angst, j - historical aspects of manic depression & schizophrenia, (2002) 571 schizophrenia research...

Historical aspects of the dichotomy between

manicdepressive disorders and schizophrenia

Jules Angst *

Epidemiological Research, Zurich University Psychiatric Hospital, Lenggstrasse 31, Mail Box 68, 8029 Zurich, Switzerland

Abstract

The history of psychiatric classification is highly complex and this presentation must be restricted to a simplified overview.

Guislain [Guislain, J., 1833. Traite des phrenopathies ou doctrine nouvelle des maladies mentales. Etablissement

Encyclopedique, Brussels] and Zeller [Beil. Med. Corresp.-Bl. Wurtemb. Arztl. Ver. 7 (1837) 321] established a unitarian

concept of psychiatric disorder, permutations of which have survived until the present day. Kraepelins [Kraepelin, E., 1899.

Psychiatrie. Ein Lehrbuch fur Studierende und Arzte (6th edn.). Johann Ambrosius Barth, Leipzig] dichotomy between

manicdepressive insanity and dementia praecox was built mainly on Kahlbaums [Kahlbaum, K., 1863. Die Gruppirung

der Psychischen Krankheiten und die Eintheilung der Seelenstorungen. AW Kafemann, Danzig] classification, which took

clinical symptoms, course and outcome into account. Kraepelins well-accepted approach sought to provide a basis for

diagnosis, prognosis, choice of treatment and causal research. Kraepelins dichotomy came to be questioned on several grounds:

(1) doubts about his unification of bipolar disorder [Gaz. Hop. 24 (1851) 18] with melancholia, (2) doubts about the

significance of Kraepelins diagnostic groups for causal research [Z. Gesamte Neurol. Psychiatr. 12 (1912) 540], illustrated best

by the work of Bonhoeffer [Bonhoefferm, K., 1912. Die symptomatischen Psychosen im Gefolge akuter Infektionen,

Allgemeinerkrankungen und innerer Krankheiten. In: Aschaffenburg, G. (Ed.), Handbuch der Psychiatrie, 3. Abt., 1. Halfte.

Deuticke, Leipzig Wien], (3) the complex psychopathological descriptions and classifications of numerous subgroups of

psychoses by Kleist [Monatsschr. Psychiatr. Neurol. 125 (1953) 526] and Leonhard [Leonhard, K., 1968. Aufteilung der

endogenen Psychosen (4th edn.). Akademie Verlag, Berlin] and (4) description of the psychoses between affective and

schizophrenic disorders (intermediate psychoses, mixed psychoses, schizo-affective psychoses) beginning with Kehrer and

Kretschmer [Kehrer, F., Kretschmer, E., 1924. Die Veranlagung zu seelischen Storungen. (Monographien aus dem

Gesamtgebiete der Neurologie 40) Springer, Berlin] and persisting up to the modern findings of a continuum between the two

major groups of psychiatric disorders. Kraepelins simplification has so far been more successful than the KleistLeonhard

approach, but the modern and more descriptive trend in psychiatric classification favours the syndromal concept of Hoche and

the concepts of continua between affective and schizophrenic disorders and between normal and pathological behaviour.

D 2002 Published by Elsevier Science B.V.

Keywords: History; Classification; Schizophrenia; Schizo-affective disorder; Affective disorder

1. Unitarian concepts of psychiatric classification

A generally accepted classification system for psy-

chiatric disorders did not exist until the end of the 19th

century. Before Kraepelin, the situation was confused.

0920-9964/02/$ - see front matter D 2002 Published by Elsevier Science B.V.

PII: S0920 -9964 (02 )00328 -6

* Tel.: +41-1-384-26-11; fax: +41-1-384-24-46.

E-mail address: [email protected] (J. Angst).

www.elsevier.com/locate/schres

Schizophrenia Research 57 (2002) 513

In his historical review, Kahlbaum (1863) summarised

about 30 different systems of classification from Plater

(1625), considered to be the founder of medical and

psychiatric classification, to Morel (1851). One such

attempt to describe or classify psychiatric symptoms or

syndromes was made by Guislain (1833) in Belgium,

who devised a complex system consisting of a mosaic

of about a hundred different states. Guislain consid-

ered the cause of all psychiatric disturbances to be

consequences of psychic pain (douleur moral, See-

lenschmerz), ultimately resulting in dementia. A stres-

sor model of psychiatric disorder was implicit in

Guislains unitarian causal theory.

