Schizophrenia Bulletin vol. 46 no. 3 pp.

471–483, 2020
doi:10.1093/schbul/sbz101
Advance Access publication 20 February 2020

The Development of Kraepelin’s Mature Diagnostic Concept of Catatonic Dementia

Praecox: A Close Reading of Relevant Texts

Kenneth S. Kendler*
1
Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Box 980126, Richmond, VA 23298-0126;
2
Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA
*To whom correspondence should be addressed; Virginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth
University, Box 980126, Richmond, VA 23298-0126; tel: 804-828-8590, fax: 804-828-1471, e-mail: kenneth.kendler@vcuhealth.org

AbstractThrough a close reading of texts, this essay
traces the development of catatonia from its origination
in Kahlbaum’s 1874 monograph to Kraepelin’s catatonic
subtype of his new category of Dementia Praecox (DP)
in 1899. In addition to Kraepelin’s second to sixth text-
book editions, I examine the six articles referenced by
Kraepelin: Kahlbaum 1874, Brosius 1877, Neisser 1887,
Behr 1891, Schüle 1897, and Aschaffenburg 1897 (Behr
and Aschaffenburg worked under Kraepelin). While
Brosius and Neisser confirmed Kahlbaum’s descriptions,
Behr, Schüle, and Aschaffenburg concluded that his cat-
atonic syndrome was nonspecific and only more narrowly
defined forms, especially those with deteriorating course,
might be diagnostically valid. Catatonia is first described
by Kraepelin as a subform of Verrücktheit (chronic nonaf-
fective delusional insanity) in his second to fourth editions.
In his third edition, he adds a catatonic form of Wahnsinn
(acute delusional-affective insanity). His fourth and fifth
editions contain, respectively, catatonic forms of his two
proto-DP concepts: Psychischen Entartungsprocesse and
Die Verblödungsprocesse. Kahlbaum’s catatonia required
a sequential phasic course. Positive psychotic symptoms
were rarely noted, and outcome was frequently good.
While agreeing on the importance of key catatonic signs
(stupor, muteness, posturing, verbigeration, and excite-
ment), Kraepelin narrowed Kahlbaum’s concept, dropping
the phasic course, emphasizing positive psychotic symp-
toms and poor outcome. In his fourth to sixth editions, as
he tried to integrate his three DP subtypes, he stressed, as
suggested by Aschaffenburg and Schüle, the close clinical
relationship between catatonia and hebephrenia and em-
phasized the bizarre and passivity delusions seen in cata-
tonia, typical of paranoid DP.
Key words: catatonia/dementia praecox/Kraepelin/history
This report is the third in a series tracing the origins of
Kraepelin’s concept of Dementia Praecox (DP) articu-
lated in the 1899 sixth edition of his textbook.1,2 The first
and second articles traced the development of the par-
anoid3 and hebephrenic subtypes.4 Here, I examine the
catatonic subtype. I review all relevant clinical sections
of the earlier editions of Kraepelin’s textbook, all of the
6 articles/monographs cited by Kraepelin in the catatonic
DP section of his sixth edition, and 2 short relevant arti-
cles by Kraepelin.5,6
I include crucial quotes in the text, but most are
placed into supplementary table 1. Table 1 summar-
izes the key catatonic signs and symptoms presented in
Kahlbaum,7 Brosius,8 Neisser,9 and all of Kraepelin’s
editions. Confusingly, Kraepelin uses the same term—
DP—for his hebephrenic subtypes in his fourth and
fifth editions as he later applies to the entire syndrome
in his sixth edition. To avoid confusion, we use the term
hebephrenia for this syndrome from the fourth to sixth
edition.
This is a relevant time to review the historical origins of
catatonic DP. For the first time in the history of the DSM,
DSM-510 does not contain a category of catatonic schiz-
ophrenia. Instead catatonia is present as a specifier asso-
ciated with any mental disorder and can be diagnosed in
the absence of knowledge as to the underlying disorder. In
addition, interest in catatonia has increased recently.11–14
Kahlbaum 1874
The modern history of catatonia begins with Karl
Kahlbaum’s (1828–1899) 1874 monograph: “Catatonia
or “Muscular Tension” Insanity: A clinical form of psy-
chiatric illness. The text contains 7 chapters and 25 case
histories. I begin with 2 quotes, from the beginning and
the end of the monograph:

© The Author(s) 2020. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.
All rights reserved. For permissions, please email: journals.permissions@oup.com

471
K. S. Kendler
In this work, I will attempt to describe a disease pattern
which has somatic components, with particular involve-
ment of the musculature; they occur as often here as in GPI
[general paresis of the insane] and go along with certain psy-
chic manifestations of the disease; in this particular mental
disorder, they also play an important part in the form taken
by the entire process of the disease. (see ref. 7, p. 8)
Catatonia is a brain disease with a cyclic, alternating
course, in which the mental symptoms are, consecutively,
melancholy, mania, stupor, confusion and eventually de-
mentia. (see ref. 7, p. 93)
Three points are noteworthy. First, Kahlbaum saw par-
allels between his concept of catatonia and GPI, a recur-
ring theme. Second, motoric/muscular abnormalities are
central to his concept of catatonia. Third, the disorder
has sequential phases experienced by all patients.
I focus on chapters 2 (symptomatology) and 6 (prog-
nosis). First, Kahlbaum distinguishes between “an initial
developmental stage” of catatonia and the terminal stage.
He emphasizes the “changing, cyclic” course of the early
stages. Sometimes the first depressive phase evolves di-
rectly into stupor. More commonly, patients transition
to a state of “mania” which Kahlbaum characterizes
as “rage, frenzy, excitation” (see ref. 7, p. 31). He writes
“repeated transitions between conditions of depression
and mania are frequently observed” (see ref. 7, p. 29).
Only “in very rare” circumstances, does catatonia start
with atonia. Kahlbaum’s approach to catatonia is part
of his “prognostic-clinical” schema, which defined dis-
orders jointly by distinct symptoms and specific stages of
illness.15
Second, the later phases of catatonia are dominated by
motoric and postural signs especially atonia, mutism and
stupor. Typically, this phase includes posturing, “a prom-
inent tendency to strange fixed positions … [patients] as-
sume very strange postures” (see ref. 7, pp. 38–40). In more
advanced cases, “grotesque stereotypes movements …
[and] frequent grimacing” (see ref. 7, p. 49) are common.
Third, negativism is often prominent during this latter
phase. Patients frequently demonstrate “involuntary ri-
gidity of the limbs which often offers remarkable resist-
ance to attempts at passive movement” (see ref. 7, p. 26).
Kahlbaum elaborates in quote Ka-1 (supplementary
table 1). Typical is case 14 (quote Ka-2).
Fourth, Kahlbaum singles out the “striking” feature
of waxy flexibility (flexibilitas cerea), “lingering signs [of
which] … may still be evidence in the stage of terminal
dementia.” This somatic feature is, he states “unique in
the diagnosis of this particular illness” (see ref. 7, p. 9).
See quote Ka-3.
Fifth, phases of catatonic excitement were frequently
present. In case 11 such “attacks” were characterized by
“Wild, insane behavior, with arbitrary striking, shouting
and talking … and biting” (see ref. 7, p. 36). Sixth, cat-
atonia also manifests itself by “numerous abnormalities
472
… of thought processes” (see ref. 7, p. 31). Most common
were particular language/thought disorders outlined in
quote Ka-4.
Seventh, active psychotic symptoms were rarely noted
in Kahlbaum’s descriptions. Such features are “less char-
acteristic and therefore less useful for the purpose of
distinguishing the disease [catatonia] from other psy-
chiatric disorders than the formal [motoric] symptoms”
(see ref. 7, pp. 46–47). Delusions were noted in only 5 of
Kahlbaum’s cases, 3 of which were bizarre, and hallucin-
ations in 8 cases.
His chapter on prognosis begins:
… catatonia shows a contrast to GPI…. Whereas the prog-
nosis of GPI is known … to be extremely bad, the prog-
nosis of all forms of catatonia is by no means hopeless….
Recovery is relatively so frequent that this gratifying con-
trast with paralysis … must be recognized immediately. (see
ref. 7, p. 87)
Kahlbaum does not comment systematically on outcome
in his case reports. However, recoveries were not rare.
Excluding cases dying in hospital, I found statements
about outcome in 13 cases. Five did poorly while 8 cases
had good outcomes. Kahlbaum notes that “as regards the
general risk of a relapse, this is on the whole relatively
small in catatonia” (see ref. 7, p. 91). However, a poor out-
come is common when the patient displayed preoccupa-
tion with delusional beliefs (see ref. 7, p. 90).
Regarding age at onset, Kahlbaum writes “Catatonia
occurs at all ages, from puberty to the most senior ages”
(see ref. 7, p. 54). Kahlbaum does not give age at onset for
his cases nor can it easily be determined. Age at evalua-
tion is given for 22 cases with a mean (SD) of 32 (7.8).
I would estimate the mean age at onset in his series was
28–30.
In summary, in addition to his emphasis on motoric
signs, seven features of Kahlbaum’s catatonia are note-
worthy (table 1): (1) sequential/phasic course, (2) wide
range of ages at onset, (3) prominent signs of stupor and
mutism, odd postures, and waxy flexibility, (4) typical
excited phases of “wild, insane behavior”, (5) thought/
language disturbances including disorganization and
verbigeration, (6) infrequent positive psychotic symp-
toms and rare bizarre delusions, and (7) a mixed course
frequently ending in recovery, although deterioration
also occurred.
Brosius 1877
Casper Brosius (1825–1910) published in 1877 a review
titled, “Catatonia: A psychiatric sketch”.8 The review be-
gins with a discussion of the symptoms, signs and course
of catatonia and then presents one case in detail and 3
more briefly. Brosius endorsed Kahlbaum’s descrip-
tion and emphasized eleven features of the catatonic
syndrome.
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox

