Schizophrenia Research 57 (2002) 5 13

www.elsevier.com/locate/schres

Historical aspects of the dichotomy between

manicdepressive disorders and schizophrenia
Jules Angst *
Epidemiological Research, Zurich University Psychiatric Hospital, Lenggstrasse 31, Mail Box 68, 8029 Zurich, Switzerland

Abstract
The history of psychiatric classification is highly complex and this presentation must be restricted to a simplified overview.
Guislain [Guislain, J., 1833. Traite des phrenopathies ou doctrine nouvelle des maladies mentales. Etablissement
rztl. Ver. 7 (1837) 321] established a unitarian
Encyclopedique, Brussels] and Zeller [Beil. Med. Corresp.-Bl. Wurtemb. A
concept of psychiatric disorder, permutations of which have survived until the present day. Kraepelins [Kraepelin, E., 1899.
rzte (6th edn.). Johann Ambrosius Barth, Leipzig] dichotomy between
Psychiatrie. Ein Lehrbuch fur Studierende und A
manic depressive insanity and dementia praecox was built mainly on Kahlbaums [Kahlbaum, K., 1863. Die Gruppirung
der Psychischen Krankheiten und die Eintheilung der Seelenstorungen. AW Kafemann, Danzig] classification, which took
clinical symptoms, course and outcome into account. Kraepelins well-accepted approach sought to provide a basis for
diagnosis, prognosis, choice of treatment and causal research. Kraepelins dichotomy came to be questioned on several grounds:
(1) doubts about his unification of bipolar disorder [Gaz. Hop. 24 (1851) 18] with melancholia, (2) doubts about the
significance of Kraepelins diagnostic groups for causal research [Z. Gesamte Neurol. Psychiatr. 12 (1912) 540], illustrated best
by the work of Bonhoeffer [Bonhoefferm, K., 1912. Die symptomatischen Psychosen im Gefolge akuter Infektionen,
Allgemeinerkrankungen und innerer Krankheiten. In: Aschaffenburg, G. (Ed.), Handbuch der Psychiatrie, 3. Abt., 1. Halfte.
Deuticke, Leipzig Wien], (3) the complex psychopathological descriptions and classifications of numerous subgroups of
psychoses by Kleist [Monatsschr. Psychiatr. Neurol. 125 (1953) 526] and Leonhard [Leonhard, K., 1968. Aufteilung der
endogenen Psychosen (4th edn.). Akademie Verlag, Berlin] and (4) description of the psychoses between affective and
schizophrenic disorders (intermediate psychoses, mixed psychoses, schizo-affective psychoses) beginning with Kehrer and
Kretschmer [Kehrer, F., Kretschmer, E., 1924. Die Veranlagung zu seelischen Storungen. (Monographien aus dem
Gesamtgebiete der Neurologie 40) Springer, Berlin] and persisting up to the modern findings of a continuum between the two
major groups of psychiatric disorders. Kraepelins simplification has so far been more successful than the Kleist Leonhard
approach, but the modern and more descriptive trend in psychiatric classification favours the syndromal concept of Hoche and
the concepts of continua between affective and schizophrenic disorders and between normal and pathological behaviour.
D 2002 Published by Elsevier Science B.V.
Keywords: History; Classification; Schizophrenia; Schizo-affective disorder; Affective disorder

1. Unitarian concepts of psychiatric classification

Tel.: +41-1-384-26-11; fax: +41-1-384-24-46.

E-mail address: jangst@bli.unizh.ch (J. Angst).

A generally accepted classification system for psychiatric disorders did not exist until the end of the 19th
century. Before Kraepelin, the situation was confused.

0920-9964/02/$ - see front matter D 2002 Published by Elsevier Science B.V.