A logical consequence was the concept of unitary

psychosis, the history of which has been extensively

described by Vliegen (1980) and recently by Berrios

and Beer (1992, 1994). Zeller (1837), who translated

the work of Guislain, was the founder of the concept

of unitary psychosis, comprising all psychotic syn-

dromes, which he regarded as representing no more

than different stages of a pathological process, itself

the result of an interaction of somatic and psycholog-

ical factors. Other important proponents of the unitary

psychosis were Griesinger (1845), an assistant of

Zeller, and Neumann (1859). Jacksons evolutionary

view of the formation of a functional hierarchy of the

brain was influential on more recent developments

(Berrios and Beer, 1992). In his review of the unitary

psychosis, Maier (1992) notes that like Griesinger but

over a century later, Ey (1963) developed a hierarch-

ical model based on the evolution of the brain as did

Foulds and Bedford (1975) on the basis of inter-

personal communication. Another 20th century expo-

nent of the unitary psychosis was Rennert (1965),

who developed the concept of the universal origin

(Universalgenese) of endogenous psychoses. He

explicitly set out to challenge the efforts by Wernicke,

Kleist and Leonhard to devise a sophisticated

diagnostic atomisation. The psychopathological

concepts developed by Janzarik (1969) are also com-

patible with a unitarian theory.

2. Forerunners of Kraepelins dichotomy

Although one source of Kraepelins dichotomy of

manicdepressive insanity and dementia praecox is

probably the distinction drawn by Griesinger between

disorders of affects and ideas/will (Vliegen, 1980),

there can be little doubt that Kraepelin (1918) based

his concept chiefly on the work of Kahlbaum, who

had introduced a dichotomy based on course and

outcome, a debt he later came to acknowledge him-

self.

In 1863, Karl Kahlbaum published his monograph

The grouping of psychological illnesses and the

classification of mental disorders, on which the

edifice of modern nosology is built. On the basis of

symptoms, course and outcome, Kahlbaum distin-

guished between two large groups of mental disor-

ders: vecordia was a limited disturbance and

vesania a complete disturbance of the mind (Table

1). The first group was characterised by a continuous

but remitting course, by continuous he meant that

the symptom complexes or states did not change their

typical symptoms over time (Kahlbaum, 1878, p.

1145). The benign group of vecordia comprised

vecordia dysthymia, which included depression

and mania. By contrast, the course of vesania showed

a changing symptomatology, was progressive and the

outcome was dementia. Vesania consisted of vesania

typica (from which dementia praecox was later

derived) and vesania progressiva, which embraced

all brain disorders such as progressive paralysis and

Table 1

Classification of psychotic disorders by Kahlbaum (1863)

J. Angst / Schizophrenia Research 57 (2002) 5136

stroke (Table 1). Later in 1879, Kahlbaum added

catatonia as a subgroup of vesania.

In 1882, he renamed vecordia dysthymia cyclo-

thymia, which comprised dysthymia (Flemming,

1844) and hyperthymia (Table 2). The terms cyclo-

thymia, dysthymia and hyperthymia were used by

Kahlbaum in order to distinguish remitting affective

disorders from melancholia and mania (as stages of

the vesania typica circularis) with a poor outcome.

From todays perspective, these two groups appear as

a clear description of mood disorders and schizo-

affective disorders. The classification system pro-

posed by Kahlbaum was not very successful; the

new terms that he introduced in order to separate

disorders with a good outcome from those ending in

dementia were too numerous.

3. Emil Kraepelins dichotomy

Emil Kraepelins first nosological publication was

his programmatic Compendium of 1883. As Roelcke

(1996) pointed out, Kraepelin put forward a classifi-

cation based on putative somatic causation of psychi-

atric diseases, which was a complete break with

tradition. Kraepelin sought to establish psychiatry on

the basis of the natural sciences, adhering to an

experimental model, inspired by his teacher Wilhelm

Wundt and the results of his own first psychopharma-

cological study (Kraepelin, 1882, 1883). But Kraepe-

lin also recognised our ignorance of the causation of

psychiatric disorders, which (as today) made it impos-

sible to consider complexes of symptoms (syndromes)

as disorders. Kraepelin wanted to create a nosology

that would provide a basis for successful prognosis,

therapy, and prevention (Roelcke, 1997). For this

purpose, Kraepelin systematically compiled informa-

tion on symptomatology, family history, and the long-

term course of the patients condition.

A significant breakthrough came with the fifth

edition of Kraepelins (1896) textbook, in which the

author conceptualised disease entities on the basis of

causation, symptoms, course and outcome and in

which he published a comprehensive chapter on

dementia praecox. In a presentation given the same

year in Heidelberg and published in 1897, Kraepelin

stressed the prognostic value of an early diagnosis,

validated by a careful long-term follow-up. In such a

way, he maintained, one could distinguish processes

leading to dementia from others. He also separated

depression from involutional melancholia.

