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Dissociation and Schizophrenia: an Historical Review of Conceptual Development and Relevant Treatment Approaches

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Dissociation and Schizophrenia: an Historical Review of Conceptual Development and Relevant Treatment Approaches DISSOCIATION AND SCHIZOPHRENIA: AN HISTORICAL REVIEW OF CONCEPTUAL DEVELOPMENT AND RELEVANT TREATMENT APPROACHES Karen Gainer, M.S.W., Karen Gainer, M.S.W., L.C.S.W., is a psychotherapist in pri- began to wane (Ellenberger, 1970; Rosenbaum, 1980; vate practice. She also serves as Social Work and Family Services Rosenbaum Weaver, 1980) . Rosenbaum (1980) speculates Consultant at the Pain Institute in Chicago, Illinois. that declining interest in DID can be correlated positively with Bleulers introduction of the term "schizophrenia" in For reprints write Karen Gainer, M.S.W., L.C.S.W., The Pain 1911. Rosenbaum also suggests that the over-inclusiveness Institute in Chicago, 325 West Huron Street, Suite 220, Chicago, of Bleulers conceptual framework has contributed to diffi- IL 60610. culties in the differential diagnosis between DID and schizophrenia and to a growing trend of misdiagnosis, in An earlier version of this paper was presented at the Ninth which many individuals suffering from DID have been mis- International Conference on Multiple Personality and diagnosed as schizophrenic. Rosenbaum quotes the follow- Dissociative States, November 15, 1992, Chicago, Illinois. ing passage by F.X. Dercum in support of his criticisms: ABSTRACT Because of his interpretation of dementia praecox as a cleavage or fissuration of the psychic functions This paper provides an historical perspective regarding the role of Bleuler has invented and proposed the name " dissociation in the development of both etiologic theory and treat- "schizophrenia which he believes to be preferable ment paradigms for schizophrenia. References to the concept of dis- to dementia praecox. However, as we have seen, sociation are drawn from classic writings on dementia praecox, and cleavages and fissuration of the personality are not from Bleuler's (1911) original conception of schizophrenia as a "split- confined to dementia praecox. They occur in many ting" of the personality. An accurate diagnostic distinction between forms of mental disease as well as in the neuroses. In my schizophrenia and dissociative disorders, such as dissociative iden- judgement [sic] the term being of such general sig- tity disorder (DID) and brief reactive psychosis (BRP), often has been nificance offers no advantages over dementia prae- difficult to ascertain due to the presence of Schneiderian First-Rank cox and should be rejected. Symptoms (FRS) in both types of disorders. The traditional Schneiderian (Dercum, cited in Rosenbaum, 1980, pp. 1384-1385) FRS, once thought to be indicative symptoms of schizophrenia, now are viewed as characteristic diagnostic indicators ofDID. Research A number of authors cite research findings in support of and theory pertaining to differential diagnosis between schizophre- this view (Bliss, 1980; Boon Draijer, 1993; Kluft, 1987; nia and trauma-related dissociative syndromes are reviewed. Early Putnam, Guroff, Silberman, Barban, Post, 1986; Ross, psychodynamic treatment paradigms for schizophrenia and con- Norton, Wozney, 1989; and Ross et al., 1990). North temporary treatment paradigms for dissociative disorders are com- American research findings indicate that between 25.6% to pared. Relevant diagnostic and treatment implications for the field 49% of DID patients have received a prior diagnosis of of dissociative disorders are emphasized. schizophrenia (Putnam et al, 1986; Ross et al., 1989; Ross et al.,1990).In the Netherlands, Boon and Draijer (1993) deter- INTRODUCTION mined that 15.6% of their 71-patient DID sample had received a prior diagnosis of schizophrenia. Boon and Dissociative identity disorder (DID), known as multiple Draijer qualify these relatively modest statistical findings with personality disorder in DSM-III-R (American Psychiatric the observation that schizophrenia traditionally has been Association, 1987), is a clinical syndrome which first gained diagnosed with less frequency in the Netherlands than it has recognition in the early nineteenth century (Bliss, 1980; been in North America. Ellenberger, 1970; Greaves, 1980; Taylor Martin, 1944). Ross et al. (1994) offer the following commentary regard- Interest in DID continued to develop throughout the latter ing the research findings cited above: "From these studies half of the nineteenth century and the early twentieth cen- it is evident that DSM-III-R criteria for schizophrenia result tury. A growing number of DID cases were reported in the in a false-positive diagnosis of schizophrenia in about one clinical literature during this period (Ellenberger, 1970; third of MPD patients. This is a major level of incorrect diag- " Putnam, 