8/6/2019 Concepts of Schitzophrenia Bleuler

1/3

1174 MAY18, 1957 CONCEPTSCONCEPTS O F SCHIZOPHRENIA*

BYE . STENGEL, M . D . , M . R . C . P .

C o n s u l t a n t P s y c h i a t r i s t , U n i t e d S h e f f i e l d H o s p i t a l s ;P r o f e s s o r o f P s y c h i a t r y , U n i v e r s i t y o f S h e f f i e l dE u g e n B l e u l e r , t h e g r e a t S w i s s p s y c h i a t r i s t , w a s b o r non A p r i l 3 0 , 1 8 5 7 . D u r i n g t h e n e x t f e w m o n t h s p s y c h i a -t r i s t s a l l o v e r t h e w o r l d w i l l h e a r a n d t a l k a g r e a t d e a la b o u t s c h i z o p h r e n i a . T h e s e d i s c u s s i o n s w i l l r e a c h t h e i rc l i m a x i n S e p t e m b e r , w h e n t h e I n t e r n a t i o n a l C o n g r e s so f P s y c h i a t r y w i l l m e e t a t Z u r i c h f o r t h e B l e u l e r c e n -t e n a r y . I s h o u l d l i k e t o m a k e a s m a l l c o n t r i b u t i o n t ot h i s w o r l d - w i d e d i s c u s s i o n b y s p e a k i n g a b o u t c o n c e p t so f s c h i z o p h r e n i a , e s p e c i a l l y t h o s e o f B l e u l e r , whoc o i n e d t h e t e r m .

E v e r y o n e who h a s a t t e n d e d m e e t i n g s o r c l i n i c a l c o n -f e r e n c e s on s c h i z o p h r e n i a m u s t o n o c c a s i o n h a v e h a dt h e u n e a s y f e e l i n g t h a t n o t a l l o f t h e p a r t i c i p a n t s w e r et a l k i n g a b o u t t h e same t h i n g , a n d t h a t , i n f a c t , t h e i rc o n c e p t s o f s c h i z o p h r e n i a d i f f e r e d c o n s i d e r a b l y . T h ei n c o n c l u s i v e n e s s o f m a n y a d i s c u s s i o n a m o ng p s y c h i a -t r i s t s i s p a r t l y d u e t o t h e i r i n s u f f i c i e n t a w a r e n e s s o ft h e s e d i f f e r e n c e s . I t t h e r e f o r e a p p e a r s p r o f i t a b l e t o r e -e x a m i n e t h e c o n c e p t o f s c h i z o p h r e n i a f r o m i t s i n c e p -t i o n a n d t o s e e w h a t h a s b e c o m e o f i t s i n c e i t w a s f i r s ta d v a n c e d .

I t i s o f t e n t a k e n f o r g r a n t e d t h a t w i t h t h e t e r m , w h i c hc a u g h t o n a l m o s t i m m e d i a t e l y , B l e u l e r ' s c o n c e p t o f t h es c h i z o p h r e n i a s , t o o , w a s g e n e r a l l y a c c e p t e d . S u c h a na s s u m p t i o n i s u n j u s t i f i e d . T h i s i s n o t s u r p r i s i n g i fB l e u l e r ' s c o n c e p t i s v i e w e d i n i t s p r o p e r h i s t o r i c a l p e r -s p e c t i v e a n d i n i t s r e l a t i o n s h i p t o o t he r n o t i o n s c o n c e r n -i n g t h i s m e n t a l d i s o r d e r o r g r o u p o f m e n t a l d i s o r d e r s .K r a e p e l i n a n d D e m e n t i a P r a e c o x

T h e m a j o r i t y o f t e x t b o o k s g i v e t h e i m p r e s s i o n t h a t t h eK r a e p e l i n i a n c o n c e p t i o n o f d e m e n t i a p r a e c o x ( K r a e p e l i n ,1 9 1 9 ) , w h i c h w a s b a s e d o n s y m p t o m s a n d o u t c o m e ss u p p o s e d l y c o m m o n t o a l a r g e m a j o r i t y o f c a s e s , h a dr e i g n e d s u p r e m e f r o m 1 8 9 6 , u n t i l i t w a s s u p e r s e d e d b yt h a t o f s c h i z o p h r e n i a w h i c h d i d j u s t i c e t o t h e f r e q u e n ta b s e n c e o f d e t e r i o r a t i o n a n d t o t h e o n s e t o f t h e i l l n e s si n v a r i o u s a g e g r o u p s . T h i s i s h i s t o r i c a l l y n o t q u i t ec o r r e c t .When B l e u l e r f i r s t p r o p o s e d t h e t e r m " s c h i z o p h r e n i a "i n 1 9 0 8 , K r a e p e l i n ' s c o n c e p t o f d e m e n t i a p r a e c o x a s ac l i n i c a l e n t i t y w a s s t i l l h i g h l y c o n t r o v e r s i a l . I t w a so p p o s e d b y a number o f l e a d i n g p s y c h i a t r i s t s . A d o l fM e y e r h a d p u b l i s h e d h i s o b j c c t i o n s a g a i n s t i t w e l l b e f o r eB l e u l e r . M e y e r n e v e r a c c e p t e d t h e n o t i o n o f a d i s e a s ee n t i t y . K r a e p e l i n s o o n b e c a m e aware o f t h e s h o r t c o m i n g s

