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\title{ A History Of Paraphrenia in the Context of Psychiatric Classification}
\date{June 26, 2011}
\author{
Projektstudie f\"ur die Diplomarbeit\\
an der Medizinischen Universit\"at Wien\\
Department und Sammlungen f\"ur Geschichte der Medizin\\
\\
von\\
Alexander Ölzant\\
alexander@oelzant.priv.at\\
	9301547\\
Betreuer: PD Dr. Hans-Georg Hofer}



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\section{Abstract (deutsch)}
Das Diplomarbeitsprojekt wird versuchen, die historische Entwicklung des
Konzepts der ``Paraphrenien'' auszuloten, das etwa 1912 in der achten Ausgabe von Emil Kraepelins ``Psychiatrie - Ein Lehrbuch f\"ur Studierende und \"Arzte'' auftauchte.

W\"ahrend er Paraphrenie 1916 in seiner ``Einführung in die psychiatrische
Klinik''\footcite[p 330f]{psykli} noch als eigenst\"andige, wenngleich
verwandte Gruppe neben dementia praecox und manisch-depressiven Irresein
anf\"uhrt, sieht auch Kraepelin sie nach einer Publikation von M. Mayer 1921
als Untergruppe der dementia praecox. Mehr noch, auch der Name dementia praecox
muss sp\"ater dem Konzept der Schizophrenien Platz machen, das erstmals von E.
Bleuer 1911\footcite[p 292]{zapotoczky} vorgeschlagen wurde und allgemeine
Verbreitung erlangte, als Nachfolgeuntersuchungen ergaben, dass wohl doch nicht
alle unter diesem Deckmantel zusammengefassten Krankheiten unweigerlich in
einen ``Endzustand'' nach Mayer-Gross m\"unden w\"urden\footcite[p
292, 297]{zapotoczky}.  M. Bleuler stellt 1943\footcite[p 263]{bleulerm1943} eine Systematik der Sp\"atschizophrenien auf, in der auch Paraphrenie (nach Kraepelin) und Involutionsparanoia (nach Kleist) erl\"autert werden.
Kolle verwendet den Begriff 1931.

1914 schlug Albrecht vor, den Begriff ``pr\"asenile Paraphrenie'' als Synonym 
f\"ur das \"Ubergangsstadium zur Demenz, das nach Kleist (1912) auch als 
``Involutionsparanoia'' bekannt war, da er Schwierigkeiten in der Abgrenzung der Begriffe sah\footcite[p 341]{albrecht1914}. 

W\"ahrend DSM-III und ICD-9 noch Definitionen und Codes f\"ur einige paraphrenische Syndrome enthalten (295.3, der paranoide Typ der Schizophrenie inkludiert paraphrenische Schizophrenie\footnote{\cite[p 451]{dsmiiir}}, und Paraphrenie findet Eintrag als Unterpunkt 297.2 bei den Paranoid Zust\"anden\footnote{\cite[p 451]{dsmiiir}}), wird in ICD-10, obwohl es keine eigenen Punkte mehr sind, durchaus noch auf die paraphrenen Diagnosen im Text hingewiesen, bei DSM-IV fehlt jede Erw\"ahnung des historischen Begriffs: 297.2 wurde ersatzlos gestrichen, 297.1  umorganisiert als wahnhafte St\"orung (``Delusional Disorder''\footcite[p 296ff]{dsmiv}). In neueren Publikationen ist der Begriff selten zu finden, obwohl er nicht v\"ollig aus dem Sprachgebrauch verschwunden ist.

Der Hauptfokus der Arbeit wird auf der Begriffskl\"arung im historischen medizinischen Kontext liegen, besonders in Bezug auf Alter, Geschlecht/Gen\-der und gesellschaftliche Stellung der PatientInnengruppen.


\section{Abstract}
The thesis project tries to follow the historic course of the term
``paraphrenia'', a concept that was introduced around 1912 in the eighth edition
of Emil Kraepelin's ``Psychiatrie - Ein Lehrbuch f\"ur Studierende und \"Arzte''. It was
originally intended as a third category besides dementia praecox and
manic-depressive illnesses for cases that started later and did n't end in
dementia, a distinction still held up in Kraepelin's ``Einführung in die
psychiatrische Klinik'' in 1916\footcite[p 330f]{psykli}.  However, in response to a publication in 1921
by M. Mayer he conceded a reclassification as a subgroup to dementia praecox.
Furthermore the name dementia praecox was subsequently abandoned and gave
way 
to the concept of schizophrenia, first introduced by E.  Bleuler in 1912 and
% or 1912? TODO!
advanced by Kolle in 1931 and M. Bleuler in 1943\footcite[p 263]{bleulerm1943} when it was understood that not all of the patients in this group were heading towards a terminal state (``Endzustand'' according to 
Mayer-Gross\footcite[p 292, 297]{zapotoczky}).

