Appendix: Goodbye to Hebephrenia

Appendix: Goodbye to Hebephrenia Despite the complex regional variance that is visible throughout the history of schizophrenia’s classification, we tend to also find classi- fiers continuously returned to archetypal ‘foundational’ schizophrenia subtypes such as hebephrenia . As such, for much of the first half of the twentieth century hebephrenia was fairly easy to find in asylums and their records, unlike catatonia . Yet although hebephrenia was more visible than catatonia, and although it held sway in much of official classification, the history of twentieth-century conceptualisation of schizophrenia reveals a growing lack of confidence in even this core concept. Possibly, its demise has its roots in comments made by Bleuler in 1924, when he admitted that hebephrenia ‘now constitutes the big trough into which are thrown the forms that cannot be classed with the other forms’ (1916/1924, p. 426). It may also have had its demise in changing asylum conditions, for by 1945 we can find that Rapaport would argue that hebephrenia, like catatonia, was now becoming increasingly rare. It perhaps only represented cases who had become deteriorated and that ‘in general relatives do not bring hopeless cases to our hospital’ (Rapaport, 1945, p. 19). [The reference to patients not being bought to the hospital possibly also reflects a growing public disil- lusionment with treatment, or distaste for lobotomy, which would see its usage begin to decline by 1948, prior to the introduction of chlor- promazine (Gelman, 1999).] Rapaport, as such, found room in his study for ‘chronic unclassified schizophrenia’, ‘coarctated preschizophrenia’ (marked anxiety, blocking, withdrawal, sexual preoccupation, feeling of strangeness, incompetence, extreme inhibition of affect), ‘over- ideational preschizophrenia’ (obsessions, wealth of fantasy, introspec- tion, self-obsession, and preoccupation with own body), deteriorated paranoid schizophrenia, and so forth. But he abandoned the category hebephrenia (Rapaport, 1945). Rapaport was not alone in having doubts about hebephrenia . For Karl Schneider, simple, catatonic, and paranoid schizophrenia were still usable terms, but ‘Hebephrenia is not in the same rank; it is a term related to the age of a person. We count hebephrenia in with simple schizophrenia ’ (1959, p. 91). Hebephrenia, which often carried with it ‘pathoplastically’ the features of the period, such as the ‘bobby soxer’ 213 214 Appendix (e.g. teenage girl; ardent Frank Sinatra fan), was now significantly downgraded by a researcher, whose influence would soon become immense. In 1963, Lorr, Klett, and McNair also downgraded hebephrenia. They identified ten syndromes in schizophrenia, which they reduced to three: ‘excitement vs. retardation’, ‘schizophrenic disorgani- sation’, and ‘paranoid process’. In doing so, they discovered that hebephrenia did not match up with the disorganised type as one might have expected, and seemingly excluded it on these grounds (Lorr et al., 1963). Although hebephrenia would make it into the 1968 DSM-II, the subtype now appeared to have few active supporters among key schizophrenia researchers. A later explanation offered by George E. Valliant was that the hebephrenics had simply ‘burned out’: ‘I have interviewed “burned out” hebephrenics who have been hospitalized for decades, but who never have admitted delusions or hallucinations vivid enough for them to be diagnosed “schizophrenic” on the Present State Examination’ (1978b, p. 83). Such comments, alongside Schneider and Rapaport’s downgrading of hebephrenia, consequently constituted part of a growing consensus that saw hebephrenia as highly problematic, and which would foreshadow a somewhat hushed replacement of hebephrenia in DSM-III with the aptly named ‘disorganised schizophrenia’.1 Although not before Anthony could suggest ‘microhebephrenia’ (alongside microcatatonia and microparanoia) for transient prepsychotic trends in children (Curran, 1974). This did not seemingly remedy the problem of dumping large number of patients into one category. In a discussion on fads in choosing diagnostic subtypes, John Romano would later report a hitherto unremarked upon ‘tendency to resort to chronic undifferenti- ated schizophrenic subtype as expedient’ (1977, p. 533). Less well known subtypes—when not simple forgotten—could also ‘disappear’. In 1976, Manfred Bleuler reported problems with the so- called ‘catastrophic schizophrenia ’ (stemming from Mauz’s 1930’s schizocaria or schizokar). It was characterised by very acute onset of a most severe psychosis early in life. It was then followed without any interruption by a severe lifelong chronic psychosis (and as noted by Langfeldt (1937) but found only in individuals with higher education; teachers, theologians and students). By 1977, it, too, had practically disappeared in recent decades (Romano, 1977). That said, by 2010, an editorial in Acta Psychiatrica Scandinavica argued that the concept of schizophrenia had failed, and called for its replacement by hebephrenia. Hebephrenia was not a subtype of schizophrenia, read the editorial; it was schizophrenia (Taylor et al., 2010). Notes Introduction 1. This work visits the nineteenth century but primarily focuses on the period 1908–87 (i.e. Bleuler to DSM-III-TR). The literature grows exponentially in size and complexity beyond 1990. 