o f t h e t e r m " d e m e n t i a p r a e c o x , " w h i c h h a d b e e n c o i n e d b yM o r e l ( 1 8 6 0 ) . H e c o n c e d e d t h a t a c e r t a i n n u m b e r o f c a s e sd i d n o t d e t e r i o r a t e a n d e v e n r e c o v e r e d , a n d t h a t t h e i l l n e s sd i d n o t a l w a y s s t a r t i n y o u n g a g e . B l e u l e r h i m s e l f d i d n o tr e g a r d h i s s t r o n g e r e m p h a s i s on t h o s e t w o f a c t s a s h i s m a i nc o n t r i b u t i o n . On t h e c o n t r a r y , h e d i s c l a i m e d a n y m e r i t ont h a t a c c o u n t . R e f e r r i n g t o t h e c o n c e p t o f d e m e n t i a p r a e c o x ,h e s a i d i n h i s m o n o g r a p h ( B l e u l e r , 1 9 1 1 ) , a l m o s t a n g r i l y :" P e c u l i a r l y e n o u g h , o n e o f t h e o b j e c t i o n s w h i c h even n o wc a n b e h e a r d f r e q u e n t l y , e s p e c i a l l y a b r o a d , i s t h a t w e a r ed e a l i n g n e i t h e r w i t h d e m e n t i a nor w i t h p r e c o c i t y . C o n -s i d e r i n g t h a t K r a e p e l i n d e f i n e d h i s c o n c e p t s o c l e a r l y , a n de x p r e s s l y r e f e r r e d t o r e c o v e r i e s a n d t o l a t e r o n s e t s , t h i s ca nb e c a l l e d a g r o s s m i s u n d e r s t a n d i n g : t h o s e c r i t i c s c o n c e n t r a t eo n t h e name, b u t t h e y r e a l l y r e j e c t t h e c o n c e p t . " B l e u l e r*A M a u d s l e y B e q u e s t L e c t u r e d e l i v e r e d on N o v e m b e r 1 2 , 1 9 5 6 .

e n d e a v o u r e d t o g a i n r e c o gn i t i o n f o r i t , t h o u g h i n a modifieda n d l e s s r i g i d f o r m ( t h e m a i n t i t l e of h i s monograph was" D e m e n t i a P r a e c o x , " with a s u b t i t l e : " The Group of th eS c h i z o p h r e n i a s " ) . I t can n ot e v e n b e s a i d t h a t the w i d e n i n gof the a r e a o f s c h i z o p h r e n i c manifestations was B l e u l e r ' ss p e c i a l c o n t r i b u t i o n . K r a e p e l i n ' s c l i n i c a l c o n c e p t ofdementia p r a e c o x w a s fo r a c e r t a i n p e r i o d o f i t s evolutionq u i t e a s wide a s B l e u l e r ' s . In w h a t r e s p e c t , t h e n , di d hi sc o n c e p t d i f f e r f r o m t h a t of K r a e p e l i n ; a n d how much ofB l e u l e r ' s c o n t r i b u t i o n ha s stood t h e t e s t of time ?

A d o l f M ey e r and Eugen BleulerBleuler a nd the other members o f the Z u r i c h s c h o o l ,a m o n g whom J u n g was p r o m i n e n t , w e r e p r o f o u n d l yi n f l u e n c e d b y F r e u d , whom Bleuler c r e d i t e d with h a v i n gi n s p i r e d h i s work. I t i s often f o r g o t t e n that K r a e p e l i n ,F r e u d , a n d Bleuler w e r e c o n t e m p o r a r i e s , b o r n i n three co n-s e c u t i v e y e a r s . T he c o n c e p t of s c h i z o p h r e n i a p r e s e n t e d b y

Bleuler i n h i s m o n o g r a p h i n 1911 was r e a l l y a j o i n t creationof those t h r e e m e n .T h e r e i s a noth e r h i s t o r i c a l f a c t which i s i n s u f f i c i e n t l y

k n o w n , a l t h o u g h i t m a y e x p l a i n th e c o m p a r a t i v e ind ifferencewith which B l e u l e r ' s c o n c e p t w a s received i n th e E n g l i s h -s p e a k i n g c o u n t r i e s . A d o l f M e y e r ' s theories o f reaction t y p e sa nd h a b i t d e t e r i o r a t i o n , i m p l y i n g a r e j e c t i o n of K r a e p e l i n ,p r e c e d e d B l e u l e r ' s c o n c e p t ; Meyer ( 1 9 0 6 ) stated hi s v i e w si n a s y m p o s i u m on d e m e nt i a p r a e c o x a t th e Annual Meetingo f t h e B r i t i s h Medic al Association a t T o r o n t o in 1906. Hisa dd re s s c o nta i n e d i n a nutshell p r a c t i c a l l y th e whole of hi st e a c h i n g s . T his a r t i c l e was known to Ble u le r. Meyer'sintervention i n th e discussion o f dementia praecox s e v e r a ly e a r s b efo r e Bleuler had c o m p l e t e d hi s work of modern izin gK r a e p e l i n was decisive fo r American p s y c h i a t r y . B l e u l e r ' smonograph w a s translated into E n g l i s h o n l y a few y e a r s a g o ,when M e y e r ' s influence was already on th e wane.

B l e u l e r ' s H i e r a r c h y o f S y m p to m sB l e u l e r ' s c l i n i c a l c o n c e p t o f s c h i z o p h r e n i a i s b a s i c a l l y

K r a e p e l i n i a n , b u t w ith a g r e a t e r e m p h a s i s on the v a r i e t y ofmanifestations and d e v e l o p m e n t s . Compared with Krae p el in,Bleuler was much less p e s s i m i s t i c about the o u t c o m e , butnevertheless was more s o than p r e s e n t - d a y p s y c h i a t r i s t s .T h e s e differences c o n c e r n i n g p r o g n o s i s are not fundamental.T h e y h a v e o b v i o u s l y been l a r g e l y due to the l o n ger follow-up p e r i o d s studied by s u c c e s s i v e generations of p s y c h i a t r i s t s .Bleuler p o s t u l a t e d some underlying structural cause. Somes u c h w o r k i n g h y p o t h e s i s has always been ado pted b y mostc l i n i c a l p s y c h i a t r i s t s and u n d e r l i e s modern research into thee x p e r i m e n t a l p s y c h o s e s produced b y drugs.

