Emil Kraepelin on Cultural and Ethnic Factors in Mental Illness

In the sixth edition of his famous 2-volume textbook Psychiatrie, which appeared in 1899, Emil Kraepelin introduced the by now well-known distinction between dementia praecox (soon to be called schizophrenia) and manic-depressive illness. Exhausted after finishing the manuscript and checking the page proofs, he decided to take a sabbatical with his older brother, the botanist Karl Kraepelin. One of their destinations was Buitenzorg (today’s Bogor), near Batavia (Jakarta), the capital of the Dutch East Indies, since it boasted both a large mental hospital and a botanical research station, located near the famous botanical gardens.

After their arrival in early 1904, Emil occupied himself with the classification and categorization of mental illness in the tropical zone, while Karl did the same with tropical flora. (He also collected a great number of ants as a favor to Auguste Forel, who used them in a monograph on Javanese ants.) Emil Kraepelin was eager to determine the environmental, social, cultural, and ethnic factors that influenced the types, prevalence, and expression of mental illness-in other words, he wanted to know the extent to which the famed categories of his Lehrbuch applied outside of Europe (some of his conclusions were published in the Zentralblad fr Nervenheilkunde und Psychiatrie in 1904). This was the basis for his title as the founder of comparative psychiatry.

The establishment of the Buitenzorg mental hospital had a long history: planning had lasted over 40 years and it took 2 decades after construction had commenced before the first patients were admitted. It proved to be very hard to ascertain the prevalence of mental illness among the Javanese and, consequently, how many beds were needed. Many colonial physicians argued that the Indonesians were more akin to noble savages and far behind the social and mental development of Europeans. Since they viewed mental illness as an inevitable accompaniment of advanced civilization, they believed that the incidence of Javanese mental illness would be very low. Others argued that the contact with a much more advanced civilization was causing widespread social dislocation and individual turmoil, leading to a much higher incidence of mental illness. These inner tensions and ambiguities in the discourse of colonial psychiatry provided great interpretive flexibility as well as few reliable estimates about mental illness.

Kraepelin investigated 100 European, 100 indigenous patients, and 25 patients of Chinese descent at the Buitenzorg mental hospital. One wonders how these interviews were conducted and the impression Kraepelin made on these patients. Kraepelin, already a rather intimidating presence for his own students and colleagues, would have needed at least 2 interpreters to interview Indonesian patients: an Indonesian physician to translate Javanese (or Sundanese, or whatever was the patient’s first language) into Dutch, and a second one to provide a translation into German. This would naturally make it more difficult to establish rapport with patients and influence the outcome of his investigations. Nevertheless, concerns like these did not deter Kraepelin who went about his business as methodically as ever.

Kraepelin’s conclusions are interesting. He discovered that paresis or tertiary syphilis was virtually absent among Java’s indigenous population. The rates among European patients were equal to those found in the Western world. Interestingly, he explained this difference by assuming that Eastern brains were less susceptible to syphilis (rather than, for example, assuming that the moral standards of Europeans were significantly looser). He also concluded that alcohol-related mental disease was virtually absent among the Javanese. This was easily explained by the absence of the consumption of alcohol among the Javanese, most of whom are Muslim.

With respect to manic-depressive illness, Kraepelin thought that it was really striking that the depressive episodes were of rather short duration in Javanese patients, who tended to have prolonged and highly expressive manic episodes (one form of which was running amok). With respect to dementia praecox, visual and auditory hallucinations were much less prevalent among the Javanese, and their delusions were less systematized. The prognosis of Javanese patients was significantly better than that of Europeans. Following Kraepelin’s lead, P.H.M. Travaglino, a Dutch colonial psychiatrist used a simple analogy to explain this finding (probably following a more Bleulerian interpretation of schizophrenia): In a poor man’s house, one only finds a few chairs and one table. It would thus take considerable effort to create a confused mess. Similarly, the primitive mind contains only a few elements, which are therefore much harder to become disorganized. Apparently, cultural biases common to colonial societies made their influence felt in psychiatric diagnosis as well.

Kraepelin did not investigate how the different ethnic groups became institutionalized. For Europeans with serious forms of mental illness, a medical certificate generally sufficed. Indigenous patients were only admitted if they had created a public nuisance or after they had broken the law (and were not considered rational). In particular, men who had run amok were commonly institutionalized (if they survived). Depressed patients, on the contrary, were almost never admitted, since they were highly unlikely to break the law. Kraepelin’s conclusions were limited because his study population was a highly selected group. Basing conclusions on the nature of mental illness on an analysis of mental hospital populations however, was not unusual at the time.

Kraepelin asked a number of questions that still occupy informed psychiatrists today. Are there forms of mental illness unique to specific cultures? To what extent is the expression of mental illness shaped by social and cultural factors? In addition, Kraepelin was inspired by the project of his senior colleague Wilhelm Wundt, who was formulating a Volkerpsycholgie (folk psychology or anthropological psychology). On the basis of his clinical observations, he concluded that the normal Javanese mind was primitive, primarily emotional, childish, and highly suggestible (even though he did not conclude that Europeans were alcoholic philanderers lacking in impulse control).

These conclusions corresponded with those of the anthropologist Lucien Lvy-Bruhl in his writings on the primitive mind. They also corresponded with biases held by the European population in the Indies. One could therefore conclude that Kraepelin asked a number of interesting and intriguing questions but was limited in the ways he sought to answer them by anthropological, psychological, and psychiatric views that were common in his time.