First, its essence “lies in motor disturbances.” Second,

Flattened affect, indifference

Notes importance of remis-
Acute onset. disorientation
Brosius endorsed the sequential phasic nature of cat-

NI, no information provided; YA, young age at onset; PC, phasic sequential course; SM, stupor and mutism; NEG, negativism; CE, catatonic excitement; PWF, posturing or
atonia. Third, stupor, a central feature of catatonia, is

waxy flexibility; TD, thought disorder; VER, verbigeration; DEL, delusions; DOI, delusions of influence; BD, bizarre delusions; HAL, hallucinations; PO, poor outcome.
characterized by “muteness and immobility” and always

Association with
occurs in catatonia but is “not permanent.” Fourth, neg-
Extra Features

ativism is often encountered including refusals to eat and

hebephrenia
toilet appropriately.
Fifth, catalepsy and posturing are frequently seen.

sions
Sixth, immobility is rarely complete, and careful observa-
tions will reveal short movements or expressions that indi-
cate that the patient is aware of his surroundings. Seventh,
+++
PO

+−

++

++
++

++

++
+-

speech abnormalities are common and quite character-

+

istic. He gives a clear description of verbigeration “the

HAL

+++

+++
+++

+++
same words or even whole sentences are repeated over
++

++
++

++
+

and over in the same way or with small changes” (see ref.
DOI,

8
, p. 780). Eighth, “movement stereotypes” are frequent
+++
++

++

++
++

++
BD

−
+

and highly indicative of catatonia. They can be violent

and unexpected: “the patients who seem mute, immobile,
DEL

+++

+++
+++
+++
+++

+++

+++

withdrawn into themselves, entirely lacking in will and

++
+

seemingly mindless, often react very violently” (see ref.

VER

, p. 775).
+++

+++
+++

+++

+++

+++

+++

8
++

++
TD,

Ninth, catatonic agitation is common in this syndrome

and described in quote Br-1. This excited phase is clini-
PWF

+++

+++
+++

+++
+++
+++

+++

+++

cally distinct from that seen in mania lacking jokes and

++

++
Table 1. Key Catatonic Signs, Symptoms, and Course of Illness as Reported by Reviewed Documents

frequent rhyming. Tenth, Brosius never comments on the

+++

+++
+++

+++

+++

+++

presence of positive psychotic symptoms (delusions and

CE

++
+

hallucinations) in catatonia. He does note that “a delu-

sional intent can often not be found” (see ref. 8, p. 777).
NEG

+++
+++

+++
+++
+++

+++

+++
++

Of his 4 cases, one presents with delusions described as

NI

NI

being of “crimes committed.” Hallucinations are not

+++
+++
+++

+++
+++
+++
+++

+++

+++

mentioned in the main text but are briefly noted in 2

SM

++

cases. Finally, Brosius provides no clear statements about

the course and prognosis of catatonia but implies that it
+++

+++
+++
−
PC

−
−
−
+

is very variable (see quote Br-2).

The terminal state of his 4 cases varied from some
+++
++

++

++
YA

symptoms of deterioration to apparent full recovery. The

−

+
−
NI

NI

NI

mean ages of his 4 cases was 23. Published 3 years after

Katatonie: Die Verblödungs-

Kahlbaum, Brosius endorsed almost entirely his descrip-

tion of catatonia.
Katatonic Verrücktheit

Katatonic Verrücktheit

Katatonic Verrücktheit
Katatonie: Psychische
Katatonic Wahnsinn

Entartungs-processe

Kraepelin’s Second Edition 1887

Dementia Praecox

Catatonia had a migratory history in Kraepelin’s early

editions (figure 1). The term does not occur in his first
Katatonie

Katatonie
Katatonie
Diagnosis

processe

edition.16 In the second edition,17 Kraepelin describes one

catatonic syndrome—a subform of Verrücktheit. This
diagnostic category, then a broad category of delusional
psychoses, evolved later into Kraepelin’s mature concept
Kraepelin’s 1889 3rd edition
Kraepelin’s 1889 3rd edition
Kraepelin’s 1893 4th edition
Kraepelin’s 1893 4th edition

Kraepelin’s 1896 5th edition

Kraepelin’s 1899 6th edition

Kraepelin 1887 2nd edition

of paranoia (1899).3,18 His description begins

As a further peculiar developmental form, primarily of hal-
lucinatory persecutory delusion, we have to consider an-
Kahlbaum 1874

other clinical picture, which has been described as catatonic

Brosius 1877
Neisser 1887
Author/Year

insanity (Verrücktheit). Initially, the psychosis displays the

gradual development of delusions involving persecution,
poisoning or also of influences…. After a short or a long
time of the illness, often in connection with a vehement

