Eugen Bleuler’s schizophrenias–synthesis of various concepts

Summary

The historical roots of the concept of schizophrenia are (1) the nosographical era of constructing disease entities,leading to Kraepelin’s nosopoietic act of collecting polymorphous psychoses in two big groups: affective disorders and dementia praecox; (2) the model of dissociation as a psychic mechanism, applied primarily to hysterical phenomena, but later extended for the interpretation of many psychopathological manifestations. This model led E. Bleuler to propose the name schizophrenia. But in the course of Post-KraepelinPsychiatry this dynamic concept of dissociation was almost lost and reserved for the nowadays “dissociative phenomena”. A continuum of dissociation is proposed between normal/adaptive/ healthy,modest and severe pathological syndromes (in posttraumatic stress disorder, borderline, dis- sociated identity disorder) and the most severe dissociation, the ego fragmentation in schizophrenic syndromes.

Zusammenfassung

Die hauptsächlichen Wurzeln der Schizophreniekonzeption von Eugen Bleuler sind (1.) die nosographische Konstruktion der Dementia praecox, die Bleuler übernahm. (2.) Die Idee der Spaltung psychischer Funktionen, ja der Persönlichkeit des Patienten hat ihre Wurzeln im Dissoziationsmodell von Pierre Janet.Sie war zur Zeit Bleulers ein weit verbreitetes Denkmodell auch und gerade für die Psychose mit vielen Namensvorschlägen, die auf dieses Konzept verwiesen. (3.) Die Idee einer speziellen Schwäche, Disposition, Vulnerabilität (Canstatt 1841) der Persönlichkeit. Sie entspricht weitgehend der Psychasthenie, welche als eine Gefährdung für Spaltungen verstanden wurde.

Schlüsselwörter: Schizophrenie; Geschichte desKonzepts; Dissoziation

The three roots of the schizophrenias

In the history of the nosological construct nowadays called schizophrenia we can find three roots: nosography, dissociation, and psychasthenia.

The nosographical era

In the nosographical era of the second half of the 19th century there was no uniform system of psychiatric disorders, each author presenting his own classification.Some authors proposed a multitude of different forms of insanity while others supposed a unitary psychosis (Einheitspsychose, Zeller [1], Griesinger [2]) which manifested itself in different stages and clinical presentations.

It was Emil Kraepelin [3] who from 1896 on in a quite bold nosopoietic act collected the disorders nowadays called affective disorders into one group and at the same time the non-affective psychoses under one dominant idea: that they began early (praecox) and inevitably led to a mental deterioration and weakness which at that time was called dementia. Kraepelin borrowed for the whole group the term dementia praecox from Morel.

Eugen Bleuler [4] agreed as early as 1902 with Kraepelin’s dichotomy of the major functional psychoses with some reservations against the early age of first manifestation and the bad prognosis.

Table 1. The concept of dissociation as the fundamental mechanism of certain psychoses named “schizophrenia” since E. Bleuler 1908, 1911.

The common psychological denominator of the personalities was seen congruently by Kraepelin and Bleuler: a characteristic disruption of the coherence and integration of the personality.

Kraepelin [3] wrote of “the peculiar destruction of the inner coherence of the psychic personality with dominant damage of the emotional life” (p. 668).

In his paper of 1908 (in which he proposed the name schizophrenia) Eugen Bleuler [5] said that the prominent symptom of the whole group of disorders was “the disruption and splitting of the psychic functions” (1908, p. 436). In 1911 Bleuler [6] presented the famous monograph.

The model of dissociation

Thus it can be seen clearly that for the founder of the nosopoietic construct Kraepelin as well as for the baptist Bleuler the underlying basis of the disorder was interpreted by the model of dissociation.

This model of dissociation is far older and broader in its conceptualisation, it is not restricted to the psychoses nowadays called schizophrenias. The roots of this model to interpret certain phenomena go back to the 18th century.Herbart [7] spoke of the dissociation of complexes. The idea was dominant in the association psychology of the 19th century.

There were many alienists who observed dissociation as a prominent characteristic of certain forms of insanity (Esquirol [8], Griesinger [2], Neumann [9], and others). Correspondingly we find many suggestions for naming the respective psychoses (table 1). That was before and at the time of Eugen Bleuler.

