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.

In 1800, mania was conceptualized as an agitated psychotic state. By 1900, it closely resembled its modern form. This paper reviews the descriptions of mania in Western psychiatry from 1880 to 1900, when Kraepelin was training and developing his concept of manic-depressive illness. Psychiatric textbooks published 1900–1960 described 22 characteristic manic symptoms/signs the presence of which were recorded in 25 psychiatric textbooks and three other key documents published 1880–1900. Descriptions of mania in these nineteenth century textbooks closely resembled those in the twentieth century, recording a mean (s.d.) of 15.9 (2.3) and 17.0 (2.3) of the characteristic symptoms, respectively (p = 0.12). The frequency with which individual symptoms were reported was substantially correlated in these two periods (r = +0.64). Mendel's 1881 monograph, Kraepelin's first description of mania in 1883 and the entry for mania in Tuke's Dictionary of Psychological Medicine (1892) described a mean (s.d.) of 19 (1.7) of these characteristic symptoms. These descriptions of mania often contained phenomenologically rich descriptions of euphoria, hyperactivity, grandiosity, flight of ideas, and poor judgment. They also emphasized several features not in DSM criteria including changes in character, moral standards and physical appearance, and increased sense of humor and sexual drive. Fifteen authors described key symptoms/signs of mania most reporting elevated mood, motoric hyperactivity and accelerated mental processes. By 1880, the syndrome of mania had been largely stabilized in its modern form. In the formation of his concept of manic-depressive illness, Kraepelin utilized the syndrome of mania as described in the psychiatric community in which he was trained.

This review seeks to determine the degree to which modern operationalized diagnostic criteria for mania reflect the clinical features of mania described historically by expert textbook authors. Clinical descriptions of mania appearing in 18 textbooks published between 1899 and 1956 were reviewed and compared to the criteria for mania from six modern operationalized diagnostic systems. Twenty-two prominent symptoms and signs were reported by five or more authors. Two symptoms (elevated mood and grandiosity) and four signs (hyperactivity, pressured speech, irritability, and new activities with painful consequences) were reported by every author. A strong relationship was seen between the frequency with which the clinical features were reported and the likelihood of their inclusion in modern diagnostic systems. However, many symptoms and signs including impulsivity, hypersexuality, mood lability, altered moral standards, increased humor, hypergraphia, and a vigorous physical appearance were not included in any modern criteria. Indeed, DSM-5 contains only eight of the historically noted clinical features. We conclude that modern operationalized criteria for mania well reflect symptoms and signs frequently reported by historical experts. This suggests that the clinical construct of mania has been relatively stable in western Psychiatry since the turn of the 20th century. However, many useful clinical features of mania described in these textbooks are missing from these criteria thereby illustrating the limitations of clinical evaluations restricted to the assessment of only current diagnostic criteria. The disorders we study and treat are considerably richer clinically than is reflected in the DSM criteria which we use to diagnose them.

Emil Kraepelin fundamentally shaped our current psychiatric nosology. Although much has been written about his diagnostic formulations, less is known about his views on the fundamental nature of psychiatric illness and the goals of psychiatric nosology. We focus on his writings from 1896 to 1903 but also review his inaugural lecture in Dorpat in 1887 and his last two papers, published in 1919–1920. Kraepelin hoped for a ‘natural’ classification of psychiatric illness but realized that the level of etiologic knowledge required to undergird this effort was not feasible in his own lifetime. This did not stop him, however, from developing a pragmatic approach based on his clinical method of careful description with detailed follow-up, coupled with the available fallible tools of pathological anatomy and, by 1919, genetics and biochemistry. Kraepelin saw psychiatric disorders as multifactorial, arising from the difficult to untangle action and interaction of internal and external causes. He was aware of the problem of defining the boundaries of illness and health but knew this was not unique to psychiatry. Contrary to his stereotype, he was sensitive to the importance of personality factors in psychiatric illness and advocated for their investigation. He also recognized the limitations of his ‘clinical method’ and was especially critical of classifications based on single prominent symptoms. Ultimately, Kraepelin was a skeptical realist when it came to psychiatric nosology. His goal of developing a consistent ‘natural’ classification of the major mental disorders has yet to be attained, but his ‘research agenda’ remains central to psychiatry to the present day.