473
K. S. Kendler
Figure 1. The relationship of Kraepelin’s catatonic categories from his second through his sixth textbook edition.
anxious exacerbation, the patient sinks into deep silence and
apparently complete apathy…. His head is sunk, eyes closed,
and his facial expression is rigid, mask-like and vacant. The
whole day he stands in one place in a down-sunken or the-
atrical posture, countering passive movement with rigid re-
sistance or, more commonly, providing pronounced “waxen
flexibility” of the limbs…. (see ref. 17, pp. 336–337)
Contrary to Kahlbaum’s view that psychotic symp-
toms play a minimal role in catatonia, Kraepelin’s
first catatonic syndrome emphasized such symptoms
prominently.
In such cases, while acutely ill, speech was typically dis-
ordered and sometimes incomprehensible. Kraepelin de-
scribes the occurrence of “…foolish, incoherent, phrases
which are repeated countless times (verbigeration ac-
cording to Kahlbaum)” (see ref. 17, pp. 338–339) noting
the diagnostic significance of this symptom “cannot be
underestimated.”
The acute phase typically lasts weeks to months.
Outcome is variable. Superficial recovery frequently oc-
curs, although a patient often “still displays clear residues
of the preceding disorder in his peculiar theatrical and
stilted behavior, occasional unmotivated ‘poses’, [and]
stereotypical … affected expressive movements” (see ref. 17,
p. 338). More rarely, “… patients never entirely come out
of the catatonic state, and instead pass over directly into
definitive, more or less deep dementia” (see ref. 17, p. 339).
Furthermore, in his section on Melancholia attonita
(ie, stuporous melancholia—a common pre-Kahlbaum
diagnosis for “catatonia”), Kraepelin distinguished it
from catatonic Verrücktheit (quote K2-1 supplemen-
tary table 1). In summarizing catatonic Verrücktheit,
Kraepelin writes
474
The circumstance that catatonic conditions could occur in a
whole series of illnesses, prompted Kahlbaum to summarize
all these forms as a single clinical picture under the name
catatonia. As this attempt does not seem satisfactory to me,
I have separated, also in the description, such very divergent
diseases according to clinical development, course and prog-
nosis. (see ref. 17, p. 339)
In the first appearance of a catatonic syndrome in his
textbook, Kraepelin does not accept Kahlbaum’s unitary
view of this syndrome. The specific form of catatonia
he describes, like Kahlbaum, included the key signs of
stupor, waxy flexibility and verbigeration. However, dis-
tinct from Kahlbaum’s formulation, his syndrome fea-
tured prominent positive psychotic symptoms and made
no mention of sequential phases.
Neisser 1887
Although Clemens Neisser’s (1841–1940) “Regarding
Catatonia—A Contribution to Clinical Psychiatry” 9 was
only a doctoral dissertation, written at the University of
Leipzig in 1887, it was considered important enough by
Kraepelin to cite. Beginning with a review of the cata-
tonia concept, focused on Kahlbaum’s monograph, the
remaining text included 12 detailed case histories inter-
spersed with a few briefer cases and more general com-
ments on the optimal nature of psychiatric diagnostic
categories generally and Kahlbaum’s concept of cata-
tonia more specifically.
Contrary to the typical cross-sectional, symptom-
focused diagnoses, Neisser was a strong advocate for
Kahlbaum’s clinical method for conceptualizing psychi-
atric disorders (see quotes N-1 and N-2 supplementary
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox
table 1). He emphasized the importance of moving away
from a solely psychological or symptomatic view of ill-
ness (quote N-3). Neisser strongly endorsed Kahlbaum’s
concept of the sequential phases of catatonia, using the
older term “melancholia attonita’ for the stuporous cata-
tonic syndrome (quote N-4).
Neisser emphasized that the catatonic patient needs to be
seen in his totality. It cannot be a symptomatic diagnosis—
the course, the pattern of key symptoms and signs need to
be taken into account. Like Kahlbaum, Neisser empha-
sizes the importance of the motoric features of catatonia.
He describes the odd ritualistic behaviors seen even during
periods of partial remissions in catatonic (quote N-5). He
concluded his introductory summary with three points:
Firstly, melancholia attonita … is not an independent ill-
ness, instead it forms a more or less defined stage during
the course of an illness process, which is distinguished by a
typical sequence of different and specifically characterized
disorders. Secondly, that a regular accompanying and es-
sential partial phenomenon of this mental clinical picture,
consists of tension anomalies in the region of the voluntary
movement apparatus…. Thirdly … in the different stages
of the illness, another series of symptoms with a more or
less pathognomonic value, tend to occur, namely negativistic
tendencies, fear of eating, mutism, verbigeration, movement
and postural stereotypes…. (see ref. 9, p. 14)
Neisser firmly rejects a psychological explanation of cat-
atonia (quote N-6) and then presents his 12 cases, hoping
that they “may provide further material to confirm the
empirical correctness of Kahlbaum’s clinical data” (see
ref. 9, p. 15). Two differences between his cases and those
of Kahlbaum are noteworthy. First, 10 of the cases dem-
onstrated delusions or hallucinations, although only two
included bizarre delusions. Second, of the 8 cases where
outcome could be meaningfully determined, only one
had a clear recovery. The mean age at evaluation of these
cases was 30.5 (8.3) and nearly all had recent onsets.
Overall, Neisser’s monograph strongly supported the
validity of Kahlbaum’s conceptualization of catatonia
including its sequential phases, its emphasis on motoric
abnormalities and a rather late age at onset. However,
the case series differed in having a worse outcome and a
much higher proportion of cases with positive psychotic
symptoms.
Kraepelin’s Third Edition 1889
In his third edition, Kraepelin’s description of the cata-
tonic form of Verrücktheit from the second edition is re-
peated with minimal change.19 In addition, he introduces
a new diagnosis of “Katatonic Wahnsinn.” Wahnsinn is
a problematic category of delusional psychosis typified,
in Kraepelin’s nosology, by an acute presentation with
mixed psychotic and affective symptoms. Behr gives a
helpful description in quote B-1 supplementary table 1.
This category, included in his second through fourth
editions disappears in his fifth, incorporated into
Melancholia. In his overall introduction, Kraepelin
writes: “Catatonic Wahnsinn, finally, includes the essen-
tial part of those clinical pictures which Kahlbaum has
given the name of ‘catatonia’” (see ref. 19, p. 311).
When he gets to this form, Kraepelin provides more
detail:
Under the name of catatonia, Kahlbaum has described a
clinical picture which presents the symptoms of melancholia,
mania, and stupor, in the case of an unfavorable course also
that of disorientation and dementia, and which in addition,
due the existence of certain motor symptoms such as spasms
and inhibitions, also has the characteristic “catatonic” symp-
toms…. Although I must consider this summary with its
conditions which are often contradictory etiologically, clin-
ically and prognostically, as a schematic over-estimation …,
as a result of certain experiences, I consider it appropriate to
single out a certain group of cases from the field of “cata-
tonia” as “catatonic Wahnsinn.” This is essentially the rather
acute occurrence of confused delusions and hallucinations
with episodic depressive or expansive states of agitation, and
the phenomena of peculiar psychomotor constraints, which
manifests, among other things, in cataleptic and spasmodic
states. (see ref. 19, p. 332)
The emphasis is on the acute onset typically in young in-
dividuals. He continues
The emergence of the psychosis is usually very rapid …The
patients then become disorientated, agitated, do not recog-
nize their environment and give totally incoherent and in-
appropriate answers…. Usually, the patients, after a short
time, sink into a peculiar condition of rigid stupor. They
stop speaking or lisp occasional incoherent words. They lie
or sit immobile, often with their eyes closed, curled up, do
not react to being spoken to, to touch, to pin pricks, refuse
to eat. (see ref. 19, pp. 333–334)
As with catatonic Verrücktheit, Kraepelin emphasized