The model of dissociation served to interpret the polymorphous manifestation of what at that time was called hysteria.The hysterical phenomena were explained by dissociation: a split between consciousness and the unconscious (Janet [16] 1886 and later), a split off of mnestic and other functions.

It was only later, after the establishment of Kraepelin’s dichotomy and the acceptance of Bleuler’s “handy” name that the concept of schizophrenia was dissociated from one of its roots, namely the model of dissociation, separation, segregation, a split of certain psychic functions from the main complexes of the psyche.

From then on the concept of dissociation served to interpret hysterical, histronic, psychogenic and nowadays dissociative disorders of various clinical presentation and course. The prominent example is the multiple personality disorder, today called dissociative identity disorder.

However, one forgets that in the disorders now called borderline personality disorders and schizophrenia many dissociative phenomena can be observed.

Concept of psychasthenia

A third source of the nosopoiesis of schizophrenia is the concept of psychasthenia.

The common interpretation of the dissociation, the separation of psychic functions, was a certain psychic impairment: a weakness of the psyche to bring and hold together various functions into one integrated mind field. This low synthetic capacity of the psyche kept some personalities vulnerable to insanity.The term psychic vulnerability was first used in 1841 by Canstatt [23]. It is close to earlier concepts of predisposition.

Concerning the genesis of psychasthenia one supposed hereditary causes, especially also the theory of a progressive degeneration of the psyche in the sequence of some generations, early psychotraumatic experiences, and unknown brain diseases.

Terms such as Evensen’s amblynoia [24] or Berze’s hypophrenia [25] for psychoses nowadays called schizophrenias remind us of this line of conceptualisation: a certain debility of cohesion.

The schizophrenias – synthesis of various concepts

Thus we can see that the schizophrenias as peculiar psychoses characterised by a severe dissociation, split, fragmentation of the experiential ego (the me in the sense of William James [26]) assemble like a magnet the lines of nosographical construction with the model of dissociation (a product of the physicalistic association psychology) and (as the aetiological basis) the concept of psychasthenia.

The name schizophrenia, itself meaning split mind, can be seen as a symbol of the convergence of different concepts into one disease model.

But: did the concept contain the synthetic capacity to assemble such heterogeneous elements?

The fate of the nosopoietic construct schizophrenia

In the course of the twentieth century generations of psychiatrists followed the suggestive power of the Kraepelinian nosology. They believed in the construct schizophrenia as a nosological entity, despite of the apparently heterogeneous and polymorphous elements assembled in the concept, and despite of the lack of strong arguments for the validity of the concept.

The descriptive-nosographic system of mental disorders was based on a rather rigid descriptive pathognostic psychopathology (of the type of K. Schneider’s first and second rank symptoms [27]). What was nearly lost, is the dynamic, psychodynamic concept of a temporary ego/self disorder, produced and triggered by biographical,situational intrinsic or exogeneous events in an individual who was vulnerable,predisposed to the breakdown for biological,personal-psychological and social (as well as cultural) weakening factors.

The fate, the course of the dementia praecox, schizophrenias was a deteriorating one: a nosological construct which was dissociated from the original dynamic contributions, an apersonal pathognostic psychopathology which is now stuck in the three syndromes (productive-positive,negative and disorganised).

This broad concept is still widely used as a basis for epidemiology, follow-up and outcome studies, prognosis, treatment experiments and for genetic and neuroscience research.

And the ominous prognosis of Kraepelin still determines the popularised opinion about patients stigmatised by the label schizophrenia.

The serious consideration of the historical conditions, the determination by the dominant zeitgeist, should strengthen our skeptical reservation against the nosological construct schizophrenia with all its negative consequences in the sense of the ominous stigma for the patients and their relatives as well as for fruitful research, based on syndromes rather than illusory nosological entities.

What can we do?

Concerning research we should rather focus on a syndromal concept (Scharfetter and Stassen [28]).

We should value the personal subjective experience of the schizophrenic ego disorder, which is accessible for empirical psychopathological research (Scharfetter [29]).

We should not let us be bound to the poor prognosis and the hopelessness of a solely molecular-genetic brain disease.

We should open our minds to the broad dynamic concept of dissociation between adaptive coping strategies (e.g. certain forms of absorption, forgetting) on the one pole and the severe fragmentation of basic dimensions of the ego/self experienced in schizophrenic disorders on the other pole.

Of course that includes the consideration of quantitative as well as qualitative differentiations of the respective supposed dissociation mechanism.