Changes in the Prognosis of Functional Psychoses Since the Days of Kraepelin

Extract

My choice of Kraepelin as a point of departure for this lecture has definite reasons. If one wants to stay within the field of clinical psychiatry (as opposed to psychiatric history), that is as far back as one can reasonably go. By this no slight is intended upon the pre-Kraepelinian psychiatrists. For our topic Henry Maudsley would indeed have been a most appropriate starting point, and by no means for reasons of courtesy. His general point of view is admirably sound as a basis for the scientific study of prognosis in psychiatry. I quote: “There is no accident in madness. Causality, not casualty, governs its appearance in the universe, and it is very far from being a good and sufficient practice simply to mark its phenomena and straightway to pass on as if they belonged not to an order but to a disorder of events that called for no explanation.” On the special problem of prognosis he shows his clinical acumen by stating that the outlook is poor when the course of illness is insidious, but this only means that these cases develop their psychoses on the basis of mental deviations which go very far back in the patient's life, so that in fact they are generally in a chronic stage at the time of their first admission to hospital. Here he actually corrects a mistake which is still quite often made. He shows his dynamic attitude when he says that prognosis is to a large extent modified by external conditions, in particular by the attitude of friends and relatives. Maudsley's dynamic reasoning was limited by the narrow framework of the degeneration hypothesis of those days. He had a sceptical attitude towards classification, which he regarded as artificial and dangerously pseudo-exact. His own classification was deliberately provisional, with very wide groups. He held that a description of various sub-forms of chronic insanity was useless, as it would mean nothing but a tiresome enumeration of unconnected details.