the positive symptom psychosis that typically accom-
pany the stuporous phase (quote K3-1). He describes a
number of classical catatonic symptoms typical of these
cases (quote K3-2). Verbigeration is noted: “The patients
declaim in pathetic but monotonous modulation, for
hours or even days, the same meaningless combination
of words…” (see ref. 19, p. 334). He refers only briefly to
the differential diagnosis of his two catatonic syndromes:
Catatonic Verrücktheit differs from catatonic Wahnsinn in
the acute development without a long-prepared delusional
system [in the latter], as also by the outcome into disorienta-
tion or recovery. (see ref. 19, p. 336)
Outcome of Catatonic Wahnsinn is generally poor: “The
prognosis is always to be regarded as doubtful. A great
number of cases go over into conditions of incurable
weakness” (see ref. 19, p. 335).
475
K. S. Kendler
Although Kraepelin’s concept of catatonic Wahnsinn
shared many of the signs described by Kahlbaum, it oc-
curs in a different context—in an active acute psychotic
state with prominent delusions and hallucinations and fre-
quently disorientation. No mention is made of required
phases. As suggested by this quote from his third edition,
at this point, Kraepelin was clearly cognizant of the var-
iability of catatonic signs and symptoms depending on
clinical context.
… catatonic phenomena, similar to those of depression
or exaltation, may develop under certain circumstances in
the course of various mental disturbances. The symptom
complex, however, appears to exhibit notable differences,
depending on the ground upon which it is formed. (see ref.
19
, p. 373)
Behr 1891
Albert Behr (1860–1919) received his medical degree
from Dorpat in 1891 with a dissertation “The Question
of Catatonia or Muscular Tension Insanity” 20 completed
under the likely close supervision of Kraepelin, Professor
at Dorpat from 1886 to 1891. His introduction reads “The
present work originated as a result of the advice of Prof.
Dr. E. Kraepelin, currently in Heidelberg, and I thank
him for the friendly congeniality he always showed me.”
Behr began with a summary of Kahlbaum’s work
(see quote B-2 supplementary table 1) and the literature
evaluating Kahlbaum’s monograph, concluding that
the majority of authors lauded the masterfulness and the
fineness of the clinical description of individual symptoms,
such as “stupor,” “verbigeration,” etc. However, [most] de-
clared that they were not in agreement with “catatonia” as a
distinct illness. (see ref. 20, p. 5)
He concludes from his review that
… there are two viewpoints with regard to the conception of
catatonia. The one speaks of catatonia as a disease unit, the
other sees in it the partial symptoms and complications of
the most varied mental disturbances. (see ref. 20, p. 7)
He supports the latter viewpoint (for details, see quote
B-3). He suggests a way forward: “Only the prejudice-free
observation and sober enumeration of facts can lead to a
system, to an acutely defined diagnosis, to a symptoma-
tology of mental disturbances” (see ref. 20, p. 8). He then
quotes admiringly from Kraepelin’s inaugural Dorpat lec-
ture21 (quote B-4). Behr specifically criticized Kahlbaum’s
sequential stage model (quote B-5). Later, Behr states that
“catatonia is not a cyclical illness and does not proceed in
phases” (see ref. 20, p. 56). He notes the nonspecificity of
many of the “catatonic” symptoms (quote B-6).
In a brief report to the Association of East-German
Psychiatrists on 15 June 1890, entitled “Regarding
Catalepsy”, Kraepelin quotes the same figure noted by
Behr (8%–10%) for the rate of catalepsy in his Dorpat
476
patients.5 Kraepelin describes 28 cases, the most common
single cause being GPI. Of these 28, only six fitted into
his most current categories of catatonic Verrücktheit or
Wahnsinn.
Behr’s cases are typical of those presented by previous
authors. Positive psychotic symptoms were seen in two
cases both involving passivity phenomenon. Average age
at evaluation was 27 (5.7). Only one case had a moder-
ately good recovery, one could perform daily tasks but
the other four had poor outcomes.
He begins his conclusion by criticizing the coherence
of the catatonia concept (quote B-7). He argues that the
diversity of the “character” of these cases, especially as
manifest by differences in their course and outcome, belie
the effort to consider them a single disease group. He
re-emphasizes this key point, probably echoing the views
of his mentor Kraepelin:
In the grouping and classification of mental disturbances es-
pecially the clinical character of the origin, the course, the
duration and the outcome should be considered, while the
formal elements, the picture of the condition, should be con-
sidered only secondarily. (see ref. 20, p. 55)
He then concludes:
As it follows from what has been discussed and from the ex-
amination of the individual case studies, that various mental
disturbances display catatonic symptoms, we thus neither
accept a common illness “catatonia” (Kahlbaum), nor do
we believe that catatonia can be allocated to certain psych-
oses…. Instead, we are of the opinion that the majority of
mental disturbances may display catatonic symptoms, that
catatonic psychoses exist, but not catatonia. (see ref. 20,
pp. 55–56)
Behr concludes that the catatonic syndrome as described
by Kahlbaum and his supporters, Brosius and Neisser,
does not constitute a single disorder. It fails to demon-
strate a common origin, course and outcome. Perhaps
Kraepelin took this conclusion as a challenge. Could he,
in his life-long nosology project, find a form of catatonia
that would meet these criteria?
Kraepelin’s Fourth Edition 1893
Catatonia syndromes are included in two places in
Kraepelin’s fourth edition.22 Catatonic Verrücktheit
is briefly described with half of the text being new, in-
cluding this opening description:
Another peculiar type of course is distinguished by the
emergence of certain catatonic characteristics. The patients
become monosyllabic, withdrawn, finally entirely mute, al-
ternating between cataleptic and negative resistance, take on
intricate positions, drape their bedding in a striking manner,
remain still for a long time in the same position. Typical
verbigeration does not appear to occur…. Most commonly
such catatonic episodes develop in the course of physical
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox
persecutory delusions or in cases where physical influencing
is present. (see ref. 22, pp. 425–426)
Kraepelin notes a specific association between this cat-
atonic syndrome and bizarre delusions of physical in-
fluence. Cases of Verrücktheit which demonstrated
such prominent delusions were re-labeled fantastic
Verrücktheit in his fifth edition and then placed into
Paranoid Dementia Praecox in the sixth edition.3
Outcome is far from benign: “In many cases, one can
observe, after the patient awakens from this state, that
there is a considerable increase in mental weakness ac-
companied by very fantastic delusions” (see ref. 22, p. 426).
In the fourth edition section on Wahnsinn,
Kraepelin writes
… I have, based on the latest observations, entirely elimin-
ated the much disputed “catatonic” Wahnsinn, and instead
placed it closer to the mental processes of degeneracy de-
cline (Psychische Entartungsprocesse). (see ref. 22, p. 318)
Kraepelin was concerned with where to best place cat-
atonic syndromes in his nosology. He decides to focus
on an entirely new chapter in his text entitled Psychische
Entartungsprocesse (Psychological Degeneration
Process). It may be no accident that he here first cites
Behr’s thesis.
This new category contains three chapters each of
which will each evolve into a major DP subtype. The
second, entitled “Katatonie,” begins with the text that
introduced his third edition description of Catatonic
Wahnsinn, supporting the thesis that part of the core of
what is to become catatonic DP comes from the third ed-
ition description of catatonic Wahnsinn. I quote the last
common sentence and then his novel perspective on the
catatonic syndrome:
… as a result of certain observations, I will now single out a
group of cases from the sphere of “Catatonia,” as a peculiar
form of illness. Here we are essentially concerned with the
acute and sub-acute appearance of peculiar states of agita-
tion, accompanied by confused delusions, isolated hallucin-