PII: S 0 9 2 0 - 9 9 6 4 ( 0 2 ) 0 0 3 2 8 - 6

J. Angst / Schizophrenia Research 57 (2002) 513

In his historical review, Kahlbaum (1863) summarised

about 30 different systems of classification from Plater
(1625), considered to be the founder of medical and
psychiatric classification, to Morel (1851). One such
attempt to describe or classify psychiatric symptoms or
syndromes was made by Guislain (1833) in Belgium,
who devised a complex system consisting of a mosaic
of about a hundred different states. Guislain considered the cause of all psychiatric disturbances to be
consequences of psychic pain (douleur moral, Seelenschmerz), ultimately resulting in dementia. A stressor model of psychiatric disorder was implicit in
Guislains unitarian causal theory.
A logical consequence was the concept of unitary
psychosis, the history of which has been extensively
described by Vliegen (1980) and recently by Berrios
and Beer (1992, 1994). Zeller (1837), who translated
the work of Guislain, was the founder of the concept
of unitary psychosis, comprising all psychotic syndromes, which he regarded as representing no more
than different stages of a pathological process, itself
the result of an interaction of somatic and psychological factors. Other important proponents of the unitary
psychosis were Griesinger (1845), an assistant of
Zeller, and Neumann (1859). Jacksons evolutionary
view of the formation of a functional hierarchy of the
brain was influential on more recent developments
(Berrios and Beer, 1992). In his review of the unitary
psychosis, Maier (1992) notes that like Griesinger but
over a century later, Ey (1963) developed a hierarchical model based on the evolution of the brain as did
Foulds and Bedford (1975) on the basis of interpersonal communication. Another 20th century exponent of the unitary psychosis was Rennert (1965),
who developed the concept of the universal origin
(Universalgenese) of endogenous psychoses. He
explicitly set out to challenge the efforts by Wernicke,
Kleist and Leonhard to devise a sophisticated
diagnostic atomisation. The psychopathological
concepts developed by Janzarik (1969) are also compatible with a unitarian theory.

2. Forerunners of Kraepelins dichotomy

Although one source of Kraepelins dichotomy of
manic depressive insanity and dementia praecox is
probably the distinction drawn by Griesinger between

disorders of affects and ideas/will (Vliegen, 1980),

there can be little doubt that Kraepelin (1918) based
his concept chiefly on the work of Kahlbaum, who
had introduced a dichotomy based on course and
outcome, a debt he later came to acknowledge himself.
In 1863, Karl Kahlbaum published his monograph
The grouping of psychological illnesses and the
classification of mental disorders, on which the
edifice of modern nosology is built. On the basis of
symptoms, course and outcome, Kahlbaum distinguished between two large groups of mental disorders: vecordia was a limited disturbance and
vesania a complete disturbance of the mind (Table
1). The first group was characterised by a continuous
but remitting course, by continuous he meant that
the symptom complexes or states did not change their
typical symptoms over time (Kahlbaum, 1878, p.
1145). The benign group of vecordia comprised
vecordia dysthymia, which included depression
and mania. By contrast, the course of vesania showed
a changing symptomatology, was progressive and the
outcome was dementia. Vesania consisted of vesania
typica (from which dementia praecox was later
derived) and vesania progressiva, which embraced
all brain disorders such as progressive paralysis and

Table 1
Classification of psychotic disorders by Kahlbaum (1863)

J. Angst / Schizophrenia Research 57 (2002) 513

Table 2
Classification of mood disorders by Kahlbaum (1882)
Cyclothymiaa

Vesania typica circularisb

. Dysthymiac
. Hyperthymiae

. Melancholiad
. Maniaf

a
b
c
d
e
f

Mood disorder.
Schizoaffective disorder.
Depression, dysthymia.
Schizo-depression.
Mania, hypomania.
Schizo-bipolar/mania.

stroke (Table 1). Later in 1879, Kahlbaum added

catatonia as a subgroup of vesania.
In 1882, he renamed vecordia dysthymia cyclothymia, which comprised dysthymia (Flemming,
1844) and hyperthymia (Table 2). The terms cyclothymia, dysthymia and hyperthymia were used by
Kahlbaum in order to distinguish remitting affective
disorders from melancholia and mania (as stages of
the vesania typica circularis) with a poor outcome.
From todays perspective, these two groups appear as
a clear description of mood disorders and schizoaffective disorders. The classification system proposed by Kahlbaum was not very successful; the
new terms that he introduced in order to separate
disorders with a good outcome from those ending in
dementia were too numerous.

3. Emil Kraepelins dichotomy

Emil Kraepelins first nosological publication was
his programmatic Compendium of 1883. As Roelcke
(1996) pointed out, Kraepelin put forward a classification based on putative somatic causation of psychiatric diseases, which was a complete break with
tradition. Kraepelin sought to establish psychiatry on
the basis of the natural sciences, adhering to an
experimental model, inspired by his teacher Wilhelm
Wundt and the results of his own first psychopharmacological study (Kraepelin, 1882, 1883). But Kraepelin also recognised our ignorance of the causation of
psychiatric disorders, which (as today) made it impossible to consider complexes of symptoms (syndromes)
as disorders. Kraepelin wanted to create a nosology
that would provide a basis for successful prognosis,
therapy, and prevention (Roelcke, 1997). For this
purpose, Kraepelin systematically compiled informa-

