly progressive cognitive impairment leading to functional and behavioural disorganization. This paper summarizes the nineteenth-century conceptualization of Hebephrenia as a developmental illness.

Kraepelin’s Final Views on Dementia Praecox

In 1921, at the age of 65, 6 years after completing the final edition of his textbook, 22 years after first proposing the concept of dementia praecox (DP), and 1 year before retiring from clinical work, Emil Kraepelin completed the last edition of his “Introduction to Clinical Psychiatry,” which contained a mini-textbook for students, 10 pages of which were devoted to DP. This work also included a series of new detailed case histories, 3 of which examined DP. This neglected text represents a distillation of what Kraepelin judged, near the end of his long career, to be the essential features of DP. The relevant text and case histories are translated into English for the first time. Kraepelin did not define DP solely by its chronic course and poor prognosis, acknowledging that remissions and even full recovery might be possible. His clinical description emphasized the frequency of bizarre delusions and passivity symptoms. He recognized the heterogeneity of the clinical presentations, outlining 6 subtypes of DP, including dementia simplex, depressive and stuporous dementia, and an agitated and circular DP. Kraepelin’s original concept of DP was not impervious to change and expanded somewhat, especially with the inclusion of Diem’s concept of simple DP. He also reviews several contributions of Bleuler, including his concept “latent schizophrenia.” He writes poignantly of the psychological consequences of DP. His 3 DP cases, for advanced students, included simple DP, “periodic catatonic,” and “speech confusion.”

Cognitive biomarkers of psychosis

Historically, the cognitive dysfunction associated with psychotic disorders was thought to result from neuroleptic exposure and/or a late-stage disease processes brought on by the progressive “dementia praecox” effects. More recently, cognitive dysfunction has come into focus as a core feature of psychotic disorders based on the strong link between cognition and functional status, neurodevelopmental patterns of disrupted cognitive development, shared cognitive dysfunction across psychotic disorders, and familial patterns. Focusing on cognitive biomarkers could facilitate identification of intermediate cognitive phenotypes and corresponding treatment targets. Furthermore, cognitive abilities are stable longitudinally and can be assessed with more reliability and objectivity than clinical symptomatology. Thus, a greater emphasis on the emergence of cognitive abnormalities using reliable and objective cognitive biomarkers may allow for tracking of early disease processes. In this manner, cognitive biomarkers could facilitate intervening at an earlier stage of disease and neurodevelopment, when treatments are more likely to be effective.

Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin’s chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin’s mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860–1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

T93. RESHAPING THE DIAGNOSTIC BORDERS OF SCHIZOPHRENIA: THE LOOK OF HISTORY OF PSYCHIATRIC PRACTICES

Background The diagnostic concept of Schizophrenia as defined by DSM and ICD is increasingly being questioned. It is criticized above all for its lack of validity. It refers to very heterogeneous disorders in terms of signs and symptoms but also in terms of evolution and heritability. Clinicians and researchers are therefore considering how to rethink this concept, in the absence of known physiopathological mechanisms and etiology, by integrating various advances in fields such as genetics, molecular biology, brain imaging and cognitive sciences. However, the renewal of the concept of schizophrenia has yet to be explored in terms of its potential impact on psychiatric practice. It is an essential point because this diagnostic concept does not correspond to a theoretical entity that exists for itself but it is a tool of psychiatrists’ daily practice when they seek to name the disorders presented by a patient. Thus, a renewal of the concept of schizophrenia would necessarily have an impact on the diagnoses made by psychiatrists and we know how important the diagnosis in psychiatry is: for the medical care but also for the personal history of the patient. This impact that a renewal of the concept of schizophrenia could have on the diagnostic practices of psychiatrists can be better understood through the analysis of a historical example: the introduction of the concept of Schizophrenia at the Psychiatric Clinic of Strasbourg in France during the period 1920–1930. The concept of Schizophrenia was first discussed in 1908 by the swiss psychiatrist Eugen Bleuler at the Annual Meeting of the German Psychiatric Association in Berlin. At the Psychiatric Clinic of Strasbourg, it was first used by psychiatrists in 1922. How did this then new concept find its place among the other diagnostic concepts that had been used until then in this institution? Methods In an attempt to answer this question, we implemented a methodology that combined a quantitative and a qualitative approach. The first is a retrospective descriptive statistical study whose objective is to establish the evolution of the proportion of the different diagnoses made at the Psychiatric Clinic of Strasbourg during the period 1920–1930. This study includes all hospitalized patients and uses admission records for data collection. This quantitative approach was complemented by a qualitative approach that consists in reconstructing the diagnostic trajectory of some patients with a diagnosis of schizophrenia after the period of introduction of this concept. The diagnoses made during their previous hospitalizations were systematically collected and analyzed, this time using the medical records of these patients as sources. Results The diagnostic concept of Schizophrenia seems to have replaced the one of Dementia praecox within the diagnostic practices: the latter was given extensively in 1924, but hardly any longer in 1928. However, in the same period of time, other diagnostic concepts of the field of psychosis like Manic-depressive Illness were less commonly used while others like Catatonia were increasingly employed. The reconstruction of patients’ diagnostic trajectories tends to show that the diagnostic of schizophrenia would have taken over from the diagnostic of Dementia Praecox but also from some of the diagnoses of Manic-depressive Illness, Hebephrenia and Psychopathy. Discussion This historical perspective makes it possible to understand the impact on psychiatrist’s diagnostic practices of a “nosological innovation” that is theoretical, such as the renewal of the concept of schizophrenia could be. In the diagnostic practices, one diagnostic concept would not simply replace another, but it’s introduction could induce a broader reshaping of diagnostic mapping.