In 1914 Albrecht proposed the term ``late paraphrenia'' (``sp\"ate/pr\"asenile
Paraphrenie'') as a synonym for the intermediary stage to dementia, then called
``involutional paranoia'' (``Involutionsparanoia''), due to difficulties in
discriminating between the diseases\footcite[p 341]{albrecht1914}. 

\nextcitefull{dsmiiir}
\nextcitefull{dsmiv}
While DSM-III and ICD-9 still contain definitions and codes for some paraphrenic
diseases (295.3, the paranoid type schizophrenic disorder, includes paraphrenic
schizophrenia\footnote{\cite[p 451]{dsmiiir}}, and paraphrenia is listed as subitem 297.2
under 297 Paranoid states\footcite[p 454]{dsmiiir}), in ICD-10 the
paraphrenic diagnoses still listed, but don't have numbers on their own, whereas
in DSM-IV all mention of the adjective paraphrenic has been removed, 297.2 has been dropped entirely, and 297.1 has been reorganised as
``Delusional Disorder''\footcite[p 296ff]{dsmiv}.
A few recent publications mention the term, but the impact on today's
psychiatric practice will still have to be determined.

The main focus of the work will be to follow the meaning of the term in its
historic setting, particularly considering the patient groups with respect to
age, gender, and socioeconomical status. 


% \section{Zusammenfassung und Erl\"auterung des Wissensstandes}
\section{Summary of Publications to Date}

A good deal has been written about the development of the classification of
schizophrenic disorders (or, more accurately, dementia praecox and successive
renamings and regroupings), but publications specific to paraphrenia are not
that numerous, even though the term still rings a bell with many psychiatrists.
Prominent authors include W. Klages, who from his experience at the psychiatric clinic of the Academy for Medicine in D\"usseldorf outlined the view on schizophrenic diseases in old age in 1961\footcite{klages} including the historic context, Zapotoczky and Fischhof from the University Clinic for Psychiatry in Graz, who did likewise\footcite{zapotoczky}, as well as Lempa and Troje, who published a collection of essays focusing on the relevance for the history of psychoanalyc method\footcite{psychosenkonzepte1kraepelin}.

The initial period outlined above was divided between those following
Kraepelin's nomenclature and his opponents.  As early as 1914 Schnizer muses
whether paraphrenia should not have been kept under the heading of paranoia:

{\it Die Frage, ob es für eine Einigung nicht zweckm\"a\ss{}iger gewesen
w\"are, wenn Kraepelin den neuerdings ausgeschiedenen F\"allen die
Bezeichnung Paranoia gegeben h\"atte, er\"ubrigt sich; Tatsache ist,
da\ss{} diese von ihm als Paraphrenien bezeichneten F\"alle sich zu einem
guten Teil mit den von seinen Gegnern als Paranoia angesprochenen
Krankheitsbildern decken. Will man die vorhandene Verwirrung in der
Paranoiafrage nicht noch unaufh\"orlich steigern, so wird man in Zukunft
f\"ur diese, offenbar unter sich nicht wesensgleichen Krankheitsbilder vom
Charakter eines Prozesses am besten die Bezeichnung Paraphrenie ---
mindestens zun\"achst --- beibehalten.}\footcite[p 116]{schnizer1914}

Also in 1914 E. Bleuler saw the term schizophrenia as more inclusive and compatible rather with Kraepelins ``Verbl\"odungspsychosen'' than dementia praecox\footcite[p 20]{bleulere1914}.

After M. Bleuer's outline on schizo\-phrenia
in 1943 consensus was mostly reached for a while. However, as Kay and Roth put
it in 1961\footcite[p 669]{kayroth}, 

\begin{quote}
All classificatory systems in psychiatry have serious shortcomings which
are inevitable at the present stage of development of knowledge. The weakness of
the Kraepelinian system, which forms the basis of most classifications, is that
it is based upon two principles. According to one, mental disorders are divided
on the basis of certain psychological symptoms and signs into ``organic''
and ``functional'' categories; according to the other, division into the same
two categories depends on the presence or absence of structural disease, whether
cerebral or somatic. This dual system leads to ambiguities which deserve careful
% analysis. $[$...$]$''}\footcite[p 669]{kayroth}
analysis. (...)
\end{quote}

In the same year, W. Klages renounced the term and preferred ``late schizo\-{}phrenia'' (``Sp\"at\-{}schizo\-{}phrenie'') due to the broader definition, however still claimed it as a distinct diagnosis that just would not fit his patients.