ations and the emergence of stereotypical and suggestible
expressive gestures and actions, which transform into stupor
and subsequent mental weakness (Schwachsinn). (see ref. 22,
pp. 445–446)
Kraepelin is singling out a subgroup of Kahlbaum’s
syndrome with two key features: positive psychotic
symptoms of delusions and hallucinations and a poor
outcome. While these features were also noted in cata-
tonic Wahnsinn, this new syndrome does not share with
the earlier version an emphasis on the acute presentation
with associated confusion, depression and elation.
In subsequent text, Kraepelin outlines his view of this
catatonic subtype of “Psychische Entartungsprocesse.”
The syndrome “almost always” begins with depressive
symptoms, the only nod seen here toward the original
phasic nature of catatonia. But prominent delusions and
often hallucinations soon ensue often of a fantastic na-
ture. Soon thereafter, the patient sinks into stupor from
which a “catatonic state” emerges, particularly charac-
terized by negativism. Here is a characteristic quote (for
the unredacted section see quote K4-1 supplementary
table 1).
The patients stop speaking entirely (mutism) or only lisp
occasional soft, incomprehensible words. They are com-
pletely inaccessible to any external input, do not react to
being spoken to, to touch or even pin pricks…. Every at-
tempt to actively intervene in the posture or movement
of the patients usually encounters obstinate and im-
movable resistance. … The facial expression is motion-
less, mask-like. The lips are often pushed forward trunk
like (“snout-spasm”) (Schauzkrampf), here and there
displaying mild, rhythmically twitching movements. (see
ref. 22, pp. 445–448)
Other motoric abnormalities are often noted:
A whole series of peculiar habits that patients display may
originate in the same way as a result of an impulse that arises
suddenly, and then, due to the tendency to stereotyping, re-
curs continuously. Amongst these are the already mentioned
peculiar postures and the automaton-like movements which
are observed here, the spasmodic pressing of splayed fingers
against particular parts of the body, the compulsive head
shaking and especially certain anomalies when eating. (see
ref. 22, p. 451)
In addition to negativism, Kraepelin also notes opposing
symptoms of an increased sensitivity to the environment
(quote K4-2). Speech disorders are also characteristic
(quote K4-3). States of mania/agitation are common in
the course of catatonia:
More frequent than the sudden transition to dementia,
is a temporary emergence of manic states of agitation.
Sometimes these are only very temporarily inserted in the
stupor. The patients suddenly become elated, merry, talka-
tive, start to sing, to dance, laugh foolishly, act destructively,
smear feces, become violent, to then just as rapidly return to
their previous motionlessness. (see ref. 22, p. 453)
There is nothing about “sequential stages” in his descrip-
tion of these states. Kraepelin describes their typical out-
come (for entire quote see K4-3):
After a good number of months … the catatonic symptoms
gradually disappear.… The patients become freer in their
movements … However, they are completely dull, impassive,
are not able to provide information about simple things.…
Traces of catalepsy, indications of posture or movement
stereotyping, lack of cleanliness, unmotivated refusal to eat
or gluttony are not uncommon. The ability to work is very
meager or entirely absent … [they] often progresses to deep,
apathetic dementia. (see ref. 22, pp. 452–454)
477
K. S. Kendler
He then disagrees with Kahlbaum on the course of
catatonia:
Kahlbaum did not consider the prognosis of catatonia as
very unfavorable and reported a number of recoveries.
I would, however, doubt that his cases were of a similar
kind…. All cases with pronounced catatonic symptoms
I have observed over the years, without exception, resulted in
the unfavorable outcome described above. (see ref. 22, p. 454)
In a final section, he comments on the young age at
onset seen with catatonia and its likely association with
hebephrenia.
All these cases involved people between the ages of 19 and
26…. Catatonia may thus be closely related to hebephrenia,
a view which is supported by the frequency of catatonic
indications in this psychosis, as well as the occurrence of
certain transitional cases between the two forms. (see ref.
22
, p. 454)
Kraepelin’s fourth edition represents a shift in his view
on catatonic illness as he begins to develop the concept
of Psychische Entartungsprocesse into which he inte-
grates his concept of catatonic Wahnsinn (figure 1) and
which matures, two editions later, into DP. For catatonia,
we see a greater focus on poor outcomes, positive psy-
chotic symptoms, young age at onset, and the begin-
nings of a closer clinical and etiologic relationship with
hebephrenia.
Kraepelin’s Fifth Edition 1896
In his fifth edition,23 Kraepelin removes all mention of
catatonic subforms from his chapter on Verrücktheit
leaving the only description of a catatonic syndrome in
the chapter Die Verblödungsprocesse (dementing pro-
cesses) of which 55% is new. His opening paragraph con-
tains new text more positive about Kahlbaum’s views
than he had previously articulated:
If, however, I have to doubt the cohesiveness of all the clin-
ical pictures [of catatonia] united by Kahlbaum, I never-
theless, as a result of many observations, am compelled to
acknowledge that a majority of those cases represent a pecu-
liar form of illness. (see ref. 23, p. 442)
Within Kahlbaum’s broad syndrome, Kraepelin argues
that a substantial proportion fit into his narrower construct
of catatonic Verblödungsprocesse. He then adds text pro-
posing a new mode of onset. He had previously described
a typical form beginning with dysphoria, withdrawal and
the slow emergence of positive psychotic symptoms before
motor signs develop. The second begins with catatonic ex-
citement (see quote K5-1 supplementary table 1).
Little change is seen in his description of the stuporous
phase into which both forms of onset evolve, and the
development of negativism, catalepsy and thought dis-
order. He gives several new examples of thought disorder
478
(quote K5-2), a photo of 6 catatonic patients and ex-
amples of handwriting. In his section on course, he notes
An additional deviation of the usual course of the illness
is distinguished by the emergence of developed delusions.
Delusions and hallucinations regularly occur temporarily
during the development of the illness. Sometimes, however,
these conceptions are retained for a longer time and devel-
oped further. (see ref. 23, p. 455)
His examples include bizarre and passivity delusions sim-
ilar to those contained in his later description of paranoid
DP (quote K5-3). Finally, he comments on remissions, a
topic which he did not discuss previously (where he noted
that all cases “with pronounced catatonic symptoms …
resulted in unfavorable outcomes”).
An extraordinarily important phenomenon during the
course of catatonia is the remissions. All observers report
that the patients suddenly are entirely lucid, clear and in-
sightful, admittedly only for a short time, for hours or days….
We encounter the patients, who until then had seemed to be
completely confused, immersed in their foolish actions …
now suddenly are calm and entirely ordered. He knows time
and place, the people in his environment, remembers events,
also his own senseless actions, admits that he is ill, and writes
a coherent, sensible letter to his relatives. (see ref. 23, p. 455)
Does this observation contradict his prior claims about
unfavorable outcomes in catatonia?
In a considerable number of cases … more than a third …,
an abatement of the illness may also continue for a long
period, so that it appears to be a recovery. Almost always
… there are certain peculiarities … which indicate that this
was never a true recovery. Included are unfree, compulsive,
stilted or strikingly quiet, withdrawn behavior, agitation and
incomplete insight into the illness. The recurrence of the
illness usually takes place after 5 years, but may in single
cases occur after 8, 10 or even more years … a recurrence
of the illness can be considered to be very likely…. (see ref.
23
, p. 456)
He continues
Whether complete recovery is possible, as Kahlbaum and
after him most researchers have indicated, I have to leave
undecided based on my observations. I have the strong sus-