Eugen Bleuler’s Views on the Genetics of Schizophrenia in 1917

In 1917, Eugen Bleuler published an article (Mendelismus bei Psychosen, speziell bei der Schizophrenie [Mendelism in the Psychoses, especially Schizophrenia]) in response to the recently published first systematic family study of dementia praecox (DP) by Ernst Rüdin, then working under Kraepelin in Munich. Although briefly commented upon by David Rosenthal in 1978, this article has never been thoroughly reviewed or translated. Of the many themes addressed, four are especially noteworthy. First, Bleuler argues that understanding the transmission patterns of schizophrenia in families requires definitive knowledge about the boundaries of the phenotype which he argues are unknown. Rüdin’s choice—Kraepelin’s concept of DP—is, he asserts, too narrow. Clarifying the genetics of schizophrenia is inextricably bound up with the problem of defining the phenotype. Second, Bleuler argues for the importance of “erbschizose” (literally “inherited schizoidia”) wondering whether his “4 As” or other “brain-anatomical, chemical, [or] neurological characteristics” might underlie the genetic transmission of schizophrenia. Third, Bleuler was deeply interested in the nature of the onset of schizophrenia, suggesting that environmental adversity could provoke “latent illness to become manifest.” It was important, he argued, to identify such risk factors and incorporate them into genetic models. Fourth, although not optimistic that current knowledge would permit a resolution of the transmission model for schizophrenia, he finds single-locus models implausible and at several points wonders whether polygenic models might better apply. A complete translation of the article is provided.

Diagnosis and conceptualization of mental illness

This chapter outlines the evolution of psychiatric understanding of mental disorders utilizing seven landmark texts that have informed current nosology. Important themes reviewed in this chapter include the foundational distinction between dementia praecox and manic-depressive insanity (Emil Kraepelin), drastic diagnostic differences between American and British psychiatrists reported in the 1970s (the US–UK diagnostic project), development of operationalized diagnostic criteria (Feighner criteria), the biopsychosocial model (George Engel), the philosophical account of mental disorder as harmful dysfunction (Jerome Wakefield), the endophenotype concept (Irving Gottesman and Todd Gould), and the Research Domain Criteria (RDoC) by the National Institute of Mental Health. Historical and theoretical links between these different texts and thinkers are highlighted and are offered to the reader in an integrated narrative of psychiatry’s conceptual development.

The Development of Kraepelin’s Mature Diagnostic Concept of Catatonic Dementia Praecox: A Close Reading of Relevant Texts

Through a close reading of texts, this essay traces the development of catatonia from its origination in Kahlbaum’s 1874 monograph to Kraepelin’s catatonic subtype of his new category of Dementia Praecox (DP) in 1899. In addition to Kraepelin’s second to sixth textbook editions, I examine the six articles referenced by Kraepelin: Kahlbaum 1874, Brosius 1877, Neisser 1887, Behr 1891, Schüle 1897, and Aschaffenburg 1897 (Behr and Aschaffenburg worked under Kraepelin). While Brosius and Neisser confirmed Kahlbaum’s descriptions, Behr, Schüle, and Aschaffenburg concluded that his catatonic syndrome was nonspecific and only more narrowly defined forms, especially those with deteriorating course, might be diagnostically valid. Catatonia is first described by Kraepelin as a subform of Verrücktheit (chronic nonaffective delusional insanity) in his second to fourth editions. In his third edition, he adds a catatonic form of Wahnsinn (acute delusional-affective insanity). His fourth and fifth editions contain, respectively, catatonic forms of his two proto-DP concepts: Psychischen Entartungsprocesse and Die Verblödungsprocesse. Kahlbaum’s catatonia required a sequential phasic course. Positive psychotic symptoms were rarely noted, and outcome was frequently good. While agreeing on the importance of key catatonic signs (stupor, muteness, posturing, verbigeration, and excitement), Kraepelin narrowed Kahlbaum’s concept, dropping the phasic course, emphasizing positive psychotic symptoms and poor outcome. In his fourth to sixth editions, as he tried to integrate his three DP subtypes, he stressed, as suggested by Aschaffenburg and Schüle, the close clinical relationship between catatonia and hebephrenia and emphasized the bizarre and passivity delusions seen in catatonia, typical of paranoid DP.