Richard Noll’s American Madness describes the electric rise and fall of the psychiatric diagnosis of the mysterious disorder known as “dementia praecox.” As the first specified disease of psychiatry, dementia praecox’s curious history has a great deal to teach us about the nature of the field. As the American Psychiatric Association engages in the vexed process of revising its Diagnostic and Statistical Manual of Mental Disorders, American Madness is a more timely study than many in the discipline would probably like to admit. We invited Noll to answer a few questions about what we can learn from the story.
Q: Prior to your work, the last time “dementia praecox” appeared in the title of a book published in English was 1950. Clearly it has slipped into our cultural unconscious. Briefly, what is the narrative of the rise and fall of dementia praecox?
Ah, yes . . . dementia praecox is indeed a vanished kingdom of suffering and despair. Hundreds of thousands of Americans who received this diagnosis between 1896 and 1952 were stigmatized by both physicians and everyday people as incurably insane. One only has to remember how frequently it was invoked in the culture of that era (such as in the Tennessee Williams play Suddenly, Last Summer) to get a sense of how terrifying those two words once were.
As the influential psychiatrist Adolf Meyer once said, the history of dementia praecox is the history of psychiatry. American Madness is, at one level, the biography of a disease, but most importantly I regard it as the story of how, in the late 1890s, American alienists (as they called themselves) strove to rejoin an American medical profession that was moving toward a science-based, laboratory-driven moral economy founded on a new (circa 1860) European concept of diseases as separate, biologically-specifiable entities with specific biological mechanisms and typical courses and outcomes. For American psychiatry to survive as an accepted branch of medicine, and not remain as a queer survival of a nineteenth-century therapeutic sect, its legitimacy and authority depended upon adopting this doctrine. In an era where one was either sane, nervous, or insane, most alienists and neurologists assumed insanity was a hydra, a single monster with many faces, not separate creatures.
In 1896 German psychiatrist Emil Kraepelin proposed a classification of mental diseases based on this new fundamental medical principle, and described dementia praecox as a psychotic process that began in the decade after puberty with a distinctive course and outcome. Mental deterioration, weakness and defect worsened and became permanent. It was a hopeless diagnosis. But Kraepelin argued that dementia praecox, as well as other major mental diseases that he created, would one day be found to be rooted in natural, biological disease processes. This claim, in part, made Kraepelinian classification attractive to American alienists who desired to retain their status as physicians. There is a co-dependency of the psychiatric profession and a biological disease concept that persists today.
Beginning in 1896, as one American asylum after another slowly introduced dementia praecox as a diagnostic box, it became the most frequently diagnosed condition, labeling a quarter to a half of all patients in each institution. How American psychiatrists were making this diagnosis is anyone’s guess—they were probably just snap decisions based on whether someone was suffering from a “good prognosis madness” (such as manic depression) or a “bad prognosis madness” (dementia praecox). What we do know is that being young and male made it more likely someone would receive this diagnosis.
As dementia praecox and its successor (a uniquely American re-interpretation of the Swiss psychiatrist Eugen Bleuler’s concept of schizophrenia) became the natural focus of biological research for much of the twentieth century, American Madness also provides the heretofore untold story of the rise of biological psychiatry and laboratory research in the United States. By 1927 schizophrenia became the preferred term for inexplicable madness, but the Americans reframed Bleuler’s disease concept as a primarily functional or psychogenic condition that was caused by mothers or maladjustments to social reality. When Bleuler visited the United States in 1929 he was horrified to see what the Americans were calling schizophrenia. He insisted it was a physical disease with a chronic course characterized by exacerbations and remissions of hallucinations, delusions and bizarre behaviors.
Q: Is it possible to speak of a “typical” case of dementia praecox?
No. The label was so frequently used in an inchoate medical environment absent of consensual agreement on classification and nomenclature that we have little historical evidence as to how, on a daily basis, an individual physician applied these social constructions in his or her practice. Historian Gerald Grob termed this problem for historians of psychiatry as that of the “Invisible Patient.” Knowing the diagnosis of a person of the past tells us next to nothing about their history, signs or symptoms. Alienists and neurologists operated on a gut-feeling level. Diagnosis was not based on an explicit cognitive exercise, like running down a checklist of signs and symptoms, but was more like the experience of recognizing a melody or a scent. A “precox” patient evoked an uncanny feeling of remoteness or of the “bizarre” in a physician, and that was the most important basis of a diagnosis.
Q: How should American Madness help us to understand the sort of epistemic crisis currently confronting American psychiatry?
As everyone knows, the American Psychiatric Association is involved in a highly controversial effort to revise its diagnostic manual. DSM-5 (as it will be called when it appears in 2013) reflects the fact that scientific medicine has not yet solved the problem identified by American alienists a century ago: the linkage of clusters of signs, symptoms, and clinical history to biologically specified disease concepts. The proposed diagnostic criteria in DSM-5 requires a “bottom-up” differentiation of patients, which can be achieved only through an objective biological test (or tests). Until such a tool is developed for schizophrenia, a heuristic associated with an unimaginable assortment of confusing biological findings, we can neither validate nor invalidate our era’s schizophrenia concept. Genetic tests will almost certainly not be the answer, nor will the exclusive emphasis on the brain. As Sabine Bahn and her associates at the University of Cambridge are demonstrating with their new biomarker-based blood test for schizophrenia, severe psychotic disorders might be due to a life-long smoldering systemic or “whole body” disease process that involves glucose metabolism and immune system dysfunction. This is what Kraepelin proposed for dementia praecox, and it might be true for our era’s schizophrenia as well.