A more elaborate classification was published in

the sixth edition of Kraepelins (1899) textbook,

where he integrated into the group of dementia

praecox the catatonia of Kahlbaum (1874), the

hebephrenia of Hecker, which was conceptionalised

by Kahlbaum (Hecker, 1871), and dementia para-

noids. Among other disorders Kraepelin distinguished

dementia praecox from involutionary psychosis,

manicdepressive insanity and paranoia as further

diagnostic categories (Table 3).

In comparison with Kahlbaum, Kraepelins termi-

nology was simpler and his comprehensive text much

easier to read and to understand. It dispelled the

confusion that prevailed in contemporary psychiatric

classification, a task in which Kahlbaum had had little

success. The success of Kraepelins dichotomy expe-

rienced later a revival in the United States in the

Neo-Kraepelinian school of St. Louis with the

introduction of the Research Diagnostic Criteria (Spit-

zer et al., 1978) as syndromal constructs (Kick, 1981).

Kraepelins influential classification did not how-

ever go unchallenged. Three developments in the

intervening century have cast serious doubts on Krae-

pelins dichotomy: the first relates to the classification

of affective disorders, the second to intermediate,

Table 2

Classification of mood disorders by Kahlbaum (1882)

Cyclothymiaa Vesania typica circularisb

. Dysthymiac . Melancholiad

. Hyperthymiae . Maniaf

a Mood disorder.b Schizoaffective disorder.c Depression, dysthymia.d Schizo-depression.e Mania, hypomania.f Schizo-bipolar/mania.

Table 3

Krapelins 1899 classification

. Dementia praecox (hebephrenia, catatonia dementia paranoids)

. Manicdepressive insanity

. Dementia paralytica

. Insanity and brain diseases

. Involutional psychosis

. Paranoid states

J. Angst / Schizophrenia Research 57 (2002) 513 7

mixed or schizo-affective disorders and the third

questions the validators of the dichotomy and suggests

a continuum concept of functional psychoses.

4. Bipolar disorder and unipolar depression

The history of the classification of affective disor-

ders is briefly summarised in Table 4. From antiquity

right up until the middle of the 19th century, melan-

cholia and mania were generally considered to be two

completely different disorders, of physical origin,

embracing all types of psychiatric syndromes includ-

ing all organic brain disorders, schizophrenia and

affective disorders. As Pichot (1995) has established,

the alternation of mania and depression was accurately

described by Esquirol in 1838 but was not considered

to be a single disorder. It is to Falret that we owe the

creation of the concept of manicdepressive disorder.

In 1851, Falret working in Paris (interesting details

were published by Haustgen, 1993) developed the term

la folie circulaire to describe what he considered to

be a new and separate psychiatric disorder. Kraepelin

was aware of Falrets concept but deliberately unified

mania, depression and bipolar disorder into one broad

category of manicdepressive insanity. In the-mid

20th century, Kleist (1953) challenged Kraepelins

model with his distinction between bipolar and monop-

olar psychoses. Kleist considered both mania and

depression to be monopolar psychoses and bipolar

psychosis to be due to a specific affiliation of the

two. The concept of bipolar psychosis propounded by

Kleist and his pupil Leonhard (1968) therefore differs

clearly from the concept current today, which sub-

sumes monopolar mania under bipolar disorder. The

modern concept is mainly based on research carried

out in the 1960s (Angst, 1966; Perris, 1966; Winokur

et al., 1969), which established the distinction between

bipolar disorder and monopolar/unipolar depression

on the basis of course and genetics. With this develop-

ment, Kraepelins dichotomy was questioned at least

in the field of manicdepressive insanity.

5. Intermediate psychosis, mixed psychosis,

schizo-affective psychosis

A second development, the development of the

concept of schizo-affective psychosis, undermined the

dichotomy in a more central point. As mentioned

earlier, a weak point of both Kahlbaum and Kraepe-

lins dichotomy is that they classified manic and

depressive syndromes among both major psychoses:

manicdepressive insanity and dementia praecox.

This resulted in schizo-affective states being sub-

sumed under vesania typica, under dementia praecox

and later under schizophrenia. Table 1 demonstrates

how, in regard of affective syndromes, the dichotomy

remained ambiguous. Little wonder that Kahlbaum

and Kraepelin both noticed the existence of inter-

mediate cases.

