The Doctor Who Trained Nazis and Changed Psychiatry

In 1998, neuroscientist Christof Koch made a bet with philosopher David Chalmers that in 25 years the “hard problem” of what constitutes human consciousness would be solved. New tools, like functional MRIs, lit up brain areas in use by tracking oxygen. Science learned a great deal, but not as much as it wanted to, and none of which solved the hard problem.

In 2023, Koch conceded and gifted Chalmers some wine. Chalmers knows his hard problems, having coined the term. I doubt any scientist now working on consciousness would risk his liquor money.

Emil Kraepelin

Source: Author Unknown / Wikimedia Commons

In the late 1800s, a German psychiatrist named Emil Kraepelin declared that madness was actually a variety of madnesses, each with its own title and disease process in the brain. Human consciousness, distressed or otherwise, went from representing something a person was to something they had. Kraepelin’s biological thinking had, in a way no one had thought of yet, flattened the hard problem.

For Kraepelin, madness didn’t involve the psyche. It was schizophrenia, bipolar disorder, and depression, a malfunctioning brain producing these states and others.

Kraepelin had sad eyes under heavy brows, a hairline that receded, and a moustache and beard that grew bushier and whiter as he aged. He became one of those men who could be tapped to wear a Santa suit, though he’d have made a depressing Santa. Kraepelin fed patients alcohol, coffee, and tea and tested their reactions. He also tried hypnosis and hypnotized, according to his memoir, lizards and lobsters.

Life situations formed a side issue, if that, of Kraepelin's diagnostics. “So-called psychic causes, unhappy love, business failure, overwork,” he wrote, “are the product rather than the cause of the disease.”

Though he died in 1926, Kraepelin trained some of the worst of Nazi doctors. He didn’t tell these doctors they should kill. He simply helped instill in them beliefs that allowed them to do so.

The disease categories most associated with Kraepelin’s reform of psychiatric thinking were schizophrenia— though he called it dementia praecox, or “premature dementia”—and manic-depression. I’m a perfect Kraepelinian, having at times been diagnosed with both.

Despite, or maybe in part because of, all that I’ve written, Kraepelin has been a dominant theoretical force in modern U.S. psychiatry. In 1978, Gerald Klerman named himself and a group of other biological psychiatrists neo-Kraepelinians. They intended to bring back Kraepelinian biology, the world of failed loves and lost jobs as outward manifestations of brain disorder, rather than the sources of mental distress.

That the focus of psychiatry should be on biological brain disorder is both Kraepelin’s belief and one of the core beliefs of contemporary neo-Kraepelinian psychiatry. Or the concept of biological brain disorder, as most of its theories still lack hard proof. It’s also at the heart of our drug-driven, 20-minute evaluation, 15-minute med check system of care.

Kraepelin resisted the psychoanalysis done by the likes of Sigmund Freud. He wanted his field to function like any other medicine, using symptom lists and diagnostic categories that well-trained practitioners could agree on. The neo-Kraepelinians wanted this, too.

It takes work to ignore Kraepelin’s mostly ignored eugenic beliefs. He wrote about social degeneration through bad “germ plasm” often. Considering degeneracy, Kraepelin cites “the well-known example of the Jews, with their strong disposition towards nervous and mental disorders.”

The damage the socially inferior do, Kraepelin wrote, as they “transfer their inferiority to their offspring, is incalculable,” and adds, “our highly developed social welfare has the sad side-effect that it operates against the natural self-cleansing of our people.”

The neo-Kraepelinians’ most tangible product was a new version of what had been a slim book of disease categories and symptom lists called the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM, as created by the neo-Kraepelinians, is both a medical philosophy and the pumping heart of our psychiatric system. Diagnosis requires a DSM label, and its disease code is required for insurance reimbursement.

The latest edition contains some 600 categories, including caffeine-induced sleep disorder, which I’ll grant a very brief symptom checklist (possibly measured in cups) could diagnose.

I am one of many possible codes for bipolar, though on any given day, picking one—Bipolar I, most recent episode in partial remission, mixed—feels less science than horoscope.

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DSM symptoms can be ludicrous—one sign of mania is “increased goal-oriented activity.” Others include sleeping less and having “flights of ideas.” Collaboration with the patient or knowledge of the patient’s life might be useful in biological medicine, but could hardly be called essential. Dialogue becomes a luxury.

The 1970s were my first years in the psychiatric system. The profession confronted angry groups of abused patients, countercultural rebellion against social control, media like One Flew Over the Cuckoo’s Nest, and telegenic anti-psychiatrists like R.D. Laing.

Beyond all this, psychiatry fought it out with psychotherapy for control of research and patient money. These struggles jump-started what historian Eric Engstrom calls “the hagiographic enthusiasm emanating from historically challenged neo-Kraepelinians in North America.” Biological psychiatry solved a lot of problems. Scientific results, in theory, aren’t biased, and psychotherapists can’t adjust neurotransmitters.

Though neurotransmitter theory, as taught, has been largely debunked and there’s a rise in the use of terms like a “biopsychosocial” psychiatry, most patients with psychic pain are treated with a prescription written in less than half an hour. The runaway bus that is Kraepelin solves many problems. It’s just that many don’t involve the patient.

Today’s methods also secretly or not so secretly lack what’s been part of positive mad-doctoring in the past: Hope for its own end. Cure or cure beyond a future of daily medication.

British psychiatric historian Michael Shepherd once said to neo-Kraepelinian Nancy Andreasen, “I was very sad to see that you’ve turned [Kraepelin] into an icon. He was a monster who had done a great deal of harm.”