Bleuler d i s t i n g u i s h e d b a s i c , or primary, from accessory,o r s e c o n d a r y , s y m p t o m s . The former were the disturbanceso f a ss oci ati on and o f a f f e c t i v i t y a s well a s the p a t i e n t ' st e n d e n c y t o r e p l a c e r e a l i t y b y f a n t a s y which was r e s p ons i b lefo r the v a r i o u s m a n i f e s t a t i o n s of autism. Hallucinations,d e l u s i o n s , and a l l th e o t h e r manifestations of schiz o ph ren i awere r e g a r d e d a s s e c o n d a r y .

Bleuler t h e r e f o r e , u n l i k e K r a e p e l i n , p r o p o s e d a h i e r a r c h yo f s y m p t o m s , o f which th e basic ones were s u p p o s e d to bed i r e c t l y c a u s e d by th e h y p o t h e t i c a l or g a nic process, whileth e s e c o n d a r y symptoms were r e g a r ded " p a r t l y as distortedm e nt a l f u n c t i o n s , p a r t l y a s th e r e s u l t of more or less un-s u c c e s s f u l , o r even s u c c e s s f u l , attempts at a d a ptati o n to thep r i m a r y d i s t u r b a nc e . " Here wemeet a l r e a d y the concept ofa d a p t a t i o n which h a s p l a y e d a considerable part in morerecent theories o f s c h i z o p h r e n i a . In differentiating primaryand s e c o n d a r y symptoms, Bleuler was influenced by Freud,who, i t s e e m s , had been im p r e s s ed b y H u g h l i n g s Jackson'sdistinction between n e g a t i v e and p o s i t i v e s y m p t o m s .

J u n g ' s " C o m p l e x e s "I n the p r i m a r y symptoms of disturbance of association,

e m o t i o n a l l y c h a r g e d l a r g e l y r e p r e s s e d g r o u p s of ideas, whichJung had called c o m p l e x e s , were regarded to be of p a r t i c u -

BRrs,M E D I C A L J O U R N A L1 1 7 4 MA Y 1 8 , 1 9 5 7 C O N C E P T S OF S C H I Z O P H R E N I A

8/6/2019 Concepts of Schitzophrenia Bleuler

2/3

MA Y 1 8 , 1 9 5 7 CONCEPTS OF SCHIZOPHRENIA B R n T I S H _ 1 1 7 5MEDICAL J O U R N A Ll a r i m p o r t a n c e . I n h i s monograph on the psychology ofd e m e n t i a p r a e c o x , which appeared three years beforeB l e u l e r ' s book on s c h i z o p h r e n i a , Jung (1909) had describedt h e ways i n w h i c h c o m p l e x e s became isolated in hysteriaa n d s c h i z o p h r e n i a a n d how they i n t e r f e r e d with the normalprocesses o f t h i n k i n g . Any idea could become the nucleuso f a c o m p l e x , w h i c h may b e transient and short-lived. Jung'sa n d B l e u l e r ' s use o f t h e t e r m di f f e r e d from it s later use inp s y c h o - a n a l y s i s , where i t was reserved for a very smallnumber o f e m o t i o n a l l y charged i d e a s of great dynamic powera n d r e p r e s e n t i n g b a s i c a n d u n i v e r s a l tendencies. Thisd i f f e r e n c e i l l u s t r a t e s t h e g r a d u a l replacement of associationp s y c h o l o g y b y a more s p e c i f i C a l l y Freudian dynamic psycho-p a t h o l o g y . J u n g a n d Bleuler were not only concernedwitht h e f o r m a l a s p e c t s of the f o r ma ti o n and isolation ofcom-p l e x e s i n s c h i z o p h r e n i a ; they a ls o studied their contents inr e l a t i o n t o t h e i n d i v i d u a l ' s history along Freudian lines.

B l e u l e r m a d e i t c l e a r , t h a t th e assumption of an underlyingo r g a n i c p r oc e s s was n ot an essential premise to his concepto f s c h i z o p h r e n i a . He said: "It i s not unthinkable thatthes y m p t o m s may b e caus ed psychologically, and that they mayd e v e l o p f r o m s l i g h t q u a n t i t a t i v e devi ations from thenormal;i n t h e same way a s i n some individuals the predispositiont o h y s t e r i c a l s y m p t o m s i s s o g r e a t th at they tend to reacth y s t e r i c a l l y t o t h e ordinary d i f f i c u l t i e s of life, while theaverage person d o e s so o n ly a s th e r e s u l t of an exceptionallys e v e r e p s y c h i c tr au ma ." H ow ev e r, Bleuler did not pursuet h i s h y p o t h e s i s f u r t h e r , a s he f a v o u r e d that of an organiccause.

A l t e r n a t i v e s to B l e u l e r ' s ViewWhat were t h e a l t e r n a t i v e s to B l e u l e r ' s concept ofschizo-

