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Schizophrenia: It's Broken and It Can't Be Fixed. a Conceptual Analysis At Isr J Psychiatry Relat Sci - Vol. 48 - No 4 (2011) Schizophrenia: It’s Broken and It Can’t Be Fixed. A Conceptual Analysis at the Centenary of Bleuler’s Dementia praecox oder Gruppe der Schizophrenien Jan Dirk Blom, MD, PhD, 1,2 and Herman M. van Praag, MD, PhD3 1 Parnassia Bavo Group, The Hague, The Netherlands 2 Department of Psychiatry, University of Groningen, Groningen, The Netherlands 3 Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands BacKGROUND ABSTRACT In 2011 it was 100 years ago that the Swiss psychiatrist Background: In 1911 Bleuler’s Dementia praecox Eugen Bleuler (1857-1939) published his famous book oder Gruppe der Schizophrenien served to launch Dementia praecox oder Gruppe der Schizophrenien schizophrenia as a group of nosological entities (1). The term schizophrenia had been introduced characterized by a “splitting of the psychic functions.” by him three years prior, in a rather inconspicuous Today, at the centenary of this opus magnum, we find paper entitled Die Prognose der Dementia praecox that the term is still in force but not the concept originally (Schizophreniegruppe) (2), but it was his impressive 420- envisaged by Bleuler. page monograph with its myriad clinical descriptions Method: For the sake of this conceptual analysis a that would propagate the name and promote its accep- literature search was carried out in PubMed, Embase, tance throughout the world. As indicated by the APA’s and the historical literature. status reports on the development of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5), to Results: The current schizophrenia concept, as be published in 2013, the name will be here to stay for operationalized in the DSM and other psychiatric the foreseeable future (3). But the concomitant concept classifications, is primarily indebted to Kraepelin and of a “split” or “fragmented” personality, as originally his degenerationist take on psychopathology. That envisaged by Bleuler, was discarded a long time ago. approach is now obsolete, but the product still prevents Paradoxically, our present schizophrenia concept bears us from moving beyond the notion of schizophrenia the name coined by Bleuler, although it is based on the as a single-disease concept with multiple etiologies, body of thought of Emil Kraepelin (1856-1926). That multiple clinical expressions, and an unfavorable body of thought derived to a significant extent from the outcome. 19th-century degeneration theory, a poorly discussed Conclusions: If we aim to investigate the biological doctrine which no longer serves as a source of inspira- underpinnings of psychotic symptoms, first a tion for psychiatry’s scientific discourse, but that exerts deconstruction of the schizophrenia concept will need its influence upon our thinking about psychotic disor- to take place. In this paper we highlight a method - called ders up until the present day (4-6). functionalization - which allows for such a deconstruction. Limitations: Functionalization will probably require AIMS a new scientific language, which will be largely discontinuous with our current nosological and In this paper we offer a concise reconstruction of the diagnostic systems. early developmental history of the schizophrenia concept. Our primary aim is to demonstrate that the 19th-century Address for Correspondence: Jan Dirk Blom, MD, PhD, Assistant Professor of Psychiatry, Director of the Residency Training Program, Parnassia Bavo Group, Paradijsappelstraat 2, 2552 HX The Hague, The Netherlands [email protected] 240 JAN DIRK BLOM AND HERMAN M. van Praag degeneration theory should be granted a more significant ting of the psychic functions” may result in an interruption role in its shaping than has hitherto been customary, and of the normal process of association: “Thus the process that this indebtedness constitutes the major reason why of association often works with mere fragments of ideas psychiatry does not succeed in moving beyond the para- and concepts. This results in associations which normal doxical notion of a single-disease concept with multiple individuals will regard as incorrect, bizarre, and utterly etiologies, multiple clinical expressions, and an unfavor- unpredictable. Often thinking stops in the middle of a able outcome. Our secondary aim is to explore possible thought; or in the attempt to pass to another idea, it may directions for the concept’s future development. suddenly cease altogether, at least as far as it is a conscious process (blocking). Instead of continuing the thought, new ideas crop up which neither the patient nor the observer METHOD can bring into any connection with the previous stream For the sake of this conceptual analysis, a literature search of