The characteristic signs and symptoms of mania and depression according to Kraepelin circa 1905: a comparison with DSM-III

Although the rise of operationalized diagnostic criteria and the creation of DSM-III were influenced in the USA by a neo-Kraepelinian ‘revival’ of interest in psychiatric nosology, Kraepelin was only a distal influence on the specific diagnostic criteria proposed. The historical origins of the DSM-III criteria for mania and major depression (MD) are traceable back to the 1950s and contain no direct link to Kraepelin's writings. George Dreyfus, a student and assistant to Kraepelin, authored in 1907 a monograph on Involutional Melancholia which reviewed cases seen by Kraepelin in Heidelberg. In this monograph, Dreyfus presents the ‘characteristic’ symptoms for mania and depression ‘as described by Kraepelin.’ This historical finding provides the unprecedented opportunity to examine the resemblance between the criteria proposed for mania and depression in DSM-III, inspired by Kraepelin's nosologic vision, and those specifically suggested by Kraepelin 73 years earlier. Kraepelin's symptoms and signs for mania paralleled seven of the eight DSM-III criteria (except the decreased need for sleep), with two not included in DSM-III (increased mental activity and short bursts of sadness). Kraepelin's signs and symptoms paralleled six of the nine DSM-III criteria for MD, lacking suicidal ideation and changes in appetite/weight and sleep but including obsessions, reduced expressive movements, and decreased mood responsiveness. Although Kraepelin's overall approach to mania and depression emphasized their close inter-relationship in the cyclic course of manic-depressive illness, it is noteworthy Kraepelin's ‘characteristic’ symptoms for mania and depression as described by Dreyfus, bear substantial but incomplete resemblance to the criteria proposed in DSM-III.

The Return of the Two Depressions (and an Anxious Postscript)

Before 1980 there had been two depressions, melancholia—also called endogenous depression—and nonmelancholia, called a number of terms such as reactive depression and neurotic depression. DSM-III flattened this distinction, abolishing the clinical distinction between the two with the homogenizing term major depression. To be sure, DSM-III reinserted the term melancholia in the discussion as a subtype of major depression, but only in letter, not in spirit. In the decades after 1980 melancholia returned, but to a landscape of mood disorder that had been leveled and laid waste by the concept of “depression.” In a world where everybody is depressed, nobody is melancholic. Emil Kraepelin had sent the diagnosis of melancholia into a death spiral. The psychoanalysts had little interest in the concept, aside from venerating a single essay of Freud, and the only people interested in keeping melancholia alive as a notion after the 1930s were the British who, with their admixture of Heidelberg science and homegrown common sense, had turned into shrewd psychopathologists. The textbook that Willi Mayer-Gross, a Heidelberg refugee, published in 1954 together with Eliot Slater and Martin Roth gave pride of place to involutional melancholia as the serious melancholic illness that oft en affected people at midlife and afterward. But world psychiatry after World War II marched to an increasingly American beat, and the Americans had little use for the antique term melancholia. The glossary of Alfred Freedman’s Comprehensive Textbook of Psychiatry, the world’s leading textbook first published in 1967, had scads of psychoanalytic terms but claimed of melancholia: “Old term for depression that is rarely used at the present time.” In Europe after World War II, endogenous depression was the serious variety and melancholia was deemed as “contaminated by Freud and the 19th century novels that degraded it to grief,” as Tom Ban, who trained in Budapest in the early 1950s, put it. “For Kraepelinians, grief and depression were not the same, and they excluded each other. Anyone who had an identifiable precipitating factor could not be labeled as having a depressive state.”