p h r e n i a ? O n e , o f course, was strict adherence toKraepelin,a course t a k e n b y many clinicians a l l over the world.A n o t h e r a l t e r n a t i v e was A d o l f Meyer's hypothesis of re-a c t i o n t y p e s a nd h a b i t deterioration, which was widelya c c e p t e d i n t h e United States and i n this country. Meyerl a c k e d B l e u l e r ' s c l a r i t y of thinking and he failed to formu-l a t e a u x i l i a r y h y p o t h e s e s . Many psychiatrists found it diffi-c u l t to understand how faulty habits in childhood shouldl e a d t o s c h i z o p h r e n i c symptoms and even to personality dis-i n t e g r a t i o n . M e y e r di d n o t expressly address himselftotheq u e s t i o n w hy t h i s sequence of events should take placesome i n d i v i d u a l s a nd n ot i n others. His aetiological theory,w h i c h m o s t p s y c h i a t r i s t s c l a s s i f i e d as psychogenic, is remark-a b l e i n t h a t i t d i d n ot undergo any noticeable changesincei t was f i r s t advanced 50 years ago. Its great value layt h e e m p h a s i s on t h e i n d i v i d u a l and h i s environment andtheiri n t e r a c t i o n . I n h i s theory o f th e aetiological importanceofcurrent l i f e s i t u a t i o n s he i ntr od u c e d an infinite numberofc h a n g e a b l e v a r i a b l e s and d i s c o u r a g e d discriminationbetweene n v i r o n m e n t a l f a c t o r s o f different pathogenic significance.H i s a p p r o a c h , though p r od u cti v e of therapeutic optimism,h a d t h e f u n d a m e n t a l w e a k n e s s of paying too little attentiont o t h e unknown.

The p s y c h o - a n a l y t i c a l theories of schizophrenia haved e v e l o p e d almost independently of Bleuler's work.r e f u s e d to t h i n k i n t e r m s of mental energy. Weossess,"h e s a i d , "nomeans of measuring psychic energyandthere-f o r e we are q u i t e u n a b l e to d i s c u s s dynamic theories."t h i s reason he ha d no use f o r Janet's (1903) abaissementdu n i v e a u m e n t a l " and s i m i l a r notions, nor didhefollowF r e u d , w h o thought in terms of mental forces. InBleuler'sconcept o f ambivalence th e i d e a of conflict sofundamentalt o p s y c h o - a n a l y s i s di d n o t e n t e r. In fact, this wordwash a r d l y m e n t i o n e d i n h i s writings. There is anothertermwhich i s conspicuous by i t s absence in his work-namely,t h a t o f r e g r e s s i o n , which one could almost callthea nd omega o f t h e psycho-analytical theory of schizophrenia;T h i s m e n t a l d i s o r d e r i s v i e w e d as a regression to oneofthee a r l i e s t phases of mental development. However,ith i gh l y p r o b l e m a t i c a l why such a regression shouldtakeplacei n some i n d i v i d u a l s . Most psycho-analysts seem toimplysome k i n d o f v e r y e a r l y p s y c h o l o g i c a l influence still

k n o w n . The v a l u a b l e p s y c h o - a n a l y t i c a l c o n t r i b u t i o n t os c h i z o p h r e n i a w i l l come t o f r u i t i o n o n l y when i t i s c o n -s i d e r e d t o g e t h e r w i t h t h e k n o w l e d g e o f o t h e r f a c t o r s , s o m eo f w h i c h w i l l p r o b a b l y b e n o n - p s y c h o l o g i c a l . S u c h a v i e wi s m o r e i n k e e p i n g w i t h F r e u d i a n p r i n c i p l e s t h a n a p u r e l yp s y c h o g e n i c h y p o t h e s i s ( S t e n g e l , 1 9 5 6 ) .

T h e r e i s y e t a n o t h e r a s p e c t o f r e g r e s s i o n i n r e l a t i o n t os c h i z o p h r e n i a - t h a t i s , t h e a n t h r o p o l o g i c a l ; S t o r c h ( 1 9 2 4 )d e s c r i b e d t h e s i m i l a r i t i e s b e t w e e n s c h i z o p h r e n i c a n d a r c h a i c -p r i m i t i v e modes o f t hi nk i n g a n d b e h a v i o u r . T h i s a s p e c t ,w h i c h h a s b e e n n e g l e c t e d f o r s o m e t i m e , w i l l n o d o u b t comet o t h e f o r e a ga i n w i t h t h e i n c r e a s i n g i n t e r e s t i n t h e s o c i a la n d a n t h r o p o l o g i c a l p r o b l e m s o f s c h i z o p h r e n i a .

S c h i z o p h r e n i a i n t h e M e l t i n g - p o tWhat i s t h e s t a t u s o f B l e u l e r ' s c o n c e p t t o - d a y ? I n 1 9 5 1M a n f r e d B l e u l e r p r e s e n t e d a b a l a n c e - s h e e t o f h i s f a t h e r ' sw o r k . H i s r e v i e w , w h i c h w a s b a s e d o n a n u n r i v a l l e d k n o w -