2. Process schizophrenia was subdivided into four more types. The atypical states were denoted as ‘schizophreniform ’, ‘pseudo schizophrenias ’, ‘symp- tomatological schizophrenias’, ‘schizophrenic reaction types’, ‘or whatever they may be called’ (Langfeldt, 1937, p. 189). 1 Schizoidia: The Lexicon 1. Oskar Kohnstamm is strongly associated with schizothymia, as is the term ‘sandbank symptom’ (Kohnstamm, 1914). 2 The Split Personality 1. Richards (1989, p. 118) argues that the psychological process of physio- morphism lies at the root of such ideas. Borges (1971/11979) also touches on this idea, in his afterword to The Book of Sand. 2. Sophie Hedwig Bleuler Wasser née Hedwig Wasser (1869–1940). A trained philologist, she appears to have influenced Eugen Bleuler in various impor- tant ways. However, there is no evidence that the term schizophrenia was a marital in-joke. 3. Lewis (1928) earlier coined the term ‘castrophrenia’ to include the clinical manifestations of thought theft obsessions in schizophrenia, which he linked to the castration complex. 3 Definitions of Schizophrenia 1. Although it would be Lacan who was later praised for his discovery of an ontological flaw in the being of the schizophrenic (Ey et al., 1977). 2. The feeling could be evoked by a passage from Victor Tausk’s Influencing Machine, according to Sass (1987). Laing (1960/1990) thought it ought to be the audience response to Ophelia when she became psychotic. See also Mauz’s and the clinicians’ use during diagnosis of the intuitive ‘dahinter’ (loosely: to suss that which lies behind something) (Langfeldt, 1937, p. 30). 3. While Bowman and Kasanin could add the term ‘constitutional schizophrenia ’ for a psychosis of insidious onset occurring in a family with a definite history of mental disease (Bowman and Kasanin, 1933). 215 216 Notes 4 Catatonia: Faces in the Fire 1. Stoddart would reference catatonia as a symptom and katatonia as a disease, through spelling variation, but such usage is not consistent across the literature. Stoddart also dubiously writes of a characteristic handshake in dementia praecox. 2. Kraepelin would translate Verrücktheit as ‘paranoia’. This possibly reflected comments made by Hecker on the difficulty of defining Verrücktheit—and the collapsing of paranoia into Verrücktheit by Kahlbaum (Hecker, 1871; Kraepelin, 1887, p. 324). 3. Freeman, who mentions Dodson, would accept katatonia. 4. In 1877 we can find Hecker asking visiting colleagues to make predictions on fresh cases. But, where Katatonie was suspected, finding such predictions less accurate than those of himself and Kahlbaum, which were based on insights on disease course (Hecker, 1877, p. 604). Hecker lauds the methodology as key to the derivation of both Hebephrenia and Katatonie. Hence, comparing results against those of unsuspecting colleagues would probably have helped convince both Kahlbaum and Hecker of the validity of both their clinical methodology and Katatonie. 5. Fink and Taylor would synonymise tödliche katatonie as ‘Bell’s mania , perni- cious catatonia , lethal catatonia, malignant catatonia, manic delirium, delirious mania, syndrome malign, acute or fulminating psychosis, fatal catatonia, mortal catatonia, catatonic delirious state, hypertoxic schizophrenia, drug- induced hyperthermic catatonia, confusocatatonia, delirium acutum, delire aigu, and exhaustion syndrome’ (2003, p. 40). 6. The history of schizophrenia in India has yet to be told. Schizophrenia treatment with sulfur injections can be found as early as 1931 in the Ranchi Indian Mental Hospital, Patna (Dhunjiboy and Bomb, 1931). 5 Chasing the Phantom: Classification 1. Claude is also associated with the term ‘schizonévrose’ (Braconnier, 2006), and ‘schizophrénie larvée’ or larval schizophrenia (Claude, 1937). 2. In 1930 Sullivan, referencing prison rape, would, however, speak of a ‘form of schizophrenia called Acute Homosexual Panic’ (1962, p. 209). 3. The literature is inconsistent in its use of terms like ‘groups’, ‘forms’, ‘types’, and ‘subtypes’. Several of the citations in this book will reveal this inconsistency. 4. Crow (1980) himself hypothesised symptoms as reversible and dopamine related (type I

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