1989; Ross, 1989; Sutcliffe Jones, 1962; Taylor nosis with profound treatment implications (p.5). Martin, 1944). However, this growth trend was short-lived. Professional interest in the field of dissociation eventually 261 DISSOCIATION. Vol. VII. No. t. December 1994 DISSOCIATION AND SCHIZOPHRENIA DISSOCIATION AND SCHNEIDERIAN ed history of childhood trauma. According to Ross andJoshi: FIRST-RANK SYMPTOMS Schneiderian symptoms are linked to other disso- Several authors suggest that the common presence of ciative symptom clusters characteristic of individu- Schneiderian first-rank symptoms (FRSs) in patients with dis- als subjected to chronic childhood trauma. If these sociative identity disorder is a prime factor contributing to findings are replicated and accepted, they may lead an inadequate differential distinction between the syn- to a reconceptualization of many "psychotic" symp- dromes of DID and schizophrenia (Bliss, 1980; Boon Draijer, toms as post-traumatic and dissociative in nature. 1993; Coons Milstein, 1986; Fink Golinkoff, 1990; Kluft, (Ross Joshi, 1992, p. 272) 1987; Putnam et al., 1986; Ross et al., 1989; and Ross et al., 1990). DISSOCIATION AND BLEULERS CONCEPT Schneider originally defined the First-Rank Symptoms OF SCHIZOPHRENIA (FRSs) of schizophrenia as phenomenological indicators of the disorder in the following manner: Schneiders empirically-derived FRSs initially promised to offer more reliable diagnostic criteria than previously had Audible thoughts; voices heard arguing; voices been offered by Bleulers original diagnostic schema. heard commenting on one ' s actions; the experi- ence of influences playing on the body (somatic The concept of specific or pathognomonic symp- passivity experiences); thought-withdrawal and toms began with Bleuler, who focused on demen- other interferences with thought; delusional per- tia praecox and renamed it schizophrenia. Unlike ceptions and all feelings, impulses (drives) and voli- Kraepelin - who was interested primarily in the tional acts that are experienced by the patient as objective portrayal of psychopathologic phenome- the work or influence of others. When any of these na and generally refrained from speculation about modes of experience is undeniably present and no the origin of schizophrenic symptoms - Bleuler basic somatic illness can be found, we may make devoted himself to understanding the basic mech- the decisive clinical diagnosis of schizophrenia. anisms that caused these symptoms. His search led (Schneider, 1939, pp. 133-134) him to what are now referred to as the four "Bleularian As" or simply the "four As" that include The traditional Schneiderian FRSs, once thought to be indica- associative loosening, affective blunting, autism, and tive symptoms of schizophrenia, currently are viewed as diag- ambivalence. Bleuler worked in an era when asso- nostic indicators of DID (Kluft, 1987). The presence of ciation psychology was preeminent. Psychological Schneiderian FRSs also has been established in connection theorists were preoccupied with determining how with several other clinical syndromes (Andreason Akiskal, thoughts were encoded or formulated in the mind; 1983; Carpenter, Strauss, Mulch, 1973). the prevailing theory was that the process of think- Kluft (1987) reports that 100% of a 303-patient DID sam- ing and rernembering was guided by associative links ple endorsed the presence of Schneiderian FRSs, with a mean between ideas and concepts. Bleuler believed that FRS index of 3.6 per patient. In a similar study, Ross et al. the most important deficit in schizophrenia was a (1989) used a sample of 236 DID patients, and obtained a disruption in these associative threads. mean FRS index of 4.5 per patient. A replication study by (Andreason Akiskal, 1983, p. 42) Ross et al. (1990) yielded a mean FRSs index of 6.4, in a series of 102 patients. Additionally, Fink and Golinkoff (1990) have Bleulers conceptualization of schizophrenia was influenced reported that 94% of their 16-patient DID sample positively by the prevailing association psychology of the era. Bleuler endorsed one or more Schneiderian FRS, with a mean FRS (1911/1950) hypothesized that an underlying process of asso- index of 4.8. The latter authors also report findings from a ciative loosening was the fundamental pathognomonic fea- comparison study involving 11 schizophrenic patients, which ture of schizophrenia, and he described a variety of disso- yielded a mean FRSs index of 5.6. Fink and Golinkoff have ciative automatisms as primary schizophrenic symptoms. concluded that the DID and schizophrenia comparison groups Bleuler listed these symptoms as follows: " Blocking " of move- showed no significant differences regarding mean number ment, speech or thoughts (including various forms of cata- of Schneiderian FRSs (F (1.35) =.72 p<.41) . In a similar com- tonic stupor or negativism); echolalia and echopraxia;
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