This gap was filled in the 1920s when the concept

of intermediate psychosis (mixed psychosis) was

developed by Kehrer and Kretschmer (1924) and

Gaupp and Mauz (1926). In 1933, Kasanin, coined

the term schizo-affective psychoses for a subgroup of

schizophreniform psychoses with a good prognosis

and simultaneous presence of schizophrenic and affec-

tive syndromes. This simultaneous co-occurrence

required for diagnosis is a constant and has been

maintained in the Diagnostic Manuals ICD-10 and

DSM-IV. Schizo-affective disorders have been defined

in a variety of ways (analysed for instance, by Brock-

ington and Leff, 1979 who demonstrated the poly-

morphism of the group and the low concordance

between the concepts).

Table 4

History of classifying affective disorders


Themodern cross-sectional concept of schizo-affec-

tive disorder suffers from the shortcoming that it does

not take into account the even more puzzling longitu-

dinal change of syndromes, the transition of manic

depressive to paranoid or schizophrenic disorders.

(Schule, 1878; Urstein, 1909; Stransky, 1911; Smith,

1925; Mayer-Gross, 1932) or vice versa the change of

schizophrenic syndromes into manicdepressive syn-

dromes (Hoffmann, 1925; Mayer-Gross, 1932).

Kretschmer (1919) disputed the whole notion of the

existence of two separate disorders and described

circular insanity and schizophrenia as disorders of

the same stratum (Schicht). Bleuler (1922) transition-

ally shared Kretschmers opinion, agreeing with his

assumption of a continuum from normal to patholog-

ical in the dimensions schizothymicschizoidschiz-

ophrenic, cyclothymic (syntonic)cycloid and circular

manicdepressive. Bleuler assumed that both forms of

disposition co-existed independently in every human

individuum. A differential diagnosis between schizo-

phrenia and manicdepressive insanity had therefore

to be questioned in principle. Gaupp (1939) considered

it as natural to have mixtures of symptoms of both

major psychoses.

It should not be forgotten that Kraepelin (1920)

himself came to express concern about the dichotomy,

admitting that, No expert will deny that cases which

cannot be classified safely are disturbingly frequent

(unerfreulich haufig). . . We will have to get used tothe idea that all signs are insufficient to delineate

manicdepressive insanity from schizophrenia. . . .and that overlap occurs.

Under Kretschmers influence, the dichotomy

seemed moribund and Birnbaum (1928) predicted that

nosology had come to a dead end, a point on which he

agreed with Bumke (1925). Bumke (1924) argued that

rather than Kraepelins disease entities only a typol-

ogy of psychiatric syndromes was feasible, a view

which was shared by Kretschmer (1929) and later by

Schneider (1967).

6. The continuum from affective to schizophrenic

syndromes

A decisive contribution came from Hoche (1912),

who criticised the view of schizophrenia as a disorder.

Hoche distinguished between disorders, symptom

complexes (syndromes) and elementary symptoms

and maintained that psychiatric disorders such as

dementia praecox could be no more than analogies

to diagnostic groups of somatic medicine and that in

reality dementia praecox was characterised by a

chaotic symptomatology. Hoche advanced the theory

that psychiatric syndromes expressed dispositions or

reaction patterns, for instance hysterical, hypochon-

driacal, neurasthenic, manic, depressive or paranoid.

In fact, it is the symptomatological change (Janzarik,

1968) and not the stability that characterises the long-

term course of psychotic disorders and none of the

European long-term studies on schizophrenia has

found symptomatological stability (Bleuler, 1972;

Ciompi and Muller, 1976; Huber et al., 1979; Mar-

neros et al., 1991).

Hoches syndromal critique of Kraepelins concept

was not the only one raised; another was made on

psychopathological grounds: no specificity of any

symptom of dementia praecox could be found,

whereas complexes of symptoms came close to the

target (Birnbaum, 1928). Furthermore, the work of

Bonhoeffer (1912), which had shown that one and the

same physical disease could result in totally different

psychopathological syndromes, raised serious doubts

about a purely clinical classification. The conflict

between etiological classification and syndromal psy-

chiatric nosology was born.

Another basic assumption, that schizophrenia ends

in dementia and that manicdepressive disorders

recover, also turned out to be wrong, which meant

that outcome as a validator had to be questioned. As

early as 1909, within Kraepelins school itself, Zendig

(1909) carried out a follow-up study of 468 cases of

dementia praecox diagnosed in Kraepelins clinic in

Munich. He found a favourable outcome in 29.8% of

the cases, a fact which he ascribed to misdiagnosis.