l ed ge o f t h e l i t e r a t u r e , w a s a s o b e r s t a t e m e n t f r e e f r o m f i l i a ls e n t i m e n t a l i t y . M a n f r e d B l e u l e r s a w t h e m o s t i m p o r t a n tr e c e n t d e v e l o p m e n t i n t h i s f i e l d n o t i n t h e g r o w t h o f t h ep h y s i c a l m e t h o d s o f t r e a t m e n t b u t i n t h e s h a t t e r i n g o f t h ec l a s s i c a l n o t i o n s c o n c e r n i n g s c h i z o p h r e n i a . E v e r y one o ft h e m h a d b e c o m e q u e s t i o n a b l e , a l t h o u g h n o n e o f t h e m h a db e e n f i n a l l y r e f u t e d . T h e w h o l e p r o b l e m w a s i n a s t a t e o ff e r m e n t a t i o n t o - d a y . What y e s t e r d a y a p p e a r e d t o b eg e n e r a l l y a c c e p t e d a n d e s t a b l i s h e d w a s t o - d a y t o s o m e a tb e s t a p r e c a r i o u s w o r k i n g h y p o t h e s i s , t o o t h e r s a d o g m a t ob e f o u g h t , a n d t o o t h e r s a g a i n a f a i r y t a l e f r o m a r e m o t ep a s t . T h i s a p p l i ed t o q u e s t i o n s s u c h a s t h o s e o f d i s e a s ee n t i t y , o f a e t i o l o g y , o f t h e i n f l u e n c e o f h e r e d i t y a n d e n v i r b n -m e n t , e t c . I n h i s v i e w t h e f o l l o w i n g f a c t s s t o o d o u t f r o m t h ew el t e r o f t h e o r i e s a n d o b s e r v a t i o n s . ( 1 ) E v e n i f a d i s e a s ep r o c e s s - t h a t i s , a n i m p e r s o n a l c a t a s t r o p h e - s h o u l d p l a ya n e s s e n t i a l p a r t i n t h e s c h i z o p h r e n i c d e v e l o p m e n t , i t d i d soi n i t s r e l a t i o n s h i p t o t h e d e v e l o p m e n t o f a p e r s o n a l i t y .( 2 ) A l l t h e o b s e r v a t i o n s w h i c h p r e v i o u s l y w e r e r e g a r d e d a si n d i c a t i v e o f a n u n d e r l y i n g s o m a t i c i l l n e s s - t h a t i s , B l e u l e r ' sp r i m a r y o r b a s i c s y m p t o m s - c o u l d n o w a d a y s b e j u s t a s w e l lo r e v e n b e t t e r e x p l a i n e d a s s e c o n d a r y - t h a t i s , a s r e s u l t so f t h e s c h i z o p h r e n i c m e n t a l d i s o r d e r w i t h i t s p r o f o u n de m o t i o n a l f l u c t u a t i o n s a n d i t s a b n o r m a l b e h a v i o u r . T h i sa l s o a p p l i e d t o a l l f i n d i n g s c o n c e r n i n g a b n o r m a l p h y s i o -l o g i c a l f u n c t i o n s i n s c h i z o p h r e n i a . He r e g a r d e d t h e e f f e c t so f t h e s o m a t i c t h e r a p i e s a s t h e o r e t i c a l l y i n c o n c l u s i v e .M a n f r e d B l e u l e r c o n c l u d e d t h a t w e h a d t r i e d t o an sw e r t h ew r o n g q u e s t i o n s , e s p e c i a l l y i n e x a m i n i n g h e r e d i t y a n de n v i r o n m e n t a s i n d e p e n d e n t f a c t o r s a n d i n i n s i s t i n g o n t h ea r t i f i c i a l a n t i t h e s i s o f o r g a n i c v e r s u s p s y c h o g e n i c a e t i o l o g y .M a n f r e d B l e u l e r ' s a p p r a i s a l o f t h e p r e s e n t s t a t e o f t h e t h e o r yo f s c h i z o p h r e n i a i s b o t h c o r r e c t a n d f a i r .

I n a d d i t io n t o t h e p s y c h o - a n a l y t i c a l a p p r o a c h t h e r e a r ea v a r i e t y o f c o n c e p t s w h i c h d e r i v e f r o m c u r r e n t b i o l o g i c a l ,s o c i o l o g i c a l , o r p h i l o s o p h ic a l t r e n d s . T h e f o l l o w i n g a r er e p r e s e n t a t i v e m o d e r n v i e w s o n s c h i z o p h r e n i a .H o s k i n s ( 1 9 4 6 ) e x p r e s s e d t h e v i e w t h a t t h i s p s y c h o s i sr e p r e s e n t e d a n e n d - r e s u l t o f a g e n e r a l f a i l u r e o f a d a p t a t i o n

a r i s i n g f r o m a d e f e c t i v e e v o l u t i o n o f t h e m a t u r i n g p r o c e s s .M a n i f e s t a t i o n s o f t h i s f a i l u r e w e r e d e f e c t i v e s o m a t i c a n dp s y c h i c h o m o e o s t a s i s , d e f e c t i v e e m p a t h y , a n d f i n a l d i s i n t e -g r a t io n o f t h e p e r s o n a l i t y . T h e a c c e s s o r y s y m p t o m a t o l o g yo f t h e p s y c h o s i s c o n s t i t u t e d s e c o n d a r y a d a p t a t i o n s t o t h ed i f f i c u l t i e s a r i s i n g o u t o f t h e p r i m a r y d e f e c t . T h e s e a r eB l e u l e r ' s i d e a s e x p r e s s e d i n t h e l a n g u a g e o f a d a p t a t i o nt h e o r y .Norman Cameron ( 1 9 4 4 ) r e g a r d s i n a d e q u a t e e m p a t h y a st h e p r i m a r y d e f e c t . H e f o r m u l a t e d h i s t h e o r y o f s c h i z o -p h r e n i a t h u s : " s o c i a l d i s a r t i c u l a t i o n r e s u l t i n g f r o m t h ec u m u l a t i v e r e p l a c e m e n t o f c o m m u n i c a t i o n b y p r i v a t ef a n t a s y , i n p e r s o n s who h a v e b e e n u n a b l e t o e s t a b l i s h t h e m -s e l v e s f i r m l y i n t h e i r c u l t u r a l p a t t e r n , b e c a u s e o f f a i l u r e t od e v e l o p a d e q u a t e r o l e - t a k i n g s k i l l s . " T h i s f o r m u l a t i o n d o e sn o tg o beyond l e u l e r a n d M e y e r , b u t a n e w a p p r o a c h w a s

8/6/2019 Concepts of Schitzophrenia Bleuler

3/3

BRNAL1 7 6 MA Y 1 8 , 1 9 5 7 C O N C E P T S OF S C H I Z O P H R E N I A M M I C A L J O U R N A La d u m b r a t e d w he n C am e ro n e x p r e s s e d t h e v i e w t h a t t h e s t u d yo f i n t er p e r s o n a l r e l a t i o n s a n d t h e i r c h a n g e s i n s c h i z o p h r e n i am u s t a l s o i n c l u d e t h e s o c i a l f i e l d s w i t h i n w h i c h a l l h umano r g a n i s m s o p e r a t e . T h i s a n d s i m i l a r i d e a s h a v e r e c e n t l y l e dt o i n t e r e s t i n g r e s e a r c h e s i n t o t h e e c o l o g y o f s c h i z o p h r e n i a .