picion that, in many cases, they have allowed themselves to
be deceived by confusing it with periodic illnesses and also
due to the occurrence of long periods of remissions…. (see
ref. 23, p. 456)
He continues to believe that dementia is the most common
outcome for catatonia, but milder, less deteriorated out-
comes do occur. Finally, he notes the young age at onset
of catatonia: “About half of the cases begin before the
age of 22” (see ref. 23, p. 458).
The description of the catatonic form of his “dementing
process” in Kraepelin’s fifth edition resembles closely that
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox
seen in his fourth edition. Two changes are noteworthy.
First, he emphasizes more the prominence and potentially
long duration of positive psychotic symptoms. Second,
likely resulting from the careful follow-up studies he was
then conducting at Heidelberg, Kraepelin reaffirmed, at
least in part, Kahlbaum’s earlier observations on remis-
sions in the course of catatonia but raised concerns about
their permanence.
Kraepelin 1896
In 1896, Kraepelin presented a paper “Regarding
Remissions in Catatonia” 6 to the Conference of Southwest
German Alienists containing new data on the long-term
course of catatonia. In his 63 “certain” patients, 24 (38%)
demonstrated remissions. Fourteen of these relapsed and
follow-up was attempted:
In the 10 cases about which there was certain news about the
behavior of the patients, there was only a single female pa-
tient who was seen as healthy by her family during the remis-
sion. In all the other cases, there was either a lack of insight
into the illness, or the patients displayed some or other small
notable traits. (see ref. 6, p. 1126)
In the remaining 10, Kraepelin obtained information
about 6 of them: “News could be obtained about 2 of
them and 4 of them presented themselves personally.”
From this contact “… it became clear that catalepsy, em-
barrassed constrained behavior, and a tendency to unmo-
tivated laughter” (see ref. 6, p. 1126) was noted in these
individuals.
Kraepelin ended with four conclusions about catatonia:
First, in catatonia remissions are frequent…. These can con-
tinue for a number of years, even more than 10. Second,
during the interval the patients are frequently not entirely
healthy, instead they present certain peculiarities. Third, if
a person has once fallen ill with catatonia, there is a good
chance that, sooner or later, they will relapse. Fourth, cat-
atonia concerns an organic illness of the brain, which leads
to a more or less high degree of dementia (Verblödung). (see
ref. 6, p. 1127)
Using follow-up methods, Kraepelin collected data to
verify that the cases of catatonia that he was diagnosing
in Heidelberg often had a remitting, relapsing course,
but typically the outcome was poor, usually ending in
dementia.
Aschaffenburg 1897
When Gustav Aschaffenburg (1866–1944)24 gave a lec-
ture to a session chaired by Kraepelin on November 7,
1897, to the Conference of South-West German Alienists
entitled “The Catatonia Question,” he was working as
Kraepelin’s first assistant in the psychiatric university
clinic in Heidelberg, where Kraepelin was Professor of
Psychiatry from 1891 to 1903. The lecture contained no
case reports25 but provides “the detailed study and the
most careful comparison of 227 case histories [admitted
to Kraepelin’s clinic] between April 1891 and September
1897” (see ref. 25, p. 1004). This study was surely done
under Kraepelin’s supervision. He starts by articu-
lating his theoretical approach to psychiatric nosology
(quote A-1).
He then reviews an exchange he had with Carl Fürstner
(1848–1906), Kraepelin’s predecessor in Heidelberg,
who suggested the impossibility of reviewing catatonia
without including hebephrenia (quote A-2). Much of this
essay reviews the history of the catatonia concept from
Kahlbaum to Kraepelin. Agreeing with my review of his
case material, Aschaffenburg writes of Kahlbaum’s de-
scription of catatonia that “He considers the prognosis
of the [affected] individuals … to be good” (see ref. 25,
p. 1007).
His comments on the recently published fifth edition of
Kraepelin’s textbook (1896) are of interest (quote A-3).
He then reviews results from his case series which sup-
ports Kraepelin’s conclusions. He reaches two conclu-
sions about the course of illness. First,
… the subsequent stage of the psychosis, whether it is a con-
dition of agitation or calm, whether delusions occur or not,
will not be mania or Verrücktheit. Instead it will only be a
specifically colored catatonic agitation, delusions on a cata-
tonic basis. (see ref. 25, p. 1013)
That is, the disease course is consistent, will not go
through the sequential stages of Kahlbaum and is not
related to the then modern concept of the affective syn-
drome of mania.26 Second, “… the outcome of the illness
will be mental weakness … [which] also has peculiar indi-
cators which allow a conclusion about the background”
(see ref. 25, p. 1013). That is, certain catatonic features per-
sist in the end state. He continues “…the ultimate degree
of impairment can be extraordinarily divergent. We can
distinguish all levels from the deepest dementia through
to seeming recovery” (see ref. 25, p. 1013).
He vividly describes the range of outcomes (quote
A-4) and then outlines other subtle catatonic signs in
the better outcome cases. He next then comments on the
close relationship between hebephrenia and catatonia,
first by noting how often cases of hebephrenia later in
their course show catatonic signs:
Sometimes, however, we may observe in a patient … that the
catatonic symptoms had only arisen recently, after the pa-
tient had already for a long time been considered demented.
These are the cases which initially corresponded to the clin-
ical picture of hebephrenia in Hecker’s sense. (see ref. 25,
p. 1015)
He further elaborates on the frequent blending of hebe-
phrenic and catatonic signs of illness (quote A-5) and
concludes that a clear distinction between them is often
impossible (quote A-6). He disagrees with Kraepelin’s
479
K. S. Kendler
fifth edition regarding the independence of the hebe-
phrenic and catatonic syndromes (quote A-7), citing data
collected in Kraepelin’s own clinic against him.
In anticipation of Kraepelin’s sixth edition,
Aschaffenburg then summarizes his thinking about the
relationship between hebephrenia, catatonia and the
emerging concept of dementia praecox:
…my knowledge does not allow any other conclusion other
than the assumption that the diseases of hebephrenia and
catatonia form a unified disease process. The name “de-
mentia praecox” seems to me to be the most suitable. It
indicates the characteristic of the illness, the premature de-
velopment of mental weakness…. (see ref. 25, p. 1017)
Aschaffenburg emphasizes 3 overall points about the
catatonia: (1) it did not fit the “sequential stage model,”
(2) the most valid form has a poor course and outcome,
and (3) that form of catatonia illness is closely related to
hebephrenia.
Schüle 1897
Heinrich Schüle (1840–1916), a major figure in late 19th
century German psychiatry, was originally to present
alongside Aschaffenburg but it was delayed due to ill-
ness, being presented later that year at a Congress in
Moscow. “Regarding the Catatonia Question—A
Clinical Study” contained no case histories.27 The
writing style is dense.
While praising Kahlbaum’s descriptions, Schüle begins
by noting the non-specificity of key catatonic signs. He
writes “...the ensemble of the phenomena … applies to a
number of different psychotic states of illness, partly per-
manent, partly episodic” (see ref. 27, p. 518). He continues
in quote S-1 supplementary table 1.
After a detailed analysis of the major motoric and
“mental” symptoms attributed to catatonia, Schüle be-
gins his conclusions elaborating further in quote S-2:
Initially I would like to state that I cannot accept any of
the illnesses included here by Kahlbaum. Even the later de-
limitation, subsequent to that of Kahlbaum, by Neisser and
more recently by Kraepelin, does not seem quite right to me.
(see ref. 27, p. 534)
Then exploring the relationship between the catatonia
syndrome and hebephrenia, he writes
I can only recognize a repetition of the so-called primary
mental impairment in the previously described (severe) clin-
ical picture [of catatonia and], in specie, [hebephrenia as