This interpretation was disproved by Langes inves-

tigation of some of the cases (Lange, 1922, p. 4). This

early finding, true but misinterpreted, namely that

dementia praecox can recover, is consistent with the

modern studies on the course and outcome of schiz-

ophrenia by Huber et al. (1979), Ciompi and Muller

(1976), Bleuler (1972) and Marneros et al. (1991),

Moller et al. (1982). Recovery cannot be explained

merely as a result of the inclusion of schizo-affective

disorders in schizophrenia; it is also true for acute

catatonia and other acute schizophrenic psychoses.


On the other hand, affective disorders should

recover and frequently do not, as already observed

by Bumke (190963240). It is a well-established

fact that 15 or more percent of cases end in chron-

icity and that another substantial proportion develops

residual affective symptoms between episodes. It is

more the quality of the residual states, which differ

between affective disorders and schizophrenia than

their presence or absence and the same applies to

cases which become chronic. It is not surprising that

Kurt Schneider, a strong believer in the dichotomy,

ceased to base the diagnosis of schizophrenia on

course or outcome but considered solely the presence

of first-rank symptoms. All studies of course and

outcome have demonstrated that schizo-affective

disorders lie midway between affective disorders

and schizophrenia (Kendell and Brockington, 1980;

Angst, 1986; Gross et al., 1986; Marneros et al.,

1991).

Another issue is the psychopathological continuity

from affective to schizophrenic syndromes as estab-

lished by Kendell and Gourlay (1970), Kick, 1981,

Angst et al. (1981, 1983), Angst (1986) and Yasamy

(1987), findings which are concordant with Janzar-

iks (1969) unitarian psychopathological view on a

clinical descriptive level. Mundt (1995) demonstrated

in his presentation on the psychotic continuum or

distinct entities from a psychopathological point of

view, based on the literature, that in terms of single

symptoms there is overwhelming evidence for the

diagnostic unspecificity of overall symptoms and

outcome, first-rank symptoms of Schneider, basic

symptoms of Huber (1966), negative symptoms of

Andreasen and Olsen (1982), thought disorder of

Chapman (1966) and of the psychophysiological

orientation reaction of Heimann (1986). Mundt con-

cludes that on the single symptom level, no specific-

ity for schizophrenia and thus no single disease

entity can be found within the spectrum of the

idiopathic psychosis.

A continuum from a genetic point of view was

postulated by Angst and Scharfetter (1985) and

Crow (1986, 1990) in contrast to the multiple thresh-

old model of Reich et al. (1975), as discussed in

detail by Maier (1992). The genetic findings of

Gershon et al. (1982, 1988) and Maier et al.

(1993) do not disprove the hypothesis of a contin-

uum (Crow, 1990).

7. The way forward

In the future, some progress may be achieved

through the more recent distinction between unipolar

depressive and bipolar affective and schizo-affective

disorders. It has not only been shown that, in course

and outcome, schizo-bipolar disorders (Cadoret et al.,

1974) lie between affective and schizophrenic psy-

choses but also that schizo-depressive psychoses are

very similar to unipolar depression and bipolar schizo-

affective disorders(?) very similar to bipolar disorders.

This fact is taken into account by the inclusion of

mood-incongruent psychotic features of bipolar

manicdepressive or depressive disorders in DSM.

Recently, Maier (1992) has postulated the need for an

at least two-dimensional model for a continuum from

unipolar or bipolar affective to schizophrenic disor-

ders. It may be worthwhile to study the whole

spectrum of idiopathic psychoses from this point of

view, because our earlier cluster analyses (Angst et al.,

1983) were unable to identify a schizophrenic symp-

tom cluster without any depression or mania. We

therefore advanced the hypothesis that affective com-

ponents could be basic and common to all endoge-

nous psychoses.

In 1995, Crow summarised: Perhaps we should

grasp the nettle and conclude that the conditions we

are concerned with are indeed continuous. There are

no defining features such as would be necessary

to establish the existence of discrete diagnostic

entities. . . But if there are no true disease entities,there is no basis for isolating one part of the patho-

logical spectrumthe whole range must be consid-

ered. . . and postulated that there are no diseaseentities but the psychoses can be regarded as boun-

dary conditions of continuous variation that is present

in the general population.

Over the years, the dichotomy has repeatedly been

declared dead and buried, but it has survived and may

even have a long future on a purely descriptive

syndromal level.

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Unitarian concepts of psychiatric classificationForerunners of Kraepelin's dichotomyEmil Kraepelin's dichotomyBipolar disorder and unipolar depressionIntermediate psychosis, mixed psychosis, schizo-affective psychosisThe continuum from affective to schizophrenic syndromesThe way forwardReferences

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