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Diss 7 4 8 OCR Rev.Pdf Karen Gainer, M.S.W., L.G.S.w., is a psychotherapist in pri­ began to wane (Ellenberger, 1970; Rosenbaum, 1980; vate practice. Shealso SCIVesasSocial Workand FamilySeIVices Rosenbaum & Weaver, 1980). Rosenbaum (1980) speculates Consultant at the Pain Institute in Chicago, Tllinois. that declining interest in DID can be correlated positively with Bleuler's introduction of the term ~schizophrenia»in For reprintswrite Karen Gainer, M.S.W" L.C.S.W., The Pain 1911. Rosenbaum also suggests that the over-inclusiveness Institute in Chicago, 325 West HuronStreet, Suite 220, Chicago, of Blculer's 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 schiwphrenic. Rosenbaum quotes the follow­ Dissociative Slates, November 15, 1992, Chicago, Illinois. ing passage by F.X_ Dercum in support ofhis criticisms: ABSTRACT Because ofhis interpretation ofdementia praecox as a cleavage orfissuration ofthe psychic functions ThU paper ~ an historical persputive regarding 1M role of Bleuler has invented and proposed the name di..ssfx:UUion in 1M d.nJel.opmenl ofboth erioiogic eMory and treot­ "schizophrenia"which he believes to be preferable mmt paradigms fOT schi:zopltrenia.. &femlCeS to 1M roncept ofdis­ to dementia praecox. However, as we have seen, JOCi4lion artdraumJrom classic writings on dementia prauox, and cleavages and fissuration ofthe personalityare not jromlJieukrj (1911) origi:nalconapticnofschiUJphrrniaaJa "JfJlit­ confined to dementia praecox. Theyoccur in many ling-of1M personality. An aauraJe diagno.stic distinction betwun farms oJmentaldisease aJ weUas in the neuros/!.f. In my schizoplrrenia and dissociative diJordm, such aJ disJocialive iden­ judgement [sic] the term being of such general Jig­ lily disorder (DID) and brUfTeactive psyclwsis (BRP), often has been nyU'onceofTers no advanlages over dementia prae­ difficult 10 aJcertain due 10 Ihe preJence ofSchneiderianFm~Rank cox and should be rejected. Symptoms (FRS) inboth lyjJes ofdisorders. The traditionalSchneiderian (Dercum, citedin Rosenbaum, 1980, pp. 1384-1385) FRS, once thought to be indicative symptoms ojschizophrenia, now are viewed as characteristic diagnostic indicators ojDID. Research A number of authors cite research findings in suppon of and theory pertaining to difJenmtidl diagnosis between schizophre­ this view (Bliss, 1980; Boon & Draijer, 1993; K1uft, 1987; nia and lrauma-related dissociative syndromes are reviewed. Early Putnam, Curoff, Silberman, Barban, & Post, 1986; Ross, psychodynamic lrecumenl paradigms JOT schiUJPhrenia and con­ Norton, & Wozner, 1989; and Ross et aI., 1990). North umpqrary lreatmem paradigms for dissociative disorders are com­ American research findings indicale that between 25.6% to pared. Rek:vam diagnostic and lrMtment impli«JlionsJor flu! fUM 49% of DID patienlS have received a prior diagnosis of ofdis.rociative disorders are emph.asized. schizophrenia (PuUlam etal, 1986; Ross etaI., 1989; Ross et al., 1990) .In theNetherlands, 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 Draijerqualifythese relatively modeststatistical findings with personality disorder in DSM-Ill-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 r«ognition in the early nineteenth century (Bliss, 1980; been in North America. Ellenberger, 1970; Greaves, 1980; Taylor & Martin, 1944). Rossetal. (1994) offer the following commentaryregard­ lnteresl in 010 continued to develop throughout the latter ing the research findings cited above: "From these studies halfofthe nineleenth 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 lilerature during this period (Ellenberger, 1970; third ofMPD patients. This isa major level ofincorrectdiag­ 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 D1SS0Cl\TIO~. \01 \'11. ~o. I, December 1994 --- - ----- --- DISSOCIATIOK Al'\D SCHIZOPHRE:\IIA DISSOCIATION AI\rn SCHNEIDERIAN ed historyofchildhood trauma. Accordingto RossandJoshi: FIRST-RANK SYMPTOMS Schneiderian symptoms arc linked to other disso­ Several authors suggest that the common presence of ciative symptom clusters characteristic ofindividu­ Schneiderian first-rank symptoms (FRSs) in patients with dis­ als subjected to chronic childhood trauma. Ifthese sociative identity disorder is a prime factor contributing to findings are replicated andaccepted, they may lead an inadequate differential distinction belWeen the syn­ to a reconceptuaJization ofmany"psychotic"symp­ dromesofDIDandschizophrenia (Bliss, 1980; Boon &Draijer. toms as post-traumatic and dissociative in nawre. 