thought” (1). To Bleuler these two basic mechanisms was carried out in the English, German, French, and constituted the heart of that which he called schizophre- Dutch historical literature, PubMed, and Embase (up to nia. He gave the ensuing symptoms, including hallucina- October, 2010), using the search terms “schizophrenia,” tions and delusions, the status of “secondary” or - from a “dementia praecox,” “Bleuler,” and “Kraepelin.” slightly different vantage point – “accessory” symptoms. As regards the etiology of schizophrenia, Bleuler took a well-considered position in which both organic and psy- RESULTS chological factors were taken into account (7). As to its THE GENESIS OF BLEULER’S SCHIZOPHRENIA CONCEPT prognosis and outcome, he showed himself somewhat In 1908 Bleuler introduced the term schizophrenia more optimistic than Kraepelin. Whereas Kraepelin because he was dissatisfied with the nomenclature used by reported an inevitable decline in 87 per cent of individuals Kraepelin. As he argued, dementia praecox - as Kraepelin with dementia praecox, Bleuler spoke of periods of remis- called it - was neither characterized by an unavoidable sion and exacerbation (1, 8). Nonetheless, Bleuler was dementia, nor by an unavoidable praecocitas. “For this convinced that the underlying “schizophrenic process” reason,” Bleuler wrote, “and because of the fact that one had a strong tendency to persist, even when superficially cannot derive adjective and substantive noun modi- the patient might appear to be “sane.” fiers from the expression dementia praecox, I take the The notion of an alleged correspondence between liberty of using the word schizophrenia to designate the Bleuler’s schizophrenia concept and Kraepelin’s demen- Kraepelinian notion” (2). Three years later he added, “I tia praecox concept has proved to be quite resistant (9). call dementia praecox ‘schizophrenia’ because (as I hope Apart from Bleuler, who characterized his work on to demonstrate) the ‘splitting’ of the different psychic schizophrenia as “nothing less than the application of functions is one of its most important characteristics. For Freud’s ideas to dementia praecox,” Kraepelin added the sake of convenience, I use the word in the singular to the myth of compatibility through numerous refer- although it is apparent that the group includes several ences to “schizophrenia” and “schizophrenic symptoms” diseases” (1). Thus he suggested that the two terms were in his later work (1, 8). On closer inspection, though, interchangeable, and that they referred to a single noso- Bleuler’s concept differed more from Kraepelin’s than logical category or group of disorders. the two men would openly admit. Thus Bleuler rejected The term schizophrenia (from the Greek wordsσχιζειν the very foundation of Kraepelin’s dementia praecox and φρην) was carefully chosen. It sought to reflect the concept, i.e., the notion of an inevitable deterioration patient’s peculiar loss of unity of the self, or “splitting of towards dementia. However, the greatest source of the psychic functions,” as Bleuler called it, and the ensuing tension between the two concepts would seem to lie emergence of isolated complexes which take turns con- in their level of operationalization. Kraepelin concep- trolling the personality. In Bleuler’s view, without a proper tualized dementia praecox as a syndrome-course unit, integration into the rest of the personality, these complexes defining it in terms of overt clinical features developing are bound to result in a fragmentation of the patient’s in a certain direction over time, whereas Bleuler consid- personality. As he asserts, “Thus the patient appears to ered it basically as a weakness of association, i.e., a dis- be split into as many different persons or personalities as turbance of mental functioning which might or might they have complexes” (1). According to Bleuler, this “split- not become manifest in overt clinical features. To him 241 SCHIZOPHRENIA: IT’S BROKEN AND IT Can’T BE FIXED overt psychotic symptoms, so important to Kraepelin’s (subsequently diagnosed with manic-depressive illness) concept, were merely of secondary importance. and those with an unfavorable one (referred to as the dementia praecox group) (19). SCHIZOPHRENIA IN THE DSMS The initial reception of Bleuler’s schizophrenia concept KRAepelin’S IDEas ON DEGENEratION was one of indifference (10). It took six years before it A fourth, and poorly discussed influence upon elicited any significant response from beyond the circle Kraepelin’s conceptualization of dementia praecox was of Bleuler’s personal collaborators. But during the 1920s, the 19th-century degeneration theory, a pseudo-scientific the usage of the term schizophrenia gradually surpassed doctrine which represented the
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