According to Decker (2007)\footcite[p 341]{decker}, at the time psychoanalytic tendencies were the
main focus of North American psychiatry. The Diagnostic and Standards Manual
DSM-II had little impact, both because in psychoanalysis diagnosis was felt to
be less of a concern and because criticism arose outside and within the
profession, for example the Rosenhan experiment Rosenhan (1973) which showed
that sane people would be kept in psychiatric wards for prolonged periods of
time. 

On the outset of appointing the committee 
for DSM-III care was taken to choose a pragmatist, Robert Spitzer, who had
already proven diplomatic skills in defusing the conflict over whether
homosexuality should be considered an illness.  

The Pubmed Database cites 2 publications 1940 - 1950, 23 1951 - 1960, 16 1961 - 1970, 23 1971 - 1980, 37 1981 - 1990, 47 1991 - 2000, and 24 more from 2001 to the present (in comparison, for the last period 37894 hits for schizophrenia and 77 for dementia praecox can be found). While many of the articles appear to have a historic focus, others deal with current cases and diagnoses.


% \section{Aufzeigen der offenen Fragen}
\section{Open Questions and Aims of the Thesis Project}

In most publications regarding paraphrenia the number of females is
% disproportionally higher than the number of males\footcite[p 12:\\ {\textit Der }{\bf Geschlechtsverteilung}{\textit  nach handelt es sich um 38 Frauen und 15 M\"anner. (Bei} M. Bleuler {\textit 62 Frauen und 32 M\"anner, bei } Knoll {\textit 62 Frauen und 21 M\"anner}]{klages}
disproportionally higher than the number of males\footcite[p 12: ``Der {\bf Geschlechtsverteilung} nach handelt es sich um 38 Frauen und 15 M\"anner. (Bei M. Bleuler 62 Frauen und 32 M\"anner, bei Knoll 62 Frauen und 21 M\"anner'']{klages}
% \footcite[p 651: During this time 42 patients consisting of 39 women and 3 men were diagnosed as ``late paraphrenia'' $[$...$]$ 57 patients of whom 48 were women and 9 men, were diagnosed as suffering from paraphrenia with onset late in life.]{kayroth}. It is hoped that indications can be found to what extent
\footcite[p 651: During this time 42 patients consisting of 39 women and 3 men were diagnosed as ``late paraphrenia'' (...) 57 patients of whom 48 were women and 9 men, were diagnosed as suffering from paraphrenia with onset late in life.]{kayroth}. It is hoped that indications can be found to what extent
aetiology is endogenous (sex) and inhowfar social aspects including gender
play a role.

While many of the articles in the medical databases appear to
have a historic focus, others deal with current cases and diagnoses. Of the 214
hits found in the Pubmed database for {\texttt paraphrenia$[$All Fields$]$ OR paraphrenic$[$All Fields$]$} only 23 
show up when the search term {\texttt history$[$All Fields$]$ OR historic$[$All
Fields$]$ OR historical$[$All Fields$]$} is included in the search, suggesting that the majority of the
publications are of a medical nature as opposed to a humanities approach.
However, both resource types will have to be evaluated to draw a more complete image of the change in 

In addition it is hoped that the context of the psychiatric field  
from Kraepelin's initial clinical methods and results to the inception of
DSM-III can be evaluated in a broader social context to shed light on the
philosophy of science involved in the classification of paraphrenia, dementia
parecox, and schizophrenia. 

% \section{Definition der Ziele der eigenen Diplomarbeit}
% \section{Aims of the Thesis Project}
% see above together with questions!

% \section{Darlegung der geplanten Durchfuehrung}
\section{Plans for Executing the Project}

Most answers are expected to be found in papers published between 1914 and 1921, some examples of which are provided in the bibliography. Focus will also have to be drawn to Kraepelin's methods and scientific understanding as well as later monographs on the topic, as far as possible looking for the sociological settings and the philosophy of science. Additional sources are expected to be found by cross-referencing quotations from articles and textbooks.

In particular, inputs from psychoanalytic circles and Karl Jasper's take on Kraepelin's diagnostic system shall be used.


\section{Motivation}

Browsing over some works of Michel Foucault and others in the field of history and philosophy of science raised an interest in the historic context. Since I'm contemplating on pursuing a career in psychiatry the obvious choice was to find a niche in the history of psychiatry and learn to understand the development and use of classification systems, diagnostic standards, and the philosophic basis.


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