described by] … Hecker. Here, as there, the same mental
symptoms of agitation and then exhaustion, mixed and al-
ternating. In both conditions the same course leads to more
or less rapid and sometimes peculiar mental weakness.
…I deviate here from Kraepelin, insofar as I am not able
to find dramatic differences [between catatonia and hebe-
phrenia]…. True catatonia (severe form) is thus essentially
480
only a primary (very often hebephrenic) mental impairment.
(see ref. 27, pp. 547–548)
Is catatonia “a new species of illness”? Schüle suggests
not. But the result is not “…that the catatonic cases
simply and without further ado disappear into what al-
ready is in existence, and that things remain as before.”
Rather, from Kahlbaum “we have discovered that cata-
tonic mental impairment maintains a peculiar formation
[and] it is … not possible to deny its special traits” (see
ref. 27, p. 549).
Schüle suggests that considering catatonia as a specific
form of mental impairment is one of the best uses of
Kahlbaum’s general insights. But he writes
The value of this [conclusion] is not decreased by the fact
that it [catatonia] occurs also in other process forms, is ob-
served sometimes in other clinical groups and with other ori-
gins …. (p. 549)
He elaborates, in quote S-3, on the possible utility of
catatonic subforms of other conditions. In his final par-
agraph, he comments on the prognostic utility of cat-
atonic signs when occurring early in an illness course
(quote S-4).
I would emphasize two points in this difficult text.
First, along with Behr, Schüle is deeply skeptical of the
validity of Kahlbaum’s concept of catatonia. The fea-
tures of this syndrome are too diverse and nonspecific.
Second, one subform likely has clinical validity and is
characterized by its poor prognosis, frequent termina-
tion in a demented state and close relationship with hebe-
phrenia. It is noteworthy that Kraepelin added to his sixth
edition references to the two recent articles by Schüle and
Aschaffenburg that both support his addition to DP, a
syndrome historically anchored in Hecker’s hebephrenia,
of a catatonic subtype.
Kraepelin’s Sixth Edition 1899
In Kraepelin’s sixth edition, the only catatonic syn-
drome described is the subtype of his new disorder DP.1
His description is based on the parallel section in Die
Verblödungsprocesse, but 64% is new largely reflecting
enriched clinical details. The introductory paragraphs are
unchanged from the fifth edition but the section in which
he introduces the onset of delusions and hallucinations
early in the disease course is expanded 3-fold.
The delusions are often bizarre and ornate, frequently
involving passivity symptoms and including persecu-
tory, grandiose, somatic and self-deprecatory themes.
Hallucinations are also prominent. For a representa-
tive quote, see K6-1 supplementary table 1. Later in this
chapter, he notes that these positive symptoms, promi-
nent during the active catatonic symptoms, often persist
after the motoric signs have disappeared.
In further new text, he emphasizes the clouding of
consciousness and bewilderment demonstrated by most
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox
patients early in their course. Their speech and thought
are highly disturbed: “The sequence of ideas is muddled
and incoherent, and thought is in most cases seriously
impaired, as is shown by the patients’ nonsensical and
contradictory utterances” (see ref. 1, p. 162).
He then describes the next phase of the illness:
This first phase of the disease, which in all principal features
resembles that of certain hebephrenic forms, is followed in
more or less distinct development by those conditions which
are characteristic of catatonia in particular, catatonic stupor
and catatonic agitation. (see ref. 1, p. 163)
He emphasizes similarities in the early phases of cata-
tonic and hebephrenia DP and their ages at onset (72%
of hebephrenic and 68% of catatonic cases onsetting be-
fore age 25 (see ref. 1, p. 201)). He then reviews the specific
catatonic signs including negativism, command automa-
tisms, mutism, catalepsy. For these new vivid clinical de-
scriptions see quote K6-2.
Kraepelin continues to support two different forms of
onset of catatonia: “stupor/depression” and agitation.
He elaborates on the description of catatonic agitation,
noting the close association of catatonic stupor and ag-
itation (Quote K6-3). Kraepelin comments on two clin-
ical features not noted previously: lack of insight and
flattened affect: “In keeping with their odd behavior and
their delusions, the patients are mostly remarkably indif-
ferent” (see ref. 1, p. 174).
He concludes his catatonia text with a new discussion
of the course and outcome of the disorder, presumably
arising from recent observations made in Heidelberg.
Forty percent of catatonic cases do not reach a state of
classical dementia. The largest proportion of this group
(68%) have continued impairments although their clas-
sical symptoms cease.
Subtle changes persist in these patients: grimacing,
mannerisms, dullness, and increased fatigability. Their
work capacity is considerably impaired. In the remaining
improved patients, are ones “which we usually consider
to be cured…. Here, all morbid disturbances disappear
so completely that the convalescents fill their former
position in life again just as they did before” (see ref. 1,
p. 178). But the long-term outcome of such cases remains
uncertain.
… the fact that the duration of the recovery has as yet only
been ascertained for a few years in most cases. … I have al-
ready seen a whole series of my seemingly cured catatonics
fall ill again and so it has to be left open, for the time being,
how many of the recoveries cited really are to be considered
… permanent. (see ref. 1, p. 179)
He notes “It has unfortunately not yet been possible for
me to discover any definite clues from which one could
infer the probable outcome of the individual case” (see
ref. 1, p. 180). The only prognostic features of which he
feels confident is rapidity of onset. This, he concludes,
explains the better outcome in catatonia vs. hebephrenia
because “an acute beginning with strong agitation” is far
more common in the former than the latter.
Compared with his fifth edition description of the cata-
tonic subtype of Die Verblödungsprocesse, three changes
are made in Kraepelin’s description of catatonic DP.
First, the presence and persistence of positive psychotic
symptoms are yet more strongly emphasized as are their
bizarre features. Second, he outlines in more detail the
course of catatonia including that an appreciable pro-
portion of cases do not, at least initially, have poor out-
comes. Third, he gives stronger greater emphasis to the
similarity of the symptoms, signs, course and age at onset
of catatonia and hebephrenia. Of these three changes,
two bring catatonia closer to hebephrenic and paranoid
DP, demonstrating substantial sharing of symptoms and
signs. One, however, pulls in the other direction—showing
a difference in course for catatonic DP compared with
the other two subtypes where remissions in the course are
considerably rarer.
Discussion
I have traced, through 13 relevant texts, the pathway
from the diagnostic construct of catatonia proposed by
Kahlbaum’s in 1874 to the catatonic subtype of Kraepelin’s
DP in his 1899 sixth textbook edition. I examined: (1)
6 articles/monographs cited in the catatonia sections of
Kraepelin’s texts, (2) sections of 5 of Kraepelin’s textbook
editions (second to sixth) (figure 1), and (3) two published
versions of talks given by Kraepelin. Two of the reviewed
articles were authored by mentees of Kraepelin so he
would have likely influenced their content.
Of the numerous issues raised, 6 are particularly note-
worthy. First, Kahlbaum and his close followers Brosius
and Neisser saw catatonia as having clear sequential stages
beginning with melancholia, and then developing manic,
catatonic and potentially demented phases. While cen-
tral to the initial conceptualization of the catatonic syn-
drome, this model was largely ignored by Aschaffenburg,
Schüle and Kraepelin in his fourth through sixth editions.
Second, a recurrent question in these texts was the
specificity of the key catatonic signs of mutism, stupor,
catalepsy, negativism, and verbigeration. Do they define
a distinct disorder or were they nonspecific occurring in
a wide array of psychiatric conditions? Two of the au-