tion on symptomatology, family history, and the longterm course of the patients condition.
A significant breakthrough came with the fifth
edition of Kraepelins (1896) textbook, in which the
author conceptualised disease entities on the basis of
causation, symptoms, course and outcome and in
which he published a comprehensive chapter on
dementia praecox. In a presentation given the same
year in Heidelberg and published in 1897, Kraepelin
stressed the prognostic value of an early diagnosis,
validated by a careful long-term follow-up. In such a
way, he maintained, one could distinguish processes
leading to dementia from others. He also separated
depression from involutional melancholia.
A more elaborate classification was published in
the sixth edition of Kraepelins (1899) textbook,
where he integrated into the group of dementia
praecox the catatonia of Kahlbaum (1874), the
hebephrenia of Hecker, which was conceptionalised
by Kahlbaum (Hecker, 1871), and dementia paranoids. Among other disorders Kraepelin distinguished
dementia praecox from involutionary psychosis,
manic depressive insanity and paranoia as further
diagnostic categories (Table 3).
In comparison with Kahlbaum, Kraepelins terminology was simpler and his comprehensive text much
easier to read and to understand. It dispelled the
confusion that prevailed in contemporary psychiatric
classification, a task in which Kahlbaum had had little
success. The success of Kraepelins dichotomy experienced later a revival in the United States in the
Neo-Kraepelinian school of St. Louis with the
introduction of the Research Diagnostic Criteria (Spitzer et al., 1978) as syndromal constructs (Kick, 1981).
Kraepelins influential classification did not however go unchallenged. Three developments in the
intervening century have cast serious doubts on Kraepelins dichotomy: the first relates to the classification
of affective disorders, the second to intermediate,
Table 3
Krapelins 1899 classification
.
.
.
.
.
.

Dementia praecox (hebephrenia, catatonia dementia paranoids)

Manic depressive insanity
Dementia paralytica
Insanity and brain diseases
Involutional psychosis
Paranoid states

J. Angst / Schizophrenia Research 57 (2002) 513

Table 4
History of classifying affective disorders

olar psychoses. Kleist considered both mania and

depression to be monopolar psychoses and bipolar
psychosis to be due to a specific affiliation of the
two. The concept of bipolar psychosis propounded by
Kleist and his pupil Leonhard (1968) therefore differs
clearly from the concept current today, which subsumes monopolar mania under bipolar disorder. The
modern concept is mainly based on research carried
out in the 1960s (Angst, 1966; Perris, 1966; Winokur
et al., 1969), which established the distinction between
bipolar disorder and monopolar/unipolar depression
on the basis of course and genetics. With this development, Kraepelins dichotomy was questioned at least
in the field of manic depressive insanity.

5. Intermediate psychosis, mixed psychosis,

schizo-affective psychosis

mixed or schizo-affective disorders and the third

questions the validators of the dichotomy and suggests
a continuum concept of functional psychoses.

4. Bipolar disorder and unipolar depression

The history of the classification of affective disorders is briefly summarised in Table 4. From antiquity
right up until the middle of the 19th century, melancholia and mania were generally considered to be two
completely different disorders, of physical origin,
embracing all types of psychiatric syndromes including all organic brain disorders, schizophrenia and
affective disorders. As Pichot (1995) has established,
the alternation of mania and depression was accurately
described by Esquirol in 1838 but was not considered
to be a single disorder. It is to Falret that we owe the
creation of the concept of manic depressive disorder.
In 1851, Falret working in Paris (interesting details
were published by Haustgen, 1993) developed the term
la folie circulaire to describe what he considered to
be a new and separate psychiatric disorder. Kraepelin
was aware of Falrets concept but deliberately unified
mania, depression and bipolar disorder into one broad
category of manic depressive insanity. In the-mid
20th century, Kleist (1953) challenged Kraepelins
model with his distinction between bipolar and monop-