H a r r y S t a c k S u l l i v a n ( 1 9 4 0 ) a l s o s t r e s s e d , a l m o s t e x c l u -s i v e l y , t h e s o c i a l a s p e c t s i n t h e a e t i o l o g y a n d s y m p t o -m a t o l o g y o f s c h i z o p h r e n i a . To h i m p s y c h i a t r y w a s t h es t u d y o f d i s t u r b e d i n t e r p e r s o n a l r e l a t i o n s . H e d i s t i n g u i s h e dd e m e n t i a p r a e c o x , w h i c h h e r e g a r d e d a s a n o r g a n i c p r o c e s s ,f r o m a v a r i e t y o f s c h i z o p h r e n i c p e r s o n a l i t y d e v e l o p m e n t sa r i s i n g f r o m s i t u a t i o n s o f p a n i c a n d r e s u l t i n g i n a t h r o w -b a c k t o t h e i n t e r p e r s o n a l r e l a t i o n s o f e a r l i e s t c h i l d h o o d .S u l l i v a n c o m b i n e d F r e u d i a n , M e y e r i a n , a n d s o c i o l o g i c a lc o n c e p t s w i t h a p h i l o s o p h y o f h i s o w n . H e s p o k e o f " ac o l l a p s e o f t h e i n d i v i d u a l - w o r l d s y n t h e s i s " a n d o f " t h er e s o r t t o a w i l d c o m p e n s a t o r y p r o g r a m m e l e a d i n g t o s c h i z o -p h r e n i a . " H e r e g a r d e d p e r s o n a l i t i e s a n d m e n t a l d i s o r d e r sa s a b s t r a c t i o n s : " T h e r e a r e o n l y d e g r e e s o f d e v e l o p m e n t sa n d v i c i s s i t u d e s o f t h e c o m m u n a l e x i s t e n c e o f t h e p e r s o nw i t h o t h e r s . "

C u r r e n t C o n t i n e n t a l T r e n d sI s h o u l d l i k e t o make s o m e b r i e f c o m m e n t s o n c o n c e p t so f s c h i z o p h r e n i a p r e v a i l i n g o n t h e E u r o p e a n C o n t i n e n t .B l e u l e r ' s h i e r a r c h y o f s y m p t o m s a n d t h e p s y c h o l o g i c a lt h e o r i e s u n d e r l y i n g i t w e r e n o t g e n e r a l l y a c c e p t e d , t h o u g hm o s t o f h i s c l i n i c a l o b s e r v a t i o n s w e r e i n c o r p o r a t e d i n t oE u r o p e a n p s y c h i a t r y .A new a n d i m p o r t a n t a s p e c t w a s i n t r o d u c e d w i t h t h ed i f f e r e n t i a t i o n o f p r o ce s s s c h i z o p h r e n i a a n d d e f e c t s c h i z o -p h r e n i a , a n a t t e m p t w h i c h h a s n e v e r q u i t e s u c c e e d e d .A n o t h e r m o d i f i c a t i o n o f B l e u l e r ' s c l i n i c a l s y s t e m wa s t h e d i s -t i n c t i o n b e t w e e n a n u c l e a r a n d a m a r g i n a l g r o u p o f s c h i z o -p h r e n i a s , w h i c h a g a i n h a s n o t f o u n d g e n e r a l a c c e p t a n c e .S i m i l a r p r o p o s a l s o f a d i f f e r e n t i a t i o n w i t h i n , o r e v e n a d i s -s o l u t i o n o f , t h e c l i n i c a l e n t i t y o f s c h i z o p h r e n i a h a v e b e e nmade r e p e a t e d l y . T h e c o n c e p t o f t h e s c h i z o i d p e r s o n a l i t y ,w h i c h w a s l a u n c h e d b y B l e u l e r a n d e l a b o r a t e d b yK r e t s c h m e r , w a s a n a d d i t i o n o f f u n d a m e n t a l s i g n i f i c a n c ef r o m b o t h t h e c l i n i c a l a n d t h e t h e o r e t i c a l p o i n t o f v i e w .T h e m o s t i m p o r t a n t t r e n d i n C o n t i n e n t a l p s y c h i a t r y s i n c eK r a e p e l i n a n d B l e u l e r h a s b e e n t h e p h e n o m e n o l o g i c a lo r i e n t a t i o n w h i c h h a s c u l t i v a t e d a c a r e f u l s t u d y o f t h es u b j e c t i v e p s y c h o l o g i c a l e x p e r i e n c e s i n m e n t a l i l l n e s s . Fromt h e c l i n i c a l p o i n t o f v i e w , i t h a s a i m e d a t e s t a b l i s h i n g d i a g -n o s t i c a n d p r o g n o s t i c c r i t e r i a b a s e d o n d i f f e r e n c e s o f s u b -j e c t i v e e x p e r i e n c e s . T h i s s c h o o l o f t h o u g h t h a s c r e a t e d