thors cited by Kraepelin, Behr—his own student—and
Schüle argued for their nonspecificity. Kraepelin’s crea-
tion of catatonic DP was likely in response to their con-
cerns, an effort to delineate a form of catatonic illness
with greater diagnostic specificity than Kahlbaum’s orig-
inal conceptualization.
Third, both Kahlbaum and Brosius described a cat-
atonic syndrome where delusions and hallucinations
were neither prominent nor diagnostically impor-
tant. Interestingly, Neisser’s cases had more prominent
481
K. S. Kendler
psychotic features. Kraepelin’s first catatonic diagnosis,
in his second edition, was a subform of the delusional
syndrome of Verrücktheit. Positive psychotic symp-
toms were a central feature. This syndrome continued
with minimal change in his third edition. However, in
his fourth edition, Kraepelin more tightly linked cata-
tonic Verrücktheit with bizarre passivity delusions. In
his fifth edition, he eliminated this category and created,
as his sole catatonic syndrome, a catatonic form of Die
Verblödungsprocesse. Kraepelin further emphasized the
prominence of bizarre and passivity delusions in the new
text added to the catatonic DP section in the sixth edi-
tion. In several stages across these documents, we see a
gradual steadily increasing emphasis on the role of posi-
tive psychotic symptoms in catatonia, from unimportant
in Kahlbaum to central in Kraepelin’s catatonic DP.
Fourth, the outcome of Kahlbaum’s and Brosius’s cases
of catatonia were quite variable, with full recovery being
common. Over Kraepelin’s early editions, he modified
this position considerably, increasingly emphasizing poor
outcome. Interestingly, Kraepelin’s position was con-
sistent with Kahlbaum’s formulation in one sense—that
the earlier author had emphasized delusional preoccupa-
tion as a poor prognostic sign for catatonia. Kraepelin,
from his second edition onward, always saw psychotic
symptoms as more central to the catatonic syndrome
than Kahlbaum. However, after arriving in Heidelberg,
where he first conducted systematic follow-ups of his
cases, he observed in his fifth edition that, at least in the
short term, remissions of catatonia were not uncommon.
Investigating this question further utilizing, he presented
data suggesting that, given sufficient time, most cata-
tonic cases eventually had a poor outcome. However, in
his sixth edition, he returns with new data showing that,
over the short-term, a significant proportion of catatonic
cases had favorable outcomes.
Fifth, as described by Kahlbaum, catatonia had onsets
throughout adult life (“from puberty to the most senior
ages”) with an estimated median age at onset in the late
20s. However, in Kraepelin’s fourth through sixth edi-
tions, he repeatedly noted the relatively early onset of
his catatonic disorder with mean onsets typically in the
early 20s. Related to this view of catatonia as a disorder
of early adult life, in his fourth edition, Kraepelin first
proposed that catatonia may have a close relationship
with hebephrenia. This point was explicitly emphasized
both by Aschaffenburg and Schüle and taken up again by
Kraepelin in his fourth edition.
Finally, as clearly stated in his second and third editions
and later amplified by his student, Behr, Kraepelin never
accepted Kahlbaum’s diagnostic concept of catatonia tout
court. He cited an additional author—Schüle—who also
rejected the coherence of Kahlbaum’s syndrome. Rather,
Kraepelin experimented in his second through sixth editions
with a range of catatonic syndromes leading up to con-
cept of catatonic DP. All of these diagnostic formulations
482
included catatonia as a form of another disorder rather than
as a free-standing condition. He clearly stated that catatonic
DP did not incorporate all possible catatonic syndromes.
Indeed, in his sixth edition, he specifically noted that prom-
inent catatonic signs can be seen in febrile delirium, general
paresis and melancholia. After substantial consideration,
Kraepelin judged that his catatonic subtype of DP was the
most valid and clinically useful of the possible subforms of
catatonic syndromes, rejecting those he initially considered
to fit better into Verrücktheit or Wahnsinn.
Supplementary Material
Supplementary data are available at Schizophrenia
Bulletin online.
Acknowledgments
Eric Engstrom, PhD provided advice on key references and
historical background material. Eric Engstrom, PhD and
Stephan Heckers, MD gave helpful comments on earlier
versions of this article. The translations from the German
appearing here were done in collaboration with Astrid
Klee, MA. The author reports no conflicts of interest.
References
1. Kraepelin E. Psychiatrie: Ein Lehrbuch fur Studirende und
Aerzte. 6th ed. Leipzig: Barth; 1899.
2. Kraepelin E. Psychiatry, a Textbook for Students and
Physicians (Translation of the 6th Edition of Psychiatrie-
Translator Volume 2-Sabine Ayed). Jaques Quen, ed. Canton,
MA: Science History Publications; 1990.
3. Kendler KS. The development of Kraepelin’s mature diag-
nostic concepts of paranoia (Die Verrücktheit) and paranoid
dementia praecox (Dementia Paranoides): a close reading
of his textbooks from 1887 to 1899. JAMA Psychiatry
2018;75:1280–1288.
4. Kendler KS. The development of Kraepelin’s mature diag-
nostic concept of hebephrenia: a close reading of rele-
vant texts of Hecker, Daraszkiewicz and Kraepelin. Mol
Psychiatry. published online ahead of print April 9, 2019.
5. Kraepelin E. Ueber Katalepsie. Allgemeine Zeitschrift fur
Psychiatrie. 1892;48:170–172.
6. Kraepelin E. Über Remissionen bei Katatonie. Allgemeine
Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin.
1896;52:1126–1127.
7. Kahlbaum KL. Catatonia: Translated from the German Die
Katatonie oder das Spannungsirresein (1874) by Y. Levij,
M.D. and T. Pridan, M.D. Baltimore, MD: The Johns
Hopkins University Press; 1973.
8. Brosius C. Die katatonie: eine psychiatrische skizze. Allgemeine
Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin.
1877;33:770–802.
9. Neisser C. Über Die Katatonie: Ein Beitrag zur Klinischen
Psychiatrie. Stuttgart: Verlag Von Ferdinand Enke; 1887.
10. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders: Fifth Edition, DSM-5.
Washington, DC: American Psychiatric Association; 2013.
 Kraepelin's Mature Diagnostic Concept of Catatonic Dementia Praecox
11. Shorter E, Fink M. The madness of fear: a history of cata-
tonia. Oxford: Oxford University Press; 2018.
12. Oldham M. A diversified theory of catatonia. Lancet
Psychiatry. 2019;6:554–555.
13. Walther S, Stegmayer K, Wilson JE, Heckers S. Structure
and neural mechanisms of catatonia. Lancet Psychiatry.
2019;6:610–619.
14. Rogers JP, Pollak TA, Blackman G, David AS. Catatonia
and the immune system: a review. Lancet Psychiatry.
2019;6:620–630.
15. Kendler KS, Engstrom EJ. Kahlbaum, Hecker, and Kraepelin
and the transition from psychiatric symptom complexes to em-
pirical disease forms. Am J Psychiatry. 2017;174(2):102–109.
16. Kraepelin E. Compendium der Psychiatrie: Zum Gebrauche
für Studirende und Aerzte. Leipzig: Verlag von Ambr. Abel;
1883.
17. Kraepelin E. Psychiatrie: Ein kurzes Lehrbuch für Studirende
un Aerzte. 2nd ed. Leipzig: Abel; 1887.
18. Kendler KS. The genealogy of dementia praecox I: signs
and symptoms of delusional psychoses from 1880 to 1900.
Schizophr Bull 2019;45:296–304.
19. Kraepelin E. Psychiatrie: Ein kurzes Lehrbuch für Studirende
un Aerzte. 3rd ed. Leipzig: J.A. Barth; 1889.
20. Behr A. Die Frage der “Katatonie” oder des Irreseins mit
Spannung Dorpat University, 1891. Riga: WF Häcker; 1891.
21. Stacey D, Clarke TK, Schumann G. The genetics of alco-
holism. Curr Psychiatry Rep. 2009;11:364–369.
22. Kraepelin E. Psychiatrie: Ein kurzes Lehrbuch für Studirende
un Aerzte. 4th ed. Leipzig: Abel; 1893.
23. Kraepelin E. Psychiatrie: Ein Lehrbuch fur Studirende und
Aerzte. 5th ed. Leipzig: Barth; 1896.
24. Kanner L. In memoriam: gustav aschaffenburg 1866–1944.
Am J Psychiatry. 1944;101:426–428.
25. Aschaffenburg G. Die Katatoniefrage. Allgemeine Zeitschrift
für Psychiatrie und psychisch-gerichtliche Medizin.
1898;54:1004–1026.
26. Kendler KS. The genealogy of the clinical syndrome of
mania: signs and symptoms described in psychiatric texts
from 1880–1900. Psychol Med. 2018;48:1573–1591.
27. Schüle H. Zur katatonie-frage: eine klinische Studie.
Allgemeine Zeitschrift für Psychiatrie und Psychisch-
Gerichtliche Medizin. 1898;54:515–552.
483