A second development, the development of the

concept of schizo-affective psychosis, undermined the
dichotomy in a more central point. As mentioned
earlier, a weak point of both Kahlbaum and Kraepelins dichotomy is that they classified manic and
depressive syndromes among both major psychoses:
manic depressive insanity and dementia praecox.
This resulted in schizo-affective states being subsumed under vesania typica, under dementia praecox
and later under schizophrenia. Table 1 demonstrates
how, in regard of affective syndromes, the dichotomy
remained ambiguous. Little wonder that Kahlbaum
and Kraepelin both noticed the existence of intermediate cases.
This gap was filled in the 1920s when the concept
of intermediate psychosis (mixed psychosis) was
developed by Kehrer and Kretschmer (1924) and
Gaupp and Mauz (1926). In 1933, Kasanin, coined
the term schizo-affective psychoses for a subgroup of
schizophreniform psychoses with a good prognosis
and simultaneous presence of schizophrenic and affective syndromes. This simultaneous co-occurrence
required for diagnosis is a constant and has been
maintained in the Diagnostic Manuals ICD-10 and
DSM-IV. Schizo-affective disorders have been defined
in a variety of ways (analysed for instance, by Brockington and Leff, 1979 who demonstrated the polymorphism of the group and the low concordance
between the concepts).

J. Angst / Schizophrenia Research 57 (2002) 513

The modern cross-sectional concept of schizo-affective disorder suffers from the shortcoming that it does
not take into account the even more puzzling longitudinal change of syndromes, the transition of manic
depressive to paranoid or schizophrenic disorders.
(Schule, 1878; Urstein, 1909; Stransky, 1911; Smith,
1925; Mayer-Gross, 1932) or vice versa the change of
schizophrenic syndromes into manic depressive syndromes (Hoffmann, 1925; Mayer-Gross, 1932).
Kretschmer (1919) disputed the whole notion of the
existence of two separate disorders and described
circular insanity and schizophrenia as disorders of
the same stratum (Schicht). Bleuler (1922) transitionally shared Kretschmers opinion, agreeing with his
assumption of a continuum from normal to pathological in the dimensions schizothymic schizoid schizophrenic, cyclothymic (syntonic) cycloid and circular
manic depressive. Bleuler assumed that both forms of
disposition co-existed independently in every human
individuum. A differential diagnosis between schizophrenia and manic depressive insanity had therefore
to be questioned in principle. Gaupp (1939) considered
it as natural to have mixtures of symptoms of both
major psychoses.
It should not be forgotten that Kraepelin (1920)
himself came to express concern about the dichotomy,
admitting that, No expert will deny that cases which
cannot be classified safely are disturbingly frequent
(unerfreulich haufig). . . We will have to get used to
the idea that all signs are insufficient to delineate
manic depressive insanity from schizophrenia. . . .
and that overlap occurs.
Under Kretschmers influence, the dichotomy
seemed moribund and Birnbaum (1928) predicted that
nosology had come to a dead end, a point on which he
agreed with Bumke (1925). Bumke (1924) argued that
rather than Kraepelins disease entities only a typology of psychiatric syndromes was feasible, a view
which was shared by Kretschmer (1929) and later by
Schneider (1967).

6. The continuum from affective to schizophrenic

syndromes
A decisive contribution came from Hoche (1912),
who criticised the view of schizophrenia as a disorder.
Hoche distinguished between disorders, symptom

complexes (syndromes) and elementary symptoms

and maintained that psychiatric disorders such as
dementia praecox could be no more than analogies
to diagnostic groups of somatic medicine and that in
reality dementia praecox was characterised by a
chaotic symptomatology. Hoche advanced the theory
that psychiatric syndromes expressed dispositions or
reaction patterns, for instance hysterical, hypochondriacal, neurasthenic, manic, depressive or paranoid.
In fact, it is the symptomatological change (Janzarik,
1968) and not the stability that characterises the longterm course of psychotic disorders and none of the
European long-term studies on schizophrenia has
found symptomatological stability (Bleuler, 1972;
Ciompi and Muller, 1976; Huber et al., 1979; Marneros et al., 1991).
Hoches syndromal critique of Kraepelins concept
was not the only one raised; another was made on
psychopathological grounds: no specificity of any
symptom of dementia praecox could be found,
whereas complexes of symptoms came close to the
target (Birnbaum, 1928). Furthermore, the work of
Bonhoeffer (1912), which had shown that one and the
same physical disease could result in totally different
psychopathological syndromes, raised serious doubts
about a purely clinical classification. The conflict
between etiological classification and syndromal psychiatric nosology was born.
Another basic assumption, that schizophrenia ends
in dementia and that manic depressive disorders
recover, also turned out to be wrong, which meant
that outcome as a validator had to be questioned. As
early as 1909, within Kraepelins school itself, Zendig
(1909) carried out a follow-up study of 468 cases of
dementia praecox diagnosed in Kraepelins clinic in
Munich. He found a favourable outcome in 29.8% of
the cases, a fact which he ascribed to misdiagnosis.
This interpretation was disproved by Langes investigation of some of the cases (Lange, 1922, p. 4). This
early finding, true but misinterpreted, namely that
dementia praecox can recover, is consistent with the
modern studies on the course and outcome of schizophrenia by Huber et al. (1979), Ciompi and Muller
(1976), Bleuler (1972) and Marneros et al. (1991),
Moller et al. (1982). Recovery cannot be explained
merely as a result of the inclusion of schizo-affective
disorders in schizophrenia; it is also true for acute
catatonia and other acute schizophrenic psychoses.