a v o c a b u l a r y o f i t s own w h i c h m a k e s t r a n s l a t i o n i n t o o t h e rl a n g u a g e s d i f f i c u l t . T h e i r s t a n d a r d w o r k i s J a s p e r s ' sA l l g e m e i n e P s y c h o p a t h o l o g i e , w h i c h a p p e a r e d i n 1 9 1 3 , o n l yt w o y e a r s a f t e r B l e u l e r ' s m o n o g r a p h . I t i s a n a m a z i n g f a c tt h a t p s y c h i a t r y i s s t i l l l i v i n g o n t h e c a p i t a l i n v e s t m e n t s m a d eb y a f e w b r i l l i a n t m e n b e f o r e t h e f i r s t w o r l d w a r . T h i si s e s p e c i a l l y t r u e f o r t h e c o n c e p t s o f s c h i z o p h r e n i a . J a s p e r sh a s f o u n d a s u c c e s s o r i n L u d w i g B i n s w a n g e r ( 1 9 4 6 ) , w h o ,l i k e B l e u l e r a n d M e y e r , i s a S w i s s p s y c h i a t r i s t . H e i s t h ef a t h e r o f " e x i s t e n t i a l a n a l y s i s , " w h i c h , h e m a i n t a i n s , o w e sa g r e a t d e a l t o J a s p e r s a n d F r e u d . He t r i e s t o e s t a b l i s hi n w h a t k i n d o f s u b j e c t i v e w o r l d , o r w o r l d s , t h e s c h i z o -p h r e n i c l i v e s a n d t h u s t o u n d e r s t a n d h i s mode o f e x i s t e n c ea n d i t s c h a n g e s . H e r e g a r d s h i s m e t h o d a s f u n d a m e n t a l l yd e s c r i p t i v e . H e c l a i m s t h a t e v e n i n a d v a n c e d s c h i z o p h r e n i at h e hu m a n m i n d h a s . a t i t s d i s p o s a l d e f i n i t e p r i n c i p l e s o fo r g a n i z a t i o n a n d s t r u c t u r e . A c c o r d i n g t o B i n s w a n g e r t h i sk i n d o f a n a l y s i s e n a b l e s t h e p s y c h i a t r i s t t o c o m m u n i c a t ew i t h h i s p a t i e n t s more c l o s e l y t h a n o t h e r m e t h o d s a n d t oh e l p t h e m b y p s y ch o t h e r a p y w h i c h h a s t o b e b a s e d o n c a r e -f u l s t u d y o f t h e i n d i v i d u a l c a s e .

T h i s a p p r o a c h i s n o t a s r e m o t e f r o m c u r r e n t t r e n d s a s i tm a y a p p e a r . I t h a s s o m e t h i n g i n c o m m o n w i t h t h e t h e o r i e so f C a m e r o n a n d S u l l i v a n , w h o s e i d e o l o g i c a l b a c k g r o u n d ,i s , o f c o u r s e , d i f f e r e n t f r o m B i n s w a n g e r ' s . W h i l e h e s p e a k so f " b e i n g i n t h e w o r l d " a n d " e x i s t e n c e , " t h e y t a l k o f i n t e r -p e r s o n a l r e l a t i o n s a n d e m p a t h y , b u t f u n d a m e n t a l l y t h e y

mean s o m e t h i n g v e r y s i m i l a r . T h e n e e d f o r e s t a b l i s h i n gc o n t a c t w i t h t h e s c h i z o p h r e n i c o n h i s o wn g r o u n d f o r t h ep u r p o s e o f t r e a t m e n t h a s b e e n r e p e a t e d l y s t r e s s e d b y p s y c h o -a n a l y s t s ; t h e y h a v e n o d o u b t t h a t t h e s c h i z o p h r e n i c ' s w o r l di s f u n d a m e n t a l l y t h a t o f t h e i n f a n t , w h i l e B i n s w a n g e r w o u l da l l o w h i m s e l f t o b e g u i d e d m a i n l y b y h i s p a t i e n t s ' e x p e r i -e n c e s . A l s o , t h e e m p h a s i s o n " o b j e c t r e l a t i o n s , " w h i c hs t a r t e d a s a c o n t r o v e r s i a l i s s u e i n p s y c h o - a n a l y s i s , i s b o u n dt o l e a d t o a c l o s e r s t u d y o f t h e s o c i a l f i e l d o f w h i c h t h ei n d i v i d u a l i s a p a r t . B u t e x i s t e n t i a l a n a l y s i s i n i t s p r e s e n tf o r m h a s g r e a t l i m i t a t i o n s . W h i l e i t m a y b e a m e t h o d o fg e t t i n g c l o s e r t o c e r t a i n t y p e s o f p a t i e n t a n d t h u s g a i n i n ga f u l l i n s i g h t i n t o s o m e a s p e c t s o f d e l u s i o n s a n d a b n o r m a lb e h a v i o u r , i t i s d i f f i c u l t t o s e e how i t c a n a d v a n c e k n o w -l e d g e o f t h e a e t i o l o g y o f a c o n d i t i o n s u c h a s s c h i z o p h r e n i a .T h e r e i s a g r o w i n g a w a r e n e s s among t h o s e i n t e r e s t e d i nt h i s a p p r o a c h t h a t i t r e q u i r e s t o b e i n t e g r a t e d w i t h o t h e rm e t h o d s .

C o n c l u s i o n sT h i s r e v i e w d e m o n s t r a t e s t h e d i v e r g e n c e s , o f t h e c o n -c e p t s c o n c e r n i n g t h i s v a s t g r o u p o f m e n t a l d i s o r d e r s .

P s y c h i a t r y h a s i n t h i s f i e l d n o t p r o g r e s s e d b e y o n d w o r k i n gh y p o t h e s e s , o f w h i c h B l e u l e r ' s h y p o t h e s i s c a n b e r e g a r d e da s t h e o n e w h i c h w a s t h e m o s t c o m p r e h e n s i v e when i t w a sf i r s t a d v a n c e d , a n d w h i c h e v e n n o w , i f b r o u g h t u p t o d a t e ,p o s e s more r e l e v a n t q u e s t i o n s t h a n a n y o t h e r . I t i s o f t e nb e l i e v e d t h a t a t t e m p t s a t c l a r i f i c a t i o n o f c o n c e p t s a r e f u t i l ei n t h e p r e s e n t s t a t e o f k n o w l e d g e b u t t o - d a y , when t h e r e i ss o much t h e r a p e u t i c a n d e x p e r i m e n t a l a c t i v i t y , i t i s m o r et h a n e v e r i m p o r t a n t f o r p s y c h i a t r i s t s t o l o o k a f t e r t h e i r t o o l so f c o m m u n i c a t i o n . i t c a n n o t e v e n b e s a i d t h a t , a l t h o u g h wea r e u s i n g d i f f e r e n t c o n c e p t s o f s c h i z o p h r e n i a , we know as c h i z o p h r e n i c when we s e e o n e .

