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Letters to the Editor
Published Online: 1 June 2018

“A True Psychiatrist Mustn’t See Anything That Is Not in Kraepelin”: What About Freud?

To the Editor: Emil Kraepelin’s work has made him the icon of the medical model favored by postpsychoanalytic psychiatry (1). However, his contemporaries did not unanimously embrace his nosology, as Kendler and Engstrom (2) have shown in a fascinating examination, published in the April 2018 issue of the Journal, of six of his major critics. The authors, however, do not mention one of his more famous critics of the time: the other “father” of 20th-century psychiatry, Sigmund Freud.
Although Freud regarded Kraepelin as the “the Super-Pope” of European psychiatry (3, p. 69), to the point of stating that “a true psychiatrist mustn’t see anything that is not in Kraepelin” (3, p. 34), he also shared some of the most pointed criticisms of Kraepelinian nosology, especially regarding the new categories of dementia praecox and manic-depressive insanity, which Freud found too broad and heterogeneous.
Early on, Freud rejected Kraepelin’s system. He generally held that dementia praecox “is often not a real diagnosis” because “it cannot be said that incurability or a bad end is a regular feature of Dem. pr.” (3, p. 158), thus sharing the view of Meyer, Jolly, Tanzi, and even Hoche that poor outcomes do not necessarily define homogeneous groups.
Regarding manic-depressive insanity, he believed that grouping various forms of clinical depression together “into a single unity [that] does not seem to be established with certainty” (4) would involve neglecting important clinical distinctions, such as those between “obsessional states of depression” (4) and pathological bereavement. A concrete example of his difference of opinion with Kraepelin can be found in their respective diagnoses of the Wolf Man, whom Kraepelin considered a case of manic-depressive insanity (5).
Interestingly, over time Freud became less critical of Kraepelin’s nosology and eventually even adopted part of it. A sign of this gradual “Kraepelinian revolution” in his thought can be found in the title he gave to his discussion of the Schreber case (6), which he viewed in terms of both “paranoia,” based on the broader German category that predated and was rendered obsolete by Kraepelin’s nosography, and “dementia paranoides,” which was Kraepelin’s own diagnosis (7). Freud added: “I am of opinion that Kraepelin was entirely justified in taking the step of separating off a large part of what had hitherto been called paranoia and merging it, together with catatonia and certain other forms of disease, into a new clinical entity—though ‘dementia praecox’ was a particularly unhappy name to choose for it” (6). This acknowledgment of Kraepelin’s contribution would seem to constitute a partial acceptance of it. Furthermore, it is noteworthy that Freud went on to revise his prior diagnoses of paranoia in light of Kraepelin’s redefinition of the concept (8), renaming them cases of “paranoid dementia” (9, 10). Freud’s later work also suggests that he appreciated the Kraepelinian criterion of illness outcome factor, as indicated in his statement that “the schizophrenias … are inclined to end in affective hebetude” (11).
Of course, Freud’s approach to diagnosis remained quite removed from today’s neo-Kraepelinian diagnostic systems, which are descriptive, symptom-oriented, and multiaxial and should also be viewed from the perspective of new psychodynamic models such as the PDM-2 (12) or OPD-2 (13). Yet precisely because neo-Kraepelinian psychiatry in the United States emerged as a form of reaction against the excesses of psychoanalysis and social psychiatry, it is worth recalling that Freud himself should be counted among the early critics of Kraepelinian nosology.

References

1.
Engstrom EJ, Kendler KS: Emil Kraepelin: icon and reality. Am J Psychiatry 2015; 172:1190–1196
2.
Kendler KS, Engstrom EJ: Criticisms of Kraepelin’s psychiatric nosology: 1896–1927. Am J Psychiatry 2018; 175:316–326
3.
McGuire W: The Freud/Jung Letters: The Correspondence Between Sigmund Freud and CG Jung. Princeton, NJ, Princeton University Press, 1974
4.
Freud S: Mourning and melancholia, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 14. London, Hogarth Press, 1957, pp 237–258
5.
Gardiner MM: The Wolf-Man and Sigmund Freud. London, Karnac, 1972
6.
Freud S: Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides) (1911), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 12. London, Hogarth Press, 1958, pp 1–82
7.
Kraepelin E: Psychiatrie: ein kurzes Lehrbuch für Studirende und Aerzte, 8th ed. Leipzig, Germany, Barth, 1909–1915
8.
Kendler KS: Kraepelin and the diagnostic concept of paranoia. Compr Psychiatry 1988; 29:4–11
9.
Freud S: Further remarks on the neuro-psychoses of defence (1896), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 3. London, Hogarth Press, 1962, pp 157–185
10.
Freud S: An autobiographical study (1925), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 20. London, Hogarth Press, 1959, pp 7–70
11.
Freud S: Neurosis and psychosis (1924), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 19. London, Hogarth Press, 1961, pp 147–154
12.
Lingiardi V, McWilliams N, Bornstein RF, et al: Psychodynamic Diagnostic Manual: PDM-2, 2nd ed. New York, Guilford, 2017
13.
OPD Task Force (ed): Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning. Cambridge, Mass, Hogrefe & Huber, 2008

Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 580
PubMed: 29869542

History

Accepted: March 2018
Published online: 1 June 2018
Published in print: June 01, 2018

Keywords

  1. History Of Psychiatry
  2. Diagnosis And Classification
  3. Psychoanalysis And Psychodynamic Therapies

Authors

Details

Thomas Lepoutre, Ph.D. [email protected]
From Aix-Marseille University, LPCPP (EA 3278), Aix-en-Provence, France.

Notes

Address correspondence to Dr. Lepoutre ([email protected]).

Funding Information

The author reports no financial relationships with commercial interests.

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