10

J. Angst / Schizophrenia Research 57 (2002) 513

On the other hand, affective disorders should

recover and frequently do not, as already observed
by Bumke (190963240). It is a well-established
fact that 15 or more percent of cases end in chronicity and that another substantial proportion develops
residual affective symptoms between episodes. It is
more the quality of the residual states, which differ
between affective disorders and schizophrenia than
their presence or absence and the same applies to
cases which become chronic. It is not surprising that
Kurt Schneider, a strong believer in the dichotomy,
ceased to base the diagnosis of schizophrenia on
course or outcome but considered solely the presence
of first-rank symptoms. All studies of course and
outcome have demonstrated that schizo-affective
disorders lie midway between affective disorders
and schizophrenia (Kendell and Brockington, 1980;
Angst, 1986; Gross et al., 1986; Marneros et al.,
1991).
Another issue is the psychopathological continuity
from affective to schizophrenic syndromes as established by Kendell and Gourlay (1970), Kick, 1981,
Angst et al. (1981, 1983), Angst (1986) and Yasamy
(1987), findings which are concordant with Janzariks (1969) unitarian psychopathological view on a
clinical descriptive level. Mundt (1995) demonstrated
in his presentation on the psychotic continuum or
distinct entities from a psychopathological point of
view, based on the literature, that in terms of single
symptoms there is overwhelming evidence for the
diagnostic unspecificity of overall symptoms and
outcome, first-rank symptoms of Schneider, basic
symptoms of Huber (1966), negative symptoms of
Andreasen and Olsen (1982), thought disorder of
Chapman (1966) and of the psychophysiological
orientation reaction of Heimann (1986). Mundt concludes that on the single symptom level, no specificity for schizophrenia and thus no single disease
entity can be found within the spectrum of the
idiopathic psychosis.
A continuum from a genetic point of view was
postulated by Angst and Scharfetter (1985) and
Crow (1986, 1990) in contrast to the multiple threshold model of Reich et al. (1975), as discussed in
detail by Maier (1992). The genetic findings of
Gershon et al. (1982, 1988) and Maier et al.
(1993) do not disprove the hypothesis of a continuum (Crow, 1990).

7. The way forward

In the future, some progress may be achieved
through the more recent distinction between unipolar
depressive and bipolar affective and schizo-affective
disorders. It has not only been shown that, in course
and outcome, schizo-bipolar disorders (Cadoret et al.,
1974) lie between affective and schizophrenic psychoses but also that schizo-depressive psychoses are
very similar to unipolar depression and bipolar schizoaffective disorders(?) very similar to bipolar disorders.
This fact is taken into account by the inclusion of
mood-incongruent psychotic features of bipolar
manic depressive or depressive disorders in DSM.
Recently, Maier (1992) has postulated the need for an
at least two-dimensional model for a continuum from
unipolar or bipolar affective to schizophrenic disorders. It may be worthwhile to study the whole
spectrum of idiopathic psychoses from this point of
view, because our earlier cluster analyses (Angst et al.,
1983) were unable to identify a schizophrenic symptom cluster without any depression or mania. We
therefore advanced the hypothesis that affective components could be basic and common to all endogenous psychoses.
In 1995, Crow summarised: Perhaps we should
grasp the nettle and conclude that the conditions we
are concerned with are indeed continuous. There are
no defining features such as would be necessary
to establish the existence of discrete diagnostic
entities. . . But if there are no true disease entities,
there is no basis for isolating one part of the pathological spectrumthe whole range must be considered. . . and postulated that there are no disease
entities but the psychoses can be regarded as boundary conditions of continuous variation that is present
in the general population.
Over the years, the dichotomy has repeatedly been
declared dead and buried, but it has survived and may
even have a long future on a purely descriptive
syndromal level.
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