T h e r e a r e many i n d i c a t i o n s t h a t d i f f e r e n c e s o f t h e o r e t i c a lc o n c e p t s , h o w e v e r v a g u e l y h e l d , a r e f r e q u e n t l y r e s p o n s i b l ef o r d i a g n o s t i c d i s a g r e e m e n t s . The u n c e r t a i n t y a b o u t t h ee f f e c t s o f v a r i o u s t r e a t m e n t s w o u l d b e l e s s g e n e r a l i f t h e r ew a s a c l o s e r u n d e r s t a n d i n g among p s y c h i a t r i s t s a b o u t t h ec o n d i t i o n s t h e y a r e t r e a t i n g . S i m i l a r d i f f i c u l t i e s e x i s t i ne x p e r i m e n t a l p s y c h i a t r y . Th e i m p o r t a n t q u e s t i o n o f t h er e l a t i o n s h i p o f t h e " m o d e l p s y c h o s e s " e x p e r i m e n t a l l y p r o -d u c e d b y d r u g s t o m e n t a l i l l n e s s c a n n o t b e a n s w e r e d w i t h o u tr e f e r e n c e t o c o n c e p t s s u c h a s t h o s e d i s c u s s e d h e r e . Somep s y c h i a t r i s t s t a k e i t f o r g r a n t e d t h a t t h e y a r e d e a l i n g w i t he x p e r i m e n t a l s c h i z o p h r e n i a , b u t t h i s h a s b e e n c o n t e s t e d b yo t h e r s .

T h e r e i s a t e n d e n c y among r e s e a r c h w o r k e r s t o g e t awayf r o m c u r r e n t c o n c e p t s o f m e n t a l i l l n e s s a l t o g e t h e r a n d t oc o n c e r n t h e m s e l v e s w i t h f u n d a m e n t a l p h e n o m e n a , b u tsome o f t h e s e w o r k e r s s e e m t o b e u n a w a r e t h a t t h e y a r ed o i n g t h i s , a n d t h e y c o n t i n u e t o t a l k a n d t o w r i t e i n t e r m so f c u r r e n t c l i n i c a l c o n c e p t s t o w h i c h t h e y p a y s c a n t r e g a r d .S u c h a s t a t e o f a f f a i r s i s a p t t o r e d u c e t h e v a l u e o f m a n yi n t e r e s t i n g o b s e r v a t i o n s . T h e s e a r e o n l y some o f t h e r e a s o n swhy c a r e f u l a t t e n t i o n t o c o n c e p t s i s e s s e n t i a l f o r p r o g r e s s i np s y c h i a t r y .R E F E R E N C E S

B i n s w a n g e r , L u d w i g ( 1 9 4 6 ) . S c h w e i z . A r c h . N e u r o l . P s y c h i a t . , 5 8 , 1 .B l e u l e r , E . ( 1 9 1 1 ) . D e m e n t i a p r a e c o x o d e r Gruppe d e r S c h i z o p h r e n i e n .L e i p z i g a n d W i e n . T r a n s l . , 1 9 5 0 , Z i s k i n , N e w Y o r k .B l e u l e r , M. ( 1 9 5 1 ) . F o r t s c h r . N e u r o l . P s y c h i a t . , 1 9 , 3 8 5 .C a m e r o n , Nor m a n ( 1 9 4 4 ) . I n T h e F u n c t i o n a l P s y c h o s e s P e r s o n a l i t y a n d t h eB e h a v i o u r D i s o r d e r s , V o l . 2 , e d i t e d b y J . McV. H u n t . N e w Y o r k .H o s k i n s , R . G . ( 1 9 4 6 ) . B i o l o g y o f S c h i z o p h r e n i a . N e w Y o r k .J a n e t , P . ( 1 9 0 3 ) . L e s o b s e s s i o n s e t l a p s y c h a s t h e n i e . P a r i s .J a s p e r s , K . ( 1 9 1 3 ) . A l l g e m e i n e P s y c h o p a t h o l o g i e , B e r l i n . ( 5 t h e d . , 1 9 4 5 .

B e r l i n and H e i d e l b e r g . )J u n g , C . G . ( 1 9 0 9 ) . Th e P s y c h o l o g y o f D e m e n t i a P r a e c o x . T r a n s l . , P e t e r -

s o n an d B r i l l , N e w Y o r k .K r a e p e l i n , E . ( 1 9 1 9 ) . D e m e n t i a p r a e c o x . T r a n s l . , B a r c l a y , E d i n b u r g h .M e y e r , A . ( 1 9 0 6 ) . . B r i t i s h M e d i c a l J o u r n a l , 2 , 7 5 7 .M o r e l , B . A . ( 1 8 6 0 ) . T r a l t t d e s m a l a d i e s m e n t a l e s . P a r i s .S t e n g e l , E . ( 1 9 5 6 ) . B r i t i s h M e d i c a l J o u r n a l , 1 , 1 0 0 0 .S t o r c h , E . ( 1 9 2 4 ) . Nerv ous a n d M e n t a l D i s e a s e s . M o n o g r a p h N o . 3 6 .

W a s h i n g t o n .S u l l i v a n , H a r r y S t a c k ( 1 9 4 0 ) . P s y c h i a t r y , 3 . 1 .