Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond.
Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond.
JAMA Psychiatry. 2018 Dec 1;75(12):1280-1288. doi: 10.1001/jamapsychiatry.2018.2377.
Over 12 years (1887-1899), in his second through sixth editions of his textbook Psychiatrie: Ein Lehrbuch für Studierende und Ärzte, Emil Kraepelin created, through an iterative, self-examining process, his mature concepts of Verrücktheit (paranoia) and Paranoide Formen Dementia Praecox. I seek in this essay to show this skilled nosologist at work. Four themes were prominent. First, Kraepelin used symptoms throughout, but he transitioned from superficial phenomenon (delusional themes) to those he considered more pathognomonic: disorganized fantastical delusions vs organized, nonbizarre delusions. Second, he increasingly emphasized the distinction between delusions arising from misinterpretations of real events vs delusions arising from hallucinations. Third, the putative causes of the disorder became more important as he came to understand Verrücktheit from a psychological and developmental perspective, whereas dementia paranoides (the precursor to paranoide formen dementia praecox) resulted from pathological brain changes. Fourth, Kraepelin appreciated the importance of disease course, but he initially lacked adequate data to elucidate it. As his research program developed, he used the well-recognized disease of general paralysis of the insane as a paradigm and correlated symptoms, modes of delusion formation, and presumed mechanisms of disease with course and outcome. Patients with slowly developing, referential, nonbizarre delusions without hallucinations were typically stable for years with minimal deterioration. Patients with rapidly developing, poorly organized, fantastical delusions emerging from prominent hallucinations tended to deteriorate quickly. Using conceptual tools first proposed by Kahlbaum and Hecker, Kraepelin developed his concepts of Verrücktheit and paranoide formen dementia praecox using an exploratory, conceptual, and data-gathering process in which each syndrome was defined in contrast to the other and, in addition to a core focus on disease course, multiple additional levels of clinical inquiry were included.
在 12 年（1887-1899 年）的时间里，埃米尔·克雷佩林（Emil Kraepelin）在他的第二版到第六版教科书中，通过迭代、自我检查的过程，形成了他成熟的“Verrücktheit（偏执狂）”和“Paranoide Formen Dementia Praecox”概念。在本文中，我试图展示这位熟练的诊断学家的工作。有四个主题非常突出。首先，克雷佩林在整个过程中使用症状，但他从表面现象（妄想主题）转变为他认为更具特征性的症状：混乱的幻想妄想与有组织的、非奇异的妄想。其次，他越来越强调由于对真实事件的误解而产生的妄想与由于幻觉而产生的妄想之间的区别。第三，随着他从心理和发展的角度理解“Verrücktheit”，这种疾病的潜在原因变得更加重要，而痴呆性偏执狂（偏执性痴呆形式的前身）则是由于病理性大脑变化而导致的。第四，克雷佩林意识到病程的重要性，但他最初缺乏足够的数据来阐明这一点。随着他的研究计划的发展，他将众所周知的精神病性全身麻痹作为一个范例，将症状、妄想形成模式和假定的发病机制与病程和结果联系起来。具有缓慢发展、参照性、非奇异妄想且没有幻觉的患者通常稳定多年，仅有轻微恶化。具有快速发展、组织不良、由明显幻觉产生的幻想妄想的患者往往迅速恶化。克雷佩林使用卡尔鲍姆（Kahlbaum）和赫克（Hecker）首次提出的概念工具，通过探索性、概念性和数据收集过程，发展了他的“Verrücktheit”和“paranoide formen dementia praecox”概念，每个综合征都是通过与其他综合征对比来定义的，除了核心关注疾病过程外，还包括多个额外的临床研究层面。