1993; Goons& Milstein. 1986; Fink & Golinkorr, 1990; Kluft, (Ross &Joshi, 1992, p. 272) 1987; Putnam et al., 1986; Ross et al., 1989; and Ross et at, 1990). DISSOCIATION AND BLEULER'S CONCEPT Schneider originally defined the First-Rank. Symptoms OF SCHIZOPHRENIA (FRSs) ofschi7.ophrenia as phenomenological indicators of the disorder in the following manner: Schneider's empirically-derived FRSs initially promised to offer more reliable diagnostic criteria than previously had Audible thoughts; voices heard arguing; voices been offered by Bleuler's 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. Unlik.e ceptionsand all feelings, impulses (drives) andvoli­ Kraepelin - who was interested primarily in the tional aCts that are experienced by the patient as objective portrayal ofpsychopathologic phenome.­ the work or influence ofothers. When any ofthese na and generally refrained from speculation about modesofexperience is undeniably presentand 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 thr. fOllr "Bleularian A's"orsimply the "fourA's" thatinclude Thetraditional Schneidcrian FRSs, oncethought tobeindica­ associative loosening.affective blunting, autism, and tive symptomsofschizophrenia, currcntly areviewed asdiag­ ambivalence. Bleuler worked in an era when ass0­ nostic indicators of OlD (Kluft, 1987). The presence of ciation psychology was preeminenL Psychological Schneiderian FRSs also has been established in connection theorists were preoccupied with determining how with several other clinical syndromes (Andreason &Miskal, thoughts were encodedorformulated in the mind; 1983; Carpenter. Strauss, & Mulch, 1973). the prevailing theory was that the process ofthink· Kluft (J987) reports that 100%ofa303-patient DlDsam­ ingandrememberingwasguided byassociative links pieendorsed the presenceofSchneiderian FRSs, with a mean between ideas and concepts. Bleuler believed that FRS index of 3.6 per patient. In a similar study, Ross et a1. the most important deficit in schizophrenia was a (1989) used a sample of 236 DID patiems, 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) Rossetal. (1990) yieldcdamean FRSs indexof6.4, in a series ofl02 patients. Additionally. FinkandGolinkoff(1990) have Bleuler'sconceptualizationofschizophrenia was innuenced reponed that94% oftheir J&.paticnt DID sample positively by the prevailing association psychology of the era. Bleuler endorsed one or more Schneiderian FRS, with a mean FRS (J911/1950) hypothesized thatan underlying processofass0­ index of4.8. The lauer authors also report findings from a ciative loosening was the fundamental pathognomonic fea­ comparisonstudyinvolving II schizophrenicpaticnts,which ture of schizophrenia, and he described a variety of disso­ yielded a mean FRSs index of 5.6. Fink and GolinkoJI have ciative automatisms as primary schizophrenic symptoms. concludedthatthe DID andschizophreniacomparisongroups Bleulerlisted thesesymptomsas folJows: "Blocking"ofmove­ showed no signijicant differences regarding mean number ment, speech or thoughts (including various forms ofcata­ ofSchneiderian FRSs (F (1.35)=.72 p<.4I). In a similar com­ tonic stupor or negalivism); echolalia and echopraxia; parison, Ross et aI. (1990) have combined outcome data thought withdrawal; "made" thoughts, fcelings or actions; from several previous studies, and have hypothesized thal and "dissociated thinking." Bleuler defined the term ~di..... Schneidcrian FRSs are more characteristic
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